**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff, resident representative, and physician interviews, the facility failed to effectively supervise a resident with moderate cognitive impairment, repeated falls, and impulsive behaviors. Around 12:00 PM on 7/13/25 Resident #1 left the facility without staff's knowledge and ambulated approximately 0.6 miles from the facility in 90-degree heat with 60% humidity. Resident #1 was discovered sitting in a ditch on the side of the road approximately 0.6 miles from the facility. Two passersby stopped to help him and called Emergency Medical Services (EMS). In addition, Housekeeper #1 was on her lunch break and in a car when she happened to see him on the ground on the side of the road. Housekeeper #1 stopped to give Resident #1 assistance and stayed with Resident #1 until EMS arrived. Resident #1 was sent to the hospital for evaluation and treatment for low blood pressure, weakness, urinary tract infection, and pneumonia. There was a high likelihood for serious injury or death considering the resident's cognition, impulsivity and resulting medical conditions. This deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents.Immediate jeopardy began on Sunday, 7/13/25, when Resident #1 left the facility without staff's knowledge and walked 0.6 miles away from the facility. Immediate jeopardy was removed on 7/17/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and ensure monitoring systems put into place are effective.The findings included: Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including chronic obstructive lung disease, Parkinson's disease, repeated falls, spinal stenosis (a narrowing of the spinal vertebra causing nerve pain and weakness), extrapyramidal symptoms (side effects from taking antipsychotics; involuntary muscle movements), schizophrenia, and anxiety disorder. Physician medication orders for Resident #1 were as follows:Gabapentin (an anti-seizure medication used for nerve pain) 400 milligrams (mg) three times per day ordered on 4/18/25. Haloperidol (an antipsychotic medication used for control of severe agitation and aggression) 10 mg three times per day ordered on 4/18/25.Clozapine (an atypical antipsychotic used to treat mental illness like schizophrenia) 100 mg 3 tablets twice per day and Clozapine 50 mg twice per day (for a total of 350 mg twice per day) ordered on 4/21/25. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired. The MDS documented Resident #1 did not wander and had no behaviors. The MDS assessed Resident #1 to require partial assistance to walk 10 feet, and he was dependent on walking 50 feet or more. The MDS documented Resident #1 did not use ambulation devices. The MDS documented Resident #1 was taking antipsychotic medications, antianxiety medications, and medications for seizure disorder. The active care plans in effect on 7/13/25 were as follows: Fall potential due to impulsivity. The interventions included resident education to call for staff assistance, place common items within reach, and remind Resident #1 to use call bell; Behaviors related to the use of psychotropic medications. The goal stated Resident #1's behaviors would not cause him distress, and interventions included to monitor for behaviors, including elopement, delusions, hallucinations, aggression, or refusing care;Cognitive impairment and included the goal that Resident #1 would not have any complications due to cognitive impairment. Interventions for this care plan included observing for changes in cognition and reorient Resident #1 as needed;Antipsychotics use, with interventions to monitor for behaviors, monitor for adverse medication reactions, and provide psychiatric services; andLevel II PASRR (Pre-admission Screening and Resident Review, a screening tool used for residents with a serious mental condition to ensure the resident receives appropriate services). The care plan interventions included psychological/psychiatric interventions or consultation as ordered. A Physician Assistant (PA) note dated 7/3/25 documented an examination after an unwitnessed fall on 7/2/25 where Resident #1 reported he had gotten up too quickly and his legs got weak. The note documented generalized weakness, fatigue, leg weakness, and anxiety. Resident #1 was confused, with impaired insight, and oriented to person. The note documented a recommendation for Resident #1 to use a wheelchair for mobility due to weakness, and to continue fall precautions and neurological checks. A phone interview was conducted with Resident #1's Representative on 7/17/25 at 10:42 AM. The Representative reported Resident #1 had paranoia and had delusions with auditory hallucinations episodes in the past and on Saturday 7/12/25 Resident #1 called the Representative and told them that a resident at the facility wanted to fight him. The Representative reported Resident #1 did not seem to be upset or mention wanting to leave the facility. The Representative reported Resident #1 said he did not want to fight this other resident. The Representative reported he had not reported to the facility that Resident #1 had called him regarding the other resident wanting to fight him because Resident #1 did not seem to be upset or concerned. An interview was conducted with Nursing Assistant (NA) #1 on 7/16/25 at 4:04 PM. NA #1 reported she was assigned to Resident #1 on Sunday, 7/13/25, and he had appeared to be his normal self. NA #1 explained that Resident #1 was mostly independent with washing up, dressing, and toileting and rarely called for help. NA #1 reported she had seen Resident #1 sometime between breakfast and lunch, but did not recall the exact time, and reported he had not said anything to her about being fed up and did not seem to be upset at all. NA #1 reported that Resident #1 had a routine of sitting in the front lobby from just after breakfast until after lunch, when he would return to his room to rest before dinner. NA #1 reported Resident #1 had never showed any signs of exit-seeking. Nurse #2 was interviewed by phone on 7/17/25 at 9:06 AM. Nurse #2 reported she was assigned to Resident #1 on 7/13/25 and had administered his morning medications to him. Nurse #2 reported Resident #1 was just fine, no distress, no discomfort and he had approached her after breakfast for his morning medications. Nurse #2 reported Resident #1 did not act abnormally or mention that he was fed up. Nurse #2 explained that Resident #1 had a routine, and he would sit in the front lobby most of the day until after lunch and then return to his room to rest in the afternoon. Nurse #2 reported Resident #1 had not been exit-seeking or expressed any desire to leave. An interview was conducted by phone with Receptionist #1 on 7/16/25 at 1:41 PM. Receptionist #1 reported he worked weekends and some evenings, and he was familiar with Resident #1. Receptionist #1 reported on Sunday, 7/13/25 sometime before noon, Resident #1 had approached Receptionist #1 and asked him to open the front door so Resident #1 could sit outside on the front porch. Receptionist #1 explained he checked the elopement book (a book kept at the front entrance and at the nursing stations with pictures and demographics of residents at risk for elopement) and because Resident #1 was not in the elopement book, he unlocked the front door and allowed Resident #1 to exit the building and sit on the front porch. Receptionist #1 reported he did not notify a nurse that Resident #1 was outside, and he recalled several other times Resident #1 had requested to sit outside. Receptionist #1 explained that sometime after 12:00 PM, Housekeeper #1 came into the facility through the front door and notified him that Resident #1 was found on the side of the road. Receptionist #1 reported that Resident #1 did not act upset or agitated, and Receptionist #1 did not think anything was wrong with allowing Resident #1 to sit outside on the porch. An interview was conducted with Housekeeper #1 on 7/16/25 at 12:09 PM. Housekeeper #1 explained she clocked out for lunch at 12:00 PM on 7/13/25. Housekeeper #1 turned right out of the facility and right again onto the road that ran behind the facility. Housekeeper #1 reported that about one half a mile from the facility, she saw a man sitting in the ditch on the side of the road and recognized him as Resident #1. Housekeeper #1 described Resident #1 as wearing long pants, shoes, a short sleeve T-shirt, and he was sitting on the ground, sweating, and appeared to be shaking. Housekeeper #1 reported two bystanders were with Resident #1 and they reported they had called EMS. Housekeeper #1 reported Resident #1 had said he was fed up and left the facility but did not say anything more than that. Housekeeper #1 reported she stayed with Resident #1 until EMS arrived and then she returned to the facility, where she notified Receptionist #1 and the Nursing Supervisor (Nurse #1). A nursing note written by Nurse #1 dated 7/13/25 documented Resident #1 went to Receptionist #1 and requested to be let out to sit on the front porch. The Receptionist opened the door and Resident #1 went to the chairs on the front porch and seated himself. Receptionist #1 went back to his desk to attend to his job. Housekeeper #1 was coming back from lunch and stated she saw this resident sitting by the ditch in the grass. Housekeeper #1 reported she stayed with Resident #1 until EMS arrived, which was called bystanders. The note documented Resident #1's representative was notified Resident #1 was taken to the hospital for evaluation. Nurse #1 was interviewed on 7/16/25 at 3:11 PM. Nurse #1 reported she was the weekend supervisor, and she usually worked from 11:00 AM to 11:00 PM on Saturday and Sunday. Nurse #1 explained she had forgotten something in her car, and she saw Resident #1 outside on the front porch when she went out to her car. Nurse #1 reported Resident #1 did not appear upset. Nurse #1 was not certain what time she had gone to her car but recalled at 12:20 PM on 7/13/25 Receptionist #1 had reported to her that Resident #1 was discovered sitting in a ditch on the side of the road and EMS had been called. Nurse #1 reported she called the hospital to get a report on Resident #1, and called the police, the resident representative, the Administrator, the Director of Nursing (DON), and the on-call physician. The EMS report dated 7/13/25 at 12:02 PM documented a clinical impression of generalized weakness with behavioral/psychiatric episode. Vital signs for Resident #1 were as follows: Blood pressure 102/58 at 12:16 PM, 93/52 at 12:18 PM, and 93/54 at 12:19 PM (normal 120/80), pulse 77 at 12:16 PM, 133 at 12:18 PM, and 132 at 12:19 PM (normal 60-100). Temperature at 12:16 PM was 98.3 (normal 98.6). The report documented Resident #1 had left the facility after an altercation with another resident. Resident #1 reported weakness, and he was assisted to stand and transfer to the stretcher where he was transferred to the hospital emergency department for evaluation. Emergency Department records dated 7/13/25 at 12:49 PM documented Resident #1 was walking for 45 minutes when a bystander called for EMS. Resident #1 reported he left the facility because he thought another resident was going to beat him up. Resident #1 reported weakness and buttocks pain from walking and sitting on the ground. Resident #1 was assessed to be alert and oriented with a blood pressure of 81/64. The note documented that Resident #1 was fed up with the facility and wanted to take a long walk. Resident #1 reported feeling disoriented, but he was assessed to be alert and oriented to person, place, time, and situation. At 1:05 PM his temperature was 100.3 degrees, heart rate 114, respiration rate 30 (normal 12-20), and blood pressure 94/61. Blood work revealed his blood glucose was elevated at 170 (normal 70-120) and lactic acid (a by-product produced by the body after exercise; elevated levels can be attributed to infection and poor oxygenation) was elevated to 3.6 (normal 0.5-2.2). A chest x-ray showed possible pneumonia. The note concluded that Resident #1 had no signs of trauma, no neurological signs indicating a stroke and he was admitted to the hospital with altered mental status, elevated lactic acid level, acute kidney injury, pneumonia, and lightheadedness. Hospital records were reviewed and urinalysis with culture and sensitivity was collected on 7/13/25 and the results on 7/14/25 showed greater than 100,000 e. faecalis (a bacteria that causes a urinary tract infection). A nursing note dated 7/13/25 documented Resident #1 was admitted to the hospital on [DATE] and remained hospitalized on [DATE].An observation of the route from the facility to the place where Resident #1 was discovered in a ditch on the side of the road was conducted by car with Housekeeper #1 and the Administrator on 7/16/25 at 12:25 PM. Turning right from the parking lot, the road was two lanes with a 35 miles per hour speed limit. The road did not have a sidewalk, and there was an incline from the facility to the stop sign at the intersection of the road. Turning right at the stop sign, this road was also 2-lane with a speed limit of 35 miles per hour with several curves and a slight incline. There was no sidewalk on this road and houses were located back from the road. The distance from the facility to where Resident #1 was located was approximately 0.6 miles. While the observation of the route was taking place, the Maintenance Director measured the distance from the front sitting area on the porch to the road as 223 feet. The weather on Sunday, 7/13/25, was mostly clear with partial clouds, the temperature was 90 degrees Fahrenheit and humidity was 60% and no wind according to historic weather on timeanddate.com. According to the national weather service, a heat index of 90 degrees and 60% humidity would be equivalent to 100 degrees Fahrenheit. The Physician was interviewed on 7/17/25 at 10:05 AM by phone. The Physician reported Resident #1 had not mentioned wanting to leave the facility and had not had a history of attempting to leave the facility. The Physician reported that Resident #1 spent most of his time sitting in the lobby and he had seen him sitting on the front porch a few times. The Physician reported he did not believe Resident #1 was cognitively able to leave the facility alone and reported Resident #1 had a significant chance of being injured by walking in 90-degree heat and without supervision. The DON was interviewed on 7/17/25 at 1:50 PM and she reported that new admission residents were assessed for elopement risk, and then quarterly and as needed after. The DON explained that Resident #1 had been assessed as a low risk for elopement and had no exit seeking behaviors, and for him to walk away from the facility was out of his normal behavior. The DON reported she was not aware Resident #1 had told his family that another resident wanted to fight him. The DON reported a binder was kept at the front desk and at each of the nursing stations with a picture of each resident who was at risk of eloping, and staff were expected to check the binder before allowing any residents to exit the building unsupervised. The Administrator was interviewed on 7/17/25 at 10:55 AM and he reported he started as the facility administrator on 7/14/25 and the former administrator was notified by phone on 7/13/25 when Resident #1 was found on the road one-half mile from the facility. The Administrator was notified of immediate jeopardy on 7/17/25 at 12:25 PM. The facility implemented a credible allegation of immediate jeopardy removal on 7/18/25.Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 diagnoses included (in part); Spinal stenosis in lumber region, pulmonary fibrosis, Chronic Obstructive Pulmonary Disease (COPD), Parkinson's Disease, and anxiety disorder. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 04/25/2025 indicated that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 10 (which indicated moderate cognitive impairment). Resident #1 was also assessed to be always understood and able to understand others. Further review of Resident #1's MDS assessment indicated Resident #1 had no short-term or long-term memory problems. Review of Section GG (functional status) of the MDS assessment indicated Resident #1 is independent with ambulation, functional cognition, and was coded with no use of functional devices (such as wheelchair, cane, and/or walker). Review of Resident #1's elopement risk assessment dated [DATE] indicated a low risk for elopement. On 07/13/2025, between 11:30 am - 12:00 pm, Resident #1 walked to the front receptionist desk and requested to sit on the front porch. Resident #1 was not an elopement risk per initial assessment; therefore, was not in the Elopement Book (Elopement Book is a binder that contains residents who are at risk for elopement). The receptionist opened the front door and allowed Resident #1 out to sit on the front porch. Resident #1 walked out of the facility without the use of a wheelchair to sit on the front porch. Historically, Resident #1 routinely sat on the front porch. The facility front porch is not enclosed. At the time of exit on 7/13/2025, Resident #1 had on sweatpants, a T-shirt, and enclosed shoes. The clothing was appropriate for the weather conditions at the time he exited the facility. A facility housekeeper, Housekeeper #1, observed Resident #1 sitting on the grass, about half a mile from the facility during her lunch break. Housekeeper #1 further reported there were a couple of bystanders with Resident #1 who had already called 911/Emergency Medical Services (EMS) at the time she arrived at the scene. Housekeeper #1 remained with Resident #1 until Emergency Medical Services (EMS) arrived to transport Resident #1 to the local hospital for further evaluation and treatment. Housekeeper #1 then drove back to the facility and informed the facility Registered Nurse (RN) Supervisor she observed Resident #1 sitting on the grass about half a mile away from the facility beside the road and that Resident #1 was transported to the local hospital for further evaluations. Resident #1 was admitted to the local hospital for further evaluation and treatment on 07/13/2025. Resident #1 hospital records indicate he was admitted to the hospital with primary diagnosis of hypotension. Resident #1 remained in Hospital as of 7/16/2025. Upon return Resident #1 will be reassessed as a re-admission to the center following the revised process outlined below. The weekend supervisor completed a headcount of all residents in the facility; all residents were accounted for as of 07/13/2025. The facility placed a sign on the front door on 7/14/2025 to alert family and visitors not to assist residents outside without checking with the receptionist first and in-serviced Receptionist #1 on 7/14/2025. The Governing body led by the Regional Clinical Director, facility Administrator and Director of Nursing in collaboration with the selected members of the facility Quality Assurance and Performance Improvement (QAPI) committee conducted the root cause analysis on 07/14/2025, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. The root cause analysis (RCA) identified that the alleged noncompliance resulted from the failure to reassess Resident #1 when noted to have change in his exit seeking behaviors on 7/13/2025. The RCA concluded that Resident #1's elopement resulted from not being assessed as an elopement risk. The Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 completed elopement assessments on all residents in the facility on 7/14/2025 to identify any resident at risk for elopement. All identified residents at risk for elopement were added to the Elopement book at each nurse's station and the front desk for easy identification. On 07/14/2025, the Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 updated care plans to include elopement risk interventions to prevent any successful attempts at elopement for all residents identified to be at risk. The Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 reviewed and updated the Elopement books to include resident demographic information and resident pictures for easy identification. This was completed on 07/13/2025 & 07/14/2025. These binders are located at each nurses' station and at the front desk. 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. Effective 07/16/2025, all new residents will have an elopement risk assessment completed on admission, readmission, quarterly, and with any changes in exit-seeking behavior, by the licensed nurse on duty. Any resident identified to be at risk for elopement will have appropriate interventions in place and an updated care plan for elopement. The nurse on duty will update residents' information in the elopement binder to include demographic information and pictures. Effective 07/16/2025, the facility clinical team including the Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1, and/or Unit Coordinator #2 revised the process of reviewing all new admits/readmits in a daily clinical meeting. This includes provisions for reviewing elopement assessments to ensure they are completed and documented in electronic medical records, appropriate care plans are in place, and the elopement binders are updated. Any discrepancies identified will be corrected promptly. Findings of this systemic change are documented on the Daily Clinical Meeting Report Form located in the Daily Clinical Meeting Binder. The Regional Clinical Director in-serviced the DON/ADON on 7/13/2025 & and 7/14/2025 on how to direct the nursing staff upon any identification of exit-seeking behaviors. These steps will be implemented to include completing the Elopement Assessment, updating the Care Plan, and updating the information in the Elopement Risk Book at each nurse's station and front desk. 100% education of all current staff, including full-time, part-time, and as-needed nursing employees, will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1 and #2). The emphasis of this education includes, but is not limited to, the importance of completing elopement assessments on admission, readmission, quarterly, and upon changes in exit-seeking behaviors. Staff education also focuses on the importance of updating care plans for each resident determined to be at risk for elopement, maintaining updated elopement binders at each nurse station and the front desk, and ensuring residents listed in the elopement binder are not allowed to exit the facility independently. This education will be completed by 07/16/2025. Any staff members not educated on or by 07/16/2025 will not be allowed to work until they are educated. This education will be provided annually and will be added to the new hire orientation for all new employees effective 07/16/2025. Immediate Jeopardy Removal date: 07/17/2025 The validation of the credible allegation of immediate jeopardy removal was conducted on 7/18/25 by interviewing nursing assistants, nurses, administration, housekeepers, receptionists regarding elopement prevention, elopement assessments, monitoring residents for exit-seeking behaviors, updating the elopement binders, and care plans. Sampled residents' medical records were reviewed for updated elopement assessments and elopement care plans. Education was reviewed. The immediate jeopardy was removed on 7/17/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and physician interviews, the facility failed to protect Resident # 2's right to be free from resident-to-resident abuse for 1 of 6 residents reviewed for abuse. On 12/7/2024, Resident #1 who had a history of aggression and anger outbursts; and received as needed antipsychotic medications, required a net bed (bed with mesh tent over hospital bed to prevent a person from getting out of bed) and a sitter while hospitalized , wandered into Resident #2's room and pulled Resident #2 from his bed while Resident #2 was asleep. Resident #1 struck Resident #2 in the throat and upper body with his foot and his fist. Both Resident #1 and Resident #2 were sent to the hospital for further evaluation on 12/7/2024. The resident-to-resident abuse had a high likelihood of resulting in serious physical and psychosocial harm. A reasonable person expects to be protected from physical abuse in their home and would suffer trauma such as feelings of fear, anxiety, and intimidation. The findings included: Hospital admission history and physical dated 10/2/2024 stated Resident #1 had been brought to the emergency department due to aggressive behavior displayed at a group home shortly after admission. Resident #1 became hostile towards staff and pulled a television off the wall. Telepsychiatry note dated 12/2/2024 while Resident #1 was in the hospital, revealed he was oriented only to self, displayed no behavioral concerns and was tolerating an increased dose of Seroquel without oversedation. The note further revealed Resident #1 had a nurse and/or sitter in the room and there were no psychiatric contraindications to placement. Hospital progress note dated 12/3/2024 stated Resident #1 was brought to the emergency department on 10/2/24 due to complaints of aggressive behavior and confusion. Resident #1 did have on and off anger outbursts and needed the net bed off and on. Resident #1 was receiving as needed (PRN) intramuscular (IM) Zyprexa (antipsychotic medication). The progress note further stated Resident #1 remained in the net bed which was opened with sitter present. Review of hospital progress note dated 12/4/2024 stated Resident #1 must remain out of restraints and the net bed for 48 hours prior to placement. The note indicated Resident #1 wanted to stay in the net bed despite it being discontinued. Hospital Discharge summary dated [DATE] included: - Resident #1's admission to the hospital on [DATE] was due to complaints of aggressive behavior and confusion - Psychiatry had been consulted to evaluate and assist with Resident #1's behavioral disturbance - Psychotropic medications had been adjusted by psychiatry: Seroquel 100 milligrams (mg) twice daily (BID); Zyprexa for anxiety as needed (PRN) Resident #1 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF) and progressive dementia with behavioral disturbance. The admission/readmission nursing collection tool written by the interim Director of Nursing dated 12/6/2024 at 2:15 PM revealed Resident #1 was ambulatory and wandering in and out of other residents' room beginning at arrival to the facility. There was no intervention documented for Resident #1's wandering or potentially aggressive behaviors. Resident #1 was [AGE] years of age, 70 inches in height and weighed 121 pounds (lbs.). Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident with left hemiparesis (paralysis on one side of the body), anxiety, and major depression. The annual Minimum Data Set (MDS) assessment dated [DATE], stated Resident #2 was severely cognitively impaired. The MDS revealed Resident #2 did not display physical or verbal behaviors toward others and had no rejection of care. Resident #2 was dependent on staff for all activities of daily living (ADL) and had upper and lower extremity impairments. Resident # 2 was [AGE] years of age, was 70 inches in height and weighed 129.2 lbs. The review of nurse progress note written by Nurse #1 dated 12/7/24 stated Resident #2 had been attacked by Resident #1 and had been pulled from bed to floor by arm, bumping his head. Resident #2 had complained of head, arm, back, throat, and leg pain. Nurse #1 called the facility Administrator who advised Nurse #1 to send both Resident #2 and Resident #1 out for evaluation. Nurse #1 called the facility provider and contacted Resident #2's emergency contact to notify of incident and transfer to hospital. The police department responded, and Resident #2 was transported to the hospital by Emergency Medical Services (EMS.) Interview with Nurse #1 on 1/7/25 at 9:24 AM revealed she recalled getting to her shift around 11:00 PM on 12/6/24. She stated she observed Resident #1 walking toward the room they originally had him in upon admission. She believed the facility moved Resident #1's room due to his original roommate having a tracheostomy (a surgical hole in the windpipe that helps with breathing). She stated the facility was nervous due to Resident #1 wandering around his roommate and fear he would touch his roommate's tracheostomy equipment. Resident #1 was moved to a 4-person room. She stated Resident #1 wandered all night in several resident rooms. Nurse #1 revealed due to his wandering she had Resident #1 sit with her at the nursing station. The resident watched a little of a movie she had on an i-pad. When Resident #1 started to fall asleep, she took Resident #1 to his room to sleep. She stated he did not sleep long because she recalled being approached by nursing assistant (NA) #2 and asked where the other nurse could be located. NA #2 reported her resident (Resident #1) was dragging Nurse #1's resident (Resident #2) out of his bed. The nursing assistants she recalled notifying her were NA #1 and NA #2. Nurse #1 stated when she got to Resident #2's room he was lying on the floor like a pretzel and screaming. Resident #2 had his night gown around his upper torso and his brief was still in the bed. Resident #2 kept screaming why did Resident #1 do that to him. She stated one of the NAs went to locate the other nurse but could not locate her. While in Resident #2's room, Resident #1 was standing against the wall with his hands in his pockets, but he looked as if he was going to aggress towards Resident #2 again. She and the NAs could not get Resident #1 from Resident #2's room although staff were trying to redirect him out of the room. She further revealed Resident #1 stated it was his bedroom, and his bed and that's why he attacked Resident #2. Nurse #1 explained due to it being difficult to redirect Resident #1 she had NA #1 and NA #2 stay with Resident #1 while Nurse #1 took Resident #2 to the nursing station where the other nurse was located. She recalled the police showing up shortly after. She recalled Resident #2 having a reddened area to his neck and Resident #2 stating his head hurt, his back hurt and she believed he also mentioned his leg. Nurse #1 indicated she contacted the Administrator and the Interim Director of Nursing. She indicated after the incident she became aware that Resident #1 had tendencies to be aggressive and had an aggressive episode at his last placement. She was unaware of any interventions put into place for Resident #1's potentially aggressive behaviors. Interview with NA #1 on 1/7/25 at 7:30 PM revealed she recalled Resident #1 was in the process of a room change upon her arrival to the facility 12/6/24. She indicated her shift was from 7:00 PM to 7:00 AM. The only report she recalled being provided about Resident #1 was that he was a new admit, he walked and might have been incontinent. She was unsure of why Resident #1 was being moved but stated he was being moved to a 4-person room. NA #1 stated as the shift went on it got harder and harder to redirect Resident #1. Resident #1 would wander in and out of other resident rooms and NAs had to continuously tell Resident #1 that it was not his room. She stated other residents in the facility started to complain about Resident #1 standing in their doorways or entering their rooms, so she notified Nurse #1. She stated she was told by Nurse #1 to redirect Resident #1 to get him familiar with his room. NA #1 recalled when she would take Resident #1 to his room, he would continue to state that it was not his house. NA #1 stated after getting a resident a snack she observed Resident #1 standing over Resident #2 yelling at Resident #1 to get out of his room. She told Resident #1 that he was not in the right room. NA #1 stated before she could get all of her words out, Resident #1 grabbed Resident #2 by his contracted arm and with one hand tossed Resident #2 onto the floor from his lowered bed. NA#1 stated it happened quickly; she screamed. She stated once Resident #2 was on the floor, Resident #1 punched and stomped on his neck and chest area. NA #1 described Resident #2 as not being able to protect himself. She further revealed the incident happened so quickly; Resident #2 didn't have time to realize what was going on. Resident #2 asked out loud, why is he doing this to me. Referring to Resident #1. NA #1 revealed she had to push Resident #1 back from Resident #2 to get between them. NA #1 stated she had to stay between Resident #1 and Resident #2 because Resident #1 was continuously trying to get to Resident #2. NA #1 stated she asked if Resident #1 was ok and called out for help. Resident #2 had a red area to his throat and stated his neck hurt. She stated NA #2 came to assist and went to get the nurse. She recalled Nurse #1 stayed with NA #1 and the other Nurse was assisting with getting Resident #1 out of Resident #2's room. She stated after they got Resident #1 out of the room, he opened the door and re-entered the room. Resident #1 continued to state Resident #2 was sleeping in his bed and with his wife. NA#1 described the situation as a street fight. An interview was conducted with NA #2 on 1/7/25 at 8:20 PM. NA#2 indicated she was assigned the rehabilitation hall 12/6/24 and NA #1 was assigned to Resident #1's hall. She recalled hearing NA #1 yell out for help. When she arrived at Resident #2's room, NA #1 looked in shock. NA #2 indicated as soon as she got to the door of Resident #2's room, she observed Resident #1 grab Resident #2 by his arm and his leg and drag Resident #2 from his lowered bed to the floor. Resident #1 stomped on Resident #2's upper body with his foot while he was on the floor. She stated Resident #1 was angry and moved quickly. NA #2 described Resident #2 as a resident who could not defend himself against Resident #1's attack. Resident #1 kept saying it was his room. NA #2 stated she called for a nurse while she and NA #1 got in-between Resident #1 and Resident #2. NA #2 stated she had to grab Resident #1 by his arm to help get him away from Resident #2. Nurse #1 arrived first then Nurse #2. She recalled Nurse #1 trying to get Resident #1 from Resident #2's room. She stated after Resident #1 was removed from Resident #2's room he re-entered the room and demanded Resident #2 get out of what he believed was his bed. Interview with Nurse #2 on 1/7/24 at 9:53 AM revealed she recalled meeting Resident #1 as he was walking down the hall 12/6/24. Her assigned shift on 12/6/24 was 11:00 PM to 7:00 AM. Nurse #2 stated she had gotten in report that there was a new admission who was confused and wanted to go home. She did not recall getting the report that Resident #1 had a history of aggression. She assumed it was Resident #1 due to him looking lost. Nurse #2 recalled introducing herself and told Resident #1 she would walk him to his room. He was assigned to a room with 3 other residents. She stated on the way to Resident #1's room she recalled a couple of residents stating Resident #1 had walked into their rooms. Nurse #2 reoriented Resident #1 to his room, but she recalled being approached later by an NA (not known) and asked if Resident #2 was hers. Before she could answer the NA, Nurse #1 stated the NA revealed Resident #1 was hurting Resident #2. Nurse #2 stated 2 NAs (NA #1 and NA #2) had already separated Resident #1 and Resident #2. She further recalled Resident #2 being on the floor and Resident #1 having already been removed from the room. Nurse progress note dated 12/7/2024 at 7:54 AM written by an unknown nurse stated NA #1 notified Nurse #2 that Resident #1 pulled Resident #2 out of his bed to the floor then stomped on him. Nurse# 2 called Emergency Services, medical provider and Resident #1's representative. Review of the initial allegation report dated 12/7/24 revealed an allegation of abuse. The details of the report stated Resident #1 pulled Resident #2 from his bed while he was asleep. Resident #1 began striking Resident #2 in the throat. Resident #1 attacked Resident #2 for no reason. Resident #1 and Resident #2 were both separated. The police had to be called to the facility as staff could not get Resident #1's behavior under control. A head-to-toe assessment was completed, and no injuries were noted to Resident #2. Both residents were sent to the hospital for additional assessments. Resident #1 was removed from the facility with law enforcement assistance. The initial report was completed by the Administrator. Review of emergency department note dated 12/7/2024 stated the first provider evaluation of Resident #2 was completed at 6:34 AM. Resident #2 underwent computed tomography (CT) of his head, pelvis, chest, spine and abdomen. All CT scans were negative and showed no injuries or acute changes. Resident #2 was discharged back to the facility 12/7/2024. The emergency department note further indicated Resident #2's psychiatric status was cooperative, and he had normal judgment. Review of Resident #1's emergency department note dated 12/7/24 revealed a chief complaint of aggressive behaviors. The history of present Illness stated Resident #1 was an [AGE] year-old male, who presented to the emergency department for evaluation of aggressive behaviors. He was brought by EMS for wandering into another patients' room and pulling him out of bed. Patient states he thought that the other resident was in his bed. Resident #1 did not fall and had no injuries. An interview was conducted on 1/7/25 at 3:17 PM with the Nurse Liaison. She revealed all the nursing liaisons had access to referrals. She stated the case manager for the hospital would do a referral in which a bedside visit would be conducted. During the bedside visit the resident was assessed for medical readiness. The Nurse Liaison indicated she was assigned to the facility to assess referrals for potential admissions. She stated she discusses the referral with the Admissions Director who also had access to the potential referrals medical chart. She would verbally tell the facility what she observed while at bedside. The Nurse Liaison stated she would ask the hospital if restraints could be removed for 48-hour prior to admission. The hospital would not remove the restraints unless the resident was stable. The Nurse Liaison indicated she assessed Resident #1 as stable for admission to the facility because he did not have a restraint or a sitter for 48 hours and was not being chemically restrained. Interview with the Admissions Director on 1/6/24 at 2:47 PM revealed the admission process was once a resident's referral was uploaded, she would ask about behaviors, wounds, medical equipment needed, etc. The nurse liaison would conduct a bedside visit with the potential admission. If a resident had restraints the nurse liaison would inquire when the restraints would be discontinued because the facility did not admit residents who required restraints. Residents could be admitted to the facility if they were not displaying the behavior they were admitted to the hospital for and had to be without a sitter or restraint for 48 hours prior to admission. The Admissions Director indicated she was not clinical, so nurses did review the information provided by the hospital as well. She indicated that prior to Resident #1's admission she recalled discussing his admission with his guardian and was further aware of the resident having aggressive behaviors. She indicated she recalled the hospital documentation indicated Resident #1 was aggressive with staff and not residents. The Admissions Director could not recall who conducted Resident #1's bedside visit. Interview with the former interim Director of Nursing (no longer employed) via telephone on 1/6/25 at 3:45 PM revealed it was the responsibility of the nurse to complete admission assessment. Within the first 24 hours an interim care plan should be developed. She stated sometimes the discharge summary was not available upon a resident's admission and was unable to be used in developing the admission assessment. She could not recall if Resident #1's discharge summary was available for review upon his admission. The interim Director of Nursing stated she documented Resident #1 was wandering in other residents' rooms upon admission because she was approached by nursing and NAs. She further stated nursing staff had indicated Resident #1 was difficult to redirect. She stated she knew nothing about the resident prior to admission due to having several admissions in a couple of days. She indicated she did not recall implementing interventions due to his wandering. Nursing staff were aware they needed to redirect residents who wandered, provide them with activity, and in the instance, they became aggressive implement a one on one. She recalled being contacted by phone that Resident #1 had gone into Resident #2's room, grabbed Resident #2 by his contracted arm, pulled him out of bed and beat him. Resident #2 was sent to the hospital to be assessed for injuries. Interview with The Administrator on 1/7/25 at 2:12 PM revealed potential admissions were initially screened by nurse liaisons. The nurse liaison would look at the resident's physical condition and if the resident was being watched by a sitter. She stated if the resident had a sitter in place they would communicate that to the facilities admission Director. Prior to admission a resident would need to be without a sitter or a restraint for 24 to 48 hours. She further revealed nursing should review a resident's record prior to admission. The Admissions Director should have access to the same information and would bring the information to the facility to review for the potential admission. The baseline care plan was put into place by the admitting nurse. The Administrator stated she was not aware Resident #1 was displaying wandering behaviors upon admission until after the incident occurred. She stated she expected the nursing staff to let her know Resident #1 was wandering so she could make a determination and included the DON for interventions. She stated interventions could be put into place such as one on one. The admission/readmission form included the interim plan of care. The admission/readmission form in the electronic medical record (PCC) form did not identify a place for behaviors. It only populated interim plan of care areas of side of effects of antianxiety, antipsychotic and antidepressant medications. The Administrator stated she believed the breakdown in communication was between the Nurse Liaison to the Admissions Director. Once the information was passed by the nurse liaison they were hands off. She stated the facility depended on the nurse liaison's expertise and that they were getting good information from the hospital. Interview with the Regional Consultant on 1/7/25 at 4:00 PM revealed the in-house admission nurse should review the discharge summary for potential behaviors and review the residents' medications. She stated Resident #1 had been cleared by psychiatry in the hospital and he was admitted to the facility. She stated when a resident began wandering in the facility, staff would have been expected to redirect the resident and to reorient him to the facility. She stated Resident #1's room was moved shortly after his admission due to his wandering. Interview with the Physician on 1/8/25 at 2:26 PM revealed it was his expectation that the facility reviews a resident discharge summary when available prior to potentially admitting a resident to the facility. As far as screening a resident prior to admission he was unaware of the process. He further stated he expected he could trust the discharge summary and the hospital discharge team when they indicated a resident was stable. The Administrator was notified of Immediate Jeopardy on 1/8/25 at 12:31 PM. The facility implemented the following Corrective Action Plan with a completion date of 12/12/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Facility failed to protect resident #2 from abuse after admitting resident #1 on 12/06/2024. On 12/7/24 at 5:30AM, Resident #1 wandered into Resident #2's room, who was a severely cognitively impaired resident and had impaired movement of both upper and lower extremities, while Resident #2 was asleep, and pulled him from his bed to the floor. Resident #1 physically attacked Resident #2 after he was pulled out of bed by his left arm (contracted) to the floor. Resident #1 stomped on Resident #2's upper body close to his neck and punched Resident #2 repeatedly. The 2 Residents (Resident #1 and Resident #2) were separated by 2 Nursing Assistants. Resident #2 was observed to have redness to his neck. Resident #1 stated he fought Resident #2 because he though Resident #2 was in his bed. Resident #2, who was receiving an anti-coagulant, complained of pain in his head, arm, back, throat, and leg pain. Nurse #1 notified the administrator and medical provider immediately. Resident #2 was sent to the hospital for evaluation. A computed tomography scan (CT) scan and chest x-ray revealed no injury. He was discharged back the facility on 12/7/24 with no new orders. Resident #1 was sent out immediately to the hospital for an evaluation. Resident # 1 was admitted to the hospital for eval and remains in psychiatric care. Resident #2 received a trauma screen assessment following the incident on 12/10/24 by Social Work staff. The 12/10/24 trauma screen indicated he was not fearful, in good spirits and not affected by the trauma. The trauma screen assessment recognizes Trauma Informed Care and acknowledges that residents who are trauma survivors may experience emotional, physical, and/or psychological difficulties that should be addressed immediately upon admission and throughout their stay in the Center. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Current residents are at risk for deficient practice. The last seven days of progress notes of all residents as of 12/10/24 were reviewed for dementia behaviors including aggression, wandering, yelling, delusions, hallucinations, paranoia to ensure interventions are in place including psychiatric services as appropriate on 12/10/24 by the Administrator. All residents identified are receiving effective interventions and services from psych services as indicated. Current resident MD notes, incident accidents reports for behaviors or any resident to resident incidents were reviewed in the last 14 days for order of psychiatric consult, and referrals made if appropriate. This was completed 12/10/24 by the Director of Nursing and the Unit manager. All identified residents from review are currently being seen as indicated by psych services. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Resident #1 has not resided at the facility since the incident on 12/7/2024. Administrator, Director of Nursing, and/or the Unit Manager ensured training to all staff in all departments utilizing online learning education modules on dementia care to include wandering and managing aggressive behaviors. This education includes examples of dementia, wandering and aggressive behaviors and ways to prevent and manage these behaviors. This was completed 12/11/24. Including agency staff. All staff in all departments were educated by Administrator or designee that when a resident exhibits aggressive behavior, they will stay with them to provide one-on-one supervision and immediately notify a supervisor. This was completed 12/11/24. The Administrator or Director of Nursing will make the decision how long the resident will continue to receive one on one based on investigation. Any staff who did not receive the education by the compliance date was removed from the schedule until completed; this will be completed by the Director of Nursing. All new staff will receive education during the orientation process prior to floor training. All agency staff will be educated prior to beginning their first shift. This will be completed by the Director of Nursing or designee to ensure education is completed. Social Work staff are responsible for the initiation of psychiatric services when a consultation is placed. Administrator provided training to current social work staff to ensure psychiatric services referral are initiated following dementia behaviors including aggression. This was completed 12/11/24. The Administrator provided training to all current Social Work staff on 12/11/24 to ensure they will notify Medical Provider and Administrator when a resident or responsible party refuses psychiatric services. The Administrator provided education to all current Medical Providers on 12/11/24 that they will discuss on a case-by-case basis with the Administrator if services for psychiatry can be managed by the Medical Provider in house or if involuntary commitment is needed to provide psychiatric services. This is for resident or responsible parties who refuse psychiatry services. Director of Nursing will educate all staff on abuse and neglect related to what abuse is, the types of abuse to include resident to resident abuse and reporting. This was completed by 12/11/24. All new staff will receive education during the orientation process prior to floor training. All agency staff will be educated prior to beginning their first shift. This will be monitored by the Director of Nursing to ensure completion of education. All Nurses are responsible for notifying Medical Providers of each instance of change in condition which includes dementia behaviors and aggression. This practice is a current process as of 12/11/2024. In reviewing a resident for potential admission, the facility admission staff reviews their history and physical and current hospital documentation including diagnosis and medication management. This process is currently in place as of 12/11/2024. Any potential admissions identified prior to admission with behaviors will be reviewed prior to admission by nursing to ensure interventions needed for potential behaviors and staff in-serviced on interventions as needed. After reviewing potential admission if resident behaviors identified are outside facility capabilities to manage admissions can deny admission of potential resident. Administrator or designee educated social work staff on 12/11/24 that when admitting a resident that has behaviors such as delusions/paranoia they will interview potential resident responsible party for information regarding current triggers and history of behaviors. This information will be communicated to the Director of Nursing. The Administrator educated The Director of Nursing on 12/11/24 that nursing will initiate interventions as appropriate at time of admission based on resident history related to aggressive behaviors and residents with signs of or history of wondering. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; On 12/11/24 the Quality Assurance committee to include Director of Nursing, Assistant Director of Nursing, Director of Admissions, Unit Coordinator, Maintenance Director, Medical Records, Director of Social Work, Activities Director, Business Office Manager, Human Resources, Administrator, Assistant Administrator, Director of Rehabilitation Services, Medical Director met and initiated the following monitoring plan. Director of Nursing and/or Unit Managers will review current resident and new admissions progress notes for dementia behaviors including aggression and ensure interventions are in place on resident baseline care plan daily Monday- Friday x 4 weeks then 3x a week x 4 weeks and then weekly x 4 weeks. Monday audits will include the prior Friday, Saturday and Sunday. Director of Nursing or designee will audit physician progress notes and ensure that any psychiatric referrals have been consented and sent to psychiatric services Monday- Friday x 4 weeks then 3x a week x 4 weeks and then weekly x 4 weeks. Monday audits will include the prior Friday, Saturday and Sunday. The Activity Director or designee will monitor Resident # 2 for changes in activity participation and will notify administrator of any changes for psychiatric intervention. This will occur 5 x weekly x 4 weeks then 3x a week x 4 weeks and then weekly x 4 weeks. Social Worker or designee will complete psychosocial visits on Resident #2 for changes in current psychosocial state such as depression and/or anxiety 3x weekly x 8 weeks, then weekly x 4 weeks. Any changes will be reported to the administrator for psychiatric intervention. The Quality Assurance Performance Improvement committee will review all monitoring tools monthly for 3 months and make any necessary changes as needed immediately. Date of Compliance: 12/12/2024 The Corrective Action Plan was validated on 01/09/25 and concluded the facility had implemented an acceptable Corrective Action Plan on 12/12/24. Interviews with nursing staff revealed the facility had provided education and training on abuse, neglect and exploitation, handling combative residents/ resistant to care and how to deescalate and provide care to aggressive residents. Review of new admissions after 12/12/24 revealed the facility screened potential new admissions to include behaviors and potential interventions. The audits conducted starting on 12/11/24 revealed audits continued weekly through the validation date. The corrective action plan was reviewed with the Quality Assurance committee. The compliance date of 12/12/24 for the corrective action plan was validated. Immediate Jeopardy was removed on 12/12/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family, staff, Medical Director, and Pharmacist interviews, the facility failed to ensure a safe and orderly discharge for 1 of 1 sampled resident when Resident #3 was discharged to the community with medications prescribed for another resident (Resident #8) instead of his own medication on 4/9/23. On 4/18/23 Resident #3's Primary Care Physician (PCP) discovered that Resident #3 had been taking multiple medications he was not prescribed and had not taken his own prescribed medications since his discharge from the facility on 4/9/23. Discharging a resident with medications not prescribed for him and without his own prescribed medications had a high likelihood of resulting in serious harm. In addition, the facility failed to have the discharge summary signed by the resident and/or responsible party. Immediate Jeopardy began on 4/9/23 when the facility discharged Resident #3 with another resident's medications in place of his own. Immediate Jeopardy was removed on 10/14/23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #3 was admitted to the facility on [DATE]. His cumulative diagnosis included cognitive communication deficit, hypertension (high blood pressure), thrombocytopenia (low platelet levels), and gout (a form of inflammatory arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints). Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #3 was moderately cognitively impaired. Review of Resident #3's electronic records showed the following allergies listed: lisinopril (used to treat blood high blood pressure) and hydrochlorothiazide (used to treat high blood pressure). The type of allergic reactions to the medications were not listed. Review of Resident #3's electronic medical records showed a physician progress note dated 4/7/23 that read in part Made aware resident is discharging on Sunday and needs discharge summary completed please. He will need. home health services for physical therapy, occupational therapy, and speech therapy. He is needing medications sent to the pharmacy of his choice for thirty days. Follow up with outside primary care provider. Review of a social worker note dated 4/7/23 read in part called (family member) to give confirmation of discharge plans - (family member) was not available but I left a detailed voice mail with all information she will need. I spoke with resident as well in regard to discharge plans. Discharge packet will be left with nurse. Review of Resident #3's Discharge summary dated [DATE] showed the following medication orders: - febuxostat 40 milligrams (mg) tablet give one tablet by mouth daily for gout. - metoprolol succinate give one tablet by mouth daily for hypertension - multivitamin tablet give one tablet by mouth daily for supplement. The discharge summary was not signed by Resident #3, Resident #3's responsible party, or the nurse (Nurse #2) who discharged Resident #3. Review of a nursing progress note completed by Nurse #2 dated 4/9/23 at 4:55 P.M. read in part Resident discharge to home with family. All belongings and medications sent with resident and family. Uneventful discharge. Medications reviewed with family and resident prior to departure and further discharge orders also reviewed. All expressed understanding at this time. Review of Resident #3's primary care follow-up visit notes dated 4/18/23 read in part Patient states was discharged on 4/9/23. Review of medications patient was discharged on reveals incorrect patient medications. Patient has subsequently been taking clopidogrel [antiplatelet medication that works by preventing clotting factors in the blood from sticking together], carbidopa & levodopa [combination medication used to treat Parkinson's disease symptoms. Levodopa changes into a chemical in the brain to help control muscle movements. Carbidopa prevents the breakdown of levodopa in the bloodstream so more levodopa enters the brain], pantoprazole [decreases the amount of acid in your stomach and used to treat acid reflux and heal stomach/throat ulcers], and methimazole [treats overactive thyroid by stopping the thyroid from making too much thyroid hormone], for the last 2 weeks, none of which he has need for. Uncertain what meds he was actually taking in the Skilled Nursing Facility. Patient's family member reports they did not think anything of the incorrect name because it came with the paperwork with his name on it. Reports the nurse read through each medication and how to take it with the patient and then provided it to them. Patient has taken 9-10 days of these medications. Resident's blood pressure on 4/18/23 at 12:45 P.M. was 134/78 millimeters of mercury (mmHg. (normal systolic blood pressure reading is less than 120 mmHg/ less than 80mmHg). An interview was attempted with Resident #3's Primary Care Physician and was unsuccessful. Review of the prescribing guides listed the following side effects are listed as possible: - clopidogrel: may cause bleeding which can be serious and lead to death, may cause clots to form in blood vessels in as little as two weeks, feeling tired/weak, seizures, fast heart rate or feeling short of breath, headaches, confusion, vision changes, stomach pain, nausea, vomiting, or diarrhea. - carbidopa & levodopa: fatigue, abdominal pain, heart attack, heart palpitations, high or low blood pression, blurred vision, decreased mental acuity, memory impairment, - pantoprazole: headache, diarrhea, nausea, stomach pain, vomiting, gas, dizziness, and joint pain - methimazole: joint/muscle pain, decreased white blood cells, decreased platelets, dizziness, swelling, upset stomach A telephone interview was conducted on 10/3/23 at 10:39 A.M. with Resident #3's family member. Resident #3's family member stated Resident #3 administered medications to himself. Resident #3's family member stated Resident #3 went to his primary care physician (PCP) on 4/18/23 for a follow-up appointment after his discharge from the facility. Resident #3 took the medication the facility had given him to his PCP appointment. During this appointment, the PCP identified Resident #3 had been provided another resident's medications and Resident #3 had taken the wrong medications since his discharge from the facility. Resident #3's family member confirmed Resident #3 was sent home with medications that did not have a label with Resident #3's name on the package and instead had the name of another resident. The family member did not disclose how many medications packages prescribed to another resident were sent home with Resident #3. The family member did state Resident #3 was not sent home with any of the medications prescribed to him when he was discharged from the facility. During the interview, Resident #3's family member provided Resident #8's name and date of birth from the bubble packages sent home with Resident #3. Resident #3's family member explained Resident #3 and the family had recognized there were more medications, but they thought the facility had changed Resident #3's medication while he was a resident at the facility. The family member explained Resident #3 had taken the medications as the nurse had instructed at discharge. Resident #3's family member stated the PCP had concerns about the effects of the blood thinners on Resident #3 due to him having a diagnosis of anemia and labs were drawn at his follow up visit with the PCP to check his blood levels. Resident #3's family member did not have the results from the lab work. Resident #3's family member stated Resident #3 appeared to have increase in weakness, confusion, and gout symptoms after his discharge from the facility. Resident #3's family member did not explain if the symptoms had improved. An interview was conducted on 10/4/23 at 10:21 A.M. with the Social Worker (SW). The SW explained due to the length of time since Resident #3 was discharged , she was unable to recall the specifics of his discharge. During the interview, the SW stated when a resident was scheduled to be discharged on a weekend, she called the family member the Friday prior to discharge and discussed the discharge plan with them. The plan included medical equipment ordered for the resident, any referrals made, and any supportive services in place to assist the resident with the transition back into the community. The SW indicated she placed a copy of the resident's demographic face sheet and the last physician progress note into an envelope and placed the envelope at the nursing station corresponding to the hallway the resident was residing on. The SW further stated nursing staff were responsible for printing a discharge summary, explaining medications, and gathering the medications to send home with the resident at the time of discharge. Review of Resident #8's medical record showed the following physician medication orders active on 4/9/23. - Aspirin (used as a blood thinner to reduce the risk of strokes) 81 one tablet daily - Carbidopa-Levodopa (used to treat symptoms of Parkinson's disease) - 61.25- 245 mg one table by mouth daily - Citalopram (used to treat depression) 40mg tablet give one tablet by mouth daily - Clopidogrel (blood thinner used to prevent strokes and heart attacks) 75mg tablet one tablet by mouth daily - Vitamin B12 (assists to form red blood cells) 500 micrograms (mcg) tablet give one tablet by mouth daily - Pantoprazole (used to reduce the amount of acid the stomach makes) 40mg tablet by mouth daily - Methimazole (used to treat an overactive thyroid) 5mg give one tablet by mouth every other day - Atorvastatin (used to lower bad cholesterol and triglycerides in the blood) 40mg tablet give two tablets by mouth at bedtime. Review of Resident #8's Medication Administration Record for 4/9/23 and 4/10/23, showed Resident #8 received his scheduled medications. A telephone interview was conducted on 10/3/23 at 6:05 P.M. with Nurse #2 who discharged Resident #3 on 4/9/23. Nurse #2 stated when a resident was discharged from the facility, the nurse who completed the discharge was responsible for reviewing all the discharge paperwork included in the discharge packages. These discharge instructions included how to take each medication and to review the medication packages sent home with the resident and/or the resident's family member at the time of discharge. The nurse indicated at discharge the resident and/or the resident's family member should have restated the discharge instructions to confirm they understood the instructions and signed a copy of the discharge summary; the signed copied stayed at the facility and a second copy was provided to the resident and/or the resident's family at the time of discharge. Nurse #2 explained she was asked by a coworker to complete Resident #3's discharge on [DATE] and the coworker told her (Nurse #2) Resident #3's medications had been gathered into the bag for his discharge. Nurse #2 was unable to recall who asked her to discharge Resident #3 or who gathered the medication packages into a bag for discharge. During the interview, Nurse #2 stated Resident #3 was not alert and oriented. Nurse #2 went over the discharge instructions with Resident #3's family member as Resident #3's family member was packing up Resident #3's belongings. Nurse #2 explained she did not review any of the medications packages when she gathered the documentations and medications for Resident #3's discharge or when she provided the discharge package and medications to Resident #3's family. The nurse stated she should have checked to see if Resident #3's name was on the medication bubble packages prior to giving the medication to his family. Nurse #2 did not provide a reason for not checking Resident #3's name on the bubble sheets of medication given to Resident #3's family at discharge. A telephone interview was conducted on 10/4/23 at 2:53 P.M. with the Pharmacist. During the interview, the Pharmacist reviewed Resident #8's medical chart and started the pharmacy had filled and sent Resident #8's prescriptions on 4/6/23 and on 4/10/23. The Pharmacist reviewed the notes in Resident #8's chart and stated there was not a note written about why the facility had requested all of Resident #8's medications to be refilled four days after the pharmacy had sent the facility his prescriptions. During the interview, the Pharmacist was unaware Resident #8's medication had been sent home with another resident at discharge. The Pharmacist explained the facility had a backup pharmacy on-site with most of the medications Resident #8 was prescribed available for administration. During the interview the Pharmacist explained medications were prescribed by a provider for very specific medical conditions and an individual should never take another individual's medications without first consulting their medical doctor. The Pharmacist explained medication reactions varied from person to person and the dosing of medications could affect these reactions. The Pharmacist did not provide possible outcomes for Resident #3 due to taking medications prescribed to Resident #8 after he was discharged from the facility. An interview was conducted on 10/4/23 at 12:49 A.M. with the Medical Director. The Medical Director reviewed the list of medications for both Resident #3 and Resident #8. After reviewing the list of medications, the Medical Director explained there should be no significant medical effects on Resident #3 after taking Resident #8's medications for nine days or for not taking his prescribed medications for the nine days. During the interview, the Medical Director stated Resident #3 should have been sent home with the medications prescribed to him and not another resident's medications. The Medical Director was unable to state how this error occurred, but stated he felt like it was a mistake made by the nursing staff during Resident #3's discharge. An interview was conducted on 10/4/23 at 1:23 P.M. with the Director of Nursing (DON). During the interview, the DON stated a resident being sent home with another resident's medications should not have occurred. The DON explained the nurse who discharged Resident #3 from the facility had the responsibility to review both the list of medications and the bubble packages of medication with Resident #3 and/or his responsible party prior to him being discharged from the facility. The DON stated she had no explanation to how Resident #3 was sent home with another resident's medication. An interview was conducted on 10/4/23 at 2:50 P.M. with the Administrator. During the interview the Administrator stated bubble packages of medications should never leave the facility with a resident who was not prescribed the medication. The Administrator stated it's not the facility's normal practice to send medication home with residents at discharge, unless the medications were sent home due to insurance requirements, and he is unsure how this mix-up occurred. The Administrator was notified of the Immediate Jeopardy on 10/12/23 at 2:51 P.M. On 10/13/23 the facility provided the following credible allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: On 4/9/2023 Universal Healthcare of Concord discharged Resident #3 home with wrong medication. Nurse #1 failed to review medication list and compare it with the actual medication with family and have it signed by family or Resident #3. Resident #3 was discharged home with family on 4/9/23. The Discharge summary dated [DATE] indicated Resident #3 was prescribed a medication for gout, hypertension, and a multivitamin. The discharge summary was not signed by the resident, family member or the nurse that discharged the resident. When Resident #3 was seen by his Primary Care Physician on 4/18/23 it was discovered Resident #3 had been taking medications prescribed to Resident #8 since his discharge from the facility on 4/9/23. On 10/3/2023 upon learning of the alleged incident the Director of Nursing began re-educating all licensed nurses on discharge process to include, all discharges home medications are to be signed and reviewed by 2 nurses prior to discharging residents with medications. All residents discharged home with medications are at risk of being affected by this alleged deficient practice. Specify action the facility will take to alter the process or system failure to prevent a serious outcome from occurring or recurring and when the action will be completed: The complete audit of all discharges home to ensure that all medications lists had been reviewed and signed by family and discharging nurse as of 4/9/2023 has been completed by Social Worker and Director of Nursing as of 10/13/2023. As of 10/13/2023 Director of Nursing re-educated all nurses on facility policy for discharge and sending medications home as of 10/13/2023. All nurses were educated to review medications with family prior to discharge and have family sign discharge medication list as of 10/13/2023. The medication list and discharge medication packets will be reconciled by two nurses and family prior to discharge as of 10/13/2023. All new hires will be educated on discharge medication process prior to starting their first shift by the Director of Nursing as of 10/13/2023. The facility does not use agency staffing. Allegation of Immediate Jeopardy removal date: 10/14/23 The credible allegation was verified on 10/17/23 through interviews conducted with nursing staff that showed they had received training about discharge procedure, all discharged medications are to be signed and reviewed by two nurses prior to discharging residents' home with medications. A review was completed of educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were viewed, staff names were randomly selected and verified to have received training. A newly hired nurse was verified to have received discharge training by the Director of Nursing. A review of discharges from 4/9/23 through 10/13/23 identified no concerns. The facility had one discharge on [DATE]. The responsible party refused to go to the facility to sign discharge paperwork. Medications were reviewed with the responsible party via telephone with two nurses. The facility's immediate jeopardy removal date of 10/14/23 was validated.