**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews with the Nurse Practitioners, resident, and staff the facility failed to protect Resident #84's right to be free of physical abuse perpetrated by Resident #64. On 1/27/25 Resident #84, who was cognitively impaired and had wandering behaviors, entered the room of Resident #64 who was also cognitively impaired. Nurse #6 heard Resident #64 yell at Resident #84 to get out of his room followed by Resident #64 taking both of his hands to lift Resident #84 off of the ground and throw him out of his room. Resident #84 fell to the floor hitting his head and Nurse #6 stated she heard a noise that sounded like a crack. Resident #84 reported pain to his left arm and head and was evaluated at the hospital with no acute injuries. There was a high likelihood of Resident #84 suffering serious physical harm as a result of the physical abuse. A reasonable person would have experienced feelings such as fear, intimidation, anxiety, and/or withdrawal as a result of being abused in their home environment. Additionally, the facility also failed to prevent resident to resident abuse when Resident #64 shoved Resident #18. The deficient practice occurred for 2 of 3 (Resident #84 and Resident #18) reviewed for abuse. Immediate jeopardy began on 1/27/25 when the facility failed to protect a cognitively impaired resident right to be free of abuse when Resident #84 wandered into the room of cognitively impaired Resident #64 who used physical force to throw Resident #84 to the floor. Immediate jeopardy remains present and on-going. Example 2 is being cited at a scope and severity of D. The findings included: 1) Resident #64 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) and cognitive communication deficit. The care plan last reviewed on 11/20/24 revealed Resident #64 had the potential to be physically aggressive related to poor impulse control and had attempted to throw a chair in the dining room. Interventions included analyzing times of day, places, circumstances, triggers, and what de-escalated behavior and document. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #64's cognition was moderately impaired. He had no upper or lower extremity range of motion impairment, did not use a device for mobility, and was able to transfer and walk independently without assistance from staff. Resident #64's height and weight was 68 inches and 184 pounds. There were no physical or verbal behaviors directed towards others during the lookback period. A review of Resident #64's Medication Administration Record (MAR) revealed behaviors were monitored each day, evening, and night shift. Behaviors being monitored included agitation/pacing/yelling, and danger to self or others. From 1/1/25 through 1/26/25 the nurses documented 0 to indicate no behaviors were present. On 1/27/25 day shift Nurse #7 documented 0 to indicate no behaviors were present. Resident #84 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and dementia. The admission MDS dated [DATE] revealed Resident #84's cognition was severely impaired, and he had demonstrated physical and verbal behaviors directed towards others, rejection of care, and wandering behaviors for 1 to 3 days during the lookback period. Resident #84's height and weight was 69 inches and 148 pounds. There was no mobility device identified on the MDS and Resident #84 was dependent on staff for walking. The MDS indicated Resident #84 was not taking anticoagulant or antiplatelet medications. The care plan last reviewed on 1/16/25 identified Resident #84 wandered related to being disoriented to place. Interventions included to intervene as needed to protect the rights and safety of others and to remove from situations to another location as needed. A review of Resident #84's MAR revealed behaviors were being monitored each day, evening, and night shift. Behaviors being monitored included agitation/ pacing/yelling, uncooperative, and wandering. On 1/10/25 and 1/13/25 the nurse documented during day shift agitation/pacing/yelling, uncooperative, and wandering behaviors were present. On 1/27/25 during day shift Nurse #6 documented behaviors of agitation/pacing/yelling, uncooperative, and wandering were present. A review Resident #84's current physician orders revealed he was not taking anticoagulant or antiplatelet medications. A review of an incident report dated 1/27/25 at 10:50 AM revealed Nurse #6 observed Resident #84 being tossed out of the room by another resident into the hallway floor landing on his left side and she unable to obtain assessment due to Resident #84 was guarding his body. Nurse #6 noted there were no injuries observed at the time of the incident and Resident #84 was alert, confused, oriented to person, ambulatory without assistance, and the predisposing factor was he wandered. A review of the progress note created on 1/27/25 at 5:29 PM by Nurse #6 revealed she was the assigned nurse for Resident #84 and at 10:50 AM was at the medication cart and observed the door to Resident #64's room was open, and Resident #84 was tossed out of the room. Nurse #6 documented she observed Resident #84 fall to the floor and land on the left side of his body and the left side facial area. Resident #84 landed in front of Nurse #6, and she heard Resident #84's body make an audible sound. The note indicated Nurse #6 told what happened in detail to the Director of Nursing (DON) and Unit Manager #5. Nurse #6 observed Unit Manager #5 contact Nurse Practitioner (NP) #1 by phone and Nurse #6 answered their questions. Neuro checks were implemented and DON assisted Resident #84 with a bed bath and the Unit Manager and DON assumed plan of care. At 4:45 PM Nurse #6 updated NP #2 and a verbal order was provided to transfer Resident #84 to the emergency room for evaluation and rule out possible head trauma. Review of the neuro check documentation for Resident #84 revealed the following: the first check was started on 1/27/25 at 10:55 AM and indicated vital signs were refused, Resident #84 was alert and Nurse #6 was unable to assess his upper and lower extremity motor function. Headache was checked yes, and no was checked for signs of seizure, ear/nose drainage, or vomiting. Neuro checks continued from 12:16 PM until 5:45 PM and indicated Resident #84 was at the hospital. During a phone interview on 1/30/25 at 11:22 AM Nurse #6 revealed on 1/27/25 she was working on the secured unit on the third floor and witnessed the altercation between Resident #64 and Resident #84. Nurse #6 revealed she heard Resident #64 yell out, Get out my room, I told you to get out. Nurse #6 revealed she saw Resident #64 take both hands and lift Resident #84 off the ground and throw him out of his room and he fell to the floor, and she heard a noise that sounded like a crack and saw Resident #84's head hit the floor. Both residents were separated, and Resident #64 stayed in his room. After the fall she did not see any obvious injuries but Resident #84 told her his left arm and head hurt but would not let her touch or assess him and was guarding his left arm. She revealed Nurse #7 stayed with Resident #84 while she went to find the Administrator or DON. The DON and Unit Manager #5 came to the secured unit on the third floor. Nurse #6 revealed she attempted to administer acetaminophen for pain but Resident #84 spit it out and the DON administered olanzapine (an antipsychotic medication) and took Resident #84 to a room and gave him a bed bath. She revealed Unit Manager #5 notified NP #1 and she (Nurse #6) was asked to tell what happened and stated she reported Resident #84 was thrown to floor. Nurse #6 revealed she heard Unit Manager #5 tell NP #1, the nurse thought the resident was hurt and was thrown on the floor. Nurse #6 revealed when NP #2 came to the facility she updated her on what happened, and an order was provided to send Resident #84 to emergency room for further evaluation. During an interview on 1/29/25 at 11:29 AM Nurse #7 revealed she was working on the secured unit on the third floor where the altercation between Resident #64 and Resident #84 occurred on 1/27/25 but she did not witness the incident. Nurse #7 revealed she was at the opposite end of hallway from Resident #64's room when she heard Nurse #6 scream he threw him on the floor. Nurse #7 revealed when she looked up, she saw Resident #84 on the floor in the hallway by Resident #64's room door. Nurse #7 revealed Resident #84 was scooting himself on the floor and around the corner of the nurse station away from Resident #64's room. Nurse #7 revealed she heard Resident #84 say he broke my arm and would not let anyone touch him. Nurse #7 revealed when she asked Resident #64 what happened he did not say anything about the incident but did say he was okay. During an interview on 1/29/25 at 3:59 PM Nurse Aide (NA) #10 revealed she worked on the secured unit on the third floor where the altercation between Resident #64 and Resident #84 occurred on 1/27/25 but she did not witness the incident. NA #10 revealed she did observe Resident #84 on the floor by the nurse station near the room of Resident #64 and was told by a nurse, she could not recall by name, that Resident #64 picked up and threw Resident #84 to the floor. NA #10 revealed she stood by Resident #84 to ensure there was no contact until the DON, Unit Manager #5, and Nurse #6 assessed the resident. NA #10 described Resident #84 had wandering behaviors prior to the altercation and would wander into other resident rooms and she would redirect him. During an interview and observation on 1/29/25 at 10:54 AM and 3:53 PM the entry door to Resident #64's room was kept closed. Resident #64 was observed sitting on the edge of the bed and was able to self-transfer and walk in and out of his room without assistance from staff. Resident #64 revealed a resident had entered his room and would not leave after he told him, you got to go. Resident #64 revealed the resident did not say anything but would not leave and he used physical force to get him out of his room. Resident #64 demonstrated he used both hands to lift up and throw the resident out of the room onto the floor. Resident #64 revealed the resident he threw was not doing anything to make him feel threatened or afraid and repeated, it was time for him to go. Resident #64 confirmed he did not ask a staff member for help and stated he did not need help from anyone. Resident #64 revealed that if someone came into his room and would not leave when asked, he would use physical force to get them out and did not need help getting someone out of his room. A review of the nurse progress note created on 1/29/25 at 1:43 PM by Unit Manager #5 was a late entry for 1/27/25 at 11:30 AM. The note revealed the Unit Manager #5 was called to the secured unit on the third floor to assess Resident #84. Unit Manager #5 and the DON noted Resident #84 was sitting on the floor near the nurse station and the assigned nurse (Nurse #6) stated Resident #84 had an unwitnessed fall. Unit Manager #5 noted Resident #84 refused assistance from staff and was assessed by the DON. Unit Manager #5 contacted NP #1 and was instructed to notify the assigned nurse (Nurse #6) to send Resident #84 out to the hospital if needed. Unit Manger #5 noted she was instructed to provide additional 30-minute checks for the NA staff and hourly checks for the nurses for Resident #84. An interview was conducted on 1/29/25 at 4:26 PM with Unit Manager #5. Unit Manager #5 revealed she was asked by Nurse #6 to come to the secured unit and when she arrived saw Resident #84 sitting on the floor and he did not want anyone to touch or help him. Unit Manager #5 revealed Resident #84 got up off the floor without help and walked to his room with the DON who provided incontinence care. Unit Manager #5 revealed she was told by Nurse #6, she heard a noise that sounded like a boom but did not see anything. Unit Manager #5 revealed 1/28/25 was the first time she heard Resident #64 threw Resident #84 to the floor. She revealed Resident #84 was not capable of describing what happened and she did assess Resident #64, and he told her he did not want anyone in his room but did not tell what happened. A review of a nurse's progress note created on 1/28/25 at 8:01 PM by the DON was a late entry for 1/27/25 at 11:30 AM. The note revealed the DON was called to the secured unit on the third floor to assess Resident #84. The DON and Unit Manager #5 saw Resident #84 on the floor near nursing station. The DON asked Nurse #6 what happened and was told Resident #84 had an unwitnessed fall to the floor. Resident #84 refused vital signs and assistance from staff. The DON noted Resident #84 eyes were reactive to light, grips were equal, and cognitive status was at baseline with no signs of distress or complaints. Resident #84 got up off the floor without assistance and walked with the DON. The DON noted there were no visible injuries, and no change in physical, emotional, or social state at the time of assessment. During an interview on 1/29/25 at 5:35 PM the DON revealed on 1/27/25 she received a text to come to the third-floor unit immediately during her morning meeting. The DON revealed when she arrived on the unit she saw Resident #84 sitting on his buttocks with his back against the wall and around the corner of the nurse station located near the room of Resident #64. Nurse #6 told her Resident #84 had an unwitnessed fall and she did not know what happened. The DON revealed Resident #84 would not let her touch him but was able to get up from the floor without assistance and walk and appeared at his baseline. The DON revealed when she asked what happened, Resident #84 stated I fell. The DON revealed Resident #84 had a history of wandering behaviors and when she checked on Resident #64, he was sitting on the edge of the bed in his room and she asked Resident #64 if someone had been in his room, and he denied that. The DON revealed she asked Nurse #6 to fill out a statement on 1/27/25 but did not get it before leaving that day. The DON revealed she was not made aware of a physical altercation involving Resident #64 and Resident #84 until 1/28/25 after reviewing Nurse 6's note and incident report during their morning meeting. An interview was conducted on 1/29/25 at 5:18 PM with NP #1. NP #1 revealed on 1/27/25 around 11:00 AM he was called and informed there was altercation between residents and named Nurse #6 was who he spoke with. NP #1 revealed he was told an aggressive altercation occurred and Resident #84 was administered olanzapine and was being monitored and was calm. NP #1 revealed his guidance was if the nurse thought Resident #84 needed to be evaluated, she could send him to the emergency room. NP #1 revealed no specifics were provided about the altercation and he could not confirm Resident #64 threw Resident #84 to the floor. NP #1 revealed he was not notified that a fall occurred during the altercation or that Resident #84's head hit the floor and if told that information he would have requested to send the resident to the emergency room for evaluation. A review Resident #84's medical record revealed NP #2 documented a follow-up note dated 1/27/25 that revealed Resident #84 was being reviewed for head injury and arm pain. NP #2 noted nursing reported around 10:50 AM Resident #84 wandered into another resident's room and was forcefully lifted into the air and thrown from out of the room. Resident #84 landed on his left side and a cracking sound was heard and he hit his head on the floor. NP #2 noted neuro checks were started and during the evening Resident #84 was arousable but would not open his eyes and minimally responded to questions. NP #2 assessed Resident #84 had no deformities or visible signs of malalignment or dislocation and appeared at baseline for the diagnosis of dementia. NP #2 recommended Resident #84 be transferred to the emergency department for evaluation to rule out head trauma, intracranial hemorrhage, or other pathology. A physician's order dated 1/27/25 at 5:00 PM provided directions to send Resident #84 to the emergency room for evaluation to rule out head trauma. A review of the emergency department summary revealed on 1/27/25 Resident #84 was evaluated due to a previous fall. A CT (computed tomography) scan (a three-dimensional imaging of the body) of the head and neck and chest x-ray showed no abnormalities or injuries, and Resident #84 was discharged back to the facility in stable condition. A review Resident #64's medical record revealed NP #2 documented a follow-up note dated 1/27/25 that revealed nursing reported Resident #64 was the aggressor in an incident after Resident #84 wandered into his room. The NP noted Resident #64 forcefully removed Resident #84 from the room. NP #2 noted the incident was isolated and Resident #64 was calm and stable and being monitored by staff with no further incidents with other residents. NP# 2 recommended to continue 1:1 monitoring for 12 hours. During an interview on 1/29/25 at 4:48 PM NP #2 revealed she was at the facility around 4:30 PM on 1/27/25 when she was told the details of an altercation between Resident #64 and Resident #84. NP #2 revealed Nurse #6 told her Resident #84 had wandered into Resident #64's room and Resident #64 threw him out. NP #2 revealed Nurse #6 stated she saw Resident #84 flying out room and was lifted off the floor and she heard a crack and saw Resident #84 hit his head. NP #2 revealed she spoke with Resident #64, and he confirmed he picked Resident #84 up and threw him to the floor. NP #2 stated when she assessed Resident #84 on 1/27/25 he was groggy but had no deformities or any obvious physical injury, but she was concerned about him being thrown onto the floor and sent him out for evaluation of injury. A phone interview was conducted on 1/31/25 at 2:23 PM with the Administrator. The Administrator revealed she became aware of the physical abuse altercation between Resident #64 and Resident #84 the next morning on 1/28/25 during their clinical morning meeting after reading Nurse #6's notes. The Administrator revealed staff had just received training and were expected to inform her or the DON of any situation between residents and she would start the investigation and determine if abuse occurred. The Administrator revealed based on the information in the medical records it appeared Resident #64 actions were willful. The Administrator was notified of IJ on 02/06/25 at 8:30 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 as a result of the noncompliance. -The facility failed to have an effective system in place to prevent resident to resident abuse and ensure the safety of all residents. -On 1/27/2025 Resident #84 entered the room of resident #64. Per witness documentation from Nurse #6, Resident #64 could be heard saying, I told you to get out of here. Per Nurse #6 documentation, Resident #64 was visualized to take both hands and pick Resident #84 up off the ground and 'throw' Resident #84 to the floor resulting in Resident #84 hitting his head on the floor. Resident #84 was assessed and assisted from the floor to his feet and proceeded to his own room receiving toileting and incontinence care provided by the Director of Nursing (DON). Fall assessments and neuro checks were initiated to be completed by licensed nurse as directed by the Director of Nursing on 1/27/25. Later in the shift Resident #84 was sent to emergency room (ER) for full evaluation per Nurse Practitioner (NP) orders to ensure no physical injury. Resident #84 returned to the facility with no negative findings. It was noted that the nurse's notes stated resident #84 had left arm pain and the hospital had not completed an x-ray of the arm, and an order was obtained for an x-ray. On 1/28/25, the order was changed to stat (now or as soon as possible) as the x-ray company had not yet come. Resident #84 demonstrated unrelated behaviors becoming combative with care resulting in discharge on [DATE] to the hospital for psych evaluation. On 1/29/25 Resident #84 returned to facility and continued to demonstrate escalating behaviors with emergency medical staff and facility staff. Resident #84 again was discharged from the facility for psych evaluation. Resident #84 remains out of the facility at this time. -Police were notified of this resident-to-resident abuse and reported to facility for statements on 01/28/25. No actions were taken by the police. Resident #64 was assessed by police and determined to not be at risk to self or others. -Residents on the dementia unit were assessed for injuries and/or physical indicators of abuse by the DON, Unit Manager, and licensed nursing staff on 1/28/25. Interviewable residents were interviewed by the DON, Unit Manager, and licensed nursing staff on 1/28/25 regarding any witnessed physical altercations, witnessed abuse, and feelings of safety while residing in the facility. No additional findings were identified. Documentation is maintained by the Administrator in the physical copy of the investigation file. 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. -Resident #64 was placed on increased monitoring of every 30 minutes via nurse aides and hourly via licensed nurse. This directive was received by the Administrator and Director of Nursing on 1/28/25. Resident #64's orders and care plans were reviewed and updated by the DON and Unit Manager on 1/28/25 to reflect 30-minute checks by nurse aides and hourly checks by licensed nurses. Staff providing care were made aware of aforementioned care plan modification on 1/28/25 by the DON and Unit Manager. Resident #64 remains in need of skilled care related to assistance required with activity of daily living (ADL), inability to self-manage medications, and cognitive impairments that result in behaviors such as wandering completed by the Director of Nursing on 2/8/25. As a result of a secondary resident to resident involving Resident #18, Resident #64 was escalated to a 1 on 1 supervision during wake hours via nurse aide or designee effective 2/1/25. This was directed by the Director of Nursing and Administrator on 2/1/25. This will continue until deemed safe to reduce or eliminate by a psych provider or until discharge. -Education was initiated by Licensed Nursing Home Administrator (LNHA)/designee related to types of abuse including resident to resident altercations, abuse identification, abuse prevention, and maintaining resident safety, with all nursing home staff on 1/28/25. Education included scenarios and quizzes for demonstration of staff competency. Education further included redirecting residents, monitoring for and identifying precipitating behaviors that could lead to possible resident to resident altercations. This education includes agency staff and newly hired employees via the facility orientation process. No staff will work after 2/7/2025 without having had this education. Licensed Nursing Home Administrator (LNHA) or designee will maintain compliance with tracking education requirements. -Additional ongoing whole nursing home staff education is being coordinated by the Regional Director of Operations on 2/8/25 with Telos psych providers or designee related to dealing with difficult behaviors and monitoring interventions, to be completed monthly with all staff. First education in this series will be conducted on 2/17/25. The facility Administrator assumes responsibility for the immediate jeopardy removal plan. The date of the immediate jeopardy removal is 2/9/25. The survey team attempted to conduct a validation of the immediate jeopardy removal on plans on 2/10/25. The facility had failed to update Resident #64's care plan to reflect 30-minute Nurse Aide checks and hourly Nurse checks. The facility failed to collaborate with the psychaitric provider for montly on-going education that was supposed to start on 02/17/25. The facility failed to have Resident #64 assessed by a psychiatric provider before reducing his one-on-one supervision. The immediate jeopardy removal date of 2/9/25 was not able to be validated. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses which included depression and alcohol related dementia (brain damage from alcohol abuse) and adjustment disorder with depressed mood (mental health disorder that can occur as a response to stressful life events). Review of the Electronic Medical Record (EMR) revealed Resident #64 was last seen for psychiatric services (psychotherapy) on 10/29/2024. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 was moderately cognitively impaired with no behaviors, rejections of care, or wandering. A care plan dated 1/7/2025 revealed Resident #64 had the potential to be physically aggressive related to poor impulse control. Resident #64 was to have psychiatric/psychogeriatric (mental health services) consulted as needed. Resident #18 was admitted to the facility on [DATE] with diagnoses which included vascular dementia. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired. Resident #18 was coded as behavior of this type occurred daily for wandering. Resident #18 had no impairment of her upper and lower extremities and did not utilize assistive devices. Resident #18 was coded as independent for walking. A care plan dated 1/13/2025 revealed Resident #18 was an elopement risk, wanderer, with interventions which included staff were to address wandering behavior by walking with Resident #18 and redirecting Resident #18 from inappropriate areas. A nurse's note dated 2/1/2025 at 12:21 pm, authored by the Unit Manager #4, revealed she was sitting at the nurse's station when she heard Resident #64 saying get out of here, get out of here. As Unit Manager #4 got up to redirect the residents, Resident #64 was observed shoving Resident #18 as she was proximal to Resident #64's door. Unit Manager #4 immediately intervened and stepped between the two residents. Resident #64 went into his room and slammed the door. Unit Manager #4 redirected Resident #18. Resident #18 walked over to the common area then proceeded to walk back towards Resident 64's room. Resident #64 came out of his room as Resident #18 started walking and antagonized Resident #18 by saying walk over here, walk over here with a grin on his face and his fist balled up. Unit Manager #4 continued to redirect Resident #18 and attempted to reeducate Resident #64 on peer-to-peer interactions with no effect. Resident #64 told Unit Manager #4 to yeah go call the police, yeah I will do it again. Unit Manager #4 made the supervisor aware at 12:14 pm, called the Administrator at 12:15 pm, and contacted the Nurse Practitioner (NP) at 12:34 pm. Unit Manager #4 reported the event to Nurse #3 at 1:10 pm. An interview was conducted on 2/10/2025 at 11:19 am with Unit Manager #4. Unit Manager #4 stated she was charting at the nurse's station on 2/1/2025 when she heard Resident #64 say get out of here, get out of here. Unit Manager #4 stated when she went to get up, she witnessed Resident #64 shove Resident #18. Unit Manager #4 was unable to recall if Resident #64 shoved Resident #18 using one hand or two hands. Unit Manager #4 stated the shove did not cause Resident #18 to lose balance or fall. Unit Manager #4 stated the shove seemed as though it was to have Resident #18 go the other way. Unit Manager #4 stated she educated Resident #64 and told him not to place his hands on anyone else. Unit Manager #4 stated Resident #64 was placed on one-on-one supervision immediately. Unit Manager #4 stated she contacted the supervisor, Guardian, and NP as well. A nurse's note dated 2/1/2025 at 2:14 pm, authored by Nurse #3, revealed she had been notified by another nurse Resident #64 had pushed another resident. Resident #64 was separated and one-on-one care during wake hours was initiated until further notice. One-hour checks were to be completed by the nurse and 30-minute checks were to be completed by Nurse Aides (NAs) while Resident #64 was sleeping. Nurse #3 documented per supervisor, a new order for lorazepam 1 milligram (mg) was to be administered every 6 hours as needed and would be placed in the system by a physician. An initial allegation report dated 2/1/2025, completed by the Administrator, revealed the facility reported an allegation due to resident-to-resident physical altercation involving Resident #64. The facility became aware of the incident on 2/1/2025 at 12:14 pm and notified law enforcement at 12:54 pm. Resident #64 was placed on one-on-one supervision while awake and hourly nursing checks with every 30-minute NA checks while Resident #64 was asleep. A five-day investigation report dated 2/7/2025 revealed the Administrator had completed an investigation and determined Resident #64 pushed Resident #18. Resident #18 was not injured, did not fall, and there were no bruises. An interview was conducted on 2/10/2025 at 11:38 am with NA #10. NA #10 stated she worked on the memory care unit on 2/1/2025 and was on the unit, sitting as a post near the elevators (to watch residents and ensure they did not go down the elevator). NA #10 stated she did not witness the incident between Resident #64 and Resident #18. NA #10 stated she was told by a nurse, name unknown, to sit with Resident #64 one-on-one. NA #10 stated Resident #64 was calm the remainder of the time she was assigned to him and stated she had taken him out to smoke after the incident to help calm his nerves. NA #10 stated she was not aware of any other instances where Resident #64 had been aggressive with other residents. NA #10 stated Resident #64 was able to ambulate independently and made his needs known. NA #10 stated Resident #18 frequently wandered and would attempt to go in other resident's rooms. NA #10 stated Resident #64 would get agitated when other residents would try to wander into his room but stated she had never witnessed him shoving anyone before. An interview was conducted on 2/10/2025 at 11:46 am with Nurse #3. Nurse #3 stated she was not on the memory care unit when the event between Resident #64 and Resident #18 occurred. Nurse #3 stated when she arrived back on the memory care unit, Resident #64 and Resident #18 were already separated. Nurse #3 stated she assessed Resident #18 for pain and injuries following the incident and stated Resident #18 was okay. An interview was conducted on 2/10/2025 at 12:17 pm with NP #2. NP #2 stated she had been called over the weekend by a facility staff member regarding the incident with Resident #64 and Resident #18. NP #2 stated she had made the recommendation to place Resident #18 on one-on-one supervision. An observation was conducted on 2/10/2025 at 3:43 pm of Resident #64. Resident #64 was observed awake, sitting on the side of his bed, and no longer had a one-on-one sitter. Resident #64 appeared calm. An observation was conducted on 2/10/2025 at 11:03 am of Resident #18. Resident #18 was observed lying in bed. Resident #18 did not answer questions. An interview was conducted on 2/10/2025 at 4:19 pm with the Director of Nursing (DON). The DON stated she had made aware of the incident involving Resident #64 and Resident #18 on 2/1/2025. The DON stated Resident #64 was immediately placed on one-on-one supervision. Follow-up interviews have been requested with the Director of Nursing (DON) and have not been successful. An interview was conducted on 2/11/2025 at 1:20 pm with the Administrator. The Administrator stated she was made aware of the incid[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #63 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, heart failure and seizure disorder. Resident #63 resided in the Memory Care Unit which is a secured unit on the third floor of the facility. The care plan revised on 06/06/24 revealed Resident #63 was a wanderer due to being disoriented to place. The goal that he will be safe would be attained by utilizing interventions such as distracting the Resident by offering distraction with activities, ensuring the areas that the Resident is wandering in is safe and monitoring for fatigue and weight loss. There was no wander guard monitoring device on the care plan. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severe cognitive impairment and wandering behaviors were not indicated on the MDS. The MDS also indicated the Resident ambulated independently and wander/elopement alarm was used daily. A review of Resident #63's physician orders dated 01/29/25 revealed an order to check electronic monitoring device via testing machine every shift and to visually check electronic monitoring device every shift. A review of Resident #63's Medication Administration Record (MAR) for 01/2025 indicated an order dated 01/29/25 to visually check the electronic monitoring device right ankle every shift and check electronic monitoring device via testing machine every shift. The MAR indicated the electronic monitoring device was checked as present every day and every shift. A review of Resident #63's MAR for 02/2025 indicated an order dated 01/29/25 to check the electronic monitoring device right ankle every shift and check electronic monitoring device via testing machine every shift. The MAR indicated the electronic monitoring device was checked as present every day and every shift except day shift on 02/06/25. An interview and observation were made of Resident #63 on 02/07/25 at 1:08 PM. The Resident was standing in the middle of the floor in his room. Resident #63 answered to his name being called but could not follow verbal command. Observation of both ankles and wrists revealed there was no wander guard alarm on the Resident. An observation was made on 02/10/25 at 1:15 PM of a sign posted on the back wall in the Providence Road elevator (one of two elevators that leads up to the Memory Care Unit) that stated STOP in a red stop sign and verbiage underneath the sign that stated PLEASE SEE THE NURSE BEFORE ALLOWING OUR SECURED RESIDENTS ON THE ELEVATOR in black capital letters. There was no sign posted on the front door of the elevator about the precaution. An observation was made of the outside door and inside back wall of the Dartmouth Road elevator which leads up to the Memory Care Unit on 02/10/25 at 2:12 PM. There were signs posted that stated STOP in a red stop sign and verbiage underneath the sign that stated PLEASE SEE THE NURSE BEFORE ALLOWING OUR SECURED RESIDENTS ON THE ELEVATOR in black capital letters. On 02/10/25 at 12:45 PM during an interview with Nurse #7 the Nurse reported that she was working on the second floor on 02/10/25 when around 7:39 AM she observed Resident #63 wandering around on the second floor near the nurses' station alone with no one attending him. The Nurse explained she sent a text message to the Director of Nursing (DON) to report her observation then called Nurse #5 who was working the Memory Care Unit at that time and reported her observation to the Nurse in which she responded that she would send a staff member down to get Resident #63. Nurse #7 continued to explain that approximately 5 minutes later Nurse Aide (NA) #11 who was scheduled to work on the Memory Care Unit came to the second floor nurses' station and assisted Resident #63 back upstairs to the Memory Care Unit. The Nurse reported that a few minutes after the NA left with Resident #63, the DON came to the second floor to collect statements from staff about Resident #63 being downstairs unattended. The Nurse stated she informed the DON that Resident #63 was observed to be walking up the long hall from the area of the Providence Road elevator. When asked how the Nurse thought Resident #63 got unattended to the second floor she indicated if his wander guard alarm did not sound on the Memory Care Unit then he could have ridden the elevator down with someone who did not know that the Resident should not be left unattended. The Nurse reported that there were a lot of new people at the facility and there were signs posted outside the elevator doors about patient safety. On 02/10/25 at 1:16 PM during an interview with Nurse Aide #12, the NA was working on the Memory Care Unit on first shift on 02/10/25 who explained that he was off the Unit when Resident #63 was found downstairs on the second floor. The NA continued to explain that a Hospice staff was on the Unit earlier that morning and the Resident could have rode the elevator down with that person. NA #12 stated Resident #63 had since had the wander guard placed on his ankle and was on a 1:1 monitoring with NA #11. An observation of Resident #63 was made on 02/10/25 at 1:19 PM. The Resident was alert and walking up the hallway while being monitored by Nurse Aide #11. The NA asked Resident #63 to lift his pant leg up and the Resident could not follow through with the request. The NA had to lift the Resident's left pant leg to expose the wander guard was present on his ankle. An interview and observation were conducted with Nurse Aide #11 on 02/10/25 at 1:20 PM. The NA was monitoring Resident #63 for the 1:1 protocol and explained that she went downstairs earlier that morning and as soon as she stepped off the elevator on the second floor the Resident was walking toward her and had already passed the nurses' station. The NA continued to explain that she asked Nurse #7 how Resident #63 got down to the second floor but neither of them knew how the Resident got downstairs by himself. NA #11 reported when she returned to the Memory Care Unit with Resident #63, she was told that she was changing assignments to monitor the Resident 1:1 for the rest of the shift. Soon afterwards the NA had to take Resident #63 to the podiatry clinic downstairs and one of the Unit Managers placed a wander guard on the Resident's left ankle. During an interview with Nurse #5 on 02/10/25 at 1:35 PM the Nurse explained that earlier that morning she received a phone call from Nurse #7 who was working on the second floor, she found Resident #63 wandering around by himself and Nurse #5 needed to send someone down to get the Resident. The Nurse stated she notified Nurse Aide #8 who was the Resident's assigned care giver that day, that Resident #63 was found on the second floor, and she needed to go downstairs and get the Resident. NA #8 informed the Nurse that she had just sat Resident #63 down in the dining room and he was watching TV when she went to the supply closet to obtain some supplies to continue her morning care of the residents. The Nurse stated as the NA went to the Dartmouth Road elevator to obtain the Resident, she observed Nurse Aide #11 and Resident #63 getting off the elevator. Nurse #5 explained that she notified the Director of Nursing that Resident #63 was found downstairs on the second floor and the DON came to the Memory Care Unit when it was discovered that Resident #63 did not have his wander guard on either ankle. The Nurse reported that the staff searched the Resident's room and could not find the wander guard. Nurse #5 stated a new wander guard was placed on Resident #63 by one of the Unit Managers and he was placed on 1:1 monitoring with Nurse Aide #11. Nurse #5 continued to explain that she worked on the Memory Care Unit on Saturday 02/08/25 first shift and Resident #63 had his wander guard on during that shift. When Nurse #5 was asked how she thought Resident #63 got to the second floor she explained that since the wander guard alarm did not sound for the Resident, he must have ridden the elevator down with someone who did not know that the Resident could not be without attendance of staff. The Nurse reported only one person was on the unit that day which was a Hospice Aide, and she thought the DON had already obtained a statement from her about the incident. On 02/10/25 at 1:45 PM an interview was conducted with Nurse Aide #8 who confirmed she was assigned to Resident #63 and explained that she had just sat Resident #63 down in the dining room to watch TV and went to the supply closet to obtain supplies to continue her care of the residents. She stated that approximately 5-7 minutes later when she opened the door to come out of the supply room Nurse #5 informed her that Resident #63 was found on the second floor by himself unattended and asked the NA to go downstairs and bring him back up but as she approached the Dartmouth Road elevator she saw that NA #11 had already brought Resident #63 back to the Unit. NA #8 reported that the Resident was supposed to have a wander guard on, but he did not have a wander guard on when he was brought back to the Unit. She stated if Resident #63 had a wander guard on then he would not have been able to get on the elevator because of the alarm sounding as he approached the elevator. The NA stated the Resident was put on 1:1 monitoring with NA #11 and the wander guard was replaced later that morning. NA #8 reported that she did not know how Resident #63 got downstairs unattended, but he should have had a wander guard on because of his wandering behavior. An interview was conducted with Unit Manager #4 on 02/10/25 at 3:30 PM. The Unit Manager explained that the Director of Nursing notified her earlier that day to put a wander guard on Resident #63 when he was at the podiatry clinic which she did. She stated the DON did not tell her why to put the wander guard on the Resident. The Unit Manager stated that she did not know that Resident #63 was found on the second floor earlier that morning unattended. An interview was conducted with the Director of Nursing on 02/10/25 at 5:25 PM. The DON was asked what she knew of Resident #63 being found downstairs on the second floor earlier that day and the DON explained that she was notified that Resident #63 was wandering around and he had to have his wander guard replaced that day. The staff informed her that they were looking for his wander guard because he was wandering in and out of the rooms and near the doors and when they noticed it off, they replaced it. The DON stated she told someone through a text message circle to replace it and left one at the Reception Desk and told the receptionist to give it to whoever comes to get it, and Unit Manager #4 ended up replacing it. The DON reported Resident #63 was not found on the second floor because that would indicate he was lost. She stated the facility had a procedure when a resident was (missing) and it was to call a color code and there was not a code called that day to indicate a missing resident. When the DON was asked what the color code was for missing residents, she indicated she did not know and would have to get back with that information. The DON continued to explain that she was informed that Resident #63 was with an agency aide, but the DON found out later that it was a Hospice Aide because the Hospice Aide was the only non-staff member up on the Memory Care Unit earlier that day. She reported she had already called the Hospice Aide because the Hospice Aide was on the Memory Care Unit to get briefs to give care and she was the last person out of any doors from the Unit. The DON continued to explain that when she called the Hospice Aide the Aide informed her that there was no one on the elevator with her when she left the Memory Care Unit, that she was by herself. The DON was asked how was it possible that Resident #63 got to the second floor by himself without the wander guard alarm sounding to alert the staff and the DON explained that since Resident #63 did not have a wander guard on he must have went down the elevator but that he had to have been with someone who knew the code to the elevator because he was not cognitively intact to manage the code of the elevator, know the code of the elevator or push button #2 on the elevator to go to the second floor. She stated, he just don't have it. At 4:25 PM on 02/10/25 during an interview with the Hospice Aide she explained that she was up on the Memory Care Unit earlier that morning but when she went back down in the elevator there was no one with her on the elevator. An interview was conducted with Nurse #8 on 02/11/25 at 1:04 PM. The Nurse confirmed she worked on the Memory Care Unit on third shift (11:00 PM - 7:00 AM) on 02/07/25 and 02/08/25. Nurse #8 explained that she checked both nights for the wander guard on Resident #63's ankle (could not remember which ankle) and the wander guard was on his ankle. The Nurse continued to explain that Resident #63 was usually awake and up all night walking the halls and often removed the wander guard. The Nurse reported it was not uncommon for her to have to replace the wander guard because Resident #63 often removed it from his ankle. The Nurse explained that she had reported it to the previous Unit Manager (who no longer worked at the facility), and she was trying to come up with a different plan for the Resident. Nurse #8 reported everybody was aware that Resident #63 removed the wander guard, even the Director of Nursing (DON), but she had not personally spoken to the DON about it. The Nurse explained that the only explanation she would have about how Resident #63 was found on the second floor unattended was that the Resident was not wearing the wander guard when he approached the elevator to sound the alarm or if he did not have the wander guard on, he must have road the elevator down to the second floor with someone who knew the code. The Nurse indicated Resident #63 was not cognitively intact enough to know the elevator code or to input the code by himself. During an interview with Nurse # 3 on 02/11/25 at 4:45 PM the Nurse reported that she recently worked on the Memory Care Unit on 02/06/25 first shift (7:00 AM - 7:00 PM) and worked with Resident #63. She stated Resident #63 wandered around the unit independently and was easily redirected. Nurse #3 explained that when she checked the Resident's wander guard (monitoring device) during the shift, the wander guard was not on the Resident. She stated she did not report it, nor did she replace it because everybody knew, even the administrative staff. The Nurse stated she had mentioned it in the past to the Director of Nursing (DON) about not having the wander guards and the reply she got was I will take care of it. The Nurse continued to explain that it was her understanding that there were not enough straps for the wander guards for everyone who needed them to have one. Nurse #3 stated she was not aware of whether Resident #63 was able to remove his wander guard. On 02/10/25 at 6:10 PM and 02/11/25 at 1:20 PM interviews were conducted with the Administrator who explained that she was not aware that Resident #63 had been found on the second floor wandering around unattended until this interview. The Administrator continued to explain that someone asked her for a wander guard, and she contacted the Maintenance Director to obtain a strap for the wander guard from a sister facility that was approximately 2 miles away and he was able to get one and they put it on him. She stated she found out who it was for, and she told the staff to put him on 1:1 monitoring until the wander guard got to the facility. The Administrator stated she did not know how Resident #63 got downstairs on the second floor. The Administrator indicated in the follow-up interview that she was still investigating how Resident #63 was able to get downstairs to the second floor because he can not press the buttons by himself. She stated as far as she knew the Resident was not unattended. Based on observations, record review, review of the transportation van training tutorial, and resident, Transportation Driver #1, Transportation Administrator, staff, and Nurse Practitioner interviews, the facility failed to ensure that Resident #336 who was cognitively intact, received dialysis services and was prescribed an anticoagulant, was safely transported back to the facility following dialysis on 01/21/25. Transportation Driver #1 who drove through a contract transportation company failed he failed to secure the lap and shoulder belt around Resident #336. During the transport, Transportation Driver #1 hit bumps in the road and Resident #336 was thrown from his wheelchair to the floor of the van. In addition, Transportation Driver #1 did not contact Emergency Medical Services for Resident #336 to be evaluated and when he was unable to assist Resident #336 back into his wheelchair, Transportation Driver #1 made the decision to leave Resident #336 on the floor of the van and transport him back to the facility. Resident #336 stated he was not injured. When Transportation Driver #1 returned to the facility Nurse #24 assessed Resident #336 for injuries and none were noted. Failing to secure the lap and shoulder belt around Resident #336 during transport and transporting Resident #336 back to the facility while he was on the floor of the van had the high likelihood of causing serious harm, or serious impairment. The facility also failed to complete an accurate safe smoking assessment for Resident #39 and have electronic monitoring devices in place for Resident #29 and Resident #76. In addition, the facility failed to provide supervision to Resident #63 who resided on the locked unit on the third floor of the facility and had a history of wandering from getting on the elevator unattended and going to the second floor of the facility where staff found him and returned him to the secured unit on the third floor. The deficient practices affected 5 of 5 residents reviewed for supervision to prevent accidents (Resident #336, Resident #39, Resident #29, Resident #76, and Resident #63). Immediate jeopardy began on 01/21/25 when Resident #336's lap and shoulder belt was not secured around him prior to transportation and he was thrown to the floor after Transportation Driver #1 hit bumps in the road. Immediate jeopardy is present and ongoing. Examples #2, 3a, 3b, and 4 are being cited a lower scope and severity of E. The findings included: 1. Per the restraint system used on the transportation van training tutorial, in order to properly secure a resident in a wheelchair with the restraint system, Transportation Driver #1 needed to lock the resident's wheelchair after loading Resident #336 followed by utilizing the retractable securing hooks to Resident #336's wheelchair and ensuring that they are locked and prevented Resident #336's wheelchair from moving. Transportation Driver #1 should have then placed the lap and shoulder belt over Resident #336, ensuring the lap belt was snug across Resident #336's lap and the shoulder belt was across the front of Resident #336. Resident #336 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. Resident #336's admission Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact with no delusions, behaviors or rejection of care. Resident #336 was coded as dependent on others for transfers and had impairments on both sides of his lower extremities. Resident #336 was also coded as taking an anticoagulant medication and receiving dialysis services. Resident #336's physician orders revealed Eliquis Oral Tablet - 5 milligrams - Give one tablet by mouth two times a day for history of stroke. This physician order was dated 01/20/25. Resident #336's care plan dated 01/20/25 revealed a care plan for receiving hemodialysis related to end stage renal disease. Resident was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. The facility's fall incident report dated 01/21/25 at 6:00 PM revealed the following: Transport Driver arrived stating resident had fell out of wheelchair and asking for assistance. Un-witnessed fall. Resident lying on right side in the floor of the transport van. Resident was laying beside his wheelchair in back. No signs of visual injury. Resident had complaints of right knee discomfort. Resident stated he did not hit his head. Aided resident back into his chair with the help of driver. This nurse asked driver to come in and write a statement and driver left without doing so. Resident stated upon returning to facility from dialysis, driver went over a speed bump when he got dispositioned in his wheelchair. Resident stated before he could get himself straightened back up in wheelchair, the driver then [stomped] on the brakes and resident fell forward out of wheelchair on transport van floor. Resident stated his right leg was slightly bent when he landed on the floor. Resident stated his seat belt was anchored around his wheelchair and not him. Resident stated van driver made an attempt away from premises to pick him up off the floor but was unsuccessful. An additional review of the incident report revealed Resident #336's vital signs were taken and were within normal limits. Per the incident report a complete body check was completed on Resident #336 and there were no signs of injury. Nurse #24 offered Resident #336 an ice pack, but he declined. The incident report was written by Nurse #24. An interview with Resident #336 on 02/07/25 at 12:16 PM revealed he remembered the incident. He reported he had gone to dialysis and was supposed to be picked up around 4:00 PM on 01/21/25. He stated Transportation Driver #1 first loaded another resident (Resident #337) and then loaded him onto the transportation van. He stated when Transportation Driver #1 loaded him on the transportation van, he locked the wheels of his wheelchair, but instead of placing the lap belt around his body, he placed it around his wheelchair. Resident #336 stated he did not question Transportation Driver at that time because, I thought he knew what he was doing. Resident #336 continued, stating as Transportation Driver #1 proceeded on to the facility, it felt as though Transportation Driver #1 hit a bump which jarred him from his wheelchair. Resident #336 stated before he could get resituated in his wheelchair. Transportation Driver #1 hit another bump which resulted in throwing him from the wheelchair onto the floor of the van. Resident #336 reported he called out for help and Transportation Driver #1 pulled over and unsuccessfully attempted to get him back into his wheelchair. Resident #336 stated Transportation Driver #1 then proceeded to tell him that they were only about 10 minutes from the facility and that he would get him off of the floor of the van when they returned to the facility. Resident #336 stated he remained on the floor of the van for the remainder of the drive and when they arrived back at the facility, a staff member came out and helped him get back into his wheelchair. Resident #336 reported that he was not injured in the event but reported he really did not like being left on the floor of the van while it was returning to the facility and that it was not a good first-time experience being transported by the transportation company. Resident #337's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. An interview with Resident #337 on 02/07/25 at 3:43 PM revealed he was on the transportation van the day Resident #336 fell. Resident #337 reported that Transportation Driver #1 loaded him [Resident #337] into the transportation van first and secured his wheelchair with four straps to his wheelchair and then placed a lap and shoulder belt over his midsection. He stated since he was loaded first, he could not see how Transportation Driver #1 loaded and secured Resident #336 in the transportation van. He stated at some point during transport, he heard Resident #336 state, Help, I need help. Resident #337 reported when he heard Resident #336 call out for help, he asked Resident #336 if he was okay, and Resident #336 replied that he needed help. Resident #337 reported he could not see Resident #336 due to their placement in the van, so he relayed that message to Transportation Driver #1. Resident #337 stated Transportation Driver #1 pulled the van into a bank parking lot and checked on Resident #336 but was unable to either get Resident #336 resituated into his wheelchair or get him off of the floor, so Transportation Driver #1 got back into the driver's seat of the van and continued on to their destination. Resident #337 indicated he did not realize Resident #336 was in the floor of the van until Transportation Driver #1 got to the facility and retrieved a staff member to come out and assist him in getting Resident #336 back into his wheelchair. Resident #337 reported he did not feel any significant bumps in the road but that there were a few times where Transportation Driver #1 applied the brakes a little hard. An interview with Transportation Driver #1 on 02/10/25 at 11:09 AM via telephone revealed he was the transportation driver for Resident #336 and Resident #337 on 01/21/25. Transportation Driver #1 reported he loaded Resident #337 onto the van first, secured his wheelchair with four straps and then placed the lap belt around Resident #337's midsection and then loaded Resident #336 onto the van and repeated the same process. He reported he was driving both residents back to the facility and when he pulled into the facility's parking lot, he was notified by Resident #337 that Resident #336 needed assistance. Transportation Driver #1 stated he stopped and went to check on Resident #336 and noted that he had started to slide out of his seat. Transportation Driver #1 reported he attempted to resituate Resident #336 back into his wheelchair but was unsuccessful. He stated he unlatched the lap belt and when he did, Resident #336 slid out of his wheelchair to the ground. Transportation Driver #1 stated Resident #336 landed on his bottom but could not recall if he was leaning to one side or the other. Transportation Driver #1 insisted that he was not aware of the issue until he was pulling into the facility's parking lot and denied pulling into any other parking lots or that Resident #336 was transported while he was on the floor. He continued, stating once he realized he could not get Resident #336 back into his wheelchair, he went and retrieved assistance from a staff member in the facility. Transportation Driver #1 reported he received in-service trainings and was tested on competencies a couple times a year and had been reminded daily to ensure that when he was transporting clients, that their wheelchairs and the clients were secured before transporting them to their destinations. Transportation Driver #1 indicated if a client were to fall during transportation, he was supposed to immediately pull over and contact his supervisor. He also stated once he retrieved assistance from a facility staff member, they were able to get Resident #336 back into his wheelchair and off of the transportation van. He reported once Resident #336 was safely back into the facility, he knew he had to contact his supervisor but noticed that his phone was dead, so he immediately left the facility so he could charge his phone and contact his supervisor. He indicated he was unaware that the facility requested him to stay and complete a written statement of the incident. Review of Transportation Driver #1's training revealed he was trained on defensive driving, along with how to secure resident's for transportation and the processes and policies in the event of an emergency. Transportation Driver #1's written statement that was received by the facility on 01/22/25 at 12:00 PM, via email, to the attention of the Administrator read, in part: I am writing to provide an account of an incident that occurred at [facility]. I arrived at the facility between 5:15 PM and 5:30 PM. As I was pulling into the driveway, [Resident #337] informed me that [Resident #336] had slid out of his wheelchair. I did not hear about or observe the incident myself but immediately inquired about [Resident #336's] condition. I then entered the facility to request assistance. The nursing staff promptly responded and assisted in helping [Resident #336] back into his wheelchair. Once [Resident #336] was safely secured in his wheelchair, the nurse wheeled him back inside. I took [Resident #337] out of the van and subsequently left to notify my manager about the situation. Unfortunately, the office was closed, and my phone battery was dead. I made haste to get home so I could inform my manager, [Transportation Administrator], of the incident as quickly as possible. An interview with the Transportation Administrator via telephone on 02/10/25 at 11:27 AM revealed she was made aware of the incident on 01/21/25 later that evening when Transportation Driver #1 contacted her. She said he reported to her that Resident #336 had slid out of his chair during transportation. She said she could not recall if Transportation Driver #1 reported he had slid completely out of the wheelchair or if he was only partially out of the wheelchair. She stated they provide training to all of their transportation drivers including proper securement of the clients and what to do in the event a client had a fall during transport. She stated her staff were trained to secure clients by hooking up four locking straps to the client's wheelchair and then placing the lap and shoulder belt over the client. Once that was complete, she expected her employees to wiggle the wheelchair to ensure it was fully secure. She continued, stating that if a client were to fall or have an emergency during transportation, she expected them to immediately pull over somewhere safe, check on the client, contact emergency services, and then notify her of the incident. She indicated she did not know if Transportation Driver #1 contacted emergency services at the time he was made aware that Resident #336 had slid out of his wheelchair. An interview with Nurse #24 on 02/10/25 at 2:26 PM, revealed she was working on 01/21/25 and was near the lobby of the facility when Transportation Driver #1 entered the facility and stated Help, help, a resident just fell in the van. She stated she ran outside and found Resident #336 who was lying flat on his side on the floor in the back of the transportation van. She questioned Transportation Driver #1 on how Resident #336 ended up in the floor and he reported to her that when he was trying to get Resident #336 out of the van, he slid out of his wheelchair and onto the floor. She stated his left leg was slightly bent and was between the wheels of his wheelchair underneath the seat. She stated she assessed and questioned Resident #336 who stated he had fallen during transport but was not injured and that he had not hit his head. She stated he did complain of some slight discomfort in his left foot or leg when she removed the wheelchair in order to get him off of the floor. She stated once she got Resident #336 off of the floor of the van and into his wheelchair, she questioned him as she took him into the facility, and he stated he had fallen during transport and was left on the floor of the van until they arrived at the facility. She stated he also informed her that Transportation Driver #1 had placed his lap belt around his chair and not his person, which resulted in him falling. Once she spoke with Resident #336 and ensured he was comfortable in his room, she immediately reported the fall to the Administrator. She reported she went back out to get a statement from Transportation Driver #1, but he refused and got into the transportation van and left the facility. An interview with Nurse Practitioner #1 on 02/10/25 at 5:08 PM via telephone call revealed Resident #336 was taking anticoagulant medication and there was a higher risk for internal bleeding following a fall. An interview with the Director of Nursing on 02/10/25 at 3:21 PM revealed all she could remember of the incident was she was completing h[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff and Resident interviews, the facility failed to implement their abuse policy in the area of protection following an incident of resident-to-resident physical abuse placing 33 of 33 other residents residing on the secured unit at risk of suffering abuse perpetrated by Resident #64. On 01/27/25 Nurse #6 witnessed Resident #64 lift Resident #84 off the floor and throw him out of Resident #64's room. Resident #84 fell to the floor, hit his head, and Nurse #6 heard a noise that sounded like a crack. The facility implemented 30-minute monitoring checks for Resident #64 on 01/28/25. The 30-minute monitoring checks were not effective in preventing further abuse. On 02/01/25 as Resident #18 was ambulating past Resident #64's room, Resident #64 pushed Resident #18. Following the incident, Resident #64 balled up his fist and stated to Resident #18, walk over here and I will do it again. Immediate Jeopardy began on 01/27/25 when protective measures were not immediately implemented to protect other residents from further abuse after Nurse #6 witnessed Resident #64 physically abuse Resident #84. Immediate Jeopardy was unable to be removed and is present and ongoing. The findings included: Review of the facility's Abuse, Neglect and Exploitation policy dated 11/01/2020 indicated the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. The policy listed examples of protection that included: increased supervision of the alleged victim and residents; and room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. The policy specified that protection was not limited to those examples. Resident #64 was admitted to the facility on [DATE]. A review of Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and did not use a device for mobility and was able to transfer and walk independently without assistance from staff. A review of an Incident Report dated 01/27/25 at 10:50 AM revealed Nurse #6 observed Resident #84 being tossed out of the room by another resident (Resident #64) into the hallway floor landing on his left side. Nurse #6 noted there were no injuries observed at the time of the incident and Resident #84 was alert, confused, oriented to person, and ambulatory without assistance. During a telephone interview on 01/30/25 at 11:22 AM Nurse #6 revealed on 01/27/25 she was working on the secured unit on the third floor and heard Resident #64 yell out, Get out my room, I told you to get out. Nurse #6 revealed she saw Resident #64 take both hands and lift Resident #84 off the ground and throw him out of his room. Resident #84 fell to the floor, and she (Nurse #6) heard a noise that sounded like a crack and saw Resident #84's head hit the floor. Both residents were separated, and Resident #64 stayed in his room. She revealed Nurse #7 stayed with Resident #84 while she went to find the Administrator or the Director of Nursing (DON). DON and Unit Manager #5 came to the secured unit on the third floor. During an interview on 01/29/25 at 11:29 AM and 02/10/25 at 12:45 PM Nurse #7 revealed she was working on the memory care unit where the incident between Resident #64 and Resident #84 occurred on 01/27/25. The Nurse reported after the incident she stayed with Resident #84 who was still in the floor outside of Resident #64's room while Nurse #6 went downstairs to get the DON and Administrator. Nurse #7 stated while she was with Resident #84, Resident #64 did not come out of his room. The Nurse explained that she did not know what system was put in place immediately following the incident to monitor Resident #64 but stated around 3:00 PM that same day the DON came up to the unit and asked where the papers were (meaning the hourly monitoring sheets) for Resident #64. Nurse #7 informed her (the DON) that she did not know anything about Resident #64 being on hourly monitoring and initiated the hourly monitoring sheets herself at that time. An interview was conducted with Nurse Aide (NA) #10 on 02/07/25 at 1:11 PM who reported after the incident with Resident #84 on 01/27/25, Resident #64 was on every 30-minute checks. During an interview on 01/29/25 at 5:35 PM and 02/06/25 at 3:40 PM the DON revealed on 01/27/25 Nurse #6 told her Resident #84 had an unwitnessed fall and she did not know what happened. The DON revealed she was not made aware of a physical abuse incident involving Resident #64 and Resident #84 until 01/28/25 after reviewing Nurse #6's note and incident report during their morning meeting. The DON indicated that after administration found out about the incident on 01/28/25, they decided to include Resident #64 in on every 30-minute observation checks done by the nurse aides and hourly checks done by the nurses to protect the other residents from Resident #64. During an interview on 01/29/25 at 10:54 AM and 3:53 PM Resident #64 demonstrated how he used both hands to lift and throw Resident #84 out of the room onto the floor. Resident #64 revealed that if someone came into his room and would not leave when asked he would use physical force to get them out and did not need help getting someone out of his room. A nurse's note dated 2/1/2025 at 12:21 pm, authored by the Unit Manager #4, revealed she was sitting at the nurse's station when she heard Resident #64 saying get out of here, get out of here. As Unit Manager #4 got up to redirect the residents, Resident #64 was observed shoving Resident #18 near to Resident #64's door. Unit Manager #4 immediately intervened and stepped between the two residents. Resident #64 went into his room and slammed the door. Unit Manager #4 redirected Resident #18. Resident #18 walked over to the common area then proceeded to walk back towards Resident 64's room. Resident #64 came out of his room as Resident #18 started walking and antagonized Resident #18 by saying walk over here, walk over here with a grin on his face and his fist balled up. Unit Manager #4 continued to redirect Resident #18 and attempted to reeducate Resident #64 on peer-to-peer interactions with no effect. Resident #64 told Unit Manager #4 to yeah go call the police, yeah I will do it again. During an interview with Unit Manager #4 on 02/06/25 at 11:13 AM she confirmed she witnessed the incident between Resident #64 and Resident #18 on 02/01/25. The Unit Manager explained that as she was charting at the nursing desk, she heard Resident #64 say get out of here twice. When she looked up, she saw Resident #64 standing in the doorway to his room facing the hallway and saw Resident #18 walk past the doorway in front of Resident #64. She continued to explain that Resident #64 put his hand(s) (she could not remember if he used one or two hands) out as if to redirect Resident #18 from going into his room. The Unit Manager reported that Resident #18 did not lose her balance or fall she was just redirected. When the Unit Manager was asked why she wrote shoving in her nurses' notes the Unit Manager stated, I guess I should not have used that word. The Unit Manager stated after the incident she made sure Resident #18 was redirected and she instructed Resident #64 not to put his hands on the other residents. She stated she reported the incident to the administration and Resident #64 was put on one to one (1:1) supervision and he was still on the 1:1 monitoring. During an interview with NA #10 on 02/07/25 at 1:11 PM she reported that she was assigned to stay with Resident #64 for a 1:1 monitoring for that current shift. She explained that the 1:1 monitoring started on 02/01/25 after the incident with Resident #18. The NA also reported Resident #64's roommates were moved to other rooms after the incident on 02/02/25 with Resident #18. Multiple observations were made of ambulatory residents on the secured Memory Care Unit on 02/06/25 at 12:45 PM, 02/07/25 at 1:08 PM, 02/10/25 PM at 1:20 PM and 02/10/25 at 2:15 PM. Ambulatory residents were walking about the unit in the hallways and in and out of resident rooms. There were residents around Resident #64's room but they were being monitored by the nursing staff. On every observation, Resident #64 was either lying on his bed and or he was being monitored with a 1:1 observation from a nurse aide. An interview was conducted with the Administrator and Director of Nursing on 02/06/25 at 3:40 PM. The DON explained that after the incident on 01/27/25 between Resident #64 and Resident #84 they included Resident #64 in the already established routine monitoring checks for the wandering residents for every 30-minute checks by the nurse aides and hourly checks by the nurses. When asked how the incident happened if all the wandering residents (that would include Resident #84) were being monitored that frequently, and the DON stated the aides must have been busy giving patient care and the Nurse must not have been watching. The DON continued to explain that Resident #64 was currently under 1:1 supervision since the 02/01/25 incident with Resident #18 and both of Resident #64's roommates were moved to other rooms. Both the DON and the Administrator were asked how the second incident between Resident #64 and Resident #18 happen if Resident #64 was being monitored every 30 minutes and every hour by the staff and the Administrator stated during the first incident on 01/27/25 she felt the intervention was appropriate to include Resident #64 in the every 30 minute and hourly checks but, in retrospect, she indicated she should have put Resident #64 on 1:1 monitoring on 01/28/25 after she was more informed of the incident between Resident #64 and Resident #84 on 01/27/25. The Administrator was notified of Immediate Jeopardy on 02/07/25 at 11:51 AM. The facility provided the following Credible Allegation of immediate jeopardy removal. o 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 follow their policy about protecting residents and ensuring safety from Resident #64 from 1/27/25 through 2/1/25. - Resident #64 was placed on every 30-minute checks on the morning of 1/28/25 due to physical abuse with resident #84 in which it was reported that that he picked up and threw resident #84 resulting in a fall. The abuse altercation occurred when resident #84 who has wandering behaviors entered Resident #64's room and Resident #64 yelled at him to get out. The hourly checks were initiated by the Director of Nursing (DON) and nursing assistants were assigned on 1/28/25 mid-morning. - On 2/1/25, the Licensed Nursing Home Administrator (LNHA) and DON were notified at 12:15 pm by the Unit manager (UM) of the resident-to-resident abuse in which resident #64 pushed resident #18. - The Nurse Practitioners (NP's) for Residents #64 and #18 were each notified at 12:34 pm by the UM of physical altercation between resident #64 and resident #18. The on-call NP for resident #64 was further updated by his assigned nurse at approximately 1:10 pm. A new order was received for Resident #64 from the NP for as needed (PRN) Ativan to be used for any additional/further signs of agitation. - Resident #18 was assessed by her assigned nurse for any skin or pain concerns and no concerns were identified. Both assessments were completed by Resident #18's assigned nurse on 2/1/25 and documented into the EMR at approx. 2:40 pm by her assigned nurse who completed the assessments. - Residents on the dementia unit were assessed for injuries and/or physical indicators of abuse by the DON, Unit Manager, and licensed nursing staff on 2/1/25. Interviewable residents were interviewed by the DON, Unit Manager, and licensed nursing staff and/or designees on 2/1/25 regarding any witnessed physical altercations, witnessed abuse, and feeling of safety while residing in the facility. No additional findings were identified. Documentation is maintained by the Administrator in the physical copy of the investigation file. o 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 - At approximately 12:15 pm on 2/1/25, Resident #64 was placed on 1:1 supervision via nurse aides or designee during wake hours until further notice and 1-hour checks by nurse and 30-minute checks by nursing assistant or designee to be completed while resident is sleeping. - On 2/5/25, a follow up call to the NP for resident #64 was placed by the DON and new orders were received for labs and psych consult due to escalated behaviors over the past week. On 2/5/25, the NP for resident #64 also started the resident on Seroquel (antipsychotic medication) 25 mg daily for behavior management and diagnosis of adjustment disorder with depressed mood. The psych consult remains pending due to the physician being out with illness, however, his following Nurse Practitioner has seen and assessed Resident #64 on 2/3/25, 2/4/25, 2/5/25 and again 2/8/25. A follow-up call will be made regarding the psych consult to determine the date they will be in to further evaluate. A Root Cause Analysis was completed on 2/3/25 by the LNHA and the DON with input from Interdisciplinary Team (IDT) and consultants in an effort to determine the cause for resident #64's behaviors that escalated beginning 1/27/25. With the initial incident, it was felt that the resident was angry that resident #84 wandered into his room and did not leave when he told him to. With the second incident on 2/1/25, resident #18 was walking past resident #64's doorway when he yelled at her to stay out of his room and pushed her. A request was made to the NP for acute work-up i.e. labs, psych consultation for resident #64 to determine if any acute illness may be process and to determine if any type of psychosis may be occurring that needed to be further addressed as well. It was discussed with resident #64 regarding placing a stop sign banner across his doorway that could possibly hinder other residents from entering his room, but he refused for this intervention. It was determined that resident #64 became agitated with other residents he did not know and/or whom he felt were entering his room. Failure of staff to redirect wandering residents resulted in abuse situation. Resident #64 was placed on 1:1 supervision on 2/1/25 at 12:15 pm by his nurse. This supervision was assigned to nursing assistant or designee with oversight by the resident's assigned nurse daily and the DON monitoring that 1:1 supervision is assigned and in place daily until such a time that Medical Doctor (MD) deems that resident #64 is no longer a risk for physical altercation. The facility's policy titled Abuse, Neglect, and Mistreatment was reviewed by the administrator on 1/28/25 with no changes indicated at that time. The abuse policy was reviewed again by the LNHA and the regional clinical consultant on 2/7/25 and no changes were made at that time. The clinical consultant reviewed the abuse policy again on 2/8/25 and corrected verbiage in section VI, section C to alleged perpetrator. The abuse policy is specific to protection as noted: VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. Increased supervision of the alleged perpetrator and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation. F. Providing emotional support and counseling to the residents during and after the investigation, as needed. Verbal education was provided by the Regional Director of Operations and Regional Clinical Consultant on 1/28/25 to LNHA and DON regarding procedures of thoroughly completing an investigation of alleged abuse, unusual events, monitoring for and identifying precipitating behaviors that could lead to possible resident to resident altercations and ensuring protection for all residents. This education also included the importance of thorough communication with the team, adequately obtaining of timely statements, and appropriate use of IDT meetings to review any incidents and/or concerns that may have occurred during the day. Nurse aides and licensed nurses received education from the Licensed Nursing Home Administrator/Designee on 02/08/25 that included direction to stay with the aggressive resident to promote and maintain safety for other residents within the facility. No nurse aide or licensed nurse will work after 2/8/25 without having had this education. The Licensed Nursing Home Administrator will be responsible to track the completion of this education. - On a phone call on 2/3/25, The regional director of operations and the regional clinical consultant reiterated to the LNHA and the Director of Nursing the responsibility that is expected for monitoring and ensuring safety and protection to the facility residents. Understanding was verbalized by the LNHA and Director of Nursing. - Immediate verbal education was initiated by LNHA/designee related to types of abuse including resident to resident altercations, abuse identification, abuse prevention, abuse reporting, and maintaining resident safety, with all nursing facility staff on 1/28/25. Education included scenarios and quizzes for demonstration of staff competency. Education further included redirecting of residents, monitoring for and identifying precipitating behaviors that could lead to possible resident to resident altercations. Education further reiterated the responsibility of the staff to promote and protect each resident. This education is for all nursing facility staff and includes agency staff and newly hired employees via the facility orientation process. No staff will work after 2/7/2025 without having had this education. The LNHA will be responsible to track the completion of this education. - Additional ongoing whole nursing home staff education is being coordinated by the Regional Director of Operations on 2/8/25 with psych providers or designee related to dealing with difficult behaviors and monitoring interventions, to be completed monthly with all staff. First education in this series will be conducted on 2/17/25. The facility administrator assumes responsibility for the immediate jeopardy removal plan. The alleged date of the immediate jeopardy removal is 2/9/25. The facility's credible allegation of Immediate Jeopardy was unable to be validated on 02/10/25. The facility was unable to explain why the Ativan order that was ordered after the resident-to-resident abuse on 02/01/25 was never entered into Resident #64's electronic health record. The Ativan was never entered as an order or received by Resident #64 at the facility. The facility failed to provide evidence that the Regional Director of Operations collaborated with the psych provider or designee to coordinate training on 02/08/25. The Administrator stated that the collaboration had not occurred and would not occur until at least 02/13/25. Resident #64 was not seen by a psychiatry provider due to illness and the following medical visits on 02/03/25, 02/04/25, 02/04/25 and 02/06/25 were not done by a psych provider. They were done by a medical nurse practitioner. The facility did not have sufficient evidence to remove the immediate jeopardy, and it remains present and ongoing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff and Responsible Party (RP) interviews, the facility failed to update an advanced directive to reflect the wishes of the resident and his RP for the resident not to be intubated (insertion of a tube into the airway to support breathing) for mechanical ventilation (helps move air in and out of the lungs) for 1 of 3 residents reviewed for advanced directives (Resident #1). This failure resulted in Resident #1 who had a history of Alzheimer's disease and had a change in condition of unresponsiveness on [DATE] being intubated during an Emergency Department evaluation on [DATE]. This intubation was against Resident #1's and the RP's documented wishes due to being transferred with an outdated Medical Orders for Scope of Treatment (MOST) form. Resident #1 remained intubated for 6 days until the RP was asked to make the decision to extubate (removal of the tube in the airway used for mechanical ventilation) the resident on [DATE]. Immediate Jeopardy began on [DATE] when the facility sent an outdated MOST form with Resident #1 to the emergency department which resulted in intubation for mechanical ventilation. The immediate jeopardy was removed for Resident #1 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 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: Review of the facility's Advance Directive policy and procedure last updated 12/2016 under Policy Interpretation and Implementation read in part: 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's legal representative. 12. Depending on State requirements, the legal representative may also have the right to refuse or forego treatment. 18. The Interdisciplinary Team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). 21. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advanced directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. Resident #1 was readmitted on [DATE] and [DATE] and transferred out to an acute care hospital on [DATE]. A review of Resident #1's electronic medical record revealed a physician's order written on [DATE] for Do Not Resuscitate. A review of Resident #1's Medical Orders for Scope of Treatment (MOST) form initiated on [DATE] and last updated on [DATE] revealed the resident was DNR (do not attempt resuscitation) with full scope of treatment which included: use intubation, advanced airway interventions, mechanical ventilation, cardioversion as indicated, medical treatment, Intravenous (IV) fluids, etc.; also provide comfort measures. In addition, the following were checked on the MOST form: Transfer to hospital if indicated. Antibiotics if indicated. IV fluids if indicated. No feeding tube. A review of Resident #1's electronic medical record (EMR) revealed a Discharge summary dated [DATE] from an acute hospitalization which read in part, spoke to patient's family member and he (Resident #1) was made Do Not Resuscitate (DNR)/Do Not Intubate (DNI) as per the family member's wishes. A review of Resident #1's EMR revealed on [DATE] at 1:14 PM a progress note written by the former Unit Manager for 3rd floor that Resident #1 was readmitted to the facility via wheelchair by hospital transportation. There was no documentation noting the change in Resident #1's MOST form to reflect Resident #1 and the RP's wishes for him to be Do Not Intubate (DNI). An attempt was made to contact Unit Manager #3 without success due to a discontinued phone number. A review of Resident #1's hard chart in medical records revealed a golden rod dated [DATE] checked for no expiration with an order for Do Not Resuscitate. Review of the record also revealed a physician order written on [DATE] for Do Not Resuscitate. Several attempts were made to contact Nurse #4 who was assigned to Resident #1 during the 7:00 AM to 3:00 PM shift on [DATE] with voicemails left for return call with no response. A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired. A review of a Care Conference Progress Note written by the facility Social Worker (SW) dated [DATE] at 12:32 PM revealed a quarterly care plan meeting had been held with the interdisciplinary team (IDT) and the resident's Responsible Party (RP) (via phone). The purpose of the quarterly care plan meeting was to update the RP on the resident's care at the facility and address any questions or concerns. The SW reviewed the resident's face sheet and code status with the RP and the RP confirmed the resident remained Do Not Resuscitate (DNR). According to the RP the resident was to continue to be at the facility for long term. The RP didn't have any concerns about the resident's care but had a question for Unit Manager #2 which was answered. The resident's plan of care remained the same with no changes made. The documentation did not indicate Resident #1's MOST form was discussed during the meeting with the RP, just the Do Not Resuscitate (DNR) status. An interview on [DATE] at 2:09 PM with the facility Social Worker revealed she had attended the care conference meeting with Resident #1's RP via phone and the IDT. She stated they had discussed that Resident #1 would remain a DNR but said the RP had not mentioned that the resident was to be a Do Not Intubate (DNI) or that he wanted any changes made to the MOST form. The SW further stated she had not asked the RP specifically if he wanted any changes made to the MOST form and said they had not discussed any specifics about the MOST form the facility had on file just that the resident was to remain a DNR. The SW indicated she was not aware of the RP's request that Resident #1 be made a DNI and said she was not aware of the Discharge summary dated [DATE] that indicated the RP's wishes for Resident #1 to be DNI. She further indicated she was not aware she was supposed to discuss the specifics of the MOST form with the RP and thought this was done by the providers. A nursing progress note written by Nurse #3 revealed on [DATE] around 8:30 PM the resident had an unwitnessed fall in the dining room. The resident was found lying on his right side in the dining room with no outward signs of injury. Resident #1 was assessed by Nurse #1 and Nurse #2 and vital signs were taken and his assessment and vital signs were documented as being within normal limits for the resident. The resident was assisted back in his wheelchair and taken to his room and assisted into bed. On [DATE] sometime between 5:00 AM and 5:30 AM, NA #4 went into Resident #1's room to do her last round and found him unresponsive. NA #4 immediately notified Nurse #3 who assessed the resident and found him unresponsive to verbal and tactile stimulation. She contacted the on-call provider at 5:31 AM and sent the resident out to the hospital Emergency Department (ED) for evaluation and treatment. The resident was sent to the hospital with a Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form and a copy of his MOST form on file at the facility. A telephone interview with Nurse #3 on [DATE] at 10:45 AM revealed she had been alerted by NA #4 on [DATE] around 5:20 AM that Resident #1 was not responding to his name and did not rouse when NA #4 touched his arm. Nurse #3 stated she went in and assessed the resident, and he was not responding to verbal or tactile stimulation, so she contacted the on-call provider who ordered Resident #1 to be sent out to the Emergency Department for evaluation and treatment. Nurse #3 further stated she sent the resident out with the Skilled Nursing Facility (SNF)/Nursing Facility (NF) Transfer to Hospital Form and Resident #1's MOST form on file. Nurse #3 indicated there was only one MOST form on file for Resident #1and she was not aware the resident was supposed to have a MOST form that indicated Resident #1 and the RP did not want the resident to be intubated. She further indicated the MOST form that went with Resident #1 via Emergency Medical Services (EMS) was the one on file at the facility that was last updated on [DATE]. A telephone interview on [DATE] at 9:38 AM with the Responsible Party (RP) for Resident #1 revealed the resident was still hospitalized and had been intubated upon arrival to the Emergency Department (ED) because the facility had sent the MOST form on file at the facility with the resident to the hospital. The RP stated he had been asked by the hospital to make the decision to discontinue the resident from life support on [DATE] even though the resident was not supposed to have been intubated, and that had been a difficult decision for him. He stated Resident #1 had been extubated and moved out of the intensive care unit and would be transferred to Hospice for comfort care. A review of Resident #1's medical records from the hospital Emergency Department (ED) dated [DATE] revealed a note written by the emergency department physician that read as follows: On review of the patient's true chart, his last reported code status was DNR, with limited scope including all interventions, did not wish for endotracheal intubation; however, on the patient's arrival he had a MOST from with him which indicated full scope of treatment including intubation and this was used to proceed with decision for intubation. Further review of the medical record from the hospital revealed on the Discharge summary dated [DATE], the resident had been evaluated by neurosurgery who felt the resident was a poor candidate for craniotomy (removing part of the bone from the skull to expose the brain). The critical care team discussed goals of care with the resident's RP who made the decision to transition resident to comfort care measures so palliative extubation was done on [DATE]. The resident was transferred out of intensive care unit (ICU) on [DATE] and the Hospitalist team assumed primary care. The Hospice team was consulted, and the resident was discharged to the inpatient Hospice House on [DATE]. A telephone interview was attempted several times with the ED physician with voicemail left for return call with no response. A telephone interview was attempted with the Hospitalist with no response. A telephone interview with the Administrator and Director of Nursing (DON) on [DATE] at 12:29 PM revealed they were both unaware of the code status change requested by Resident #1's RP on his Discharge summary dated [DATE]. The Administrator nor the DON were aware of the information in the discharge summary or that the providers were not aware of the information in the resident's discharge summary. The DON stated she was a part of the interdisciplinary team that had attended Resident #1's care conference meeting on [DATE] and said she did not recall discussing the specifics of his MOST form just that the RP wanted the resident to remain DNR. She further stated it was the responsibility of the Unit Manager and receiving nurse to review the discharge summary and orders to ensure all orders were completed when the resident returned to the facility. The DON indicated Unit Manager #3 and Nurse #4 who were assigned to the resident on his return from the hospital on [DATE] were no longer working at the facility and she could not answer why the requested change to the MOST form had been missed. She further indicated she could not answer why the medical providers had not seen the documentation in the discharge summary but said they should have reviewed it and signed it as being reviewed. Several attempts were made to contact the Medical Director and voicemails left with no response. The Administrator was aware of the need to interview the Medical Director and had provided his contact information. The Administrator was notified of the Immediate Jeopardy via telephone on [DATE] at 6:10 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 as a result of the noncompliance. The facility failed to update the Medical Order for Scope of Treatment (MOST) with the hospital information from Resident #1's readmission on [DATE] that indicated Resident #1's family requested DNR/Do Not Intubate (DNI) and failed to review and update MOST form during the quarterly care plan meeting in [DATE] to discuss any changes to the scope of treatment for Resident #1. Resident #1 sustained an unwitnessed fall on [DATE]. Ongoing neurological assessment following the unwitnessed fall, was not completed per policy. The resident was found to be unresponsive with trace amounts of vomit in bed on [DATE]. Resident #1 was sent to the hospital. The resident was intubated upon admission to the hospital requiring the resident's family to make a decision to remove the resident from the ventilator. Resident was transferred to Hospice House from the hospital on [DATE] and expired on [DATE]. Resident #1 MOST form was not updated and reviewed after a readmission. A full review of all resident MOST forms was conducted by the Administrator or designee on [DATE] with the responsible party, for compliance with the MOST form accurately reflecting the resident's wishes. There are two residents identified as at risk for serious adverse outcomes requiring the MOST form to be updated with the responsible party on [DATE] by the Administrator. 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. A review of Advance Directives policy procedure will be completed by the Administrator or designee, and changes, as needed, will be made by the QAA committee by [DATE]. The administrator or designee will educate the interdisciplinary care plan team and all licensed professional nurses on the requirements of completing and maintaining an accurate MOST form at least annually and following hospitalizations, quarterly, or annually, as indicated or discussed with the responsible party before the staff's next worked shift. If staff have not received education, they will be removed from the schedule on [DATE], until education is received. In the event that the information on the MOST form is updated, the previous MOST form will be placed into archived documents within the medical record by the Medical Records staff or designee. This verbal education was completed by the Administrator or designee with the Medical Records staff on [DATE]. If staff have not received education, they will be removed from the schedule on [DATE], until education is received. Current and accurate MOST forms will be provided to EMS staff and sent with the transferring resident, by the licensed nurse or designee, at the time of transfer from the facility. This verbal education was completed by the DON or designee on [DATE] to all licensed nursing staff. If staff have not received education, they will be removed from the schedule on [DATE], until education is received. The Administrator or designee will track the completion of all education provided to ensure the staff completes it before they work. The facility administrator assumes responsibility for the immediate jeopardy removal plan. The date of the immediate jeopardy removal is [DATE]. Alleged date of IJ removal: [DATE]. On [DATE], the credible allegation of Immediate Jeopardy removal date of [DATE] was validated by onsite verification through staff interviews and record reviews. The staff interviewed included members of administration, Social Services, Medical Records, and Licensed Nurses. The staff interviews related to Advanced Directives policy and procedure revealed they had received in-services and education regarding the requirements for completion of the Medical Orders for Scope of Treatment (MOST) form, what to do when a MOST form is updated, and sending the MOST form with the resident when they are sent out of the facility via Emergency Medical Services (EMS). The IJ removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and responsible party, facility staff, and on-call Nurse Practitioner (NP) interviews, the facility staff failed to complete ongoing neurological assessments after an unwitnessed fall for a resident with severely impaired cognition. On [DATE] at 8:30 PM Nurse Aide (NA) #1 heard a loud boom in the dining room, she and NA #3 discovered Resident #1 on the floor in the dining room with his hands behind his head, and his wheelchair beside him. Resident #1 was assessed by Nurse #1 who noted the resident was within his normal limits for range of motion, he denied any pain, and told her he had not hit his head. Nurse #1 Resident #1 was assisted back into his wheelchair and then assisted to bed. A head-to-toe assessment completed by the weekend Nursing Supervisor conducted at 8:45 PM revealed no abnormal results. There were no other documented neurological checks located in the medical record after the initial note following the incident. During the night of [DATE] into the morning of [DATE], the resident was checked for incontinence every 2 to 3 hours by NA #4 and she stated he was snoring but roused easily until her last round at between 5:00 AM and 5:30 AM. Resident #1 was assessed by Nurse #3 and was noted to be unresponsive to tactile and verbal stimuli. Emergency Medical Services (EMS) was dispatched and Resident #1 was taken to the hospital for evaluation. Resident #1 was intubated (insertion of a tube into the airway to support breathing) for mechanical ventilation (helps move air in and out of the lungs) in the Emergency Department and a Computed Tomography (CT) (a noninvasive medical imaging procedure that uses x-rays to create detailed images of the inside of the body) scan was completed which revealed a life threatening subdural hematoma (collection of blood that forms between the brains surface and the tough outer layer of the brain caused by head injury) of the right frontotemporal (front and sides of the brain) and parietal lobes (large uppermost portion of the brain) measuring 1.7 centimeters (cm) thickness and approximately 15 cm diameter with a 1.5 cm right to left shift (brain shifted off center). Resident #1's Responsible Party (RP) made the decision to extubate (removal of tube from the airway used for mechanical ventilation) the resident on [DATE]. The resident was moved out of intensive care unit on [DATE], discharged to Hospice on [DATE], and died on [DATE]. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #1). Immediate Jeopardy began on [DATE] when Resident #1 had an unwitnessed fall and the facility staff failed to complete ongoing comprehensive neurological assessments, routine monitoring, and recognize symptoms indicating the need for urgent medical attention for a resident following an unwitnessed fall to determine if a higher level of care was needed. The immediate jeopardy was removed for Resident #1 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 (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 #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included Alzheimer's disease, repeat falls, and unspecified head injury related to fall. A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired. Resident #1 was coded as requiring substantial to maximal assistance with most activities of daily living except eating. He was coded as using a wheelchair for mobility and was documented as having two or more falls since admission. A review of Resident #1's care plan last updated on [DATE] revealed a focus area for the resident being at risk for falls related to confusion and a history of falls. The goal was for the resident not to sustain serious injury through the review date. The listed interventions included to follow the facility fall protocol. A review of Resident #1's Medication Administration Record (MAR) and medical orders dated [DATE] revealed an order for aspirin Low Dose Tablet 81 milligrams (mg) 1 tablet by mouth one time a day related to cerebral infarction. Review for the MAR for the period of [DATE] through [DATE] revealed the resident received the aspirin daily as ordered. On [DATE] at 12:11 PM an interview was conducted with NA #1 who worked 3:00 to 11:00 PM on [DATE]. NA #1 stated she was in the hallway charting on her residents when she heard a boom in the dining room. She stated NA #3 was coming down the hallway and she followed her, and they found Resident #1 lying on his right side on the floor beside his wheelchair. She further stated he had his hands behind his head and said, I'm not hurt, just get me up. NA #1 said Nurse #1 assessed him and there were no outward signs of injury, so they assisted him back into his wheelchair and NA #3 took him to his room and put him in the bed. On [DATE] at 4:33 PM a telephone interview was conducted with NA #3 who was assigned to care for Resident #1 during the 3:00 to 11:00 PM shift on [DATE]. NA #3 stated dinner was over, and she asked Resident #1 if he was ready to go to bed and he told her no that he wanted to watch TV for a little while before going to bed. She said she assisted two other residents to bed, going back and forth from the dining room to resident rooms. NA #3 stated she was coming up the hallway and saw Resident #1 lying on the floor in the dining room and she and NA #1 got to him and called for the nurse who was in the nurses' station. Both Nurse #2 and Nurse #1 responded and assessed the resident for injuries, completed vital signs, an initial neurological check, they assisted him up off the floor, and back into his wheelchair. NA #3 explained she then took the resident to his room and put him to bed for the night. NA #3 stated after she had put the resident to bed, she had checked the resident one time during her incontinence rounds for any injuries and the resident was sleepy but roused when she was in the room. She indicated she did not witness the fall and did not see any outward signs of injury on the resident during her shift which ended at 11:00 PM. A nursing progress note written by Nurse #1 dated [DATE] at 8:55 PM revealed Resident #1 was found on the floor in the dining room at 8:30 PM. He stated he was trying to self-transfer, stood and fell. After an initial assessment for injuries, he was assisted up in his wheelchair and put to bed. Neurological check was completed and within his normal range, pupils were equal, round and reactive to light, his range of motion was within his normal limits, denied pain, no change in his normal cognition of alert with confusion/dementia as his baseline. Resident #1's vital signs were documented as temperature of 97.7, pulse 62, respirations 19, blood pressure 174/89 and oxygen saturation of 93% on room air. The weekend Nursing Supervisor, Director of Nursing, and resident's Responsible Party were all made aware of the fall. On [DATE] at 11:58 AM a telephone interview was conducted with Nurse #1. Nurse #1 stated she worked 3:00 PM to 11:00 PM on [DATE] and was assigned to care for Resident #1. She further stated she was in the nurse's station charting when she heard Nurse Aide (NA) #3 and NA #1 call for the nurse. She said she and Nurse #2 were both in the nurse's station and both got up and went to the dining room. Nurse #1 indicated they found Resident #1 lying on the floor on his right side and he had attempted to get up and ambulate and fell. She said they examined the resident and saw no signs of injury, completed vital signs, assessment, and an initial neurological check on the resident and all results were within the resident's normal range. Nurse #1 further indicated they assisted the resident up off the floor and into his wheelchair and NA #3 took him and put him to bed. She stated she notified the weekend Nursing Supervisor of the fall, and she came up and the weekend Nursing Supervisor assessed the resident from head to toe and determined there were no outward signs of injury, and since he was not on a blood thinner, they would monitor him closely through the night during incontinent rounds. According to Nurse #1 the Nursing Supervisor contacted the on-call provider and the decision was made by the on-call provider not to send Resident #1 out since there were no changes, no outward signs of injury, and he was not on an anticoagulant. Nurse #1 indicated she had not witnessed Resident #1's fall and said she had been charting in the nurse's station and had her back turned towards the dining room. She further indicated she had not done an assessment or neuro check on the resident after the initial one she had done right after the resident fell. Nurse #1 said neuro checks had to be initiated in the electronic medical record to alert staff to do the neuro checks and that had not been done by the weekend Nursing Supervisor. Nurse #1 indicated she knew as a nurse that residents who had an unwitnessed fall should be monitored and assessed with neuro checks and said she assumed once she reported the fall to the weekend Nursing Supervisor that she had taken over with assessments of the resident. On [DATE] at 1:12 PM a telephone interview was conducted with Nurse #2. Nurse #2 worked on [DATE] on the 3:00 to 11:00 PM shift. She stated she had been in the nurses' station charting on [DATE] when she heard NA #3 and NA #1 call for a nurse. She stated she immediately got up and went into the dining room and saw Resident #1 had fallen onto his right side beside his wheelchair. Nurse #2 further stated she made sure the resident was ok, and Nurse #1 took over and she left the dining room and went back into the nurses' station to finish her charting. She further stated she had been sitting down in the nurses' station charting on her computer and had not witnessed Resident #1's fall. A late entry nursing progress note written by the weekend Nursing Supervisor on [DATE] at 1:13 PM for [DATE] at 8:40 PM revealed Resident #1 had a fall in the dining room and upon arrival to the floor was notified by NA #3 that the resident was now in his room lying in the bed, so the Nursing Supervisor went to Resident #1's room to assess the resident. Resident #1 was lying in bed on his left side, awake, and alert with bilateral pupils equal and reactive to light, denied headache, dizziness, blurred vision, nausea and had no vomiting, no increased confusion noted, equal hand grips bilaterally, no shortness of breath or dyspnea noted, denied pain or aches to body when assessed, no edema noted to upper or lower extremities, positive pedal pulses, head to toe assessment completed. Resident #1 was able to converse with nurse regarding fall, stated he was trying to stand up from his wheelchair, denied hitting his head, no acute changed noted neurologically. No acute distress noted, vital signs taken by nurse were within normal limits, on-call provider notified of fall and no injury noted and no new orders received. Director of Nursing (DON) notified, Resident #1's Responsible Party (RP) made aware of resident fall and no injury noted. On [DATE] at 12:54 PM a telephone interview was conducted with the weekend Nursing Supervisor. She stated she worked 8:00 AM to 12:00 midnight on [DATE]. The Nursing Supervisor stated she was notified of Resident #1's fall and asked to come and assess the resident who was now in his room in the bed. She further stated she did a head-to-toe assessment of the resident, and he denied dizziness, headache, blurred vision, nausea, and had not had any vomiting. Resident #1 told the Nursing Supervisor he had not hit his head when he fell, and she examined his head and did not feel any bumps or lumps and said he was able to move all his limbs as per his usual and his initial neurological check was normal. The Nursing Supervisor indicated after her assessment she had contacted the on-call provider, and the decision was made to monitor the resident closely and not send him out to the hospital since he was not taking an anticoagulant. She further indicated she did not see any outward signs of injury on the resident. The Nursing Supervisor stated she had done a neurological check on the resident during her head-to-toe assessment but had not continued doing them because the resident had no outward signs of injury and said she had not instructed NA #3 or Nurse #1 to continue with neurological checks on the resident but to monitor him during medication and incontinence rounds. A review of Resident #1's medical record revealed the only documented vital signs and neurological check were included in Nurse #1's progress note written on [DATE] at 8:55 PM. Resident #1's vital signs were documented as temperature of 97.7 (normal range 97.8 to 99.1 degrees Fahrenheit), pulse 62 (normal range 60 to 100 beats per minute), respirations 19 (normal range 12 to 18 breaths per minute), blood pressure 174/89 (normal range 90/60 to 120/80) and oxygen saturation of 93% (normal range 95% to 100%) on room air. The neurological checks work sheet had been initiated in the electronic medical record, but it was blank. On [DATE] at 4:48 PM a telephone interview was conducted with NA #4 who had cared for Resident #1 during the 11:00 PM to 7:00 AM shift on [DATE] leading into [DATE]. NA #4 stated she had checked Resident #1 about every 2 to 3 hours during the night and said he was snoring but was rousable until her last round on him at 5:00 AM or 5:30 AM. She further stated during this round she was unable to elicit a response from him and noticed he had something coming from his mouth and there was a small amount of vomit on his sheet. NA #4 indicated she immediately notified Nurse #3 who assessed him, notified the on-call provider and sent the resident out to the hospital. NA #4 further indicated she had not noticed any signs of injury to his head or any swelling on his head or any marks on him from his fall and was aware he had a fall on [DATE] around 8:30 PM. NA #4 indicated the resident sometimes slept through the night and sometimes was up during the night and said he sometimes snored, so she had not paid much attention when he was snoring that night. A late entry nursing progress note written by Nurse #3 on [DATE] at 12:08 PM for [DATE] at 6:00 AM revealed Resident #1's skin was warm and dry, and the patient was unresponsive to tactile and verbal stimuli. Patient was breathing and noted to have a small amount of vomit in his bed. The on-call provider was made aware and gave orders to send the resident out to the emergency room (ER). On [DATE] at 1:58 PM a telephone interview was conducted with Nurse #3 who was assigned to care for Resident #1 on the 11:00 PM to 7:00 AM shift on [DATE] leading into [DATE]. Nurse #3 stated Resident #1 had not complained of headache, dizziness, or blurred vision throughout the night. Nurse #3 further stated NA #4 had checked on him about every 2 to 3 hours throughout the night and when NA #3 checked him during the night for incontinence care stated he had roused until NA #3 checked him between 5:00 and 5:30 AM at which time he did not rouse. NA #4 notified Nurse #3 immediately and when Nurse #3 went into Resident #1's room to assess him he did not rouse to verbal or tactile stimulation. It was also noted that he had vomited a small amount in his bed, so Nurse #3 called the on-call provider and received orders to send him out to the hospital for evaluation and treatment. Nurse #3 further stated she never noticed any outward signs of injury, any marks or any swelling on the resident and stated she had not completed neuro checks on the resident during her shift. Nurse #3 indicated Resident #1 sometimes slept through the night and sometimes he would wake during the night but said they had not noticed anything out of the ordinary for him until they were unable to rouse him at 5:30 AM. A review of the facility's Situation, Background, Appearance, and Review and Notify (SBAR) form dated [DATE] completed by Nurse #3 revealed under Situation - Resident #1 was found unresponsive at 5:00 to 5:30 AM on [DATE]. Under Background it was documented he was long-term care and was on a platelet inhibitor of Aspirin 81 mg by mouth daily. Vital signs were documented as blood pressure of 120/68, pulse of 60, respiration of 18, temperature of 97.0, weight of 148 pounds, mental status was documented as unresponsive, functional status was documented as general weakness, respirations were documented as other respiratory changes - snoring respirations, neurological evaluation was documented as altered level of consciousness - unresponsive and code status was documented as Do Not Resuscitate. Appearance was documented as patient unresponsive to verbal and tactile stimuli, pupils dilated and non-reactive to light. Review and notify was documented as on call provider notified at 6:00 AM on [DATE] and orders received to send to emergency room. A review of the facility's Hospital Transfer Form dated [DATE] completed by Nurse #3 revealed the resident's vital signs were 102/68, pulse 60, respiration 18, temperature 97 and oxygen saturation 99% on room air. Resident #1's pain level was scored at 0 on scale of 0-10. Code status was documented as Do Not Resuscitate (DNR). The resident's functional status was coded as independent for eating and needs assistance with toileting and transfers and the resident was incontinent. The resident was coded as not alert, unresponsive and it was documented the Responsible Party (RP) and provider were notified of the transfer. Risk factors for Resident #1 were listed as anticoagulation (Aspirin), aspiration, needs medications crushed and swallowing precautions. The resident's face sheet and Medical Orders for Scope of Treatment (MOST) form were attached with the transfer form. On [DATE] at 11:35 AM an interview was conducted with the on-call Nurse Practitioner (NP). The on-call NP stated he had been notified at on [DATE] at 8:39 PM that Resident #1 had an unwitnessed fall in the dining room but had no injury and vitals and assessment were within normal limits for the resident. The NP stated the Nursing Supervisor had reported to him the resident had no outward signs of injury and no change in his mentation. The NP stated he advised they monitor the resident closely through the night and call with any change in condition for further orders. He further stated at 5:31 AM on [DATE] he was contacted again by the facility, and it was reported the resident was now unresponsive and he gave orders for the resident to be transferred to the hospital for evaluation and treatment. The NP indicated he was the on-call provider and had never seen the resident and was not familiar with the resident's normal state except as reported by the facility staff. Review of the Emergency Medical Services dispatch revealed they were dispatched on [DATE] at 5:34 AM and arrived on scene at 5:47 AM to find Resident #1 lying in bed unresponsive with vital signs of blood pressure 205/110 (out of normal range), blood glucose level of 103 (normal range), oxygen saturation of 98% on room air (normal range), snoring respirations with heavy accessory muscle use, weak radial pulses, strong rapid carotid pulses, pupils 5 millimeters (mm) equal round and non-reactive to light. Skin color was mottled pale with capillary refill less than 2 seconds, poor skin turgor and lungs equal with increased respiratory effort bilaterally. In route to the hospital Resident #1 had a blood pressure of 220/125 (out of normal range), pulse of 120 (out of normal range), respirations of 10 (out of normal range) and oxygen saturation of 99%. A nasopharyngeal tube (tube inserted through the nasal passage down into the throat) was inserted to provide an airway, and a bag valve mask (BVM) was used to provide positive pressure ventilation (delivery of pressurized oxygen into the lungs) to the resident because he was not breathing adequately on his own. An intravenous (IV) access was attempted but not successful. The resident was transported with lights and siren to the acute care hospital within 3 minutes and care transferred to the Emergency Department physician and nurse. Hospital records dated [DATE] through [DATE] revealed Resident #1 arrived via EMS from the facility unresponsive after a fall the night before. Resident was being ventilated by the paramedic on arrival to the emergency department and the decision was made based on the MOST form to intubate the resident. A computed tomography (CT) scan of the head was performed which revealed a life-threatening subdural hematoma of the right frontotemporal and parietal lobes measuring 1.7 centimeters (cm) thickness and approximately 15 cm diameter with 1.5 cm right to left shift. The resident was admitted to the Intensive Care Unit and neurosurgery consulted and felt the patient would be a poor candidate for craniotomy (removing part of the bone from the skull to expose the brain) and critical care team discussed goals with the resident's Responsible Party (RP) and the decision was made to transition to comfort care measures and palliative extubation was done on [DATE]. The resident was moved from the intensive care unit on [DATE] and later that evening was transferred to inpatient Hospice on [DATE] and the resident expired at Hospice on [DATE]. Several attempts were made to contact the emergency department physician and voicemail left with no return calls. An attempt was made on [DATE] at 10:34 AM to contact the hospitalist but the hospitalist was unable to interviewed. On [DATE] at 3:50 PM an interview was conducted with the Director of Nursing (DON). The DON stated the process when they have a resident with a fall was the nurse assesses the resident before they were moved and that assessment included vital signs, and assessment for any injuries to ensure they were safe to be moved. After it was determined it was safe to move the resident and their assessment was completed with any injuries noted, calls were made to the DON, family or representative of the resident, and if needed the provider. If it was determined the resident needed medical attention the nurse would stay with the resident and others would make the calls. The Medical Director or Nurse Practitioner, family, DON and Administrator would all be notified of the fall. Based on the findings of the nursing assessment and medications the resident was prescribed the responsible nurse, Nursing Supervisor or Unit Manager or their designee would consult with providers and potentially send the resident out if the provider ordered to do so. Documentation would be completed in the progress notes, SBAR would be completed and if the resident was sent out a transfer form was completed. For unwitnessed falls the responsible nurse, Nursing Supervisor or Unit Manager or their designee would do neurological checks in addition to vital signs and assessments and if the findings were out of the normal range for the resident, the provider would be called to obtain orders to send the resident out to the hospital for evaluation and treatment. For witnessed falls the responsible nurse, Nursing Supervisor, or Unit Manager or their designee would do an assessment and monitor the resident more frequently for signs of injury and pain. The DON stated she was initially notified that Resident #1's fall had been witnessed and he had not hit his head and that was probably why he had not been sent out to the hospital after the fall and why his vital signs, neuro checks, and assessments had not continued. She further stated she learned later that the fall had not been witnessed but the resident had not had any change in his mental status and there were no outward signs of injury. The DON indicated Resident #1's vital signs, neuro checks, and assessments should have been continued since his fall was unwitnessed. The DON explained there must have been miscommunication between Nurse #1, who was assigned to care for the resident, and the weekend Nursing Supervisor as to who was going to continue with assessing the resident. The Medical Director was unavailable for interview The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:33 AM. The facility implemented 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 noncompliance; o The facility's noncompliance of not providing ongoing neurological assessment after an unwitnessed fall had a high likelihood of a significant decline in physical function and/or life-threatening condition. o The facility failed to have and implement effective systems to ensure that the staff are continuously assessing residents who sustain unwitnessed falls. o Resident #1 sustained an unwitnessed fall on [DATE]. Ongoing neurological assessment following the unwitnessed fall, was not completed per policy. The resident was found to be unresponsive with trace amounts of vomit in bed on [DATE]. Resident #1 was sent to the hospital. Resident was transferred to Hospice House from the hospital on [DATE] and expired on [DATE]. o A full review by the DON or designee of all unwitnessed falls incident reports, documented neurological assessments and progress notes in the last 30 days, [DATE] through [DATE], will be completed. The facility has identified 4 residents who are at risk for an adverse outcome because the facility has not provided ongoing neurological assessment after an unwitnessed fall, with a high likelihood of a significant decline in physical function and/or life-threatening conditions. The director of nursing will complete this review by [DATE]. On [DATE], the DON or designee instructed all licensed nurses with verbal education to complete a head-to-toe assessment on any identified resident who is at risk for an adverse outcome. Following the assessment, the licensed nurse is required to notify the resident's physician of the findings. - 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. o A review of the Fall policy and procedure and the Neurological Assessment policy and procedure will be completed and communicated to the QAA committee by the Administrator or designee, and changes, if needed, will be made as identified by the QAA committee by [DATE]. o All licensed professional nurses will receive education from the Administrator or designee on the policy and procedure regarding neurological assessment completion after an unwitnessed fall before their next shift via verbal education. Any licensed professional nurses not having had this education by [DATE] will be removed from the schedule until education is received. o On [DATE], the DON or designee instructed all licensed nurses with verbal education to complete a head-to-toe assessment on any identified resident who is at risk for an adverse outcome. Following the assessment, the licensed nurse is required to notify the resident's physician of the findings. Any licensed professional nurses not having had this education by [DATE] will be removed from the schedule until education is received. o All certified nursing assistants will receive education from Administrator or designee on symptoms to look for after an unwitnessed fall and the reporting process if any of the symptoms are identified. Certified Nursing Assistants will be notified by the licensed nurse or designee, that an unwitnessed fall with ongoing neurological assessment is actively being completed on a specified resident. All certified nursing assistants not having had this education by [DATE] will be removed from the schedule until education is received. o For all education provided, the administrator or designee will track completion to ensure the education is completed before the staff working. Staff will complete a written quiz to validate competency of all licensed nursing staff and certified nursing assistants. The quiz will be administered and reviewed by the administrator or designee. The facility administrator assumes responsibility for the immediate jeopardy removal plan. Alleged date of immediate jeopardy removal: [DATE]. On [DATE], the credible allegation of immediate jeopardy removal with a removal date of [DATE] was validated by onsite verification through staff interviews, record review, and education review. The interviewed staff included members of administration, licensed nurses, and nursing assistants. Staff interviews were conducted with administration, licensed nurses and nurse aides related to the facility's policy and procedures for falls and neurological checks. The interviewed staff revealed they had received in-service training regarding what steps to take when a witnessed and unwitnessed fall occurred. The interviewed staff provided further answers and detailed when to initiate neurological checks, and the initiation of the worksheet in the electronic medical record which identifies the timeline. Additional interviews with nursing assistants indicated they had received education related to reporting any changes post fall. In-service records of education and quizzes provided to staff were reviewed and were ongoing. Head-to-toe assessments were reviewed for high-risk residents identified. The immediate jeopardy removal date of [DATE] was validated.

Based on record review and interviews with the Medical Director (MD), Nurse Practitioner (NP), Driver #1 and staff, the facility failed to leave Resident #12 in place for a clinical assessment of injury. Resident #12 was in a parked transportation van, unsupervised, with the engine on and the air conditioning on, when she unbuckled her seat belt and fell from her wheelchair. Driver #1 witnessed Resident #12 face down on the floor of the van, and Resident #12 complained to Driver #1 that her head hurt. Driver #1 called the Administrator to notify of the fall. The Administrator instructed Driver #1 to look for any visible signs of injury, and to make Resident #12 comfortable. Driver #1 notified the Administrator she saw a knot forming on the Resident's forehead and received instructions to call 911 (Emergency Medical Services - EMS) for paramedics to further evaluate. While on the phone with the Administrator, Driver #1 transferred Resident #12 back into her wheelchair, before paramedics arrived and secured the Resident with her seatbelt. Driver #1 then called 911. When paramedics arrived, Resident #12 was transported to the hospital where she was diagnosed with a tiny acute hemorrhage of the left lateral ventricle posteriorly (bleeding in and around the brain's ventricles), subcutaneous hematoma (collection of blood underneath the skin) of the right forehead and a painful, swollen right eye. This deficient practice occurred for 1 of 2 sampled residents reviewed for quality of care (Resident #12). Immediate jeopardy began on 5/22/24 when Driver #1 failed to leave Resident #12 in place for a clinical assessment of injury and transferred Resident #12 back into her wheelchair before EMS arrived. Immediate jeopardy was removed on 7/19/24 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: Resident #12 admitted to the facility 3/12/24 with diagnoses that included non-Alzheimer's dementia, mild neurocognitive disorder with behavioral disturbance, end stage renal disease (ESRD), dependence on hemodialysis, glaucoma of the left eye, and bilateral amputation of the lower extremities. A 3/12/24 Transfer, Mobility Evaluation, assessed Resident #1 required the caregiver to perform 100% of the transfer task with the use of a mechanical lift because she was alert/oriented with intermittent confusion, non-ambulatory due to bilateral amputee status, unable to stand, non-weight bearing and required partial support of a rail or a person to sit at the bedside. A 3/19/24 admission Minimum Data Set (MDS) assessment indicated Resident #12 expressed herself with clear speech, made herself understood, understood others, moderately impaired cognition with no acute changes in mental status, bilateral lower extremity impairment and used a wheelchair for mobility. The MDS recorded Resident #12 required partial to moderate assistance to move from a sitting to lying position, reported she did not have pain in the last five days of the assessment and received dialysis services. A 3/25/24 Care Plan indicated Resident #12 required staff assistance with activities of daily living due to poor impulse control, ESRD, with dependence on hemodialysis, glaucoma of the left eye, cognitive communication deficits and bilateral partial traumatic amputation of the lower extremities. Interventions included assessing and anticipating resident needs and assessing resident's understanding of the situation. An observation and interview of Resident #12 occurred in her room on 7/16/24 at 8:54 AM. Resident #12 did recall having a recent fall or being transported to the hospital. Resident #12 did not recall the date of the fall or any details surrounding the fall of 5/22/24. During the interview, Resident #12 stated, I am fine. A 5/22/24 6:30 PM incident report, documented by the Administrator, recorded that on 5/22/24 it was reported by staff that Resident #12 fell and hit her head. The incident report recorded 911 was called and Resident #12 was taken to the hospital for evaluation and treatment. The incident report recorded injuries at the time of the incident as a hematoma to the top of scalp. The incident report described Resident #12 as disoriented to place, situation, time, and oriented to person. The incident report documented predisposing factors were chair position, impulsive behavior, impaired awareness, weakness, confusion, lost balance, and a history of confusion after dialysis treatments. A witness to the fall was recorded as Resident #55. A 7/18/24 9:25 AM interview with Resident #55, a Resident identified by the facility as alert/oriented to person, place, situation, and time, revealed she was on the facility transportation van when Resident #12 fell. Resident #55 stated Resident #12 was on the transportation van on Wednesday, 5/22/24 at 4:30 PM, parked in front of the dialysis center, when Resident #55 walked onto the facility van after dialysis. Resident #55 stated that Resident #12 was in her wheelchair on the van with her seatbelt fastened and that Resident #12 asked Driver #1 to call a family member. Resident #55 stated that after she got on the van, Driver #1 got off the van to assist Resident #79 from the lobby of the dialysis center onto the van. Resident #55 stated that while the Driver was off the van, Resident #12 also asked Resident #55 for assistance to call a family member. Resident #55 explained that when Resident #55 responded to Resident #12 that she could not assist her because Resident #55 did not know the number, Resident #12 unfastened her seatbelt, reached towards a mobile phone that was nearby, and fell face down on the floor of the van. Resident #55 stated after Resident #12 fell, Resident #55 blew the horn on the van, one long blow and one short blow to alert the Driver of an emergency and the Driver immediately returned to the van, without Resident #79. Resident #55 further stated that when Driver #1 returned to the van, Resident #12 was face down on the floor of the van, Driver #1 moved Resident #12 to her wheelchair and called 911. A 5/22/24 EMS Run Report documented paramedics arrived at the facility transportation van at 4:56 PM in response to Resident #12's fall from a wheelchair. The report documented that on arrival Resident #12 was found sitting in her wheelchair in the facility transportation van. Per the report, Driver #1 reported to paramedics that Resident #12 did not lose consciousness. Paramedics recorded that at 5:00 PM Resident #12 was assessed with a hematoma to the right side of her forehead, with no crepitus (grading, popping, or clicking of a joint) felt. Per the report, Resident #12 complained of right upper arm pain to paramedics, and her pupils were reactive to light. Per the report, Resident #12 was transported by paramedics to the hospital in stable condition for further evaluation. A 5/23/24 hospital discharge summary recorded Resident #12 admitted to the hospital for evaluation after a fall and discharged back to the facility on 5/23/24 in stable condition. The hospital course described Resident #12 as oriented to self, but unable to determine baseline due to a diagnosis of dementia. The hospital course documented that a CT scan of the head (a computed tomography which is a diagnostic procedure that uses X rays and computers to create detailed cross-sectional images of the inside of the body) showed a tiny acute hemorrhage of the left lateral ventricle posteriorly and a subcutaneous hematoma of the right forehead. Resident #12 was referred for a neurosurgery consult, a second CT scan was completed with stable results. A tertiary exam (a final means of identifying injury), although limited due to Resident #12's dementia, showed negative results. Her right eye was swollen and painful upon palpation (touch). A 7/18/24 9:44 AM interview with Driver #1 revealed she was the transportation driver for about a year and a nurse aide for the facility. Driver #1 stated that on Wednesday, 5/22/24 she was the only staff member on the van and around 3:50 PM she picked up Resident #12 from dialysis, placed her on the transportation van and secured her in the wheelchair with restraints and a seatbelt. Driver #1 stated that after she secured Resident #12 on the transportation van, she then drove to a second dialysis center and arrived around 4:30 PM to pick up three additional residents from dialysis. Driver #1 stated that when she pulled up to the dialysis center, she parked in front of the dialysis center, left the transportation van running and the air conditioning on while Resident #55 got on the transportation van, sat down and fastened her seatbelt. Driver #1 stated she advised the residents to remain in their seats secured with their seatbelts while she went inside the dialysis center to get Resident #79. Driver #1 said she left the van to go get Resident #79 and as soon as she walked inside of the dialysis center, Driver #1 heard the horn blow one long blow and one short blow, so she left Resident #79 in the lobby of the dialysis center and immediately returned to the transportation van because she knew it was an emergency. Driver #1 stated when she returned to the transportation van, she saw Resident #12 lying face down on the floor of the van. Resident #55 told Driver #1 that Resident #12 unfastened her seat belt to get up to call her sister and fell. Driver #1 stated she got Resident #12 up off the floor and put Resident #12 back in her wheelchair. When asked why Driver #1 put Resident #12 back into her wheelchair, Driver #1 stated because the floor of the van was hot, and I did not want to leave her there. Driver #1 said Resident #12 said her head was hurting and when Driver #1 got Resident #12 up she could see a knot forming over her right eye. Driver #1 stated that when she saw Resident #12 on the floor of the van, she called the Administrator and while Driver #1 was on the phone with the Administrator, Driver #1 picked Resident #12 up at the same time, told the Administrator that she was putting Resident #12 back in her wheelchair and about the knot on her forehead. Driver #1 said the Administrator told her to call 911. Driver #1 said she called 911 and when the paramedics arrived, Resident #12 was seated in her wheelchair with her seatbelt fastened and Resident #12 told the paramedics I am fine. Driver #1 stated the paramedics assessed Resident #12 seated in her wheelchair. Driver #1 stated that she was trained as a NA that if an accident occurred during transportation, to call 911 immediately and not to move the resident but that in the case of Resident #12 she did not want to leave the Resident on the hot floor of the transportation van. A 7/18/24 9:33 AM interview with Unit Manager (UM) #1 revealed she was notified during the morning clinical meeting on 5/23/24 that Resident #12 was in the hospital for evaluation of a hematoma. UM #1 further stated that she did not know what transportation drivers were trained to do, but that NAs were trained not to move the resident after a fall until the nurse could assess the resident. The Director of Nursing (DON) was interviewed on 7/18/24 at 11:57 AM. The DON stated that nursing staff were trained that if a resident sustained an injury from a fall the nurse should assess the resident in the position observed from the fall before the resident was moved. The DON stated, That's what we train and expect. The DON further stated that if there was major injury from a fall on the transportation van, the resident should remain in place until EMS arrived, but in the case of Resident #12, the DON supported the Driver's decision to get Resident #12 off the floor to prevent any further injury. The Administrator was interviewed on 7/18/24 at 11:34 AM and stated that she completed the incident report regarding a 5/22/24 fall Resident #12 had on the transportation van. The Administrator stated that on 5/22/24 at approximately 4:40 PM, she received a call from Driver #1 who notified the Administrator that the Driver was inside the dialysis center when the Driver heard the horn on the van and came back out to the transportation van. The Administrator said that when the Driver got back on the van, she saw Resident #12 on the floor of the van. The Administrator stated that the Driver said Resident #55 told the Driver that Resident #12 unbuckled her seatbelt, moved around, and landed on the floor of the transportation van. The Administrator stated she asked Driver #1 if Resident #12 was alert, breathing, and to look for signs of injury. The Administrator said Driver #1 told the Administrator that Resident #12 had a knot on her forehead, but that the Driver did not see any further injuries. The Administrator stated she told the Driver not to move the van, make Resident #12 comfortable, call 911, tell them where the van was parked so they could locate the van and evaluate Resident #12. The Administrator stated that she could not say that she was made aware that Driver #1 moved Resident #12 off the floor of the van back to her wheelchair before EMS arrived. The Administrator stated if she had known that Driver #1 needed to move Resident #12 off the floor of the van, the Administrator would have asked more questions to determine if it was necessary to move the Resident. A 7/18/24 12:16 PM phone interview with the NP revealed she was notified of the fall that occurred on the transportation van for Resident #12. The NP stated that typically a resident should remain in place for EMS to evaluate, but that the NP could understand why Driver #1 moved Resident #12 off the floor of the van since Driver #1 thought the floor of the van was hot. The NP stated she thought that it was okay to move Resident #12 if the transfer was safe to prevent a worse injury described by the NP as possibly a burn. A phone interview with the MD occurred on 7/18/24 at 8:31 PM. The MD stated he was notified on the day of the fall when Resident #12 fell on the transportation van, but that he could not recall the specific date. The MD said he was certain staff told him that she sustained a hematoma and was sent to the hospital but that he did not recall the details of the incident. The MD also stated that if a resident sustained a neck injury or some other significant injury, he would agree to leave the resident in place until paramedics arrived, but given the circumstances that Driver #1 felt like the floor of the van was hot, he could agree with moving her off the floor of the van and he had no concern with moving Resident #12 under those circumstances. The Administrator was notified of immediate jeopardy on 7/18/24 at 3:55 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 as a result of the noncompliance. On 5/22/2024, Resident #12, a resident with a diagnosis of dementia, unbuckled her seat belt, leaned forward and fell from her wheelchair while on the facility's transportation van. Driver #1, who is a certified nursing assistant, witnessed Resident #12 face down on the floor of the van. Resident #12 complained to Driver #1 that her head hurt. Driver #1 observed Resident #12 with a knot forming on her forehead above her left eye. Driver #1 stated she called the administrator, who is also a registered nurse and notified the administrator of the fall and knot forming to the Resident's forehead. It was reported to the Administrator that no other obvious injuries were identified by Driver #1. The administrator instructed Driver #1 to assist with making resident #12 comfortable. Driver #1 then assisted Resident #12 from the hot floor of the van back to her wheelchair while on the phone with the administrator and received instructions to call 911. Driver #1 called 911 and remained with the resident until emergency services arrived. Resident #12 was transported to the hospital and diagnosed with a tiny acute hemorrhage of the left lateral ventricle posteriorly. Resident #12's responsible party and physician were notified of fall with subsequent transfer to the hospital. All residents who are transported by the facility van have the potential to be affected. 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 5/22/2024, the Administrator re-educated Driver #1 on facility van transportation policies and completed a Transportation Skills Assessment of the Transportation Aide/ CNA with no concerns noted. On 5/23/2024, an Ad Hoc meeting was held with the following in attendance: the Administrator, the Director of Nursing, the Nurse Managers, the Rehab director, the MDS nurse, the Activity Director, and the Wound Care Nurse. The Medical Director, who was notified of the incident on 5/22/2024, was not in attendance, but was updated by the Administrator of the meeting's agenda and findings. Other resident incidents were reviewed during this meeting. There were no incidents identified in which a resident was moved before being assessed by licensed professionals. On 7/18/2024, the [NAME] President of Clinical Services provided education to Director of Nursing (DON) and Nursing Home Administrator (NHA) regarding facility policy of the following: In the event of a transportation related incident, resident is not to be moved until a licensed professional can assess for injuries. No changes to policy were necessary at this time. On 7/18/2024, DON provided in person one on one education to facility Driver #1 regarding facility policy of the following: In the event of a transportation related incident, resident is not to be moved until a licensed professional can assess for injuries in person. Driver #1 is an employee of the facility; no other drivers are employed at this time. Driver #1 is directly supervised by the facility Administrator, who received in person education regarding facility policy by [NAME] President of Clinical Services. On 7/18/2024, individual interviews were conducted with all residents with a BIMS 13 or above who were transported by the facility transporter by the DON and Assistant Director of Nursing (ADON) to ensure no unreported incidents occurred during facility transportation requiring assessment by a licensed professional. No other residents were affected by this deficient practice. On 7/18/2024 education was started with all staff, including agency staff by the ADON/Nurse Managers on the following: If the transport driver notifies the facility regarding a transportation related incident, inform them to contact emergency services and not move resident until a licensed professional can assess them. The facility Administrator and Director of Nursing's contact information is posted at all three nurse's stations. No staff will be allowed to work, including any new hires and agency staff, without receiving this education. This information will also be added to the new hire orientation. The Administrator will notify the Assistant Director of Nursing and/or Nurse Manager of this responsibility. Any newly hired facility van drivers will be educated during orientation by the DON/Administrator regarding facility policy: In the event of a transportation related incident, resident is not to be moved until a licensed professional can assess for injuries. On 7/18/2024 an in person Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held. The Administrator, the Director of Nursing, the Nurse Manages, the Rehab director, the MDS nurse, and the Wound Care Nurse attended this meeting to review the incident and credible allegation for the removal of the immediate jeopardy. Effective 7/18/2024, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. IJ removal date 7/19/2024. The Credible Allegation of IJ removal plan was validated onsite on 7/26/24 with an effective date of 7/19/24. The facility provided documentation of re-education, verification of facility approved contract and facility-employed transportation drivers, documentation of transportation driver's safety skills assessment, and QAA plan. Interviews with alert and oriented residents who used facility transportation resulted in no concerns expressed related to emergency response during transportation. Staff hired or contracted for transportation were interviewed and communicated knowledge of emergency response protocols and safety re-education during transportation incidents per the facility policy. Nursing staff were interviewed and communicated knowledge of how to advise a driver who calls the facility to communicate a transportation related incident, per facility policy and re-education. An observation of staff boarding residents for transportation demonstrated contract staff and facility employed staff following safety protocols for residents with health issues per facility policy. The IJ removal date of 7/19/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility smoking policy revised 01/22/24 titled, Resident Smoking revealed under Policy Explanation and Compliance Guidelines that smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Resident #38 was originally admitted to the facility on [DATE] with diagnoses which included nicotine dependence, traumatic subarachnoid hemorrhage without loss of consciousness, fracture of occiput (skull fracture), psychosis, altered mental status, acute cystitis without hematuria, hyperlipidemia, and hypertension. Review of Resident #38's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance for most activities of daily living (ADL). The MDS further revealed resident #38 was not coded for oxygen. Review of progress note dated 05/22/24 revealed Resident #38 stated that she sat down on side porch steps to gather cigarette butts to smoke. The note further revealed Resident #38 was educated on safety practices of smoking cigarette butts and transferring while outside. Resident #38 was assisted back to her wheelchair back into the facility. The note indicated no injuries were noted, no pain or discomfort noted, and the Nurse Practitioner (NP) and Resident representative (RR) was notified. Review of Resident #38's quarterly smoking assessments dated 06/29/24 revealed the resident was an unsafe smoker and required supervision. During an interview with the Director of Nursing (DON) on 07/18/24 at 11:15 AM it was revealed Resident #38 was deemed unsafe due to an incident on 5/22/24 when she got out of her wheelchair and was picking up used cigarettes off the ground. Review of Resident #38's most recently signed smoking agreement was dated 03/13/24. The agreement revealed the resident was verbally educated on the smoking policy and how to store smoking materials. (This was just sent to me by the DON) Review of progress note dated 07/13/24 revealed Nurse #3 smelled cigarette smoke in Resident #38's room during second shift. The note further revealed Resident #38 confirmed that she smoked in the room and the cigarette and lighter was taken and locked away by Nurse #3. The note indicated Resident #38 was reeducated on the facility smoking policy. An interview conducted with Nurse #3 on 07/17/24 at 11:20 AM revealed it was during second shift on 07/13/24 and she passed Resident #38's room there was a strong odor of cigarettes. Nurse #3 further revealed she entered the room and a half-smoked cigarette and lighter were sitting on the bedside table put out. Nurse #3 indicated Resident #38 admitted to smoking in the room but did not observe any ashes in the room. Nurse #3 stated she reported to Nurse Supervisor #2 who was the supervisor on duty and the residents' smoking materials were confiscated and locked up. An interview conducted with Resident #38 in the residents' room on 07/17/24 at 10:35 AM revealed she used to be an independent smoker but was recently switched to a supervised smoker due to getting into trouble. Observation revealed Resident #38 had a roommate with no oxygen found in the room. Resident #38 further revealed on 07/13/24 she went out to smoke during the supervised smoke break and staff had given her smoking materials and left the residents unsupervised. Resident #38 admitted she took her smoking materials back to her room because she does not like to be supervised and lit a cigarette in her room. Resident #38 indicated she knew she shouldn ' t smoke in the facility and would not do it again because nursing staff was not happy with her. Resident #38 stated staff often leave residents unsupervised during smoking times in the evenings. An observation and interview with smoking residents (Resident #37, Resident #44, and Resident #50) who were cognitively intact on 07/17/24 at 11:00 AM revealed they were independent smokers but often smoked during supervised smoking times. It was further revealed staff often would hand out smoking materials and would leave during supervised smoking times. A phone interview conducted with Nurse Supervisor #2 on 07/17/24 at 12:10 PM revealed on 07/13/24 around 7:30 PM Nurse #3 reported that Resident #38 had smoking materials in her room. Nurse Supervisor #2 indicated she observed a half-smoked cigarette and lighter on the Resident ' s nightstand. Nurse Supervisor #2 further revealed she took materials away from Resident #38 but did not report this incident to any upper management because she got busy on shift and forgot to report. An interview conducted with Nurse Aide #3 on 07/17/24 at 1:05 PM revealed he was assigned on 07/13/24 to assist supervised smokers during smoking times during second shift. NA #3 further revealed he could not recall if Resident #38 was a supervised smoker. NA #3 stated he was not sure how Resident #38 had gotten back to her room with smoking materials because he had stayed with Resident #38 and supervised smokers and observed them smoking. NA #3 indicated he assumed Resident #38 had put smoking material in her pockets and does not recall if he took Resident #38 ' s smoking materials after the supervised smoking time during second shift An interview conducted with the Director of Nursing (DON) on 07/18/24 at 11:15 AM revealed Resident #38 was a supervised smoker due to previous behaviors of hiding cigarettes and picking up cigarettes off the ground. The DON further revealed a resident that was assessed to be supervised has their smoking materials locked up and was to be observed while smoking. The DON stated she expected supervised smokers to not be able to retrieve smoking materials without staff present. An additional interview conducted with the DON on 07/25/24 at 10:25 AM revealed she was made aware of the incident on 07/13/24 by Nurse Supervisor #2. The DON stated there was one resident on the first floor (100 Hall) and two residents on the third floor (300 Hall) who were ordered for oxygen. No residents had orders for oxygen on Resident #38 ' s floor. The DON explained all smokers have a locked box at the entrance of the smoking patio. It was indicated independent smokers have a key to their own box, but supervised smokers had to be opened by nursing staff. The DON revealed Resident #38 was able to light her own cigarette, but smoking materials were to be confiscated after her smoking time to be locked up. Nurse Supervisor #2 on 07/13/24 indicated to the DON Resident #38 had smoking materials in her room but found no evidence of ashes and that she had smoked in her room. The DON the incident was reviewed on 7/15/24 during the morning clerical meeting. The DON further revealed she interviewed Resident #38 on 07/16/24 and the resident denied smoking in the room but admitted she had smoking materials on her bedside table. The DON stated it was undetermined how the cigarette and lighter got back to the resident's room. The DON indicated on 07/16/24 she educated Resident #38 and all smokers on the smoking policy, conducted a sweep of looking for smoking materials in facility, and reviewed smoking assessments and did not identify any issues. The DON indicated interventions for Resident #38 was to continue to be a supervised smoker. The DON stated in-service was completed with all nursing staff by the ADON on 07/16/24 which reviewed the smoking policy, smoking times, extinguishing cigarettes in the proper area, and supervisions for supervised smokers. The DON stated nobody had notified her that residents had been left unsupervised during smoking times. An interview conducted with the Administrator on 07/18/24 at 3:05 PM revealed she was made aware of Resident #38 having smoking materials in her room on 07/15/24 during clerical morning meeting. It was further revealed verbal education was given to nursing staff to always keep constant visual on supervised smokers and Resident #38 was educated on the smoking policy. The Administrator stated she is not sure how Resident #38 was able to get back to her room with any smoking materials because the smoking materials are collected and locked up at the entrance of the smoking area. The Administrator further revealed Resident #38, or any supervised smoker should have not been able to go back to their room with any smoking materials. Based on observation, record review and interviews with residents, Medical Director (MD), Nurse Practitioner (NP), Driver #1 and staff, the facility failed to supervise Resident #12, a Resident diagnosed with dementia and bilateral amputations, to prevent a fall. Driver #1 left Resident #12, unsupervised while secured in her wheelchair on the facility's parked transportation van with the engine and air conditioning left on and other residents on the van. While unsupervised by Driver #1, Resident #12 unbuckled the seatbelt to her wheelchair, leaned forward and fell face down to the floor of the van. Driver #1 immediately returned to the transportation van when she heard the horn sound and found Resident #12 face down on the floor of the van. Resident #12 complained to Driver #1 that her head hurt. Driver #1 called the Administrator and received instructions to look for signs of injury. Driver #1 told the Administrator she saw a knot on the Resident's head and received instructions to call 911. Driver #1 called 911 and when paramedics arrived, Resident #12 was transported to the hospital where she was diagnosed with a tiny acute hemorrhage of the left lateral ventricle posteriorly (bleeding in and around the brain's ventricles), subcutaneous hematoma (collection of blood underneath the skin) of the right forehead and a painful, swollen right eye. Additionally, the facility failed to supervise Resident #38, assessed as a resident who required supervision when smoking cigarettes, when Resident #38 maintained smoking materials and smoked a cigarette in her room while unsupervised. This deficient practice occurred for 2 of 13 residents reviewed for supervision to prevent accidents at a scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) (Residents #12 and #38). Immediate jeopardy began on 5/22/24 when Resident #12 was left unsupervised in the facility's transportation van, fell and sustained injuries. Immediate jeopardy was removed on 7/19/24 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: 1. Resident #12 admitted to the facility 3/12/24 with diagnoses that included non-Alzheimer's dementia, mild neurocognitive disorder with behavioral disturbance, end stage renal disease (ESRD), dependence on hemodialysis, glaucoma of the left eye, and bilateral amputation of the lower extremities. A 3/12/24 Transfer, Mobility Evaluation, assessed Resident #1 required the caregiver to perform 100% of the transfer task because she was alert/oriented with intermittent confusion, non-ambulatory due to bilateral amputee status, unable to stand, non-weight bearing and required partial support of a rail or a person to sit at the bedside. A 3/12/24 Fall Risk evaluated Resident #12 at high risk for falls due to a history of falls, impaired gait and impaired mental status. A 3/19/24 admission Minimum Data Set (MDS) assessment indicated Resident #12 expressed herself with clear speech, made herself understood, understood others, moderately impaired cognition with no acute changes in mental status, bilateral lower extremity impairment and used a wheelchair for mobility. The MDS recorded Resident #12 required partial to moderate assistance to move from a sitting to lying position, had no falls since admission to the facility and received dialysis services. A 3/25/24 Care Plan indicated Resident #12 had impaired cognitive function regarding her diagnosis of dementia and poor impulse control which placed her at risk for falls. The Care Plan identified Resident #12 required staff assistance with activities of daily living due to ESRD, with dependence on hemodialysis, glaucoma of the left eye, cognitive communication deficits and bilateral amputation of the lower extremities. Interventions included to cue, reorient, supervise as needed, to assess, anticipate resident needs, assess resident's understanding of the situation and follow facility fall protocol. A 4/12/24 physician order for Resident #12 recorded (named kidney center) every Monday, Wednesday, and Friday at 12:15 PM for hemodialysis. A 5/15/24 11:00 AM incident report documented Resident #12 fell from her wheelchair in the dining room and the fall was witnessed by another resident. The incident report documented Resident #12 was assessed without visible signs of injury. The NP was notified, and an order was obtained to send Resident #12 to dialysis as ordered with instructions for continued monitoring. A 5/15/24 NP progress note recorded Resident #12 was assessed after a fall from her wheelchair. The NP progress note recorded there was no change in mental status, vital signs were assessed at baseline and Resident #12 was transferred to dialysis. The NP ordered neuro checks prior to dialysis, monitor vital signs and notify dialysis to monitor closely during treatment. A 5/22/24 (Wednesday) 12:45 PM nurse progress note recorded Resident #12 left the facility for dialysis. A 5/22/24 6:30 PM incident report, documented by the Administrator, recorded that on 5/22/24 it was reported by staff that Resident #12 fell and hit her head. The incident report recorded 911 was called and Resident #12 was taken to the hospital for evaluation and treatment. The incident report recorded injuries at the time of the incident as a hematoma to the top of her scalp. The incident report described Resident #12 as disoriented to place, situation, time, and oriented to person. The incident report documented predisposing factors were chair position, impulsive behavior, impaired awareness, weakness, confusion, lost balance, and a history of confusion after dialysis treatments. A witness to the fall was recorded as Resident #55. A 5/22/24 witness statement documented by Driver #1 recorded the following On Wednesday, 5/22/24, at (named dialysis center) parking lot, while going in to get Resident #79 out of the building, around 4:30 PM, Resident #12 took off her seatbelt and fell on the floor. Resident #55 stated that Resident #12 was trying to get up and call her sister. I immediately called my Administrator and helped Resident #12 back in her chair. I was told to call 911 and that's what I did. 911 came soon and checked out Resident #12 and took her to (named) hospital. A 5/22/24 EMS Run Report documented paramedics arrived at the facility transportation van at 4:56 PM in response to Resident #12's fall from a wheelchair. Per the report, Driver #1 reported to paramedics that Resident #12 took her seatbelt off and fell face first onto the floor of the van. Paramedics recorded that at 5:00 PM Resident #12 was assessed with a hematoma to the right side of her forehead, with no crepitus (grading, popping, or clicking of a joint) felt. Per the report, Resident #12 complained of right upper arm pain to paramedics, her pupils were reactive to light and her lungs were clear and equal. Per the report, the injuries and complaint of pain were sustained when Resident #12 fell 3 feet from a seated position onto the floor of the van. Per the report, Resident #12 was transported by paramedics to the hospital in stable condition for further evaluation. A 5/23/24 hospital discharge summary recorded Resident #12 admitted to the hospital on [DATE] for evaluation after a fall and discharged back to the facility on 5/23/24 in stable condition. The hospital course described Resident #12 as oriented to self, but unable to determine baseline due to a diagnosis of dementia. The hospital course documented that a CT scan of the head (a computed tomography which is a diagnostic procedure that uses X rays and computers to create detailed cross-sectional images of the inside of the body) showed a tiny acute hemorrhage of the left lateral ventricle posteriorly and a subcutaneous hematoma of the right forehead. Resident #12 was referred for a neurosurgery consult, a second CT scan was completed with stable results. A tertiary exam (a final means of identifying injury), although limited due to Resident #12's dementia, showed negative results. Her right eye was swollen and painful upon palpation (touch). An observation of and interview with Resident #12 occurred in her room on 7/16/24 at 8:54 AM. Resident #12 was observed in her bed and stated she did recall having a recent fall and transported to the hospital. Resident #12 did not recall the date of the fall or any details surrounding the fall of 5/22/24. During the interview, Resident #12 stated, I am fine. A 7/18/24 at 9:25 AM interview with Resident #55, a Resident identified by the facility as alert/oriented to person, place, situation, and time, revealed on Wednesday, 5/15/24 around 11:00 AM Resident #55 and Resident #12 were in the 1st floor dining room, Resident #12 was in her wheelchair, released the brakes on her wheelchair and slid out of her wheelchair onto the floor. Resident #55 said nurses came right away, checked her out, determined she was not injured and that she was fine. Resident #55 said she and Resident #12 went to dialysis that day and Resident #12 appeared fine on the ride to/from dialysis. Resident #55 further stated that she was also on the facility transportation van the next Wednesday, 5/22/24, when Resident #12 fell. Resident #55 stated Resident #12 was on the transportation van on Wednesday, 5/22/24 at 4:30 PM, parked in front of the dialysis center, when Resident #55 walked onto the facility van after dialysis. Resident #55 stated that Resident #12 was in her wheelchair on the van with her seatbelt fastened and that Resident #12 asked Driver #1 to call a family member. Resident #55 stated that after she got on the van, and fastened her seat belt, and Driver #1 got off the van to assist Resident #79 from the lobby of the dialysis center onto the van. Resident #55 stated that while the Driver was off the van, Resident #12 also asked Resident #55 for assistance to call a family member. Resident #55 explained that when Resident #55 responded to Resident #12 that she could not assist Resident #12 because she did not know the number, Resident #12 unfastened her seatbelt, reached towards a mobile phone that was nearby, and fell face down on the floor of the van. Resident #55 stated after Resident #12 fell, Resident #55 blew the horn on the van, one long blow and one short blow to alert the Driver of an emergency and the Driver immediately returned to the van, without Resident #79. Resident #55 further stated that when Driver #1 returned to the van, Resident #12 was face down on the floor of the van. Resident #55 stated that the Driver always left the other Residents for a minute or two on the van while she left to get Resident #79 from the lobby of the dialysis center and help him onto the van. A 7/18/24 9:44 AM interview with Driver #1, with the Unit Manager (UM) #1 present, revealed she was the transportation driver for about a year and a nurse aide for the facility. Driver #1 stated she received driver safety training when she became the Driver for the facility and received re-education in May 2024 after the fall incident with Resident #12 occurred on the transportation van. Driver #1 stated that on Wednesday, 5/22/24 at around 3:50 PM she picked up Resident #12, a Resident described with dementia and intermittent confusion, from dialysis, placed her on the transportation van and secured her in the wheelchair with restraints and a seatbelt. Driver #1 stated that after she secured Resident #12 on the transportation van, she then drove to a second dialysis center and arrived around 4:30 PM to pick up additional Residents (Residents described as alert, oriented, and without confusion) from the dialysis center. Driver #1 stated that when she pulled up to the dialysis center, she parked in front of the dialysis center, left the transportation van running and the air conditioning on while Resident #55 got on the transportation van, sat down and fastened her seatbelt. Driver #1 stated she advised the Residents to remain in their seats secured with their seatbelts while she went inside the dialysis center to get Resident #79. Driver #1 said it typically took about one to two minutes to get Resident #79 from the lobby of the dialysis center and bring him to the transportation van as he waited for the Driver in the lobby of the dialysis center. Driver #1 said that it was her routine to park in front of the dialysis center, secure the other Residents on the transportation van and have them wait on the van while she left the van, and went to the lobby of the dialysis center to get Resident #79. The Driver further stated, but this time as soon as she walked inside of the dialysis center, Driver #1 heard the horn blow one long blow and one short blow, so she left Resident #79 in the lobby of the dialysis center and immediately returned to the transportation van because she knew it was an emergency. Driver #1 stated when she returned to the transportation van, she saw Resident #12 lying face down on the floor of the van. Resident #55 told Driver #1 that Resident #12 unfastened her seat belt to get up to call a family member and fell. Driver #1 said Resident #12 said her head was hurting and Driver #1 could see a knot forming over the Resident's right eye. Driver #1 stated that when she saw Resident #12 on the floor of the van, she called the Administrator and told the Administrator about the fall and the knot on the Resident's forehead. Driver #1 said the Administrator told her to call 911. Driver #1 said she called 911 and when the paramedics arrived, Resident #12 told the paramedics I am fine. Driver #1 stated the paramedics assessed Resident #12 and transported the Resident to the hospital. Driver #1 stated that she always transported Residents to/from dialysis alone because it was a quick drop off and pick up. Driver #1 stated Resident #12 had periods of confusion, but she had never taken her seatbelt off before on the transportation van when the Driver instructed her to stay buckled in her seat. Driver #1 also stated that she probably heard about her fall on 5/15/24 in the dining room, but that was months ago, and she did not recall. A 7/18/24 9:33 AM interview with UM #1 revealed she was notified during the morning clinical meeting on 5/23/24 that Resident #12 was in the hospital for evaluation of a hematoma. The UM #1 said she was notified that Resident #12 sustained a hematoma over her right eye after a fall when she unbuckled her seatbelt on the transportation van, leaned forward and fell onto the floor of the transportation van. The UM #1 described that it was not unusual for Resident #12 to have intermittent confusion and lean forward in her wheelchair, especially when she was tired and that she was often more tired and confused on the days she went to dialysis. The Director of Nursing (DON) was interviewed on 7/18/24 at 11:57 AM. The DON stated she expected Residents with confusion to be supervised during transport. The Administrator was interviewed on 7/18/24 at 11:34 AM and stated that she completed the incident report regarding a 5/22/24 fall Resident #12 had on the transportation van. The Administrator stated that on 5/22/24 at approximately 4:40 PM, she received a call from Driver #1 who notified the Administrator that the Driver was inside the dialysis center when the Driver heard the horn on the van and came back out to the transportation van. The Administrator said that when the Driver got back on the van, she saw Resident #12 on the floor of the van. The Administrator stated that the Driver said Resident #55 told the Driver that Resident #12 unbuckled her seatbelt, moved around, and landed on the floor of the transportation van. The Administrator stated she asked Driver #1 if Resident #12 was alert, breathing, and to look for signs of injury. The Administrator said Driver #1 told the Administrator that Resident #12 had a knot on her forehead, but that the Driver did not see any further injuries. The Administrator stated she told the Driver not to move the van, make Resident #12 comfortable, and to call 911. The Administrator stated that it was not the facility's practice to send an additional staff member to supervise residents when there was more than one resident on the facility transportation van to drop off or pick up residents from dialysis because the drop off and pick up was so quick. The Administrator also stated that per the facility policy, a resident with a diagnosis of dementia who displayed confusion, would satisfy the facility policy for a resident with other health issues who required supervision. The Administrator further stated that Driver #1 received driver safety training when she became the Driver for the facility and received re-education in May 2024 after a fall incident occurred on the transportation van. The Administrator provided documentation of driver safety re-education for Driver #1, but stated she could not locate documentation of initial driver safety training when Driver #1 began in this role about a year ago. A 7/18/24 12:16 PM phone interview with the NP revealed she was notified of the fall that occurred on the transportation van for Resident #12. The NP described Resident #12 as a confused Resident with a diagnosis of dementia and a history of falls and for these reasons she would expect Resident #12 to always be supervised during transportation on the facility transportation van. A phone interview with the MD occurred on 7/18/24 at 8:31 PM. The MD stated he was notified on the day of the fall when Resident #12 fell on the transportation van. The MD stated that he did not agree with, nor was it a good idea to leave Resident #12 unsupervised on the transportation van due to her intermittent confusion and dementia. The Administrator was notified of immediate jeopardy on 7/18/24 at 3:55 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 as a result of the noncompliance. On 5/22/24, the facility transportation aide, who is also a certified nursing assistant (CNA), transported four residents from dialysis to the facility. During transport, a resident with a diagnosis of dementia, was left unsupervised while secured in her wheelchair on the facility's transportation van. The van was parked, left running while the AC unit was on. While unsupervised by the transportation aide/CNA, the resident unbuckled the seatbelt to her wheelchair, leaned forward and fell. All residents who are transported by the facility van have the potential to be harmed by this alleged deficiency. The resident who had the fall was sent to the emergency room for evaluation and treatment. The remaining residents on the van returned to the facility. The Administrator who was on site at the time of the incident and who is also a registered nurse, assessed the remaining 3 residents. No injuries and no distress were noted, and those residents continued with their established routines for the evening. The facility van was not used for the remainder of the day. The transportation aide/CNA gave her statement to the facility administrator concerning the incident. It was determined that she was the only staff member on the van with multiple residents being transported from their appointments that day. This staff member was unable to both supervise the residents on the van and board the remaining residents, causing the incident. This driver has only transported a maximum number of 4 residents to dialysis alone and on days that nurse manager has determined that an escort is needed for outside appointments, staff have accompanied the van driver, or the family of the resident meets the driver at the appointment. For resident outing activities that use the facility van, the activity assistant accompanies the driver for supervision of the residents. The transportation schedule was reviewed with the Nurse Managers, and it was determined that one resident who had an appointment the next day did not require supervision. No other residents required transportation. The resident's cognitive ability, history of behaviors, and their most recent functional ability assessment which identifies such tasks as the resident's mobility status, transfer from car, bed, chair status, bending and picking up an object and ambulation capabilities, was used to make that determination. On 5/22/2024, the Administrator re-educated Driver #1 on facility van transportation policies and completed a Transportation Skills Assessment of the Transportation Aide/ CNA with no concerns noted. On 5/23/2024, an Ad Hoc meeting was held with the following in attendance: the Administrator, the Director of Nursing, the Nurse Managers, the Rehab director, the MDS nurse, the Activity Director, and the Wound Care Nurse. The Medical Director, who was notified of the incident on 5/22/2024, was not in attendance, but was updated by the Administrator of the meeting's agenda and findings. It was also determined that the van driver could not supervise all four residents to dialysis. The number of residents the transportation aide/CNA would now transport for appointments will be two residents, allowing the driver to keep the residents in eyesight during boarding and offloading. Additionally, any resident with a predetermined need for additional supervision due to cognitive impairment, history of behaviors, or functional limitations will be escorted by facility staff/designated individuals during transportation. On 5/23/2024, the Administrator initiated audits of the boarding and off-loading residents onto the van to ensure that the residents were secured appropriately in their chairs. This audit was weekly for a total of four weeks with no concerns 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 7/18/24, the Director of Nursing provided one on one education to the transportation aide/CNA regarding the need for supervision for residents who are identified as requiring supervision during transportation. The transportation aide/CNA will be accompanied by an additional staff member, a CNA or a personal care assistant (PCA) for the supervision of more than 1 resident who require supervision as determined by a review to the resident's cognitive status, past or current behaviors and their latest functional ability assessment. This staff member will remain on the van with the residents while the driver is boarding, during the drive and while off-loading the residents. There is one transportation aide/CNA who is supervised by the Administrator of the facility. On 7/18/24, the Director of Nursing assessed all residents with a BIMS of 9 or below, past or active behaviors, and the resident's most recent functional ability assessment to determine the need for supervision during transportation. All residents identified as needing supervision will be supervised by facility staff/designated individuals during transportation. A CNA or a personal care assistant (PCA) will be scheduled to serve as an additional staff member for the supervision of the residents. This information will be posted on the transportation schedule that is posted at each nursing station daily. Also on this posting, the Administrator and Director of Nursing information will be available. On 7/18/2024, care plans were updated as appropriate by the Director of Nursing/Assistant Director of Nursing and the Administrator, for any resident requiring this s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #2 was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes with peripheral angiopathy (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) without gangrene and bilateral below the knee amputations. A review of his annual Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and required supervision to limited assistance of one person for activities of daily living (ADL). An interview was conducted with Resident #2 on 10/19/2023 at 9:10 AM: Resident #2 stated he had been outside on the smoking porch, by himself, at nighttime, he could not recall the date of the incident, when he decided his wheelchair needed to be cleaned. He found an unlabeled spray bottle of pink liquid, that he assumed was a cleaning product, which was sitting on the smoking porch. Resident #2 picked up the spray bottle and sprayed his wheelchair seat with the pink liquid, he accidentally sprayed his right pant leg with the solution. He sat back down on the wheelchair seat with the pink liquid on the seat. He reported that at first, he felt a warm sensation on his right buttock and right thigh, the warm sensation intensified to pain by the time he got from the downstairs smoking porch to his room on the 2nd floor. He removed his clothes and put himself to bed. He stated the pain was so intense that he called the nurse to come into his room. The nurse attempted to wash the chemical off his right buttock and right thigh, but it did not help. The nurse called 911. Resident #2 reported that when the emergency medical services (EMS) arrived, they gave him some pain medication. His pain was a 10/10 on the pain scale. He stated that while he was in the hospital, his pain level was 10/10. The nurses at the hospital attempted to scrub his right buttock and right thigh, but the pain was so intense, 10/10 on the pain scale, that he could not tolerate the procedure. He stated that his pain level would have been higher than 10/10 if there was a number higher. Resident #2 reported that while in the hospital he received pain medication and that he currently was not on any pain medication as his burn had healed. He rated his current pain as 3 or 4 out of 10 on the pain scale. Resident #2 stated he knew he should have asked for help to clean his wheelchair but did not and decided to clean the wheelchair himself. Review of the Nursing note dated 8/28/2023 at 11:02 PM by Nurse #3 stated, Resident with reaction to thigh, unknown what happened but skin darkened and abrasions appearing. DON (Director of Nursing) alerted. MD (Medical Doctor) to send resident to ER (Emergency Room). 911 activated to (name of hospital). Nurse #3 was unavailable for interview. Review of the statement she provided to the facility revealed: On Monday, 8-28-2023, at approximately 10:45 PM, Resident #2 rang doorbell for entry from smoke porch. Nurse Aide (NA) let resident in, when I then witnessed resident roll by desk independently with shirt unbuttoned wearing grey sweat shorts. Resident made no contact with nurse, complained of no pain or distress. Resident independently rolled self to his room and got in bed. Approximately 10 minutes later, Resident called out loudly for NA. NA went to resident's room immediately and came back to this nurse to report that resident complained of pain to his leg and what she visualized as a blackened area to resident's leg. This nurse then went to Resident's room and noted resident laying naked, on right side in bed. Resident with cell phone in hand states, my leg is burning; I want to go to the hospital. This nurse noted Resident's right back of thigh was dark, appeared to be burnt, and noted abrasions forming to skin. When this nurse asked resident what happened, resident states, spilt cleaning stuff in wheelchair. This nurse immediately assessed surroundings, noted that grey sweat shorts were in wheelchair and the leg of the shorts were wet and smelled of chemical. Area immediately rinsed with normal saline flushes. Resident refused to go to shower room and kept repeating, I want to go to hospital. Education on importance of rinsing affected area was unsuccessful. Area continuously rinsed while 911 was activated at approximately 11:00 PM. DON made aware. First responders were fire department, who investigated cleaning stuff resident reported to be on the porch that was in a spray bottle. MSDS (Material Safety Data Sheet) book obtained, and this nurse escorted Fire Chief to basement to attempt to locate pink solution. Fire Chief found what was thought to match spray bottle and contacted poison control per bottle instructions. This nurse left resident in care of first responders, reported off to oncoming nurse who was made aware of situation and EMS (Emergency Medical Services) arrived at approximately 11:35 PM. Resident taken to hospital for further evaluation. Review of the hospital Discharge summary dated [DATE] revealed: A [AGE] year-old male with a complicated past medical history significant for HTN (hypertension), DM2 (type 2 diabetes) on insulin, PVD (peripheral vascular disease) and bilateral BKA (below the knee amputation both legs) who presents to the emergency department for evaluation of burn. Physical exam revealed partial thickness burn extending from buttocks to mid-thigh on posterior surface and superficial burn on left posterior thigh. Burn does not appear to have any peritoneal (tissue that covers most of the organs in your abdomen) involvement. Partial thickness burn is approximately 7 to 8% body surface area by patient's hand as measurement. Sensation intact over entire burn area. EMS and fire department were called to scene and patient was reported to be cleaning his wheelchair with chemical solution and somehow had accidental chemical spill onto wheelchair for which he sat on and felt pain with burning. The spray bottle with chemical solution had an unknown label so fire got facility to open storage and found an industrial chemical with similar color and consistency labeled as Clean Slate Knoxville (disinfectant, sanitizer and virucide kills SARS-C0V-2, which causes Covid-19 on hard porous surfaces and kills 99.9% of bacteria and viruses on hard, non-porous surfaces). The poison center was consulted and informed of possible chemical burn and the name of possible chemical solution. They recommended reported chemical is detergent and recommended heavy irrigation and wound care. Trauma was consulted and saw patient at bedside. They recommended consulting the Burn Center for recommendations. Burn Center consulted due to burn extending over major joint and possible chemical burn. They recommended heavy irrigation, followed by scrub with warm soapy water, and applying Silvadene to areas where skin was removed and lotion to burn area. Nursing staff heavily irrigated patient's burn with 3 liters of normal saline over 20 minutes and attempted to scrub with warm soapy water, but patient could not tolerate pain even after pain medication. Trauma was informed of poison control and burn center recommendations as well as nursing staff attempt to scrub with warm soapy water but unsuccessful due to patient not being able to tolerate procedure due to pain. Trauma said they will admit patient for wound debridement and care with possible OR (operating room) usage if pain control not able to be achieved at bedside. Patient was admitted to trauma service. Resident #2 hospitalized from [DATE] through 9/1/2023. Review of the label for the concentrated Clean Slate Knoxville reads: Disinfectant+Sanitizer+Virucide: Kills SARS-CoV2, which causes Covid-19 on hard non-porous surfaces in just 30 seconds! Kills 99.9% of bacteria and viruses on hard, non-porous surfaces. If product gets on skin: take off contaminated clothing. Rinse skin immediately with plenty of water for 15-20 minutes. Call poison control center or doctor for treatment advice. HAZARDS TO HUMANS AND DOMESTIC ANIMALS. DANGER: KEEP OUT OF REACH OF CHILDREN, CORROSIVE. Causes irreversible eye damage and skin burns. Do not get in eyes, on skin, or on clothing. Wear goggles or face shield, rubber gloves, and protective clothing. Harmful if swallowed. Remove contaminated clothing and wash before reuse. Wash thoroughly with soap and water after handling. An interview was conducted with Nurse Aide (NA) #2 on 10/18/2023 at 3:29 PM: NA #1 stated he was familiar with Resident #2 and that he was cognitively intact. He reported he had not witnessed any housekeeping supplies left out. He stated if he saw any housekeeping supplies left out, he would pick them up and return them to the Director of Nursing (DON). He revealed he had received training after the incident on making sure all housekeeping supplies are put up after use. He reported he had not seen any cleaning products in Resident #2's room. NA #1 was interviewed on 10/19/2023 at 8:46 AM: NA #1 stated she was familiar with Resident #2. She reported that he was cognitively intact. NA #1 reported she had seen 2 housekeeping bottles of cleaner left out in a resident's room, and she picked up the 2 bottles and returned them to the housekeeper, this happened last week. NA #1 reported that the cleaning bottles were not in Resident #2's room. She stated she had never found the housekeeping closet left unlocked. NA #1 stated that Resident #2 told her that he had picked up a bottle of housekeeping cleaner outside on the smoking porch. Resident #2 reported to her that his wheelchair was dirty, and he had decided to clean it himself by spraying the liquid on the seat of his wheelchair and then sat in the fluid, causing a burn. She reported she had never seen a cleaning bottle without a label. NA #1 stated she had received training after the incident on making sure cleaning supplies are put up in a locked cabinet. An interview was conducted with Nurse #2 on 10/18/2023 at 3:42 PM: Nurse #2 stated he was familiar with Resident #2, and he was cognitively intact. He stated he did work on the day the chemical burn happened, but he worked 1st shift and the incident happened on the 2nd shift. Nurse #2 stated he had not seen any housekeeping cleaning supplies left out on the unit and if he did, he would pick them up and report to the DON's office. He also clarified that he had not seen any cleaning supplies in Resident #2's room. He reported he had received training after the incident on not leaving cleaning supplies out but to make sure they are put up in a locked cabinet. An interview was conducted with Nurse #3 on 10/19/2023 at 9:32 AM: Nurse #3 stated she was familiar with Resident #2, and he was normally on her assignment when she worked. She reported that Resident #2 was cognitively intact. Nurse #3 reported she had never found any cleaning supplies in his room or any left out in the building or on the smoking porch. Nurse #3 stated Resident #2 was no longer receiving treatments to the chemical burn on his right buttock and right thigh because it had healed and was just a large scar now. She reported he had been on pain medication, oxycodone, when he had the chemical burn and now that it had healed, he only received Tylenol. Nurse #3 stated she had received training after the incident on making sure that all cleaning supplies are put up in a locked cabinet. Nurse #1 was interviewed by telephone on 10/19/2023 at 9:39 AM: Nurse #1 stated she was familiar with Resident #2 and that he was cognitively intact. She reported she had never seen housekeeping liquids left out in the facility or on the outside smoking porch. Nurse #1 stated she had not found the housekeeping closet unlocked, the only people that have the code is the housekeepers and maintenance. She reported that the cabinets in the shower room also have a combination lock on them and they are high up on the wall so that residents cannot reach them. Nurse #1 reported that Resident #2 had told her that he had gotten the housecleaning cleaner outside on the smoking porch. She stated she had not seen any cleaning supplies in Resident #2's room. She stated she had received training after the incident on making sure no housekeeping cleaners were not left out and were to be locked up. The Wound Nurse was interviewed on 10/19/2023 at 10:44 PM: The Wound Nurse stated she was familiar with Resident #2. She stated he was cognitively intact. The Wound Nurse stated she was no longer treating the chemical burn on Resident #2, that it had healed and was only a pink-white scar now. He had no drainage or treatments to the wound at the present time. She stated that Resident #2 had received pain medication (oxycodone) prior to his burn treatments. The Wound Nurse reported that Resident #2 had told her that he had gotten the bottle of chemical cleaner outside on the smoking porch. She reported that supervised smoking occurred daily from 8:00 AM- 8:00 PM and residents that are not assessed to be supervised go outside on the smoking porch and smoke at all hours. She stated she had received training after the incident to make sure all cleaning supplies are put up and locked up after use. She reported she had not seen any housekeeping supplies left unattended and had not seen any cleaning supplies in Resident #2's room. Observation of the right buttock and right posterior thigh was conducted on 10/19/2023 at 9:20 AM: Area noted to be from right buttock to right posterior thigh, past the knee to the area below the knee, approximately 3 inches. The area was pinkish-white, leathery appearance, no open areas or drainage noted. The area was approximately 4-6 inches wide. An interview was conducted with Housekeeper #1 on 10/19/2023 at 9:25 AM: Housekeeper #1 stated she normally worked on 200 hall; this is the hall that Resident #2 resided on. She reported she was not working when the incident happened with Resident #2. She stated she had not left any housekeeping chemicals out and she locked cleaning supplies in her housekeeping cart when she was finished with them. She reported that only housekeeping staff had the code to enter the housekeeping closets. Her cart was audited every morning by the housekeeping supervisor to make sure the cart was locked, and the cleaning supplies were secured. She stated if she found any housekeeping supplies left out, she would pick them up and take the cleaning supplies to her supervisor. She reported she had not seen any cleaning chemicals in Resident #2's room. Housekeeper #1 stated she had received training on making sure all housekeeping supplies are put up when not in use and locked up. The Housekeeping Supervisor was interviewed on 10/19/2023 at 3:00 PM: She reported that housekeeping staff are expected to lock up any chemicals after use. If another staff member asked them for cleaning supplies, the housekeeper was to obtain the supplies asked for, go with the employee while they used the cleaning supplies, and then the housekeeper was responsible for locking up the chemical when finished. The Housekeeping Supervisor reported that the facility was unable to determine what chemical cleaner with which he was burned. She stated that to her knowledge, no housekeeping supplies had been left out in the facility unattended or in any resident room, except for one time when she found a bottle of Clorox left out, approximately 1-2 months ago, she picked up the bottle of Clorox and locked it back up. The Housekeeping Supervisor stated she had not seen any housekeeping chemicals in Resident #2's room. She stated she had searched the facility with the fire department, looking for a pink liquid in a bottle. She stated that the only pink solution found was pink fabric softener and red concentrated, commercial cleaner, called Clean Slate Knoxville, this commercial cleaner had to be diluted with water for use, and when diluted would lighten up the red color to pink. This information was reported to the hospital. She reported she made a round before the beginning of the shift and checked the housekeeping carts to make sure they were locked and what chemicals were stored on the cart. When the employee was ready to start the shift, she would check the cart again with the employee present and then the employee would sign that the cart had been checked. She stated that after the incident, staff were reeducated on making sure cleaning supplies were not left out after use and locked up either on the housekeeper's cart, in the housekeeping closet or in the locked cabinet in the shower rooms. She stated that the bottle with pink liquid was discarded in the trash. The Medical Doctor (MD) from Poison Control was interviewed by telephone on 10/20/2023 at 11:30 AM and a second telephone interview was conducted on 10/20/2023 at 2:07 PM: The MD stated that poison control was notified on 8/29/2023 at approximately 12:00 AM, by the hospital, that a [AGE] year-old male had been cleaning his wheelchair with a commercial cleaner and sat down on the cleaner and suffered partial thickness burns to his right buttock and right posterior thigh. The facility provided information to the hospital and poison control regarding the substance that they felt had caused the chemical burn. It was a product called Clean Slate. This is a commercial detergent. He stated that in his opinion, that the burns that Resident #2 had sustained was in-line with the chemical Clean Slate and not a fabric softener. The MD stated that fabric softener was not mentioned to poison control or the hospital. He stated that poison control did not go to the hospital that they consulted with the emergency room Doctors by telephone. He reported that Clean Slate left on the skin was not good and the compound would cause an injury to the person. He stated that he had contacted several of his colleagues and no one had heard of anyone sustaining a burn like this from fabric softener and that literature did not support a burn like this coming from fabric softener. The Director of Nursing (DON) was interviewed on 10/19/2023 at 3:58 PM: The DON stated she was familiar with Resident #2, and he was cognitively intact. She was not present when Resident #2 received his chemical burn, the incident happened late on 2nd shift. The DON reported she did an investigation after the incident and was not able to determine what chemical he was burned with and corporate came into the facility and tried to figure it out but were not able to determine what the chemical was. She stated she did find a can of Lysol in his room on 8/29/2023 and removed the can from the room. No other chemicals were found. The DON reported that Resident #2 did report generalized pain after the incident, no specific area about which he was complaining. Staff were educated after the incident to make sure that all chemicals are secured after use and to report to the Administrator herself, or the Housekeeping Supervisor if any chemicals were left unattended. An interview was conducted with the Administrator on 10/19/2023 at 4:23 PM: The Administrator stated she was familiar with Resident #2 and that he was cognitively intact. She reported that an investigation was conducted after the incident, and they were not able to determine where he obtained the chemical or what the chemical was. His room was checked after the incident and a can of aerosol air freshener, and a bottle with clear liquid in it, the bottle was thrown out. The Administrator stated that audits were being conducted by housekeeping weekly to make sure housekeeping carts are locked and to make sure that no chemicals are left out unattended. She stated that no bottle of pink cleaning fluid was found in Resident #2's room. Staff were educated on making sure that all cleaning supplies are secured behind a locked cabinet, locked housekeeping closet or a locked housekeeping cart. Administrator was notified of immediate jeopardy on 10/19/23 at 1:40 PM. The facility provided the following corrective action plan. - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to properly store a bottle of cleaning fluid on 8/28/2023 at approximately 10:45 PM, which resulted in Resident #2 sustaining a chemical burn on 7% of his body surface. On 8/28/23 during the second shift Resident #2 reported having pain to his sacral area while seated in his wheelchair. The resident was assessed, and Resident #2 was transported to the Emergency Dept for treatment. The event was immediately reported to the Director of Nursing on 8/28/2023 and based on the Charge Nurses investigation a strong chemical smell was identified on the wet wheelchair cushion observed in the wheelchair used by Resident #2. On 8/29/23 the Administrator and Director of Nursing initiated an investigation into the event. The Administrator identified an unlabeled spray bottle with a pink substance and when Resident #2 was interviewed by the Administrator he explained that he had obtained the cleaner from a visitor at his request. He did not report this to the nurse for review. All residents are at risk because of this deficient practice. - Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 8/29/23 the Administrator and the Housekeeping Supervisor completed an audit of all chemicals located in the facility and no similar substance was identified. The liquid was then discarded. On 8/29/23 the Administrator and the Housekeeping Supervisor completed an audit of the entire facility to ensure all chemicals are secured safely. - Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 8/30/23 the Administrator educated Resident #2 and all residents with BIMs scores 10 and above, regarding requirements to check in all items brought in from outside with the Nurse to ensure items are safe. On 8/30/23 the Administrator educated the current staff regarding safe handling of chemicals, location and use of the Material Safety Data Sheets and ensuring chemicals are stored securely. For weekends and nights, the nurse manager and/or a nurse designated by the Director of Nursing, will complete staff education. Nurse Managers on all shifts will ensure no staff will be allowed to work, including any newly hired facility staff and agency staff, without receiving this education. Education will be completed verbally with handouts for reference. The Director of Nursing will be responsible for tracking staff to ensure all staff are educated before being allowed to work. Staff were made aware of this task on 08/30/23. The education consists of: 1. All chemicals must the identified and labeled. 2. All chemicals must be secured appropriately. 3. Material Safety Data Sheets are required for chemicals in use and stored. 4. Any chemicals seen without labels must be removed immediately and given to the housekeeping supervisor, available manager, or Administrator to be appropriately discarded. 5. No sharp items are allowed. If staff identify sharp items they must be removed from the area and given to the housekeeping supervisor, available manager, or Administrator to be appropriately discarded. On 8/30/23 the Housekeeping Supervisor re-educated the cleaning staff regarding the safe use, labeling, and storage of all cleaning products. This will be added to the new hire orientation. On 8/30/23 the Housekeeping Supervisor and Maintenance Director reviewed all chemicals and ensured all were properly labeled. On 8/30/23 the Director of Nursing ensured Material Safety Data Sheets are available in the basement, in the laundry department, in the dietary department, and one at each of the three nurse's stations for all chemicals used in the facility. - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. For 8 weeks, daily audits are performed by the housekeeping supervisor of the housekeeping carts to ensure that there are no unauthorized chemicals being used and that the chemicals that the facility uses are in correct bottles with appropriate labeling. This audit started on 08/31/2023. For 8 weeks, weekly audits are performed by the Director of Nursing. Five random residents are checked to see if they have chemicals or sharps in their room, dining rooms, activity areas, shower rooms, nurse's station, the exit lobby, smoking porch, and the front lobby. These audits started on 08/30/2023. On 8/30/2023, the Administrator held an Ad Hoc QAPI meeting with the Interdisciplinary team to develop a plan to correct to prevent further incidents. On 09/12/2023 and 10/10/23, the Administrator held the monthly QAPI meeting with the Interdisciplinary team. The results for the audits were discussed and the audits will continue for compliance. No concerns were identified, and no revisions were made to the Corrective action plan. The next QAPI meeting will be held on 11/14/2023. Effective 8/30/23 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. On 10/25/23, the facility's corrective action plan with a completion date of 09/01/23 was verified through onsite validation. Staff interviews revealed they had received education on safe handling of chemicals, location and use of the Material Safety Data Sheets and ensuring chemicals are stored securely. Audits were completed that cleaning supplies were not left unsupervised, and residents did not have chemicals in reach. Observations revealed no chemical was left out in reach of residents. The facility's corrective action plan for this example could not be validated as past noncompliance due to example #1. Based on observations, record review, staff, and nurse practitioner interviews the facility failed to assess a resident's ability to safely operate the motorized wheelchair in the community, failed to educate the resident about safely operating the motorized wheelchair in the community, and failed to attempt safeguards for the resident with a diagnosis of dementia, traumatic brain injury and poor decision-making skills. On the morning of 10/17/23, Resident #1 left the facility in his motorized wheelchair and was struck by a garbage truck traveling 35 miles per hour (mph) when attempting to cross a four-lane highway with no marked crossing. Resident #1 was hospitalized with multiple bilateral fractures of the ribs both displaced and non-displaced, sternal fracture, multiple facial fractures, and spinal fractures, required intubation, and admitted into intensive care unit (ICU) where he remained hospitalized during the survey. In addtion, on 8/28/23 Resident #2 used an unlabeled bottle of a chemical solution he found in a common area to clean the seat of his wheelchair and accidentally sprayed his right pant leg. Resident #2 reported burning and pain of his right buttocks and the back his right leg at a level of 10 on a pain scale of 1 to 10 (10 being the worst pain) to the nurse and was sent to the hospital for evaluation and treatment. Resident #2 suffered partial thickness chemical burns to his right buttocks extending to the posterior surface of the mid-thigh which was assessed as approximately 7% to 8% body surface. The partial thickness chemical burn required heavy irrigation with normal saline, followed by scrub with warm soapy water. Resident #2 stated he could not tolerate the procedure and indicated his pain level was higher than 10. He was discharged back to the facility on [DATE]. This was for 2 of 4 residents reviewed for provide supervision to prevent accidents (Resident #1 and Resident #2). Immediate Jeopardy for Resident #2 began on 08/28/23 when he sprayed his wheelchair seat and right pant leg with a chemical solution in an unlabeled spray bottle. Immediate Jeopardy for Resident #1 began on 10/17/23 when he was struck by a garbage truck while in his motorized wheelchair and had not been assessed, educated, and had no safeguards in place. Immediate Jeopardy was removed on 10/22/23 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anxiety, and depression. Review of Resident #1's medical record revealed the Resident was his own responsible party (RP). Review of progress note dated 03/23/23 Resident #1 got up at 5:20 AM and revealed he was going to a family member's house. Resident #1 refused to sign out, to tell nursing staff where he was going or how he was getting there and refused to wait until daylight. Resident #1's care plan revised on 05/02/23 revealed the resident had a behavior problem due to refusing care at times, yelling and cursing staff, refusing to be changed and dressing inappropriately, refusing showers, refusing medications, attempting to leave the facility without signing out and leaving the facility without taking medication. Interventions included discuss the Resident's behavior and explain/reinforce why behavior is inappropriate or unacceptable and educate the resident of the possible outcomes of not complying with treatment or care. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required supervision with one staff assist with transfers. The MDS further revealed Resident #1 was coded for no upper and lower impairment and was also coded for no hearing or vision impairment. Review of Resident #1's fall risk assessment dated [DATE] revealed Resident #1 was coded under Mental Status, overestimates or forgets limits, and was marked high risk for falling. Review of Resident #1's wandering assessment dated [DATE] revealed under Diagnosis Resident #1 was coded for medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength. Review of Resident #1's medical record revealed no safety assessment completed for Resident #1 to operate his motorized wheelchair out of the facility. The record review also revealed there was no documentation that Resident #1 had received any education on the risks of operating a motorized wheelchair in the community. The facility sign out sheet revealed on 10/17/23 Resident #1 signed out to leave the facility. The sign out sheet further revealed no time was documented when the resident had signed out. The weather report dated 10/17/23 revealed at approximately 6:45 AM it was clear with the beginning of sunrise. The report further revealed the temperature to be about 44 degrees Fahrenheit. Law Enforcement report dated 10/17/23 at 7:05 AM revealed Resident #1 was in a motorized wheelchair and was struck by a driver. The report further revealed Resident #1 crossed at an area that was not marked as a cross walk and was dimly lit during the morning rush hour traffic. The report documented a witness observed a shadow roll into the street before Resident #1 was hit. The report revealed the driver had obeyed traffic laws. The report indicated Resident #1 was transported to the hospital with non-life-threatening injuries to his face and neck. Review of the admission emergency room (ER) note revealed on 10/17/23 Resident #1 was admitted with large hematoma to right forehead, swelling to bilateral eyes with periorbital ecchymosis, multiple facial lacerations, swelling to the bridge of nose, laceration of the upper lip, facial instability, blood around bilateral nares and mouth clear fluid leaking around nares and eyes, soft tissue swelling to the neck, tenderness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and Psychiatric Nurse Practitioner, Nurse Practitioner interviews the facility failed to follow their abuse policy and procedure in the area of protection when they failed to implement measures to ensure residents were protected from Resident #2 who had known physically aggressive behaviors that included hitting Resident #1 in the eye resulting in a traumatic subdural hematoma, a serious condition where blood collects between the skull and the surface of the brain. This failure put 55 of the 89 residents who resided on the unsecured units at high likelihood of suffering serious physical and psychosocial harm enacted by Resident #2. Immediate Jeopardy began on 03/17/23, the date after the recertification exit date (3/16/23), when the facility failed to implement measures to ensure all residents on the unsecured units were protected from Resident #2. The immediate jeopardy was removed on 04/13/22 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems put into place are effective. The findings included: A review of the facility policy and procedure titled Abuse, Neglect, and Exploitation, with a revised date of 10/22/20, read in part, it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The Protection of Resident: section specified, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to increased supervision of the alleged victim and resident. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia, and schizoaffective disorder (bipolar type). Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and was not coded for behaviors. He was assessed as requiring limited assistance with transfers and was independent with walking/locomotion. Review of Resident #2's active care plan as of 03/17/23 revealed Resident #2 was physically aggressive and hits resident's secondary to agitation with the resident/situation. The care plan further revealed Resident #2 had a history of physical altercations with his roommates. The goal was for Resident #2 to have fewer episodes of hitting other residents through the review date. Interventions included separate residents having altercations, attempt to identify the cause of agitation, attempt to redirect and calm resident, assess and anticipate resident's needs, provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, and monitor/document/report as needed (PRN) any signs and symptoms of resident posing danger to self and others. An interview conducted with Nurse #1 on 04/12/23 at 11:30 AM revealed she heard commotion in Resident #1 and Resident #2's room on 3/10/23 and went to the room and found Resident #2 had hit Resident #1 in the right eye. Nurse #1 further revealed Resident #2 admitted to hitting Resident #1 because he was trying to watch TV and Resident #1 would not be quiet. Nurse #1 indicated both residents were separated and sent to the hospital for evaluation. Nurse #1 stated Resident #2 required one-on-one supervision when he returned from the hospital (3/12/23) for a day or two but could not recall any other safety interventions put in place on his return. Nurse #1 indicated Resident #1 was moved to another floor when he returned from the hospital. Nurse #2 revealed she was not educated on any interventions to implement to protect other residents after Resident #2 was taken off of one-on-one supervision. Nurse #2 indicated Resident #2 was able to continue to be around residents without any supervision. An interview conducted with Nurse Aide (NA) #1 on 4/12/23 at 1:30 PM revealed she had worked on the same hall as Resident #2 and Resident #1 on 03/10/23. NA #1 further revealed she heard Resident #2 being loud and had entered the room after the incident had occurred and nursing staff were already present. NA #1 indicated she rarely had worked that floor but was never educated that Resident #2 had previous aggressive behaviors. NA #1 revealed after the incident she was not aware of any safety intervention in place for Resident #2. Review of the medical record revealed Resident #1 was admitted to the facility on the secured Memory Care Unit on 9/2/22 due to wandering behaviors. The record indicated Resident #1 was moderately cognitively impaired with diagnoses of atrial fibrillation, muscle weakness, and vascular dementia. Resident #1 did receive a blood thinning medication, Eliquis. Resident #1 was moved out of the secured Memory Care Unit due to no wandering behaviors and into a room with Resident #2 on 2/26/23. On 3/2/23 it was documented that nursing staff found Resident #2 standing over Resident #1 while he was in bed, threatening to whoop him. Nursing staff deescalated the situation by sitting with the resident. No interventions were put in place and there was not an incident report completed. On 3/11/23 the record revealed Resident #2 hit Resident #1 in the right eye. Both residents were sent to the hospital for evaluation and treatment. Resident #2 returned to the facility on 3/12/23, and staff completed one on one for a brief period of time. When Resident #1 returned to the facility he was moved to another room on a different floor from Resident #2. The incident report revealed Resident #2 was moved to a private room closer to the nurse's station. Adult Protective Services and Law Enforcement were notified by the facility. Review of the hospital Discharge summary dated [DATE] revealed Resident #1 was admitted to the Neuro Intensive Care Unit service on 3/12/23 for a traumatic subdural hematoma (SDH), and was receiving Eliquis, a blood thinner. He had a past medical history of atrial fibrillation, and vascular dementia and presented to the emergency department after being hit in the face by another resident at his skilled nursing facility. A head computed tomography (CT) was completed with results of a moderate sized right SDH. The resident was discharged back to the skilled nursing facility on 3/15/23. An interview conducted with the facility Nurse Practitioner (NP) on 04/12/23 at 11:45 AM revealed Resident #2 hit Resident #1 with his fist to the right eye on 3/10/23 and Resident #1 sustained a traumatic subdural hematoma injury. It was revealed after the incident Resident #1 was unable to feed himself and engage in conversation. The NP stated Resident #1 had passed and she believed it was possible Resident #1's head injury sustained from Resident #2 could have played part to Resident #1's death. The NP further revealed Resident #2 had other altercations with residents previously and it was unsafe for Resident #2 to be placed with other residents. She indicated she was unsure what the facility had done to ensure the safety of other residents. An interview conducted with Nurse #2 on 04/12/23 at 9:45 AM revealed Resident #2 had ongoing aggressive physical and verbal behavior towards residents and staff. Nurse #2 indicated Resident #2 had physically hit two other residents during his stay at the facility. He was unable to recall the dates of these incidents. Nurse #2 further revealed Resident #2 had threatened a roommate with a butter knife, threatened to hit Resident #1, and had recently assaulted Resident #1. Nurse #2 further revealed he did not recall previous safety interventions other than to re-direct him if he got agitated. Nurse #2 stated Resident #2 had ongoing physical behaviors and was a safety concern to other residents because he was allowed to go wherever in the unsecured area of the facility and was not supervised around other residents. Review of Resident #2's medical record revealed on 2/14/23 nursing staff found Resident #2 threatening his former roommate, before Resident #1 stating he could not come in the room and if he did, he was going to stab him. Staff retrieved a butter knife from Resident #2 and the resident stated his roommate was bothering him. Staff educated the resident about violent threats and consequences. Staff removed the roommate from the room. There was no incident report completed and law enforcement was not notified. No new interventions were put into place. An interview conducted with the facility Psychiatric Nurse Practitioner (NP) on 04/12/23 at 11:55 AM revealed she visited the facility after the altercation between Resident #1 and Resident #2. The Psychiatric NP indicated she had seen Resident #2 prior to the incident that occurred on 03/10/23 but nursing staff had failed to inform her of previous physical altercations between Resident #2 and other residents. She stated due to Resident #2's previous physical and verbal altercations he should not have been placed in a room with another resident. The Psychiatric NP revealed Resident #2 should not be in the facility because he was a safety concern to all residents and had access to other residents and staff and felt the facility could not ensure the safety of all the residents. The Psychiatric NP indicated Resident #2 was alert and knew he had caused harm to Resident #1. She reported that she believed Resident #2 was triggered easily. She explained this meant Resident #2 got agitated easily. An interview conducted with Nurse Supervisor #1 on 04/12/23 at 1:15 PM revealed she was aware Resident #2 had previous physical altercations and had made verbal threats to Resident #1 and other residents. The Nurse Supervisor stated on 02/14/23 Resident #2 had a butter knife on his tray and threatened to stab his previous roommate. She reported the only interventions included the facility took the knife away and deescalated the situation. The Nurse Supervisor further revealed on 03/10/23 Resident #2 was put on one-to-one supervision for a short period of time after hitting Resident #1 and felt that Resident #2 would not be a safety concern to other residents due to being placed in a room by himself. It was revealed Resident #2 was no longer supervised and was able to be around other residents without any supervision. An interview conducted with the Director of Nursing (DON) and the Administrator on 04/12/23 at 2:45 PM revealed they were aware Resident #2 had physical altercations with other residents prior to the incident on 03/10/23. It was revealed it was known Resident #2 had made threats to Resident #1 and other residents prior. The Administrator and DON indicated on 02/14/23 Resident #2 had threatened his previous roommate with a butter knife and interventions included to de-escalate the situation and move Resident #2's roommate to another room. On 03/02/23 Resident #2 was observed by staff threatening to hit Resident #1 in his bed. Safety interventions included to de-escalate the situation. The Administrator further revealed when Resident #2 returned to the facility on 3/12/23 he was placed one-on-one for over a day, and he was moved closer to the nurses' station on 03/29/23. When asked why Resident #2 was taken off of one to one they reported the facility no longer had staff available to watch him, and they also felt like he no longer needed it. The Administrator reported before the incident with Resident #1 that the facility would de-escalate the situation by separating Resident #2 from others when Resident #2 became aggressive until he had calmed down. No other interventions were put in place. The Administrator revealed to ensure the safety of other residents Resident #2 was moved closer to the nurses' station so he could be heard. The Administrator stated Resident #2 had not shown any signs of physical aggression since he had been moved into a room by himself. The Administrator was notified of immediate jeopardy on 04/14/23 at 3:45 PM. The facility provided the following the following Immediate Jeopardy removal plan with completion date of 4/13/2023. · 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 put safety interventions in place to protect all residents from another resident known to have previously exhibited aggressive behaviors. After the incident on 3/11/23, Clonazepam was discontinued on 3/24/23 due to a fall. On 4/10/2023 a new order for Oxcarbazepine 150mg twice a day was obtained and on 4/13/2023 a new order for monthly ammonia levels was started. 03/21/2023: Nurse Practitioner completed med review and adjusted psych medications. 03/24/2023: Nurse Practitioner recommended to continue current plan of care and to continue to follow psych recommendations and adjust meds as needed. 03/28/2023: Physician assessed resident due to fall with no changes. 04/07/2023: Nurse Practitioner from psych assessed and ordered new medication. On 3/29/23 the perpetrator was moved to the room beside the Nurses station and remains in a private room. On 4/12/23 the Administrator placed the perpetrator on one-on-one supervision. On 4/12/23 the Administrator assigned a Nurse Aide to provide one on one supervision to the Resident with aggressive behaviors to ensure safety to all other residents. The Director of Nursing will be responsible for ensuring the resident has a 1:1 aide 24 hours a day. On 4/12/23 the Director of Nursing educated all Nurse Aides and Licensed Nurse regarding monitoring behaviors that include agitation, yelling, physical aggression and notifying the Director of Nursing and Nurse Manager in the event behavior escalation occurs. On 4/12/23 the Administrator, Director of Nursing and Nurse Managers completed an interview with all residents with BIMS greater than 10 to identify any allegations of abuse related to the perpetrator. On 4/12/23 the Nurse Managers and Wound Nurse conducted a skin assessment for those residents unable to be interviewed to identify any injuries that could have been caused by the perpetrator. On 4/12/23 the Director of Nursing received a Dietary order for no knives on the resident ' s meal tray and educated the Dietary Manager, Dietary staff and Nursing staff on no knives on the meal tray. On 4/12/23 the Director of Nursing and Nurse Managers assessed the resident ' s room for other dangerous objects, and none 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 4/12/23 the Administrator, Director of Nursing and Nurse Managers re-educated all facility staff, including agency staff, on the facility policy for preventing abuse, providing safety and protection to residents from perpetrators to prevent further abuse by providing one on one supervision. On 4/12/23 the Nursing staff were educated regarding monitoring and documenting behaviors in the electronic medical record and the requirement to report new or escalating behaviors to the Director of Nursing or Nurse Managers to prevent abuse. On 4/12/23 the Director of Nursing and Nurse Managers educated all staff regarding the requirement to immediately provide safety for any resident in an abusive situation including providing one on one supervision for the perpetrator to provide safety for other residents from abuse, and then immediately report any observation or allegation of abuse to the Administrator or Director of Nursing for further investigation and interventions prior to removing the increased supervision. On 4/12/23 the staff were notified that the contact information for the Administrator and Director of Nursing is posted at each Nurses station for after hours and weekend reporting On 4/12/23 the Administrator notified the Director of Nursing of her responsibility to provide the education and maintain the tracking tool to ensure no staff are allowed to work without receiving training. The Director of Nursing will ensure any newly hired staff and agency staff receive this training during orientation. The Director of Nursing will be responsible for maintaining the one-on-one schedules. On 4/12/23 the Director of Nursing will ensure Behavior monitoring, including any residents with one-on-one supervision is reviewed during the morning Clinical meeting to identify escalating behaviors and ensure interventions are in place for prevention of abuse. On 4/12/23 the Administrator began reviewing all allegations of abuse with the Interdisciplinary team during the Morning Meeting and with the Regional Director of Operations and Regional Director of Clinical Services to include a review of safety measures put in place to prevent further abuse from perpetrators. On 4/12/23 the Regional Director of Operations and Regional Director of Clinical Services will begin a weekly review of all incidents to ensure interventions are in place to provide safety interventions to protect residents. Effective 4/12/23 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 4/13/2023 On 04/18/23, the facility's corrective action plan for immediate jeopardy removal effective 04/13/23 was validated by the following: Interviews with facility staff revealed in-service was completed and educated on policy for preventing abuse, providing safety and protection to residents from perpetrators to prevent further abuse by providing one on one supervision, nursing staff were educated regarding monitoring and documenting behaviors in the electronic medical record, to immediately provide safety for any resident in an abusive situation including providing one on one supervision for the perpetrator to provide safety for other residents from abuse, and then immediately report any observation or allegation of abuse to the Administrator or Director of Nursing for further investigation, and Resident #2 could not have a knife on his meal tray. It was observed Resident #2 was put on one-to-one supervision 24 hours a day to ensure the safety of the other residents. Interview with the dietary manager revealed Resident #2 was noted on his meal ticket and a sign was present on the meal line that Resident #2 could not receive a knife on his meal tray. The removal date of 04/13/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to protect a cognitively impaired resident from staff to resident physical abuse for 1 of 1 resident (Resident #396) reviewed for abuse. On 02/27/22 when nursing staff were serving breakfast, Resident #396 was standing next to the meal cart and reached for a carton of milk. Nurse Aide (NA) #9 told Resident #396 to stop twice in a loud aggressive manner and when the resident did not comply NA #9 pushed the resident on the left side of his torso above his hip onto the ground. Resident #396's cognitive impairment prevented him from expressing an adverse outcome. A reasonable person would have been traumatized by being physically abused by a caregiver in their home environment. Immediate Jeopardy began on 02/27/22 when Nurse Aide (NA) #9 pushed Resident #396 to the ground while the resident was reaching for an item from the meal cart on the memory care unit of the facility. The Immediate Jeopardy was removed on 03/11/23 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #396 was admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's disease, muscle weakness, and difficulty walking. Resident #396's care plan with a revision date of 10/14/21 revealed the resident had impaired cognitive function and impaired thought processes and communication due to dementia. The care plan goals indicated Resident #396 would be able to communicate basic needs daily through the review date. Interventions included to use the resident preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, and reduce any distractions. Interventions also included the resident understands consistent, simple, directive sentences and provide the resident with necessary cues and return if the resident was agitated. The care plan for Resident #396 also revealed he had a behavior problem that included, in part, the following behaviors: refusing care, wandering, and sitting on the floor, and taking food from other residents. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #396 was moderately cognitively impaired and required extensive assistance with ambulation and locomotion. majority of activities of daily living. The MDS further revealed Resident #396 was coded for no behaviors or rejection of care. Resident #396 was not steady but able to stabilize without staff assistance for walking. Review of the facility initial allegation report completed by Administrator #2 dated 02/27/22 (a Sunday) revealed on 02/27/22 at 4:00 PM Administrator #2 was made aware of a staff to resident abuse allegation. Nurse #6 alleged NA #9 pushed Resident #396. The report further revealed Resident #396 sustained no injuries. An interview conducted with Nurse #6 on 03/09/23 at 8:15 AM revealed on 02/27/22 she was sitting at the nurses' desk charting while other staff were giving out breakfast trays. Nurse #6 further revealed she heard NA #9 tell Resident #396 in a loud manner to stop and she looked up to observe Resident #396 standing next to the meal cart reaching for an item on the meal cart. Nurse #6 stated NA #9 walked back to the cart towards the nurses' desk and told Resident #396 to stop again but said it in a louder and aggressive tone. Nurse #6 observed NA #9 push Resident #396 on his left side in the middle of his torso above his hip and the resident fell to the floor on his right side. Nurse #6 indicated she immediately went to Resident #396 who was observed to look startled and assisted the resident off the floor and assessed for injuries. Nurse #6 revealed Resident #396 sustained no injuries but was observed to be startled. An interview conducted with NA #8 on 03/09/23 at 9:40 AM revealed on 02/27/22 she was handing out breakfast trays and heard NA #9 state to Resident #396 twice to stop it in a loud aggressive manner. NA #8 further revealed she heard a loud thump and left a resident's room and observed Nurse #6 assisting Resident #396 off of the floor. An interview conducted with NA #9 on 03/10/23 at 11:10 AM revealed on 02/27/22 she was handing out breakfast trays and Resident #396 kept trying to grab a milk carton off the meal cart. NA #9 further revealed she told Resident #396 to stop a couple times because he continued to grab for a milk carton. NA #9 indicated she never touched Resident #396 and the resident never went down to the floor. Administrator #2 was notified of immediate jeopardy on 3/9/23 at 4:20 PM. The facility provided the following immediate jeopardy removal plan on 3/16/23. On 3/10/23 the Regional Director of Operations re-educated the Administrator, Director of Nursing and Nurse Managers on the facility policy for Prevention of Abuse and Neglect, the Elder Justice Act as well as providing care for residents with Dementia, Impaired Cognition. This education includes the following: · The definition of abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental and emotional distress · There will be a zero tolerance for resident abuse. · A focus on a calm approach, allowing time for residents to complete tasks without rushing and explaining what to expect before beginning to provide care, as well as giving agitated residents a break before continuing care. · The requirements to immediately intervene and provide safety for any resident in an abusive situation. · The expectation that the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. · The following signs and symptoms of abuse -Welts, bruises, abrasions or lacerations of unexplained origin, especially those that appear symmetrical -Broken bones, fractures, or dislocations (unknown cause/multiple) -Broken glasses or black eyes/dentures or broken teeth -Sexual exploitation/Rape -Excessive exposure to heat or cold -Visible signs of restraint, markings on wrist -Multiple burns or human bites -Fearful demeanor when specific care giver is around · On 3/9/23 the Administrator, Director of Nursing and Nurse Managers re-educated all facility staff, including agency staff, on the facility policy for Prevention of Abuse and Neglect including and the Elder Justice Act as well as providing care for residents with Dementia and Impaired Cognition. This education includes a focus on a calm approach, allowing time for residents to complete tasks without rushing and explaining what to expect before beginning to provide care, as well as giving agitated residents a break before continuing care. · Staff were also educated to walk away if they are feeling frustrated with a resident and not to place your hands on them. Staff were provided with reassurance to express challenges and frustration with their job without retaliation. This education includes the following: · The definition of abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental and emotional distress · There will be a zero tolerance for resident abuse. · A focus on a calm approach, allowing time for residents to complete tasks without rushing and explaining what to expect before beginning to provide care, as well as giving agitated residents a break before continuing care. · The requirements to immediately intervene and provide safety for any resident in an abusive situation. · The expectation that the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. · The following signs and symptoms of abuse -Welts, bruises, abrasions or lacerations of unexplained origin, especially those that appear symmetrical -Broken bones, fractures, or dislocations (unknown cause/multiple) -Broken glasses or black eyes/dentures or broken teeth -Sexual exploitation/Rape -Excessive exposure to heat or cold -Visible signs of restraint, markings on wrist -Multiple burns or human bites -Fearful demeanor when specific care giver is around All staff were re-educated regarding requirements to report any observation or allegation to the Administrator or Director of Nursing. On 3/10/23 The staff were notified that the contact information for the Administrator and Director of Nursing was posted at each Nurses station for after hours and weekend reporting. The Administrator or Director of Nursing will ensure any staff member accused of abuse or neglect will immediately be removed from the resident care area and supervised until exiting the facility pending an investigation. The Administrator or Director of Nursing will ensure any staff member accused of abuse or neglect will immediately be removed from the resident care area and supervised until exiting the facility pending an investigation. The Director of Nursing will ensure any new hired staff and agency staff receive this training during orientation and their responsibility to maintain the tracking tool to ensure no staff are allowed to work without receiving training. The Director of Nursing will ensure any new hired staff and agency staff receive this training during orientation. Effective 3/10/23 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 3/11/2023 On 3/16/23, the facility credible allegation for immediate jeopardy removal of 3/11/23 was verified through onsite validation. Staff interviews revealed they had received education and training on resident abuse. This included information on the facility's policy for prevention of abuse and neglect, the Elder Justice Act, how to provide care for residents with dementia and impaired cognition, what resident abuse and neglect looks like, and the importance of reporting immediately. Interviews confirmed nursing staff was educated on how to how to walk away from a resident if the resident that is frustrated or agitated and how to approach in a calm manner. The facility's immediate jeopardy removal plan was validated to be completed as of 3/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to protect residents when Nurse Aide (NA) #9 was not removed from a resident care assignment after Nurse #6 witnessed NA #9 push Resident #396 on the left side of his torso above his hip onto the ground. The facility also failed to thoroughly investigate abuse and to notify Adult Protective Services and Law Enforcement of abuse for 1 of 1 resident reviewed for abuse (Resident #396). Immediate Jeopardy began on 02/27/22 when the facility allowed NA #9 to continue working after she was observed by Nurse #6 to physically abuse Resident #396. The immediate jeopardy was removed on 3/11/23 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (no actual harm with potential for harm) to ensure monitoring systems are put into place are effective. The findings included: A review of the facility policy and procedure titled Abuse, Neglect, and Exploitation, with a revised date of 10/22/20, read in part it is the policy of this facility to provide protections for the health, welfare, and rights of each residents by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Investigation of Alleged Abused, Neglect, and Exploitation: Section specified in part: 6. Providing complete and thorough documentation of the investigation. The Reporting/Response section specifies in A1, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies (e.g. law enforcement when applicable) within specified time frames. The Protection of Resident section reads in part: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after an investigation. Resident #396 was admitted to the facility on [DATE]. Review of the facility initial allegation report completed by Administrator #2 dated 02/27/22 (a Sunday) revealed on 02/27/22 at 4:00 PM Administrator #2 was made aware of a staff to resident abuse allegation. Nurse #6 alleged NA #9 pushed Resident #396. The report further revealed Resident #396 sustained no injuries. Review of the facility internal investigation completed on 02/27/22 by Administrator #2 related to the staff to resident physical abuse allegation involving NA #9 and Resident #396 revealed no documentation of statements from those involved, education provided to staff, or notification that law enforcement and adult protective services was completed. An interview conducted with Nurse #6, an agency nurse, on 03/09/2023 at 8:15 AM revealed on 02/27/22 she was sitting at the nurses' desk charting while other staff were giving out breakfast trays. Nurse #6 further revealed she heard NA #9 tell Resident #396 in a loud manner to stop and she looked up to observe Resident #396 standing next to the meal cart reaching for an item on the meal cart. Nurse #6 stated NA #9 walked back to the cart towards the nurses' desk and told Resident #396 to stop again but said it in a louder and aggressive tone. Nurse #6 observed NA #9 push Resident #396 on his left side in the middle of his torso above his hip and the resident fell to the floor on his right side. Nurse #6 indicated she immediately went to Resident #396 who was observed to look startled, and she assisted the resident off the floor and assessed for injuries. Nurse #6 revealed Resident #396 sustained no injuries. Following the assessment of the resident she went to Administrator #2's office to report the incident, but Administrator #2 had people in his office and she was unable to report what was observed. Nurse #6 stated she went back to the memory care unit and contacted Unit Manager (UM) #1 who was on call and reported the incident she observed. Nurse #6 revealed she was told somebody from the facility would handle the situation and speak to NA #9. Nurse #6 indicated NA #9 continued to work the rest of the shift working with residents until 3:00 PM. Nurse #6 indicated she was hired through agency but was educated to report any kind of abuse immediately to an upper management staff. Nurse #6 stated she did not think it was appropriate for NA #9 to continue to work the rest of the shift but was told by UM #1 somebody for the facility would handle it. Nurse #6 indicated she did not work at the facility again after the incident date. An interview conducted with NA #8 on 03/09/23 at 9:40 AM revealed on 02/27/22 she was handing out breakfast trays and heard NA #9 state to a Resident #396 twice to stop it in a loud aggressive manner. NA #8 further revealed she heard a loud thump and left a resident's room and observed Nurse #6 assisting Resident #396 off the floor. NA #8 stated she spoke to Administrator #2 at the end of shift and reported the same information but did not write a written statement. NA #8 indicated she believed NA #9 pushed Resident #396 down and could not understand why the NA was allowed to work the full shift. NA #8 revealed she recalled Nurse #6 had reported to staff over the phone. An interview conducted with NA #9 on 03/10/23 at 11:10 AM revealed on 02/27/22 she was handing out breakfast trays and Resident #396 kept trying to grab a milk carton off the meal cart. NA #9 further revealed she told Resident #396 to stop a couple times because he continued to grab for a milk carton. NA #9 indicated she never touched Resident #396 and the resident never went down to the floor. NA #9 revealed she had worked the full shift and spoke to Administrator #2 at the end of her shift. NA #9 stated she did not complete a written statement but was suspended for further investigation for a couple of days. NA #9 indicated she did not receive any abuse training after the incident had occurred. An interview conducted with the Unit Manager (UM) #1 on 03/09/23 at 11:12 AM revealed she was the on-call supervisor on 02/27/22 but was not involved with the incident that occurred with Resident #396. The UM #1 did not recall Nurse #6 reporting the incident to her. An interview conducted with the prior administrator, Administrator #2, on 03/09/23 at 9:50 AM revealed he was the abuse coordinator at the time of 2/27/22 incident involving the staff to resident physical abuse allegation for NA #9 and Resident #396. He revealed he could not locate any written documentation for the investigation completed on Resident #396 on 02/27/22. Administrator #2 further revealed he was not made aware of the incident until later in the day on 02/27/22 but could not recall who had reported it. Administrator #2 indicated he did not report the incident to law enforcement or adult protective services because he felt like it was not a crime. Administrator #2 could not recall Nurse #6 coming to him to report abuse and had not gathered written statements from nursing staff but had interviewed staff about the incident. Administrator #2 stated NA #9 had worked the full shift on 02/27/22 but was suspended for a few days after this date to complete an investigation. Administrator #2 revealed he had completed in-service with NA #9 and nursing staff he interviewed who worked the memory care unit during the incident on how to re-direct residents. Administrator #2 was unable to locate documentation of who he had in-serviced and what education was received. Administrator #2 could not recall if he had assessed residents who could have been affected. Administrator #2 further revealed he had suspended NA #9 during an investigation for a couple days, but NA #9 was allowed back to work because he felt like no crime was committed. Administrator #1 was notified of immediate jeopardy on 3/9/23 at 4:20 PM. The facility provided the following immediate jeopardy removal plan on 3/16/23. · 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 #396 and maintain the right to be free from physical abuse. Resident #396 has a diagnosis of dementia and lives in the memory care unit. Resident #396 was observed being pushed by staff and sustained a fall. Resident #396 was assessed by the charge nurse following the incident and no injuries were identified. The facility failed to protect Resident #396 and other residents after physical abuse was observed at approximately 12:00 noon on 2/27/22. The accused Nurse Aide was allowed to continue to work with residents until 4:00pm on 2/27/22, when the allegation of abuse was reported to the Administrator. The Administrator initiated a 24-hour report on 2/27/22 and delivery was verified with the Health Care Personnel Registry on 3/10/23. The Administrator notified Adult Protective Services and Law enforcement on 3/10/23. A five-day report was resubmitted on 3/10/23 with documentation of completed investigation. On 3/10/23 the Administrator and Director of Nursing reviewed the grievance log for the last 30 days to ensure there were no unreported allegations of abuse or neglect. Any allegations identified as a result of this audit will be followed up, the accused staff will be suspended pending investigation, a 24-hour report will be initiated, Adult Protective Services and Law enforcement will be notified. On 3/10/23 the Administrator and Director of Nursing reviewed previously reported allegations of abuse occurring during the last 90 days and validated the investigation was completed and residents were protected. All residents have the potential to be affected by these deficient practices. · 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 3/10/23 the Regional Director of Operations re-educated the Administrator and Director of Nursing on the facility policy for completing a 24 hour and 5-day report for abuse and neglect, reporting to the survey agency within 2 hours when there is a suspicion of a crime, notification to law enforcement and notification of Adult Protective Services. This education included requirements for a complete investigation including resident and staff interviews, medical record review and incident re-enactment when appropriate. On 3/10/23 the Administrator, Director of Nursing and Nurse Managers re-educated all facility staff, including agency staff, on the facility policy for preventing abuse and neglect, providing protection to residents and immediate reporting to the Administrator and Director of Nursing including location of contact information for after hours and weekend reporting. All staff were re-educated regarding the requirement to immediately provide safety for any resident in an abusive situation and then report any observation or allegation of abuse or neglect to the Administrator or Director of Nursing. On 3/10/23 the staff were notified that the contact information for the Administrator and Director of Nursing is posted at each Nurses station for after hours and weekend reporting. The Administrator or Director of Nursing will ensure any staff member accused of abuse or neglect will immediately be removed from the resident care area and supervised until exiting the facility pending an investigation. On 3/10/23 the Administrator notified the Director of Nursing and Assistant Director of Nursing of their responsibility to provide the education and maintain the tracking tool to ensure no staff are allowed to work without receiving training. The Director of Nursing will ensure any newly hired staff and agency staff receive this training during orientation. On 3/10/23 the Administrator began reviewing all allegations of abuse or neglect with the Interdisciplinary team during the Morning Meeting. On 3/10/23 the Regional Director of Operations will begin a weekly review of all 24- hour reports to ensure staff are suspended, thorough investigations are completed with 5- day report submitted and documentation to reflect timely submissions. Effective 3/10/23 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 3/11/2023 On 3/16/23, the facility's credible allegation for immediate jeopardy removal effective 3/11/23 was validated by the following: Administrator #1 and Director of Nursing (DON) interview revealed they were re-educated on the facility for completing a 24 hour and 5-day report for abuse and neglect, reporting to survey agency within two hours when there is a possible crime, and notification to adult protective services (APS) and law enforcement. Education included when completing a thorough investigation to conduct staff interview, medical record review, and incident re-enactment when appropriate. Through interviews with nursing staff they verified education was provided for preventing abuse and neglect, provide protection to residents, and reporting possible neglect or abuse to the Administrator or DON immediately. Staff also revealed they were notified that the contact numbers for the DON and Administrator were posted at the nurses ' desks in case of possible abuse or neglect to report if they were not in the building. Administrator #1 further reveled she had started a new investigation on the incident and had suspended NA #9 pending the investigation. The Administrator indicated reports had been re-submitted. The facility's immediate jeopardy removal plan was validated to be completed as of 3/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, resident, Nurse Practitioner and Medical Director interview the facility failed to prevent severely cognitively impaired residents from exiting the facility through unlocked doors without supervision for 2 of 2 residents reviewed for supervision to prevent accidents (Resident #88 and #68). Resident #88 who was severely cognitively impaired, exited the building through an unlocked door on the first floor to smoke without supervision. An unidentified male intruder entered facility behind Resident #88 through the unlocked door of facility and vandalized the second-floor dayroom by shattering the TV, knocking a hole in the wall, and breaking out two windows. The facility failed to repair broken windows only covering windows with cardboard and wooden board that was easily removable leaving broken windows and shards of broken glass accessible to residents and failed to complete a facility investigation. Resident #68 was severely cognitively impaired and exited the memory care unit through an unlocked door to the staircase. The resident went down three flights of stairs and exited the facility through a side door. Resident #68 was found by a Nurse Aide (NA) when he went to his car, the resident was laying in the backseat of the NA's car asleep. The NA left Resident #68 in the unlocked car with the windows up, unattended in 74-degree weather while he went back inside for help. Immediate Jeopardy began on 7/30/22 for Resident # 68 and 2/2/23 for Resident # 88 when the facility failed to provide supervision to cognitively impaired residents and failed to correct environmental hazards which put residents at a high likelihood for serious harm and injury. The immediate jeopardy was removed on 08/02/22 for Resident # 68 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The immediate jeopardy was removed on 03/11/23 for Resident # 88 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Findings included: 1. Facility smoking policy dated 02/01/20 revealed smoking by residents who have been identified and assessed as unable to safely smoke independently may smoke only at the designated times and smoking will be supervised by a staff member. All smoking and fire igniting materials for residents who have been identified and assessed as unable to safely smoke independently shall be maintained by the facility and will be provided to residents by facility staff during designated smoking times. Resident #88 was a female admitted to the facility on [DATE] with diagnoses to include impaired cognitive function, impaired thought processes related to memory and major depressive disorder. Resident #88 was petite in stature, suffered from unavoidable weight loss and was being treated under Hospice care due to diagnosis of cirrhosis of liver. Review of admission smoking assessment dated [DATE] revealed Resident #88 was assessed to require supervision while smoking due to her inability to verbalize or demonstrate her understanding of the facility time and place to smoke listed under section B for cognition. Review of admission minimum data set (MDS) dated [DATE] revealed Resident #88 was severely cognitively impaired, required use of walker and occasional use of wheelchair for mobility, and was assessed as a current tobacco user. Review of admission care plan dated 12/26/22 revealed Resident #88 was identified as a smoker with a goal of not smoking without supervision through next review. Interventions included instruct Resident #88 of the facility policy on smoking: locations, times, safety concerns and Resident #88 requires supervision while smoking. Review of Police Department Incident Report dated 02/02/23 revealed vandalism incident at facility occurred between 5:20 AM and 5:41 AM and included damages to windows, television, and interior wall located on second floor. The incident report stated, On 02/02/23 at approximately 5:34 AM, officers were dispatched to facility in reference to a report of commercial breaking or entering call for service. When officers arrived on the scene, the listed suspect was on scene damaging the facility's property on the second floor. The suspect was detained by officers and transported to nearby medical facility. Warrants were issued for the listed suspect. A telephone interview was conducted with Nursing Assistant #7 (NA) on 03/07/23 at 7:04 PM revealed she worked on the second floor of the facility from 11 PM to 7 AM and was working the morning of 02/02/23 when the incident occurred. She stated residents on the second floor wake up between 4 AM and 6 AM and come down to the dining room to have their morning coffee and then would go outside to smoke unsupervised including Resident #88. She revealed at 5:20 AM she was in the shower room, which was located next to the dining room, assisting another NA and resident when she heard someone walking down the hall. NA #7 stated she looked outside the shower room door and saw an unknown male intruder wearing a jacket, scrubs and what appeared to be men's briefs on his head like a mask heading towards the dining room. She revealed she had told the other NA to stay in the shower room with the resident while she investigated who the unknown male intruder was and checked on the residents in the dining room. She stated when she came out of the shower room the unknown male intruder was standing in the dining room looking around and had taken off his jacket and kicked it in the air. NA #7 revealed the unknown male intruder then began walking down the hall towards the second-floor dayroom and that is when she told the residents in the dining room to go back to their rooms or to go downstairs to the first floor. She stated she had asked Nurse #5 who was on the floor to call 911 while she stood in the hallway and watched the unknown male intruder in the dayroom. She revealed the unknown male intruder had sat down at the desk located in the dayroom and was mumbling to himself and then picked up a three-hole punch from the desk and threw it at the TV on the wall shattering the screen. NA #7 stated the unknown male intruder picked up a chair from the dayroom and busted out two of the windows and then threw TV remotes which caused a hole in the wall. She revealed the unknown male intruder turned around and started to charge back up the hall and that is when she went into nurse's station and locked the door. She stated the unknown male intruder had gone back into the dining room when the police arrived and removed him from the floor. She also stated she provided her statement to the police but was never asked to give a verbal or written statement to the facility. NA #7 revealed she was later informed the unknown male intruder had entered the building and rode the elevator to the second floor with Resident #88 who had been outside smoking unsupervised. She stated she was not aware of Resident #88 being a supervised smoker and requiring supervision, but she and other residents would go outside during all hours of night and early mornings to smoke unsupervised. She revealed the door leading out to the smoking porch had been left unlocked after-hours to accommodate residents and staff with coming in and out of the building. NA #7 stated the facility had placed a camera and two-way speaker outside of the door but was not aware of who supposed to be monitoring the camera and the door continued to require a manual lock and wasn't aware of who's responsibility it was to manually lock door. She revealed she had worked from 11 PM- 7AM last night and door was unlocked all through the night and residents were continuing to go outside and smoke unsupervised. NA #7 stated the broken windows and glass had been there since incident happened and maintenance had placed a piece of cardboard and wood over the broken windows that were able to be removed by one hand. She revealed in her opinion this could have been dangerous to residents on the second-floor due residents being ambulatory or able to reach from wheelchair, easy removal of coverings placed on windows, and cognitive issues of residents causing them to hurt themselves or others. A telephone interview was conducted with Nurse #5 on 03/07/23 at 5:52 PM revealed she was working 11 PM to 7 AM on 02/02/23 when incident occurred. She stated apparently Resident #88 had gone outside that morning to smoke unsupervised and around 5:20 AM when entering back into the building, an unknown male intruder entered the building behind her and rode the elevator up to the second floor. Nurse #5 stated at first, she believed the unknown male intruder to be an agency staff due to him wearing scrubs but started noticing erratic behaviors such as standing in the dining room and taking off his jacket and kicking it in the air. She revealed Nursing Assistant #7 (NA) came out of the shower room and began watching the unknown male intruder while she went behind the nurse's station to call 911. She stated while NA #7 watched the unknown male intruder and told residents to go to their rooms, she went down to the first floor to escort officers up to second floor where they removed the unknown man from the dining room. Nurse #5 revealed she later learned the unknown male intruder had gone into the dayroom and broken out the windows, shattered the TV and knocked a hole in the wall. She stated the door leading to the smoking porch has always been kept unlocked at night for staff and residents to be able to go outside and smoke. She revealed a camera and two-way speaker had now been placed outside the door, but the door still had to be manually locked and to her knowledge continued to stay unlocked. Nurse #5 stated maintenance came up after incident and covered windows with just a board and cardboard which in her opinion was dangerous because the second-floor residents could easily remove coverings and hurt themselves or others. Observation of second-floor dayroom on 03/07/23 at 3:00 PM revealed two broken windows that had not been repaired. Both windows measured waist high while standing and chest high while sitting and would have been accessible to all ambulatory residents and residents who required wheelchairs and rollators. One window had been broken through first pane and had sharp edges still intact on window and broken glass inside window and on windowsill and was only covered with cardboard. The second window had been broken through both panes only leaving the window screen intact with broken glass inside window and on windowsill and was only covered by a wooden board. Both window coverings were easily removable by hand and accessible to all residents. The second-floor dayroom was still accessible to all residents but there were no residents located in dayroom during observation. An interview was conducted with Administrator #1 on 03/07/23 at 3:23 PM revealed she had started as the current Administrator of the facility on 02/27/23 and prior to that had been the Director of Nursing. She stated she was informed by Administrator #2 of the incident with the unknown male intruder entering the building and vandalizing the second-floor dayroom. Administrator #1 revealed to her understanding, Resident #88 was outside on the smoking porch of the facility during the early morning hours of 02/02/23 smoking unsupervised. She stated an unknown male intruder followed Resident #88 back into the facility and rode the elevator with her to the second floor. She revealed Resident #88 nor staff knew who the unknown male intruder was so staff called 911 and before the police could arrive to remove him from the facility, he vandalized the second-floor dayroom by shattering the television on the wall, knocked a hole in the wall, and had used a chair to break out two of the windows. Administrator #1 stated she was told no residents had witnessed the incident but was not aware if Administrator #2 had spoken with any of the residents about the incident or had completed an investigation. She revealed that she and Administrator #2 had discussed having a camera with a two-way speaker installed at the door leading to the smoking porch, but the door would still require to be locked manually. She stated the nursing staff on the first floor would be responsible for making sure door was locked afterhours. Administrator #1 revealed maintenance had placed a wooden board and a piece of cardboard to cover the broken windows until a contractor could come and repair the broken windows and to her knowledge the contractor had been contacted but no date scheduled for the repair. She stated the facility had scheduled smoking times for supervised smokers and Resident #88 had been assessed as requiring supervision while smoking and should not have been allowed outside to smoke unsupervised. An interview was conducted with Administrator #2 on 03/09/23 at 9:55 AM revealed he had been the facility Administrator from 2017 until 02/27/23 and was the acting Administrator when the incident occurred on 02/02/23. He stated he had received a text from staff about the incident and when he arrived at the facility the unknown male intruder had been removed from the facility and there were two officers there receiving statements from staff. He revealed that his understanding of the incident was that Resident #88 had gone outside earlier that morning to spoke unsupervised and she allowed an unknown male intruder to come back into the building with her and ride the elevator to the second floor with her. The Administrator #2 stated the unknown male intruder vandalized the second-floor dayroom by shattering the TV, knocking a hole in the wall, and breaking out two of the widows with a chair. He revealed he only received verbal statements from staff, but no written statements and no investigation was completed. He stated he did not speak with any of the residents on the second floor about the incident and was not aware that any of the residents had been up that morning or had witnessed the incident. The Administrator #2 revealed he did not have a formal meeting with staff about the incident, he and the Director of Nursing spoke and decided to implement the camera and two-way speaker to the outside of door leading to smoking porch. He stated the door would still have to be manually locked and first floor nursing was responsible for making sure the door was locked after-hours. The Administrator #2 revealed although the facility had implemented smoking times for supervised smokers, he knew there had still been issues with residents going out to smoke unsupervised all hours of day and night and issues with the doors staying unlocked, but they were working with residents and staff on these issues. He stated that Resident #88 was a supervised smoker and should not have been outside smoking unsupervised. He revealed he was responsible for having maintenance board up windows and was not aware that broken glass had been left in the window that was accessible to residents and that maintenance should have cleaned out windows and done a better job with boarding up the windows. The Administrator #2 stated that he had contacted a contractor about the windows, and they had come out and measured for the replacements but did not have scheduled date to come out and replace them. Observation of door leading to smoking porch on 03/07/23 at 6:20 PM being unlocked and Resident #88 sitting in wheelchair smoking unsupervised. An interview was conducted with Maintenance Director on 03/08/23 at 12:15 PM revealed on 02/02/23 he arrived at work around 7 AM and was informed by Administrator #2 of the vandalism that had occurred in the second-floor dayroom. He stated he accompanied Administrator #2 to the second-floor dayroom and observed the television on wall with shattered screen, a hole in the wall, and two broken windows. The Maintenance Director revealed he was asked by Administrator #2 to remove television from wall and to cover broken windows until a contractor could be notified to repair broken windows. He stated he removed television from wall and covered both broken windows with materials he had available at the facility. The Maintenance Director revealed one window was covered with cardboard and the other window had been covered by a piece of wood and both had been secured in place by three nails placed at the bottom of the window into the windowsill but were easily removable to give access to contractor when he came to measure for replacement windows. He stated he did not think to remove the broken glass out of the windows or from the windowsills before applying the coverings to windows or the broken glass being accessible to residents. He revealed Administrator #2 was responsible for contacting contractor for replacement windows and to his knowledge a contractor had been out to the facility to measure for the replacement windows, but no date had been scheduled for the repair. The Administrator was notified of immediate jeopardy on 03/07/23 at 5:50 PM. The facility provided the following plan for IJ removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #88 with a brief interview for mental status (BIMS) of 6 and assessed as a supervised smoker was outside on the smoking porch on 2/2/23 at approximately 5:20 AM smoking unsupervised. The door to the smoking porch was unlocked. An unknown individual who did not reside in the facility, was on the smoking porch with Resident #88 and came into the facility with her when she finished smoking, rode the elevator with her to the 2nd floor, walked by the nurse's desk to the end of hall and busted the windows of the day room with a chair and then busted the TV glass with a chair. Staff went into the medication room, locked the door and called 911 leaving the residents unsupervised. On 2/2/23 the Administrator came to the facility immediately following notification from the facility regarding the event at 5:20am. The Maintenance Director assisted the Administrator to cover the broken windows prior to residents getting up for the day. On 3/7/23 the windows in the dayroom on the 2nd floor revealed shards of glass exposed, one window covered with cardboard, and a second window covered with wood. The glass repair vendor visited the facility on the afternoon of 2/2/23 to obtain measurements for replacement and did not resecure the window covering. A quote was accepted for required repairs on 2/8/23 and the work is scheduled for completion. On 2/2/23 there were no other residents in the hallway outside their rooms when the event occurred. Once the stranger was removed from the facility the 3rd shift Nursing staff immediately completed a round on all residents on the 2nd floor to ensure their safety. There have been no reported injuries associated with the remaining shards of glass and this was validated with weekly skin assessments completed by the charge nurse and reviewed by the wound nurse on 2/8/23. An interview was completed with current smokers by the Director of Nursing, Assistant Director of Nursing and Nurse Managers on 3/8/23 to identify any attempts by unknown individuals to enter the facility through the smoking porch door. No new incidents were identified. . o 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 2/7/23 the Administrator secured an outside vendor who installed a doorbell and a camera at the smoking porch door that is monitored at the Nurses station. Beginning 2/7/23 the smoking porch door always remains locked. The key to this door is secured with the Administrator. Facility staff are able to open the door from the inside without the key to allow entry. When the doorbell rings, the nursing staff view the visitor on the camera prior to unlocking the door for entry. By 3/8/23 the Director of Nursing and Nurse Managers trained all facility staff including agency staff on this process. On 3/8/23 the Administrator secured an outside vendor to repair the identified broken windows. Work is scheduled to be completed by 3/15/23. On 3/7/23 the Maintenance Director securely covered the identified windows with plywood. By 3/8/23 the Director of Nursing and Nurse Managers trained all facility staff including agency staff on the facility policy for Workplace Safety, the process for managing a Non-Medical Emergency and allowing entry into the smoking porch door. This education includes, staff will immediately call 911, announce a code silver over the intercom, staff will assist residents into rooms, close doors, monitor hallways. All staff will be trained to request information from visitors entering through the smoke porch door regarding whom they are visiting or the purpose of the visit prior to allowing entry into the facility. This training will be completed by 3/8/23 by the Director of Nursing and Nurse Managers. On 3/8/23 a smoking attendant will be assigned daily by the Director of Nursing to monitor the smoking porch from 8am-8pm . All staff assigned to cover as a smoking attendant were educated by the Director of Nursing on 3/8/23 on the facility policy for smoking, managing Workplace Violence as outlined in the Emergency Preparedness Plan including the requirement to call 911 immediately in the event an unknown individual attempts to enter the facility through the smoking porch door. No one will be assigned this responsibility without receiving training. All current smokers have been educated regarding the facility smoking policy including a review of the smoking schedule for supervised smokers. All smokers have been educated to ring the doorbell and notify staff if a visitor or unknown individual approaches the smoking area. This education will be completed by 3/8/23 by the Director of Nursing and Nurse Managers. By 3/8/23 all staff will be trained by the Director of Nursing and Nurse Managers on notifying the Administrator and Director of Nursing of any building repairs that represent a safety concern for residents. After 3/8/23, the Assistant Director of Nursing and Nurse Managers will ensure no staff will be allowed to work, including any new hired staff and agency staff, without receiving this education. Effective 3/8/23 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 3/11/2023 On 03/16/23, the facility's credible allegation for immediate jeopardy removal effective 03/11/23 was validated by the following: Staff interviews revealed they had received training on workplace violence to include making sure to secure all residents, call code silver, call 911, and notify administration. Staff interviews also revealed they had received training on security of the facility and that doors are supposed to be locked at all times and staff making sure all doors are locked so all staff and visitors are using the smoking porch entrance so they could be seen on the camera and allowed entrance into the facility and on the smoking policy and that all residents are supervised smokers and there would be a smoking attendant during designated smoking times to ensure smoker safety and no residents allowed out to smoke except during smoking times. Observed broken windows on second floor dayroom to have been repaired and receipt showing they had been repaired on Friday 03/10/22. Observation of all entry doors being locked from outside and camera with two-way speaker working at smoking porch entrance and camera feed and speaker in working order at first shift nursing station. The Administrator had possession of all manually locked doors to ensure the doors stay locked and visitors are being allowed entrance into facility by staff. Audits were in process of being completed with all smoking residents about supervised smoking policy, smoking times, smoking attendant, and doors staying locked at all times and use of camera and two-way speaker. 2. Resident #68 was admitted to the facility on [DATE] with diagnosis that included: schizophrenia and Alzheimer's disease. A wandering assessment was completed on 07/31/22 and indicated that Resident #68 was at high risk for wandering. An annual Minimum Data Set (MDS) dated [DATE] indicated that Resident #68 was severely cognitively impaired and required limited assistance with mobility on the unit. The MDS indicated that Resident #68 had shown no wandering behaviors during the assessment reference period. A care plan initiated on 06/30/21 and updated on 1/19/23 revealed a focus area related to Resident #68 being an elopement risk/wanderer. The goal was for the resident's safety will be maintained through the review date. Interventions included address wandering behavior by walking with resident; redirect residents from inappropriate areas; Administer and monitor for the effectiveness and side effects of medications. A wanderguard was applied to Resident #68's left ankle. A nursing behavior note dated 6/27/22 at 10:33 PM revealed Resident #68 was up on the unit with increased wandering into other residents' rooms. Redirection was attempted and the residents Responsible Party (RP) was notified. A nursing progress note dated 7/30/22 at 11:08 PM written by Nurse #4 revealed at 10:57 PM Resident #68 was found inside an employee's vehicle, asleep in the backseat. Resident #68 was last seen by staff at 10:00 PM and provided incontinence care. Resident #68 was last seen by Nurse #4 at 9:30 PM when administered his medication. The note revealed Resident #68 had a wanderguard on his left lower extremity that did not sound when he exited the floor. Resident #68 exited using the back stairs, no alarm was sounded. The resident was assisted back to the unit by a Nurse Aide (NA) #5. No bruising or injuries were noted. Resident #68 was in no pain or discomfort. He was placed back in the bed and put on every 15-minute monitoring. Nurse #4 documented she had notified the Director of Nursing (DON). A Medication Administration Record (MAR) note dated 7/30/22 at 11:04 PM written by Nurse #4 revealed under the order to check wander guard placement for functioning every shift that Resident #68 needed a new wander guard because the current one in place did not sound. A wandering assessment was completed on 07/31/22 and indicated that Resident #68 was at high risk for wandering. On 3/8/23 at 1:47 PM an interview was conducted with Resident #68's Responsible Party (RP). During the interview she stated the facility contacted her on 7/31/22 to explain that Resident #68 was found in a Nurse Aide's car around 11:00 PM the night before. The interview revealed Resident #68 had not exited the building prior to that incident nor had he exited after the incident. She stated he wandered constantly in the facility and that is why he was admitted on to the locked unit. On 3/8/23 at 3:09 PM an interview was conducted with the Administrator. She stated at the time of the incident she was the Director of Nursing (DON) and was notified by Nurse #4 that Resident #68 had gotten out of the building via text message. She stated she did not see the message on her phone until the following morning. The interview revealed it was reported to her when staff were doing their rounding on the unit they did not see Resident #68. The Administrator stated Nurse #4 had last seen the resident at 9:30 PM when she was administering bedtime medication and Resident #68 was wandering on the unit. She stated NA #6 assisted him with incontinence care and helped him get into bed around 10:00 PM. It was reported at 10:30 PM Resident #68 had gotten back out of bed and was wandering the halls when Nurse #4 assisted him back to bed for the second time. The Administrator stated at 10:45 PM NA #5 had gone to his car when he saw Resident #68 laying in the backseat. She stated it was reported to her he then called into the building to get a staff member to assist the resident back into the building. The interview revealed Nurse #4 completed a head-to-toe assessment, initiated every 15-minute monitoring, and notified her. On 3/8/23 at 3:40 PM an interview was conducted with Nurse Aide (NA) #1. NA #5 stated he was about to end his shift at 10:45 PM. He stated when he got into his car parked outside of the facility in the parking lot, he sat down in the driver's seat when he started to feel like someone was behind him. He stated he looked behind him and saw Resident #68 laying down in the backseat of his car. The interview revealed he immediately jumped out of the car without locking the doors and ran into the building to the third floor to get Resident #68's Nurse Aide (NA). He stated NA #6 was responsible for Resident #68 and did not know he was missing when he saw her on the third floor. The two NAs went back down to NA #5's car and assisted Resident #68 get his shoes on and ambulate back inside of the building. He stated the staff from the third floor were all in shock because they had not noticed he was missing from his room. NA #5 stated Resident #68 was hot and sweating from being in the backseat of the car. He stated Resident #68 was startled and did not say much when they were assisting him inside. NA #5 stated he did not know the door was unlocked because he did not work on the memory care unit. On 3/8/23 at 4:01 PM an interview was conducted with Nurse #4. She stated she worked as agency staffing in the building since June 2022 and was responsible for Resident #68 on the night of 7/30/22. Nurse #4 stated she believed a man that was working the 3:00 PM to 11:00 PM shift went to his car and noticed the resident in his backseat asleep. She stated she did not know the resident was missing from the third floor until NA #5 came and said he had found the resident. Nurse #4 stated she had been charting in the dining room so she could see the door to the stairway because the lock had been broken for several weeks and she knew residents could get out. The interview revealed she was providing care to other residents and did not see the resident leave the unit. Nurse #4 stated she had not specifically told anyone the door was unlocked on the third floor because she felt like everyone knew the lock was broken to the door going to the stairway. The interview revealed the door had always been open since she had orientation in the building in June and staff did not have to put in a key code to get through the door. She stated the NAs on the floor were completing their last rounds on the 3:00PM to 11:00 PM shift when she saw Resident #68 out of bed wandering on the unit. She stated she assisted him back to his bed at approximately 10:30 PM. When the NA's brought Resident #68 back to the unit she assessed him for any injuries and saw no bruising. Nurse #4 stated Resident #68 was sweaty but did not seem in distress. She stated she assisted the resident back to bed and initiated every 15-minute monitoring. Nurse #4 notified the Director of Nursing (DON) via text message and gave report to the oncoming shift. On 3/8/23 at 4:24 PM an interview was conducted with NA#2. She stated she had been working on the third floor and was Resident #68's NA on 7/30/22. The interview revealed she had gotten Resident #68 situated in bed around 10:00 PM and went onto complete other resident's care. She stated the next thing she remembered was NA #5 came running onto the unit saying Resident #68 was laying in the backseat of his car asleep. NA #6 stated she was shocked along with everyone that had been working on the third floor to learn the resident was outside of the building. She stated when she got to the car, she saw Resident #68 laying in the backseat asleep with his hat off and shoes off in the floorboard. She stated Resident #68 was sound asleep. NA #6 stated Resident #68 was sweaty because the [TRUNCATED]