**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, staff, paramedic, and physician interview the facility failed to notify the physician regarding a significant change in condition for one (Resident # 3) of two sampled residents. On the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed signs Resident # 3 was experiencing a significant change in condition including a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. The physician was not notified when staff noted the change in condition. Resident # 3 was found in the afternoon on 9/27/23 unresponsive, with a temperature reading of 102 Fahrenheit, and using accessory respiratory muscles to breathe (muscles other than the diaphragm and muscles within the rib cage which are used in labored breathing.) Resident #3's condition had declined to the point where Emergency Medical Services (EMS) was called, and Resident # 3 was transferred to the hospital where he was admitted to the hospital Intensive Care Unit (ICU) with severe sepsis with septic shock (when a person is not getting enough blood flow through their body). Immediate Jeopardy began on 9/27/23 when staff members observed but failed to notify the physician that Resident # 3 was experiencing a change in condition which resulted in the resident's admission to the hospital ICU with sepsis and septic shock. Immediate Jeopardy was removed on 12/7/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident # 3 was admitted to the facility on [DATE] with diagnoses which in part included spinal stenosis and functional mobility problems, and neurogenic bladder with a chronic indwelling catheter. A review of hospital records revealed Resident # 3 was hospitalized from [DATE] to 7/18/23 with sepsis due to a urinary tract infection caused by obstructive nephrolithiasis (kidney stones). A stent was placed at that time. Resident # 3's quarterly MDS (Minimum Data Set) assessment, dated 7/21/23 coded Resident # 3 as cognitively intact and as having an indwelling catheter. According to hospital records, Resident # 3 was hospitalized again from 7/29/23 until 8/2/23 with a urinary tract infection and sepsis. On 9/27/23 at 7:10 AM Resident # 3's vital signs were documented as the following by Nurse # 2. Temperature 98; pulse 76; respirations 18; blood pressure 128/62. NA (Nurse Aide) # 1 was the NA who had cared for Resident # 3 on 9/27/23. NA # 1 was interviewed on 11/29/23 at 9:05 AM and reported the following. She had taken his vital signs that morning and they were low. His systolic blood pressure was below 100 and his diastolic was also low. She took them twice to make sure they were registering. She did not enter them into the record. She told Nurse # 2, Resident #3's assigned nurse, about them. Usually, Resident # 3 did not eat breakfast, but he always asked for coffee and would drink it. That morning he did not ask for or drink coffee. He seemed off. Around 10 AM, she bathed him. Normally he was very alert and would carry on a full conversation during his care. He normally would also assist to turn in the bed and hold onto the rail. That morning, he was not doing nothing. His eyes would open a little bit and then close. He would mumble but not carry on a full conversation. He also had blood in his catheter bag. She told Nurse # 2 how he was acting and that he had blood in his catheter bag. That morning the treatment nurse also went into Resident # 3's room to do wound treatments for him. She told the treatment nurse also that Resident # 3 was not acting right. This was before lunch. Nurse # 3 said she would tell Nurse # 1. At lunch time Resident # 3 did not eat anything and she was still concerned. She was hoping they would send him to the hospital. Nurse # 1 did come to check him in the afternoon, and he was sent out. Nurse # 1 asked her (NA # 1) why she had not let her know sooner about his condition, and she informed her that she had been alerting Nurse # 2 throughout the day. Nurse # 3 was interviewed on 11/29/23 at 10:15 AM and reported the following. She went to provide wound treatments to Resident # 3 sometime between 10 AM and lunch on 9/27/23. Usually, Resident # 3 would initiate conversation on his own when you entered his room. That morning he did not do so. She could not engage him in conversation. If she would say, Hey (Resident # 3), he would just say, ah . in a slurred way. His speech was slurred, and he was sluggish. Normally he would help them turn, but he did not help that AM turn for treatments. She knew something was not right with him. NA # 1 also told her he had not been acting right. After she left the room, she went to Nurse # 2 and told her, You better check on (Resident # 3). He's not acting right. Nurse # 2 told her that it had taken her awhile to get him to take his morning medications, but he took them, and he was on an antibiotic. She had also said she would check on him. According to Nurse # 3, if Resident # 3 had been assigned to her then she would have called the provider at that point in the morning given the change she had seen in Resident # 3 and alerted the provider about the change. The treatment nurse stated she would have asked the physician if he wanted to do labs or send the resident out for evaluation. She thought that was what Nurse # 2 was going to do after she spoke to Nurse # 2 in the morning. Therefore, she went on to do her treatments. Later after lunch she returned, and NA # 1 again told her Resident # 3 still was not right and Nurse # 2 had not done anything. At that point, Nurse # 3 stated she went to Nurse # 1 and Nurse # 1 immediately went to check on Resident # 3. Nurse # 1 was interviewed on 11/29/23 at 4:30 PM and reported the following. Nurse # 1 stated she was the rehabilitation nurse manager, but also served as the point of contact for the unit where Resident # 3 resided. On 9/27/23 she had been in her office when Nurse # 3 alerted her Resident # 3 was not acting right. She went right away to check on him. It was around 3:00 or 4:00 PM when she was alerted. When she assessed him, she found he could not talk and would not follow commands, but he did respond to a sternal rub a little. She immediately had him sent to the hospital. Nurse # 2 was interviewed on 11/28/23 at 3:00 PM and again on 11/29/23 at 5:30 PM and reported the following. It was not unusual for Resident # 3 to be groggy or sleepy in the AM. She did not recall all the specific details of 9/27/23. She just recalled Resident # 3 took his medications that morning, throughout the day she was in and out to check on him, and he was eventually sent out because he was not responding. She did not recall if she took his vital signs as she was in and out checking on him. There was no documentation the physician was notified of Resident # 3's change in condition which Nurse # 3 and NA # 1 had observed before lunch on 9/27/23. On 9/27/23 at 5:03 PM, Nurse # 1 entered the following entry into the record. Resident was found in his bed in the supine position [on his back] with mouth agape [open] and using his accessory muscles to breathe. He had blood tinge urine as well. Resident would not respond to his name or sternum rub. Writer [Nurse #1] immediately called 911 and went to grab the AED [automated external defibrillator]. Writer [Nurse #1] held pt [patient] airway opened until EMS [Emergency Medical Services] arrived. Resident BP [blood pressure] was very low and he was clammy and hot. He had a fever of 102 and BP was 82/46. NP [Nurse Practitioner] [Name of Nurse Practitioner] was notified of the emergency transfer out to the ER [Emergency Room]. Resident # 3's 9/27/23 EMS records revealed EMS received the facility's call at 2:53 PM and arrived on the scene at 3:02 PM. They noted the following in their EMS assessment. At 3:05 PM Resident #3's vital signs were BP 84/53; pulse 94; respirations 19 and oxygen level 93%. The resident's temperature was 102.1 degrees Fahrenheit. There was visible blood in Resident # 3's catheter. Upon initial EMS arrival, Resident # 3 was unresponsive, and his skin was hot. He was moved to the stretcher, and once on the stretcher, he opened his eyes briefly. Several IV (intravenous attempts) were made, and a successful IV was established. The resident began to respond to voice, but only with one- word answers. The Lead Paramedic that had responded on 9/27/23 was interviewed on 12/4/23 at 4:30 PM and reported the following. She had been concerned he might not live given his condition. Review of Resident # 3's emergency room notes revealed the physician documented EMS reported, they [EMS] state staff at facility was unable to answer most of her [the paramedic's] questions about what baseline is. Resident # 3's hospital admission history and physical revealed the physician noted the following information on 9/27/23. In the emergency room Resident # 3's blood pressure was 64/36; heart rate 118, respirations 23 and temperature 39.6 degrees Celsius. (103.28 Fahrenheit). His WBC (white blood count) was high at 28 (normal range 4.2 to 10.9). The physician noted Resident # 3 was obtunded and met the criteria for septic shock. The physician also noted his hypotension did not respond to fluid resuscitation and he was given Levophed (a medication that can raise the blood pressure in septic shock). A central line (a catheter line placed in the large vein above the heart for fluids and medications) was placed and the resident was given antibiotics. Resident # 3 was hospitalized for treatment in the Intensive Care Unit. He remained In ICU until 10/1/23. He remained hospitalized until 10/4/23. Resident # 3's 10/4/23 hospital discharge summary listed Resident # 3's first two discharge diagnoses as septic shock and urinary catheter associated urinary tract infection. The discharge summary also noted, His AMS [altered mental status] was resolved after receiving antimicrobials, etiology due to sepsis. (The reason for the altered mental status was due to sepsis.) On 10/4/23, Resident # 3 was transferred back to the facility for care. Resident # 3's physician was interviewed on 12/4/23 at 11:11 AM. NA # 1 and Nurse # 3's 9/27/23 observations were shared with the physician. The physician reported the following. Based on the observations of NA # 1 and Nurse # 3, it did appear Resident # 3 experienced a change in condition on the AM of 9/27/23 and he should have been notified in the morning of 9/27/23. Resident # 3's physician was interviewed regarding possible danger if the facility staff delayed in notifying the provider about changes in condition in residents. According to the physician the outcome of a delay in physician notification could be different on a case-by-case scenario. On 12/5/23 at 2:56 PM the Administrator was informed of Immediate Jeopardy and subsequently provided the following Immediate Jeopardy removal plan. Removal Plan F580 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #3 was found nonresponsive by the lead nurse on the afternoon of 9/27/23. Resident was discharged to the hospital via Emergency Medical Services at 2:53 p.m. Resident #3 is currently a resident of the facility and had no noted change of condition when assessed by the Director of Nurses when readmitted to the facility on [DATE] or on 12/05/2023. Current residents are at risk of experiencing a change in condition that requires assessment and notification of the physician. On 12/5/2023, the Director of Nurses met with all floor nurses and initiated assessment of all current residents to identify any resident with any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where physician notification of the resident change in condition was delayed. 4 of 86 current residents were assessed by the assigned nurse or Director of Nurses and identified as having a new change in condition and the physician was notified on 12/5/23 by the assigned nurse or Director of Nurses. On 12/06/2023 the Regional Nurse Consultant audited all residents transferred to the hospital in the last 30 days (11/01/2023- 12/06/2023) for timely notification of the physician. The physician of all 13 residents who were transferred to the hospital was notified when the change in condition was observed by the attending nurse. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/05/2023 the Director of Nurses/Nurse Consultant and Staff Development Coordinator began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN), certified nursing assistants and medication aides (full time, part time, and as needed, including agency) on any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Additional education included, if resident's condition worsened and nurse's assessment warrants, the nurse is to activate emergency medical services. At the time the change is observed, the Physician and family/responsible party are to be notified to ensure the resident receives the care needed to address the change. The Director of Nurses will ensure that all licensed nurses, RN's, LPN's, and CNA's, Med Aides (full time, part time, and as needed including agency) who do not complete the in-service training by 12/06/2023 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and as needed including agency.) Alleged date of IJ removal 12/07/2023 Onsite validation of the immediate jeopardy removal plan was completed on 12/8/23. Documentation of all the residents' assessments for change in condition on 12/5/23 were reviewed and verified the physician was notified for the four residents identified with changes in condition and verbal orders were received and implemented as determined necessary by the physician. Nursing staff (licensed practical nurses, registered nurses, nurse aides, medication aides) who worked different shifts were interviewed and verified they had received training on what constituted a change in condition, the steps to take when a change in condition is first identified, and steps to take if a change in condition worsened to include activation of emergency medical services. Inservice sign-in logs verified the education was provided as indicated. This education was confirmed to be added to the new employee facility and agency orientation for licensed and unlicensed nursing staff. The facility's immediate jeopardy removal date of 12/7/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, staff, paramedic, and physician interview the facility failed to effectively assess and address a significant change in condition for one (Resident # 3) of two sampled residents whose condition necessitated Emergency Medical Services (EMS) to be called. Resident # 3 had a history of sepsis (when an infection triggers widespread inflammation in a person's body which can lead to organ damage) and on the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed Resident # 3 was experiencing a change in condition prior to the lunch meal that included: a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. Resident # 3 was found in the afternoon on 9/27/23 unresponsive, with a temperature reading of 102 degrees Fahrenheit, and using accessory respiratory muscles to breathe (muscles other than the diaphragm and muscles within the rib cage which are used in labored breathing). EMS was called at 2:53 PM. Upon their arrival, EMS also found Resident # 3 to be unresponsive and with what appeared as an undissolved pill in the resident's mouth. Resident # 3 was transferred by EMS to the hospital where he was admitted to the hospital Intensive Care Unit (ICU) with severe sepsis with septic shock (when a person is not getting enough blood flow through their body). Immediate Jeopardy began on 9/27/23 when staff failed to comprehensively assess Resident # 3 after a significant change in condition was noted to determine if medical interventions were necessary. Immediate Jeopardy was removed on 12/7/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident # 3 was admitted to the facility on [DATE] with diagnoses which in part included spinal stenosis and functional mobility problems. Additionally, the resident had a diagnosis of neurogenic bladder with a chronic indwelling catheter. A review of hospital records revealed Resident # 3 was hospitalized from [DATE] to 7/18/23 with sepsis due to a urinary tract infection caused by obstructive nephrolithiasis (kidney stones). A stent (a tube used to hold open a bodily passage) was placed at that time. Resident # 3's quarterly MDS (Minimum Data Set) assessment, dated 7/21/23 coded Resident # 3 as cognitively intact and as having an indwelling catheter. Resident # 3 was also coded as having clear speech, able to feed himself after set up, able to perform his oral care with supervision, and required substantial/maximum assistance with bathing and bed mobility. According to hospital records, Resident # 3 was hospitalized again from 7/29/23 until 8/2/23 with a urinary tract infection and sepsis. On 8/2/23 Resident # 3 was ordered to receive Methenamine Hippurate 1 gram two times per day. (A medication used to prevent returning urinary tract infections). This remained as an active order through 9/27/23. Resident # 3's care plan, updated on 8/10/23, revealed staff had noted Resident # 3 had recurrent urinary tract infections and included this on the care plan update of 8/10/23. One of the interventions was to monitor the resident for symptoms of altered mental status, behavioral changes, and hematuria (bloody urine). On 9/27/23 at 7:10 AM Resident # 3's vital signs were documented as the following by Nurse # 2. Temperature 98; pulse 76; respirations 18; blood pressure 128/62. NA (Nurse Aide) # 1 was the NA who had cared for Resident # 3 on 9/27/23. NA # 1 was interviewed on 11/29/23 at 9:05 AM and reported the following. She had taken his vital signs that morning and they were low. His systolic blood pressure was below 100 and his diastolic was also low. She took them twice to make sure they were registering. She did not enter them into the record and instead reported them to Nurse # 2 as this was the normal protocol. Usually, Resident # 3 did not eat breakfast, but he always asked for coffee and would drink it. That morning he did not ask for or drink coffee. He seemed off. Around 10 AM, she bathed him. Normally he was very alert and would carry on a full conversation during his care. He normally would also assist to turn in the bed and hold onto the rail. That morning, he was not doing nothing. His eyes would open a little bit and then close. He would mumble but not carry on a full conversation. He also had blood in his catheter bag. She told Nurse # 2, Resident # 3's assigned nurse, how he was acting and that he had blood in his catheter bag. That morning the treatment nurse, Nurse #3, also went into Resident # 3's room to do wound treatments for him. She also told Nurse # 3 that Resident # 3 was not acting right. This was before lunch. Nurse # 3 said she would tell Nurse # 1. At lunch time Resident # 3 did not eat anything and she was still concerned. She was hoping they would send him to the hospital. Nurse # 1 did come check him in the afternoon and he was sent out. Nurse # 1, a nurse manager, asked her (NA # 1) why she had not let her know sooner about his condition, and she informed her that she had been alerting Nurse # 2 throughout the day. Nurse # 3 was interviewed on 11/29/23 at 10:15 AM and reported the following. She went to provide wound treatments to Resident # 3 sometime between 10 AM and lunch on 9/27/23. Usually, Resident # 3 would initiate conversation on his own when you entered his room. That morning he did not do so. She could not engage him in conversation. If she would say, Hey [Resident # 3], he would just say, ah . in a slurred way. His speech was slurred, and he was sluggish. Normally he would help them turn, but he did not help that morning with turning for treatments. She knew something was not right with him. NA # 1 also told her he had not been acting right. After she left the room, she went to Nurse # 2 (Resident # 3's assigned nurse) and told her, You better check on [Resident # 3]. He's not acting right. Nurse # 2 told her that it had taken her awhile to get him to take his morning medications, but he took them and he was on an antibiotic. She (Nurse # 2) had also said she would check on him. According to Nurse # 3, if Resident # 3 had been assigned to her then she would have called the provider at that point in the morning given the change she had seen in Resident # 3 and alerted the provider about the change. She thought that was what Nurse # 2 was going to do after she spoke to Nurse # 2 in the morning. Therefore, she went on to do her treatments. Later after lunch she returned to Resident #3's unit and NA # 1 again told her Resident # 3 still was not right and Nurse # 2 had not done anything. At that point, Nurse # 3 stated she went to Nurse # 1 and Nurse # 1 immediately went to check on Resident # 3. Nurse # 1 was interviewed on 11/29/23 at 4:30 PM and reported the following. Nurse # 1 stated she was the rehabilitation nurse manager, but also served as point of contact for the unit where Resident # 3 resided. On 9/27/23 she had been in her office when Nurse # 3 alerted her Resident # 3 was not acting right. She went right away to check on him. It was around 3:00 or 4:00 PM when she was alerted. When she assessed him, she found he could not talk and would not follow commands but he did respond to a sternal rub a little. She immediately had him sent out to the emergency room (ER). Nurse # 2 was interviewed on 11/28/23 at 3:00 PM and again on 11/29/23 at 5:30 PM and reported the following about 9/27/23. It was not unusual for Resident # 3 to be groggy or sleepy in the morning. She just recalled Resident # 3 took his medications that morning, throughout the day she was in and out to check on him, and he was eventually sent out because he was not responding. She did not recall if she took his vital signs as she was in and out checking on him and did not recall the actions she took while checking in on him. There was no further nursing assessment, progress note, or vital signs noted in Resident # 3's record after 7:10 AM on 9/27/23 until the following note was documented at 5:03 PM by Nurse # 1. On 9/27/23 at 5:03 PM, Nurse # 1 entered the following entry into Resident #3's record. Resident was found in his bed in the supine [on his back] position with mouth agape [open] and using his accessory muscles to breathe. He had blood tinge urine as well. Resident would not respond to his name or sternum rub. Writer immediately called 911 and went to grab the AED (automated external defibrillator). Writer held pt [patient] airway opened until EMS (emergency medical services) arrived. Resident BP (blood pressure) was very low and he was clammy and hot. He had a fever of 102 and bp (blood pressure) was 82/46. NP [Name of Nurse Practitioner] was notified of the emergency transfer out to the ER. Resident # 3's 9/27/23 EMS records revealed EMS received the facility's call at 2:53 PM and arrived on the scene at 3:02 PM. They noted the following in their EMS assessment. At 3:05 PM Resident #3's vital signs were BP 84/53; pulse 94; respirations 19 and oxygen level 93%. The resident's temperature was 102.1. There was visible blood in Resident # 3's catheter. Upon initial EMS arrival, Resident # 3 was unresponsive and his skin was hot. He was moved to the stretcher, and once on the stretcher, he opened his eyes briefly. Several IV (intravenous attempts) were made, and a successful IV was established. The resident began to respond to voice, but only with one- word answers. The Paramedic further noted, while assessing the resident, EMS noticed, what looked like an undissolved pill in the patient's mouth. The hospital was made aware of this when transferring patient care. The Lead Paramedic that had responded on 9/27/23 was interviewed on 12/4/23 at 4:30 PM and reported the following. From her assessment at arrival to the facility, she had thought Resident # 3 could be septic. In route to the hospital, they had noticed what appeared to be a pill in his mouth that had not completely dissolved. She had been concerned he might not live given his condition. Review of Resident # 3's hospital record revealed on 9/27/23 the physician documented EMS reported, they [EMS] state staff at facility was unable to answer most of her [the paramedic's] questions about what baseline is. Resident # 3's hospital admission history and physical revealed the physician noted the following information on 9/27/23. In the emergency room Resident # 3's blood pressure was 64/36; heart rate 118, respirations 23 and temperature 39.6 degrees Celsius (103.28 Fahrenheit). His WBC (white blood count) was 28 (normal range 4.2 to 10.9) . The physician noted Resident # 3 was obtunded (decreased level of consciousness) and met the criteria for septic shock. The physician also noted his hypotension did not respond to fluid resuscitation and he was given Levophed (a medication that can raise the blood pressure in septic shock). A central line (a catheter line placed in the large vein above the heart for fluids and medications) was placed, and Resident # 3 was given antibiotics. Resident # 3 was hospitalized for treatment in the Intensive Care Unit. He remained In ICU until 10/1/23. He remained hospitalized until 10/4/23. Resident # 3's 10/4/23 hospital discharge summary listed Resident # 3's first two discharge diagnoses as septic shock and indwelling catheter associated urinary tract infection. The discharge summary also noted His AMS [altered mental status] was resolved after receiving antimicrobials, etiology due to sepsis. He was directed to follow up with a urologist following discharge and placed on a medication to help with hypotension (Midodrine). On 10/4/23, Resident # 3 was transferred back to the facility for care. Resident # 3 was interviewed on 11/28/23 at 2:10 PM. During the interview, Resident # 3 was observed to be very alert, articulate in his conversation, and capable of using his hands and arms to use his cell phone and access information during the interview. Resident # 4 reported the following. He had been concerned that the facility staff did not send him to the hospital earlier on 9/27/23. He had already had other urinary tract infections that had made him very sick. Nurse # 2 had given him his morning medications that day and he did not recall anything after that. After he recovered, NA # 1 had later told him that she could not get him to wake up during the morning on 9/27/23 and had alerted Nurse # 2 about this. He was concerned that when NA # 1 could not arouse him that nothing had been done at that point. The DON (Director of Nursing) was interviewed on 11/29/23 at 11:00 AM and reported the following. She had reviewed Resident # 3's record and found no evidence of an assessment or vital signs being taken after the vital signs at 7:10 AM on 9/27/23. It would be her expectation that the resident would have been assessed when a change was observed, and she wished he had been sent out sooner. Resident # 3's physician was interviewed on 12/4/23 at 11:11 AM. NA # 1 and Nurse # 3's 9/27/23 observations were shared with the physician. The physician reported it was the expectation that an assessment needed to be done when a change in condition was noted, and from NA #1's and Nurse # 3's observations it appeared Resident # 3 had experienced a change prior to lunch on 9/27/23. On 12/5/23 at 2:56 PM the Administrator was informed of Immediate Jeopardy. The facility provided the following Immediate Jeopardy (IJ) removal plan. Removal Plan F684 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #3 was found nonresponsive by the lead nurse on the afternoon of 9/27/23. Resident was discharged to the hospital via Emergency Medical Services at 2:53 p.m. Resident #3 is currently a resident of the facility and had no noted change of condition when assessed by the Director of Nurses when readmitted to the facility on [DATE] and on 12/05/2023. Current residents are at risk of experiencing a change in condition that requires assessment and notification of the physician. On 12/5/2023, the Director of Nurses met with all floor nurses and initiated assessment of all current residents to identify any resident with any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. 4 of 86 current residents were identified by the assigned nurse or Director of Nurses as having a new change in condition. Notification of the Physician was conducted at the time the change was observed. The attending Physician gave verbal orders related the individual resident's change as he determined necessary on 12/5/23. The responsible party/family was notified of this change and new orders prescribed after speaking with the Physician. The orders were carried out as prescribed on 12/5/23. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/05/2023 the Director of Nurses/Nurse Consultant and Staff Development Coordinator began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN), certified nursing assistants and medication aides (full time, part time, and prn including agency) on any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Additional education included, if resident's condition worsened and nurse's assessment warrants, the nurse is to activate emergency medical services. At the time the change is observed, the Physician and family/responsible party are to be notified to ensure the resident receives the care needed to address the change. The Director of Nurses will ensure that all licensed nurses, RN's, LPN's, and CNA's, Med Aides (full time, part time, and prn including agency) who do not complete the in-service training by 12/06/2023 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency.) Alleged date of IJ removal 12/07/2023 Onsite validation of the immediate jeopardy removal plan was completed on 12/8/23. Documentation of all the residents' assessments for change in condition on 12/5/23 were reviewed and verified the physician was notified for the four residents identified with changes in condition and verbal orders were received and implemented as determined necessary by the physician. Nursing staff (licensed practical nurses, registered nurses, nurse aides, medication aides) who worked different shifts were interviewed and verified they had received training on what constituted a change in condition, the steps to take when a change in condition is first identified, and steps to take if a change in condition worsened to include activation of emergency medical services. Inservice sign-in logs verified the education was provided as indicated. This education was confirmed to be added to the new employee facility and agency orientation for licensed and unlicensed nursing staff. The facility's immediate jeopardy removal date of 12/7/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interviews, and staff interviews the facility failed to protect the rights of two residents (Resident # 5 and Resident # 6) to be free of abuse. Following a verbal altercation, Resident # 6, who was cognitively intact, reported feeling threatened by Resident # 5, who was cognitively impaired. Resident # 6 and Resident # 5 then became involved in a physical fight during which Resident # 6 held Resident # 5 down on his bed by Resident # 5's neck and hit him multiple times in the face. Resident # 5 sustained scratches to his neck and finger. This was for two of three sampled residents reviewed for abuse. The findings included: Record review revealed Resident # 5 was admitted to the facility on [DATE]. Resident # 5's diagnoses in part included dementia, depression, diabetes, and history of right lower leg amputation and history of left foot amputation for which he used prosthetic devices. Resident # 5's annual Minimum Data Set assessment, dated 3/8/23, revealed Resident # 5 was severely cognitively impaired. He was coded as being independent in his locomotion around the unit on which he resided. Resident # 5 was not coded as having behavioral problems. Record review revealed Resident # 6 was admitted to the facility on [DATE]. Resident # 6's diagnoses in part included cancer, chronic obstructive pulmonary disease, and a history of heart attack. Resident # 6's quarterly Minimum Data Set assessment, dated 5/17/23, coded Resident # 6 as cognitively intact. He was assessed to need oversight supervision for locomotion around the unit on which he resided. He was not assessed to have behavioral problems. Review of Resident # 6 and Resident # 5's records revealed they shared a room together up until the date of 5/18/23. On 5/18/23 at 10:19 PM Nurse # 1 made the following entry into Resident # 5's record. Writer was attempting to give insulin. Resident stated 'No, I'm not taking that I just received that, get the (expletive) on.' Writer attempted to explain the type of insulin being given. Resident stated 'dumb (expletive) I'm not taking it.' Writer exited. Writer heard roommate state 'Stop talking to the nurses like that.' (Resident # 5) stated 'well if you don't like it come on over and do something about it.' (Resident # 5) then stated 'I'm sick of your mouth and theirs.' After that statement residents connected physically. Review of the facility's investigative file regarding the 5/18/23 incident revealed the following written statement by Nurse # 1. At around 8 PM writer was passing medication. Once I got to (Resident # 5's room) he allowed me to take his blood sugar. Insulin offered. Resident stated 'What the (expletive) are you giving me?' Writer explained what insulin it was, he then proceeded to say 'No I'm not taking that get the (expletive) on.' He again stated 'dumb (expletive) nurses I'm not taking that.' I then exited the room. I then started giving medication to (Resident #6). Once his medication was given, they proceeded to talk. Writer overheard (Resident # 6) state 'Stop talking to the nurses like that.' (Resident # 5) stated 'well if you don't like it come over and do something about it.' A few minutes later I could hear what sounded like hits landed. I walked in and noticed (Resident # 6) on top of (Resident # 5) with his left hand around his neck and the right hand punching him. (Resident # 5) did hit back. After a few minutes I was able to separate the two. (Resident # 5) was placed in TV room until police came into the facility. According to Resident # 5's record and the facility's investigative file, Resident # 5 was moved to a private room and did not reside with Resident # 6 following the altercation. On 5/18/23 at 10:16 AM Nurse # 3, who worked as the facility social worker, noted the following. On 5/18/23, she had talked to Resident # 5, who stated he did not recall anything about the altercation and did not know who Resident # 6 was. Resident # 5 also reported he did not recall talking to the police. He further reported to Nurse # 3 that if everyone just leaves me alone everything will be fine. Nurse # 3 noted a referral was sent to for psychological services. Nurse # 3 noted she visited to check on Resident # 5 again on 5/22/23, 5/24/23, and 5/25/23. In Nurse # 3's 5/25/23 notation, she documented that Resident # 5 was sick of being asked questions about the incident. He continued to deny he knew Resident # 6. On 5/25/23 Resident # 5 was seen for a comprehensive psychotherapy assessment. Review of the therapist's report revealed Resident # 5 reported he did not recall any memory of an altercation. The psychotherapist further noted the following. He was alert to person and place, but not fully oriented to time or situation. He had cognitive decline. During the conversation with the therapist he would at times rock back and forth while sitting on his bed and crying. He answered some of the therapist's questions and then concluded with her by saying, 'I am through talking with you.' The therapist noted that his loss of independence and his environment were contributing to depression. On 5/18/23 at 10:22 AM Nurse # 3 noted she also visited with Resident # 6 and spoke to him about the incident. Nurse # 3 documented that Resident # 6 reported the following to her. Resident # 5 was cursing at the staff, and he asked Resident # 5 to stop being ugly to the staff. Resident # 5 then told Resident # 6 to come over and make him stop. Words were exchanged between the two of them. Then Resident # 5 walked towards his (Resident #6's) bed and he (Resident # 6) felt endangered and stood up himself. Resident # 6 did not recall much following that. Nurse # 3 further noted that Resident # 6 was very soft spoken and appeared upset about the incident while stating, 'I don't want to get in trouble. He's (Resident # 5) mean to the staff.' Nurse # 3 concluded her notation by documenting that an emergency psychiatric referral was made for Resident # 6. According to the facility's investigative file, Resident # 5 had sustained the following injuries: a small scratch to his neck, redness to both lateral sides of his neck , 3 small scratches to his left ring finger with some swelling. Resident # 6 had not sustained injuries. Review of a police report noting the incident revealed the following information. The police officer had responded on 5/18/23 at 8:10 PM. The police officer noted he had spoken to Resident # 5 who stated he had gotten into a fight with Resident # 6 because he was tired of hearing his mouth. The police officer also spoke to Resident # 6 and noted Resident # 6 reported Resident # 5 was being disrespectful to the nurses and he had told him to relax and let the nurses help him. Then Resident # 6 stated he had enough of Resident # 5's mouth and got into a fight with him. The officer noted Resident # 5 was bleeding from his neck and left pinky finger due to a scratch. Nurse # 1 was interviewed on 5/31/23 at 4:25 PM and reported the following about the incident. Resident # 5 and Resident # 6 had no history of prior altercations of which she was aware. Resident # 5 could at times curse at staff, but not at residents. Resident # 6 had no history of aggressive behavior. Both the residents had been sitting on their own beds when she left the room on the night of the incident. After she left the room, she did hear them continue to talk from the hallway, but Resident # 6 used a rollator walker to move around and at times needed oxygen. Resident # 5 used prosthetic devices. She thought it was just talk between them. Then she heard a noise as if someone was hitting someone. She went immediately into the room. When she entered Resident # 6 was not physically on top of Resident # 5. Rather, Resident # 6 was standing over the top of Resident # 5 while Resident # 5 was in his bed. Resident # 6 was holding Resident # 5 down with his left hand. Resident # 6 had done this by cupping his left hand around Resident # 5's neck. It was clear to Nurse # 1 that Resident # 6 was not trying to strangle Resident # 5 but had positioned his left hand to hold him down. She (Nurse # 1) witnessed Resident # 6 use his right hand to punch Resident # 5 on the left side of Resident # 5's face. Resident # 6 did this about four times. Resident # 5 was also hitting back. She (Nurse # 1) witnessed Resident # 5 hitting Resident # 6 in the torso about two times. She yelled at them to stop, and it took about one minute and she was able to get them to stop. They were separated and the police were called. The police tried to ascertain who had hit who first, but could not determine that. At the time of the police arrival, Resident # 5 wanted to continue fighting. Following the altercation, Resident # 5 had some scratches to his finger and neck, with a little blood from his finger scratch. Resident # 6 had no injuries. According to the nurse, there was nothing that signified to her that the incident would have occurred before it actually did. Nurse # 2 was interviewed on 5/31/23 at 12:30 PM. Nurse # 2 had routinely cared for both Resident # 5 and Resident # 6 prior to the incident and was familiar with them. She reported the two residents had no history of altercations prior to the incident of 5/18/23. Resident # 6 was interviewed on 5/31/23 at 1:00 PM and again at 4:15 PM. Resident # 6 reported the following. On the night of the incident, Resident # 5 was cursing the nurses and he (Resident # 6) asked him to stop. Then Resident # 5 came over to his (Resident # 6's) side of the room and threatened him. Resident # 5 hit him first. He (Resident # 6) then went to Resident # 5's side of the room and held him on the bed and hit him. They had never had an altercation before that date. Nurse # 3 was interviewed on 5/31/23 at 1:15 PM and reported the following. She was employed as the facility social worker. There had been no altercations between Resident # 5 and Resident # 6 prior to the incident. They were immediately separated, and psychological referrals were placed for both residents. Resident # 5 reported he had had no recall of the incident. On 5/31/23 at 3:45 PM the Administrator, Director of Nursing (DON) and facility corporate Nurse Consultant were interviewed. They reported the following. They had investigated the incident and found no evidence the altercation could have been anticipated by their staff. Immediately following the incident, the police and Director of Nursing were called. The DON came to the facility the night of the incident to assure safety for Residents # 5, Resident # 6, and other residents. Resident # 5 was placed in a private room where he currently remained. The facility completed a review of incident reports to assure there were no other residents at risk for altercations that could lead to abuse. They talked to residents to assure compatibility between roommates. They also completed education training for their staff regarding abuse and dealing with challenging behaviors in residents. They had a system in place to monitor for future occurrences by discussing clinical needs in daily meetings, reviewing grievance reports, and monitoring clinical records for behavioral issues. They had reviewed the care plans and updated as needed. On 5/31/23 at 5:55 PM the Administrator was notified of immediate jeopardy. The Administrator presented the following corrective action plan. Date of Incident was 5/18/2023. Residents involved were Resident #5 in A Bed and Resident #6 in B Bed. Resident #5 has a Brief Interview for Mental Status (BIMS) of 7 and Resident #6 has a BIMs of 15. There were no staff involved. Initial Report Why Investigation Was Needed: Resident on Resident Altercation reported by staff. Resident 5 obtained scratches from altercation with roommate Resident #6. A 24 hour report was submitted. The police were notified on 5/18/2023 and came out to interview Residents #5 and #6. There were no employees involved. Notifications to family and physician were made for both Residents #5 and #6. Skin assessments by assigned nurse were completed for Residents #5 and #6 on 5/18/2023. First aide was rendered as follows: assigned nurse cleansed scratches for Resident #5 with normal saline, applied with an antibiotic ointment and left opened to air. Head to toe assessments were completed for Residents #5 and #6. Both residents were assessed for pain and signs/symptoms of injuries with no other signs or symptoms of injuries noted. Final Investigation The following documents were completed: Witness statements, audits education, quality assurance. The timeline of events is as follows: At 8:50pm Residents #5 and #6 were separated immediately and Resident #5 was moved to another hall. Body audits were completed on Residents #5 and #6 and both residents were assessed for injuries. Police were called and interviewed Residents #5 and #6. Physician and Responsible Parties were notified for both Residents #5 and #6. Adult Protective Services was notified of incident. The root cause of the event was: Resident to resident altercation due to both residents having poor impulse control. The root cause analysis statement is as follows: Resident to resident altercation is related to unanticipated poor impulse control. Plan for Correcting specific area of concern identified, including the process that led to the concern: Corrective action for resident involved: On 5/18/2023 the assigned nurses assessed the residents for any noted change in condition or signs/symptoms of injuries. Residents were immediately separated and Resident #5 was moved to another room on another hallway. Both residents were monitored by floor nurses and nurse aides assigned to respective halls (200 and 500) for any further behaviors or signs/symptoms of injuries. Resident #5 sustained some scratches on his left hand. Root cause of injury was resident to resident altercation related to poor impulse control. Resident #5 does not currently have a roommate. Resident #6 does have a roommate. Interventions to address root cause of poor impulse control and to prevent further incidents are as follows: Both Resident #5 and Resident #6 were referred for psychological evaluations. Evaluation has been completed on Resident #5 on 5/ 25 /2023. Resident #6 has been referred for psych services but was out of the building at the time psych services visited on 5/25/23 and will be seen on their next visit. Corrective action for potentially impacted residents: On 5/19/2023 the Director of Nursing audited incident reports for the last 14 days for any incidents of resident altercations with none found. On 5/19/2023 the social worker interviewed alert and oriented residents on the 200 Hall with no room compatibility issues identified. Systemic changes: On 5/18/2023 the Director of Nursing and Assistant Director of Nursing began an in-service of all staff (including agency) on Resident to Resident Abuse and Handling Challenging Behaviors. As of 5/26/2023, 100% of staff have attended the in-service. The Director of Nursing will ensure that any of the above mentioned staff who do not complete the in-service by 5/26/2023 will not be allowed to work until the training is completed. Quality Assurance: Quality assurance monitoring will be completed by the Administrator/Director of Nursing on an ongoing basis utilizing facility processes related to the Daily Clinical Review Process for change in condition, the Daily Standup Meeting with the interdisciplinary team, which includes a review of incident reports and applicable interventions; an ongoing review of grievances and a monthly review of Resident Council Minutes. The Daily Clinical Review is separate and distinct from the Daily Standup Meeting. Daily Clinical Review process for a change in condition is: Review of the Real Time Report, the 24 hour report from the electronic health record system, search of key words by clinical staff, and review of staff 24 hour reports collected from clinical floor staff. (Key word search is the process of looking for words anywhere in the record utilizing the search engine). The interdisciplinary team members include: Administrator, Director of Nursing, Minimum Data Set Coordinator, Activities Director, Assistant Director of Nursing, Social Worker, Dietary Manager, and Rehab Director. The Social worker will complete ongoing monitoring through interviews of 25 alert and oriented residents on various halls weekly x 2 for any concerns with roommate compatibility. Reports will be presented to the weekly QA Committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. The Administrator and Director of Nursing are responsible for this plan of correction. Compliance will be monitored and ongoing auditing reviewed at the weekly QA meeting. The weekly QA meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Rehab Director, Health Information Manager, and Dietary Manager. Corrective Action Completion Date: 5/26/2023 On 5/31/23 the facility's plan of correction was validated by the following. Resident # 5 was observed residing in a private room on 5/30/23 at 11:05 AM. The resident appeared without any signs of injury and was able to report he had no complaints about care and treatment. Resident # 6's care plan was updated on 5/19/23 to reflect he had the potential for physical behaviors related to poor impulse control. Multiple interventions were listed on Resident # 6's care plan which included but were not limited to monitoring his behavior and if he became agitated then staff were to intervene before things escalated. The facility presented documented evidence of education for their staff regarding abuse and dealing with residents who displayed challenging behavior. Staff interviews were conducted on 5/31/23 on multiple units which validated education had been provided for staff. Staff also reported in the interviews that they were no residents they felt displayed behaviors that might endanger other residents or place other residents at risk for abuse. On 5/31/23 the facility presented evidence they had audited their incident reports to assure other residents were not in altercations that could lead to abuse. This had been done on 5/19/23. On 5/31/23, the facility's correction date of 5/26/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, the facility failed to protect 1 of 1 resident (Resident #65) from employee to resident physical abuse. On 12-24-21 while providing care to Resident #65 Nursing Assistant (NA) #1 grabbed onto his right arm, jerked his arm and slapped his face resulting in the bridge of Resident #65's nose bleeding and bruising to his right upper and lower arm. Immediate Jeopardy began on 12-24-21 when the facility failed to protect Resident #65 from employee to resident physical abuse. Immediate Jeopardy was removed on 2-25-22 when the facility implemented an acceptable credible allegation on Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #65 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was not coded for any behaviors or refusal of care and had not received any anticoagulant (blood thinner) medications during the look back period. Resident #65's care plan was reviewed and revealed no care plans related to behaviors or refusals of care. A nursing note completed by Nurse #1 dated 12-24-21 at 5:35am documented Resident #65 was combative with NA #1 during incontinence care and when the NA attempted to reposition the resident in bed, Resident #65 hit himself in the face. A nursing note completed by Nurse #1 dated 12-24-21 at 6:20am documented an assessment of Resident #65's face showing a scratch to the bridge of Resident #65's nose. Another note completed by Nurse #1 on 12-24-21 at 7:10am revealed an assessment of Resident #65 was completed showing bruising to the resident's right upper arm and right forearm with Resident #65 informing Nurse #1 that NA #1 grabbed him and yanked him. Resident #65 was interviewed on 2-21-22 at 2:15pm. The resident stated on Christmas Eve (12-24-21) a NA came into his room, held his arms down and hit him on his forehead leaving a bruise and broke his skin on his thumb with her fingernail. He explained he had informed the Administrator, nurse and that the police were notified. Resident #65 stated he was concerned that the NA still worked at the facility. During a telephone interview with NA #1 on 2-23-22 at 3:58pm. NA #1 explained she was unfamiliar with Resident #65 because it was her first day (12-24-21) working at the facility and when she had entered Resident #65's room around 5:30am on 12-24-21, the resident had requested to be repositioned in the bed. She reported when she grabbed Resident #65's draw sheet, the resident swung at her, so she grabbed his arm, but the resident continued to try and hit her. NA #1 stated she then left the room and reported the incident to Nurse #1. She said she had not hit Resident #65. She explained she had education on abuse over the years and would not hurt a resident. NA #1 stated Resident #65 had hurt himself to get her into trouble. The NA said she had not encountered an aggressive resident before but now thought she should have just left the room instead of grabbing his arm. She also explained she had not been back to the facility since 12-24-21. Nurse #1 was interviewed by telephone on 2-23-22 at 4:45pm. Nurse #1 confirmed she was the nurse on duty caring for Resident #65 on 12-24-21 from 11:00pm to 7:00am. She stated she entered Resident #65's room for medication pass around 5:45am and found Resident #65 upset and crying. Nurse #1 reported Resident #65 informed her NA #1 had held his arms down and hit him in his face. She stated she assessed Resident #65 briefly and saw his right arm was red and then went and discussed the allegation with NA #1. The nurse said NA #1 told her Resident #65 had hit her and she held his arms down but had not hit him in his face. NA #1 informed her that the resident hit himself in his face while she (NA #1) was trying to reposition him in the bed. She stated she informed the Director of Nursing and the Nursing Supervisor of the allegation of employee abuse and instructed NA #1 to not enter Resident #65's room for the rest of the shift. Nurse #1 stated she continued her medication pass entering another resident room and the resident had informed her NA #1 had been rough with her while providing incontinence care. The nurse stated she did not ask the resident any questions or examine the resident. She further stated, I just did not think about it. I was concerned with Resident #65. She also said she could not remember who the other resident was. Nurse #1 spoke about Resident #65 and explained that he sometimes had agitation expressed through verbal behaviors, but he had never been combative or stated anything to indicate that a staff member had physically abused him before. A nursing note by Nurse #2 dated 12-24-21 at 10:15am documented she saw bruises on Resident #65's right forearm and a small laceration on his nose with dried blood. The nurse documented that Resident #65 told her he was beat up and that he had his arms held down and hit in the nose. Nurse #2's note indicated she had worked the day before (12-23-21) and Resident #65 did not have any bruises or laceration to his nose. Nurse #2 was interviewed by telephone on 2-23-22 at 1:55pm. Nurse #2 confirmed she worked 7:00am to 3:00pm on 12-24-21 and was assigned to care for Resident #65. She explained Nurse #1 had informed her of the incident with Resident #65 and NA #1 that occurred during the 11:00pm to 7:00am shift. Nurse #2 stated when she saw Resident #65 around 8:00am on 12-24-21, the resident told her he had been beat up with his arms held down and hit in the nose. She observed bruising to his right arm and a laceration to his nose that had dried blood. Nurse #2 also explained when she worked on 12-23-21 during the 7:00am to 3:00pm shift, Resident #65 did not have any bruising on his arms or laceration to his nose. Nurse #2 stated Resident #65 had always been pleasant with her and had never been combative. She also said Resident #65 had not made allegations of physical abuse before and that she trusted that what he told her was the truth. Review of the initial allegation report completed by the former Director of Nursing (DON) dated 12-24-21 revealed the following: Resident #65 reported NA #1 came into his room at approximately at 5:30am on 12-24-21 and snatched the covers off of me. He stated the NA told him I have been a NA for 30 years and I am going to show you to pull [yourself] up. The resident stated in the report the next thing he knew the NA was grabbing onto his right arm and jerking him. He reported he began shaking his arm trying to get the NA to let him go and the next thing he knew NA #1 slapped him in the face causing the bridge of his nose to bleed. The report indicated on assessment of Resident #65 he had fresh reddish-purple bruising on his entire right forearm down to the top of his wrist and a bruise to the base of his right thumb. Resident #65 also had a fresh abrasion to the bridge of his nose that was no longer bleeding. Report documentation revealed the police were notified on 12-24-21 at 2:10pm. Review of the police report dated 12-24-21 at 4:00pm revealed documentation of minor injuries to Resident #65 to include bruising to his right arm and a cut to the bridge of his nose. The Administrator was interviewed on 2-25-22 at 11:30am. The Administrator stated Resident #65 never displayed any type of aggressive behaviors towards the staff or refused care prior to the incident on 12-24-21. He also stated Resident #65 had not made previous allegations of physical abuse. He revealed that due to the resident's injuries and recollection of the events the allegation was substantiated. The Administrator was notified of immediate Jeopardy on 2-23-22 at 1:38pm. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 12/24/2021, Resident #65 reported to his nurse that his assigned nursing assistant had hit him. At approximately 5:30am on 12-24-21 a Nursing Assistant (NA #1) came into Resident #65's room and snatched the covers off and when the resident asked the NA not to snatch his covers off the NA told him that she was going to show him how to reposition himself and grabbed his right arm. Resident #65 stated that he tried to get loose from the NA's grasp and that was when the NA slapped Resident #65 on his face causing the bridge of his nose to bleed. The Director of Nursing was notified by the staff nurse on 12/24/2021. Resident #65 was assessed immediately on 12/24/2021 by the staff nurse. The nurse noted that the resident had a fresh reddish-purple bruise on his right forearm down to his wrist, top of right thumb. Also has a fresh abrasion/scab with no bleeding on bridge of nose. No other injuries noted The Physician and resident responsible party were notified on 12/24/2021 by staff nurse. No new orders were received. The involved agency staff member was suspended, and the agency was notified that the staff member would not be allowed to return. On 12/24/2021 the police were notified, and they obtained a statement from the resident. A 24-hour report was also submitted on 12/24/2021 by the facility and an investigation report was submitted on 12/29/2021. The facilities investigation concluded that it is likely that the resident was hit by the nursing assistant. After interviews and chart reviews the Director of Nursing identified that the root cause was that the aide did not follow policies and did not ensure resident safety by exiting the room to de-escalate the situation related to an agitated or aggressive resident. All residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 02/23/2022, current residents that were able to be interviewed, were asked if they had been abused or mistreated by staff. This was completed by the activity director and the health information director. No new allegations of abuse were identified. Also, on 02/23/2022, skin assessments were completed on current residents that were not interviewed. This was completed by the staff nurses. These residents were assessed to identify if there were any sign of abuse such as bruises or scratches of unknown origin. No additional residents were identified. On 12/24/2021, the staff development coordinator in-serviced all nursing staff on the abuse and prohibition policy. This training was completed for all staff and has been ongoing since 12/24/2021 for new hires. Additional training began on 02/23/2022. This training will include all current staff including agency. This training included how to manage behaviorally difficult residents. Training was completed by the Nurse Clinical Consultant and Staff RN. Areas discussed include: attempting to identify the cause of the resident behavior and eliminate it if possible, respect the resident's need for personal space, taking threats seriously and keeping distance, remaining calm, speaking in soft, low, calm voice, not making the resident feel trapped or cornered, not turning your back on the resident, avoid touching the resident, show interest in what they are saying, empathize with the resident, reassure the resident, praise self-control, do not argue with the resident and make sure that your body language is not threatening. The Director of Nursing and Nurse Clinical Consultant as well as Facility Administrator will ensure that any staff who does not complete the in-service training by 2/24/2022 will not be allowed to work until the training is completed. Alleged IJ Removal Date: 2/25/22 The facility's credible allegation of Immediate Jeopardy was validated on 2-25-22 with interviews with facility staff including nursing staff, dietary and housekeeping. The staff verbalized receipt of education on types of abuse, reporting abuse and how to interact with behaviorally challenged residents. A sample of residents were interviewed and stated they were questioned about abuse and educated on reporting abuse. Staff education documentation, audits and monitoring were reviewed. The facility's date of Immediate Jeopardy removal of 2-25-22 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Physician interview, the facility failed to follow their abuse policy to implement interventions to protect residents from physical abuse. On 12-24-21 at approximately 5:30am Nursing Assistant (NA) #1 grabbed Resident #65's right arm, jerked his arm and slapped his face resulting in the bridge of Resident #65's nose bleeding and bruising to his right upper and lower arm. NA #1 was allowed to complete her shift and continue to provide care to other residents following the incident. The facility also failed to implement their abuse policy in the areas of reporting and investigating abuse. This was for 1 of 1 resident (Resident #65) reviewed for abuse. Immediate Jeopardy began on 12-24-21 when NA #1 physically abused Resident #65 and the facility failed to implement interventions to protect other facility residents from NA #1. Immediate Jeopardy was removed on 2-25-22 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure education is completed and monitoring systems put in place are effective. Example 1b was cited at scope and severity level of D. Findings included: Review of the facility's Abuse Prohibition policy and procedure dated January 2021 revealed in part, the individual conducting the investigation will interview/review resident abuse report, interview person reporting the incident, resident, witnesses, resident's physician, roommate, other residents the employee had contact with, staff members and review events leading up to the incident. All potentials for harm must be removed during the investigation, this may constitute suspending an employee of suspected activity. The report must be submitted to the state agency immediately but not later than 2 hours following the allegation of abuse. 1. Resident #65 was admitted to the facility on [DATE]. Review of the census report for hall 200 on 12-24-21 revealed 20 residents resided on the hall. A nursing note completed by Nurse #1 dated 12-24-21 at 5:35am documented Resident #65 was combative with NA #1 during incontinence care and when the NA attempted to reposition the resident in bed, Resident #65 hit himself in the face. Nurse #1 documented on 12-24-21 at 5:58am that the facility's Director of Nursing was notified of the allegation of employee to resident physical abuse. A nursing note completed by Nurse #1 dated 12-24-21 at 6:20am documented an assessment of Resident #65's face showing a scratch to the bridge of Resident #65's nose. Another note completed by Nurse #1 on 12-24-21 at 7:10am revealed an assessment of Resident #65 was completed showing bruising to the resident's right upper arm and right forearm with Resident #65 informing Nurse #1 that NA #1 grabbed him and yanked him. Review of the initial allegation report completed by the former Director of Nursing dated 12-24-21 revealed the following: Resident #65 reported NA #1 came into his room at approximately 5:30am on 12-24-21 and snatched the covers off of me. He stated the NA told him I have been a NA for 30 years and I am going to show you to pull [yourself] up. The resident stated in the report the next thing he knew the NA was grabbing onto his right arm and jerking him. He reported he began shaking his arm trying to get the NA to let him go and the next thing he knew NA #1 slapped him in the face causing the bridge of his nose to bleed. The report indicated on assessment of Resident #65 he had fresh reddish-purple bruising on his right forearm down to the top of his wrist and a bruise to the base of his right thumb. Resident #65 also had a fresh abrasion to the bridge of his nose that was no longer bleeding. Report documentation revealed the police were notified on 12-24-21 at 2:10pm. 1a. NA #1 was interviewed by telephone on 2-23-22 at 3:58pm. NA #1 confirmed she was the NA for all of 200 hall including Resident #65 on 12-24-21 during the 11:00pm to 7:00am shift. The NA discussed Resident #65 being agitated most of her shift and around 5:30am she entered Resident #65's room to reposition him in the bed. She explained when she grabbed his draw sheet to reposition him, the resident swung at her, so she grabbed his arms, but the resident continued to swing hitting himself in the face. NA #1 stated she reported the incident to Nurse #1 and Nurse #1 instructed her to stay out of Resident #65's room. She said after she reported the incident, she still had 17 other residents to care for, so she continued her care of the other residents. Review of NA #1's time sheet for 12-24-21 confirmed NA #1's interview revealing she clocked out of work at 7:00am. A telephone interview occurred with Nurse #1 on 2-23-22 at 4:45pm. Nurse #1 confirmed she was the nurse for Resident #65 on 12-24-21 during the 11:00pm to 7:00am shift. She explained she entered Resident #65's room at approximately 5:45am (12-24-21), she found Resident #65 upset and crying. She stated the resident informed her that NA #1 had slapped him in his face and held his arms down. Nurse #1 said she spoke with NA #1 of the physical abuse allegation then reported the allegation to the DON. She discussed not remembering what the DON told her to do with NA #1 but stated NA #1 continued with her resident assignment and rounds until the end of the shift at 7:00am. Nurse #1 stated she did not think about removing the NA from the floor and said she thought NA #1 only had 1-2 more residents to provide care to. Nurse #1 stated she continued her medication pass entering another resident room and the resident had informed her NA #1 had been rough with her while providing incontinence care. The nurse stated she did not ask the resident any questions, examine the resident or report the information to management and she stated, I just did not think about it. I was concerned with Resident #65. She also said she could not remember who the other resident was. The former Director of Nursing (DON) was interviewed by telephone on 2-23-22 at 3:37pm. The DON confirmed she was the DON for the facility on 12-24-21. She discussed receiving a call from Nurse #1 who told her Resident #65 had made an allegation of physical abuse by NA #1. She further discussed the allegation involved NA #1 slapping Resident #65 in the face causing an abrasion to the bridge of his nose and holding Resident #65's arms down causing bruising to his right arm. The DON stated she instructed Nurse #1 to remove NA #1 from the hall but not to let the NA leave the building before she arrived. She explained that she had not wanted the NA to have any further resident contact after the allegation was made because it could put other residents at risk for harm. She stated she arrived at the facility around 7:45am and observed NA #1 sitting at the nurse's station writing out her recall of events leading to the allegation of physical abuse. The DON stated she allowed the NA to stay at the nursing station while she went to assess and interview Resident #65. She revealed she had not known that NA #1 continued to provide resident care after the allegation was reported. The Administrator was interviewed on 2-24-22 at 11:48am. The Administrator stated he was not aware NA #1 continued with her assignment after the allegation of physical abuse was made and did not know why Nurse #1 did not remove her immediately. He stated Nurse #1 knew the abuse policy which indicated an employee was to be removed immediately from the floor and placed in a non-resident area if an allegation of abuse was made. The facility's Medical Director was interviewed by telephone on 2-24-22 at 2:48pm. The Medical Director stated he would have expected NA #1 to be suspended immediately and escorted out the door. The Administrator was notified of Immediate Jeopardy on 2-24-22 at 1:46pm. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 12/24/2021, Resident #65 reported to his nurse that his assigned nursing assistant had hit him. At approximately 5:30am on 12-24-21 a Nursing Assistant (NA #1) came into Resident #65's room and snatched the covers off and when the resident asked the NA not to snatch his covers off the NA told him that she was going to show him how to reposition himself and grabbed his right arm. Resident #65 stated that he tried to get loose from the NA's grasp and that was when the NA slapped Resident #65 on his face causing the bridge of his nose to bleed. The Director of Nursing was notified by the staff nurse on 12/24/2021. Resident #65 was assessed immediately on 12/24/2021 by the staff nurse. The nurse noted that the resident had a fresh reddish-purple bruise on his right forearm down to his wrist, top of right thumb. Also has a fresh abrasion/scab with no bleeding on bridge of nose. No other injuries noted The Physician and resident responsible party were notified on 12/24/2021 by staff nurse. No new orders were received. The DON instructed Nurse #1 to remove the NA from the floor and have her wait until she arrived at the facility to leave. Nurse #1 stated she could not remember what the DON instructed her to do with the accused NA. Nurse #1 allowed the NA to finish her rounds. The NA clocked out at 7AM on 12/24/2021. The accused NA was suspended, and the agency was notified on 12/24/2021 that the staff member would not be allowed to return. All residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 02/23/2022, all current residents that were able to be interviewed, were asked if they had been abused or mistreated by staff. This was completed by the activity director and the health information director. No new allegations of abuse were identified. Also, on 02/23/2022, skin assessments were completed on current residents that were not interviewed. This was completed by the staff nurses. These residents were assessed to identify if there were any sign of abuse such as bruises or scratches of unknown origin. No additional residents were identified. On 12/24/2021, the staff development coordinator in-serviced all nursing staff on the abuse and prohibition policy. This training was completed for all staff and has been ongoing since 12/24/2021 for new hires. Additional training began on 02/24/2022 by the Nurse Consultant and Nurse Administration Team. This training will include all contracted, full time, part time, prn - all staff. This training included: When abuse is suspected or reported, staff must immediately report the suspicion or allegation to the nurse, Administrator, or Director of Nursing. Facility investigation beginning steps (Take whatever steps are necessary to protect the residents and to prevent further acts of abuse, neglect, misappropriation of property, drug diversion, or fraud while the investigation is in progress. This includes immediate suspension of the accused employee or employees.) It is imperative that all staff understand that when an allegation of staff to resident abuse is made that the accused staff member must immediately be removed from the floor with no resident contact until the investigation is completed to protect the facility residents. The Director of Nursing and Nurse Clinical Consultant as well as Facility Administrator will ensure that any staff who does not complete the in-service training by 2/24/2022 will not be allowed to work until the training is completed. Alleged IJ Removal Date: 2/25/2022 The facility's credible allegation of Immediate Jeopardy was validated on 2-25-22 with interviews with facility staff including nursing staff, dietary and housekeeping. The staff verbalized receipt of education on types of abuse, reporting abuse and removing the accused staff member from any further resident interactions. A sample of residents were interviewed and stated they were questioned about abuse and educated on reporting abuse. Staff education documentation, audits and monitoring were reviewed. The facility's date of Immediate Jeopardy removal of 2-25-22 was validated. 1b. The facility's initial allegation report for the staff (NA #1) to resident (Resident #65) physical abuse allegation that occurred on 12-24-21 at approximately 5:30 AM revealed it was reported to the state by the Director of Nursing on 12-24-21 at 4:50pm. Review of the facility's investigation report dated 12-29-21 revealed no documentation that other residents, who had contact with Nursing Assistant (NA) #1 after the alleged physical abuse of Resident #65 were interviewed or assessed for injuries. During a telephone interview with the former DON on 2-23-22 at 3:37pm, the DON indicated she arrived at the facility around 7:45am on 12-24-21 and began completing the initial allegation and investigation of employee to resident physical abuse by NA #1 to Resident #65. She stated she was aware allegations of physical abuse needed to be reported to the state agency within 2 hours. The DON said she believed the Administrator was going to send the initial allegation to the state and did not realize it was not sent until 4:30pm on 12-24-21. She verified there were no interviews conducted with other residents because she believed NA #1 did not have any further contact with the residents after she was made aware of the allegation of physical abuse. The Administrator was interviewed on 2-23-22 at 9:15am. The Administrator stated he was unaware the initial report of employee to resident physical abuse on 12-24-21 was not faxed to the state agency within the 2 hour requirement. He stated the facility policy was for abuse allegations to be reported to the state agency within 1 hour. The Administrator verified there were no interviews or assessments of the other residents who had contact with NA #1 after the allegation of physical abuse was reported. The facility's Medical Director was interviewed by telephone on 2-24-22 at 2:48pm. The Medical Director stated he would have expected the DON to assess and conduct interviews with the other residents that NA #1 had contact with to ensure no other residents were physically abused.