**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the accuracy of the comprehensive assessment addressed the wandering behaviors for one of 30 sampled residents (R) (R1). R1's wandering led to physical altercations with multiple residents, including a physical altercation on 1/25/2024 when R1 wandered into R12's room and R12 pushed R1, causing R1 to sustain a fracture of the left elbow. On 2/28/2024, 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 Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. 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 3/2/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing abuse in the facility. Findings included: A review of the clinical record for R1 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to adjustment disorder with depressed mood, psychotic disorder with delusions due to known physiological diagnosis, and dementia with agitation. A review of the quarterly MDS assessment dated [DATE] revealed R1 presented with a BIMS score of three, indicating that the resident had severe cognitive impairment, R1 was independent in mobility. The assessment documented that R1 did not exhibit any wandering behaviors. A review of the clinical record and other facility documents revealed the following incidents of resident-to-resident altercations: A review of the progress notes documented by Licensed Practical Nurse (LPN) KKKK dated 9/30/2023 revealed that R17 was involved in a resident-to-resident altercation. It was documented that R17 was slapped by R1, a male resident; R17 was removed from immediate danger; and LPN KKKK observed redness to right of R17's face. A review of the progress notes documented by LPN FFFF dated 9/30/2023 revealed R1 slapped R17. When R18 attempted to intervene, R1 hit R18 and R19. Staff intervened. A review of the written statement of Certified Nursing Assistant (CNA) LLLL dated 9/30/2023 revealed that she observed R1 being physically aggressive towards other residents. She stated that R1 picked up a chair and an unknown resident grabbed the chair from R1, R1 fought R18 outside the breakroom, and that R1 was the aggressor. A review of the written statement of CNA MMMM dated 9/30/2023 revealed that she heard residents shouting in the dining room. She stated that some residents were stating that R1 grabbed R17's hair and slapped her. CNA MMMM stated that she was unable to calm R1 and R1 continued fighting, striking R18 before he was subdued and placed in his room. A review of the facility investigation summary written by the Director of Nursing (DON) dated 9/30/2023 revealed that R17 was seated in the common area in her wheelchair; R1 walked up to R17 and slapped R17 across her face unprovoked; and R18 and R19 attempted to intervene and R1 struck R18 and R19. The DON documented R1 directed his aggression towards staff when staff intervened and was not redirectable. Police were notified and R1 was hospitalized for three days. A review of the written statement of LPN GGGG dated 10/23/2023 revealed that R1 wandered into R12's room, and an argument occurred; and R1 was scratched by R12 on his hands. LPN GGGG documented that she cleansed R1 with nontoxic cleansing solution and notified the Unit Manager. A review of the progress notes documented by LPN IIII dated 11/13/2023 revealed he notified the police department following a verbal altercation between R1 and R16. LPN IIII documented he heard R16 yelling at R1 to get out of R16's room. A review of the facility incident report dated 11/19/2023 revealed that LPN YY documented R1 was exhibiting aggressive behavior; R22 came to get a snack at the nurses' station; and R1 slapped R22, stating that R22 got too close. A review of the progress notes documented by LPN IIII dated 12/13/2023 revealed R1 wandered into R12's room and attempted to pull R12 out of bed by her wrists. Staff immediately intervened and assisted R1 out of the room. A review of the progress notes documented by LPN JJJJ dated 1/25/2024 revealed R1 wandered into R12 room and R12 pushed R1. R1 fell and sustained a fracture of the left elbow. During an observation on 2/20/2024 at 2:30 pm showed R1 walked along the hallway of the third floor with his head facing down. R1 continued pacing along the hallway in the locked unit. During an interview 2/26/2024, at 1:44 pm the DON stated R1 was not cognitively intact and that R1 wanders into resident rooms. The DON stated that the staff constantly had to redirect R1 and that R1 had been involved in resident-to-resident altercations when he wandered into other residents' rooms. During an observation on 2/26/2024 at 3:15 pm, R1 was not in his room and an attempt to locate him was unsuccessful. Approximately five to six minutes later, CNA FFF located R1 in R20's room. During an interview at this time, R20 stated R1 was in his room messing with his table. R20 stated his attempts to make R1 leave were unsuccessful. R20 stated on numerous occasions staff had to help remove R1 from his room. R20 further stated that no one likes to be around R1 and that he was afraid that R1 was going to continue to be physically abusive towards other residents. R20 stated he was afraid R1 would eventually get hurt by other residents. During an interview on 2/27/2024 at 1:23 pm, CNA DDD revealed R1 had dementia and was a wanderer and that the DON instructed staff to continue redirecting R1 when he gets into other residents' rooms. CNA DDD stated that they always heard female residents in the unit yelling at R1 to leave their rooms. During an interview on 2/27/2024 at 1:40 pm, CNA EEE revealed that R1 did not like to stay in his room. CNA EEE stated R1 walked continuously around the unit. During an interview on 2/27/2024 at 4:33 pm, the Physician Assistant (PA) QQ revealed she was aware R1 had behaviors and was physically aggressive towards other residents. She stated R1 wanders into other residents' rooms and has trouble sleeping so they made some medication adjustments and non-pharmacological interventions such staff redirecting R1 to his room. During an interview on 2/27/2024 at 4:33 pm, Nurse Practitioner (NP) RR revealed that she had worked with R1 and visits with him monthly. NP RR stated R1 was ambulatory, walked freely around the secured memory unit and went into other resident rooms. The facility implemented the following actions to remove the IJ: 1. On 2/28/2024, R1's MDS and care plan was updated to reflect the behavior of wandering. 2. On 2/29/2024, an Ad Hoc QAPI meeting was held with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan. The MDS/Care Plan policy was reviewed with no changes. 3. On 2/29/2024, the Corporate Nurse Consultant conducted an in-service with the three of three MDS department staff and one of two Social Services department staff on the MDS/Care plan Policy and how to develop a comprehensive care plan. 4. On 2/29/2024, a Wandering MDS and Care Plan Audit was completed on the secure unit. A total of 35 of 63 residents were identified as wanderers and care plans were updated to reflect the behavior of wandering. 5. On 2/29/2024, a behavior management meeting was held with the MDS Director, two MDS Coordinators, and the Social Services Director. They were provided with a copy of all residents involved in resident-to-resident altercations from September 2023 through current and care plans were reviewed for those that wander. Care plans were updated as necessary to reflect individualized interventions. 6. The corrective actions were completed on 3/1/2024 and facility alleges that immediate jeopardy is removed on 3/2/2024. All corrective actions were completed on 3/1/2024. The facility alleges that the IJ is removed on 3/2/2024. 1. A review of the MDS assessment and care plans showed, the MDS and care plans were updated for Residents with behaviors and for wandering residents. Staff were educated on 2/29/2024 and interventions were put in place. The following interviews verified; facility interventions were in place: During an interview on 3/6/2024 at 1:57 pm, the SSD revealed she completed an in-service on 2/29/2024, which was conducted by the staff development coordinator. The topics discussed included care plans. SSD expected the MDS coordinator to update care plans in a timely manner. SSD stated, care plans should be updated to include wandering behaviors. The interdisciplinary team (IDT) was responsible for care plan updates. SSD was part of the IDT. SSD stated Abuse and Care plan In-service's will be ongoing. 2. A review of the sign in sheet revealed that the QAPI Meeting was held on 2/29/2024 with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan. The MDS/Care Plan policy was reviewed with no changes. During an interview on 3/5/2024 at 12:46 pm, NC NN revealed on 2/29/2024, she educated the Administrator, DON, and SSD regarding monitoring residents behaviors including verbally aggressive behavior and physically aggressive behavior. NC NN stated that the QAPI policy was reviewed, she talked to the MDS- Coordinator regarding comprehensive care plans. She identified the care plan was not updated on other occasions. Discussed staff the care plan should be updated as soon as an incident or behavior is identified. Documentation revealed staff were educated. 3. A review of the policy education to staff, QAPI minutes and Resident to Resident documentation audit was conducted and was completed as outlined in the plan. During an interview on 3/5/2024 at 11:56 am, ADON revealed all staff received the education. During an interview on 3/5/2024 at 12:46 pm, Nurse Consultant NN stated the QAPI policy was reviewed, she talked to the MDS- Director MM regarding comprehensive care plans on 2/29/2024. During an interview on 3/5/2024, at 1:13 pm, MDS coordinator MMM, confirmed that education was received related to MDS and Care Plans. During an interview on 3/6/2024 at 1:14 pm, the administrator revealed she attended a personalized additional computerized education. During an interview on 03/07/2024 at 1:25 pm, with the MDS Coordinator EEEE, confirmed that education was received related to MDS and Care Plans. During an interview on 03/07/2024 at 1:45 am MDS director/ RN, MM. NN educated all MDS staff on 2/29/2024 in her office. 4. During an interview on 3/5/2024, at 1:13 pm, MDS coordinator MMM, revealed care plans are updated quarterly, annually, whenever there was a significant change and whenever an incident happened. She was part of a facility wide in service. Review of the wandering Care Plan Audit revealed that it was completed on the secure unit. A total of 35 of 63 residents were identified as wanderers and care plans were updated to reflect the behavior of wandering. 5. A review of the sign in sheet revealed that on 2/29/2024, a behavior management meeting was held with the MDS Director, two MDS Coordinators, and the Social Services Director. 6. It was verified that the corrective actions were completed by 3/1/2024 and the immediate jeopardy was removed on 3/2/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure eight of 30 sampled residents (R) (R16, R17, R19, R12, R1, R18, R30 and R22) were free from abuse. On 2/28/2024, 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 Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. 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 3/2/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing abuse in the facility. Findings included: A review of the facility Abuse Prevention Policy dated 9/5/2016 and last revised 11/1/2021 documented the following: The resident has the right to be free from verbal, sexual, physical, and mental abuse including corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. The facility has a zero-tolerance abuse standard regarding all proven allegations of verbal, sexual, physical, mental, neglect, misappropriation of resident property and involuntary seclusion. Abuse means, willful infliction of injury unreasonable confinement intimidation or punishment including physical harm pain or mental anguish. And this also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being abuse maybe resident to resident, staff to resident, family to resident, or visitor to resident. 1. A review of the clinical record for R16 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to alcohol abuse dependence, vascular dementia with psychotic disturbance, and adjustment disorder. A review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed R16 presented with a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. 2. A review of the clinical record for R17 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to mood disorder due to known physiological diagnosis, delusional disorder, and anxiety disorder. A review of the quarterly MDS assessment dated [DATE] revealed R17 presented with a BIMS score of 15, indicating that the resident was cognitively intact; R17 required staff supervision and oversight for dressing, eating, bathing and toileting; and R17 was independent in mobility. 3. A review of the clinical record for R19 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to adjustment disorder, a history of alcohol abuse, and a history of falling. A review of the quarterly MDS assessment dated [DATE] revealed R19 presented with a BIMS score of 15, indicating that the resident was cognitively intact. 4. A review of the clinical record for R12 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to major depressive disorder, schizoaffective disorder, and dementia without behavioral disturbance. A review of the annual MDS assessment dated [DATE] revealed R12 presented with a BIMS score of 13, indicating that the resident had mild cognitive impairment; R12 required staff supervision and oversight for dressing, eating, bathing and toileting; and R12 was independent in mobility. 5. A review of the clinical record for R1 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to adjustment disorder with depressed mood, psychotic disorder with delusions due to known physiological diagnosis, and dementia with agitation. A review of the quarterly MDS assessment dated [DATE] revealed R1 presented with a BIMS score of 3, indicating that the resident had severe cognitive impairment; R1 required staff supervision and oversight for dressing, eating, bathing and toileting; and R1 was independent in mobility. 6. A review of the clinical record for R18 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to vascular dementia, psychotic disturbance, mood disturbance, and difficulty walking. A review of the discharge MDS assessment dated [DATE] revealed R18 presented with a BIMS score of 3, indicating that the resident had severe cognitive impairment; and R18 required staff assistance with activities of daily living. 7. A review of the clinical record for R30 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to spinal stenosis (when the space inside the backbone is too small), unsteadiness on feet, repeated falls, and cognitive communication deficit. A review of the quarterly MDS assessment dated [DATE] revealed R30 presented with a BIMS score of 7, indicating that the resident had severe cognitive impairment; and R30 required staff assistance with activities of daily living and used a wheelchair. 8. A review of the clinical record for R22 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to cognitive communication deficit, liver disease, and difficulty walking. A review of the discharge MDS assessment dated [DATE] revealed R22 presented with a BIMS score of 12, indicating that the resident had mild cognitive impairment; and R22 was independently mobile and did not require assistance with activities of daily living. A review of the clinical record, observations, and interviews revealed the following incidents of resident-to-resident abuse: A review of the progress notes documented by Licensed Practical Nurse (LPN) KKKK dated 9/30/2023 revealed that R17 was involved in a resident-to-resident altercation. It was documented that R17 was slapped by R1, a male resident; R17 was removed from immediate danger; and LPN KKKK observed redness to right of R17's face. A review of the progress notes documented by LPN FFFF dated 9/30/2023 revealed R1 slapped R17. When R18 attempted to intervene, R1 hit R18 and R19. Staff intervened. A review of the written statement of Certified Nursing Assistant (CNA) LLLL dated 9/30/2023 revealed that she observed R1 being physically aggressive towards other residents. She stated that R1 picked up a chair and an unknown resident grabbed the chair from R1, R1 fought R18 outside the breakroom, and that R1 was the aggressor. A review of the written statement of CNA MMMM dated 9/30/2023 revealed that she heard residents shouting in the dining room. She stated that some residents were stating that R1 grabbed R17's hair and slapped her. CNA MMMM stated that she was unable to calm R1 and R1 continued fighting, striking R18 before he was subdued and placed in his room. A review of the facility investigation summary written by the Director of Nursing (DON) dated 9/30/2023 revealed that R17 was seated in the common area in her wheelchair; R1 walked up to R17 and slapped R17 across her face unprovoked; and R18 and R19 attempted to intervene and R1 struck R18 and R19. The DON documented R1 directed his aggression towards staff when staff intervened and was not redirectable. Police were notified and R1 was hospitalized for three days. A review of the written statement of LPN GGGG dated 10/23/2023 revealed that R1 wandered into R12's room, and an argument occurred; and R1 was scratched by R12 on his hands. LPN GGGG documented that she cleansed R1 with nontoxic cleansing solution and notified the Unit Manager. A review of the progress notes documented by LPN IIII dated 11/13/2023 revealed he notified the police department following a verbal altercation between R1 and R16. LPN IIII documented he heard R16 yelling at R1 to get out of R16's room. A review of the facility incident report dated 11/19/2023 revealed that LPN YY documented R1 was exhibiting aggressive behavior; R22 came to get a snack at the nurses' station; and R1 slapped R22, stating that R22 got too close. A review of the progress notes documented by LPN IIII dated 12/13/2023 revealed R1 wandered into R12's room and attempted to pull R12 out of bed by her wrists. Staff immediately intervened and assisted R1 out of the room. A review of the progress notes documented by LPN JJJJ dated 1/25/2024 revealed R1 wandered into R12 room and R12 pushed R1. R1 fell and sustained a fracture of the left elbow. During an observation and interview on 2/20/2024 at 1:30 pm, R17 was observed in her room. When interviewed, she was unable to recall the events on 9/30/2023. R17 stated she does not want male residents in her room. During an observation on 2/20/2024 at 2:30 pm, R1 was observed unsupervised and independently ambulating back and forth in the hallway on the third-floor secured memory unit with his head facing down. During an interview on 2/21/2024 at 2:55 pm, R31 revealed that he is afraid of R1 and that R1 always comes into his room and sits on his bed without his permission. He stated that he has to wait for several hours before staff come in to redirect R1. During an interview on 2/26/2024 at 1:44 pm the DON stated R1 was not cognitively intact and wanders into other resident rooms. The DON stated that staff must constantly redirect R1 and confirmed that R1 has been involved in multiple resident-to-resident altercations when he wandered into other residents' rooms. The DON stated R1 was not intentionally aggressive towards other residents but R1 was involved in three or four physical altercations with other residents due to his wandering. The DON stated that R1 was referred to receive psych services and is being seen by a consultant once every quarter as an intervention. During an observation on 2/26/2024 at 3:15 pm, R1 was not in his room and an attempt to locate him was unsuccessful. Approximately five to six minutes later, CNA FFF located R1 in R20's room. During an interview at this time, R20 stated R1 was in his room messing with his table. R20 stated his attempts to make R1 leave were unsuccessful. R20 stated on numerous occasions staff had to help remove R1 from his room. R20 further stated that no one likes to be around R1 and that he was afraid that R1 was going to continue to be physically abusive towards other residents. R20 stated he was afraid R1 would eventually get hurt by other residents. A review of the progress notes documented by LPN TT dated 2/26/2024 revealed that R1 was wandering through hallway and LPN TT observed an altercation between R1 and R30. LPN TT documented that R30 yelled at R1 and pushed R1; R1 retaliated and hit R30 in the face; R1 was immediately separated by staff, assessed for injury, no noted injury; and the family and physician were notified. During an interview on 2/27/2024 at 9:34 am, the administrator stated she was aware of R1's aggression when she came on board at the facility in September 2023. She stated R1's aggressive behavior was discussed in meetings with the Medical Director on several different occasions. She confirmed that the facility was unable to assign a staff member to the resident for one-to-one supervision. During an interview on 2/27/2024 at 1:23 pm, CNA DDD revealed R1 had dementia and was a wanderer. They further stated the DON instructed staff to continue redirecting R1 when he gets into other residents' rooms. They confirmed that there was never an assigned staff to manage R1's behavior. CNA DDD stated that they always hear female residents in the unit yelling at R1 to leave their rooms. During an interview on 2/27/2024 at 1:30 pm LPN TT revealed on 2/26/2024 at approximately 7:30 pm, they noticed R30 was irritable and then R30 pushed R1, causing R1 to stumble back. They stated that R1 then swung and hit R30 on the face. LPN TT stated the incident happened at the nurse's station which was located a few feet from R30's room. R30 stated he was fed up with R1 messing with his possessions. TT instructed staff to continue redirecting R1. TT stated redirection was the only intervention staff had been successfully implemented by the facility. TT stated most of the residents in the locked unit were unbale to verbalize their concerns and it was normal for the residents to retaliate when confronted. TT stated there were sixty-four residents in the locked unit. During an interview on 2/27/2024 at 1:40 pm, CNA EEE revealed that R1 did not like to stay in his room and walked continuously around the unit. CNA EEE stated that R1 gets aggressive and violent when other residents confront him and that she would hate to see R1 get hurt by other residents. CNA EEE confirmed that R1 is not always supervised and that it was impossible for the staff to continuously watch all the residents. During an interview on 2/27/2024 at 4:33 pm, the Physician Assistant (PA) QQ revealed she was aware R1 had behaviors and was physically aggressive towards other residents. She stated R1 wanders into other residents' rooms and has trouble sleeping so they made some medication adjustments and non-pharmacological interventions such staff redirecting R1 to his room. PA QQ stated she advised staff to leave R1 alone when R1 gets agitated and to attempt to reapproach later. During an interview on 2/27/2024 at 4:33 pm, Nurse Practitioner (NP) RR revealed that she had worked with R1 and visits with him monthly. NP RR stated R1 was ambulatory, walked freely around the secured memory unit and went into other resident rooms. NP RR stated they were aware that R1 has had resident-to-resident altercations and confirmed that R1 required closer surveillance. They stated that the most plausible way for that to happen is to increase staff on the unit. During an interview on 2/27/2024 at 6:49 pm, R1's representative revealed R1 used to walk continuously on his previous job. She stated that R1 enjoyed exercise and was unable to sit down for long periods, but over the last two years, R1 has been unable to hold a conversation and his confusion has progressed. She stated that she visited R1 on 2/24/2024 and staff took approximately five minutes to locate R1. She said that when the staff found R1, he was in another resident's bathroom. She stated that she was unaware of an action plan staff implemented to stop R1 from roaming and wandering in other resident rooms. The facility implemented the following actions to remove the IJ: 1. On 2/26/2024, R1 was assessed by the Psych Physician Assistant per physician order. On 2/27/2024, a skin assessment was conducted on R1 with no skin alterations noted. On 2/28/2024, the Corporate Operations Consultant, the Administrator and the Social Services Director met to discuss placement options for the R1. On 2/28/2024 at 9:00 pm, the R1 was transferred to a Psychiatric Facility per the physician order. The facility Social Worker will assist the Psychiatric facility with finding placement for R1. On 2/29/2024, an immediate discharge notice was issued to R1 and R1's legal representative. 2. On 2/29/2024 the Behavioral Health Physician's Assistant, the facility's Psychiatric provider, the Administrator, the Director of Nursing Services, and Corporate Operations Consultant had a telephone conference to discuss alternate placement for current of future residents that may present to be a danger to self or others. 3. On 2/29/2024, an Ad Hoc QAPI meeting was held with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan, altercations involving R1 and alternate placement of R1. The Abuse Policy and the Behavior Management Policy were reviewed, and no changes were made. 4. On 2/29/2024 and 3/1/2024, the Staff Development Coordinator educated the following facility staff on the Abuse Policy, the Behavior Management Policy, and Resident to Resident Altercation Policy: three of four Registered Nurses; 21 of 22 Licensed Practical Nurses; 17 of 17 Medication Technician; the Activity Director, three of three Activity Assistants; 33 of 33 Certified Nursing Assistants; the Administrator; the Human Resources Director; the Admissions Director; the Marketing Director; four of four receptionists; the Business Office Manager; the Business Office Assistant, two of two Medical Records Coordinators; the Dietary Manager; 13 of 13 Dietary Assistants; the Housekeeping/ Laundry Director; the Maintenance Director; the Maintenance Assistant; the Laundry Supervisor; 11 of 11 Environmental Employees; the Therapy Director; three of three therapy assistants; the Social Services Director; two of two Social Services Assistants; the MDS Director; and two of two MDS Coordinators. In-services will be conducted on an ongoing basis by the Staff Development Coordinator and nurse managers. Agency staff will be educated on the facility policies prior to working in the facility. Those employees identified to be on LOA or FMLA will be in-serviced upon return, prior to their shift. All new employees will be in-serviced during the facility orientation. 5. On 3/1/2024, a Skin Assessment Audit was conducted by the nurse management team for 63 of 63 residents on the secured memory unit. There were no new areas of concern identified. 6. The corrective actions were completed on 3/1/2024 and facility alleges that immediate jeopardy is removed on 3/2/2024. All corrective actions were completed on 3/1/2024. The facility alleges that the IJ is removed on 3/2/2024. 1. Review of notes taken revealed three facility physicians and the Medical Director and Corporate Operations Consultant, DON and the Administrator met and discussed placement options for R1. A review of the physician's order dated 2/29/2024 revealed that R1 was transferred to a Psychiatric Facility. 2. During an interview on 3/6/2024 at 6:45 pm the Medical Director (MD) revealed he attended a QAPI meeting on 2/29/2024 and they discussed placement for R1 and other residents with behaviors in the future. 3. During an interview on 3/5/2024 at 1:13 pm, the Corporate Nurse NN confirmed that they educated MDS staff regarding abuse, behaviors were discussed regarding who staff should notify and making sure the residents were safe and notifying the proper authorities' doctors and families. During an interview on 3/7/2024 at 10:25 am Corporate Operations Director (COD) HH revealed the Administrator, Medical Director DON, SSD, MDS Director were educated regarding the immediate jeopardy concerns. HHH stated QAPI staff will be tracking trends, and she will be reviewing abuse logs monthly. HHH stated, Nurse Consultant, will be monitoring incidents and accidents. HH stated, R1 will not be returning to the facility. R1 was given an immediate discharge notice, and the facility is assisting R1 in finding alternative placement. 4.On 3/5/2024 at 2:15 pm, RN KKK Infection Preventionist and educator revealed she educated staff and in serviced all nursing and non-nursing staff on Resident-to-Resident altercations, behaviors, care plans and abuse and neglect reporting on 2/29/2024. RN, KKK, stated the in-service will be ongoing, which will include new hires. Record review showed a total of fifty-six staff were interviewed from 3/5/2024 through 3/6/2024, which included Nursing staff, Dietary staff, housekeeping staff, laundry staff, Maintenance staff, Reception staff and Management staff. Signatures and interviews verified staff were in serviced on 2/29/2024 by RN KKK. On 3/5/2024 the following clinical staff were interviewed: LPN KKK at 2:15 pm; LPN RRR at 7:04 pm; CNA HHH at 1:30 pm; CNA III at 1:38 pm; CNA JJJ at 1:49 pm.; CNA EEE at 1:56 pm; CNA AAA at 2:03 pm; CNA SSS at 7:15 pm. On 3/6/2024 the following clinical staff were interviewed: HK OOO at 2:38 pm; Laundry Aide PPP at 3:03 pm; HK Director QQQ at 3:04 pm; Dietary [NAME] LLL at 3:20 pm; Dietary [NAME] UUU at 2:32 pm; Business Office WWW at 2:05 pm; PTA XXX at 2:19 pm; COTA YYY at 2:23 pm; Human Resources ZZZ at 2:26 pm; Activity Aide AAAA at 2:35 pm; and CMT DDDD at 3:28 pm. 5. Record review revealed skin observations audit was conducted on 3/1/2024, of the sixty-three residents assessed one resident refused to be assessed and two residents were actively being seen by a wound care nurse. During an interview on 3/6/2024 at 1:14 pm, The administrator revealed she attended a personalized additional computerized education. In addition, the NC-NN in-serviced the Medical Director (MD), DON, SSD, Staff Development Coordinator (SDC) regarding QAPI review and ongoing quality assurance performance and improvement, which included wandering residents and residents with aggressive behaviors. For residents with repetitive aggressive behaviors, one staff will be instructed to supervise the resident until the behavior improves other services such as psych services will be provided. She stated Care plans should be updated immediately as soon as an incident arises, and an IDT will make a follow up, assessment All staff were educated regarding abuse and behavioral monitoring. New staff will be educated during orientation and the Inservice will be ongoing. During an interview on 3/7/2024 at 10:55 am LPN, TTT revealed on 3/1/2024 she conducted skin assessments on the locked unit on sixty-three residents. TTT was assisted by LPN, XX regarding skin assessments. TTT stated the weekly skin assessments audit will be on going for all the residents. 6. It was verified that the corrective actions were completed by 3/1/2024 and the immediate jeopardy was removed on 3/2/2024.

Based on record review, interviews, and review of the Administrator's Job Description, Administration failed to provide protective oversight of the facility environment including adequate supervision for wandering residents and failed to protect residents on the secured memory unit from an abuse free environment. This failure had the likelihood of affecting all residents residing on the secured memory unit. In addition, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility. On 2/28/2024, 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 Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. 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 3/2/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff conformance with the facility's policies and procedures governing abuse in the facility. Findings included: Review of the Administrator Job Description signed and dated 9/18/2024 by the Administrator, documented the summary of the position is to lead and direct facility functions in accordance with the resident's needs, government regulations, and company policies to maintain care for the residents. Essential job functions include: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Makes routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Assist the Quality Assurance and Assessment Committees in developing and implementing appropriate plans of action to correct identified quality deficiencies. Conducts regular rounds to monitor residents' needs are being met. Ensure that all facility personnel, residents, visitors Maintains a working knowledge and ensures compliance with all governmental regulation Ensures that residents rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including rights to wage complaints, are well established, and always maintained. Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident family as appropriate. 1. R1 with a history of wandering, repeatedly engaged in resident-to-resident physical altercations starting on 9/30/2023 with, R16, R17, R18, R19, R22 and R30. In addition, the facility failed to monitor R1 when R1 continuously wandered into R12's room over a three-month time frame and on 1/25/2024, R12 pushed R1 out of her room and R1 fell and sustained a fracture of the left elbow. During an interview on 2/27/2024 at 9:34 am, the administrator stated she was aware of R1's aggression when she came on board at the facility in September 2023. She stated R1's aggressive behavior was discussed in meetings with the Medical Director on several different occasions. She confirmed that the facility was unable to assign a staff member to the resident for one-to-one supervision. Staff interview on 2/27/2024 at 1:40 pm, CNA, EEE revealed, R1 did not like to stay in his room, and R1 walked continuously around the unit. R1, gets aggressive and violent when other residents confront him. EEE further stated she would hate to see R1 get hurt by other residents. CNA EEE concluded it was impossible for staff to continuously watch all the residents. During an interview on 2/27/2024 at 4:33 pm, Nurse Practitioner (NP) RR revealed that she had worked with R1 and visits with him monthly. NP RR stated R1 was ambulatory, walked freely around the secured memory unit and went into other resident rooms. NP RR stated they were aware that R1 has had resident-to-resident altercations and confirmed that R1 required closer surveillance. They stated that the most plausible way for that to happen is to increase staff on the unit. Cross refer to F600 2. An observation and interview on 2/22/2024 at 10:30 am, the Fourth-Floor call light system at the nurse's station was blank and there was no sound or signal alerting that residents needed assistance. Licensed Practical Nurse (LPN) UU was observed behind the nursing station and confirmed that the fourth-floor nursing call system was not functioning and stated the sound was not audible and the monitor did not blink or show residents who required assistance. He stated he was not sure how long the system had not been working. Observations on 2/22/2024 at 10:40 am on the 400 Hall revealed the following rooms were tested by pushing the red button. However, the light above the door did not light up and no sound was heard.: 415 bed A and B; 416 bed A and B; 417 bed A and B; 420 bed A and B and 424 bed A and B. An interview on 2/22/2024 at 10:50 am LPN WW stated the nursing call system had not been operational for three weeks and that the maintenance Director had been made aware, and that the staff put in requests for repair in the electronic maintenance care log. An interview on 2/22/2024 at 10:55 am, the Maintenance Director stated he was not sure why the call light monitoring system was not functioning. He stated that he was aware staff documented in the maintenance care system when equipment needed to be repaired. A review of a letter signed and dated by the facility administrator on 10/22/2023 revealed that the facility call light system was malfunctioning at that time. An interview on 2/22/2024 at 12:06 pm, the administrator revealed the monitoring system was a concern when she got hired and added it was not audible. She was unaware the monitors had stopped working again. Cross refer to F919 The facility implemented the following actions to remove the IJ: 1. On 2/29/2024 at 10:00 am, an Ad Hoc Abuse Performance Improvement Meeting was held with the Administrator, Director of Social Services, the DON, Corporate Operations Consultant, and the Corporate Nurse Consultant to identify the root cause of resident-to-resident altercations with a subsequent plan of action. The Abuse Prevention Policy, Resident to Resident Policy, and the Behavioral Management Policy were reviewed no changes made. 2. On 3/1/2024 the Administrator's job description was reviewed with the Administrator by the Corporate Operations Consultant. No revisions were made. 3. On 2/29/2024, the Corporate Operations Consultant in-serviced the Administrator, DON, and Social Services Director (SSD) on how to properly conduct an abuse investigation, how to track and to determine trends, root cause analysis and communication among departments on abuse reporting. The facility QAPI policy was reviewed specifically regarding how to determine root cause analysis. 4. On 2/29/2024, the Corporate Operations Consultant audited, completed, and signed the facility Abuse Log from September 2023 through current for any further areas of concern. Name of Audit- Abuse Log Audit. Trends noted to be primarily on third floor and in the evenings involving R1. Residents and the time of altercations were discussed with the Administrator and Director of Social Services. Interventions were put into place on the Abuse Performance Improvement Plan. 5. On 2/29/2024 the Corporate Nurse Consultant and DON audited the resident-to-resident altercations from September 2023 through current. The audit is named Resident to Resident Documentation Audit. It was identified that care plans were not initiated on all resident-to-resident altercations. Care plans were implemented on 3/1/2024. The DON and Administrator will discuss all abuse allegations in the morning meeting to ensure all departments respond appropriately. Documentation will be monitored through the Abuse Performance Improvement Plan and reported during QAPI by the Director of Nursing and Administrator. 6. On 2/29/2024, the Administrator was educated through the company online training modules on Implementation of QAPI Programs in Nursing Facilities through a one hour approved course. The Administrator successfully completed a post class test and received a certification. On 2/29/2024, the Corporate Operations Consultant conducted educated the Administrator on how to conduct a QAPI meeting and how to identify and complete a Root Cause Analysis. All corrective actions were completed on 3/1/2024. The facility alleges that the IJ was removed on 3/2/2024. 1. A review of Abuse/Resident to Resident Altercations staff education on 2/9/2024 attended by four Registered Nurses (RN) twenty-two Licensed Practical Nurses (LPN), seventeen medical technicians (CMT), four Certified Nurses Assistants (CNA), twelve administration staff, seventeen environmental/maintenance staff, nine Therapy staff, two staff from Social Services and the MDS coordinator. During an interview on 3/5/2024 at 11:51 am, the DON revealed that in services were held regarding abuse, wandering and resident to resident altercations. She verified that all abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning, when interventions are discussed during the QAPI, in service starts the same day if possible. 2. A review of the job description titled, Administrator last revised 3/1/2024, revealed the administrator was hired on 9/18/2024. Review of the administrator's job description included directing day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be always provided to all residents. Additionally, duties included Administrative Functions, Committee Functions, Personal Functions, Staff Development, Safety and Sanitation, Equipment and Supply Functions, Budget and Planning Functions, Residents Rights and Working Conditions. 3. The QAPI policy was reviewed and showed the composition of the performance Improvement Committee including, the Administrator, DON, Medical Director, Nurse Practitioner, Resident Assessment Instrument Coordinator. The policy documented QAPI program had the responsibility for designing and implementing corrective action plans as needed to resolve identified resident aspects of care/service problems. During an interview on 3/5/2024 at 12:46 pm, Nurse Consultant (NC) NN, revealed the facility abuse policy was not updated, she stated it was reviewed. On 2/29/2024, she educated the Administrator, DON, and SSD regarding monitoring residents behaviors including verbally aggressive behavior and physically aggressive behavior. The consultant stated, the QAPI policy was reviewed, she talked to the MDS- Coordinator, MMM regarding comprehensive care plans. She identified the care plan was not updated on other occasions. Discussed staff the care plan should be updated as soon as an incident or behavior is identified. Documentation revealed staff received the in-service on 2/29/2024. 4. Documentation and interviews of facility staff (nurses, CNA's, Housekeeping and the Laundry department) and The Abuse Log Audit. During an interview on 3/5/2024 at 11:56 am, Assistant Director of Nursing (ADON) revealed the following, all staff were in serviced, regarding behavioral management, specifically the way staff are to manage residents with behaviors, skin assessments, QAPI was reviewed. Staff were informed to immediately assess residents for injuries and report to the abuse coordinator immediately whenever a resident-to-resident altercation occurs. Staff discussed alternative placement for residents involved in repetitive resident to resident altercations. There were no changes made to the Abuse Policy. ADON stated all abuse must be reported to the abuse coordinator immediately and to the state within two hours. 5. The QAPI meeting was held for the following Tags F600, F656 and F835, and signatures were documented regarding completion of the in service. A total of fifty-six staff were interviewed from 3/5/2024 through 3/6/2024, which included Nursing staff, Dietary staff, housekeeping staff, laundry staff, Maintenance staff, Reception staff and Management staff. Signatures and interviews verified staff were in serviced on 2/29/2024 by RN-KKK. 6. Reviewed the audit tools dated 2/29/2024 verified that 100% of audits had been completed. A sample was reviewed for R1, R11, R12, R16, R19, R20, and R22. The documentation reviewed for Care Plans, MDS, and Pocket Guides was accurate.