**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Family Member #1 and Medical Director interviews, the facility failed to recognize the current treatment plan was not effective and the seriousness of a resident with a diagnosis of hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone) not responding to high doses of levothyroxine (medication used to treat hypothyroidism). As of [DATE] Resident #1 had an active order for an endocrinology consultation for hypothyroidism. On [DATE] lab work was obtained and resulted in a critically high TSH (Thyroid Stimulating Hormone) level of 50.3 (normal range 0.5 to 5.0). The endocrinology consultation order was not faxed by the facility to the consultation office until [DATE] and a referral to an endocrinologist for an evaluation was not scheduled. Resident #1's thyroid medication remained at the same dosage for the month of [DATE] and [DATE] at 225 mcg (microgram) by mouth daily. On [DATE] Resident #1 had a thyroid stimulating hormone (TSH) level of 50.3 (normal range 0.5 to 5.0). A TSH level of 50 is considered critically high and indicates severe hypothyroidism, which can lead to serious health complications if not addressed. A Nurse Practitioner note dated [DATE] revealed Resident #1 was evaluated due to increased confusion and a decrease in appetite. On [DATE] Resident #1 was observed in an unresponsive state at the facility. Emergency Medical Service (EMS) was dispatched to the facility and Resident #1's heart rate was 32 beats per minute (bpm) (normal range 60-100 beats per minute) and a transcutaneous pacemaker (temporary external pacing method used to stimulate the heart to contract by delivering electrical impulses through the chest wall) was placed on Resident #1 by EMS. An improvement in heart rate was noted with a reading of 82 bpm (beats per minute). Upon arrival at the Emergency Department (ED), she was unresponsive, pulseless, with a pulse oximetry (measures the percentage of oxygen in the blood) reading of 7% (normal level 95-100%) and cardiopulmonary resuscitation (CPR) was initiated. She required emergent intubation (medical procedure where a tube is inserted into a windpipe to keep the airway open when a person is unable to breathe on their own) and was placed on a ventilator (a machine utilized to support or take over breathing). Hospital records dated [DATE] revealed Resident #1 was in a severe hypothyroid state with a diagnosis of myxedema coma (a life-threatening endocrine emergency that occurs when thyroid hormone regulation is disrupted). Resident #1's TSH level was 240. Resident #1 was admitted into the intensive care unit (ICU) with continued intubation and ventilation until [DATE]. The deficient practice occurred for 1 of 3 residents reviewed for quality of care (Resident #1). Immediate jeopardy began on [DATE] when Resident #1 had a thyroid stimulating hormone (TSH) level of 50.3 (normal range 0.5 to 5.0) and the facility failed to initiate effective medical treatment. Immediate jeopardy was removed on [DATE] 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 completion of education.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, acute kidney failure, obstructive uropathy, muscle weakness, hypertension and anemia. Resident #1's active physician orders as of [DATE] included: - Referral for an endocrinology consultation related to a diagnosis of hypothyroidism. - Draw TSH level every 6 weeks related to hypothyroidism.- Levothyroxine 225 mcg 1 tablet by mouth daily for hypothyroidism at 6:00 AM. A review of Resident #1's [DATE] Medication Administration Record revealed the following medications were prescribed and a review of the medications revealed none interfered with the absorption of Levothyroxine.Amlodipine besylate oral tablet daily for hypertensionTrazodone HCL tablet (antidepressant) for insomniaLevothyroxine 225 mcg for hypothyroidismDepakote Sprinkles oral capsule (antiepileptic) for dementia with behaviors disturbance. Hydroxyzine HCL oral tablet as needed for anxietyOxybutynin chloride tablet for overactive bladder. Myrebetriq for overactive bladder. Losartan potassium for hypertension. Cyanocobalamin tablet for vitamin B12 deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required extensive assistance of one staff member with activities of daily living (ADL). Resident #1's lab results dated [DATE] revealed a TSH level of 50.3. (Previous labs completed on [DATE] resulted in a TSH level of 29.336.) A Nurse Practitioner note written by Nurse Practitioner (NP) #1 dated [DATE] revealed Resident #1 was evaluated on this date. The resident was receiving a dose of (Levothyroxine) thyroid medication at 250 micrograms by mouth daily with a most recent TSH result of greater than 50. The note revealed a referral was initiated for Resident #1 to be evaluated by endocrinology in [DATE]. Resident #1 was noted to have no symptoms of hypothyroidism at the time of the evaluation. Review of Resident #1's Medication Administration Record (MAR) dated [DATE] revealed an order initiated on [DATE] for levothyroxine 225 mcg 1 tablet by mouth daily for hypothyroidism. The medication was administered daily in the AM except on the dates of 6/7 (resident sleeping) and 6/12 (resident sleeping). Further review of the [DATE] MAR revealed no order for levothyroxine 250 mcg. A nursing progress note written by Nurse #2 dated [DATE] at 3:34 PM revealed Resident #1 had eaten 50% or less for 2 or more meals in the day. The note revealed the nursing team had notified the Nurse Practitioner. An interview conducted on [DATE] at 3:03 PM with Nurse #2 revealed she was responsible for Resident #1 on [DATE], [DATE] and [DATE] during the 7:00 AM to 3:00 PM shift and Resident #1 had taken her medication without issues. On [DATE] Resident #1's blood pressure was 150/60 during the morning medication administration pass. She stated Resident #1 hadn't eaten as much for breakfast and lunch on [DATE]. However, she was out of bed and sitting in the common area as she normally did. She stated Resident #1 was confused at baseline, but the Nurse Practitioner was notified any time a resident had a decrease in appetite or seemed more lethargic. Nurse #2 stated Resident #1 did not seem to have an increased sense of thirst nor did anything, stand out. The Nurse Practitioner was in the building, so she saw the resident. She stated she was shocked to learn Resident #1 went to the hospital on [DATE] because she didn't remember the resident having any change of condition in the day's prior. A Nurse Practitioner note written by (NP) #1 dated [DATE] at 8:15 PM revealed Resident #1 was evaluated on this date. The note revealed Resident #1 experienced increased confusion from baseline per nursing staff and a loss in appetite over the last 12 to 24 hours. Resident #1 was noted to have not gotten out of bed as much as she usually did. NP #1's note revealed upon assessment Resident #1 appeared at baseline, was easy to awaken and interacted in conversation. Resident #1 was noted with suprapubic tenderness and an order was given to obtain a urinalysis for further evaluation. A faxed letter was sent to the Endocrinology office for a consultation on [DATE] by Unit Manager #1 for Resident #1. On [DATE] at 1:46 PM an interview was conducted with Unit Manager #1. Unit Manager #1 stated the facility had another Unit Manager that was no longer working in the facility who was responsible for sending Resident #1's endocrinology referral in [DATE]. Unit Manager #1 indicated she became aware of the referral after a Nurse Practitioner note on [DATE] and had seen the physician's order from April was missed. Unit Manager #1 confirmed the first time the referral was sent to the endocrinologist was on [DATE]. Unit Manager #1 stated she felt like the referral was missed by the previous Unit Manager and the mistake had not been identified by any other facility staff members. She stated the typical process was for a Unit Manager to receive a referral for a consultation and then call the physician's office immediately and set up an appointment. The interview revealed typically NP #1 would place her own orders into the electronic medical record (EMR) and the Unit Managers did not always have time to look over NP #1's progress notes. She stated the nursing staff wouldn't have known to increase Resident #1's thyroid medication unless told by NP #1 or the physicians order was placed into the system. Unit Manager #1 stated she did not recall any orders given by Nurse Practitioner #1 after her evaluation of Resident #1 on [DATE]. Unit Manager #1 revealed she had seen Resident #1 in the days prior to [DATE] and she did not recall any changes in the resident's condition. Resident #1 was confused as she typically was, and Unit Manager #1 had seen her attempting to stand up out of her wheelchair which was normal behavior for her. Staff had to keep a close eye on her at all times.An incident report dated [DATE] at 8:30 PM written by Medication Aide (MA) #1 revealed a Nurse Aide (NA #1) reported to MA #1 that Resident #1 had experienced a change of condition. Upon observing Resident #1, MA #1 began to obtain vital signs and told NA #1 to go and notify Nurse #1 of the situation. Nurse #1 applied supplemental oxygen to the resident and called 911 emergency services. On [DATE] at 11:40 AM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she was responsible for Resident #1 on [DATE] during the 3:00 PM to 11:00 PM shift. NA #1 stated when she came on shift at 3:00 PM Resident #1 was her normal self, talking and attempting to get up from her wheelchair as she constantly did. She stated the resident was served the supper meal and was able to feed herself with setup assistance provided. NA #1 stated Resident #1 did not appear to have a decrease in appetite on [DATE]. Around 8:00 PM NA #1 was completing resident charting sitting directly across from Resident #1 approximately 4 feet away. NA #1 stated she looked at Resident #1 and noticed she was mumbling words. She then asked Resident #1 if she was okay and Resident #1 stated, help me. NA #1 stated Resident #1 was alert at that time but seemed weak and began slumping down into her chair. She immediately told MA #1 to obtain vital signs, and she went to get Nurse #1. Nurse #1 went to assess Resident #1 and told them to take her to her room and stay with her while she called 911 emergency services. NA #1 stated EMS was in the building within minutes because they were across the street from the facility. She stated, everyone moved so quickly. The interview revealed once EMS arrived Resident #1 was transported to the hospital for an evaluation. NA #1 indicated she had taken care of Resident #1 in the days prior to the incident and had not noticed any changes in her behavior. On [DATE] at 11:55 AM an interview was conducted with Medication Aide (MA) #1. During the interview she stated she was working on [DATE] during the 3:00 PM to 11:00 PM shift on an adjoining hall to Resident #1's. MA #1 stated she had observed Resident #1 during the shift and saw her eating the supper meal around 5:15 PM with no issues. She stated she was standing at the medication cart in the common area with Resident #1 and NA #1 around 8:00 PM. NA #1 stated to check Resident #1's vital signs because she had just said, help me and went unresponsive. MA #1 then went to the resident and obtained her vital signs while NA #1 went to get Nurse #1. She stated she wrote Resident #1's vital signs down on a piece of paper and gave it to Nurse #1. MA #1 stated Resident #1 was taken to her room and placed in bed while Nurse #1 called 911 emergency services. EMS were in the building within minutes of the staff placing Resident #1 in her bed. MA #1 stated she heard a code blue on the overhead speaker however EMS was already in the building and had assumed care of the resident. She stated Resident #1 still had a pulse and was breathing with supplemental oxygen in place. MA #1 stated she had worked on the days prior to Resident #1 going to the hospital however she was not directly assigned to the resident. MA #1 indicated she had seen Resident #1 eating her meals and she was able to eat the meals without assistance from staff. She stated she did not recall noticing any changes in the resident's behavior prior to [DATE].On [DATE] at 9:57 PM (late entry progress note) a nursing progress note written by Nurse #1 revealed Nurse Aide (NA) #1 had notified her that Resident #1 did not look well and needed to be assessed. NA #1 stated Resident #1 was sitting up in her chair and stated, help me before going unresponsive. Resident #1 did not respond to verbal or tactile (sense of touch) stimulation. Resident #1 was noted to be a full code, her eyes were open, but she was breathing shallow. The resident's vital signs were the following: temperature 97.1, pulse 67, respirations 8, oxygen saturation 88% on room air with a blood pressure reading of 105/76. A call was placed to 911 emergency services, and the resident was provided with supplemental oxygen at 2 liters per minute via nasal cannula. The 911 dispatcher advised Nurse #1 to prepare for Cardiopulmonary Resuscitation (CPR) and a code blue was paged overhead for staff to hear. Emergency Medical Services (EMS) was able to arrive quickly at the facility and already were entering Resident #1's room. EMS decided that CPR was not needed, and Resident #1 was transported to the hospital for further evaluation at 8:30 PM. On [DATE] at 3:45 PM an interview was conducted with Nurse #1. Nurse #1 stated she was responsible for Resident #1 on [DATE] during the 3:00 PM to 11:00 PM shift. She stated when she came on shift at 3:00 PM she saw Resident #1 sitting in her chair in the common area watching television. Resident #1 was her typical self, talking and attempting to stand up during the shift like she normally did. Nurse #1 stated Resident #1 was served her supper meal around 5:30 PM. Resident #1 was able to feed herself without assistance from staff members. During the gathering of meal trays, Resident #1 was observed to be alert, sitting watching television and interacting with other residents in the common area. Nurse #1 was notified by NA #1 around 7:50/8:00 PM that Resident #1 had experienced a change of condition. She stated the resident looked at NA #1 and said, help me before becoming unresponsive. Nurse #1 immediately went to the resident to assess her vital signs. MA #1 and NA #1 assisted Resident #1 to her room and into bed. Nurse #1 called 911 emergency services, and they advised her to prepare to perform CPR however Resident #1 still had a pulse and was breathing at that time. Nurse #1 stated EMS arrived quickly because they were right across the street. EMS took over the care of Resident #1, stabilized the resident and transported her to the hospital for an evaluation. When she was transported out of the facility, Resident #1 was alert and talking again. Nurse #1 stated she had seen no change in Resident #1's behavior throughout the shift until NA #1 alerted her to a change of condition. She also stated she had cared for Resident #1 in the days prior to the incident and had seen no overall change in the resident's condition. The interview revealed she did not remember Resident #1 having any increased confusion nor had nurse aides notified her the resident had a decrease in appetite. Emergency Medical Service (EMS) records dated [DATE] at 8:02 PM revealed Resident #1 was lying on her bed in the facility unresponsive. Staff members from the facility were standing at the doorway stating the resident was okay ten minutes prior to calling 911. Resident #1's heart rate was 32 beats per minute (bpm) and a transcutaneous pacemaker (temporary external pacing method used to stimulate the heart to contract by delivering electrical impulses through the chest wall) was placed on Resident #1 by EMS. An improvement in heart rate was noted with a reading of 82 bpm (beats per minute). During transportation to the hospital Resident #1's heart rate began to drop with a reading of 44 bpm. EMS was able to increase the residents heart rate back up to 62 bpm while en route to the hospital. Upon arrival at the hospital Resident #1 was moved from the EMS stretcher to an Emergency Department (ED) bed and hospital staff assumed care for the resident. During the transfer of the beds Resident #1 was noted to decline rapidly without a pulse. The ED initiated CPR and Resident #1 was ultimately intubated in the ED by hospital staff. Emergency Department records dated [DATE] at 8:34 PM revealed Resident #1 was found in an unresponsive state at the nursing facility. Resident #1 had arrived at the ED unresponsive with a transcutaneous pacemaker in place. Upon assessment by the ED Physician Resident #1 was noted to have a pulse oximetry (measures the percentage of oxygen in the blood) of 7% (normal level 95-100%). CPR was initiated for a duration of 2 minutes. An emergent intubation was required, and Resident #1 was placed on a ventilator. Resident #1 was noted to be in a severe hypothyroid state with a diagnosis of myxedema coma (a life-threatening endocrine emergency that occurs when thyroid hormone regulation is disrupted) and a TSH level of 240. The resident received 200 mcg of Levothyroxine intravenously in the ED. Resident #1 was admitted into the hospital intensive care unit with diagnosis of bradycardia (low heart rate), respiratory arrest, myxedema coma and cardiac arrest with profound hypothyroidism contributing to the diagnosis. Hospital records dated [DATE] revealed Resident #1 was intubated in the ED and noted to be hypothermic (low body temperature) with a lowest temperature of 91.1 degrees Fahrenheit (normal body temperature 98.6). Resident #1's TSH level was 242.997. She was admitted into the ICU with continued intubation and ventilation. The primary admission diagnosis was myxedema coma followed by bradycardia, unresponsiveness and hypothermia. The hospitalist consulted with endocrinology; Resident #1 received a loading dose of levothyroxine (thyroid medication) 375 mcg intravenous on [DATE]. It was recommended she continue to receive 100mcg levothyroxine daily. Resident #1 was extubated on [DATE] and was still in the hospital setting during the survey period receiving occupational therapy, physical therapy, speech therapy and hospitalist services. On [DATE] at 9:11 AM and 3:51 PM an interview was attempted with a Hospitalist. No phone call was returned to the surveyor. On [DATE] at 8:49 AM the Director of Nursing (DON) from the Hospital called and stated the surveyor would need to submit a formal request for an interview with the Hospitalist. On [DATE] at 10:05 AM a formal request was submitted and faxed by the Department of Health and Human Services Division of Health Service Regulation for an interview with the Hospitalist. No return phone call was received. An interview conducted on [DATE] at 9:45 AM with Family Member #1 revealed she was notified on [DATE] Resident #1 was found in an unresponsive state and sent to the hospital for an evaluation. She stated Resident #1 was still in the hospital, was drowsy but doing better. Family Member #1 stated she felt the facility was not giving the residents medication correctly for her thyroid level to be so high on the paperwork from the hospital. She stated she had visited in the weeks prior to the incident on [DATE] and hadn't noticed a change in Resident #1's behavior but had not visited on [DATE]. Family Member #1 indicated Resident #1 had not reported that she was not feeling well. On [DATE] at 1:58 PM an interview was conducted with the Director of Nursing (DON). The DON stated she was in the facility on the night of [DATE] but did not see Resident #1 until she was being taken out of the front hall by EMS. The interview revealed Resident #1 had a diagnosis of hypothyroidism and was followed by Nurse Practitioner #1 and the Medical Director. The DON indicated Nurse Practitioner #1 had put in an order on [DATE] for an endocrinology consult due to the resident's elevated TSH level and the Unit Manager at the time did not complete the referral. This was not identified until [DATE] by Unit Manager #1 and Unit Manager #1 then faxed the referral over to the endocrinology office. However, an appointment was never made because when the endocrinology office called the facility back the resident was already at the hospital. She stated the original endocrinology consult should have been completed within a week when it was received back in [DATE]. She stated while reviewing paperwork during the survey she realized Nurse Practitioner #1 had put in her progress note dated [DATE] to increase Resident #1's thyroid medication to 250 mcg by mouth daily for hypothyroidism. The DON stated NP #1 would typically, 99% of the time put her own orders into the electronic medical record (EMR). She stated NP #1 should have put the physicians' order into the EMR or told a nursing staff member to put the order in so it could have been relayed to the MAR. The DON confirmed Resident #1's thyroid medication had not been increased to 250 mcg during the months of [DATE] and [DATE] prior to her hospitalization. Nurse Practitioner #1 was unable to be interviewed during the survey due to a medical emergency. On [DATE] at 12:40 PM an interview was conducted with the Medical Director. The Medical Director stated the resident was admitted into the facility with a diagnosis of hypothyroidism in [DATE]. The facility had closely monitored Resident #1's thyroid level and adjusted her medication accordingly. An order for an endocrinology consult was made in [DATE] by Nurse Practitioner #1 being proactive in the resident's care since she had an elevated TSH level. The Medical Director indicated he had seen NP #1's progress note dated [DATE] to increase her thyroid medication dosage. The Medical Director stated it was a common error, NP #1 forgot to write the order for the increased medication. The Medical Director stated increasing Resident #1's thyroid medication wouldn't have made a difference in the outcome of her TSH level. The Medical Director stated NP #1 was handling Resident #1's care appropriately and had been monitoring her lab work closely since admission and adjusted her thyroid medication throughout the past year. He did not recall NP #1 contacting him regarding Resident #1's TSH level of 50.3 on [DATE]. The Medical Director further stated he felt like the diagnosis of myxedema coma was due to the hospital assuming the resident's thyroid levels were not being monitored or treated, and they had a mistaken impression because the resident was lethargic with a TSH of 240 and jumped to conclusions.On [DATE] at 4:00 PM an interview was conducted with the Administrator. He stated the facility should have completed the endocrinology consultation in a timely manner. The Administrator indicated there had been a gap in Unit Managers and the consultation order had just been missed by nursing staff. The Administrator further stated the physician order for the [thyroid] medication increase was missed and should have been in the EMR and Resident #1's medication should have been increased if ordered by the physician. The Administrator was notified of the immediate jeopardy on [DATE] at 11:46 AM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncomplianceThe facility failed to provide effective medical evaluation and treatment to Resident #1. Resident #1 had labs completed on [DATE] resulting in a thyroid stimulating hormone (TSH) level of 29.336. The Nurse Practitioner wrote an order for an Endocrinology Consultation on [DATE]. Resident #1 did not have an endocrinology appointment scheduled. Resident #1 had labs completed on [DATE] for a T4 lab, with results of 3.8 (normal 4.5-12.0), Free T3 results 1.59 (normal 1.58-3.9. The Nurse Practitioner saw Resident #1 on [DATE] and increased Resident #1's medication from 225 micrograms (mcg) to 250 mcg by mouth daily, which was in the Nurse Practitioner Progress Note, but was not entered into Resident #1's electronic medical record as an order at the time by the Nurse Practitioner, so therefore Resident #1 did not have the recommended increase in the thyroid medication from 225mcg to 250mcg implemented on [DATE] on the Medication Administration Record (MAR). Resident #1 remained on 225mcg of thyroid medication from [DATE] to [DATE]. Resident #1's TSH level on [DATE] was 50.3, which was not addressed at that time. The Nurse Manager faxed the order to schedule the Endocrinology Consultation on [DATE]. On [DATE], the Director of Nursing reviewed the electronic medical record of current residents to determine those on thyroid medications. Based on the list, the Director of Nursing identified 6 other residents receiving thyroid medication. The Director of Nursing reviewed the Nurse Practitioner's most recent progress notes for these 6 residents to ensure their current orders for thyroid medication corresponded to the dose which was indicated in the progress notes and that the medication orders are accurately transcribed to the Medication Administration Record (MAR).Current residents on thyroid medications had their most recent TSH lab results that were completed in the past 120 days reviewed by the Medical Director on [DATE] and [DATE] to ensure the thyroid medication doses are effective. Current residents' orders for the past 30 days were reviewed by the Director of Nursing (DON) /Assistant Director of Nursing (ADON) on [DATE] to ensure that orders for consultations to include endocrinology have been carried out or are scheduled for a consultation at a future date.Medical Doctor/Nurse Practitioner notes for recommendations for consultations were reviewed for the past 30 days on [DATE] by the DON/ADON to ensure any recommendations had been carried out. On [DATE], current residents on thyroid medications and/or upcoming endocrinology appointments, per the electronic medical record order listing report, had a head-to- toe physical assessment by the Assistant Director of Nursing who is a Registered Nurse, as well as a focused based physical examination by the Nurse practitioner, which included vital signs to ensure their vital signs were stable and they were not experiencing a change in condition to include signs and symptoms of hypothyroidism (fatigue, cold sensitivity, constipation, dry skin, and unexplained weight gain) and hyperthyroidism (weight loss, rapid or irregular heartbeat, sweating, and irritability) which would require further medical intervention or a transfer to a higher level of care, and no other residents were identified. On [DATE], the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reviewed the last 90 days of the Pharmacy recommendations to ensure residents receiving thyroid medications did not have any outstanding recommendations that needed to be implemented. No concerns were identified.On [DATE], the Pharmacist reviewed the 6 residents on thyroid medication to ensure no drug to drug interactions with medications that would be taken at or around the same time of the thyroid medication or that could affect absorption of the medication. The Pharmacist additionally reviewed the 6 residents to ensure the thyroid medication is scheduled to be given at the proper time of 6 am daily. Last, the Pharmacist reviewed the 6 residents to ensure current lab orders are in place to monitor thyroid drug therapy. 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 completeThe Nurse Practitioner was re-educated by the Medical Director on [DATE] on ensuring any medication orders which the Nurse Practitioner orders while making rounds in the facility are entered into each resident's individual electronic medical record by the Nurse Practitioner and should correspond with the Nurse Practitioner progress notes. The DON and ADON were educated on [DATE] by the Regional Clinical Director that a review of Medical Provider progress notes will be done daily by the DON/ADON during morning clinical meeting to ensure the Medical Provider's progress notes that make mention of medication changes correspond to the residents' current medication orders that have been input into the electronic medical record. The Nurse Practitioner was educated on [DATE] by the Medical Director to obtain thyroid panel labs at least every 3-6 months for monitoring of those residents on thyroid medications. Abnormal lab results will be addressed by the Medical Provider including the Medical Director/ Nurse Practitioner to ensure a comprehensive plan for treatment which may include but not be limited to physical assessment of the resident for signs and symptoms of hypothyroidism or hyperthyroidism, further lab monitoring, increases/decreases in medication regimen, consultation with endocrinology specialist, or transfer to a higher level of care. Licensed nursing staff have been educated by the Director of Nursing/Assistant Director of Nursing on [DATE] and [DATE] on the following: - ensuring thyroid medication orders are entered accurately, at the time recommended by the physician and the pharmacy/ or procedure which is at 6 am on an empty stomach, given with water, and if crushed then it can be given with a small amount of applesauce or pudding- to avoid drinks that could interact with the medication which would be caffeinated drinks such as coffee, tea, fizzy drinks and calcium containing drinks such as milk, fruit juices should not be consumed until 30-60 minutes after receiving thyroid medications- when taking thyroid medication, you must wait 30-60 minutes before eating - medications that have the potential to reduce adsorption for thyroid medication are antacids, Carafate, cholestyramine, colestipol, phosphate binders, and some antibiotics, as well as calcium and iron supplements. - recognizing changes in condition along with notification to the medical provider to include identification of and notification of signs and symptoms of hypothyroidism (fatigue, cold sensitivity, constipation, dry skin, and unexplained weight gain) and hyperthyroidism (weight loss, rapid or irregular heartbeat, sweating, and irritability), this education also included monitoring every shift for signs and symptoms of hypothyroidism and hyperthyroidism and to notify the provider accordingly upon identification of any signs or symptoms- notification of abnormal TSH lab results to ensure notification to the Physician/Nurse Practitioner- the signs and symptoms of hypothyroidism and hyperthyroidism have been added to the Medication Administration Record by the Director of Nursing/Assistant Director of Nursing on [DATE]. Any Licensed Nurses not educated by [DATE] will be educated prior to the start of their next scheduled shift. This education will be provided by the Director of Nursing/Assistant Director of Nursing. On [DATE] and [DATE] The Director of Nursing/Assistance Director of Nursing educated all Certified Nursing Assistance (CNAs) on notification to Licensed Nurses on any changes in condition. Any Certified Nursing Assistance (CNAs) that were not educated on [DATE] will be educated prior to the start of their next scheduled shift which will be provided by the Director of Nursing/Assistant Director of Nursing.The DON/ADON reviewed the facility's process for carrying out consultation orders on [DATE]. No changes were required.Licensed Nurses/Unit Managers were educated on the process for consultation orders on [DATE] and [DATE] by the Director of Nursing and Assistant Director of Nursing to include the process for carrying out consultation orders:- At the time that the order is written for consultation in the electronic medical record eit[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Resident, Nurse Practitioner (NP) #2, NP #3 and Medical Director (MD), the facility failed to immediately consult with NP #3, the on-call medical provider, when Resident #49 who had a pre-existing traumatic brain injury lost consciousness and was slumped in his chair after being hit on the back of his head by Resident #79, his roommate. On 09/14/24 at 9:05 AM Nurse #3 heard a loud hit or thud coming from across the unit. She noted Resident #49 was in his wheelchair rolling out from his room and witnessed Resident #79 swing his arm with a fist and hit Resident #49 on the back of the head. NP #3 was notified after the incident occurred about an altercation between Resident #49 and Resident #79 but was not consulted about the blow to Resident #49's head, the slumping in the chair and the loss of consciousness for a few seconds. Resident #49 had a change of condition after the altercation occurred. He slid out of his wheelchair. His level of assistance needed for transfer and bed mobility changed and he was confused. Later in the day and as his condition continued to decline, staff assessed Resident #49 with altered mental status (AMS) and he was sent to the hospital for evaluation due to a concern for a concussion after a fall. The deficient practice affected 1 of 3 residents reviewed for physician notification (Residents #49). Immediate jeopardy began on Saturday, 09/14/24, when the facility failed to immediately consult with NP #3 about Resident #49 who had a pre-existing traumatic brain injury and had a significant change in condition following a blow to the head with a brief loss of consciousness. The immediate jeopardy was removed on 11/23/24 when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #49 was admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI). A review of Resident #49's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #49 was coded as independent for eating and putting on/ taking off footwear. He required set up or clean up assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #49 required supervision assistance for chair to bed transfers, toileting transfers, tub/shower transfers and lying to sitting on the side of the bed. The resident was noted to be independent for rolling left and right while in bed. Resident #49 was continent of bowel and bladder during the assessment period and was documented to have no behaviors. A nursing note written by Nurse #3 dated 09/14/24 at 10:11 AM revealed she heard hitting noises and turned around to observe Resident #79 hit Resident #49 get hit in the head. The note revealed the residents were separated and assessed for injuries. Resident #49's vital signs were the following: blood pressure 138/66; pulse 72; temperature 97.9; respirations 20; and oxygen saturation level 96% on room air. The Resident was noted with no signs of acute distress at the time of the incident and no complaints of pain. Redness was noted to the back of the Resident's neck. The Resident's Responsible Party, Director of Nursing and on call Nurse Practitioner (NP #3) were notified about the abuse and the Resident's status. On 11/19/24 at 11:38 AM an interview was conducted with Nurse #3. Nurse #3 stated on 09/14/24 around 9:00 AM she heard a loud hit or thud coming from across the unit. She then saw Resident #49 rolling out from his room in his wheelchair and witnessed, Resident #79 swinging his arm with a fist and hit Resident #49 in the back of the head making a second thud sound as his fist hit the back of Resident #49's head. Resident #49 immediately slumped over in his wheelchair as a result of the incident. Nurse #3 stated Resident #49 regained consciousness within a couple of seconds after she got to him to assess his condition. She stated she saw redness at the back of Resident #49's head and neck area. When Resident #49 came to he asked to go outside to smoke so NA #2 took him to the smoking area. Nurse #3 indicated she had obtained initial vital signs on Resident #49 which were within normal range, assessed him. Nurse #3 stated she did not recall reporting the loss of consciousness and slumping in the chair to Unit Manager #1. Nurse #3 explained Resident #49 was moved from his hall around 10:00 AM. Nurse #3 no longer was his nurse and did not see him again that day. The interview revealed Nurse #3 had initiated an action rounding log which documented where Resident #49 was in the facility every 15 minutes. Nurse #3 stated Nurse #4 took over Resident #49's care when he moved to his new room around 10:00 AM. On 11/21/24 at 12:32 PM an interview was conducted with Scheduler #1. She stated she was working as the Manager on Duty on 09/14/24. Scheduler #1 stated her office door was open and she overheard a nurse screaming for help. When she went out into the hall, she saw Nurse #3 in the hall and went to her. She noticed Resident #49 sitting in his wheelchair slumped over around 9:00 AM. Nurse #3 explained to her that he had just been hit in the back of the head by his roommate. After separating the residents, she stated she notified Unit Manager #1 via the facility paging system and Nurse #3 called the Director of Nursing. Scheduler #1 stated Resident #49 was taken to the smoking area because he stated he wanted to go smoke however she stated she did not see him smoking. She stated Resident #49 immediately seemed spaced out and not to be thinking clearly when he went to the smoking area around 9:30 AM. When he initially woke up after being hit and came to, his abilities were not the same, he was using his hands but nothing else like he had before. The interview revealed Resident #49 started trying to go in the wrong direction and had to be redirected by staff, they took him to his new room, and it took Scheduler #1, NA #2 and Nurse #3 to all assist him into the bed. Scheduler #1 stated she left the building at 3:00 PM. She stated they were so concerned with Resident #49's condition they had placed a fall mat under his bed because they felt like he may have a fall from the bed due to his state of immobility. Scheduler #1 stated she did not voice her concerns to anyone because she thought Nurse #3 and Nurse #4 were communicating the Resident's changes to the Medical Provider. On 11/19/24 at 12:52 PM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she was responsible for Resident #49 on 09/14/24 during first shift (7:00 AM to 3:00 PM). She stated she did not witness the incident but was notified of what had happened by Nurse #3. NA #2 recalled she was told by Nurse #3 to take the resident outside to smoke and to move Resident #49's belongings out of his room into a new room on another unit. NA #2 indicated she moved Resident #49's belongings and assisted him from the smoking area to his new room around 10:00 AM and assisted him into the bed which was different from that morning. Earlier in morning, he was able to transfer himself. The interview revealed when she went to the smoking area to get Resident #49, he did not have a cigarette and was just sitting outside. NA #2 stated she immediately noticed a difference in the way Resident #49 was responding and moving around 9:30 AM when she took him to the smoking area. He was unable to self-propel his wheelchair. NA #2 stated Resident #49 could not assist her at all for bed mobility and had to remain in bed for the rest of her shift. NA #2 stated she did not recall Resident #49 eating lunch on 09/14/24. Resident #49 had gone from being able to transfer himself that morning to being unable to roll from left to right in the bed following the incident occurring around 10:00 AM and providing incontinent care while the resident was in the bed. NA #2 also noted Resident #49 seemed slow to respond when spoken to immediately following the altercation. NA #2 stated she had discussed Resident #49's change of condition with both Nurse #3 and Nurse #4 as soon as she assisted Resident #49 into his bed that morning. NA #2 stated she was not given instructions to obtain vital signs on Resident #49 during first shift and gave report to NA #1 at 3:00 PM. On 11/19/24 at 2:00 PM an interview was conducted with NA #1. During the interview she stated she came on shift at 3:00 PM and received a report from NA #2. She and Unit Manager #1 assisted Resident #49 to his wheelchair because his legs were dangling off of the bed. NA #1 noted Resident #49 to be disoriented, leaning back in his wheelchair, sliding out of his wheelchair and overall, not looking like he typically did sitting up, self-propelling himself in a regular wheelchair in the hallway. Resident #49 was incontinent of urine and staff were changing his brief while he was in bed. NA #1 remembered having assisted him back up in his wheelchair during that evening and he eventually had a fall around 6:30 to 7:00 PM after sliding completely out of his wheelchair into the floor in the hallway. The interview revealed Resident #49 was sent to the hospital for an evaluation. NA #1 stated she did not recall obtaining vital signs for Resident #49 nor was she asked about his condition. The interview revealed she had notified Nurse #4 during her shift around 4:00 PM that Resident #49 seemed different from his baseline state. A late entry incident report dated 09/14/24 at 11:02 PM written by Nurse #4 revealed Resident #49 had experienced a fall and was found in the hallway sitting on his bottom around 6:30 PM. Resident #49 stated he had slid off his wheelchair. No injuries were observed however the resident was sent to the hospital due to recent change in cognition. On 11/19/24 at 2:49 PM an interview was conducted with Nurse #4. She stated she was in the building on 09/14/24 during the first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM). The interview revealed Resident #49 was moved to her hall following an altercation with his roommate where he was hit in the back of the head. She stated she assumed Resident #49's care for second shift at 3:00 PM. She stated she did not recall the exact time the resident was moved to her unit. The interview revealed Resident #49 was noted to be in bed, which was not typical for him. Nurse #4 stated she was not very familiar with the resident however she did know he was typically up during the day. She stated the nurse aides were telling her he was experiencing a significant change of condition from his normal baseline. She stated she did not contact the on-call provider. The interview revealed Resident #49 was gotten up to his wheelchair for the supper meal and he kept sliding out of the wheelchair. Nurse #4 had to obtain other staff members to assist her to pull him up in his chair. She stated around 6:30 PM Resident #49 was noted to fall out of his wheelchair into the floor in the hallway. The interview revealed he was immediately sent to the hospital for an evaluation based on the nurse aides telling her of the resident's drastic change of condition. Nurse #4 stated she had known Resident #49 was independent in his wheelchair, however when he left to go to the hospital, he was dependent upon staff for all transfers. On 11/21/24 at 9:06 AM an interview was conducted with Unit Manager (UM) #1. During the interview UM #1 stated on 09/14/24 around 9:00 AM she was paged on the overhead call system to come to Resident #49's room around 9:00 AM. Upon arrival Nurse #3 told her Resident #49 had been hit on the back of his head by his roommate. UM #1 stated she looked at the Resident and he was able to respond to her. UM #1 had NA #2 remove Resident #49 from the room and contacted the Director of Nursing (DON) who stated she (UM #1) needed to notify the resident's family and the provider on call. (UM #1) stated the provider on call (NP#3) asked her how the resident was doing, and UM #1 stated it was her first time laying eyes on him, and he seemed okay so she told the provider he seemed fine with no injuries. NP #3 instructed the facility to notify her of any change of condition. UM #1 stated NA #2 immediately moved Resident #49 to another room around 10:00 AM. Unit Manager #1 stated as she was rounding later in the day around 2:30 PM and saw Resident #49's call light on, she stated he was trying to transfer himself from the wheelchair to the toilet which the NA said he was normally able to do. UM #1 stated she had to get two other staff members to assist due to his observed weakness. She stated Resident #49 was so weak she asked the Resident to hold off on all transfers for the rest of the day because he was a full assist. She contacted NP #2 who told her she would be in the building to round shortly. UM #1 stated the DON told her to activate Emergency Medical Services (EMS) because she did not feel comfortable with his condition. EMS arrived at the same time as NP #2 came onsite around 3:00 PM. NP #2 completed an assessment of Resident #49 and stated to her (UM #1) to turn EMS away because the resident had no reason to go out for an evaluation. She stated shortly after she had them turn EMS away, Resident #49 slid out of his wheelchair onto his bottom. Unit Manager #1 called NP#2 and stated Resident #49 was going to be sent to the hospital for an evaluation. UM #1 stated the staff had moved Resident #49 to his wheelchair because his legs kept dangling off of the bed and she was afraid he was going to fall. On 11/22/24 at 9:38 AM an interview was conducted with Nurse Practitioner #3. During the interview she stated she was the on-call Nurse Practitioner assigned to the facility on [DATE]. NP #3 stated she did recall being notified of an altercation with Resident #49 around 9:00 AM but did not recall specific details of the incident or who notified her. NP #3 stated if she was notified a resident was struck in the head she would recommend sending the resident to the hospital for an evaluation. She stated she was not contacted by the facility for Resident #49 anymore that day because they had an in-house NP (NP #2) who was rounding on the residents. The interview revealed she did not have any notes from the day as to what orders she gave the facility. An SBAR (Situation, Background, Assessment and Recommendation) Summary dated 09/14/24 at 3:35 PM written by Unit Manager #1 revealed Resident #49 had experienced a change of condition after a physical altercation with another resident. The chief complaint was listed as Resident #49 had become increasingly weak on the left side after a physical altercation at the hands of another resident. The on- call provider was notified of the resident's condition and instructions were placed to activate Emergency Medical Services (EMS) for an evaluation at the Emergency Department. A SBAR (Situation, Background, Assessment and Recommendation) Summary dated 09/14/24 at 3:35 PM written by Unit Manager #1 revealed Resident #49 had experienced a change of condition after a physical altercation with another resident. The chief complaint was listed as Resident #49 had become increasingly weak on the left side after a physical altercation at the hands of another resident. The on- call provider was notified of the residents' condition and instructions were placed to activate Emergency Medical Services (EMS) for an evaluation at the Emergency Department. On 11/22/24 at 9:14 AM an interview was conducted with Nurse Practitioner #2. She stated she was an in-house provider that rounds in the facility on the weekends. She stated she remembered evaluating Resident #49 while he was sitting in a chair and did not know what had happened that morning with an altercation. NP#2 stated she only recalled sending the resident out to the hospital following a fall and did not recall telling anyone to stop EMS from coming at 3:00 PM. She stated when the resident became unstable and fell, she sent him out. EMS records dated 09/14/24 revealed they were dispatched to the facility with a chief complaint of increased weakness and a fall after an assault earlier in the morning. The resident had a history of TBI and wanted to be evaluated. Resident #49 stated he was hit in the head by his roommate earlier in the morning around 9:00 AM. He stated the roommate used his fist to hit him in the head and denied loss of consciousness. Staff, however, said the resident lost consciousness. The resident was cleared initially by his facility physician (NP #2) to stay at the facility and not be transported to the hospital. Around 6:30 PM Resident #49 was sitting in his wheelchair, when he tried to reposition himself. He had increased weakness that caused him to slide down the chair onto the floor. Resident #49 was noted to be on the floor until a medic arrived. Hospital records dated 09/14/24 revealed Resident #49 was evaluated on this date after sliding out of his wheelchair around 6:30 PM. Per the Medic the resident was also punched in the head by his roommate earlier in the morning around 9:30 AM but cleared by the facility. A computed tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility with strict precautions to return with any new or worsening symptoms. Hospital records dated 09/17/24 revealed Resident #49 presented to the hospital for evaluation of acute chronic left-sided weakness. The resident was reported to be punched in the head by a roommate three days prior. He was originally evaluated in the Emergency Department on 09/14/24 and cleared for discharge. He presented back to the hospital complaining of lightheadedness and felt that his left side was weaker than his baseline from prior brain injury. He was also complaining of blurred vision and headaches. Resident #49 was admitted for neuroimaging. The exam showed a decreased edema signal within the brainstem (indicating potential damage or abnormality within the brainstem region) since the prior exam. Neurology was consulted with orders to follow up outpatient. The note revealed the Neurologist felt the findings could represent post concussive changes in the setting of extensive chronic progressive leukoencephalopathy (a rare, progressive brain infection that destroys cells that produce myelin, an insulating material for nerve cells). Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. On 11/19/24 at 3:12 PM an interview was conducted with Resident #49. During the interview he stated he had gotten hit in the back of the head by his former roommate a couple of months prior. The interview revealed he was sitting in the doorway when his roommate came at him from behind. Resident #49 revealed he did not recall any details about what had occurred after he was hit and did not remember going to the hospital after the incident. He stated since the incident he felt his condition had changed and he could no longer transfer himself from his bed to the wheelchair or self-propel in his wheelchair. The interview revealed he no longer was able to use his regular wheelchair which was still located outside of his room door because he was no longer able to sit up in it. Resident #49 stated he was now confined to a specialized chair and was dependent upon staff for all activities of daily living (ADL). He stated he was unable to assist himself to the toilet to use the restroom so he was now having to wear a brief and reliant of staff to change him. He stated two nurse aides used the mechanical lift to change him. On 11/20/24 at 11:02 AM an interview was conducted with the Medical Director (MD). The MD stated the nurse was responsible for contacting the on-call provider and notifying them of the change of condition. On 11/20/24 at 2:51 PM an interview was conducted with the Director of Nursing. She stated she was notified by Unit Manager #1 early in the morning around 9:00 on 09/14/24 that Resident #49 was hit in the head by his roommate and had no injuries. The interview revealed she was unaware Resident #49 had experienced any change of condition on 09/14/24. The interview revealed if a resident had a change of condition the on-call provider should be notified immediately. On 11/20/24 at 3:17 PM an interview was conducted with the Administrator. During the interview he stated he was notified about the altercation on a weekend day. The interview revealed the Administrator was unaware of any change of condition on the date of 09/14/24. The Administrator was notified of the immediate jeopardy on 11/20/24 at 4:17 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. - On 09/14/24 at 9:05 AM Nurse #3 heard a loud hit or thud coming from across the unit. She then noted Resident #49's wheelchair rolling out from his room with him in the wheelchair and witnessed his roommate swing his arm with a fist and hit Resident #49 on the back of the head. Based on staff interview Resident #49 had a significant change of condition recognized by sliding out of his wheelchair, decrease in level of assistance with transfers, a decrease in bed mobility and confusion. - On 9/14/2024 Unit Manger #1 notified the on-call Nurse Practitioner (NP #3) at approximately 10:00 AM to report the altercation with the roommate and change in level of care needs, as more assistance was needed with transfers as it took several people to get him into the bed. The Nurse Practitioner (NP #2) arrived at the facility at approximately 3:20 PM and examined the resident related to mental status changes after an altercation with his roommate. The Nurse Practitioner arrived at the same time as EMS who had been called by the nurses and upon examination by the NP, the NP determined that the resident did not need to go out to the hospital, so EMS was turned away. - The on-call Nurse Practitioner (NP #2) was notified at approximately 6:15 PM after Resident #49 was noted to be lying on the floor after sliding out of his wheelchair with Altered Mental Status (AMS). Resident was sent to the hospital for further evaluation due to a concern for a concussion from the hit to the back of Resident's head on 09/14/24. Hospital records indicate no acute trauma or concussion diagnosed related to the event. Resident #49 returned to the emergency room on [DATE] and was admitted for further neurological workup to include a Magnetic Resonance Imaging (MRI). MRI showed redemonstration of severe infratentorial and infratentorial white matter signal abnormality mildly worsened since prior MRI of 2020. It showed decreased edema signal within the brainstem, moderate ventriculomegaly, secondary to white matter volume loss. There was no acute infarction. No significant vascular disease. MRI of the Cervical Spine showed severe C4-5 left foraminal stenosis. - On 11/21/24 and 11/22/24, a nursing assessment was completed by the Licensed Nurses to verify all residents were currently stable and were not experiencing a change in condition requiring notification to the physician for further orders. The nursing assessment results are noted in the residents' electronic health record. The DON reviewed the results of the Licensed Nurse assessments and the 24-hour report to ensure there were no residents experiencing a change in condition requiring notification to the physician for further orders. Additionally, the DON reviewed the 24-hour report to ensure no other incidents requiring notification to the provider for which the Medical Provider had not been notified. No adverse outcomes were identified in this audit. 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. - Nurse #3 was re-educated on notification of medical provider per the policy and procedure for a resident with a change in condition on 11/22/24 based on the urgency of the situation to include but not be limited to falls, resident to resident altercations, injuries, unstable vital signs, head trauma and indwelling catheter with recurrent symptomatic urinary tract infections, or recurrent pneumonia, changes in skin color or condition. - All licensed nurses, agency/contract staff, and all newly hired licensed nursing employees along with Certified Nurse Aides will be educated on proper notifications to the Medical Provider or to the On Call Provider after hours and on weekends when a resident has a change in condition or incident, immediately after the incident or immediately at the time when a change in condition occurs. The On Call After Hours provider numbers are posted at each nurses' station. Education will be completed by the DON/Nurse Manager on 11/22/2024. Nursing staff not educated by 11/22/2024 will be educated prior to the start of their next scheduled shift. This education will be completed in person or by telephone. Education for newly hired staff will be completed by the Director of Nursing/Nurse Manager during the orientation period. Staff who were not educated on 11/22/2024 either in person or by telephone will be educated prior to the start of their next scheduled shift. The DON is responsible for tracking staff who still require education. The DON/Licensed Nurse Manager will provide education to staff not educated by 11-22-24 prior to the start of the next scheduled shift. DON and Licensed Nurse Manager were notified of this responsibility on 11-22-24. The Administrator will be responsible for the completion of the immediate jeopardy removal plan. The immediate jeopardy removal date is 11/23/2024. On 10/27/22, the credible allegation of immediate jeopardy removal date of 11/23/24 was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on proper notifications to the Medical Provider or to the On Call Provider after hours and on weekends when a resident has a change in condition or incident, immediately after the incident or immediately at the time. The facility's in-service log and training material was reviewed. The IJ removal date of 11/23/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, facility staff, Nurse Practitioner (NP), Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to protect a resident's right to be from physical abuse (Resident #49). On 09/14/24 at approximately 9:00 AM Nurse #3 heard a loud hit or thud coming from across the unit and then observed Resident #49 rolling out of his room in his wheelchair and witnessed Resident #79 swinging his arm with a fist and hit Resident #49 on the back of the head. Resident #49 was noted to slump over in his wheelchair and have a loss of consciousness for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of a traumatic brain injury and immediately after being hit in the head by Resident #79 he was noted to have a change of condition as evidenced by a change in level of assistance needed for transfer and bed mobility changed, confusion and inability to self-propel in his wheelchair. Later in the day Resident #49 slid out of wheelchair to the floor and was assessed with worsening generalized weakness and concern for a concussion. Emergency Medical Services (EMS) was dispatched on 9/14/24 at 6:31 PM and Resident #49 was taken to the hospital for evaluation. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. Resident #49 returned to the hospital on 9/17/24 for evaluation of acute chronic left-sided weakness, lightheadedness, blurred vision and headaches. Resident #49 was admitted for neuroimaging (brain scanning). The Neurologist felt the findings could represent post concussive changes and Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. At the time of the survey, Resident #49 reported he felt his condition had changed since the incident and noted he was now confined to a specialized chair and was dependent upon staff for all activities of daily living and required the use of mechanical lift for transfers. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #49). Immediate Jeopardy began on 09/14/24 when Resident #49 who had a history of a traumatic brain injury was hit with a closed fist in the back of the head by Resident #79. The immediate jeopardy was removed on 11/23/24 when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #49 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI). A review of Resident #49's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #49 was coded as independent for eating and putting on/ taking off footwear. He required set up or clean up assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #49 required supervision assistance for chair to bed transfers, toileting transfers, tub/shower transfers and lying to sitting on the side of the bed. The resident was noted to be independent for rolling left and right while in bed. Resident #49 was continent of bowel and bladder during the assessment period and was documented to have no behaviors. Resident #79 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of TBI. A review of Resident #79's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #79 was coded as independent for all activities of daily living (ADL) including eating, toileting, oral hygiene, shower/bathe self, upper body dressing, lower body dressing and all transfers. He was coded as using a cane to ambulate during the assessment period. Resident #79 was documented to have no behaviors. A review of the facility's investigation report initiated on 09/14/24 at 9:05 AM by the Administrator revealed Resident #49 was hit on the back of his neck/head by his roommate. After the nurse assessed Resident #49, he was noted with no injuries and the residents were immediately separated by moving Resident #49 to another room. Staff were briefed on the incident and monitored the residents every 15 minutes to avoid further incidents. Resident #49's roommate had stated he hit the resident because he was trying to exit the room and Resident #49 was blocking the doorway with his wheelchair. A nursing note written by Nurse #3 dated 09/14/24 at 10:11 AM revealed she heard hitting noises and turned around to observe Resident #49 get hit in the head by his roommate. The note revealed the residents were separated and assessed for injuries. Resident #49's vital signs were the following: blood pressure 138/66, pulse 72, temperature 97.9, respirations 20, oxygen saturation level 96% on room air. The resident was noted with no signs of acute distress at the time of the incident and no complaints of pain. Redness was noted to the back of the resident's neck. The residents Responsible Party, Director of Nursing and on call Nurse Practitioner were notified. New orders were obtained for a psychological evaluation of Resident #79 and every 15-minute monitoring for a duration of 24 hours. On 11/19/24 at 11:38 AM an interview was conducted with Nurse #3. Nurse #3 stated on 09/14/24 around 9:00 AM she heard a loud hit or thud coming from across the unit. She then saw Resident #49 rolling out from his room in his wheelchair and witnessed (Resident #79) who was cognitively intact, swinging his arm with a fist and hit Resident #49 at the back of the head making a second thud sound as his fist hit the back of Resident #49's head. Resident #49 immediately slumped over in his wheelchair and regained consciousness within a couple of seconds after she got to him to assess his condition. She stated she saw redness at the back of Resident #49's head and neck area. When Resident #49 came to he asked to go outside to smoke so Nurse Aide (NA) #2 took him to the smoking area. Nurse #3 indicated she had obtained initial vital signs on the resident which were within normal range, assessed him and the Unit Manager notified the Nurse Practitioner of what had occurred. Nurse #3 explained when Resident #49 was moved from her hall around 10:00 AM, she no longer was his nurse and did not see him again that day. On 11/21/24 at 12:32 PM an interview was conducted with Scheduler #1. She stated she was working as the Manager on Duty on 09/14/24. Scheduler #1 stated her office door was open and she overheard a nurse screaming for help. When she went out into the hall, she saw Nurse #3 and went to her. Scheduler #1 stated Resident #49 sitting in his wheelchair slumped over and was unconscious for approximately a minute. Nurse #3 explained to her that he had just been hit in the back of the head by Resident #79. When he initially woke up after being hit and came to, his abilities were not the same, he was using his hands but nothing else like he had before. She stated he was no longer able to self-propel himself in the hallway as he had done that morning or self-transfer to bed. After separating the residents, she stated she notified the Unit Manager #1 via the facility paging system and Nurse #3 called the Director of Nursing. Scheduler #1 stated Resident #49 was taken to the smoking area by NA#2 because he stated he wanted to go smoke. She stated Resident #49 immediately seemed spaced out by responding slowly when spoken to and not thinking clearly. The interview revealed Resident #49 started trying to go in the wrong direction and had to be redirected by staff. When they took him to his new room, it took Scheduler #1, NA #2 and Nurse #3 to all assist him into the bed. Scheduler #1 told Nurse #3 she would need to complete neurological assessments. She stated they were so concerned with Resident #49's condition they had placed a fall mat under his bed because they felt like he may have a fall from the bed due to his state of immobility. On 11/21/24 at 9:06 AM an interview was conducted with Unit Manager (UM) #1. During the interview she stated on 09/14/24 around 9:00 AM she was paged on the overhead call system to come to Resident #49's room. Upon arrival Nurse #3 told her Resident #49 had been hit on the back of his head by Resident #79. She stated she looked at the resident and he was able to respond to her. She had them remove Resident #49 from the room and contacted the Director of Nursing (DON) who stated she needed to notify the resident's family and the provider on call. She stated the provider on call (NP #3) asked her how the resident was doing, and she stated it was her first time laying eyes on him, and he seemed okay. UM #1 recalled they immediately moved Resident #49 to a room in another hall around 10:00 AM. Unit Manager #1 stated she was rounding later in the day and saw Resident #49's call light on, she stated he was trying to transfer himself from the wheelchair to the toilet which the NA said he was normally able to do. She stated she had to get two other staff members to assist due to his weakness. On 11/19/24 at 12:52 PM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she was responsible for Resident #49 on 09/14/24 during first shift (7:00 AM to 3:00 PM). She stated she did not witness the incident but was notified of what had happened by Nurse #3. NA #2 recalled she was told by Nurse #3 to move Resident #49's belongings out of his room into a new room on another unit. NA #2 indicated she moved Resident #49's belongings and assisted him from the smoking area to his new room around 10:00 AM and assisted him into the bed which was different from that morning. Earlier in morning, he was able to transfer himself. NA #2 stated she had discussed Resident #49's change of condition with both Nurse #3 and Nurse #4 as soon as she assisted Resident #39 into his bed in the new room that morning. NA #2 stated she immediately noticed a difference in the way Resident #49 was responding and moving. NA #2 stated Resident #49 could not assist her at all for bed mobility and had to remain in bed for the rest of her shift. NA #2 explained she decided to continue to provide care to the resident despite him being on another unit due to staffing concerns. NA #2 indicated Resident #49 had gone from being able to transfer himself that morning to being unable to roll from left to right in the bed following the incident. For the remainder of the shift Resident #49 was provided with incontinent care in bed, which was a change of condition. NA #2 also noted Resident #49 seemed slow to respond when she spoke to him. On 11/19/24 at 2:00 PM an interview was conducted with NA #1. During the interview she stated she came on shift at 3:00 PM and received report from NA #2. She and the Unit Manager #1 assisted Resident #49 to his wheelchair because his legs were dangling off of the bed around 4:00 PM. NA #1 noted Resident #49 to be disoriented, leaning back in his wheelchair, sliding out of his wheelchair and overall, not looking like he typically did, sitting up, self-propelling himself in a regular wheelchair in the hallway. NA #1 indicated she was changing Resident #49's brief while he was in bed, which was a change as he could usually transfer himself to the bathroom. NA #1 remembered having to assist him back up in his wheelchair during that evening and he eventually slid completely out of his wheelchair into the floor in the hallway around 6:30 to 7:00 PM. On 11/19/24 at 2:49 PM an interview was conducted with Nurse #4. She stated she was in the building on 09/14/24 during the first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM). The interview revealed Resident #49 was moved to her hall following an altercation with Resident #79 during which Resident #79 hit Resident #49 on the back of his head. She stated she assumed Resident #49's care for second shift at 3:00 PM. The interview revealed Resident #49 was noted to be in bed, which was not usual because he was typically up and out in the facility in the hallway during the day. Nurse #4 stated the NA #1 and NA #2 were telling her he was experiencing a significant change of condition from his normal baseline by being in bed, a decrease in mobility, decreased alertness and incontinence throughout the day. Nurse #4 explained Resident #49 was gotten up to his wheelchair for the supper meal and he kept sliding out of the wheelchair and Nurse #4 had to obtain other staff members to assist her to pull him up in his chair. Nurse #4 indicated around 6:30 PM Resident #49 was noted to fall out of his wheelchair onto the floor in the hallway. A late entry incident report dated 09/14/24 at 11:02 PM written by Nurse #4 revealed Resident #49 had experienced a fall and was found in the hallway sitting on his bottom around 6:30 PM. Resident #49 stated he had slid off his wheelchair. No injuries were observed however the resident was sent to the hospital due to recent change in cognition. On 11/19/24 at 3:12 PM an interview was conducted with Resident #49. During the interview Resident #49 stated he had gotten hit in the back of the head by Resident #79 a couple of months prior. The interview revealed he was sitting in the doorway when Resident #79 came at him from behind. Resident #49 revealed he did not recall any details about what had occurred after he was hit and did not remember going to the hospital after the incident. He felt his condition had changed since the incident and noted he could no longer transfer himself from his bed to the wheelchair or self-propel in his wheelchair. Resident #49 revealed he was no longer able to use his regular wheelchair, which was still located outside of his room, because he was no longer able to sit up in it. Resident #49 stated he was now confined to a specialized chair and was dependent upon staff for all activities of daily living and required the use of mechanical life for transfers. He stated he was unable to transfer himself to the toilet to use the restroom and was having to wear a brief, urinate on himself, and reliant on staff to change him. A Nurse Practitioner note written by NP #2 on 09/15/24 as late entry for 09/14/24 revealed she was asked to see Resident #49 for altered mental status after an altercation in which the resident ended up on the floor knocked out cold, he did not hit his head and regained consciousness right away but now seen with altered mental status. At the time of the assessment, although he was able to follow simple commands, he was noted to have worsening generalized weakness drop in extremity sitting in the chair. She was noted to be concerned for a concussion and escalated the resident to the emergency room for an evaluation and management. On 11/22/24 at 9:14 AM an interview was conducted with Nurse Practitioner #2. She stated she was an in-house provider that rounded in the facility on the weekends. She stated she remembered evaluating Resident #49 while he was sitting in a chair, but NP #3 was originally notified that morning about an altercation. NP #2 stated staff did tell her the resident had been hit in the head by his roommate and had experienced altered mental status. However, she did not witness the incident and therefore it was only hearsay. She stated when the resident became unstable and fell, she sent him out. Review of the Emergency Medical Services (EMS) dispatch log for the facility on 09/14/24 revealed they were notified to respond for Resident #49 at 6:31 PM due to a fall in which the resident slipped from his chair to the floor. EMS arrived at the facility and transported Resident #49 to the hospital. EMS records dated 09/14/24 revealed they were dispatched to the facility with a chief complaint of increased weakness and a fall after an assault earlier in the morning. The resident had a history of TBI and wanted to be evaluated. Resident #49 stated he was hit in the head by Resident #79 earlier in the morning around 9:00 AM. He stated Resident #79 used his fist to hit him in the head and denied loss of consciousness. Staff, however, did say the resident lost consciousness. The resident was cleared initially by his facility physician to stay at the facility and not be transported to the hospital. Around 6:30 PM Resident #49 was sitting in his wheelchair, when he tried to reposition himself, he had increased weakness that caused him to slide down the chair onto the floor. The resident was noted to be on the floor when the medic arrived. Resident #49 was mechanically lifted into the medic's stretcher. EMS documented the resident's vital signs at 6:52 PM to include the following: blood pressure 120/76, pulse 70 beats per minute (bpm), respirations 16, oxygen saturation level 94% (normal >92%). Resident #46 was noted to be oriented to person, place and time. The resident stated to EMS he felt safe at the facility, however, would like a new roommate. The note read, Patient is requesting we transport him to the hospital for further evaluation. Hospital records dated 09/14/24 revealed Resident #49 was evaluated on this date after sliding out of his wheelchair around 6:30 PM. Per the Medic the resident was also punched in the head by his roommate earlier in the morning around 9:30 AM but cleared by the facility. The residents' diagnoses included fall, closed head injury and generalized weakness. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. A nursing progress note dated 09/15/24 at 6:55 AM revealed Resident #49 had returned to the facility from the hospital by EMS transport. Resident #49 was noted to be in no acute distress or discomfort. A Nurse Practitioner note dated 09/16/24 written by NP #1 revealed she was asked to evaluate Resident #49 on this date by the Director of Nursing (DON) due to the resident being sent to the Emergency Department (ED) after he was forcefully hit in the head by his roommate and had experienced a couple of falls since the incident. Resident #49 was noted to have been evaluated for a close head injury while in the hospital. At the time of her assessment the resident was noted to be in a stable condition with no complaints of pain or weakness. During the evaluation he was noted to be in bed resting with no acute distress. On 11/19/24 at 3:36 PM an interview was conducted with Nurse Practitioner #1. During the interview she stated Resident #49 was sent to the hospital on [DATE] following a fall in the facility. She stated she was not in the facility or on call the weekend the incident occurred but learned of the altercation the following Monday after returning to the facility. NP #1 stated Resident #49 had experienced two falls after returning back to the facility from the hospital and she was asked to evaluate him on 09/16/24 following the second fall. Resident #49 was in no distress during her evaluation. The interview revealed Resident #49 started experiencing headache, weakness and lightheadedness on 09/17/24 while she was in the building and was sent back to the hospital. He was discharged back to the facility on [DATE]. NP #1 stated she had written a progress note on 10/21/24 discussing the hospital course and they had conducted a neurological work up while the resident was in the hospital. She stated the hospital notes did discuss the resident could have had post concussive findings meaning it was possible he had experienced a concussion from the incident, but they were unable to determine if it was that or a past misdiagnosis. NP #1 stated Resident #49 is now in a specialized wheelchair that leaned back unlike the chair he was in prior to the incident which was a regular wheelchair. She stated once he came back from the hospital, he was slow to respond with occasional headaches and was not as active as he was prior to the incident. She stated it was possible the effects he has experienced could be from the altercation, but the resident had other conditions that could have contributed to the changes he had experienced. Hospital records dated 09/17/24 revealed Resident #49 presented to the hospital for evaluation of acute chronic left-sided weakness. The resident was reported to have been punched in the head by a roommate 3 days prior. He was originally evaluated in the Emergency Department on 09/14/24 and cleared for discharge. He presented back to the hospital complaining of lightheadedness and felt that his left side was weaker than his baseline from prior brain injury. He was also complaining of blurred vision and headaches. Resident #49 was admitted for neuroimaging. The exam showed a decreased edema signal within the brainstem (indicating potential damage or abnormality within the brainstem region) since the prior exam. Neurology was consulted with orders to follow up outpatient. The note revealed the Neurologist felt the findings could represent post concussive changes in the setting of extensive chronic progressive leukoencephalopathy (a rare, progress brain infection that destroys cells that produce myelin, an insulating material for nerve cells). The resident's hospital course included a full stroke workup resulting in no findings of a stroke, Physical Therapy and Occupational Therapy evaluation, lab workup and inpatient neurology evaluation. Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. On 11/20/24 at 11:02 PM an interview was conducted with the Medical Director (MD). The MD stated she had only been in the facility since September 2024 and was not familiar with Resident #49's prior state. She stated she knew of the incident occurring, but the on-call Nurse Practitioner was notified since the incident occurred on a weekend. The MD indicated the resident was sent to the hospital following a fall in the hallway and his CT at the hospital was negative, so he was sent back to the facility. The interview revealed Resident #49 continued to have symptoms of a concussion, so he was sent to the hospital for a reevaluation on 09/17/24. The MD explained it could take a couple of days for symptoms of a concussion to appear. She stated at the hospital there were changes from his previous MRI with a decreased signal to the brainstem which she felt couldn't have happened from a hit to the resident's head. Neurology was consulted while Resident #49 was hospitalized and mentioned post concussive findings in their note, however they were also ruling out a possible misdiagnosis in the past. The interview further revealed concussion symptoms would have included lightheadedness, light sensitivity and blurred vision, all which Resident #49 was noted to have during his 09/17/24 hospitalization. On 11/27/24 at 2:05 PM an interview was conducted with the Neurologist Physician Assistant. She stated she had evaluated Resident #49 during his follow up appointment on 10/18/24. She stated the resident was being seen due to an abnormal brain MRI, white matter disease, left side numbness, incoordination and weakness. The PA stated she had only seen the resident during a one-time snapshot, and it is very hard to say the findings came directly from the altercation. She stated she had ordered follow up blood work, a lumbar puncture and was going to be reevaluating Resident #49 at the first of the year to see if there was a possible relationship between the altercation and the changes the resident has experienced. On 11/20/24 at 2:51 PM an interview was conducted with the Director of Nursing (DON). The DON stated she was notified early in the morning around 9:00 on 09/14/24 that Resident #49 was hit in the head by Resident #79. She stated Resident #49 was sitting in his wheelchair in the doorway of the room and Resident #79 wanted to get out of the room. On 11/20/24 at 3:17 PM an interview was conducted with the Administrator. During the interview he stated he was notified about the altercation on a weekend day. Staff had told him Resident #79 had popped Resident #49 on the back of the neck. The Administrator stated based on his understanding of what had happened that day staff did not make it seem like Resident #49 was hit hard by Resident #79. He was unaware Resident #79 used a fist to swing and hit Resident #49 in the back of the head. The Administrator was notified of the Immediate Jeopardy on 11/20/24 at 4:17 PM. The facility provided the following Credible Allegation of immediate jeopardy removal. Plan for Removal of Immediate Jeopardy for F600 Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: The facility failed to protect Resident #49's rights to be from physical abuse. On 09/14/2024 at 9:05 AM Nurse #1 heard a loud hit or thud coming from across the unit. She then noted Resident #49's wheelchair rolling out from his room with the resident in the wheelchair and witnessed his roommate who was cognitively intact swing his arm with a fist and hit Resident #49 in the back of the head. Resident #49 was noted to slump over in his wheelchair for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of traumatic brain injury. On 9/14/2024 at approximately 3:20pm, Resident #49 was seen by the Nurse Practitioner at the facility at the same time that Emergency Medical Services arrived. After assessing the resident, the Nurse Practitioner did not feel the resident needed to go to the hospital for further treatment despite the knowledge that Resident #49 had an altercation with the roommate and was struck in head with a significant decline from baseline as reported by several staff during the observation period. On 09/14/2024, at approximately 9:05 AM Resident #49 was separated from his roommate by the nurse and was assessed by the nurse. Resident #49 was then moved to another room away from the roommate to ensure their safety. The 15-minute safety checks are done by nursing staff to ensure residents are visualized and placed and not in harm's way. The 15-minute safety checks were initiated for both Resident #49 and his roommate. On 09/14/2024, Resident #49 and the roommate had a skin check performed by a licensed nurse status post the event to check for apparent injuries without findings. On 9/14/2024 at 7:00 PM the nurse called the Nurse Practitioner gave the order to send Resident #49 out to the hospital related to the resident sliding out of his chair and in conjunction with significant changes in condition related to Resident #49's altered mental status, and increased need for assistance with transfer mobility and bed mobility. On 11/22/2024 the Nurse Manager and the Social Services Director completed interviews with residents with a Brief Interview for Mental Status (BIMS) of 13 and above were interviewed to ensure no abuse or neglect. On 11/21/2024, current residents with a Brief Interview for Mental Status (BIMS) of 12 and below had skin checks performed by a licensed nurse and documented on a skin inspection sheet, to ensure no suspicious injuries or indication of abuse or neglect. On 11/22/2024, the Administrator and the Director of Clinical Services reviewed the incident log for the past 30 days for any other potential abuse allegations needing to be self-reported to the state of North Carolina without any further instances noted. 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 11/22/2024, current residents with targeted physical behaviors of becoming aggressive to others were identified by the Interdisciplinary Team to include the Administrator, Director of Nursing, Medical Director, Nurse Practitioner, Social Services Director, Activities Director, Therapy Director. On 11/22/2024, current residents with targeted physical behaviors care plans and behavior monitoring tools were reviewed and updated as needed by the Interdisciplinary Team to ensure interventions are in place for safety. On 11/21/2024, the Regional Director of Clinical Services reviewed the policy with and completed re-education of the facility's policy and procedures for abuse and neglect with the Administrator and the Director of Nursing to ensure understanding with a verbal return demonstration as to the types of abuse and neglect to include but not be limited to delay of care and treatment or sending a resident to a higher level of care when they have a significant change in condition. Additionally, education included what to do if you witness abuse and neglect, when to report abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator, who is the facility administrator. On 11/22/2024, the Director of Nursing and Nurse Managers completed re-education with all current staff, including Dietary, Housekeeping, Laundry, administration, Maintenance, Social Services, Therapy, Activities, Department Managers, Nursing, including Licensed Nurses, Medication Aides and Certified Nursing Assistants, including agency staff on the facility's policy and procedure for abuse and neglect to ensure understanding with a verbal return demonstration as to the types of abuse and neglect to include but not be limited to delay of care and treatment or sending a resident to a higher level of care when they have a significant change in condition. Additionally, education included what to do if you witness abuse and neglect, when to report abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator, who is the facility administrator. This education for the nursing staff will be the responsibility of the DON/Licensed Nurse Manager for current staff. Staff who were not educated on 11/22/2024 either in person or by telephone will be educated prior to the start of their next scheduled shift. The DON is responsible for tracking staff who still require education. The DON/Licensed Nurse Manager will provide education to staff not educated by 11-22-24 prior to the start of the next scheduled shift. DON and Licensed Nurse Manager were notified of this responsibility on 11-22-24. Education will be done by the DON/RN Nurse Manager during the orientation period for any newly hired staff ongoing, including agency staff for abuse and neglect. An Ad-Hoc Quality Assurance Performance Improvement Committee was held on 11/21/2024, which included the Regional Clinical Director, Medical Director, the Director of Nursing, Administrator, Maintenance Director, Unit Managers, Social Service Director, Activities Director, Rehab Program Manager and a Certified Nursing Assistant to formulate and approve a plan of correction for the deficient practice. The Administrator will be responsible for the completion of the corrective action plan. Alleged date of IJ removal: 11/23/2024 On 10/27/22, the credible allegation of Immediate Jeopardy removal date of 11/23/24 was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including Dietary, Housekeeping, Laundry, administration, Maintenance, Social Services, Therapy, Activities, Department Managers, Nursing, including Licensed Nurses, Medication Aides and Certified Nursing Assistants, and agency staff on the facility's policy and procedure for abuse and neglect revealed they had received in-service training regarding spotting, identifying, and reporting abuse. Records were reviewed of residents identified with targeted physical behaviors. A sample of residents were interviewed to ensure they had been asked about abuse and neglect by the facility. Skin assessments were reviewed for residents with a BIMS score of less than 12. The IJ removal da[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, right below the knee amputation, abnormalities of gait/mobility and muscle weakness. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was cognitively intact, had lower extremity impairment on one side, utilized a manual wheelchair for mobility, required supervision to moderate assistance with transfers, and received dialysis treatments. The MDS further revealed Resident #55 was not coded for receiving an anticoagulant. A review of the Care Plan dated 11/13/24 indicated Resident #55 required minimal to extensive assistance with activities of daily living, was a right lower extremity amputee with a prosthesis, utilized a wheelchair to assist with mobility and received dialysis treatment 3 times a week. A review of Driver #1's statement dated 11/15/24 indicated he picked up Resident #55 from the dialysis center, loaded him in the transportation van and secured his wheelchair. Driver #1 was pulling out of the parking lot onto the main road when he heard Resident #55 yelling whoa, whoa, and he looked back to find Resident #55 had fallen backwards in his wheelchair. Driver #1 immediately pulled over into a parking lot and stopped the van, waved down a person to help and they lifted Resident #55 back into an upright position. Driver #1 noted Resident #55 had a small amount of blood to the back of his head which he cleaned with an alcohol wipe. Driver #1 secured Resident #55's wheelchair, started driving back to the facility and called Unit Manager #1 to inform her of the incident. Upon returning to the facility, Driver #1 took Resident #55 to the nurse's station and informed the nurse of the incident. An interview with Driver #1 on 11/19/24 at 2:02 PM indicated on 11/12/24 the Former Administrator trained him on how to properly secure a wheelchair in the facility van and on 11/13/24 he transported 3 residents to appointments without incident. Driver #1 revealed on 11/15/24 around 11:00 AM he picked up Resident #55 from the dialysis center, secured his wheelchair in the transport van, and when he drove out of the parking lot and turned right onto the main road, Resident #55 began yelling whoa, whoa. Driver #1 stated he looked back and Resident #55 had fallen backwards in his wheelchair. Driver #1 indicated he drove about 200-300 feet, pulled over into a parking lot and stopped the van. He revealed he went to the back of the van and Resident #55 was tipped over in his wheelchair and lying on his right side. Driver #1 indicated he asked Resident #55 if he was ok and he said he was, so he waved down a person in the parking lot and they lifted Resident #55 back into an upright position. He revealed that Resident #55 had a little bit of blood on the back of his head which he cleaned with an alcohol wipe. He stated he secured Resident #55's wheelchair and drove him back to the facility. He indicated that while he was driving back to the facility, he called Unit Manager #1 and told her what happened. Driver #1 revealed when they arrived at the facility, he took Resident #55 to the nurse's station and informed Nurse #1 of the incident. Driver #1 stated that the training provided by the Former Administrator on 11/12/24 did not include education on what to do if a resident had a medical emergency, accident, fall or injury while he was transporting them in the van. An interview was conducted with Unit Manager #1 on 11/20/24 at 10:06 AM. Unit Manager #1 revealed on 11/15/24 she received a phone call from Driver #1 informing her that Resident #55 fell backwards in his wheelchair and hit his head while being transported in the facility van. Unit Manager #1 indicated Driver #1 informed her he lifted Resident #55 back into an upright position and there was a little blood on the back of his head that he wiped off. She revealed Driver #1 reported no other injuries to Resident #55 so she told him to bring Resident #55 back to the facility. A review of the facility incident report dated 11/15/24 written by Nurse #1 indicated Resident #55 was being transported in the facility van from dialysis and when the driver accelerated the van and turned right onto the main road, he fell backwards in his wheelchair and hit his head. Resident #55 returned to the facility and Nurse #1 completed a full body assessment. Resident #55 had an area to the back of his head with a small amount of bleeding, redness, and swelling. Resident #55 was alert and oriented and his vital signs were stable. Nurse #1 cleaned the area to his head and applied a border gauze dressing. Resident #55 was complaining of head pain and requested to go to the hospital. Nurse #1 notified the on-call physician and obtained an order to transfer Resident #55 to the emergency department (ED). Nurse #1 called 911 and Resident #55 was transported to the ED via emergency medical services for further evaluation. An interview with Nurse #1 on 11/20/24 at 10:21 AM indicated she was assigned to Resident #55 on 11/15/24. She stated Driver #1 returned to the facility with Resident #55 after his dialysis appointment and informed her the resident fell backwards in his wheelchair in the van and hit his head on the floor. Nurse #1 revealed she completed a head-to-toe assessment and noted Resident #55 had a large swollen area to the back right side of his head with abrasions and a small amount of bleeding. She indicated she also completed a neurological assessment which was within normal limits and Resident #55 was alert, oriented and at his baseline. She stated she cleaned the area and applied a border gauze dressing (absorbent gauze pad with a sticky border to hold it in place). Nurse #1 indicated that Resident #55 was complaining of severe head pain, so she administered his pain medication ordered as needed. She revealed that Resident #55 requested to go to the hospital, so she called the on-call physician and obtained an order to transfer him to the ED. Nurse #1 stated she called 911 and Resident #55 was transported to the ED for further evaluation via emergency medical services. An interview with Resident #55 on 11/19/24 at 12:36 PM indicated Driver #1 transported him to dialysis on 11/15/24 and on the way back to the facility he was driving out of the parking lot and turned right onto the main road and he fell backwards in his wheelchair and hit his head on the van floor. Resident #55 stated Driver #1 stopped the van and asked if he was injured, and he told him his head hurt. He stated that Driver #1 waved down a person to come and help and they lifted him back into an upright position. Resident #55 revealed that Driver #1 secured his wheelchair and drove him back to the facility. He stated a nurse assessed him when he returned to the facility, but he did not recall her name. He indicated he told the nurse he was having severe head pain and that he wanted to go to the hospital and she obtained an order from the on-call physician to send him to the ED. Resident #55 revealed the nurse called 911 and he was transferred to the ED for further evaluation. A review of the emergency department (ED) records dated 11/15/24 revealed Resident #55 reported he fell backwards in his wheelchair in a transport van hitting his head on the van floor. He was noted to have a wound to the back of his head with the bleeding controlled prior to his arrival at the ED. A computed tomography (CT) scan of the head and spine, and x-rays of the pelvis and chest were obtained. The CT scan results were negative for intracranial hemorrhage (brain bleed) and fractures, the x-rays were negative for fractures and no treatment was required for the scalp abrasion. Resident #55 was stable and discharged back to the facility on [DATE] with diagnoses including closed head injury, scalp abrasion, and strain of the neck muscle and a new order for Acetaminophen 325 milligrams two tablets to be administered by mouth every 6 hours as needed. An interview conducted with the Former Administrator on 11/19/24 at 3:08 PM revealed the training he provided to Driver #1 on 11/12/24 did not include what to do if a resident had a medical emergency, accident, fall or injury while he was transporting a resident in the van. The education included how to operate the van, using the electric lift and securing the wheelchair. An interview was conducted with the Director of Nursing (DON) on 11/20/24 at 10:27 AM. The DON stated Driver #1 started transporting residents in the facility van on 11/13/24. She revealed she was not involved in Driver #1's training on 11/12/24. The DON indicated she was notified on 11/15/24 Resident #55 was not secured properly in the transport van, fell backwards in his wheelchair and hit his head on the floor. She indicated Driver #1 lifted Resident #55 back into an upright position, secured the wheelchair and returned to the facility. The DON revealed Nurse #1 assessed Resident #55 when he returned to the facility and noted an abrasion and swelling to the back of his head. She stated Nurse #1 notified the on-call physician and received an order for Resident #55 to be transferred to the ED for further evaluation. The DON indicated she suspended Driver #1 and the van was taken out of service pending an investigation. She revealed that Driver #1 should not have moved Resident #55 and should have called 911. An interview conducted with the Medical Director on 11/20/24 at 11:01 AM indicated she was aware Resident #55 was being transported in the facility fan and fell backwards in his wheelchair hitting his head on the van floor. The Medical Director revealed that Resident #55 should have been assessed by a medical professional before he was moved to prevent further injury. An interview with the Administrator on 11/19/24 at 3:30 PM revealed he started working at the facility on 11/12/24. He stated he was aware of the incident that occurred on 11/15/24 involving Resident #55. He indicated Driver #1 had not properly secured Resident #55's wheelchair and when the van started moving Resident #55 fell backwards in his wheelchair and hit his head on the van floor. The Administrator indicated Driver #1 lifted Resident #55 back into an upright position, secured his wheelchair and drove him back to the facility. The Administrator stated Driver #1 should not have moved Resident #55 and should have called 911. The Administrator was notified of immediate jeopardy on 11/20/24 at 2:04 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the non-compliance: On 11/15/2024 at approximately 11:20 AM Resident #55 had a fall in the facility van during return from dialysis when the wheelchair tipped backwards, and Resident #55 struck his head on the van floor resulting in an injury to the back of his head and pain. The facility Transportation Driver immediately pulled over to the next parking lot, flagged down someone in the parking lot and they lifted Resident #55 back into an upright position. Resident #55 was not assessed by a medical provider before he was moved from the floor of the van. The Facility Transportation Driver called the Unit Manager at the facility on the way back. On 11/15/2024 at approximately 11:30 AM Resident #55 returned to the facility. The nurse immediately assessed Resident #55 including a Head-to-Toe assessment, Range of Motion all extremities, pupils equal, round and reactive to light and accommodation, and completed a pain assessment. Resident #55 was alert and oriented x 4 per baseline. Resident #55 sustained a hematoma to the back of his head with a small abrasion noted to the area. First aid was provided by the nurse to the area on resident's head, and medications administered per schedule and pain medication administered. The resident reported to the nurse that when the van moved, he fell backwards and hit his head. The nurse called 9-1-1 and sent Resident #55 out via EMS at approximately 12:01 PM. The Director of Nursing and the Nurse Practitioner were notified along with Resident #55's Responsible Party. On 11/15/2024 the facility Transportation Driver was suspended pending investigation, and an investigation was immediately initiated by the Director of Nursing, which included interviewing the facility Transportation Driver. As per the facility Transportation Driver's interview and the visualization of return demonstration by the facility Transportation Driver, Resident #55 was strapped into the van with all 4 wheelchair restraints and the seatbelt. The wheelchair locks were also locked on both wheels. The facility Transportation Driver could not recall if he had been trained not to move the resident, notify the facility or call 911. The facility Transportation Driver stated he moved Resident #55 from the van floor out of instinct, as he just wanted to make sure Resident #55 was comfortable. On 11/15/2024 the Director of Nursing scheduled all resident transport with contracted transportation company until further notice. On 11/15/2024, at approximately 5:49 PM, Resident #55 returned from the Emergency Department status post Computed Tomography Scan which was negative. No orders were received from the Emergency Room. Upon return to the facility, neurological checks were initiated. Head to toe skin assessment and pain assessment completed. Resident #55 complained of headache, and Hydrocodone/APAP 5/325mg was administered by the nurse as ordered. Resident #55 was alert and oriented per baseline. Upon return to the facility the Nurse Practitioner was notified, and orders were obtained to apply ice to the to the back of Resident #55's head and an additional order to cleanse the area and apply a dry dressing to his head daily and as needed. On 11/15/2024 Head-to-toe skin assessments were completed for all residents on the transport schedule for the facility van from 11/13/2024-11/15/2024 as a precaution since the Facility Transportation Driver had only started driving the van on 11/13/24. No concerns were identified. 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 11/15/2024, at approximately 12:20PM the Regional Clinical Director provided re-education by phone to the Administrator and Director of Nursing. This education included emergency protocols, including not moving the resident if an accident/event occurs on the facility or contracted vehicle, immediate notification to the facility and/or Administrator and the Director of Nursing, calling 9-1-1 and keeping the resident safe until Emergency Medical Services (EMS) arrives. On 11/15/2024, at approximately 1:00 PM, Immediate re-education provided by the Director of Nursing to the facility Transportation Driver per facility written policy. This re-education included emergency protocols, including not moving the resident if an accident/event occurs on the facility or contracted vehicle, immediate notification to the facility and/or Administrator and the Director of Nursing, calling 9-1-1 and keeping the resident safe until Emergency Management Services (EMS) arrives. On 11/15/2024, the Director of Nursing contacted the only contracted transportation company utilized by the facility. The 2 van drivers and the owner were educated via phone on emergency protocols, including not moving the resident if an accident/event occurs on contracted vehicle, immediate notification to the facility and/or Administrator and the Director of Nursing, calling 9-1-1 and keeping the resident safe until Emergency Management Services (EMS) arrives. The van drivers and the owner voiced understanding. A written copy of the policy was provided to the contracted transportation company. Per the contracted transportation company owner, this education will be added to the company orientation process for any new hires. On 11/15/2024 the Director of Nursing began education for all staff, including administration, housekeeping, laundry, dietary, maintenance, department managers and nursing including agency staff on the facility protocol if receive a call from the facility Transportation Driver or contracted transportation driver/company of an accident/event occurrence on the van. This education included immediately instructing the driver not to move the resident, ensure resident(s) were safe at all times, calling 9-1-1 and calling the facility Administrator and the Director of Nursing. This education was provided in person and via phone for the staff who were not working. This education was completed for all staff on 11/16/2024. This education will be added to the facility orientation program, including agency staff. Alleged Date of Immediate Jeopardy Removal: 11/19/24 The facility's credible allegation of immediate jeopardy removal was validated on 11/22/24. A review of the head-to-toe skin assessments for residents that were transported on the facility van 11/13/24 through 11/15/24 had been completed and no concerns were identified. Interviews conducted with the facility transport drivers indicated the DON provided education related to emergency protocols and what to do if a resident fell or was injured while they were transporting them in the van. The transportation drivers revealed the education also included the importance of calling 911, not moving the resident and keeping them safe until EMS arrived. Interviews conducted with nursing, housekeeping, dining and maintenance staff revealed they were educated on the protocol to follow when there was a resident accident, injury or fall in the facility van and if they received a call from a transport driver concerning a resident incident to instruct them not to move the resident, call 911 and notify the Administrator and DON. The facility's immediate jeopardy removal date of 11/19/24 was validated. Based on observations, record review, and resident, facility staff, Nurse Practitioner (NP), Medical Director (MD), and Physician Assistant (PA) interviews, the facility staff failed to recognize the seriousness of a significant change in condition, complete comprehensive and ongoing assessments, and identify the need for urgent medical attention. On 09/14/24 at 9:05 AM Nurse #3 heard a loud hit or thud coming from across the unit and then observed Resident #49 rolling out of his room in his wheelchair and witnessed Resident #79 swinging his arm with a fist and hit Resident #49 on the back of the head. Resident #49 was noted to slump over in his wheelchair and have a loss of consciousness for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of a traumatic brain injury and immediately after being hit in the head by Resident #79 he was noted to have a change of condition as evidenced by a change in level of assistance needed for transfer and bed mobility changed, confusion and inability to self-propel in his wheelchair. There was a lack of effective communication between staff after Resident #49 was transferred to a different hall around 10:00 AM and no care or assessments were provided by a nurse until 3:00 PM. There were no documented comprehensive assessments or neurological checks located in the medical record after the initial nursing note after the incident. Later in the day Resident #49 slid out of wheelchair to the floor and was assessed with worsening generalized weakness and concern for a concussion. Emergency Medical Services (EMS) was dispatched on 9/14/24 at 6:31 PM and Resident #49 was taken to the hospital for evaluation. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. Resident #49 returned to the hospital on 9/17/24 for evaluation of acute chronic left-sided weakness, lightheadedness, blurred vision and headaches. Resident #49 was admitted for neuroimaging (brain scanning). The Neurologist felt the findings could represent post concussive changes and Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. At the time of the survey, Resident #49 reported he felt his condition had changed since the incident and noted he was now confined to a specialized chair and was dependent upon staff for all activities of daily living and required the use of mechanical lift for transfers. In addtion, the facility failed to assess a resident for injury before moving them when Driver #1 was transporting Resident #55 in the facility van and he fell backwards in his wheelchair and hit his head on the van floor resulting in severe head pain. Driver #1 lifted Resident #55 back into an upright position and drove him back to the facility without being assessed by a medical professional. Driver #1 had not been trained on how to respond or what to do in emergency situation or accident. Resident #55 was assessed by Nurse #1 and noted to have a swollen area with abrasions to the back of his head. Resident #55 was transferred to the hospital for further evaluation and was diagnosed with a closed head injury, scalp abrasion and strained neck muscles. This deficient practice occurred for 2 of 3 sampled residents reviewed for quality of care (Resident #49 and Resident #55). Immediate Jeopardy began on 09/14/24 when Resident #49 who had a history of a traumatic brain injury was hit in the head and facility staff failed to identify the seriousness of the change in condition and complete comprehensive assessments to determine if a higher level of care was needed. Immediate jeopardy began for Resident #55 on 11/15/24 when he was lifted back into an upright position by Driver #1 before he was assessed for injury by a medical professional. The immediate jeopardy was removed for Resident #55 on 11/22/24 and for Resident #49 on 11/23/24 when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: 1. Resident #49 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI). A review of Resident #49's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #49 was coded as independent for eating and putting on/ taking off footwear. He required set up or clean up assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #49 required supervision assistance for chair to bed transfers, toileting transfers, tub/shower transfers and lying to sitting on the side of the bed. The resident was noted to be independent for rolling left and right while in bed. Resident #49 was continent of bowel and bladder during the assessment period and was documented to have no behaviors. Resident #79 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of TBI. A review of Resident #79's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #79 was coded as independent for all activities of daily living (ADL) including eating, toileting, oral hygiene, shower/bathe self, upper body dressing, lower body dressing and all transfers. He was coded as using a cane to ambulate during the assessment period. Resident #79 was documented to have no behaviors. A review of the facility's investigation report initiated on 09/14/24 at 9:05 AM by the Administrator revealed Resident #49 was hit on the back of his neck/head by his roommate. After the nurse assessed Resident #49, he was noted with no injuries and the residents were immediately separated by moving Resident #49 to another room. Staff were briefed on the incident and monitored the residents every 15 minutes to avoid further incidents. Resident #49's roommate had stated he hit the resident because he was trying to exit the room and Resident #49 was blocking the doorway with his wheelchair. An Occupation Therapy (OT) Discharge summary dated [DATE] revealed Resident #49 received therapy services initiated on 07/18/24 through 09/06/24. Skilled interventions provided included instructing and training Resident #49 in proper body mechanics, positioning/ pressure relieving techniques, safe transfer techniques and use of adaptive equipment in order to improve independence and engagement of ADL and self-care task. At the time of therapy discharge Resident #49 was set up assistance for eating, partial/moderate assistance for toileting hygiene, supervision for toileting transfers and set up assistance for bathing. The resident's self-care function score on a scale of 0-12 (12 being the highest function of independence) was a 10. A nursing note written by Nurse #3 dated 09/14/24 at 10:11 AM revealed she heard hitting noises and turned around to observe Resident #49 get hit in the head by his roommate. The note revealed the residents were separated and assessed for injuries. Resident #49's vital signs were the following: blood pressure 138/66, pulse 72, temperature 97.9, respirations 20, oxygen saturation level 96% on room air. The resident was noted with no signs of acute distress at the time of the incident and no complaints of pain. Redness was noted to the back of the resident's neck. The residents Responsible Party, Director of Nursing and on call Nurse Practitioner were notified. New orders were obtained for a psychological evaluation of Resident #79 and every 15-minute monitoring for a duration of 24 hours. A review of Resident #49's medical record revealed the only documented vital signs were included on Nurse #3's progress note on 9/14/24 at 10:11 AM. Further review of the medical record revealed no neurological or resident assessments were documented. On 11/19/24 at 11:38 AM an interview was conducted with Nurse #3. Nurse #3 stated on 09/14/24 around 9:00 AM she heard a loud hit or thud coming from across the unit. She then saw Resident #49 rolling out from his room in his wheelchair and witnessed (Resident #79) who was cognitively intact, swinging his arm with a fist and hit Resident #49 at the back of the head making a second thud sound as his fist hit the back of Resident #49's head. Resident #49 immediately slumped over in his wheelchair and regained consciousness within a couple of seconds after she got to him to assess his condition. She stated she saw redness at the back of Resident #49's head and neck area. When Resident #49 came to he asked to go outside to smoke so Nurse Aide (NA) #2 took him to the smoking area. Nurse #3 indicated she had obtained initial vital signs on the resident which were within normal range, assessed him and the Unit Manager notified the Nurse Practitioner of what had occurred. Nurse #3 explained when Resident #49 was moved from her hall around 10:00 AM, she no longer was his nurse and did not see him again that day. The interview revealed she had initiated an action rounding log which documented where the resident was in the facility every 15 minutes. Upon review of the action rounding sheet Nurse #3 confirmed her initials were on the sheet documenting on the resident from 9:00 AM to 3:00 PM, however she did not recall putting her initials on the paper nor had she checked on the resident every 15 minutes during the shift. Nurse #3 stated Nurse #4 took over Resident #49's care when he moved to his new room around 10:00 AM. Nurse #3 gave Nurse #4 a short description of what had occurred between the two residents and went back to her unit. The interview revealed the facility would typically complete neurological assessments after a head injury, however since Nurse #4 assumed responsibility for the resident it would have been up to her to complete the assessments and monitoring. Nurse #3 stated she did not initiate neuro checks for the resident. On 11/21/24 at 12:32 PM an interview was conducted with Scheduler #1. She stated she was working as the Manager on Duty on 09/14/24. Scheduler #1 stated her office door was open and she overheard a nurse screaming for help. When she went out into the hall, she saw Nurse #3 and went to her. Scheduler #1 stated Resident #49 sitting in his wheelchair slumped over and was unconscious for approximately a minute. Nurse #3 explained to her that he had just been hit in the back of the head by Resident #79. When he initially woke up after being hit and came to, his abilities were not the same, he was using his hands but nothing else like he had before. She stated he was no longer able to self-propel himself in the hallway as he had done that morning or self-transfer to bed. After separating the residents, she stated she notified the Unit Manager #1 via the facility paging system and Nurse #3 called the Director of Nursing. Scheduler #1 stated Resident #49 was taken to the smoking area by NA#2 because he stated he wanted to go smoke. She stated Resident #49 immediately seemed spaced out by responding slowly when spoken to and not thinking clearly. The interview revealed Resident #49 started trying to go in the wrong direction and had to be redirected by staff. When they took him to his new room, it took Scheduler #1, NA #2 and Nurse #3 to all assist him into the bed. Scheduler #1 told Nurse #3 she would need to complete neurological assessments. She stated they were so concerned with Resident #49's condition they had placed a fall mat under his bed because they felt like he may have a fall from the bed due to his state of immobility. Scheduler #1 stated she did not voice her concerns to anyone because she thought Nurse #3 and Nurse #4 were communicating the residents' changes to the Medical Provider. The interview revealed Resident #49 had experienced a couple of falls following the incident and was sent back to the hospital on [DATE] for a reevaluation due to complaints of a headache. On 11/21/24 at 9:06 AM an interview was conducted with Unit Manager (UM) #1. During the interview she stated on 09/14/24 around 9:00 AM she was paged on the overhead call system to come to Resident #49s room. Upon arrival Nurse #3 told her Resident #49 had been hit on the back of his head by Resident #79. She stated she looked at the resident and he was able to respond to her. She had them remove Resident #49 from the room and contacted the Director of Nursing (DON) who stated she needed to notify the resident's family and the provider on call. She stated the provider on call (NP #3) asked her how the resident was doing, and she stated it was her first time laying eyes on him, and he seemed okay. NP #3 instructed the facility to notify them of any change of condition. UM #1 recalled they immediately moved Resident #49 to a room in another hall around 10:00 AM. She stated it was her understanding after talking with Nurse #3 that Nurse #4 was going to assume care of the resident when he moved to the new room. Unit Manager #1 stated she was rounding later in the day and saw Resident #49's call light on, she stated he was trying to transfer himself from the wheelchair to the toilet which the NA said he was normally able to do. She stated she had to get two other staff members to assist due to his weakness. She stated Resident #49 was so weak she asked the Resident to hold off on all transfers for the rest of the day because he was now a full assist for transfers. She contacted Nurse Practitioner (NP) #2 who told her she would be in the building to round shortly. UM #1 explained she spoke with the DON after she called NP #2 to let her know NP #2 was going to evaluate the resident. UM #1 revealed the DON told her to activate Emergency Medical Services (EMS) because she did not feel comfortable with his condition. EMS arrived at the same time as NP #2 came onsite around 3:00 PM. NP #2 completed an assessment of Resident #49 and stated to her (UM #1) to turn EMS away, that the resident had no reason to go out for an evaluation. UM #1 indicated she [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, Medical Director and staff interviews, the facility failed to provide safe van transportation when Driver #1 failed to secure Resident #55's wheelchair in the facility van per the manufacturer's instructions. On 11/15/24, during transport from the dialysis center, Driver #1 did not secure Resident #55's wheelchair in the facility van per the manufacturer's instructions, and when he drove out of the parking lot and turned right onto the main road, Resident #55 fell backwards in his wheelchair and hit his head on the van floor. Resident #55 was assessed by Nurse #1 when he returned to the facility, was noted to have an abrasion and swelling to the back of his head and was complaining of severe head pain. He was transported to the Emergency Department (ED) for further evaluation and diagnosed with a closed head injury, scalp abrasion, and strained neck muscles. There was a high likelihood of a serious adverse outcome or injury when Resident #55's wheelchair was not secured in the transportation van per the manufacturer's instructions. Resident #55 was not receiving an anticoagulant (blood thinner). This deficient practice occurred for 1 of 9 residents reviewed for accidents (Resident #55). Immediate jeopardy began on 11/15/24 when Resident #55's wheelchair was not secured in the facility's transport van per the manufacturer's instructions, and he fell backwards in his wheelchair and hit his head on the van floor. Immediate jeopardy was removed on 11/19/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: A review of the manufacturer's instruction manual for the transport van 4-point wheelchair securement system provided by the facility read in part: Attach the tie-down (fabric strap connecting a hook and a floor anchor) anchor into the floor anchorages and lock them into place. Attach the 4 tie-down hooks to a solid part of the wheelchair frame below the seat ensuring the tie downs are fixed at approximately 45 degrees. Ensure all tie-downs are locked and properly tensioned (tightened). A review of Driver #1's training records revealed a competency evaluation dated 11/12/24 completed by the Former Administrator that Driver #1 was reviewed for securing a wheelchair into the facility's transport van per the manufacturer's instructions and all competencies were checked as met. Resident #55 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, right below the knee amputation, abnormalities of gait/mobility and muscle weakness. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was cognitively intact, had lower extremity impairment on one side, utilized a manual wheelchair for mobility, required supervision to moderate assistance with transfers and was receiving dialysis treatment. The MDS further revealed Resident #55 was not coded for receiving an anticoagulant. A review of the Care Plan dated 11/13/24 indicated Resident #55 required minimal to extensive assistance with activities of daily living, was a right lower extremity amputee with a prosthesis, utilized a wheelchair to assist with mobility and received dialysis treatment 3 days a week. A review of the facility incident report dated 11/15/24 written by Nurse #1 indicated Resident #55 was being transported in the facility van from dialysis and when the van started moving forward, he fell backwards in his wheelchair and hit his head. Resident #55 returned to the facility and Nurse #1 completed a full body assessment. Resident #55 had an area to the back of his head with a small amount of bleeding, redness, and swelling. Resident #55 was alert and oriented and his vital signs were stable. Nurse #1 cleaned the area to his head and applied a border gauze dressing (absorbent gauze pad with a sticky border to hold it in place). Resident #55 was complaining of head pain and requested to go to the hospital. The on-call physician was notified, an order was received and Resident #55 was transported to the emergency department (ED) via emergency medical services for further evaluation. A review of the ED records dated 11/15/24 revealed Resident #55 reported he fell backwards in his wheelchair in a transport van hitting his head on the van floor. He was noted to have a wound to the back of his head with the bleeding controlled prior to his arrival at the ED. A computed tomography (CT) scan of the head and spine, and x-rays of the pelvis and chest were obtained. The CT scan results were negative for intracranial hemorrhage (brain bleed) and fractures, the x-rays were also negative for any fractures and the scalp abrasion did not require any treatment. Resident #55 was stable and discharged back to the facility with diagnoses including closed head injury, scalp abrasion, and strain of the neck muscle. A review of Driver #1's statement dated 11/15/24 indicated he picked up Resident #55 from the dialysis center loaded him in the transportation van and secured his wheelchair. Driver #1 was pulling out of the parking lot onto the main road when he heard Resident #55 yelling whoa, whoa, and he looked back to find Resident #55 had fallen backwards in his wheelchair. Driver #1 immediately pulled over into a parking lot and stopped the van, waved down a person to help and they lifted Resident #55 back into an upright position. Driver #1 noted Resident #55 had a small amount of blood on the back of his head which he cleaned with an alcohol wipe. Driver #1 secured Resident #55's wheelchair, started driving back to the facility and called Unit Manager #1 to inform her of the incident. Upon returning to the facility, Driver #1 took Resident #55 to the nurse's station and informed the nurse of the incident. In an interview with Driver #1 on 11/19/24 at 2:02 PM he indicated the Former Administrator trained him on how to secure a wheelchair in the facility van on 11/12/24. Driver #1 indicated he watched the Former Administrator secure a wheelchair in the van using the manufacturer instructions. Driver #1 stated the Former Administrator then observed him secure an empty wheelchair in the van, and then the Former Administrator sat in a wheelchair, he secured it in the van and drove the van out of the parking lot and on the main road for a few minutes to ensure the wheelchair was properly secured. Driver #1 indicated the Former Administrator filled out a vehicle safety and operation competency evaluation and he was checked off for meeting the competencies for proper placement and securement of the wheelchair. Driver #1 stated he started transporting residents in the facility van on 11/13/24 and transported 3 residents to appointments on that day without incident. Driver #1 indicated on 11/15/24 around 11:00 AM he picked up Resident #55 from the dialysis center, secured his wheelchair in the transport van, and started to drive out of the parking lot. He stated when he accelerated the van and turned onto the main road, Resident #55 began yelling whoa, whoa, and when he looked back Resident #55 had fallen backwards in his wheelchair. Driver #1 indicated he drove about 200-300 feet, pulled over into a parking lot, and stopped the van. He stated he went to the back of the van and Resident #55 was tipped over in his wheelchair and lying on his right side. Driver #1 stated he observed that the front left anchor on the tiedown strap had come loose from the floor anchorage. He indicated he asked Resident #55 if he was ok and he said he was. Driver #1 stated he waved down a person in the parking lot to help and they lifted Resident #55 back into an upright position. Driver #1 revealed he secured Resident #55's wheelchair making sure all of the tie-down anchors were locked into the floor anchorages and then drove back to the facility. He stated that while he was driving back to the facility he called and reported the incident to Unit Manager #1. Driver #1 indicated when he arrived at the facility, he took Resident #55 to the nurse's station and reported the incident to Nurse #1. An interview with Resident #55 on 11/19/24 at 12:36 PM indicated the facility transports him to dialysis on Mondays, Wednesdays and Fridays. He stated Driver #1 transported him in the facility van for the first time on 11/13/24. Resident #55 revealed when the van was moving his wheelchair was moving around a little and he did not feel properly secured but did not report this to Driver #1. Resident #55 indicated Driver #1 transported him to dialysis on 11/15/24 and on the way back to the facility when he drove out of the parking lot and turned onto the main road, he fell backwards in his wheelchair and hit his head on the van floor. Resident #55 stated Driver #1 stopped the van and asked if he was injured, and he told him his head hurt. He stated that Driver #1 waved down a person to come and help and they lifted him back into an upright position. Resident #55 revealed that Driver #1 secured his wheelchair and drove him back to the facility. He stated a nurse assessed him when he returned to the facility but he did not recall her name. Resident #55 indicated he told the nurse he was having severe head pain and that he wanted to go to the hospital. He revealed the nurse called 911 and he was transferred to the ED for further evaluation. An interview was conducted with Unit Manager #1 on 11/20/24 at 10:06 AM. Unit Manager #1 revealed on 11/15/24 she received a phone call from Driver #1 informing her that Resident #55 fell backwards in his wheelchair while being transported in the facility's van. She stated she asked Driver #1 how it happened, and he told her the tie-downs were not secured properly and came loose. Unit Manager #1 indicated Driver #1 informed her he lifted Resident #55 back into an upright position and there was a little blood on the back of his head he wiped off. She revealed Driver #1 reported no other injuries, so she told him to bring Resident #55 back to the facility. An interview with Nurse #1 on 11/20/24 at 10:21 AM indicated she was assigned to Resident #55 on 11/15/24. She stated Driver #1 returned to the facility with Resident #55 after his dialysis appointment and informed her the resident fell backwards in his wheelchair in the van and hit his head on the floor. Nurse #1 revealed she completed a head-to-toe assessment and noted Resident #55 had a large swollen area to the right back side of his head with abrasions and a small amount of bleeding. She indicated Resident #55 did not have hair, so she was able to clean the area and applied a gauze border dressing. She stated that Resident #55 was complaining of severe head pain and requested to go to the hospital. She revealed she administered Resident #55 pain medication ordered as needed, called the on-call physician and obtained an order to transfer Resident #55 to the ED for further evaluation. An interview conducted with the Former Administrator on 11/19/24 at 3:08 PM indicated on 11/07/24 the facility's transport driver resigned, and the facility's part time receptionist (Driver #1) was hired as the transport driver. He stated on 11/12/24 he trained Driver #1 by showing him how to secure a wheelchair in the transport van using the manufacturer instructions for the 4-point wheelchair securement system and then watched Driver #1 secure an empty wheelchair in the van. The Former Administrator revealed he then sat in a wheelchair while Driver #1 secured it in the van and drove the van out of the parking lot and on the main road. He indicated Driver #1 secured the wheelchair properly and no concerns were identified. The Former Administrator stated he filled out the facility's vehicle safety and operation competency evaluation and Driver #1 met all the competencies on the form including proper placement and securement of the wheelchair per the manufacturer instructions. An interview conducted with the Medical Director on 11/20/24 at 11:01 AM indicated she was aware of the van incident that occurred with Resident #55. She stated she was informed Resident #55's wheelchair was not secured properly in the transport van and when the van started moving, he fell backwards in his wheelchair hitting his head on the van floor. The Medical Director revealed that residents should be secured properly in the transport van and a resident that fell should be evaluated by a medical professional prior to being moved to prevent further injury. An interview with the Administrator on 11/19/24 at 3:30 PM revealed he started working at the facility on 11/12/24. He stated he was aware of the incident that occurred on 11/15/24 involving Resident #55. He indicated Driver #1 had not secured Resident #55's wheelchair and when the van started moving Resident #55 fell backwards in his wheelchair and hit his head on the van floor. The Administrator indicated Driver #1 lifted Resident #55 back into an upright position, secured his wheelchair and drove him back to the facility. The Administrator stated Resident #55's wheelchair should have been properly secured in the transport van. The Administrator was notified of immediate jeopardy on 11/20/24 at 2:04 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the non-compliance: On 11/15/2024 at approximately 11:20 AM Resident #55 had a fall in the facility van during return from dialysis when the wheelchair tipped backwards and Resident #55 struck his head on the van floor resulting in an injury to the back of his head and pain. The facility Transportation Driver failed to provide safe van transportation for Resident #55 by not securing his wheelchair in the transportation van per the manufacturer's instructions. On 11/15/2024 at approximately 11:30 AM Resident #55 returned to the facility. The nurse immediately assessed Resident #55 including Head-to-Toe assessment, Range of Motion all extremities, pupils equal, round and reactive to light and accommodation, and completed a pain assessment. Resident #55 was alert and oriented x 4 per baseline. Resident #55 sustained a hematoma to the back of his head with a small abrasion noted to the area. First aid was provided by the nurse to the area on resident's head, and medications administered per schedule and pain medication administered. The resident reported to the nurse that when the van moved, he fell backwards and hit his head. The nurse called 911 and sent Resident #55 out via emergency medical services at approximately 12:01 PM. The Director of Nursing and the Nurse Practitioner were notified along with Resident #55's Responsible Party. On 11/15/2024 the facility Transportation Driver was suspended pending investigation, and the facility van was removed from service until the Regional Maintenance Director inspection was complete. On 11/15/2024 an Investigation immediately initiated by the Director of Nursing, which included an interview and the visualization of return demonstration by the facility Transportation Driver. The facility Transportation Driver stated that Resident #55 was strapped into the van with all 4 wheelchair restraints and the seat belt. The wheelchair locks were also locked on both wheels. The facility Transportation Driver stated he pulled out of the parking lot, turning right, when he heard Resident #55 say whoa, he looked in the mirror and saw Resident #55 fall backward to the side. The conclusion is that a strap was not fully engaged in the track which allowed the wheelchair to come loose and fall backwards, whereby the resident hit his head. On 11/15/2024, at approximately 5:49 PM, Resident #55 returned from the Emergency Department status post Computed Tomography Scan which was negative. No orders were received from the Emergency Room. Upon return to the facility, neurological checks were initiated. Head to toe skin assessment and pain assessment completed. Resident #55 complained of headache, and Hydrocodone/Acetaminophen 5/325mg was administered by the nurse as ordered. Resident #55 was alert and oriented per baseline. Upon Resident #55's return to the facility the Nurse Practitioner was notified, and an order was given to apply ice to the back of Resident #55's head and an additional order to cleanse the area and apply a dry dressing to his head daily and as needed. On 11/15/2024 the Director of Nursing scheduled all resident transport with contracted transportation company until further notice. On 11/15/2024 Head-to-toe skin assessments were completed for all residents on the transportation schedule for the facility van from 11/13/2024-11/15/2024 as a precaution since van driver had only started driving the van on 11/13/2024. No concerns were identified. Alert and oriented residents that had been scheduled for transportation on the facility van from 11/13/2024-11/15/2024 were asked if they felt safe and secure on the van during transport. No concerns were identified. 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 11/15/2024, at approximately 12:20 PM immediate education was provided via phone by the Regional Director of Clinical Services to the Administrator and Director of Nursing. This education included Vehicle Driver Safety Program, proper use of wheelchair securement devices per manufacturer's instructions, vehicle lift competency evaluation, placing the van out of service immediately, and not allowing the facility transportation driver to drive until investigation completed. On 11/15/2024, at approximately 3:00 PM, Immediate education provided by the Director of Nursing to the facility Transportation Driver. This written and verbal education included Vehicle Driver Safety Program, proper use of wheelchair securement devices as per manufacturer's instructions, vehicle lift competency evaluation, placing the van out of service immediately, not allowing the facility transportation driver to drive until investigation completed. On 11/15/2024, the Contracted Transportation company provided the facility with their policy and procedures for securing and strapping a wheelchair and competencies for the 2 current drivers. The education and competencies are completed upon hire and annually. On 11/18/2024 the facility Transportation Driver, Maintenance Director and Maintenance Assistant were re-educated by the Regional Maintenance Director on the Facility Vehicle Driver Safety Program, including proper use of wheelchair securement devices ensuring proper tension of devices per manufacturer's instructions, with return demonstration, and competency check off completion, and validated facility Transportation Driver was able to safely operate facility van. This education will be added to the facility orientation program for new Transportation Drivers, Maintenance Director or Maintenance Assistant. This education and competencies will be completed annually for the current Transportation Driver, Maintenance Director and Maintenance Assistant. On 11/18/2024 the Regional Maintenance Director inspected the facility van. The Regional Maintenance Director placed the facility van back in service. The facility Transportation Driver resumed transportation for the facility on 11/19/2024. Alleged Date of Immediate Jeopardy Removal: 11/19/2024 The facility's credible allegation of immediate jeopardy removal was validated on 11/22/24. Observations were conducted of transport drivers securing a wheelchair for transport according to the manufacturer instructions which included securing the tie-down anchors into the floor anchorages and locking them into place. A review of the head-to-toe skin assessments for residents that were transported on the facility van 11/13/24 through 11/15/24 had been completed and no concerns were identified. Interviews conducted with the facility transporters revealed education was provided by the Regional Director of Maintenance which included vehicle driver safety and how to properly secure a resident in the facility van using the 4-point wheelchair securement system per the manufacturer's instructions. The facility transporters also stated they had to verbalize their understanding of the education and complete a return demonstration of how to properly secure a wheelchair in the facility van. An interview conducted with the Regional Director of Maintenance indicated he completed a safety inspection of the wheelchair securement system in the facility van and no concerns were identified. The Regional Director of Maintenance stated he provided education to the facility transporters on how to use the 4-point securement system per the manufacturer's instructions and observations of return demonstrations by the drivers indicated they were able to properly secure a resident in the van. The facility's immediate jeopardy removal date of 11/19/24 was validated on 11/22/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident interview, staff interviews and record review, the facility failed to report an incidence of physical abuse to facility administration to protect a resident from further physical abuse. Resident #5 experienced physical abuse twice on 12/27/23. Both incidents occurred on 12/27/23 before 2:30 PM. Resident #4 first physically assaulted Resident #5 in the dining room. This occurrence of physical abuse was not reported to the facility administration. As a result, Resident #4 physically assaulted Resident #5 again in the hallway. The deficient practice occurred for 1 of 4 sampled residents reviewed for abuse (Resident #5). The findings included: The facility's policy, Abuse Prevention, Intervention, Reporting and Investigation, effective November 2016, recorded in part, The facility will ensure the protection, prompt reporting, and interventions in response to alleged, suspected, or witnessed abuse of any resident. It is the responsibility of employees to promptly report to facility management any incident or suspected incident of abuse from other residents, staff, family, or visitors. Residents are to be protected during incident investigations by ensuring the administrator is immediately informed. A resident who is allegedly mistreated by another resident is removed from contact with that resident during the investigation. It is the facility policy that residents will be protected from alleged offender(s). Resident #5 re-admitted to the facility on [DATE]. Diagnoses included dementia with agitation, anxiety disorder, mood affective disorder, psychosis, and major depressive disorder. Resident #4 re-admitted to the facility on [DATE]. Resident #4 was her own responsible party (RP). Diagnoses included recurrent major depressive disorder, post-traumatic stress disorder, and anxiety disorder. Review of a Facility Reported Incident completed by the Director of Nursing (DON) and dated 12/27/23 at 1:45 PM indicated Resident #4 and Resident #5 were both in the dining room when Resident #5 shouted to dietary staff that she was hungry. Resident #5 received a sandwich and juice but continued to shout for more food. Resident #4 asked Resident #5 to stop harassing the dietary staff at which time Resident #5 turned to Resident #4 and responded with expletives. Resident #4 stated that she became extremely frustrated because Resident #5 had been harassing her for weeks, and that this incident made her so angry that she rolled up behind Resident #5 in the hallway and put her in a headlock from behind. A Resident Incident Report for Resident #5 completed by the DON recorded that on 12/27/23 at 1:45 PM, Resident #4 and Resident #5 were both in the dining room when Resident #5 began to harass the kitchen staff. When Resident #4 told Resident #5 to stop harassing the staff, Resident #5 turned to Resident #4 and cursed at her. At this, Resident #4 stated that she got upset and put Resident #5 in a chokehold in the hallway, witnessed by the Human Resources (HR) Director, because Resident #5 had been harassing her for weeks. The Resident Incident Report documented that Resident #5 was assessed by the DON without injury. The Resident Incident Report did not record that a second incident of physical abuse by Resident #4 against Resident #5 also occurred on 12/27/23 before 2:30 PM. A Nursing General Note dated 12/28/23 at 8:38 AM by the DON recorded that on 12/27/23 at approximately 1:45 PM, Resident #5 and Resident #4 were in the dining room. Resident #4 reported that Resident #5 started harassing kitchen staff and when Resident #4 asked Resident #5 to stop harassing the kitchen staff, Resident #5 cursed at her. At this, Resident #4 stated that she got upset and put Resident #5 in a chokehold because Resident #5 had been harassing her for weeks. Staff heard the commotion and separated the Residents. The Nursing General Note recorded that Resident #5 was assessed without injury. The Nursing General Note dated 12/28/23 did not record that a second incident of physical abuse by Resident #4 against Resident #5 also occurred on 12/27/23 before 2:30 PM. During an interview with Resident #4 on 4/11/24 at 10:30 AM, and a follow-up interview on 4/12/24 at 9:15 AM, she stated that on 12/27/23, she remembered that she and Resident #5 were in the dining room sometime before bingo which was scheduled for 2:30 PM, when Resident #5 kept messing with staff in the kitchen saying she was hungry. Resident #4 said she told Resident #5 to leave the kitchen staff alone and to eat the food she had been given. At that time, Resident #5 turned to her, got in her face, and said f*** you. Resident #4 said she got so tired of Resident #5 talking to her that way, so she knocked on the activity door, which was an office inside the dining room, but then decided she would go find a staff member. Resident #4 stated that as Resident #5 was leaving the dining room Resident #4 stated, she rolled up behind her (Resident #5) in the hallway and stated, that's when I blacked out and then the next thing I knew staff told me that I grabbed her around her neck and was pulling her hair. Resident #4 stated that staff had to tell her what she did when she blacked out because she did not remember that she grabbed Resident #5 around her neck and pulled her hair. She stated staff also told her that on the same day, 12/27/23, there was another incident between the two Residents that occurred before she grabbed Resident #5 around her neck. Resident #4 said the activity assistant told her that while the two Residents were in the dining room before bingo, the activity assistant had to separate them because Resident #4 placed her arms around the neck of Resident #5 and pulled her forward. Resident #4 stated she did not recall putting her arms around the neck of Resident #5 and pulling her forward, but that Resident #5 must have continued to curse at her in order for her to physically assault Resident #5 twice. Resident #4 stated this was not her usual behavior, she stated I don't put my hands on people, and I asked God to forgive me for what I did. She stated that she did not have a chance to apologize to Resident #5 before she passed away and that she felt bad about that, but that Resident #5 should not have gotten in her face and cursed at her. Resident #4 stated that she talked to a mental health nurse practitioner after these incidents, who adjusted her medications for depression, which has helped. An interview with the Activity Director (AD) and the Activity Assistant occurred on 4/11/24 at 5:37 PM. During the interview, the AD stated that on 12/27/23, she did not know the exact time, but sometime before bingo which was scheduled at 2:30 PM, she was in her office, which was a room inside the dining room, and she heard Resident #5 talking loudly in the dining room and using profanity. Resident #4 told Resident #5 nobody wants to hear that. During the interview, the Activity Assistant stated that before the 2:30 PM bingo activity, she was not sure of the exact time, she was in/out of the dining room setting up bingo, and she told Resident #5 to calm down. The Activity Assistant stated that Resident #5 got upset, continued using profanity and yelled at Resident #4 b**** I will f*** you up. The Activity Assistant stated she called the AD to come and help her when she saw Resident #5 propel in her wheelchair towards Resident #4, Resident #4 put her arms around the neck/shoulders of Resident #5 and pulled her forward. The Activity Assistant stated she separated the Residents, directed Resident #4 to go to her room while the AD took Resident #5 to her room. The Activity Assistant said she returned to setting up bingo and that she did not report to administration that she had to separate the two Residents. The interview continued and the AD stated that the Activity Assistant asked for her help. The AD stated that when she came out of her office into the dining room, she saw the Activity Assistant pulling the two residents apart. The AD said that the Activity Assistant told her what occurred, the AD took Resident #5 to her nurse (Nurse #1), reported the incident to Nurse #1 and returned to the dining room for bingo. The AD stated that she did not report the incident to the administration, but rather took Resident #5 to her Nurse. Nurse #1 was interviewed via phone on 4/12/24 at 3:35 PM. He stated that he was the assigned Nurse on the South Unit for the 7A - 3P shift on 12/27/23. He stated that close to the end of the shift on 12/27/23 he heard staff stating that Resident #5 said something to Resident #4 that got her upset and caused her to hit Resident #5. Nurse #1 said he was told that an incident report had been made, but he could not recall who told him that, so he did not make a report about the incident because he did not witness it and he was not asked to do any follow up. Nurse #1 said after he heard about the incident, he did recall seeing Resident #5 in her wheelchair at the end of the hall near her room, but that she did not mention what occurred. Nurse #1 said he was not made aware that there were two incidents between Resident #4 and Resident #5 that day. Nurse #1 stated that if staff had reported the first incident directly to him, he would have contacted the DON and administrator to get the police involved if a resident was assaulted and followed the facility's abuse policy to protect Resident #5 from further physical abuse. The Human Resources (HR) Director was interviewed on 4/11/24 at 1:20 PM and stated that on 12/27/23 she was in the DON's office sometime after lunch, she did not recall the exact time, when she heard Resident #4 say I told you not to f*** with me no more. When she went into the hallway, she saw Resident #4 and Resident #5 in the hallway in front of the dining room. The HR Director described that Resident #4's arm was around the neck of Resident #5, in a headlock, Resident #5's face was red, and she was gasping. The HR Director stated she told Resident #4 to let go of Resident #5, but she did not, so the HR Director had to physically separate them. The HR Director stated that the DON came into the hallway after the incident, so she reported to the DON what happened and called the administrator to report to him what occurred. The HR Director stated that she was not aware of a second incident of physical abuse by Resident #4 towards Resident #5 that occurred in the dining room. An interview on 4/11/24 at 5:30 PM occurred with the DON. She stated that she was notified on 12/27/23 by the HR Director that at around 1:45 PM, the HR Director overheard commotion coming from the hallway near the dining room. The HR Director said she went to the hallway and saw Resident #4 holding Resident #5 in a headlock. The HR Director said she separated the Residents, and Resident #5 was taken to her room. The DON stated she notified the administrator and started an investigation. The DON said that both Residents were monitored every 15 minutes for two hours and then hourly for the next 24 hours. During the interview, the DON was asked by the surveyor if she was aware that on 12/27/23 sometime before bingo, the activity assistant separated Resident #4 from Resident #5 in the dining room when she put her arms around the neck of Resident #5 and pulled her forward. The DON stated that she was not notified by staff that both Residents were separated earlier that day on 12/27/23 due to another physical altercation that occurred in the dining room before bingo. She said that if she had been made aware of the first physical altercation that occurred between the two Residents in the dining room, she would have separated the Residents then which would have prevented the second incident from occurring later in the hallway. The Administrator stated in an interview on 4/11/24 at 5:45 PM that he was notified on 12/27/23 by the DON that Resident #4 physically assaulted Resident #5 in the hallway after an argument occurred in the dining room. He stated he did not recall the exact time he was notified. He stated that he told the staff to separate the Residents, assess them for injury, place the Residents on monitoring every 15 minutes for the first two hours and then hourly checks thereafter. When asked by the Surveyor if he was aware that two incidents of physical abuse occurred on 12/27/23 between the two Residents, he said that he was not notified of a prior incident involving physical abuse by Resident #4 to Resident #5 on the same day. He stated that he was only aware of the physical abuse by Resident #4 that occurred in the hallway. He stated that he expected residents to be protected from abuse and if he had been notified of the first incident of physical abuse by Resident #4 that occurred in the dining room, he would have strategized a plan to prevent further interactions between the two residents and protected Resident #5 from further abuse that occurred in the hallway. The Administrator and the DON were notified of immediate jeopardy on 4/12/24 at 2:05 PM. The facility provided the following corrective action plan with a completion date of 12/29/23. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 12/27/23 during the 7a - 3p shift, the Activity Director reported to nursing that Resident #4 placed both arms around the neck/shoulder area of Resident #5, a confused resident, and pulled Resident #5 towards her when she was approached by Resident #5 in the dining room after a verbal altercation between the two Residents. This resident-to-resident altercation was not reported to the administration, and therefore protection was not put into place or implemented. On 12/27/2023, at approximately 1:45pm, Resident # 4 was sitting in the facility's dining room in her wheelchair when a staff member brought Resident #5 into the dining room. Resident # 5 proceeded to shout that she was hungry to get the attention of the kitchen staff. A sandwich and juice were brought to the resident, but the resident continued to shout out after the kitchen staff went back into the kitchen and closed the door. Resident #4 then asked Resident #5 to stop harassing the kitchen staff and eat the food that was brought to her. On hearing what Resident #4 stated, Resident #5 turned around and uttered expletives to Resident #4. Resident #4 explained that when she heard the expletives, she was extremely frustrated because Resident #5 has been harassing her for weeks and this incident made her get so angry that she rolled up to Resident #5 and put her in a headlock from behind. Staff members outside the dining room heard the commotion and ran in to separate the two residents. The residents were separated by the Human Resources (HR) Manager. Resident #5 was examined by the Director of Nursing for any injuries. No injuries were noted, and the resident was taken to her room while Resident #4 was allowed to remain in the dining room. The facility's Nurse Practitioner was informed of the incident on 12/27/2023. Law Enforcement was notified on 12/27/2023 and Adult Protective Services (APS) was notified on 12/27/2023. Resident #4 is her own Responsible Party. Resident #5's Responsible Party was notified. Resident # 4 was placed on Q15mins every 15 minutes) checks for 2hrs (hours) and then Q1hr for the next 24 hrs on 12/27/2023. No aggressive behavior was observed during the observation period. Resident #4's next psych visit was 1/9/2024. No changes were made to the medications. Progress notes states that the resident will have follow up in one month. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 12/27/2023 abuse questionnaires were completed by the facility's Social Worker on all residents with Brief Interview for Mental Status (BIMS) score of 9 and above with no adverse responses to determine if any other residents had any unidentified allegations of abuse that had not been reported. The questions included with Social Worker Assistant's interviews with residents were the following: 1. Have you had inappropriate interactions with others that was uncomfortable? i.e. personal space was crossed with another resident. If so, describe specifically your encounter in detail. 2. Have you observed poor interactions from residents on your unit toward others, if so, describe your observation. Based on resident interviews there were no other reported incidents of abuse from any residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing educated current facility staff on the facility abuse policy. Education was completed on 12/27/2023. Education included but not limited to the various types of abuse such as physical, mental, sexual, neglect, misappropriation of property, and involuntary seclusion. Education is also inclusive of the procedure for reporting any observed or suspected events of abuse. Education also included the importance of protecting residents following an allegation of abuse. Staff will not be permitted to work until education is completed. The Director of Nursing will verify completion of education. Education will be included in new hires orientation by Human Resources as of 12/28/2023. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing/Unit Managers will audit progress notes and incident reports during clinical meetings beginning on 12/27/23 to ensure any behaviors or altercations between residents were reported to administrator and/or Director of Nursing. Auditing will be completed 5 x per week for 4 weeks then weekly for 4 weeks starting on 12/27/2023. The Director of Nursing will report all findings of audits to the Quality Assurance Performance Improvement committee monthly until substantial compliance is obtained. Facility completed AdHoc QAPI to review investigation and current action plan to ensure all components were done and followed on 12/27/2023. IJ removal date: 12/29/2023 On 4/29/24 the facility's credible allegation of immediate jeopardy removal date of 12/29/23 was validated. The validation was evidenced by interviews with staff and residents, record review, and review of in-service agendas and staff attendance records. In-service agendas and staff attendance records revealed staff were in-serviced on the facility's Abuse, Prevention, Intervention, Reporting, and Investigation policy, effective November 2016, One on One Monitoring and updating the care guide. Interviews conducted with staff from all shifts and all disciplines, and interviews conducted with residents indicated knowledge of the in-services provided. Review of QA records, monitoring tools and audits revealed ongoing monitoring systems were in place by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, physician, and staff interview the facility failed to protect a severely cognitively impaired resident from the right to be free from physical abuse (Resident #5). Resident #5 experienced physical abuse twice on 12/27/23 when before bingo Resident #4 placed her arm around the Resident #5's neck, and pulled her forward, and then on the same day, placed Resident #5 in a chokehold with her arm while she was seated in her wheelchair. Resident #5 was held in the chokehold position which caused the resident to gasp and her face to become red. In addition, the facility failed to protect a severely cognitively impaired resident from the right to be free from sexual abuse (Resident #3). Resident #3 experienced sexual abuse on 2/26/24 when Resident #2 touched and rubbed her pubic area. Based on the reasonable person concept, being placed in a chokehold and non-consensual sexual contact would cause a reasonable person to experience psychosocial harm, trauma and fear from physical or sexual abuse. Abuse occurred for 2 of 4 sampled residents reviewed for protection from abuse (Resident #5 and Resident #3). The findings included: 1. Resident #4 re-admitted to the facility on [DATE]. Diagnoses included recurrent major depressive disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. A 12/4/23 quarterly Minimum Data Set (MDS) assessment evaluated Resident #4 with adequate hearing and vision (with corrective lenses), clear speech, made herself understood, able to understand others, intact cognition, no behaviors, used a motorized wheelchair for mobility and independent or required supervision with activities of daily living (ADL). Review of the care plan for Resident #4 revised 12/7/23 revealed she did not have a comprehensive person-centered behavior care plan. The care plan did document that Resident #4 required staff assistance with ADL due to her history of PTSD. Staff interventions included allowing rest breaks between tasks, encouraging participation in small tasks, and allowing adequate time to complete tasks. A 12/27/23 skin audit conducted by the Director of Nursing (DON) recorded no injuries noted for Resident #4. Resident #5 re-admitted to the facility on [DATE] and expired in the facility with hospice services on 3/18/24. Diagnoses included dementia with agitation, anxiety disorder, mood affective disorder, psychosis, and major depressive disorder. A care plan revised 3/7/23 recorded Resident #5 cursed at a resident and at staff. Interventions included referral for psych services as needed, provide psych medications as ordered, involve the Responsible Party (RP), if possible, redirect her when she is noted with agitation/aggression, and educate her that cursing others is not acceptable. A 11/21/23 quarterly MDS assessment evaluated Resident #5 with adequate hearing, impaired vision, clear speech, made self-understood, able to understand others, severely impaired cognition, no behaviors, no functional limitation in upper extremity range of motion (ROM), impaired function limitation in lower extremity ROM on both sides, wheelchair use for mobility and dependent on staff for ADL. A 12/27/23 skin audit conducted by the DON recorded no injuries noted for Resident #5. 1a. Medical record review for Resident #4 and Resident #5 revealed there was no documentation in either medical record that Resident #4 placed her arms around the neck of Resident #5 on 12/27/23 and pulled the Resident forward. An interview with the Activity Director (AD) and the Activity Assistant occurred on 4/11/24 at 5:37 PM. During the interview, the AD stated that on 12/27/23, she did not know the exact time, but sometime before bingo which was scheduled at 2:30 PM, she was in her office, which was adjacent to the dining room, and she heard Resident #5 talking loudly in the dining room and using profanity. Resident #4 told Resident #5 nobody wants to hear that. During the interview, the Activity Assistant stated that before the 2:30 PM bingo activity, she was not sure of the exact time, she was in/out of the dining room setting up bingo, and she told Resident #5 to calm down. The Activity Assistant stated that Resident #5 got upset, continued using profanity and yelled at Resident #4 b**** I will f*** you up. The Activity Assistant stated she called the AD to come and help her when she saw Resident #5 propel in her wheelchair towards Resident #4, Resident #4 put her arms around the neck/shoulders of Resident #5 and pulled her forward. The Activity Assistant stated she separated the Residents, directed Resident #4 to go to her room while the AD took Resident #5 to the Nurse. The Activity Assistant said she returned to setting up bingo and that she did not report to the administration that she had to separate the two Residents. The interview continued and the AD stated that the Activity Assistant asked for her help. The AD stated that when she came out of her office into the dining room, she saw the Activity Assistant pulling the two residents apart. The AD said that the Activity Assistant told her what occurred, the AD took Resident #5 to her Nurse (Nurse #1), reported the incident to Nurse #1 and returned to the dining room for bingo. The AD stated that she did not report the incident to the administration, but rather took Resident #5 to her Nurse. Both the AD and the Activity Assistant stated they were unaware that a second incident occurred between Resident #4 and Resident #5 on the same day (12/27/23) in the hallway. Nurse #1 was interviewed via phone on 4/12/24 at 3:35 PM. He stated that he was the assigned Nurse on the South Unit for the 7A - 3P shift on 12/27/23. He stated that close to the end of the shift on 12/27/23 he heard staff stating that Resident #5 said something to Resident #4 that got her upset and caused her to hit Resident #5. He stated that no one reported the incident to him directly. Nurse #1 said he was told that an incident report had been made, but he could not recall who told him that, so he did not make a report about the incident because he did not witness it and he was not asked to do any follow up. Nurse #1 said after he heard about the incident, he did recall seeing Resident #5 in her wheelchair at the end of the hall near her room, but that she did not mention what occurred. Nurse #1 said he was not made aware that there were two incidents between Resident #4 and Resident #5 that day. Nurse #1 stated that if staff had reported the incident directly to him, he would have contacted the DON and Administrator to get the police involved if a resident was assaulted and followed the facility's abuse policy. Nurse #1 described Resident #5 as confused intermittently and heard staff say she made racial comments and cursed staff/resident, but that he was not aware that Resident #5 ever physically hit another resident. Nurse #1 described that Resident #4 seemed like the sweetest person, but that she could be aggressive at times and made verbal threats of what she would do in different circumstances if she were provoked. He stated that he never reported the behavior of Resident #4 because these were comments that he heard in passing. 1b. A Resident Incident Report for Resident #4 completed by the DON recorded that on 12/27/23 at 1:45 PM, Resident #4 and Resident #5 were both in the dining room when Resident #5 began to harass the kitchen staff. The report recorded that when Resident #4 told Resident #5 to stop harassing the staff, Resident #5 turned to Resident #4 and cursed at her. At this, Resident #4 stated that she got upset and put Resident #5 in a chokehold because Resident #5 had been harassing her for weeks. The report recorded that staff heard the commotion, separated the Residents, and both Residents were assessed by the DON without injury. The report recorded that the Physician (MD), RP for Resident #5, law enforcement and Adult Protective Services (APS), were notified of the incident. Review of a Facility Reported Incident, completed by the DON, dated 12/27/23 at 1:45 PM indicated Resident #4 put Resident #5 in a headlock. The Summary of Facility Investigation recorded, Resident #4 and Resident #5 were both in the dining room when Resident #5 shouted to dietary staff that she was hungry. The DON recorded Resident #5 received a sandwich and juice but continued to shout for more food. Resident #4 asked Resident #5 to stop harassing the dietary staff at which time Resident #5 turned to Resident #4 and responded with expletives. The DON documented that Resident #4 stated that she became extremely frustrated because Resident #5 had been harassing her for weeks, and that this incident made her so angry that she rolled up behind Resident #5 and put her in a headlock from behind. A police report dated 12/27/23 at 2:08 PM recorded that Resident #4 verbally threatened Resident #5 with bodily injury. Resident #5 alleged that Resident #4 threatened to choke her to death. Multiple attempts to interview the police officer were unsuccessful. A Nursing General Note for Resident #5 dated 12/28/23 at 8:38 AM by the DON recorded that on 12/27/23 at approximately 1:45 PM, Resident #5 and Resident #4 were in the dining room. The DON recorded that Resident #4 reported that Resident #5 started harassing kitchen staff and when Resident #4 asked Resident #5 to stop harassing the kitchen staff, Resident #5 cursed at her. At this, the DON recorded that Resident #4 stated that she got upset and put Resident #5 in a chokehold because Resident #5 had been harassing her for weeks. The DON recorded that staff heard the commotion and separated the Residents. The RP for Resident #5 was made aware of the incident and the incident was recorded in the MD communication book. During an interview with Resident #4 on 4/11/24 at 10:30 AM, and a follow-up interview on 4/12/24 at 9:15 AM, she stated that on 12/27/23, she remembered that she and Resident #5 were in the dining room. Resident #4 said she recalled Resident #5 kept messing with staff in the kitchen saying she was hungry. Resident #4 said she told Resident #5 to leave the kitchen staff alone and to eat the food she had been given. At that time, Resident #5 turned to her, got in her face, and said f*** you. Resident #4 said she got so tired of Resident #5 talking to her that way, so she knocked on the activity door, which was a room in the dining room, but then decided she would go find a staff member. Resident #4 stated that as Resident #5 was leaving the dining room Resident #4 stated, she rolled up behind her (Resident #5) in the hallway and stated, that's when I blacked out and then the next thing I knew staff told me that I grabbed her around her neck and was pulling her hair. Resident #4 stated that staff had to tell her what she did when she blacked out because she did not remember that she grabbed Resident #5 around her neck and pulled her hair. She stated staff also told her that on the same day, 12/27/23, there was another incident between the two Residents that occurred before she grabbed Resident #5 around her neck. Resident #4 said the Activity Assistant told her that while the two Residents were in the dining room before bingo, the Activity Assistant had to separate them because Resident #4 placed her arms around the neck of Resident #5 and pulled her forward. Resident #4 stated she did not recall putting her arms around the neck of Resident #5 and pulling her forward, but that Resident #5 must have continued to curse at her in order for her to physically assault Resident #5 twice. Resident #4 stated this was not her usual behavior, she stated I don't put my hands on people, and I asked God to forgive me for what I did. She stated that she did not have a chance to apologize to Resident #5 before she passed away and that she felt bad about that, but that Resident #5 should not have gotten in her face and cursed at her. Resident #4 stated that she talked to a Mental Health Nurse Practitioner after these incidents, who adjusted her medications for depression, which has helped. The Human Resources (HR) Director was interviewed on 4/11/24 at 1:20 PM and stated that on 12/27/23 she was in the DON's office sometime after lunch, she did not recall the exact time, when she heard Resident #4 say I told you not to f*** with me no more. When she went into the hallway, she saw Resident #4 and Resident #5 in the hallway in front of the dining room. The HR Director described that Resident #4's arm was around the neck of Resident #5, in a headlock, Resident #5's face was red, and she was gasping. The HR Director stated she told Resident #4 to let go of Resident #5, but she did not, so the HR Director had to physically separate them. The HR Director stated that the DON came into the hallway after the incident, so she reported to the DON what happened and called the Administrator to report to him what occurred. An interview on 4/11/24 at 5:30 PM occurred with the DON. She stated that she was notified on 12/27/23 by the HR Director that at around 1:45 PM, the HR Director overheard commotion coming from the hallway near the dining room. The HR Director said she went to the hallway and saw Resident #4 holding Resident #5 in a headlock. The HR Director said she separated the Residents, and Resident #5 was taken to her room. The DON stated she notified the Administrator, started an investigation, contacted law enforcement, and the RP for Resident #5. The DON said she assessed and interviewed both Residents. Resident #4 was assessed without injury and when she was interviewed, she explained she was tired of Resident #5 picking on her and this is what she gets. The DON said that about an hour later, Resident #4 came to her office, very remorseful and said she should not have choked Resident #5 but reported her concerns regarding Resident #5 to staff instead. She said that she just lost it. Resident #4 said that Resident #5 picked on her for weeks and she was tired of it. She stated that while the Residents were in the dining room, Resident #5 started banging on the kitchen door, asking for food. The kitchen staff gave her a sandwich and juice, but Resident #5 continued to yell out for more food. Resident #4 said she told Resident #5 to stop shouting and to eat the food she had. That's when Resident #5 cursed at her, so Resident #4 went up to Resident #5 and put her in a headlock. The DON stated that Resident #5 was assessed without injury, but during the assessment, she was still upset and cursing, so the DON had to allow her time to calm down. When Resident #5 was interviewed, she said that Resident #4 tried to choke her, but that she was fine. The DON said that both Residents were monitored every 15 minutes for two hours and then hourly for the next 24 hours. During the interview, the DON was asked by the Surveyor if she was aware that on 12/27/23 sometime before bingo, the Activity Assistant separated Resident #4 from Resident #5 in the dining room when she put her arms around the neck of Resident #5 and pulled her forward. The DON stated that she was not notified by staff that both Residents were separated earlier that day on 12/27/23 due to another physical altercation that occurred in the dining room. She said that if she had been made aware of the first physical altercation that occurred between the two Residents in the dining room, she would have separated the Residents then which would have prevented the second incident from occurring later in the hallway. The Administrator stated in an interview on 4/11/24 at 5:45 PM that he was notified on 12/27/23 that Resident #4 physically assaulted Resident #5 in the hallway after an argument occurred in the dining room. He stated that he told the staff to separate the Residents, assess them for injury, place the Residents on monitoring every 15 minutes for the first two hours and then hourly checks thereafter. He also informed staff to notify law enforcement, the MD, the RP for Resident #5, and APS. The Administrator stated that when he returned to work on 12/28/23, he spoke to Resident #4 about her behavior and advised her that she should have reported her previous concerns with Resident #5 to the DON, that her behavior was unacceptable and that he expected to see improvement. Resident #4 stated that she understood what she did wrong and that her behavior needed to improve. He stated that at the time of the incident, Resident #4 was being followed weekly by mental health services for depression and after the physical abuse toward Resident #5, she was referred for psych services. He said that he was not notified of a prior incident involving physical abuse by Resident #4 to Resident #5 on the same day. He stated that he expected residents to be protected from abuse and if he had been notified of the first incident of physical abuse by Resident #4 that occurred in the dining room, he would have strategized a plan to prevent further interactions between the two Residents and protected Resident #5 from further abuse. A phone interview with the MD occurred on 4/11/24 at 9:06 AM. The MD stated that she was notified that Resident #4 physically assaulted Resident #5 on 12/27/23 and that she remembered the incident vaguely. The MD stated she recalled Resident #4, physically assaulting other residents was not her history and such an incident had not occurred before with Resident #4. The MD stated both Residents were separated, both Residents were assessed without injury and assessed for any contributing factors that attributed to the events of 12/27/23. The MD stated that Resident #4 was already followed by mental health services for a history of depression and when this occurred, she was referred for psych services. The MD stated that to her knowledge, Resident #4 had no further incidents of physical assault. The facility put ongoing monitoring into place for both Residents and the family of Resident #5 did not want to press charges. MD stated that the facility had a responsibility to protect all residents in the facility and due to the facility's high-risk population of residents with a mental health/behavior history, that made managing behaviors difficult. The MD stated that she was no longer the MD at the facility, but while she was the MD, the facility met the mental health needs of the residents by making mental health services readily available. 2. Resident #2 was admitted to the facility on [DATE] from a previous nursing home with diagnoses that included other sexual dysfunction not due to a substance or known physiological condition, dementia, mild with other behavioral disturbance, cerebrovascular accident with hemiplegia affecting the left non-dominant side, anxiety disorder, depression, and adjustment disorder with depressed mood. The February 2024 Medication Administration Record (MAR) for Resident #2 recorded a Physician (MD) order for Fluoxetine Hydrochloride (Prozac) 20 milligrams (mg) to give one tablet once daily for depression. The medication start date was 2/1/24. A 2/2/24 Psychotherapy Diagnostic Assessment written by the Licensed Clinical Social Worker (LCSW) recorded Resident #2 displayed inappropriate sexual behaviors as noted in a previous assessment completed by the Psych Mental Health Nurse Practitioner (PMHNP) in a previous nursing home. The assessment also noted that Resident #2 met the criteria for adjustment disorder due to impulsivity and inappropriate sexual behaviors. A phone interview with the LCSW occurred on 4/15/24 at 11:08 AM. She stated that her initial visit with Resident #2 occurred on 2/2/24 for Psychotherapy Talk Services. She stated that he was referred to mental health services regarding his diagnoses of adjustment disorder and mild dementia with other behavioral disturbance. The LCSW said during her initial assessment on 2/2/24, he did not seem oriented and appropriate for services due to some confusion. The LCSW said she reviewed the progress notes of his history from the psych services he received while he was a Resident at the previous nursing home. The LCSW said she saw in the notes that he was accused by two female residents of inappropriately touching them, presented with mild cognitive impairment during his stay at the previous nursing home and received Prozac 20 mg daily to assist with sexual behaviors by decreasing his libido (sexual desire). The LCSW said she communicated to the Administrator that Resident #2 had a history of inappropriate touching while he was a Resident at the previous nursing home and that the electronic psych records from the previous nursing home were faxed to the facility. A 2/7/24 psychiatric initial consult progress note written by the Doctor of Nurse Practitioner, (DNP) recorded that Resident #2 was referred for mild dementia with other behavioral disturbance and other sexual dysfunction not due to a substance or known physiological condition. The DNP documented that she reviewed the prior psych records from the previous nursing home which indicated Resident #2 displayed inappropriate sexual behaviors when he was noted touching another female resident, but that he had not been noted to display any current sexual behaviors at the facility. The DNP documented that the Administrator informed her of a conversation he had with Resident #2 regarding his behaviors at the previous nursing home and advised that those types of behaviors were not allowed in the facility under any circumstances. The DNP recommended to continue Prozac 20 mg daily. The DNP was interviewed by phone on 4/12/24 at 8:07 AM. She stated that Resident #2 was admitted to the facility from the previous nursing home where he received psych services with the same provider group. The DNP said she had access to his prior psych records because the psych services were from the same provider group. She stated that when she reviewed his previous psych records she noted his history of inappropriate sexual behavior, which she spoke to the Administrator about on 2/7/24. The DNP said Resident #2 was placed on Prozac 20 mg when he exhibited inappropriate sexual behaviors at the previous nursing home. The DNP said she had a very candid conversation with Resident #2 on her first visit with him on 2/7/24, regarding his behavior at the previous nursing home and he was informed that inappropriate sexual behavior was not going to be tolerated at the facility. A 2/9/24 admission Minimum Data Set assessed Resident #2 with adequate hearing, adequate vision, clear speech, understood by others, and understands others, intact cognition, no mood disorders, no behaviors, no functional limitation in upper/lower extremity range of motion (ROM), and he independently used a manual wheelchair for ambulation. Review of the 2/21/24 care plan for Resident #2 revealed he did not have a behavior symptoms care plan. During an interview on 4/12/24 at 3:00 PM, Resident #2 said a few days after he came to the facility, he told the Administrator and Director of Nursing (DON) about the time he touched (named Resident) at the previous nursing home. Resident #2 said They asked me if I had touched anyone inappropriate at (the previous nursing home) and I told them I touched her breast, she said I could, but the Administrator told me not to do that here, I told him that I would try to be good here, he said I had to behave and that I could not touch anyone here. During an interview with the Administrator and DON on 4/12/24 at 1:45 PM, the Administrator said the LCSW notified him after her first session with Resident #2 on 2/2/24 that she had access to the psych progress notes for Resident #2 from the previous nursing home since Resident #2 was seen by a Practitioner from the same provider group. Per the Administrator, the LCSW said when she reviewed the psych progress notes from the previous nursing home, she saw documentation that Resident #2 had poor, inappropriate behaviors at the previous nursing home that required one-to-one monitoring. The Administrator stated that the LCSW was not specific about the behaviors, and that he did not ask specifics, but that the Administrator and the DON went to Resident #2 and asked him what happened. The DON said when interviewed, Resident #2 said that he tried to fist bump two residents and accidentally contacted their shoulder, and then he said, I did not touch anyone. The Administrator stated he advised Resident #2 of the expectation to have appropriate behavior while he was a Resident at the facility, Resident #2 expressed understanding. The Administrator stated that he did not request the psych notes from the previous nursing home at that time. Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder, and dementia without behavioral disturbance. A 1/29/24 quarterly MDS assessed Resident #3 with severely impaired cognition, dependent on staff for all activities of daily living (ADL) and used a wheelchair for ambulation. Resident #1 was admitted to the facility on [DATE] and discharged home on 3/2/24. A 12/5/23 quarterly MDS assessment indicated Resident #1's cognition was intact. A 2/26/24 Facility Reported Investigation for resident abuse recorded that on 2/26/24 at 4:40 PM, staff notified nurse leadership of poor resident interaction that was witnessed by Resident #1. The Summary of Investigative Findings recorded that on 2/26/24, Resident #1 witnessed Resident #2 touch Resident #3 on the leg while the Residents were seated in the commons area of the [NAME] Unit. Resident #1 yelled for Resident #2 to stop touching the leg of Resident #3 which prompted staff to separate Resident #2 from Resident #3. Resident #2 was placed on one-to-one monitoring ongoing, Resident #3 was assessed without injury, and notifications were made to the Administrator, law enforcement, Adult Protective Services (APS), the Responsible Party (RP) for Resident #3, the Emergency Contact for Resident #2, and the MD. The Summary of Findings included a written statement from Resident #1 which recorded I, (Name of Resident), saw the young man put his hands between a resident's legs, the resident was trying to move his hands, but he continued to rub her between her legs or crotch; I saw it and approached him telling him to stop because it was wrong. A 2/26/24 police report noted that law enforcement was notified at 5:03 PM on 2/26/24 that the listed suspect (name withheld) sexually assaulted the victim (name withheld) at the facility on 2/26/24 at approximately 5:00 PM. The North Carolina Offense Category was listed as adult sex offense/assault/sexual battery, and the classification was listed as forcible fondling. Attempts to interview law enforcement were unsuccessful. A 2/28/24 11:34 AM Triage Note from the DON to DNP recorded that on 2/26/24, Resident #2 was caught fondling a female resident who was oriented to self only due to dementia, the Resident (Resident #2) was placed on one-to-one since then, he is on Prozac for depression, please advise. The DNP responded on 2/28/24 to the Triage Note from the DON that Resident #2 was not on Prozac for depression, but for his history of inappropriate sexual behavior, to refer to the DNP progress note of 2/7/24, increase Prozac to 40 mg daily and under no circumstances leave Resident #2 alone with Resident #3. A 2/29/24 Resident Incident Report for Resident #3 recorded that on 2/26/24 at 5:00 PM, Resident #3 was seated in her wheelchair when Resident #1 screamed get away from her when she saw Resident #2 put his hands between the legs of Resident #3. The report recorded that Resident #3 began moving the hands of Resident #2, but Resident #2 continued rubbing the Resident's leg. The report described Resident #3 as alert to person only, the Immediate Action Taken as staff separated and monitored the two Residents, and the MD and RP for Resident #3 were notified. A 3/1/24 Resident Incident Report for Resident #2 recorded that on 2/27/24 at 5:38 PM, Resident #1 yelled What are you doing at Resident #2 and accused him of rubbing Resident #3 between her legs. The Resident Incident Report described Resident #2 as alert, oriented to person, place, and time. The Immediate Action Taken recorded Resident #2 was sent to the emergency room (ER) for a psych evaluation and returned to the facility before midnight with no new orders. The Administrator, MD and Emergency Contact for Resident #2 were notified of the incident. During review of the 3/1/24 Resident Incident Report for Resident #2, with the Administrator on 4/10/24 at 12:30 PM, he stated that the date of 2/27/24 was an error and should have been 2/26/24. The medical record for Resident #2 included progress notes from the previous nursing home faxed to the facility on 3/1/24 at 10:02 AM which included the following: - A Triage Note dated 1/16/24 recorded Resident #2 inappropriately touched another resident's breast and the staff requested medication management. - A Physician Assistant (PA) progress note dated 1/16/24, recorded the PA was asked to assess Resident #2 for sexual behavior issues due to complaints by staff of inappropriate gestures and touching. The progress note recorded a MD order was written for a psych referral and for Prozac 20 mg daily. - A Psych Mental Health Nurse Practitioner (PMHNP) progress note dated 1/22/24, recorded Resident #2 was seen for an urgent Telehealth psych evaluation for the diagnoses of mild dementia, with other behavioral disturbance and other sexual dysfunction not due to a substance or known physiological condition after accusations from two female residents of inappropriately touching them. The progress note recorded that Resident #2 reported to the PMHNP when interviewed that he accidently touched a female resident. The progress note recorded that the Resident was placed on Prozac 20 mg daily after this incident to assist with sexual behaviors by reducing his libido. A 3/1/24 psychotherapy progress note written by the LCSW recorded that staff reported that on 2/26/24, Resident #2 displayed inappropriate sexual behaviors. The progress note recorded that Resident #2 acknowledged during the 3/1/24 psychotherapy session that he inappropriately touched a resident, made hand motions towards his private area when asked where he touched the resident and stated that the resident said he could. The note also recorded that Resident #2 stated that he was being kept in his room, but that he did not want to stay there when he referred to the one-on-one support provided by the facility because of his inappropriate behavior. The progress note recorded that he expressed he understood that he should not ask other peers to be touched inappropriately as some residents may not have the cognition to consent appropriately. The progress note recorded Resident #2 received Prozac 40 mg daily to decrease libido and manage his sexual behaviors. Resident #2 was interviewed on 4/10/24 at 1:00 PM. He stated that he was recently admitted to the facility and that since his admission, staff spoke to him about touching a resident. Resident #2 said he touched a resident on her vagina while she was clothed. When asked to show the surveyor where he touched the Resident, he touched the center of his pubic area and said, I touched her here, I asked her if I could touch her, and she said yes. He said they were in the TV area watching TV near the nurse's station when he touched Resident #3. Then he said, But then (named Resident #1) yelled at me to stop, I told her what is it to you, nobody is touching you, but she told on me, so I am supposed to be going to court so [NAME] can get guardianship of me. A [AGE] year-old with a guardian, what do I need a guardian for? Now I have a sitter with me all the time. It's like I am a chap. When asked if anything like this happened before he said yeah, I had a sitter while I was at a (previous nursing home), I touched a lady there, I asked her too and she said I could, but[TRUNCATED]