**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy titled Notification of Changes, the facility failed to notify the resident representative of a significant change in condition for two of 32 sampled residents (R) (R#20 and R#24). On 2/4/22, the facility failed to notify R#20's representative of an increase in the resident's mood and behaviors and failed to notify the resident's representative of the resident signing an Against Medical Advice (AMA) discharge form and exiting the facility. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was not able to make safe decisions about signing out AMA. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record review, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: 1. A review of policy titled Notification of Change with a revision date of January 2023, revealed the following compliance guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status, or a transfer or discharge of the resident from the facility. This policy indicated that for competent individuals, the facility must still contact the resident's physician and notify resident's representative if known. For residents incapable of making decisions, the representative would make any decisions that need to be made. A review of the clinical record for R#20 revealed he was admitted to the facility on [DATE] with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#20 presented with a Brief Interview for Mental Status (BIMS) score of six. The scale of 0-6 indicates the resident has severe cognitive impairment. A review of the discharge information from the previous skilled nursing facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needs placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Further review revealed the resident was not independent prior to admission to the previous facility and had been living with family. His discharge goal barriers included cognitive impairment and physical challenges. He was determined a fall risk and had been referred to therapy. The interventions included to continue to monitor and readjust medications as needed. A review of an initial psychiatric evaluation for R#20 dated 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that the resident had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder; and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation, and frequent reorientation to reality. A review of the clinical record for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission, and to consider Gradual Dose Reduction (GDR). Staff had reported resident was alert, confused, forgetful, was able to ambulate, and was incontinent at times. The resident was also reported to continue to wander and was not manageable at times, difficult to redirect verbally, and not co-operative with care and medications. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations, or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote, check testosterone level, consider Depo-Provera if the sexually inappropriate behavior continues, provide cognitive social stimulation and frequent reorientation to reality, and to continue close monitoring. Behavioral interventions included distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nurses note dated 2/4/23 at 3:01 p.m., revealed the following: The resident got on elevator and refused to get off. (R#20) went down to first floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect (R#20). (R#20) requesting to leave the facility. Patient spoke to the nurse, scheduler, and Doctor (Dr. ZZZ), in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility (AMA). An interview was conducted with R#20's representative on 7/12/23 at 3:13 p.m. S/he stated that R#20 was put out of the facility with a garbage bag and a wheelchair. S/he stated that s/he was told that R#20 signed a paper that was read to him. R#20's representative stated that the form had a signature on it but that it wasn't R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair and still was never told why R#20 had been discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and because he was short of breath, the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin. S/he stated that the cousin then called them of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home from the apartment. R#20's representative stated that R#20 had been with them for less than a week and had to go to the hospital. S/he also stated that R#20 was now in another facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. A phone interview on 7/12/23 at 3:50 p.m. with Dr. ZZZ revealed that he was at the facility on that day R#20 was discharged . He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and he told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ ended the phone interview stating that upon leaving the facility, he saw R#20 going up the road and he stopped R#20 and offered him some money, a ride, a call to Uber, or money to get a hotel room. He stated that R#20 refused. A phone interview was conducted on 7/13/23 at 6:15 p.m., with License Practical Nurse (LPN) CCC. She revealed that she was an agency nurse that had only worked one shift at the facility and confirmed it was Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred. She stated that the resident had become adamant that he was going home and stated that R#20 was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA form to R#20. She stated that R#20 did sign the AMA form. LPN NNN also stating that the doctor and she were standing in front of the door, and due to the resident being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN confirmed that she had not spoken with R#20's representative prior to his AMA discharge. 2. A review of policy titled Notification of Change with a revision date of January 2023, revealed the following compliance guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include accidents resulting in injury and/or potential to require physician intervention and significant change in the residents physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status which may include life-threatening conditions or Clinical complications. Circumstances that require a need to alter treatment may include new treatment, discontinuation of current treatment due to adverse consequences such as acute condition, exacerbation of a chronic condition, a transfer or discharge of the resident from the facility, a change of room or roommate assignment; and/or a change in resident rights. A review of the Electronic Medical Record (EMR) of R#24 revealed that she was admitted to the facility on [DATE] and was discharged to the hospital on 9/30/22. R#24 was admitted with diagnoses that included, but was not limited to, end stage renal disease, dependence on renal dialysis, chronic respiratory failure, dependence on oxygen, atrial fibrillation, sleep apnea, and needed assistance with personal care. A review of the MDS dated [DATE] revealed that R#24 had a BIMS score of eight, which indicated that the resident is moderately cognitively impaired, and she required extensive assistance with ADL's. During a phone interview on 7/17/23 at 5:16 p.m. R#24's responsible party, s/he stated that the facility never contacted them that the resident was sent to the hospital in September 2022. S/he was contacted by the hospital two days after the R#24 was sent to the hospital. S/he further stated that the dialysis center had contacted them regarding R#24 missing six sessions. S/he stated that s/he was told by the dialysis center that the facility never contacted them regarding the resident being COVID-19 positive and told the responsible party that they would have still treated R#24, even with the positive test for COVID-19. A review of the EMR for R#24 revealed there was no nurses note or any documentation related to when or why R#24 was sent to the hospital on 9/30/22 and no documentation that the responsible party was notified. An interview with LPN JJJ on 7/18/23 at 3:40 p.m. revealed that as long as next of kin is listed, they should be called if there is a change of condition. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23 at 3:00 p.m. with the Medical Director, Center Nurse Practitioner, Director of Nursing (DON), Unit Managers (UM), Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to notification of changes, to review the findings for the IJ, and plan for the removal of IJ issues. 2. R#20 was discharged from the facility on 2/4/23. 3. On?7/13/23,?the Center Regional Director of Operations, DON, and Regional Director of Clinical Operations reviewed the center policy?on Notification of Change.?No changes or recommendations were made or given. 4. On 7/13/23, to identify other residents that may be affected by this practice, a 100% review was completed of residents with known mood and behavioral problems with a verbal expression to leave the facility AMA by the UM (a licensed nurse) of residents for the past 30 days (6/13/23 through 7/13/23) to ensure that their responsible party or legal representative was informed of an increase in mood or behavioral related to their desire to leave AMA to ensure ongoing safety. Any resident found to have had a change in mood and behavior related to their desire to leave AMA without responsible party/legal representative being informed, responsible party/legal representative was informed by a licensed nurse on 7/14/23. 5. On 7/13/23, the DON reeducated licensed nurses on the importance of ensuring that the responsible and/or legal representatives are notified of a change in condition related to increased mood and behavioral problems with an expressed, voiced desire to leave the center without the advice of their physician to ensure safety and to reduce risk of a delay in potential interventions to establish safety. Education also included the importance of nurses to report altered mental status specific to an increase in behaviors to the resident's representative, as well as the attending physician so appropriate interventions can be initiated. Currently there are 16 of 19 licensed nurses of which 88% have been educated. Any clinical staff members who were not reeducated due to Vacation, PRN (as needed) Status, etc., will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, or Charge Nurse. Newly hired clinical staff, such as Agency or PRN's (as needed staff), will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 6. The Regional Director of Clinical Services reeducated the center DON, UM's, and MDS team on the importance of ensuring that the responsible and/or legal representatives are notified of a change in condition related to increased mood and behavioral problems with an expressed, voiced desire to leave the center without the advice of their physician in order to ensure safety, a safe discharge, and to reduce risk of a delay in potential care interventions to establish safety. 7. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 7/14/23. 8. All corrective actions were completed on 7/14/23. 9. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the minutes from ad hoc meeting on 7/13/23 revealed that topics reviewed were concerns related to the Plan of Correction (PoC), and Quality Assurance Performance Improvement (QAPI) actions. Subject Matter: Complaint Survey 7/13/23 IJ Citations F580, F600, F624, F710, F7835. Initiated abatement. Attendance was dated 7/13/23 and signed by Medical Director, Center Nurse Practitioner, DON, UM, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members. 2. Verified census list that listed R#20 as discharged on 2/4/23. 3. Reviewed attestation form attached to the policy titled Notification of Change and no changes or recommendation were made at the time of the review. This document was signed by the Regional Director of Operations, the DON, Regional Director of Clinical Operations, and the Medical Director. 4. A review of the audit revealed one resident (R#20) was identified to have increase in behaviors/risk of AMA discharge. 5. The in-service record was reviewed dated 7/13/23 related to the policy titled Notification of Changes. Policy to notify residents' responsible party, guardian, legal representatives, and physicians are notified of resident change of condition was reviewed. 6. The in-service record was reviewed related to in-service on 7/13/23 and conducted by the Regional Director of Clinical Services at 5:00 p.m. entitled Notification of Change revised date of January 2023. Reviewed importance of reporting altered mental status specific to increases in behaviors to resident's representative and the attending physician so appropriate interventions can be initiated. Document date and time of notifications. Residents with mood and behaviors expressing desire to leave AMA, ask MD, NP, and RP to consider 1013 to provide acute level of care. Interviews with the Social Service Director on 7/17/23 at 2:55 p.m., with the DON on 7/17/23 at 4:10 p.m., with LPN/UM AAA on 7/17/23 at 4:30 p.m. revealed that they had received education regarding safe discharge of residents and making sure all parties are notified during the discharge process to ensure safe discharge. 7. A review of QAPI meeting minutes dated 7/14/23 revealed the meeting included review of audits completed as part of the removal plan and plan of correction. The attendance sheet was signed by the QAPI Committee members. 8. All corrective actions was verified as being completed on/by 7/14/23. 9. The IJ was verified as being removed on 7/15/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident representative interviews, record review, and review of the facility policies titled Abuse, Neglect and Exploitation, Transfer and Discharge (including AMA), and Notification of Changes, the facility failed to protect one of 32 sampled residents (R) (R#20) from neglect by not ensuring the resident's cognitive level and mental status was appropriate for him to make an informed decision to discharge by signing an Against Medical Advice (AMA) form and exiting the facility. On 2/4/22, R#20 was allowed to sign an AMA form and then exited the facility without the knowledge or assistance from his representative or a discharge plan in place. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was unable to make safe self-care decisions. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record review, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: A review of the policy titled Transfer and Discharge (including AMA) with reviewed/revised date of January 2023 indicated: In cases of a resident desiring to be discharged AMA, the resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives of both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of the physician's notification should be entered in the nurses' notes by the nurses' department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protective Services, or other entity, as appropriate if self-neglect is suspected, and document accordingly. A review of the policy titled Abuse, Neglect and Exploitation with reviewed/revised date of 9/8/22 indicated: The definition of neglect is failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Components of the facility abuse prohibition plan includes the screening of prospective residents to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. An assessment of the individuals' functional and mood/behavioral status, medical acuity and special needs will be reviewed prior to admission. The facility will also make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. Prevention of abuse, neglect and exploitation includes the identification, ongoing assessment, care planning for the appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. A review of the policy titled Notification of Changes, with reviewed/revised in January 2023 indicated Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status, or a transfer or discharge of the resident from the facility. This policy indicates that for competent individuals, the facility must still contact the resident's physician and notify resident's representative if known. For residents incapable of making decisions, the representative would make any decisions that need to be made. A review of the clinical record revealed R#20 was admitted to the fourth floor on 12/12/22 with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. The clinical record further revealed that on 1/29/23, R#20 was moved from the 400 Hall to the less secure unit on the 200 Hall and remained on that unit until discharged on 2/4/23. An interview with the Regional VP of Operations on 7/18/23 at 2:56 p.m. revealed the fourth floor is utilized for residents with cognitive or behavioral issues, such as wandering. The elevator on the fourth floor requires a code for the elevator doors to open, and to activate the elevator to go down. The first, second and third floor elevator doors will open without inputting a code and can be activated to go to the first floor without a code. Regardless of where the elevator accessed, a code is required to go up to all floors. A review of R#20's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as a six (the scale of 0-6 indicates the resident has severe cognitive impairment); that R#20 exhibited no mood or behavioral issues; no psychosis noted, and no behaviors exhibited; has limited assistance with bed mobility, transfer, walking in room, walking in corridor and locomotion; requires one-person physical assist for dressing, toileting, and personal hygiene; and needs supervision with eating. It was further noted that R#20 was not steady and only able to stabilize with staff assistance and does not use any mobility devices. The assessment noted that R#20 was receiving antidepressants. The discharge MDS dated [DATE] revealed R#20 was also receiving antipsychotics upon discharge. A review of discharge information from the previous skilled nursing facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needed placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Record review also revealed R#20 was not independent prior to admission to a previous facility and had been living with family. His discharge goal barriers included cognitive impairment and physical challenges, he was at risk for falls, and had been referred to therapy. Other goals included were to continue to monitor and readjust medications as needed. An interview on 7/18/23 at 2:45 p.m. with Occupational Therapist (OT) NNN revealed that residents with cognitive issues are usually housed on the fourth floor. The fourth floor is the only floor with elevators that require a password to open the elevator doors, and password to activate the elevator buttons to go up or down. The first, second and third floor elevators do not require a code to open the elevators doors or go down but do require a code to go up. Record review for R#20 revealed an initial psychiatric evaluation on resident on 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that R#20 had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation, and frequent reorientation to reality. A review of the provider notes for R#20 dated 2/1/23 revealed a post hospitalization status note for his return to the facility on 1/30/23 revealed and order for every 15-minute checks, and a new medication order for 25mg Seroquel every evening. The record revealed, Today resident is sitting up in bed, comfortable, denies pain. He is hard of hearing, confused at times, has difficulty following conversation and answering questions. The plan at readmission included, but was not limited to, dementia, continue on Razadyne, and for major depressive disorder, continue on Seroquel and Trazadone, continue to follow with psychiatry, and continue on every 15-minute checks for behaviors. A review of the progress notes for R#20 revealed that on 2/1/23 at 7:13 a.m. the resident was roaming in hallways and kept on close monitoring with every 15-minute checks. A review of the Psychiatric follow-up visits for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission and to consider Gradual Dose Reduction (GDR). Staff had reported resident to be alert, confused, forgetful, ambulates and is incontinent at times. The resident is also reported to continue wandering and is not manageable at times, difficult to redirect verbally and not as co-operative with care and medications. No suicidal or homicidal ideations. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote. Check testosterone level. Plan to consider Depo-Provera if the sexually inappropriate behavior continues. Provide cognitive social stimulation and frequent reorientation to reality, continue close monitoring. Behavioral interventions to include distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nursing note dated 2/4/23 at 11:30 a.m., revealed R#20 was on an every 15-minute observations related to behaviors. Record review for R#20 revealed that on 2/4/23 at 3:01p.m., The resident got on elevator and refused to get off. (R#20) went down to the first floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect (R#20). (R#20) requesting to leave the facility. R#20 spoke to the nurse, scheduler, and Doctor (Dr.) ZZZ, in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility against medical advice. During an interview with R#20's representative on 7/12/23 at 3:13 p.m. s/he stated that R#20's was put out of the facility with a garbage bag and a wheelchair. S/he stated that s/he was informed that R#20 signed a paper that was read to him. The R#20's representative stated that, when s/he examined the form, the signature that was on the form wasn't R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair and still was never told why R#20 was discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and because he was short of breath and the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin. S/he stated that the cousin then called them of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home from the apartment. R#20's representative stated that R#20 had been with them for less than a week and had to go to the hospital. S/he stated that R#20 was now residing in another facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. An interview on 7/12/23 at 3:50 pm. with Dr. ZZZ revealed that he was there on the day R#20 was discharged AMA. He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, he talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and that he told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ stated that upon leaving the facility, he saw R#20 going up the road, stopped and offered him some money, a ride, a call to Uber, or money to get a hotel room but R#20 refused. An interview with the Regional VP of Operations was conducted on 7/12/23 at 4:15p.m. revealed that R#20 had not had an appropriate discharge. An interview with Licensed Practical Nurse (LPN) HH on 7/12/23 at 4:45 p.m. revealed that she was the supervisor that weekend and revealed that R#20 was on every 15 minutes one-to-one watch related to the incident that occurred with the resident in January 2023. She could not recall what doctor was in the facility on 2/4/23 but does remember that it was a Saturday. She revealed that she saw R#20 leave the building and stated that the nurse on duty made the note regarding how R#20 left. LPN HH stated she had received training on handling difficult behaviors, dementia training, and AMA training. She stated that she was supposed to check what the residents BIMS score was if the resident wanted to sign out of the facility AMA, but she didn't check R#20's BIMS score because she was just the supervisor. A phone interview with CNA/Scheduler OO on 7/13/23 at 10:05 a.m. revealed that she was present but was unsure if she was the one who read the AMA form to R#20. She said that she was passing by and did not have much to do with the situation. She was not sure if she observed R#20 sign the AMA but was asked to sign the form because she was present. A phone interview was conducted on 7/13/23 at 6:15 p.m. with LPN CCC revealed that she was an agency nurse that had only worked one shift at the facility, she verified that she had worked on Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred with R#20 and stated that the resident had become adamant that he was going home and stated that he was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA paper to R#20. She stated that R#20 did sign the AMA form and that the doctor and she were standing in front of the door. Due to R#20 being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN stated that she did not see him leave with anyone or get in any car. It was determined that the temperature on 2/4/23 was between 34 degrees Fahrenheit and 46 degrees Fahrenheit. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23, at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to freedom from abuse and neglect, to review the findings for the IJ, and plan for removal of the IJ issues. 2. On?7/13/23,?the Center Director of Operations, DON, and Regional Director of Clinical Services reviewed the center policy?on Abuse, Neglect and Exploitation.? No changes or recommendations were made or given. 3. On 7/13/23, to identify other residents that may be affected by this practice, an 100% review of residents with known mood and behavioral problems with a verbal expression to leave the facility AMA were reviewed by the unit manager (a licensed nurse) of residents for the past 30 days (6/13/23 through 7/13/23) to ensure appropriate follow-up for care needs are provided and to ensure the necessary supervision is provided to prevent neglect and to provide a safe discharge for residents who express expressed a desire to leave the facility against the advice of the physician. Any resident found to have had a change in mood and behavior related to their desire to leave AMA without appropriate supervisions was investigated and corrective actions taken. 4. On 7/13/23, the UM (a licensed nurse) reeducated licensed nurses, CNA's, social services, dietary, environmental, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Currently there are 16 of 19 licensed nurses of which 88% have been educated; dietary six of seven (86%), activities staff two of two (100%); administration staff seven of eight (88%) , physician services four of four (100%), CNA's 10 of 11 (91%), CMA's four of four (100%), therapist eight of nine (89%) Respiratory Therapist two of three (67%), social services three of three (100%) and environmental services 13 of 13 (100%) staff have been reeducated. Staff members who did not attend the reeducation will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, department supervisor, or Charge Nurse. Newly hired clinical staff such as agency or as needed (PRN) staff will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 5. The Regional Director of Clinical Services reeducated the centers Interim DON, UM's, and MDS team on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. 6. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 7/14/23. 7. All corrective actions were completed on 7/14/23. 8. The facility alleges that the IJ was removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the sign-in sheet revealed a Plan of Correction (PoC) meeting was held on 7/13/23 with Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to freedom from abuse and neglect, to review the findings of the survey, and plan for removal of IJ issues. R#20 was verified as being discharged from the Center on 2/4/23. 2. A review of the sign-in sheet revealed on 7/13/23,?the Center Director of Operations, DON, and Regional Director of Clinical Services reviewed the center policy?on Abuse, Neglect and Exploitation and no changes or recommendations were made or given. 3. A review of the census revealed 100% audit was conducted on residents with known mood and behavioral problems with a verbal expression to leave the facility AMA were reviewed by the UM (a licensed nurse) of residents for the past 30 days (6/13/23 through 7/13/23) to ensure appropriate follow-up for care needs were provided and to ensure the necessary supervision is provided to prevent neglect and to provide a safe discharge for residents who express expressed a desire to leave the facility against the advice of the physician. 4. A review of sign-in sheets revealed staff were educated 7/13/23 on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. A total of 73 staff members was documented as being in attendance. The ad hoc sign-in sheet dated 7/13/23 revealed that the Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members were in attendance. Interview with Nurse Practitioner (NP) BBB on 7/17/23 at 1:52 p.m.; with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) AAA on 7/17/23 at 2:27 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m. It was confirmed thru interviews that they had attended an ad hoc meeting and was reeducated on Abuse, Neglect and Exploitation. 5. A review of sign-in sheet revealed Clinical Services reeducated the centers Interim DON, UM's, and MDS team on 7/13/23 on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge six staff members on attendance. This was confirmed by the DON during interview. During an interview with the DON on 7/17/23 at 4:10 p.m. and with LPN/UM AAA on 7/17/23 at 4:31 p.m. it was confirmed thru interviews that they had received reeducation on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge and that they had attended the emergency ad hoc in-service with the Regional Director of Operations. 6. A review of the sign-in sheet signatures revealed Ad Hoc Quality Assurance Performance Improvement Committee was conducted on 7/14/23 to review audits and findings. 7. All corrective actions were verified as being completed on 7/14/23. 8. The IJ was verified as being removed on 7/15/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident representative interviews, record reviews, and the facility policy titled Transfer and Discharge (including AMA), the facility failed to ensure one of 32 sampled residents (R) (R#20) had an appropriate discharge by ensuring the resident's cognitive level and mental status was appropriate for him to make an informed decision for self-discharging by signing an Against Medical Advice (AMA) form and exiting the facility. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record reviews, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: A review of the policy titled Transfer and Discharge (including AMA) with reviewed/revised date of January 2023 indicated: In cases of a resident desiring to be discharged AMA, the resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives of both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of the physician's notification should be entered in the nurses' notes by the nurses' department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protective Services, or other entity, as appropriate if self-neglect is suspected, and document accordingly. A review of the clinical record for R#20 revealed he was admitted to the fourth floor at the facility on 12/12/22 with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. It was noted that R#20 was moved from the fourth floor to a less secured unit on the second floor on 1/29/23 and remained on that unit until discharged from the facility on 2/4/23. A review of R#20's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as a six (the scale of 0-6 indicates the resident has severe cognitive impairment); exhibited no mood or behavioral issues; no psychosis was noted and no behaviors exhibited; required limited assistance from staff with bed mobility, transferring, walking in the room, walking in the corridor and locomotion; required one-person physical assistance from staff for dressing, toileting, and personal hygiene; requires needs supervision with eating (set up only). It was also noted that R#20 was not steady and only able to stabilize with staff assistance and does not use any mobility devices. At the time of this assessment, R#20 was receiving antidepressant medication. The discharge MDS dated [DATE] revealed he was also receiving antipsychotic medication. A review of the discharge information from the previous facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needs placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Record review also revealed the resident was not independent prior to admission to a previous facility and had been living with his family. His discharge goal barriers included cognitive impairment and physical challenges. He was determined a fall risk and had been referred to therapy. Interventions included to continue to monitor and readjust medications as needed. An interview on 7/18/23 at 2:45 p.m. with Occupational Therapist (OT) NNN revealed that residents with cognitive impairments are housed on the fourth floor, which is the only floor with elevators that require a password to open the doors and requires a password to activate the elevator buttons to go up or down. OT NNN confirmed that the first, second, and third floor elevators do not require a code to open the elevators doors or go down; those elevators only require a code to go up. An interview with the Regional [NAME] President of Operations on 7/18/23 at 2:56 p.m. revealed the fourth floor is utilized for residents with cognitive or behavioral issues, such as wandering. The elevator on the fourth floor requires a code for the elevator doors to open, and to activate the elevator to go down. The first, second and third floor elevator doors will open without inputting a code and can be activated to go to the first floor without a code. Regardless of where the elevator is accessed, a code is required to go up to all floors. A review of an initial psychiatric evaluation for R#20 dated 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that the resident had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation and frequent reorientation to reality. A review of the clinical record for R#20 revealed that on 2/1/23 at 7:13 a.m. the resident was roaming in hallways and kept on close monitoring with every 15-minute checks. A review of the clinical record for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission and to consider Gradual Dose Reduction (GDR). Staff had reported resident to be alert, confused, forgetful, ambulates and is incontinent at times. The resident is also reported to continue wandering and is not manageable at times, difficult to redirect verbally and not as co-operative with care and medications. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote. Check testosterone level. Plan to consider Depo-Provera if the sexually inappropriate behavior continues. Provide cognitive social stimulation and frequent reorientation to reality, continue close monitoring. Behavioral interventions to include distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nurses note dated 2/4/23 at 11:30 a.m., revealed that R#20 was continued every 15-minute observations related to behaviors. A review of the nurses note dated 2/4/23 at 3:01 p.m., revealed the following: The resident got on elevator and refused to get off. Patient went down to 1st floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect patient. Patient requesting to leave the facility. Patient spoke to the nurse, scheduler, and Doctor (Dr. ZZZ), in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility against medical advice. An interview was conducted with R#20's representative on 7/12/23 at 3:13 p.m. S/he stated that R#20 was put out with a garbage bag and a wheelchair. S/he stated that R#20 signed a paper that was read to him but when they reviewed the form, it was not R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair, and no one explained why R#20 had been discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and, because he was short of breath, the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin and the cousin then called them to inform of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home but less than a week later, R#20 had to be taken to the hospital. S/he also stated that R#20 was now in another skilled nursing facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. An interview on 7/12/23 at 3:50 pm. with Dr. ZZZ revealed that he was at the facility on that day R#20 was discharged . He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ ended the phone interview stating that upon leaving the facility, he saw R#20 going up the road and he stopped R#20 and offered him some money, a ride, a call to Uber, or money to get a hotel room. He stated that R#20 refused. During an interview with the Regional VP of Operations on 7/12/23 at 4:15p.m. they confirmed that R#20 had not had an appropriate discharge. An interview with Licensed Practical Nurse (LPN) HH on 7/12/23 at 4:45 p.m. revealed that she was the supervisor the weekend when R#20 was discharged and stated that R#20 was on every 15 minute one to one watch related to the incident that occurred with the resident in January 2023. She could not recall what doctor was in the facility that day but does remember that it was a Saturday. She revealed that she saw R#20 leave the building and stated that the nurse on duty made the note regarding how R#20 left. She confirmed that she had received AMA training and that she was supposed to check the residents BIMS score if the resident wanted to sign out of the facility AMA. She confirmed that she didn't check R#20's BIMS score because she was just the supervisor. A phone interview was conducted on 7/13/23 at 6:15pm, with LPN CCC revealed that she was an agency nurse that had only worked one shift and revealed that the one shift that she worked was on 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred. She stated that the resident had become adamant that he was going home and stated that he was growing more and more agitated. LPN NNN revealed that the doctor and herself read the AMA paper to R#20. She stated that R#20 did sign the AMA form. LPN NNN also stating that the doctor and herself were standing in front of the door, and due to the resident being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN stated that she did not see him leave with anyone or get in any car. LPN NNN confirmed that she had not spoken with R#20's representative prior to his AMA discharge. The facility implemented the following actions to remove the IJ: 1. An Ad hoc meeting was held on 7/13/23, at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to safe resident discharge, to review the findings for the IJ, and plan for removal of IJ issues. 2. R#20 discharged from the center on 2/4/23. 3. On?7/13/23,?the Center Regional Director of Operations, DON, and Regional Director of Clinical Operations reviewed the center policy?on Transfer and Discharge (including AMA). No changes or recommendations were made or given. 4. On 7/13/23, the Regional Director of Clinical Operations reeducated the DON on the importance of ensuring a safe, appropriate discharge process and procedures for residents with mood and behavior who express a desire to leave the facility against the medical advice of their physician to ensure the health and safety of residents and so that residents continue to receive necessary medical interventions upon discharge. 5. On 7/13/23, the UM (a licensed nurse) reeducated licensed nurses, certified nursing assistants, social services, dietary, environmental, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Currently there are 16 of 19 licensed nurses of which 88% have been educated; Dietary six of seven (86%), Activities staff two of two (100%); Administration staff seven of eight (88%), Physician Services four of four (100%), CNAs 10 of 11 (91%), CMAs four of four (100%), Therapist eight of nine (89%) RT two of three (67%), and Social Services three of three 100% have been reeducated. Any staff members who were not reeducated due to vacation, PRN (as needed) status, etc., will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, department supervisor, or Charge Nurse. Newly hired clinical staff such as Agency or PRN staff will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 6. To identify other residents with the potential to be affected by this practice, the DON or a Licensed Nurse reviewed 100% of AMA discharges from 2/4/23 through 7/13/23 to ensure residents with mood and behaviors who expressed a desire to leave the center against the advice of their physician were discharged safely. Any resident that was identified with mood and behavior expressing a desire to leave the center AMA responsible party was contacted to ensure continuity of care could be provided to establish or maintain safety of the resident. 7. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on 7/14/23. 8. All corrective actions were completed on 7/14/23. 9. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Record Review of the Plan of Correction (PoC) book revealed QAPI meeting minutes with signature sheet of staff in attendance for an Ad hoc QAPI meeting held on 7/13/23 with Medical Director, DON, UM, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members reviewed topics: concerns, Plan of Correction, and QAPI action items. Interview with Nurse Practitioner (NP) BB on 7/17/23 at 1:52 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) on 7/17/23 at 2:27 p.m. revealed they had all received the in-service on safe discharge. 2. Record review of the census list indicated R#20 was discharged from the facility on 2/4/23. 3. Record Review of the PoC book revealed the Regional Director of Operations, the DON, and the Regional Director of Clinical Operations reviewed and approved the policy and procedures on 7/13/23 related to Transfer and Discharge (including AMA) with no changes or recommendations made or given. 4. Record Review of the PoC book revealed record of in-service sheet dated 7/13/23 with the DON signature and educational materials attached indicated she received education related to safe discharge. Interview with the DON on 7/17/23 at 4:10 p.m. revealed she received education from the Regional Director of Clinical Services on behavior changes to notify physician's and responsible party and on safe discharge. 5. Record Review of PoC book revealed record of in-service sheet dated 7/13/23 with staff signatures and educational materials attached indicated the UM (a licensed nurse) reeducated licensed nurses, CNA's, social services, dietary, environmental, and facility administrative staff on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Interview with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m. Revealed they had been reeducated related to safe discharges. 6. Record Review of PoC revealed the DON and a Licensed Nurse reviewed 100% of AMA dated 7/13/23 listed discharges from 2/4/23 through 7/13/23. Interview conducted on 7/17/23 at 4:30 p.m. with LPN AAA reported she conducted the 100% AMA discharge audit. She reported they only had one resident (R#20) to discharge since 2/4/23. She confirmed she received education over the discharge process. She reported if a resident is not able to make decisions, they would be not allowed to sign out AMA. She reported they would notify the physician, family, and if necessary, the police. She reported they would not allow them to leave but keep them safe. 7. Interview conducted on 7/17/23 at 3:50 p.m. with the Regional Director of Operations reported that he reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee on 7/14/23. Record Review of PoC revealed QAPI Meeting Minutes dated 7/14/23 with signatures of staff in attendance and topics reviewed: Concerns included PoC and QAPI action items in addition to review of audits that were completed as a part of the removal plan and PoC. 8. All corrective actions was verified to have been completed on 7/14/23. 9. It was verified that the IJ was removed on 7/15/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident representative interviews, record reviews, and the facility policy titled Transfer and Discharge (including AMA), the physician failed to assess one of 32 sampled residents (R) (R#20) to ensure the resident's cognitive level and mental status was appropriate for him to make an informed decision for self-discharge by signing an Against Medical Advice (AMA) form and exiting the facility. On 2/4/23, the resident was allowed to sign an AMA form and then exited the facility without the knowledge or assistance from his representative or a discharge plan in place. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was unable to make safe self-care decisions. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record reviews, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: A review of the clinical record for R#20 revealed he was admitted to the facility on [DATE] with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#20 presented with a Brief Interview for Mental Status (BIMS) score of six. The scale of 0-6 indicates the resident has severe cognitive impairment. A review of the discharge information from the previous skilled nursing facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needs placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Further review revealed the resident was not independent prior to admission to the previous facility and had been living with family. His discharge goal barriers included cognitive impairment and physical challenges. He was determined a fall risk and had been referred to therapy. The interventions included to continue to monitor and readjust medications as needed. A review of an initial psychiatric evaluation for R#20 dated 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that the resident had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder; and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation, and frequent reorientation to reality. A review of the clinical record for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission, and to consider Gradual Dose Reduction (GDR). Staff had reported resident was alert, confused, forgetful, was able to ambulate, and was incontinent at times. The resident was also reported to continue to wander and was not manageable at times, difficult to redirect verbally, and not co-operative with care and medications. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations, or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote, check testosterone level, consider Depo-Provera if the sexually inappropriate behavior continues, provide cognitive social stimulation and frequent reorientation to reality, and to continue close monitoring. Behavioral interventions included distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nurses note dated 2/4/23 at 3:01 p.m., revealed the following: The resident got on elevator and refused to get off. (R#20) went down to first floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect (R#20). (R#20) requesting to leave the facility. Patient spoke to the nurse, scheduler, and Doctor (Dr. ZZZ), in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility (AMA). An interview was conducted with R#20's representative on 7/12/23 at 3:13 p.m. S/he stated that R#20 was put out of the facility with a garbage bag and a wheelchair. S/he stated that s/he was told that R#20 signed a paper that was read to him. R#20's representative stated that the form had a signature on it but that it wasn't R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair and still was never told why R#20 had been discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and because he was short of breath, the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin. S/he stated that the cousin then called them of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home from the apartment. R#20's representative stated that R#20 had been with them for less than a week and had to go to the hospital. S/he also stated that R#20 was now in another facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. A phone interview on 7/12/23 at 3:50 p.m. with Dr. ZZZ revealed that he was at the facility on that day R#20 was discharged . He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and he told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ ended the phone interview stating that upon leaving the facility, he saw R#20 going up the road and he stopped R#20 and offered him some money, a ride, a call to Uber, or money to get a hotel room. He stated that R#20 refused. A phone interview was conducted on 7/13/23 at 6:15 p.m., with License Practical Nurse (LPN) CCC. She revealed that she was an agency nurse that had only worked one shift at the facility and confirmed it was Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred. She stated that the resident had become adamant that he was going home and stated that R#20 was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA form to R#20. She stated that R#20 did sign the AMA form. LPN NNN also stating that the doctor and she were standing in front of the door, and due to the resident being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN confirmed that she had not spoken with R#20's representative prior to his AMA discharge. A phone interview with CNA/Scheduler OO on 7/13/23 at 10:05 a.m. revealed that she was present but was unsure if she was the one who read the AMA form to R#20. She said that she was passing by and did not have much to do with the situation. She was not sure if she observed R#20 sign the AMA but was asked to sign the form because she was present. A phone interview was conducted on 7/13/23 at 6:15 p.m. with LPN CCC revealed that she was an agency nurse that had only worked one shift at the facility, she verified that she had worked on Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred with R#20 and stated that the resident had become adamant that he was going home and stated that he was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA paper to R#20. She stated that R#20 did sign the AMA form and that the doctor and she were standing in front of the door. Due to R#20 being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN stated that she did not see him leave with anyone or get in any car. It was determined that the temperature on 2/4/23 was between 34 degrees Fahrenheit and 46 degrees Fahrenheit. A review of the policy titled Transfer and Discharge (including AMA) reviewed/revised in January 2023 indicated: In cases of a resident desiring to be discharged AMA, the resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives of both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of the physician's notification should be entered in the nurses' notes by the nurses' department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protective Services, or other entity, as appropriate if self-neglect is suspected, and document accordingly. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23 at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, Unit Managers (UM), Regional Director of Operations, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to physician services, to review the findings for the IJ and plan for removal of the IJ issues. 2. Physician CCC no longer serves as an attending physician for any residents at the center and is no longer a provider at the center. 3. R#20 discharged from the center on 2/4/23. 4. On 7/13/23, to identify other residents with the potential to be affected by this practice, an 100% review of residents with known mood and behavioral problems who express a desire to leave the facility against the advice of their physician was completed to ensure ongoing safety of residents who discharged from the center. Any resident identified will be assessed by the Medical Director. 5. On 7/13/23, the Regional Director of Operations, Chief Medical Officer, and Regional Director of Clinical Operations reviewed and reapproved the policy on Medical Staff Credentialing and Privileging. No changes or recommendations were made or given. 6. On 7/13/23, the Chief Medical Officer educated the Medical Director and attending providers on the policy on Physician Services, the importance of ensuring that residents receive appropriate supervision, and medically necessary physician services including participating in the assessment and care planning, monitoring changes in residents' medical status, and providing consultative treatment as needed for residents with mood and behaviors problems who express a desire to leave the center against the advice of their physician in order to ensure ongoing safety and a safe and orderly discharge. 7. Currently, there are four medical providers of which four Medical Providers (100%) were educated. 8. On 7/13/23, to identify other residents with the potential to be affected by this practice, the UM (a licensed nurse) conducted an 100% audit of residents who discharged AMA from 2/4/23 through 7/13/23, were reviewed for appropriate physician services prior to discharge. 9. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on 7/14/23. 10. All corrective actions were completed on 7/14/23. 11. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the Plan of Correction (PoC) book revealed that an ad hoc meeting was held on 7/13/23 with the following staff member present which included the Medical Director, MDS Coordinator, District Leader, Admissions Concierge, LPN UM, Wound Care Nurse, Dietary Manager, LPN, QOL Director, Social Service Director, DON, Human Resource Director, RN, Regional Director of Clinical Operations, VP of Clinical Operations. All staff listed had a signature on the Attendance Sheet. The ad hoc meeting was held on 7/13/23 to address the IJ concerns. The IJ was called on 7/13/23 at 2:19 p.m. The IJ concerns included Physician Services. Interview with Nurse Practitioner (NP) BBB on 7/17/23 at 1:52 p.m., with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) AAA on 7/17/23 at 2:27 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m., with the Director of Nursing (DON) on 7/17/23 at 4:10 p.m. revealed they had received the reeducation and was able to verbalized knowledge related to the training. 2. A review of the facility's tool titled Healing Medical Professionals revealed as of 7/13/23, at 7:43 p.m. Physician CCC had no residents in the facility assigned to his care. During an interview on 7/17/23 at 2:53 p.m. with the Interim Administrator, he revealed that the report was ran on 7/13/23 at 7:43 p.m. that Physician CCC no longer had any resident under his services at the facility. Administrator further stated that Physician CCC was not on staff prior to 7/13/23 and he was not sure of the last date of service. Administrator stated that he is not sure if there was a written notification provided or if the Medical Director gave Physician CCC verbal notification regarding his services at the facility. During an interview on 7/17/23 at 5:11 p.m. with VP of Operations revealed that Physician CCC's R#34 discharged from the facility on 2/9/23 and R#33 discharged from the facility on 2/11/23. He stated that these were the last two residents who were cared for under Physician CCC's services. He further stated that the Chief Medical Officer pulled Physician CCC from the facility's services per a verbal conversation on 2/21/23. 3. A review of the facility's tool titled Healing Census List revealed R#20 had an effective date of discharge from the facility on 2/4/23 at 3:05 p.m. 4. A review of the facility's tool titled Healing Daily Census Audit was conducted on 7/13/23 of all residents who were currently residing in the facility. A review of the audit revealed one resident was identified with increased behaviors and to be at risk of AMA. 5. A review of the facility's policy titled Medical Staff Credentialing and Privileging revealed that on 7/13/23 the policy was reviewed and reapproved with no changes or recommendations made. There were signatures for the Regional Director of Operations, DON, Regional Director of Clinical Operations, and Chief Medical Officer. 6. A review of the facility's tool titled Record of Service dated 7/13/23 revealed the Chief Medical Officer conducted an training titled Physician Services. The content contained the following information: It is important to ensure that residents receive appropriate supervision, and medically necessary physician services including participating in the assessment and care planning, monitoring changes in resident's medical status, and providing consultative treatment as needed for residents with mood and behaviors problems who express a desire to leave against the advice of their physician in order to ensure ongoing safety and a safe and orderly discharge. It is important to document to document your assessment of the resident and to include social services in residents who express a desire to leave the center against medical advice. In addition, the policies on Notification of Change, Abuse, Neglect and Exploitation, Transfer and Discharge Policy and Medical Staff Credentialing/Privileging were discussed. There were four providers listed on the in-service attendance sheet including two Physicians and two Nurse Practitioners. 7. A review of the facility's tool titled Record of Service dated 7/13/23 revealed the Chief Medical Officer conducted a training titled Physician Services. The content contained the following information: It is important to ensure that residents receive appropriate supervision, and medically necessary physician services including participating in the assessment and care planning, monitoring changes in resident's medical status, and providing consultative treatment as needed for residents with mood and behaviors problems who express a desire to leave against the advice of their physician in order to ensure ongoing safety and a safe and orderly discharge. It is important to document to document your assessment of the resident and to include social services in residents who express a desire to leave the center against medical advice. In addition, the policies on Notification of Change, Abuse, Neglect and Exploitation, Transfer and Discharge Policy and Medical Staff Credentialing/Privileging were discussed. 8. A review of the facility's tool revealed that LPN UM AAA conducted an 100% audit of residents who discharged from the facility AMA from 2/4/23 through 7/13/23. The audit concluded with only one resident, R#20, who discharged AMA during the timeframe. During an interview conducted on 7/17/23 at 4:30 p.m. with LPN AAA she reported she conducted the 100% AMA discharge audit. She reported they only had one residents R#20 to discharge since 2/4/23. She confirmed she received education over the discharge process. She reported if a resident is not able to make decisions, they would be not allowed to sign out AMA. She reported they would notify the physician, family, and if necessary, the police. She reported they would not allow them to leave but keep them safe. 9. A review of the PoC audits were reviewed and shared with the Ad Hoc QAPI Committee on 7/14/23 with staff members present including the Medical Director, MDS Coordinator, District Leader, Admissions Concierge, LPN UM, Wound Care Nurse, Dietary Manager, LPN, QOL Director, Social Service Director, DON, Human Resource Director, RN, Regional Director of Clinical Operations, VP of Clinical Operations. All staff listed had a signature on the attendance sheet. 10. All corrective actions were verified as being completed on 7/14/23. 11. The IJ was verified as being removed on 7/15/23.

Based on record review, review of the Nursing Home Administrator and Director of Nursing (DON) job descriptions, and staff interviews, the facility administration failed to effectively oversee the facility's discharge process resulting in an unsafe discharge for one of 32 sampled residents (R) (R#20). On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record reviews, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: The facility job description for Administrator revealed that the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The facility job description for DON revealed that the position purpose is planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents.' Facility Administration, specifically the Administrator and DON, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to ensure the resident representative was notified of an increase in R#20's mood and behaviors and failed to notify the resident's representative of resident signing an AMA and was being discharged from the facility. Cross refer to F580. 2. Administration failed to ensure that R#20 was protected from neglect by facility staff. Cross refer to F600. 3. Administration failed to ensure a safe and orderly discharge from the facility for R#20. Cross refer to F624. 4. Administration failed to ensure that R#20 was medically evaluated, supervised, and monitored by the Physician. Cross refer to F710. An interview on 7/12/23 at 4:15 p.m. with the Regional Director of Operations (acting as interim Administrator) revealed R#20 was not appropriately appropriate discharge. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23, at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, Unit Managers (UM), Regional Director of Operations, [NAME] President of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to administration to review the findings for the IJ and plan for removal of the IJ issues. 2. R#20 was discharged from the center on 2/4/23. 3. On?7/13/23,?the Center Regional Director of Operations, Chief Medical Officer, and Regional Director of Operations reviewed the center policies?on Notification of Change, Abuse and Neglect, and Transfer, Discharge (including AMA).? No changes or recommendations were made or given. 4. On 7/13/23, the Regional Director of Clinical Services reeducated the center's administration to include Nursing Administration, Social Services on the importance of implementing effective processes for residents with mood and behaviors who express a desire to leave the center against the medical advice of their physician to ensure family/responsible party is notified, implementing care consistent with the resident's care plan, and to arrange a safe and orderly discharge. Education included making sure nursing staff is knowledgeable about safe discharge practices. 5. On 7/13/23, the UM (a licensed nurse) reeducate licensed nurses, Certified Nursing Assistants (CNA's), social services, dietary, environment, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Education was also conducted to licensed nurses on the importance of notifying the responsible party/family member of residents with mood and behaviors who expressed a desire to leave the center against the medical advice of their physician. Education was also conducted on providing a safe and orderly discharge for residents with mood and behavioral problems to ensure ongoing safety and to provide continuity of care after discharge to the facility staff. Currently there are 16 of 19 licensed nurses of which 88% have been educated; dietary staff six of seven (86%), activities staff two of two (100%); administration staff seven of eight (88%), physician services four of four (100%), CNAs 10 of 11 (91%), Certified Medication Assistants (CMAs) four of four (100%), therapist eight of nine (89%), Respiratory Therapist two of three (67%), social services three of three 100% and environmental services 13 of 13 (100%) of staff have been educated. Any staff members who were not reeducated due to vacation, as needed (PRN) status, etc., will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, department supervisor, or Charge Nurse. Newly hired clinical staff such as agency or PRN staff will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 6. On 7/13/23, the Regional Director of Clinical Services educated the DON on addressing behaviors changes that can lead to unsafe resident discharges. Education also included responsible party notification and physician notification of change in behaviors. 7. On 7/13/23, the Regional Director of Operations reviewed job descriptions for Administrator and DON to ensure that they understand their duties and responsibilities. Review shows that Administrator and DON can carry out their job duties. 8. The Regional Director of Operations reviewed the results of the findings from the facility's oversight and shared the findings with the Ad Hoc QAPI Committee on 7/14/23. The Regional Director of Operations will share the findings of audits related to proper notification to responsible parties and/or legal representatives with the QAPI Committee. 9. All corrective actions were completed on 7/14/23. 10. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the ad hoc sign-in form dated 7/13/23 revealed that the Medical Director, Center Nurse Practitioner, Director of Nursing, Unit Managers, Regional Director of Operations for Georgia, [NAME] President of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members had attended the meeting. Interviews with Nurse Practitioner (NP) BBB on 7/17/23 at 1:52 p.m., with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) AAA on 7/17/23 at 2:27 p.m., Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m., DON on 7/17/23 at 4:10 p.m. revealed they had received education on the five IJ citations and was able top verbalize the information revealed in the training. 2. A review of electronic health records revealed R#20 left the facility AMA on 2/4/23. A review of PoC book revealed the facilities census list indicated discharge date of 2/4/23 for R#20. 3. A review of PoC book revealed Regional Director of Operations, DON, and Regional Director of Clinical Operations reviewed and approved the Transfer and Discharge (including AMA) policy and procedures on 7/13/23 and there were no changes or recommendations made or given. 4. A review in-service sheet dated 7/13/23 revealed the Regional Director of Clinical Services reeducated the center's administration to include Nursing Administration, Social Services on the importance of implementing effective processes for residents with mood and behaviors who express a desire to leave the center against the medical advice of their physician to ensure family/responsible party is notified, implementing care consistent with the resident's care plan, and to arrange a safe and orderly discharge. Education included making sure nursing staff is knowledgeable about safe discharge practices. 5. A review of the in-service sheet dated 7/13/23 with staff signatures and educational materials attached indicated the UM (a licensed nurse) reeducated licensed nurses, CNA's, social services, dietary, environmental, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Interview with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m. revealed they had received the in-serviced by the Director of Nursing and Regional Director of Clinical Operations and were able to verbalize knowledge and understanding. 6. A review of sign in sheet dated 7/13/23 revealed an in-service conducted by the Regional Director of Clinical Services provided to the DON. Interview with the DON on 7/17/23 at 4:10 p.m. revealed she received education from the Regional Director of Clinical Services on behavior changes to notify physician's and responsible party on 7/13/23. 7. A review of the job description for the Administrator and DON revealed that it was reviewed by the Regional Director of Operations on 7/13/23 to ensure that they understand their duties and responsibilities. Review shows that Administrator and DON can carry out their job duties. 8. Interview conducted on 7/17/23 at 3:50 p.m. with the Regional Director of Operations reported that he reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee on 7/14/23. A review of the PoC revealed QAPI Meeting Minutes dated 7/14/23 with signatures of staff in attendance and topics reviewed: Concerns, PoC, and QAPI action items in addition to review of audits that were completed as a part of the removal plan and plan of correction. 9. All corrective actions were verified to have been completed on 7/14/23. 10. It was verified that the IJ was removed on 7/15/23.