**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews and review of the facility policies titled Abuse Prevention Program, Preventing Resident Abuse, Investigating Allegations of Neglect, Investigating Allegations of Resident to Staff Abuse, Protection of Residents During Abuse Investigations, and Investigating Allegations of Resident-to-Resident Abuse, the facility failed to ensure that one of 37 sampled residents (R) (R#209) was free from physical abuse by R#68. In addition, the facility failed to ensure that all residents were safe from potential abuse by not pursuing placement for R#68 with documented behaviors of verbal and physical aggression toward other residents and staff. On [DATE] 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 noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE] when Resident (R) #68 forcefully pushed R#209 causing her to fall onto her bottom and her head to jerk in a sudden backward motion. The facility failed to do neuro checks related to the unwitnessed fall. On [DATE] throughout the day shift, R#209 displayed confusion, nausea/vomiting, poor appetite, erratic breathing, and became unresponsive. No thorough assessment was completed of R#209 following the altercation. On [DATE], R#209 was transferred to the local hospital and intubated/ventilated due to her erratic/ineffective breathing. She was extubated the same day due to a diagnosis of a brain bleed and was kept comfortable as there was no treatment for her diagnosis. On [DATE], R#209 was transferred to a hospice facility where she expired later that day. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: F0600 -- S/S: J -- 483.12(a)(1) Free from Abuse and Neglect F0609 -- S/S: J -- 483.12(c)(1), (4), Reporting of Alleged Violations F0657 -- S/S: J -- 483.21(b)(2) Comprehensive Care Plan Revision F0658 -- S/S: J -- 483.21(b)(3)(i) Professional Standards F0835 -- S/S: J -- 483.70 Administration Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. An Acceptable Removal Plan was received on [DATE]. The removal plan included placing R#68 on one-to-one supervision on [DATE] and then discharging R#68 out to a behavioral health facility on [DATE]; staff training; reevaluating behavioral service needs and room placement for all residents exhibiting aggressive behaviors. The survey team conducted observations, reviewed staff training records and monitoring logs, clinical record review of revised care plans, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a lower scope and severity 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 the identification, reporting, investigation, and protection of residents from abuse. Findings include: Review of the facility policy Abuse Prevention Program undated, revealed Residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, injury of unknown origin, corporal punishment, and involuntary seclusion. Standard and Practice Guidelines include but is not limited to 1. Our facility is committed to protecting our Residents from abuse by anyone including, but not necessarily limited to, facility staff, other Residents, consultant's volunteers, staff from other agencies providing services to our Residents, family members, legal guardians, sponsors, friends, or visitors. Review of the facility policy Preventing Resident Abuse undated, revealed our facility will not tolerate any form of Resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing Resident abuse. Standard and Practice Guidelines include but is not limited to b. rotating staff working with challenging or abusive Residents. f. Training programs to assist staff in understanding the Resident's abusive or aggressive behaviors. i. Assessing, care planning, and monitoring Residents with needs and behaviors that may lead to conflict or neglect. j. Assessing Residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. l. Involving attending physicians and the Medical Director when finding of abuse have been determined. m. Involving psychiatric medical professionals in aiding the staff to manage difficult or aggressive Residents. Review of the facility policy Investigating Allegations of Neglect undated, revealed under Standard Practice Guidelines 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a Resident's physical or mental condition. Neglect also means the failure to protect the Resident from abuse or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or substantial risk of death. Review of the facility policy Investigating Allegations of Resident to Staff Abuse undated, under Standard Practice Guidelines revealed Resident to staff abuse is defined as a Resident hitting, slapping, pinching, kicking, making sexual advances, responding with catastrophic reactions, etc., to a staff member. c. Temporarily separate the Resident from other Residents as a therapeutic intervention to help reduce the agitation. h. consult psychiatric services for assistance in assessing the Resident and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team including Social Services. i. Review incident log to determine if similar incidents have occurred in the recent past. Review of the facility policy Protection of Residents During Abuse Investigations undated, under Standard and Practice Guidelines revealed c. If the alleged abuse involves another Resident, the accused Resident's legal representative and attending physician will be informed of the alleged abuse incident and that the accused Resident will not be permitted to make visits to other Resident rooms unattended. If necessary, the accused Resident's family members may be required to provide assistance in meeting this requirement. Review of the facility policy Investigating Allegations of Resident-to-Resident Abuse undated, under Standard Practice Guidelines revealed 1. Resident to Resident abuse is defined as aggressive/inappropriate behavior towards other Residents. B. Temporarily separate the aggressive Resident from other Residents as a therapeutic intervention to help reduce the agitation until an interdisciplinary team can develop a plan of care to meet the needs of the Resident. h. Consult psychiatric services for assistance in assessing the Resident and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician and/or interdisciplinary care planning team. i. If it is determined that the Resident is an eminent danger to him/herself or to others by the interdisciplinary care planning team and medical director transfer him/her out for a psychiatric evaluation. A review of the clinical record revealed that R#209 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hyperlipidemia, essential (primary) hypertension, hypothyroidism, and unspecified atrial fibrillation. Review of the [DATE] quarterly Minimum Data Set (MDS) for R#209 in Section (C) revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Section (E) Behaviors revealed R#209 had no behaviors. Section (G) Function Status revealed R#209 was independent with all Activities of Daily Living (ADL)s. A review of the clinical record revealed that R#68 was a [AGE] year-old ambulatory male resident, admitted to the facility on [DATE] with diagnoses that include but is not limited to, end stage renal disease, unspecified dementia without behavioral disturbance, dependence on renal dialysis, and other symptoms and signs involving cognitive functions and awareness. R#68 was prescribed Aricept 5mg one by mouthy daily since admission on [DATE]. Review of the facility Progress Notes dated [DATE] through [DATE] revealed that on [DATE] at 4:57 p.m. the Licensed Practical Nurse (LPN) AA spoke with the responsible party and the Nurse Practitioner for R#209 following the resident-to-resident altercation in hallway when R#68 pushed R#209 to the ground. It was noted that R#209 was assessed for injury, and no injury was noted at that time. Superiors notified. No new orders at that time. On [DATE] at 4:08 p.m. LPN AA documented R#209 was approached by another resident and suffered an anxiety attack and retreated to her room. R#209 stated she did not want to go back out that day. This nurse sat with resident and attempted to console her. R#209 has calmed down since her initial reaction but remained somewhat anxious. On [DATE] at 9:20 p.m. LPN AA documented R#209 was found unresponsive in her room. R#209 had vomit on her chest; respirations 33; Blood Pressure 200/66; heart rate fluctuated between 84 and 129; Oxygen Saturation 84% on room air then up to 90% on 15 liters of oxygen via non-rebreather; 911 was called; Emergency Medical Technician took resident to the local hospital. Review of the hospital records for R#209 dated [DATE] beginning at 9:38 p.m. revealed EMS reported they arrived at the facility and the facility staff reported to them that R#209 was found unresponsive at 9:00 p.m. Review of the computerized tomography (CT) scan revealed a large acute left holo hemispheric subdural hematoma measures up to 4.3 centimeters in thickness along the convexity and 3.0 centimeters along the posterior falx. Severe herniation with approximately 2.4 centimeters rightward midline shift, left uncal herniation, and downward transtentorial herniation with effacement of the suprasellar cistern. Diffuse left sulcal effacement and compression of the left cerebral hemisphere. Effacement of the left lateral ventricle. The right lateral ventricle and temporal horn are dilated, concerning for ventricular entrapment. On [DATE] R#68 was evaluated by the Psychiatrist related to confusion, wandering, trying to find family, dementia history, and added that these behaviors are exhausting to R#68 and can increase chances for peer conflicts, but he is not acting depressed and is not psychotic with clear delusions, just misinterpretations and added a diagnosis of vascular neurocognitive disorder with behavior disturbance, which was not added to the list of diagnoses by the facility until [DATE] but, per the [DATE] Psychiatric note for R#68, coordination of care was discussed with nursing. Recommendations by the Psychiatrist at this time for R#68 for the Primary Care Provider (PCP) and facility staff revealed R#68 has progressing dementia with wandering and repetition, not aggressive or refusing care at this point but seems more distressed as time goes on. Nursing Home tries to provide activity and socialization but R#68 is inattentive and with dialysis is constantly changing locations which increases confusion. Will address the behaviors and anxiety it is causing with a gentle Depakote trial. Begin Depakote sprinkles 125mg by mouthy twice daily at 1:00 p.m. and 8:00 p.m. for impulsive behaviors and see if he settles. Can increase dose as needed. Follow-up in 2 - 4 months. During a telephone interview on [DATE] at 9:08 a.m. with the Psychiatrist for R#68, he confirmed he had consulted with R#68 on three dates, [DATE], [DATE], and [DATE] but was not sure if he was notified about the physical aggression exhibited by R#68 in [DATE]. He revealed R#68 has dementia, cognitive impairment, walks and talks ok with intermittent periods of severity, and most days his behavior is fair but when off the Memory Unit he becomes over stimulated and confused. Psychiatrist revealed he is not always consulted related to residents being moved off the Memory Unit or if they should remain on the Memory Unit but revealed he is consulted when there are behavioral reasons that require an evaluation or consultation. He revealed if R#68 had a couple of months without incident, he might consider moving him but was not involved in the decision to move him out. Continued interview with the Psychiatrist for R#68 revealed he was treating the symptoms of R#68 and the intermittent severity with his problematic behaviors. He revealed he did not know if it was safe to move R#68 out of the Memory Unit and that he had not been notified or consulted about behaviors exhibited by R#68 while in the Memory Unit. He further stated that he was not involved in the decision related to moving R#68 out of the Memory Unit on [DATE]. Psychiatrist revealed it would be more favorable to have more people giving input related to moving R#68 out of the Memory Unit such as an Interdisciplinary Team (IDT) meeting where people involved in the care of R#68 had an input and added that he would favor being consulted prior to moving someone out of the Memory Unit. During an interview on [DATE] at 4:28 p.m. with LPN AA he revealed he was working the day R#68 pushed R#209 causing her to fall. He revealed the fall was unwitnessed and upon review of the video it did not show R#209 to have hit her head but stated she did fall very hard on her bottom. LPN AA revealed the fall was unwitnessed by staff and in thinking about it, it wasn't very smart of him not to start neuro checks and he should have started them, but she appeared to be fine. He stated his concern was more related to R#68 and where they were going to put him. He revealed no vital signs were taken of R#209 until 45 minutes to an hour after her fall and that the vital signs were all fine. He stated he saw R#209 coming out of the dining room on [DATE] and she looked distressed, and he asked her what was wrong, and she stated to him the man that pushed her down was in the dining room and she was feeling panicked. LPN AA stated he escorted her to her room, and she lay down in her bed. Review of the clinical medical record for R#209 revealed no documented vital signs after the fall on [DATE]. Review of the video during Activities in the dining room on [DATE] revealed R#68 standing near the exit of the dining room, behind and out of view of R#209 who was observed sitting at a table with another male resident, R#107, with their backs to the camera and unable to see R#68 from where he was standing. R#209 stands up with her hand over her mouth and walks toward R#68 as she had to pass him to exit the dining room. An interaction between the two, R#68 and R#209, revealed she placed her hand on his back moving him out of her path to leave the dining room and R#68 smiled at her, and touched her arm, as she went by. R#209 does not appear to be distressed by R#68 but noted to still have her hand over her mouth as she was exiting the dining room. During an interview on [DATE] at 9:29 a.m. with R#107 he stated on [DATE] at 3:00 p.m. he and his special friend R#209 were sitting in the dining room for Bingo which was something they loved doing together. He stated R#209 was a great bingo player and was good with numbers and when the numbers were called, she was quick to find the number on her card. R#107 stated on this day he observed something very different with R#209 in that when the numbers were called, she would look at him, point at the numbers on her card, and ask if that was the correct number and stated he knew right away something was not right. He stated at that point she began gagging and placed her hand over her mouth and he noticed some vomit on her fingers and then R#209 stated to him that she was through playing and that she was so . confused she didn't even know where she was. R#107 stated at that point R#209 left the table and went up the hallway. He stated he got up and walked toward the hallway and he saw LPN AA assisting her to her room. He stated one of R#209s friends told him then that she (R#209) had fallen, and he stated he did not know anything about her falling and added that he didn't see her fall. R#107 stated by then bingo was over so he went on down the hallway to check on R#209 and when he went into the room she was asleep and he thought she was probably getting the flu or a stomach virus and felt that her sleeping was really what she needed and at that point he went out into the hallway and told LPN AA, that R#209 was sleeping and that LPN AA told him he should go back in the room and comfort R#209 and let her know he was there so he did. R#107 stated R#209 woke up and began to vomit again and it got on her clothes, and he stated she acknowledged he was there and then she went back to sleep. He stated her supper tray by this time was brought in and was sitting on her bedside table and told staff that R#209 was not able to eat and asked them to please take it out and added that after that happened, he did not stay in the room with R#209 and he went back to his room to allow her to rest. R#107 stated he had planned on going back later to check on R#209, but LPN AA came and told him that R#209 had been sent to the hospital and the next day the Administrator and some other staff came and told him that R#209 had passed away. During an interview on [DATE] at 4:55 p.m. with the DON revealed she started in [DATE] at the facility, and they have tried to transfer R#68 to a facility which handled more aggressive residents but were unsuccessful. She stated R#68 was transferred back to the Memory Unit and the Physician adjusted his medication but was at a loss as to what else to do to keep their other residents and staff safe. DON revealed for any unwitnessed fall, or fall with head injury, neuro checks should be initiated immediately. At the time of exit on [DATE], the facility had not provided proof of attempts to transfer R#68 to a facility which handled more aggressive residents. During an interview on [DATE] at 5:03 p.m. with current Administrator KK she revealed she spoke with the Medical Director on [DATE] around 2:00 p.m. related to R#68 having increased agitation and Psychosis and with his permission attempted to 1013 R#68 but the non-emergency transport could not transport a resident to the ER for a 1013 and Emergency Services took so long, the order ended up being cancelled and staff were instructed to monitor R#68 for further behaviors. She stated on [DATE] R#68 became physically aggressive with staff and pacing the floor making threats and Police and Emergency Medical Services (EMS) were called but stated when Police arrived, they refused to take him because of a new law in place preventing them from being able to handcuff a person diagnosed with Dementia and when the Emergency Medical Services (EMS) arrived, R#68 had calmed down and was not physically aggressive any longer so they refused to take him. Administrator KK revealed the Psychiatrist came in and evaluated R#68 during this time and he did not want R#68 1013'd. Administrator revealed she has worked in the facility less than a month and is aware R#68 was removed from the Memory Unit and placed back onto the long-term care floor on [DATE] and had documented behaviors of wandering and aggression toward staff and other Residents. She confirmed the Psychiatrist should be involved as soon as there are aggressive behaviors observed by a resident and stated as of today R#68 has been placed in a private room receiving one on one care until they find a place for him to go. During an interview on [DATE] at 5:15 p.m. with Social Worker (SW) EE she revealed she is responsible for arranging appointments for residents and doing bed changes in the facility. She revealed Administrator BB came to her and Social Services Director (SSD) FF and said he needed a bed in the Memory Unit and that R#68 was more stable, and other residents were a greater flight risk, so he made the decision to move R#68 from the Memory Unit back to the long-term care floor to accommodate other residents. SW EE stated she had several conversations with the wife of R#68, and she (wife of R#68) revealed he had a diagnosis of inoperable macular degeneration causing him to lose his vision and she felt that this was part of the cause of his negative behaviors. During a telephone interview on [DATE] at 10:30 a.m. with previous Administrator BB he could not confirm speaking with any physician or provider involved in the care of R#68 related to moving him out of the Memory Care Unit on [DATE] but that he had a discussion with the social workers prior to moving R #68 out and added that he did not just decide on his own to move R#68 to the long-term care floor. He stated the Social Workers should have the IDT notes. He revealed he could not recall who was involved in the IDT meeting and again stated the Social Workers had the notes. During a joint interview on [DATE] at 10:55 a.m. with the SW FF and SW EE, SW FF stated she remembered the discussion of moving R#68 out of the Memory Unit on [DATE]. She revealed she and SW EE did not feel R#68 was appropriate to leave the Memory Unit because of his diagnosis of dementia and it was not good for him to be moved around so much with his level of confusion. She stated they talked to Administrator BB at that time about the concern they had related to moving R#68 out of the Memory Unit, but Administrator EE disagreed with them stating he felt another resident needed to be in the Memory Unit more than R#68 and that R#68 had not had any recent behaviors. SW EE stated the Social Worker's do not ever initiate room changes unless they are directly involved or in contact with something that has happened and added that staff usually report the need or potential need for a room change to the Social Worker's and together have a discussion as to what do. SW FF stated, under previous Administrator BB, the non-clinical managers were dismissed from the IDT, or morning meetings, once they made their contributions, so they were not always privy to the clinical information. SW FF stated she already looked at the Psychiatrist notes/visits for R#68 trying to find documentation about his recommendations but stated there was little or no discussion in the notes related to whether to move R#68 from the Memory Unit. She stated normally, after recommendations have been tried, if they're not helping then staff will try something else. SW FF stated the Psychiatrist generally writes a standard follow-up note 2 to 4 months after seeing a resident to ensure residents with behaviors, dementia, and mood issues are being seen on a regular basis and added that R#68 was seen by the Psychiatrist on a regular basis. SW FF revealed staff would come to them, CNA's mainly, and sometimes charge nurses, to let them know what was going on with the residents but without documentation, she and SW EE did not always know what was going on unless it's discussed in the IDT or morning meetings which she and SW EE were dismissed for the clinical portion under previous Administrator BB. She stated current Administrator KK is always involved in the IDT/morning meetings and she allows everyone to stay for the duration of the meetings. During a telephone interview on [DATE] at 12:23 p.m. with Nurse Practitioner (NP) DD she stated R#68 was in the Alzheimer's unit for a couple of months and then was moved out to the long-term care floor on [DATE], but no one discussed it with her, and she felt that resident moves in general should be discussed before moving, especially in and out of the Memory Unit. She stated, depending on what kind of behaviors the resident was having, it may be appropriate to move a resident from the Memory Unit, however, it's usually not good to move dementia residents too much because they become even more confused. During a telephone interview with the Psychiatrist on [DATE] at 1:30 p.m., he stated he knew a 1013 wouldn't work for R#68 because the process is destabilizing to a dementia resident. He stated the emergency room (ER) would send him back to the facility in 8 hours and medications will not get started, or will be changed, and R#68 would not be accepted to a Psychiatric Unit due to being a dialysis patient. He stated when a dementia resident goes to the ER, they tend to look and act normal when they arrive, and the receiving facility will not accept the 1013 resident without objective data. He revealed the stress of transferring and returning the dementia resident is more than he was willing to risk, however, he would not have deterred the facility from doing what was necessary to protect the residents and staff. Psychiatrist revealed there is a potential harm to a dementia resident when they go to the ER because the ER will review the old admissions and sometimes will re-start previous medications and discontinue current medications which can cause even more behavioral issues and added that R#68 is traumatized by new environments. Review of the clinical medical record for R#68 revealed on [DATE] he was admitted to room [ROOM NUMBER]-B. On [DATE] R#68 was moved from room [ROOM NUMBER]-B to 312-C until [DATE] when he was moved to room [ROOM NUMBER]-A in the Memory Care Unit where he stayed until [DATE] and at that time R#68 was moved back out to the Long-Term Care floor to room [ROOM NUMBER]-B. On [DATE] R#68 was moved back to the Memory Care Unit to room [ROOM NUMBER]-A until [DATE] when he was moved out private room [ROOM NUMBER]-B and provided one on one care until an accepting facility could be found for him. During an interview with LPN OO on [DATE] at 3:25 p.m. she revealed she had witnessed R#68 lunge aggressively toward two residents, R#35, and R#73 on [DATE]. She stated, during lunch that day, R#68 got up from his table and started to attack R#35, but LPN OO stopped him. Further interview revealed on the same day at dinner time R#68 tried to punch R#73 while she was seated at her table. LPN OO stated she stopped R#68 from attacking the resident and redirected him. She further revealed that she probably left a message for the nurse practitioner but that she couldn't remember speaking directly to the nurse practitioner or Physician. During an interview on [DATE] at 3:35p.m. with CNA PP revealed she has witnessed R#68 become agitated with R#37 during mealtimes or when seated at a table. She stated R#37 tends to talk non-stop and that agitates R#68 and when she (CNA PP) sees R#68 becoming agitated and starting toward R#37, she separates them and redirects R#68 because she felt he may become physically violent. She revealed this happens two to three times a day when she is working on the Memory Care Unit. During an interview on [DATE] at 4:44 p.m. with the Medical Director he revealed he was not aware a decision was made to move R#68 out of the Memory Unit. The facility implemented the following actions to remove the IJ: 1. On [DATE], upon returning from dialysis, R#68 was moved to a private single room under one-on-one staff supervision. On-on-one staff supervision will be provided when R#68 is in the facility. 2. On [DATE], the Corporate Nurse Consultant and Director of Clinical Services reviewed the facility policy on Abuse, Neglect, and Exploitation. No revisions were made. 3. On [DATE] at 1:00 p.m., the Licensed Nursing Home Administrator facilitated the Quality Assurance and Performance Improvement (QAPI) meeting with the QAPI Committee to evaluate and review areas for improvement related to Abuse Prevention and Reporting. The facility Medical Director was in attendance. The QAPI Committee developed an action plan which include assigning a task force to address each area of concerns, initiating comprehensive staff education, and conducting a review of residents currently exhibiting or has the potential to exhibit physical and/or verbal aggression toward others to ensure appropriate room placement. A task force was assigned to address each area of concerns, including initiation of comprehensive staff education, review or audit of facility incident reports, resident medical records, resident care plans, incidents of unwitnessed falls and tracking of staff who have received and not received the required education. 4. On [DATE] at 6:00 p.m., an Adhoc QAPI Committee meeting was held to review the process for determining appropriate room placement for residents exhibiting physical and /or verbal aggression toward others. The discussion resulted to a development of a Room Change Task Force, which will consist of, but not limited to, the Licensed Nursing Home Administrator, Director of Nursing, Social Workers, and the MDS Coordinators. The task force will meet to review the resident's current condition prior to moving the resident from the memory care unit and to evaluate proper room placement for a resident exhibiting physical and/or verbal aggression toward others to ensure the safety and well being of other residents in the facility. 5. On [DATE], the facility initiated comprehensive staff education on Abuse Prevention and Reporting by the Staff Development Coordinator (SDC) and Corporate Nurse Consultant. The education will include a review of the facility policy on Abuse, Neglect, and Exploitation. 6. On [DATE], the Medical Record Director, Unit Managers, and Social Workers completed a review of resident medical records to identify documented behaviors of actual or potential physical and/or verbal aggression toward others. The residents identified were evaluated by the interdisciplinary team, in consultation with behavioral services for proper room placement to ensure the safety and well-being of all facility residents. The findings revealed the identified residents are currently residing in appropriate room placements. 7. On [DATE], the facility developed a monitoring system by which the Licensed Nursing Home Administrator and/or the Director of Nursing would review and approve all room changes for residents. The Licensed Nursing Home Administrator will send the list of room changes to Corporate Nurse Consultant on a weekly basis for additional review and monitoring. 8. On [DATE], the facility reinforced a system by which the Licensed Nursing Home Administrator would notify the Corporate Nurse Consultant with each incident of allegation of abuse to ensure appropriate and immediate interventions are in place to ensure the safety and well-being of other residents in the facility and preventive measures are implemented to prevent or recurrence. 9. On [DATE], the facility implemented a procedure by which the results of the monitoring referenced above, and comprehensive staff education would be presented to the Quality Assurance and Performance Improvement (QAPI) Committee each month by the Licensed Nursing Home Administrator, to allow the QAPI[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy titled Abuse Investigation and Reporting, the facility failed to ensure that alleged physical abuse was reported to the State Survey Agency (SSA) within a two-hour timeframe for one of 37 sampled residents (R)(R#209). On [DATE] 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 noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE] when Resident (R) #68 forcefully pushed R#209 causing her to fall onto her bottom and her head to jerk in a sudden backward motion. The facility failed to do neuro checks related to the unwitnessed fall. On [DATE] throughout the day shift, R#209 displayed confusion, nausea/vomiting, poor appetite, erratic breathing, and became unresponsive. No thorough assessment was completed of R#209 following the altercation. On [DATE], R#209 was transferred to the local hospital and intubated/ventilated due to her erratic/ineffective breathing. She was extubated the same day due to a diagnosis of a brain bleed and was kept comfortable as there was no treatment for her diagnosis. On [DATE], R#209 was transferred to a hospice facility where she expired later that day. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: F0600 -- S/S: J -- 483.12(a)(1) Free from Abuse and Neglect F0609 -- S/S: J -- 483.12(c)(1), (4), Reporting of Alleged Violations F0657 -- S/S: J -- 483.21(b)(2) Comprehensive Care Plan Revision F0658 -- S/S: J -- 483.21(b)(3)(i) Professional Standards F0835 -- S/S: J -- 483.70 Administration Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. An Acceptable Removal Plan was received on [DATE]. The removal plan included placing R#68 on one-to-one supervision on [DATE] and then discharging R#68 out to a behavioral health facility on [DATE]; staff training; reevaluating behavioral service needs and room placement for all residents exhibiting aggressive behaviors. The survey team conducted observations, reviewed staff training records and monitoring logs, clinical record review of revised care plans, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a lower scope and severity 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 the identification, reporting, investigation, and protection of residents from abuse. Findings include: Review of the policy titled Abuse Investigation and Reporting with a revised date of [DATE] revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment . will be reported by the administrator or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility b. The local/State Ombudsman c. The Residents Representative (sponsor) of Record. d. Adult Protective Services (where state law provides jurisdiction in long-term care) e. Law enforcement officials. f. the resident's Attending Physician; and g. The facility Medical Director 2. An alleged violation of abuse, neglect exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24 hours) if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Review of the clinical record for R#209 revealed that she was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarct, adult failure to thrive, major depressive disorder, hemiplegia and hemiparesis, dysphagia and vascular dementia. Review of the clinical record revealed R#68 was admitted on [DATE] and had diagnoses including but not limited to end stage renal disease, Vascular dementia with behavioral disturbances, impulsive aggression, anemia, congestive heart failure, hypertension, and hyperthyroidism. Review of the report to the SSA dated [DATE] revealed that the type of incident reported to the SSA was a resident-to-resident encounter. Continued review revealed that R#68 was observed forcefully pushing R#209 in the corridor in front of her room. Further review revealed resident fell onto her buttocks with her head thrashing backwards but did not hit her head. Additional review revealed that R#68 was escorted away from R#209 and placed back into his room before notification of responsible parties was completed. Review of the 5-day summary dated [DATE] addressed to the state agency dated [DATE], revealed in that on [DATE], R#209 found R#68 in her bed. R#68 got out of her bed. R#209 then walked into the hallway followed by R#68. As R#68 exited the room, R#209 turned around to face R#68. R#68 shoved R#209 causing her to lose her balance. R#209 fell onto her bottom and did not fall back onto her head. The resident stated that she was not injured. Skilled nurse assessed R#209 for injury, and none noted. The investigation did not include specifics of the assessment for R#209 related to the incident on [DATE] and review of the medical record for R#209 revealed there was no assessment completed. According to the Accidents and Incidents - Investigating and Reporting, the following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time of the accident for incident took place b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc) c. The circumstances surrounding the accident or incident. d. Where the accident or incident took place; e. The name(s) of the witness and their accounts of the accident or incident f. The injured persons account for the accident or incident g. The time the injured person's Attending Physician was notified h. The date/time the injured person's family was notified and by whom. i. The condition of the injured person, including his/her vital signs. j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work etc) k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. Review of the Accidents and Supervision policy dated [DATE] documents in the Policy Explanation and Implementation Guidelines: Reporting of Accidents/Incident A. Regardless of how minor and injury may be all accidents or incidents involving a resident, staff member, or visitor must be reported to the facility. B. Report all accidents or incidents to the supervisor or Charge Nurse as soon as possible. However, do not leave and accident victim unattended unless it is absolutely necessary to summon assistance. During an interview on [DATE] at 12:05 p.m., the current administrator revealed that R#68 was recently transferred from the memory care unit to the general population residents. She stated she learned of the incident on Monday [DATE] by the Manager. It was further revealed that the reportable was submitted as soon as she received the information of the incident. The administrator revealed she was just stepping into the role of administrator at the facility and Friday [DATE] she came in to meet with the DON, and came in on [DATE] as week, she assumed her role of administrator on site with 8-hour days on [DATE], completing her transfer from a sister facility. The administrator stated she was aware of the two-hour reporting requirement for abuse. The report to the SSA was dated [DATE] without a time. Review of facility documentation revealed the facility failed to report the allegation of physical abuse by R#68 toward R#209 within a two-hour timeframe. A review of the facility's intake confirmation, on [DATE] revealed the initial report was sent via computer to the SSA. Cross refer to F600. The facility implemented the following actions to remove the IJ: 1. On [DATE], the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were provided education by the Corporate Nurse Consultant on facility policy on Abuse, Neglect, and Exploitation and State and Federal Regulations related to proper procedures for reporting allegations of abuse. The LNHA is the Facility Abuse Coordinator. 2. On [DATE], the Corporate Nurse Consultant and Director of Clinical Services reviewed the facility policy on Abuse, Neglect and Exploitation. No revisions were made. 3. On [DATE] at 1:00 p.m., the Licensed Nursing Home facilitated the monthly Quality Assurance and Performance Improvement (QAPI) meeting with the QAPI Committee to evaluate and review areas for improvement related to timely reporting of allegations of abuse to the State Agency. The Medical Director was in attendance. The QAPI Committee developed an action plan which include assigning a task force to address each area of concerns, initiating comprehensive staff education, and conducting a review of facility incidents related to allegations of abuse to ensure compliance with the reporting requirement to the State Agency. A task force was assigned to address each area of concerns, including initiation of comprehensive staff education, review or audit of facility incident reports, resident medical records, resident care plans, incidents of unwitnessed falls and tracking of staff who have received and not received the required education. 4. On [DATE], the facility conducted a review of facility incidents from [DATE] to [DATE] to identify additional incidents that were not reported to the State Agency within the required timeframe. No concerns were identified. 5. On [DATE], the facility initiated a comprehensive staff education on facility policy on Abuse, Neglect and Exploitation with emphasis on timely and proper procedures for reporting allegations of abuse to the facility abuse coordinator. The staff education is provided by the Corporate Nurse Consultant and Staff Development Coordinator. 6. On [DATE], the facility reinforced system process by which the DON would inform the LNHA immediately upon knowledge of an allegation of abuse. The Corporate Nurse Consultant provided re-education to the DON on the process. 7. On [DATE], the facility initiated a system process by which the Licensed Nursing Home Administrator and/or Director of Nursing would be required to notify the Corporate Nurse Consultant at the time of every incident of allegation of abuse for additional evaluation and guidance on reporting to the State Agency. The Corporate Nurse Consultant provided education to the LNHA and DON on the process. 8. On [DATE], the facility initiated a tracking system by which the LNHA would keep track of the time an incident of allegation of abuse occurred to ensure compliance with the required reporting timeframe to the State Agency. The LNHA would use an Incident Time tracking tool which was developed and provided to the LNHA on [DATE]. The LNHA would be required to send the Incident Time tracking tool to the Corporate Nurse Consultant on a weekly basis. The Corporate Nurse Consultant provided education to the LNHA on the process. 9. On [DATE], the facility implemented a procedure by which the results of the monitoring referenced above, and comprehensive staff education would be presented to the Quality Assurance and Performance Improvement (QAPI) Committee each month by the Licensed Nursing Home Administrator and/or the Director of Nursing, to allow the QAPI Committee to monitor staff compliance with the facility's policies and procedures regarding proper and timely reporting of allegations of abuse. 10. On [DATE], the Licensed Nursing Home Administrator and [NAME] Director of Scheduling sent communication to all contracted staffing agencies with instruction to direct their licensed nurses and certified nursing assistants to receive the facility education on facility policy on Abuse, Neglect and Exploitation with emphasis on timely and proper procedures for reporting allegations of abuse to the facility abuse coordinator prior to reporting to their work area. 11. As of [DATE], one RNs, 11 LPNs, 21 CNAs of contract staff have received the facility education. 12. As of [DATE], 88 out of 94 facility staff have received the education (94% of facility received the education). Six (Two RNs, two dietary staff, two CNAs) out of 94 facility staff are not available to receive the education due to being off duty or on leave. Out of the 94-facility staff, eight RNs out of 10 RNs, 20 LPNs out of 20 LPNs, 19 CNAs out of 21 CNAs have received the education. The staff members who were unavailable will receive the education upon their return to work and prior to starting his/her duties. Facility Staff shall include administrative staff, nursing staff, contract dietary staff (eight out of total of 10), contract housekeeping and laundry staff (seven out of total of seven), and contract rehab staff (nine out of total of nine). 13. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. The facility and corporate leadership provided education to the staff on [DATE] related to timely reporting of abuse allegations to the SSA, confirmed by sign-in sheets and telephone logs. 2. The CNC and DCS reviewed and signed-off on the facility policy, Abuse, Neglect, and Exploitation on [DATE] with no revisions made. 3. A QAPI meeting was held on [DATE] at 1:00 p.m. which included the Medical Director and included the topics of behavior modification and reporting of accidents and incidents; confirmed by sign-in sheets. 4. Review of the Reportable Event Log dated [DATE] through [DATE] revealed all eligible events were reported to the SSA. 5. The facility-initiated staff education on [DATE] related to abuse, neglect, and exploitation, timely reporting, and care plan revision, verified by sign-in sheets and staff interviews. 6. The CNC provided education to the DON on communicating with the Administrator on each new allegation of abuse in the facility verified by the sign-in sheet. 7. The CNC conducted education for the Administrator, DON, and onboarding DON related to tracking, reporting, and communicating with corporate leadership all allegations of abuse. 8. The facility developed a tracking tool to monitor compliance in reporting allegations of abuse on [DATE]. 9. A QAPI meeting was held on [DATE] at 3:00 p.m. related to discussion of deficiencies cited including abuse, timely reporting, falls, change of condition, and communication with corporate leadership. Sign-in sheets reviewed. 10. Correspondence was sent via email on [DATE] and [DATE] to four staffing agencies informing them of the need to educate their staff on the following topics before returning to the facility for work: abuse, resident-to-resident abuse, reporting abuse timely, falls, unwitnessed falls, and post-incident 72-hour change in condition monitoring. 11. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 12. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 14. All corrective actions were completed on [DATE]. The facility IJ was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to revise the care plan for one of 37 sampled residents (R) (R#68) after multiple incidents of attempted physical aggression against other residents which occurred from [DATE] through [DATE]. On [DATE] 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 noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE] when Resident (R) #68 forcefully pushed R#209 causing her to fall onto her bottom and her head to jerk in a sudden backward motion. The facility failed to do neuro checks related to the unwitnessed fall. On [DATE] throughout the day shift, R#209 displayed confusion, nausea/vomiting, poor appetite, erratic breathing, and became unresponsive. No thorough assessment was completed of R#209 following the altercation. On [DATE], R#209 was transferred to the local hospital and intubated/ventilated due to her erratic/ineffective breathing. She was extubated the same day due to a diagnosis of a brain bleed and was kept comfortable as there was no treatment for her diagnosis. On [DATE], R#209 was transferred to a hospice facility where she expired later that day. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: F0600 -- S/S: J -- 483.12(a)(1) Free from Abuse and Neglect F0609 -- S/S: J -- 483.12(c)(1), (4), Reporting of Alleged Violations F0657 -- S/S: J -- 483.21(b)(2) Comprehensive Care Plan Revision F0658 -- S/S: J -- 483.21(b)(3)(i) Professional Standards F0835 -- S/S: J -- 483.70 Administration An Acceptable Removal Plan was received on [DATE]. The removal plan included placing R#68 on one-to-one supervision on [DATE] and then discharging R#68 out to a behavioral health facility on [DATE]; staff training; reevaluating behavioral service needs and room placement for all residents exhibiting aggressive behaviors. The survey team conducted observations, reviewed staff training records and monitoring logs, clinical record review of revised care plans, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a lower scope and severity 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 the identification, reporting, investigation, and protection of residents from abuse. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated [DATE], revealed: The comprehensive care plan will be revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. A review of the clinical record revealed that R#68 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include end-stage renal disease (ESRD), congestive heart failure (CHF), dementia without behavioral disturbance, and vascular dementia with behavioral disturbance. He was transferred to a local hospital on [DATE] for behavioral assessment. Review of the admission Minimum Data Set (MDS) assessment for R#68, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment; a Mood score of zero, indicating no depression; no behaviors. Documentation of the functional status revealed: independent for eating; supervision for bed mobility, transfer, walking in room/corridor, locomotion on/off unit, toilet use, bathing; limited assist for dressing and personal hygiene. Review of the quarterly MDS assessment for R#68, dated [DATE], documented a BIMS score of zero, indicating severe cognitive impairment; Mood score of four, indicating no depression; Behaviors of verbal one to three days, rejection of care one to three days, wandering daily. Review of the quarterly MDS assessment for R#68, dated [DATE], documented a BIMS score of zero, indicating severe cognitive impairment; Mood score of three, indicating no depression; Behaviors of wandering daily. Review of the quarterly MDS assessment, dated [DATE], documented a BIMS score of zero, indicating severe cognitive impairment; Mood score of five, indicating mild depression; Behaviors of wandering daily. A review of the clinical record revealed the following timeline of escalating behaviors: On [DATE] at 12:59 p.m. R#68 pushed a housekeeper. On [DATE], R#68 threatened to become physically aggressive with the Kitchen Manager, but staff redirected him. On [DATE] the care plan for R#68 was revised and a new intervention of 'receiving services with Psych Medical Doctor as needed and ordered' was put into place. On [DATE] at 7:06 a.m. R#68 was very agitated and threatened to hit the Certified Nursing Assistant (CNA), refused care, vital signs, and to take medication. There was no evidence that the care plan related to behaviors for R#68 was reviewed or revised after [DATE]. On [DATE] at 11:09 p.m. R#68 was observed getting in the face of and threatening a staff member, but staff intervened. On [DATE] at 12:20 p.m. R#68 became verbally aggressive and attempted to punch another resident, but staff intervened. On [DATE] at 4:27 p.m. R#68 attempted to punch a female resident and stood up and charged at her, but staff intervened. On [DATE] at 1:10 a.m. R#68 became physically aggressive with staff during ADL care. There was no evidence that the care plan was reviewed or revised after aggressive behaviors by R#68 on [DATE], [DATE], or [DATE]. In an interview with the MDS Director on [DATE] at 5:10 p.m., she stated her department was responsible for closing out MDS assessments once all departments completed the sections for which they were responsible. She stated the MDS Coordinators should update the care plan within 21 days of completion of the MDS assessment, if applicable. She confirmed the care plan for R#68 had not been updated to reflect his escalating aggressive behaviors. She stated typically, the interdisciplinary team (IDT) would discuss R#68's escalating behaviors, but the facility hadn't had traditional IDT meetings in about a year. She stated Activities, Social Services, and MDS did not have access to all the information because they were dismissed from morning meetings after they made their respective contributions under the former Administrator. She stated it was his practice to dismiss non-direct caregivers from the morning meetings while the nursing staff reviewed charts and clinical data. She stated 24-hour reports, diagnosis codes, and incident reports were not reviewed at all in morning meetings. She stated the only way she knew someone went to the hospital was to review the daily census. She stated the former Administrator did not want anyone to be involved with negative or positive issues in the facility. She stated, under the new Administrator, there is new focus daily morning meetings, consistent IDT meetings, and on updating care plans with emphasis on aggressive behaviors. In an interview with Administrator KK on [DATE] at 1:32 p.m., she stated going forward she intends to restore consistent and open communication throughout the facility's departments through morning meetings, IDT meetings, updating the care plans consistently, and thorough documentation in Progress and Nurse's Notes. The facility implemented the following actions to remove the IJ: 1. On [DATE], upon returning from dialysis, R#68 was moved to a private single room on one-on-one staff supervision, which will be provided when resident is in the facility. Resident care plan was reviewed and revised to reflect current status and intervention. 2. On [DATE] at 1:00 p.m., the Licensed Nursing Home Administrator facilitated the Quality Assurance and Performance Improvement (QAPI) meeting with the QAPI Committee to evaluate and review areas for improvement related to Care Plan Development and Revision. The facility Medical Director was in attendance. The QAPI Committee developed an action plan which include assigning a task force to address each area of concerns, initiating staff education, and conducting an audit of resident care plans who currently exhibits with physical and/or verbal aggression to ensure they reflect current condition and interventions. A task force was assigned to address each area of concerns, including initiation of comprehensive staff education, review or audit of facility incident reports, resident medical records, resident care plans, incidents of unwitnessed falls and tracking of staff who have received and not received the required education. 3. On [DATE], the Corporate Nurse Consultant and Corporate MDS Consultant reviewed the policy on comprehensive care plans for necessary revisions. No revisions were made. 4. On [DATE], the Director of Nursing and Corporate Nurse Consultant initiated licensed nurse education on proper procedures for development and revisions of care plans for residents who exhibits with physical and/or verbal aggression toward other residents and staff to reflect their current status and interventions. 5. On [DATE], the Corporate MDS Consultant provided education to the interdisciplinary team, which consists of the Social Workers, Activity Director, Rehab Director, Dietary Manager, Wound Nurse, and Director of Nursing on proper procedures for development and revisions of resident care plans with emphasis on care plans for residents who presents with physical and/or verbal aggression toward other residents and staff. 6. On [DATE], the MDS Coordinators completed an audit of incidents involving resident physical and/or verbal aggressive behaviors toward others to determine if the current care plans for the identified residents require revisions to reflect the current status and interventions. Total of seven incidents were identified. Care Plans for residents involved were reviewed and revised as appropriate. 7. On [DATE], the facility initiated a new system process by which the Social Workers will have the ability to access resident incident reports from the facility electronic medical record system. The process will enable the Social Workers to review timely the incidents involving resident physical and/or verbal aggression toward others and to develop or revise resident care plans to reflect current status and interventions as appropriate. Total two out of two Social Workers were provided education on how to access incident reports in the electronic medical record system by the Corporate Nurse Consultant on [DATE]. 8. On [DATE], the facility initiated a monitoring system by which the MDS Coordinators, Director of Nursing, or the Corporate MDS Consultant would conduct a weekly review of care plans for residents who exhibit changes in condition, including physical and /or verbal aggression, to ensure a care plan is developed or revised to reflect current status and interventions. 9. On [DATE], the facility reinforced a system process by which the Director of Nursing would facilitate daily Clinical Meetings during weekdays to discuss and review with the interdisciplinary team members the residents who exhibit changes in condition using the completed 24-hour Shift Reports and incident reports in order to identify if new resident care plan will need to be developed or revisions to current plan of care is appropriate. Interdisciplinary Team Members will include the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers, Wound Nurse, and Social Workers. On [DATE], the Corporate Nurse Consultant provided re-education to the Director of Nursing on how to effectively facilitate the Clinical Meeting. 10. On [DATE], the facility implemented a procedure by which the results of the monitoring referenced above, and comprehensive staff education would be presented to the Quality Assurance and Performance Improvement (QAPI) Committee each month by the Licensed Nursing Home Administrator and/or the DON, to allow the QAPI Committee to monitor staff compliance with the facility's policies and procedures regarding Care Plan Development and Revision. 11. On [DATE], the Medical Director and Psychiatrist were consulted by Manager and Corporate Nurse Consultant regarding an appropriate transfer of R#68. At 3:08 p.m. on [DATE]. R#68 was transferred to Behavioral Health facility, per physician order and family consent. Medical Director was informed of the resident transfer. R#68 care plan was reviewed and revised to reflect current status and intervention. R#68 is not residing in the facility. 12. On [DATE], the Licensed Nursing Home Administrator and [NAME] Director of Scheduling sent communication to all contracted staffing agencies with instruction to direct their licensed nurses to receive the facility education on proper procedures for development and revisions of care plans for residents who presents with physical and/or verbal aggression towards other residents and staff to reflect their current status and interventions from the facility designated educator prior to reporting to their work area. 13. As of [DATE], one RNs and11 LPNs of contract licensed nursing staff have received the facility education. 14. As of [DATE], 28 out of 30 facility licensed nursing staff have received the education (93% of facility received the education). Two out of 30 (Two RNs) facility licensed nursing staff are not available to receive the education due to being off duty or on leave. Out of the 30 staff, eight RNs out of 10 RNs and 20 LPNs out of 20 LPNs have received the education. The staff members who were unavailable will receive the education upon their return to work and prior to starting his/her duties. 15. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. The room change was confirmed with a Change of Room or Roommate Form for R#68 dated [DATE]. 2. The QAPI meeting on [DATE] at 1:00 p.m. addressed MDS assessments with corresponding care plans, staff development, and behavior modification; confirmed by sign-in sheets and staff interviews. 3. The Corporate Clinical Nurse signed-off on review of the Comprehensive Care Plans policy on [DATE]. 4. The facility-initiated staff education on [DATE] related to abuse, abuse reporting, care plan revision related to physical/verbal aggression confirmed by sign-in sheets and staff interviews. 5. The facility-initiated education to the IDT related to care plan revision of aggressive behaviors confirmed by sign-in sheets and staff interviews. 6. Resident audits were completed as indicated; confirmed by audit tools and staff interviews. 7. CNC RR educated both Social Workers on [DATE] on how to access resident incident reports in the EMR, confirmed by sign-in sheets and interviews. In a joint interview with the Social Services Director (SSD) and the Social Worker (SW) on [DATE] at 2:47 p.m., they each stated Administrator BB did not allow them to access certain areas of the EMR and did not allow them to participate in the entire morning meeting process because they were not direct caregivers. They stated the non-caregivers were excused from morning meetings after they made their departmental contributions to the meetings and were not made aware of the clinical concerns that might impact their Social Services concerns. They stated they now have morning meetings and IDT meetings they were accustomed to having before Administrator BB's tenure and will have access to all resident data and assessments and will be able to better serve the facility's residents. 8. CNC RR educated both Social Workers on [DATE] on how to access resident incident reports in the EMR, confirmed by sign-in sheets and interviews. In a joint interview with the SSD and the SW on [DATE] at 2:47 p.m., they each stated Administrator BB did not allow them to access certain areas of the EMR and did not allow them to participate in the entire morning meeting process because they were not direct caregivers. They stated the non-caregivers were excused from morning meetings after they made their departmental contributions to the meetings and were not made aware of the clinical concerns that might impact their Social Services concerns. They stated they now have morning meetings and IDT meetings they were accustomed to having before Administrator BB's tenure and will have access to all resident data and assessments and will be able to better serve the facility's residents. 9. The facility developed a tool titled, Clinical Manager Meeting Agenda, to conduct daily clinical meetings. 10. In an interview with Administrator KK on [DATE] at 1:32 p.m. she stated routine morning and IDT meetings now include all the facility's departments full participation and the QAPI Committee would receive ample information from those departments to determine adequate participation, monitoring, and compliance. 11. Review of the clinical record revealed a physician's order for transfer of R#68 to the ER for behavioral assessment. 12. Correspondence was sent via email to four staffing agencies informing them of the need to educate their staff on the following topics before returning to the facility for work: abuse, resident-to-resident abuse, reporting abuse timely, falls, unwitnessed falls, and post-incident 72-hour change in condition monitoring. 13. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 14. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 15. All corrective actions were completed on [DATE]. The facility IJ was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Rules and Regulations of the State of Georgia Department 393 Rules of Georgia State Board of Long-Term Care Facility Administrators dated [DATE], and the Georgia Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, and staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality for two of 37 sampled residents (R) (R#68 and R#209) related to the failure of the Administration and clinical staff to conduct an Interdisciplinary Team (IDT) Meeting to include the Psychiatrist, Medical Director, and other direct care staff related to ensuring that all residents were safe from potential abuse by R#68 and failed to initiate neurological checks related to an unwitnessed fall for R#209. On [DATE] 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 noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE] when Resident (R) #68 forcefully pushed R#209 causing her to fall onto her bottom and her head to jerk in a sudden backward motion. The facility failed to do neuro checks related to the unwitnessed fall. On [DATE] throughout the day shift, R#209 displayed confusion, nausea/vomiting, poor appetite, erratic breathing, and became unresponsive. No thorough assessment was completed of R#209 following the altercation. On [DATE], R#209 was transferred to the local hospital and intubated/ventilated due to her erratic/ineffective breathing. She was extubated the same day due to a diagnosis of a brain bleed and was kept comfortable as there was no treatment for her diagnosis. On [DATE], R#209 was transferred to a hospice facility where she expired later that day. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: F0600 -- S/S: J -- 483.12(a)(1) Free from Abuse and Neglect F0609 -- S/S: J -- 483.12(c)(1), (4), Reporting of Alleged Violations F0657 -- S/S: J -- 483.21(b)(2) Comprehensive Care Plan Revision F0658 -- S/S: J -- 483.21(b)(3)(i) Professional Standards F0835 -- S/S: J -- 483.70 Administration An Acceptable Removal Plan was received on [DATE]. The removal plan included placing R#68 on one-to-one supervision on [DATE] and then discharging R#68 out to a behavioral health facility on [DATE]; staff training; reevaluating behavioral service needs and room placement for all residents exhibiting aggressive behaviors. The survey team conducted observations, reviewed staff training records and monitoring logs, clinical record review of revised care plans, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a lower scope and severity 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 the identification, reporting, investigation, and protection of residents from abuse. Findings include: Review of the Rules and Regulations of the State of Georgia Department 393 Rules of Georgia State Board of Long-Term Care Facility Administrators dated [DATE], revealed that: A nursing home Administrator may receive disciplinary action upon evidence that he/she (l) failed to exercise a professional regard for the safety, health, and life of the patient. Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a Physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, dialysis, specialty labs, home health care, or other such areas of practice. A review of the clinical record revealed that R#68 was admitted to the facility on [DATE] with diagnoses that include but is not limited to, end stage renal disease, unspecified dementia without behavioral disturbance, dependence on renal dialysis, and other symptoms and signs involving cognitive functions and awareness. R#68 was prescribed Aricept 5mg one by mouthy daily since admission on [DATE]. On [DATE] R#68 was evaluated by the Psychiatrist related to confusion, wandering, trying to find family, dementia history, and added that these behaviors are exhausting to R#68 and can increase chances for peer conflicts, but he is not acting depressed and is not psychotic with clear delusions, just misinterpretations and added a diagnosis of vascular neurocognitive disorder with behavior disturbance, which was not added to the list of diagnoses by the facility until [DATE] but, per the [DATE] Psychiatric note for R#68, coordination of care was discussed with nursing. Recommendations by the Psychiatrist at this time for R#68 for the Primary Care Provider (PCP) and facility staff revealed R#68 has progressing dementia with wandering and repetition, not aggressive or refusing care at this point but seems more distressed as time goes on. Nursing Home tries to provide activity and socialization but R#68 is inattentive and with dialysis is constantly changing locations which increases confusion. Will address the behaviors and anxiety it is causing with a gentle Depakote trial. Begin Depakote sprinkles 125mg by mouthy twice daily for impulsive behaviors and see if he settles. Can increase dose as needed. Follow-up in two to four months. A review of the clinical record revealed that R#209 was admitted on [DATE] with diagnoses of cerebral infarction, hyperlipidemia, essential (primary) hypertension, hypothyroidism, and unspecified atrial fibrillation. A review of the [DATE] Quarterly Minimum Data Set (MDS) Assessment for R#209 in Section (C) revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Section (E) Behaviors revealed R#209 had no behaviors. Section (G) Function Status revealed R#209 was independent with all Activities of Daily Living (ADL)s. Review of the facility Progress Notes dated [DATE] through [DATE] revealed LPN AA spoke with the responsible party and the Nurse Practitioner for R#209 on [DATE] at 4:57 p.m. following resident receiving physical aggression in hallway. R#209 assessed for injury, and none noted at this time. Superiors notified. No new orders at this time. On [DATE] at 4:08 p.m. LPN AA documented R#209 was approached by another resident and suffered an anxiety attack and retreated back to her room. R#209 stated she does not want to come back out today and doesn't want too each. This nurse sat with resident and attempted to console her. R#209 has calmed down since her initial reaction but remains somewhat anxious. On [DATE] at 9: 20 p.m. LPN AA documented R#209 was found unresponsive in room. R#209 had vomit on chest. Respirations 33, Blood Pressure 200/66, heart rate fluctuated between 84 and 129, Oxygen Saturation 84% on room air then up to 90% on 15 liters of oxygen via non-rebreather. 911 called, Emergency Medical Technician too resident to the local hospital. Review of the hospital records for R#209 dated [DATE] beginning at 9:38 p.m. revealed EMS reported they arrived at the facility and staff reported to them they found R#209 unresponsive at 9:00 p.m. Per staff, R#208 fell 2 days ago, while on Eliquis. Reported last known normal was at 8:00 p.m. and that R#209 had fallen one to two days ago after being pushed by another nursing home resident. Review of the computerized tomography (CT) scan revealed a large acute left holohemispheric subdural hematoma measures up to 4.3 centimeters in thickness along the convexity and 3.0 centimeters along the posterior falx. Severe herniation with approximately 2.4 centimeters rightward midline shift, left uncal herniation, and downward transtentorial herniation with effacement of the suprasellar cistern. Diffuse left sulcal effacement and compression of the left cerebral hemisphere. Effacement of the left lateral ventricle. The right lateral ventricle and temporal horn are dilated, concerning for ventricular entrapment. During an interview on [DATE] at 4:55 p.m. with the DON revealed for any unwitnessed fall, or fall with head injury, neuro checks should be initiated immediately. During a telephone interview on [DATE] at 9:08 a.m. with the Psychiatrist for R#68, he confirmed he had consulted with R #68 on three dates, [DATE], [DATE], and [DATE] but was not sure if he was notified about the physical aggression exhibited by R#68 in [DATE]. He revealed R#68 has dementia, cognitive impairment, walks and talks ok with intermittent periods of severity, and most days his behavior is fair but when off the Memory Unit he becomes over stimulated and confused. Psychiatrist revealed he is not always consulted related to residents being moved off the Memory Unit or if they should remain on the Memory Unit but revealed he is consulted when there are behavioral reasons that require an evaluation or consultation. He revealed if R #68 had a couple of months without incident, he might consider moving him but was not involved in the decision to move him out. Continued interview with the Psychiatrist for R #68 revealed he was treating the symptoms of R #68 and the intermittent severity with his problematic behaviors. He revealed he did not know if it was safe to move R#68 out of the Memory Unit or not but had not been notified or consulted about behaviors exhibited by R#68 while in the Memory Unit or involved in the decision related to moving R#68 out of the Memory Unit on [DATE]. Psychiatrist revealed it would be more favorable to have more people giving input related to moving R#68 out of the Memory Unit such as an Interdisciplinary Team (IDT) meeting where people involved in the care of R#68 had an input and added that he would favor being consulted prior to moving someone out of the Memory Unit. During an interview on [DATE] at 5:15 p.m. with Social Worker (SW) EE she revealed she is responsible for arranging appointments for residents and doing bed changes in the facility. She revealed Administrator BB came to her and Social Services Director (SSD) FF and said he needed a bed in the Memory Unit and that R#68 was more stable, and other residents were a greater flight risk, so he made the decision to move R#68 from the Memory Unit back to the long-term care floor to accommodate other residents During a telephone interview on [DATE] at 10:30 a.m. with previous Administrator BB he could not confirm speaking with any physician or provider involved in the care of R#68 related to moving him out of the Memory Care Unit on [DATE] but that he had a discussion with the social workers prior to moving R#68 out and added that he did not just decide on his own to move R#68 to the long-term care floor. He stated the Social Workers should have the IDT notes. He revealed he could not recall who was involved in the IDT meeting and again stated the Social Workers had the notes. During a joint interview on [DATE] at 10:55 a.m. with the SW FF and SW EE, SW FF stated she remembered the discussion of moving R#68 out of the Memory Unit on [DATE]. She revealed she and SW EE did not feel R#68 was appropriate to leave the Memory Unit because of his diagnosis of dementia and it was not good for him to be moved around so much with his level of confusion. She stated they talked to Administrator BB at that time about the concern they had related to moving R#68 out of the Memory Unit, but Administrator EE disagreed with them stating he felt another resident needed to be in the Memory Unit more than R#68 and that R#68 had not had any recent behaviors. SW FF stated, under previous Administrator BB, the non-clinical managers were dismissed from the IDT, or morning meetings, once they made their contributions, so they were not always privy to the clinical information. SW FF stated she already looked at the Psychiatrist notes/visits for R #68 trying to find documentation about his recommendations but stated there was little or no discussion in the notes related to whether to move R #68 from the Memory Unit. SW FF revealed staff would come to them, CNA's mainly, and sometimes charge nurses, to let them know what was going on with the residents but without documentation, she and SW EE did not always know what was going on unless it's discussed in the IDT or morning meetings which she and SW EE were dismissed for the clinical portion under previous Administrator BB. She stated current Administrator KK is always involved in the IDT/morning meetings and she allows everyone to stay for the duration of the meetings. There were no notes provided by the facility related to an IDT meeting discussing moving R #68 from the Memory Care Unit on [DATE] at time of exit on [DATE]. During a telephone interview on [DATE] at 12:23 p.m. with Nurse Practitioner (NP) DD she stated R#68 was in the Alzheimer's unit for a couple of months and then was moved out to the long-term care floor on [DATE], but no one discussed it with her, and she felt that resident moves in general should be discussed before moving, especially in and out of the Memory Unit. During an interview on [DATE] at 4:44 p.m. with the Medical Director he revealed he was not aware a decision was made to move R#68 out of the Memory Unit on [DATE] but stated that is a decision that should be left up to, mostly, the Psychiatrist. During an interview on [DATE] at 5:00 p.m. with current Administrator KK she revealed the facility does not have a policy or process in place by which to put a resident into the Memory Care Unit or remove a resident from the Memory Care Unit. She revealed the facility does not have anything related to policies, procedures, or guidance for the Memory Care Unit. She stated any decisions to move a resident out of the Memory Care Unit should be discussed with the Psychiatrist and the Medical Director for safety purposes and is not a decision that should be made by any one person. During an interview on [DATE] at 4:28 p.m. with Licensed Practical Nurse (LPN) AA he revealed he was working the day R#68 pushed R#209 causing her to fall. He revealed the fall was unwitnessed and upon review of the video it did not show R#209 to have hit her head but stated she did fall very hard on her bottom. LPN AA revealed the fall was unwitnessed by staff and in thinking about it, it wasn't very smart of him not to start neuro checks and he should have started them, but she appeared to be fine. He stated his concern was more related to R#68 and where they were going to put him. He revealed no vital signs were taken of R#209 until 45 minutes to an hour after her fall and that the vital signs were all fine. Continued interview with LPN AA revealed he did not know what physical Review of the clinical medical record for R#209 revealed no documented vital signs after the fall on [DATE]. During an interview on [DATE] at 2:00 p.m. with the previous employer for LPN AA revealed he was terminated due to cussing out a female resident that he did not get along with. During an interview on [DATE] at 10:00 a.m. with the Administrator, the personnel file for LPN AA was reviewed and she revealed she was not aware of the note written on the file indicating that LPN AA was a no re-hire for the facility and was not allowed to work in the facility through Agency, or that his reference check from his previous employer indicated he was terminated and was a no re-hire due to a substantiated complaint. Review of the clinical medical record for R#209 revealed there was no assessment documented related to her fall on [DATE] when she was forcefully pushed by R#68 and no neurological checks were done. Further review of the clinical medical record for R#209 revealed she was on Eliquis 5mg twice daily, a blood thinning medication. Review of the facility Job Description and Performance Evaluation for the Administrator revealed the Administrator is responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state, and local standards, guidelines and regulations and as directed by corporate office and for ensuring that the highest degree of quality patient/resident care is maintained. Marginal Functions: 3. Assist in the planning of purposeful in-service training classes and on-the-job- training programs that will lead to better understanding of patient/resident needs. 9. Review and check competence of the work force and make necessary adjustments/corrections as required or that may become necessary. 10. Receive advice from department supervisors concerning the operation of their departments, and other related areas, to assist in eliminating problem areas, author improvement of services. Review of the facility Job Description and Performance Evaluation for LPN AA revealed Data Collection: 4. Changes in patient's/resident's physical/psychological condition (i.e., changes in lab data, vital signs, mental status) are reported appropriately. Evaluation of Care: 1. Observations related to the effectiveness of nursing interventions, medications. Etc., are reported as appropriate and documented in the progress notes. General Patient/Resident Care: 2. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided. 8. Emergency situations are recognized, and appropriate action is instituted. Communication: 2. Incident Reports are completed accurately and in a timely manner. Professionalism: 1. Decisions are made that reflect knowledge and good judgment and demonstrate and awareness of patient/resident/family/physician needs. 2. Awareness of own limitations are evident, and assistance is sought when necessary. The facility implemented the following actions to remove the IJ: 1. On [DATE], the Corporate Nurse Consultant and Director of Clinical Services reviewed the facility procedures for performing neuro-checks after an incident of unwitnessed fall. No revisions were made. 2. On [DATE] at 1:00p.m., the Licensed Nursing Home Administrator facilitated the Quality Assurance and Performance Improvement (QAPI) meeting with the QAPI Committee to evaluate and review areas for improvement related to licensed nurses performing neuro-checks after an incident of unwitnessed fall. The QAPI Committee developed an action plan which include assigning a task force to address each area of concerns and initiating licensed nursing staff education. A task force was assigned to address each area of concerns, including initiation of comprehensive staff education, review or audit of facility incident reports, resident medical records, resident care plans, incidents of unwitnessed falls and tracking of staff who have received and not received the required education. 3. On [DATE], the Staff Development Coordinator and Regional Nurse Consultant initiated licensed nurse education on proper procedure for performing neuro-checks after an incident of unwitnessed fall. 4. On [DATE], the Director of Nursing and Corporate Nurse Consultant completed a review of incidents of unwitnessed fall for the past 30 days to identify if neuro-checks were initiated or completed as appropriate. Total of seven unwitnessed fall incidents were reviewed. Identified concerns were reviewed and will include in the plan for process improvements. 5. On [DATE], the facility reinforced the monitoring system by which the Director of Nursing and Unit Managers would review each incident of unwitnessed fall during the Clinical Meeting to ensure neuro-checks were initiated and completed, according to proper procedures. The Corporate Nurse Consultant provided reeducation on the system to the Director of Nursing and Unit Managers on [DATE]. 6. On [DATE], the facility initiated a monitoring system by which the Corporate Nurse Consultant will conduct a weekly review of incidents of unwitnessed fall to verify completion and documentation of neuro-checks in the medical record. 7. On [DATE], the facility implemented a procedure by which the results of the monitoring referenced above and comprehensive licensed nursing staff education would be presented to the Quality Assurance and Performance Improvement (QAPI) Committee each month by the Director of Nursing, to allow the QAPI Committee to monitor staff compliance with performing neuro-checks according to facility procedures. 8. As of [DATE], 18 out of 22 licensed nurses received the education. Four out of22 licensed nurses were not available to receive the education due to being off duty or on leave. The licensed nurses who were unavailable will receive the education upon their return to work and prior to starting his/her duties. 9. On [DATE], the Licensed Nursing Home Administrator and Regional Director of Scheduling sent communication to all contracted staffing agencies with instruction to direct their licensed nurses to receive the facility education on proper procedures for performing neuro-checks after an incident of unwitnessed fall from the facility designated educator prior to reporting to their work area. As of [DATE], six of contract licensed nurses have received the facility education. 10. As of [DATE], one RNs and 11 LPNs of contract licensed nursing staff have received the facility education. 11. As of [DATE], 28 out of 30 facility licensed nursing staff have received the education (93% of facility received the education). Two out of 30 (2RNs) facility licensed nursing staff are not available to receive the education due to being off duty or on leave. Out of the 30 staff, eight RNs out of 10 RNs and 20 LPNs out of 20 LPNs have received the education. The staff members who were unavailable will receive the education upon their return to work and prior to starting his/her duties 12. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. The Director of Clinical Services reviewed the User-Defined Assessments Staff Training tool for the neuro checks protocol on [DATE]. No revisions were made. 2. A QAPI meeting was held on [DATE] at 1:00 p.m. which included the Medical Director and included the topics of behavior modification and reporting of accidents and incidents; confirmed by sign-in sheets. 3. The facility-initiated staff education on [DATE] related to performing neuro checks with unwitnessed falls; confirmed with sign-in sheets and staff interviews. 4. The facility initiated a review of residents related to unwitnessed falls and neuro checks performed/not performed. In addition, the facility developed a weekly monitoring tool to track unwitnessed falls/suspected head injuries. 5. Re-education to the DON and Unit Managers was confirmed by sign-in sheets on [DATE]. 6. The facility developed a monitoring tool for the CNC to track unwitnessed falls and verify documentation of neuro checks in the clinical record. 7. In an interview with Administrator KK on [DATE] at 1:32 p.m. she stated routine morning and IDT meetings now include all the facility's departments full participation and the QAPI Committee would receive ample information from those departments to determine adequate participation, monitoring, and compliance. 8. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 9. Correspondence was sent via email to four staffing agencies informing them of the need to educate their staff on the following topics before returning to the facility for work: abuse, resident-to-resident abuse, reporting abuse timely, falls, unwitnessed falls, and post-incident 72-hour change in condition monitoring. 10. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 11. Confirmed by staff listings, sign-in sheets, telephone logs, and staff interviews. 12. All corrective actions were completed on [DATE]. The facility IJ was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and Administrator Job description titled, Administrator issued: [DATE]. Previous Administrator BB failed to ensure that one of 37 sampled residents (R) (R#209) was free from physical abuse by R#68. In addition, previous Administrator BB failed to ensure that all residents were safe from potential abuse by not pursuing placement for R#68 with documented behaviors of verbal and physical aggression toward residents and staff. Previous Administrator BB failed to implement an effective process to protect residents and staff from abuse. On [DATE] 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 noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of [DATE] when Resident (R) #68 forcefully pushed R#209 causing her to fall onto her bottom and her head to jerk in a sudden backward motion. The facility failed to do neuro checks related to the unwitnessed fall. On [DATE] throughout the day shift, R#209 displayed confusion, nausea/vomiting, poor appetite, erratic breathing, and became unresponsive. No thorough assessment was completed of R#209 following the altercation. On [DATE], R#209 was transferred to the local hospital and intubated/ventilated due to her erratic/ineffective breathing. She was extubated the same day due to a diagnosis of a brain bleed and was kept comfortable as there was no treatment for her diagnosis. On [DATE], R#209 was transferred to a hospice facility where she expired later that day. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: F0600 -- S/S: J -- 483.12(a)(1) Free from Abuse and Neglect F0609 -- S/S: J -- 483.12(c)(1), (4), Reporting of Alleged Violations F0657 -- S/S: J -- 483.21(b)(2) Comprehensive Care Plan Revision F0658 -- S/S: J -- 483.21(b)(3)(i) Professional Standards F0835 -- S/S: J -- 483.70 Administration An Acceptable Removal Plan was received on [DATE]. The removal plan included placing R#68 on one-to-one supervision on [DATE] and then discharging R#68 out to a behavioral health facility on [DATE]; staff training; reevaluating behavioral service needs and room placement for all residents exhibiting aggressive behaviors. The survey team conducted observations, reviewed staff training records and monitoring logs, clinical record review of revised care plans, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a lower scope and severity 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 the identification, reporting, investigation, and protection of residents from abuse. Findings include: A review of the facility's Job Description titled, Nursing Home Administrator issued 9/2003 revealed: Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state, and local standards, guidelines and regulations and as directed by corporate office and of ensuring that the highest degree of quality patient/resident care is always maintained. Review and check competence of the work force and make necessary adjustments/corrections as required or that may become necessary. A review of the admission Packet (Georgia Handbook) Revealed TEAM MEETINGS Interdisciplinary Team Meetings are held periodically to coordinate your treatment program. These meetings allow our clinical staff to share information about your progress toward stated goals and to implement a treatment program based on your needs. A review of the Rules and Regulations of the State of Georgia Department 393 Rules of Georgia State Board of Long-Term Care Facility Administrators dated [DATE], revealed that: A nursing home Administrator may receive disciplinary action upon evidence that he/she (l) failed to exercise a professional regard for the safety, health, and life of the patient. Further investigation revealed: 1. Administration failed to ensure that resident R#209 was free from physical abuse from R#68 and potential for further abuse to others by resident R#209. 2. Administration failed to ensure that all alleged violations involving abuse and neglect were reported timely. 3. Administration failed to assure revision for care plan for R#68. 4. Administration failed to ensure Professional Standards of Practice for Licensed Practical Nurse (LPN) AA to maintain professional standards of care as evidenced by lack of immediate post assessment including but not limited to vital signs, neuro checks, monitoring, and assessments for change of condition. An interview with the facility Psychiatric Services Director on [DATE] at 9:08 a.m. confirmed he had consulted with R#68 on three dates. However, he was not 100% sure if he was notified about the physical aggression in September. Continued interview revealed R#68 has dementia and a cognitive impairment. He walks and talks ok with intermittent periods of severity most days he is fair but when off the unit he becomes over simulated and confused. Continued interview revealed he is not always consulted if residents are moved off the unit or if they should stay on the unit. But revealed if there are behavioral reasons that require an evaluation or consultation method. Further revealed if he had a couple of months without problems, he might consider moving him but was not involved in the decision to move him out. Further revealed based on this case and the situation he was treating his symptoms and he had intermittent severity with his problematic behaviors. Further revealed he did not know if it was safe to move him out or not but had not been notified or consulted about the move. Further revealed it probably would be more favorable to have more people giving input. Whether that results in safety or not is hard is hard to know, but it probably would work better to have more people giving input about what to do. The physiatrist stated, Ideally, I would favor being consulted prior to the move. The Psychiatrist revealed when changing his level of stimulation dramatically he would want to know. Further revealed he was it was not discussed with him to move R#68 off the unit, and he felt it would have been more ideal to have been part of the discussion to move him off the unit. Continued interview revealed he was not consulted or made aware of R#68 moving off memory care unit. An interview with Assistant Social Services Director (SSD) EE on [DATE] at 5:15 p.m. revealed R#68 was moved from the memory unit by previous Administrator BB at his sole discretion. Further revealed the Administrator had stated they needed a bed in the Memory Unit; R#68 was more stable & other residents were a greater flight risk. Former Administrator BB (at the facility for five months) made the decision to move R#68 from the Memory Unit back to the general floor to accommodate other residents. Continued interview revealed the previous Administrator BB was more concerned about elopement than residents with aggressive behaviors. During a telephone interview on [DATE] at 10:30 a.m. with previous Administrator BB he could not confirm speaking with any physician or provider involved in the care of R#68 related to moving him out of the Memory Care Unit on [DATE] but that he had a discussion with the social workers prior to moving R#68 out and added that he did not just decide on his own to move R#68 to the long-term care floor. He stated the Social Workers should have the Interdisciplinary Team (IDT) notes. He revealed he could not recall who was involved in the IDT meeting and again stated the Social Workers had the notes. During a joint interview on [DATE] at 10:55 a.m. with the Social Worker (SW) FF and SW EE, Assistant SW FF stated she remembered the discussion of moving R#68 out of the Memory Unit on [DATE]. She revealed she and SW EE did not feel R#68 was appropriate to leave the Memory Unit because of his diagnosis of dementia and it was not good for him to be moved around so much with his level of confusion. She stated they talked to Administrator BB at that time about the concern they had related to moving R#68 out of the Memory Unit, but Administrator EE disagreed with them stating he felt another resident needed to be in the Memory Unit more than R#68 and that R#68 had not had any recent behaviors. SW EE stated the Social Worker's do not ever initiate room changes unless they are directly involved or in contact with something that has happened and added that staff usually report the need or potential need for a room change to the Social Worker's and together have a discussion as to what do. SW FF stated, under previous Administrator BB, the non-clinical managers were dismissed from the IDT, or morning meetings, once they made their contributions, so they were not always privy to the clinical information. SW FF stated she already looked at the Psychiatrist notes/visits for R#68 trying to find documentation about his recommendations but stated there was little or no discussion in the notes related to whether to move R#68 from the Memory Unit. She stated normally, after recommendations have been tried, if they're not helping then staff will try something else. SW FF stated the Psychiatrist generally writes a standard follow-up note two to four months after seeing a resident to ensure residents with behaviors, dementia, and mood issues are being seen on a regular basis and added that R#68 was seen by the Psychiatrist on a regular basis. SW FF revealed staff would come to them, Certified Nursing Assistant (CNA's) mainly, and sometimes charge nurses, to let them know what was going on with the residents but without documentation, she and SW EE did not always know what was going on unless it's discussed in the IDT or morning meetings which she and SW EE were dismissed for the clinical portion under previous Administrator BB. She stated the previous Administrator BB was always involved in the morning meetings, but Social Services were not allowed to give input or suggestions. She stated current Administrator KK is always involved in the IDT/morning meetings and she allows everyone to stay for the duration of the meetings. During a telephone interview on [DATE] at 12:23 p.m. with Nurse Practitioner (NP) DD she stated R#68 was in the Alzheimer's unit for a couple of months and then was moved out to the long-term care floor on [DATE], but no one discussed it with her, and she felt that resident moves in general should be discussed before moving, especially in and out of the Memory Unit. She stated, depending on what kind of behaviors the resident was having, it may be appropriate to move a resident from the Memory Unit, however, it's usually not good to move dementia residents too much because they become even more confused. An interview with the MDS Coordinator JJ on [DATE] at 5:10 p.m. revealed the MDS staff are responsible for updating the care plan. Further interview revealed regarding R#68 typically, the IDT team would discuss his escalating behaviors, but they haven't had traditional IDT meetings in about a year. Activities, Social Services and MDS did not have access to all the information because they were dismissed from morning meetings after they made their respective contributions. Previous Administrator BB dismissed non-direct care (SS, activities, MDS) staff to leave morning meetings while nursing staff remained to review charts. 24-hour reports were not reviewed at all in the morning meetings. In the meetings diagnosis codes, or any incident reports were discussed (falls, behaviors). The only way she knew someone went to the hospital was to review the daily census. Previous Administrator BB did not want anyone to be involved with negative or positive issues in the facility. An interview [DATE] at 9:45 a.m. with the Director of Nursing (DON) revealed the former Administrator BB dismissed many of the departments from the morning including social services, therapy dept and dietary. Further interview revealed staff had voiced concerns to her and the social services department staff of not feeling included or having a voice in the resident's care while the previous administrator oversaw the facility. Further revealed here were no formal interdisciplinary team (IDT)meetings during the previous Administration just morning stand up meetings and he was not open to discussions or suggestions about resident's care or behavior issues. An interview [DATE] 10:35 a.m. in the Social Workers office with SSD EE and Assistant SW FF revealed in the five months Administrator BB oversaw the facility they were not allowed to stay and discuss resident concerns in the morning meetings. Further interview revealed when they learned about R#68 being moved from the Memory Care Unit they went to the Administrator BB together to voice their concerns due to his diagnosis and aggressive behaviors. Continued interview revealed they were told R#68's bed was needed for a resident that was an elopement risk. Further interview revealed the Administrator had stated that a residents need to remain in the memory care unit was not as serious as someone eloping. The Social Workers revealed their concerns were dismissed by the Administrator and he would not listen to their concerns. The Social Workers both revealed the Administrator BB had great fear of residents leaving the building and possibly being ran over by a car and if a resident was seen standing by a door, he would panic and announce they are trying to leave the building. SSD FF further revealed one of R#68's moves to the Memory Care unit was because the Administrator had observed him standing looking out the door at which time the Administrator had been reminded by staff R#68 was wearing a wander guard. The Social Services staff did not agree with the previous Administrator BB's decision to move R#68 out of the memory care unit due to aggressive behaviors he had exhibited while in the unit. An interview [DATE] at 11:30a.m. with the current Administrator KK revealed in her professional opinion the decision to move residents in and out of the memory unit should not be the sole decision of the Administrator. Further interview revealed the decision should be discussed with the staff caring for the resident, social workers, along with the psychiatrist and or physician. Continued interview revealed the resident's history and diagnosis should be considered before moving a resident. The facility implemented the following actions to remove the IJ: 1. On [DATE], in consultation with the physician and family, R#68 was placed in a private single room, under one-on-one staff supervision. 2. On [DATE], the Licensed Nursing Home Administrator provided one-on-one education to the licensed nurse assigned to R#68 at the time of the incident on [DATE]. Education included proper and timely reporting of resident incidents to facility administrator for additional guidance on appropriate interventions. 3. On [DATE], the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were provided education by the Corporate Nurse Consultant on facility policy on Abuse, Neglect, and Exploitation and State and Federal Regulations related to proper procedures for reporting allegations of abuse. The LNHA is the Facility Abuse Coordinator. 4. On [DATE] at 6:00 p.m., Licensed Nursing Home Administrator facilitated an Adhoc Quality Assurance and Performance Improvement (QAPI) Committee meeting to include discussions and review of Immediate Jeopardy citations and delegation of tasks. Assigned teams included Staff Education team (Staff Development Coordinator, Corporate Nurse Consultant, and Director of Nursing); Audit Team (MDS coordinators, Medical Record Director, Social Workers, and Unit Managers); and Policy Review Team (Administrator, Corporate Nurse Consultant, Director of Clinical Services, Corporate MDS Consultant). 5. On [DATE], a facility wide review of resident condition was conducted to identify appropriate room placement, specifically of residents with actual and/or potential physical and/or verbal aggression. Three residents were identified. One of the residents was R#68 who was placed under one-on-one staff supervision on [DATE]. A male resident was identified who is currently residing in the memory care unit as appropriate. A female resident was identified who is currently residing in the general population in a room by herself which is appropriate at this time. 6. On [DATE] at 3:00 p.m., the Licensed Nursing Home Administrator facilitated an Adhoc Quality Assurance and Performance Improvement (QAPI) Committee meeting to evaluate the progress of comprehensive staff education, to review the medical record audit findings and revisions made, and to create a task force responsible for appropriate room placement of residents. The Licensed Nursing Home Administrator reviewed the process of initiating a transfer of a resident through 1013 with the QAPI Committee. 7. On [DATE] Licensed Nursing Home Administrator and Corporate Nurse Consultant provided re-education to the licensed nurse assigned to R#68 at the time of the incident on [DATE] on proper evaluation of resident after a fall which include procedures for conducting neuro-checks and evaluation for changes in condition and timely interventions and reporting to appropriate supervisors. 8. R#68 no longer resides at the facility. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. The room change was confirmed with a Change of Room or Roommate Form for R#68 dated [DATE]. 2. The Administrator provided one on one education on [DATE] to the nurse attending to R#209 on [DATE] and [DATE], confirmed by sign-in sheet and interviews. 3. The CNC provided education to the Administrator, DON, and onboarding DON on the Abuse, Neglect, and Exploitation facility policy and state/federal regulations related to timely reporting; confirmed by sign-in sheet and interviews. 4. The Ad hoc QAPI meeting of [DATE] at 6:00 p.m. was confirmed by sign-in sheets and staff interviews. 5. The facility staff printed a census to guide them in the review of appropriate room placement. Confirmed by staff interviews. 6. The Ad hoc QAPI Committee meeting was held on [DATE] at 3:00 p.m. confirmed by sign-in sheets and staff interviews. 7. LPN AA was reeducated on [DATE]. 8. All corrective actions were completed on [DATE]. The facility IJ was removed on [DATE].