**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, pharmacy regimen review, policy review, resident representative interview and staff interviews, the facility failed to prevent a significant medication error for Resident #150. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #150, who had a known history of hypothyroidism and myxedema coma (a life-threatening condition caused when the level of thyroid hormones become very low or hypothyroidism which causes lethargy, confusion, weakness, and difficulty breathing) in 2021 and 2022, was not ordered or administered, Synthroid, used to treat hypothyroidism from admission on [DATE] through 04/20/24 when the resident was transferred to the hospital due to a deterioration in the resident's condition. On 04/20/24 the resident was transferred to the hospital with decreased consciousness, weakness, decreased appetite and trouble swallowing. The resident's heart rate was bradycardic at 46 beats per minute. The resident was admitted to the intensive care unit (ICU) for treatment of acute toxic metabolic encephalopathy likely myxedema coma and elevated thyroid stimulating hormone (TSH) of 59.9 (normal 0.5 and 5 microunits per milliliter). The hospital noted a concern for medication non-compliance at the nursing home due to no recent fill history and the medication/Synthroid not being listed on the resident's nursing home paperwork. Information obtained during the investigation revealed following the incident, the resident never walked again, developed a pulmonary embolism, and subsequently passed away on 07/24/24. This affected one resident (Resident #150) of five residents reviewed for medication errors. The census was 128. On 09/19/24 at 10:08 A.M., the Administrator, Director of Nursing (DON), Regional Nurse (RN) Regional #815, Administrator in Training (AIT) #816 and Licensed Practical Nurse (LPN) Unit Manager (UM) #860 were notified Immediate Jeopardy began on 04/20/24 when Resident #150 was transferred to the emergency room and subsequently diagnosed with acute toxic metabolic encephalopathy likely myxedema coma and elevated thyroid stimulating hormone (TSH). At the time of admission [DATE]) the resident's admission order for Synthroid was not transcribed accurately by the nursing staff and the resident's Synthroid (hypothyroidism medication) was not administered from 09/07/23 until the resident's discharge to the hospital on [DATE]. The facility failed to identify the lack of Synthroid medication for Resident #150 with a history of myxedema coma in 2021 and 2022. The Immediate Jeopardy was removed on 09/19/24 when the facility implemented the following corrective actions: • On 04/20/24 at 7:41 P.M. Resident #150 was transferred to the hospital and did not return to the facility. The resident was subsequently discharged to an alternate facility post-hospitalization. • On 09/18/24 from 12:30 P.M. to 12:40 P.M. the facility completed an ADHOC Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Physician #825 (medical director), the DON, RN #937 (staff development coordinator), LPN UM #906, Admissions #969, LPN UM #860, Social Service Designee (SSD) #884, Licensed Social Worker (LSW) #820, LPN Minimum Data Set (MDS) #809, Human Resources (HR) #872 to discuss the survey concern and to develop an immediate plan of correction/action that was approved by the Medical Director. • On 09/18/24 at 12:30 P.M., RN Regional #815 educated the DON and RN #937 on a new Medication Reconciliation Addendum which included two nurse verification at the time of admission, speaking directly with the provider Certified Nurse Practitioner (CNP)/physician via phone (no texting, faxing or picture taking) and included orders that were discontinued (on admission) must be noted in the admission progress notes. • On 09/18/24 from 12:40 P.M. to 4:00 P.M., RN #937 educated 37 of 37 licensed nurses on a new Medication Reconciliation Addendum as well as transcribing physician orders and notifying the physician/CNP when a new admission/readmission entered the facility and verifying medications with two nurses and with the provider as well as entering a progress note reflecting verification of medications and any medications that were discontinued at the time of the verification. All nurses were educated prior to working their next shift. • On 09/18/24 from 2:00 P.M. to 3:15 P.M., RN MDS #982 conducted care plan audits for all residents with diagnoses of hypothyroidism and hyperthyroidism to ensure care plans were addressed for their specific health needs. Care plans were revised and updated as needed. • On 09/18/24 from 2:00 P.M. to 3:15 P.M., LPN UM #860 and LPN UM #906 audited all admissions/readmissions in the last two weeks to verify medications were transcribed correctly and verified with the physician/CNP timely. • On 09/18/24 from 2:00 P.M. to 3:00 P.M. the DON completed chart audits on all residents with a diagnosis of hypothyroidism and all residents receiving Synthroid (Levothyroxine) to ensure the orders were transcribed properly, and the medications was administered as ordered. • On 09/18/24 from 2:34 P.M. to 2:44 P.M., RN Regional #815 completed one-to one education for the two nurses who admitted Resident #150, LPN #822 and LPN #823, on medication reconciliation to include two nurse verification at the time of admission, speaking with the provider CNP/physician via telephone (no texting, no faxing and no picture taking) and any orders that were discontinued must be noted in the admission progress note. • On 09/19/24 from 1:45 P.M. to 1:50 P.M., Regional RN #815 educated CNP #824 and Physician #825 regarding progress notes and the need for a plan (of care) for diagnosis present in each resident's medical records. • On 09/19/24 from 1:50 P.M. to 1:55 P.M., Regional RN #815 educated Pharmacist #840 on ensuring pharmacy reviews included all diagnoses having an appropriate plan of care in place including medications administered to the residents. • Beginning 09/19/24 the facility implemented a plan for the DON/designee to review CNP and physician notes weekly for four weeks to ensure the diagnosis of hypothyroidism has an appropriate plan in place. • Beginning on 09/19/24 the facility implemented a plan for the DON/designee to review pharmacy recommendations monthly for three months to ensure residents with a diagnosis of hypothyroidism have been reviewed and have an appropriate plan of care in place to address the diagnosis of hypothyroidism. • Beginning 09/19/24, the DON/designee would complete daily chart audits, Monday through Sunday for three months on all new admissions/readmissions to ensure the orders were transcribed properly, medications were verified with two nurses and with the provider and the progress note entered in the medical record reflected verification of orders as well as any changes made during the verification progress. The audits would continue until compliance could be maintained for three consecutive months. • The facility would complete weekly QAPI meetings for four weeks to review all audits regarding this action plan. Although the Immediate Jeopardy was removed on 09/19/24, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #150's previous skilled nursing facility (SNF) discharge paperwork (used for the resident's 09/07/23 facility admission) revealed the resident was receiving the thyroid medication, Synthroid 125 micrograms (mcg) one tablet by mouth one time a day for hypothyroidism. The medication order had been in place since 04/12/22. Review of Resident #150's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, anxiety and hypothyroidism. Resident #150 was transferred to the emergency room on [DATE] and did not return to the facility. Review of Resident #150's progress note dated 09/07/23 at 6:39 P.M. and authored by LPN #822 revealed the resident arrived at the facility from another SNF around 5:00 P.M. The resident was alert and oriented to self. Resident #150's medical record revealed Guardian/Conservator #801 was listed as the resident's responsible party and included responsibility for financial, clinical and legal needs. Review of Resident #150's History and Physical form dated 09/11/23 authored by CNP #824 indicated on 09/07/23, the resident was admitted to the SNF from another SNF for continuation of care. Per the previous facility records, the resident became increasingly agitated, exit-seeking, and was wandering in and out of other resident's rooms. At times, the resident would also become combative with staff and refuse care. The power-of-attorney (POA) requested the resident's transfer to a secured nursing facility. The resident's past medical problems included hypertension, anemia, dementia, psychosis, malnutrition, depression, anxiety, insomnia, hypothyroidism, myxedema coma. There was no plan or information related to treatment or monitoring of the resident's hypothyroidism/myxedema coma conditions contained in the history and physical. Review of Resident #150's lab work form dated 09/11/23 revealed the resident's TSH 3 (thyroid stimulating hormone) level was 4.98 (normal 0.340 to 5.50). (TSH levels below 0.4 indicate hyperthyroidism, while levels of about 4.0 and above indicate hypothyroidism.) Review of Resident #150's care plans dated 09/19/23 revealed the resident had impaired metabolic status related to hypothyroidism, malnutrition, hyperlipidemia and myxedema coma with an intervention (dated 09/19/23) to administer medications and treatments as ordered; and an intervention dated 09/19/23 to observe for and report to the physician, CNP changes in signs/symptoms of hypothyroidism (fatigue, increased sensitivity to cold, constipation, dry skin, unplanned weight gain, muscle weakness, elevated cholesterol levels, muscle aches/tenderness, stiffness, joint pain/swelling, thinning hair, slowed heart rate, depression, goiter, decline in memory). Encourage the resident to report onset of new or worsening symptoms to the nurse. A second plan of care related to activities of daily living (ADL) revealed the resident had ADL self-care performance deficits related to dementia, depression, fluctuating ADLs, generalized weakness and hypothyroidism with an intervention dated 09/19/23 to report changes in ADL abilities to the nurse, physician, CNP and/or therapy. Review of Resident #150's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #150's medication administration records (MARS) and treatment administration records (TARS) from 09/07/23 through 05/03/24 revealed no evidence the resident's Synthroid medication for hypothyroidism was ordered or administered from admission [DATE]) through discharge (04/20/24). Review of Resident #150's monthly pharmacy reviews authored by Consultant Pharmacist #839 and completed from 10/01/23 to 04/20/24 revealed no evidence Consultant Pharmacist #839 identified the resident's hypothyroidism, addressed the resident's lack of medication to treat the hypothyroidism and/or addressed the lack of laboratory testing related to the resident's hypothyroidism during this time period. Review of Resident #150's progress note dated 04/20/24 at 7:41 P.M. and authored by LPN #826 revealed the resident was observed with a decreased heart rate and increased confusion. The resident had decreased consciousness, weakness, decreased appetite and trouble swallowing. The resident's vital signs included: 110/68 blood pressure, heart rate (HR) of 46 (bradycardic), oxygen level of 94% on room air. New orders were obtained to send the resident to the emergency room (ER). The resident's power of attorney (POA)/(guardian) was notified. The CNP gave new orders to send the resident out via emergency services squad (EMS) to the hospital and the EMS arrived and transferred the resident to the hospital via a cot at 7:40 P.M. Review of Resident #150's progress note dated 04/21/24 at 8:04 A.M. (interdisciplinary progress note or IDT) authored by LPN Unit Manager #827 indicated the resident was admitted to the intensive care unit (ICU) with hypotension and acute metabolic encephalopathy. The CNP and guardian were made aware. Review of Resident #150's hospital History and Physical Progress Note dated 04/21/24 at 12:29 A.M. revealed the resident had a past medical history (PMH) of hypothyroidism, history of myxedema coma in 2022, depression and recurrent admissions related to medication non-compliance. She presented from the SNF to the ER for changes in mental status and after being found on the floor. She had hypotension, hypothermia and multiple lab abnormalities. Review of Resident #150's hospital Initial Consult Endocrinology note dated 04/21/24 at 1:43 P.M. revealed the resident had a known history of hypothyroidism since 2016 according to prior records. The resident was not able to give any history herself. She was admitted on [DATE] for obtundation (state of mild to moderate alertness reduction), felt to be in part due to myxedema coma. She had two previous admissions for myxedema coma in 2021 and 2022. The resident's TSH level on 04/20/24 was 59.9 (normal range 0.270 to 4.200 mIU/L or milli-international units per liter), free T3 was less than 0.4 (normal 2.3 to 4.1 pg/ml or picograms per milliliter) and free T4 was less than 0.1 (normal 0.9 to 1.7 ng/dl or nanograms per deciliter). The assessment impression indicated the resident had myxedema coma because the labs appeared that she had not been receiving Levothyroxine (Synthroid) or it may have been administered incorrectly. Review of Resident #150's hospital Progress Note form dated 04/22/24 at 6:48 A.M. revealed the resident had a PMH of hypothyroidism and major depressive disorder presented from a SNF with altered mental status after being found on the floor. She was not alert or awake and would grimace to painful stimuli but could not arouse her fully to have a conversation. When she presented initially to the ED, she would say only her name but not answer any other questions. In the ED, her blood pressure was 95/60 (hypotensive) with a heart rate of 53 (bradycardic). The resident's TSH level was 59.9 with a T4 blood level of less than 0.1 and a T3 blood level of less than 0.4. She was administered intravenous (IV) Solumedrol 100 mg and 500 cc of dextrose 5% half normal saline (NS) and 200 mcg of IV Levothyroxine. The Assessment and Plan section of the form indicated the resident presented to the ER from the SNF with altered mental status after being found on the floor. She was found to have elevated TSH, low T3-T4 and a concern for central nervous system (CNS) infection given the resident's neck rigidity on presentation. The resident was admitted for treatment of acute toxic metabolic encephalopathy likely myxedema coma and elevated TSH of 59.9. The concern for medication non-compliance at the SNF was identified due to no recent fill history and (no Synthroid) being on the NH paperwork. On 09/18/24 at 12:01 P.M., LPN #822 was contacted by telephone by the Administrator, Regional RN #815 and surveyor and the nurse indicated she could barely remember admitting Resident #150 but felt the resident came at shift change so she probably started the admission, and the next nurse (LPN #823) would have finished the admission. On 09/18/24 at 12:07 P.M., LPN #823 was contacted by telephone by the Administrator, Regional RN #815 and surveyor and the nurse stated he was new to his nursing role when Resident #150 was admitted , and he felt he had faxed the admission orders to the physician or CNP for review and they would have text him back with any changes. He could not remember if Resident #150 was ordered Synthroid. He stated the morning manager would have helped him with this admission, and he could not remember the details. LPN #823 indicated he had deleted the messages from the physician from his phone. Telephone interview on 09/18/24 at 12:15 P.M. with CNP #824 revealed she did not have a fax machine, and the facility would have to call her for resident admission orders. CNP #824 revealed the standards of practice for new admissions was to draw labs upon admission including a comprehensive metabolic panel which indicates the sodium, potassium, creatinine, calcium and albumin levels; lipid profile which indicates the cholesterol and triglyceride levels; magnesium level; Vitamin B12 level; and TSH level. During the interview, CNP #824 stated she could not remember if she gave admission orders for Resident #150. Telephone interview on 08/18/24 at 12:32 P.M. with Physician #825 indicated the CNP usually handled admission orders, and he did not remember the specifics about Resident #150's admission. Physician #825 stated he would review the resident's chart and return the phone call. Interview on 09/18/24 at 12:54 P.M. with the DON revealed Resident #150's Synthroid was not transcribed accurately during the resident's admission from the previous SNF by the admitting nurse and the resident did not receive the Synthroid (hypothyroidism medication) as ordered (during her stay in the facility). Attempted interviews on 09/18/24 and 09/19/24 with Resident #150's guardian (Guardian #801) revealed the guardian was not available. Interview on 09/19/24 at 8:45 A.M. with the Administrator, DON and AIT #816 confirmed LPN #822 was the nurse who had admitted Resident #150, and the nurse did not transcribe the physician (medication) order (for the resident's Synthroid) correctly. The Administer revealed the facility revised their Medication Reconciliation policy on 09/18/24 (following surveyor investigation) to reflect new procedures on admission orders including the facility must speak to the physician or CNP on the phone (no texting, no faxing etc); two nurses must verify admission orders and any orders that were discontinued by the provider must be put in the admission progress note (spelling out each medication that was discontinued). A second telephone interview on 09/19/24 at 10:42 A.M. with Physician #825 revealed he remembered Resident #150 and stated her heart rate decreased, and she was sent to the hospital with a change in condition in 04/2024. At the time of the interview, Physician #825 stated he was under the impression two nurses always reviewed the resident medication list for accuracy and per the revised policy going forward, the facility would ensure two nurses verified resident orders on admission. Telephone interview on 09/19/24 at 2:37 P.M. with Client Services Manager #400 revealed he worked with Consultant Pharmacist #839, who was the facility pharmacist, but this pharmacist was on vacation. Client Services Manager #400 stated he was unsure how Resident #150's Synthroid hypothyroidism medication was missed for several months. Interview on 09/19/24 at 3:04 P.M. with RN Regional #815 revealed the consultant pharmacist should have caught during the monthly pharmacy reviews that Resident #150's Synthroid was not reordered per the prior facility's physician orders or identified the resident had a diagnosis of hypothyroidism and questioned where the medication was to correct the hypothyroidism. RN Regional #815 stated the facility reviewed the consultant pharmacist recommendations for several months following Resident #150's admission and no recommendations were made regarding the resident's diagnosis of hypothyroidism or the use of Synthroid medication for the hypothyroidism. Review of the Admissions to the Facility policy revised 02/01/22 revealed prior to or at the time of the admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least the type of diet; medication orders including a medical condition or problem associated with each medication; and care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. Review of the Medication Administration policy revised 01/17/23 revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the Medication Reconciliation policy revised 01/30/24 revealed medication reconciliation involved the collaboration with the resident/representative and multiple disciplines including admission liaisons, licensed nurses, physicians and pharmacy staff. Resident identifiers would be verified on all medication labels and documents containing medication information to verify the correct person and that the documents were placed in the correct resident's medical record. Review of the Medication Reconciliation policy revised 09/18/24 revealed the facility must speak to the physician or CNP on the phone (no texting, no faxing etc) for admission orders. Two nurses must verify admission orders and any orders that were discontinued by the provider must be put in the admission progress note (spell out each medication that was discontinued). This deficiency represents non-compliance investigated under Master Complaint Number OH00157684 and Complaint Number OH00157142.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, open and closed medical record review, hospital medical record review, Self-Reported Incident (SRI) review, facility incident report review, staff schedule review, review of the facility Abuse policy and interviews, the facility failed to ensure Resident #119 was free from an incident of resident-to-resident physical abuse. This resulted in Immediate Jeopardy, serious life-threating injuries, and subsequent death beginning on 08/15/23 when Resident #119, who was cognitively impaired and had a history of wandering, wandered into Resident #40's room and Resident #40, who had a history of physical aggression toward other residents when entering her room, willfully pushed Resident #119 causing Resident #119 to fall to the ground. Resident #119 was assessed to have a quarter-sized red bump to her upper right forehead, an acute right femoral neck fracture and was in severe pain (shaking and crying) requiring hospitalization as a result of the fall with injury. Resident #119 was transferred to the local hospital where she was admitted , diagnosed to have additional fractures to the superior and inferior pubic rami and a mild T11 compression deformity, underwent surgery for fixation of the right hip but subsequently expired four days after the resident-to-resident abuse incident. On 08/29/23 at 4:08 P.M., the Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operations (VPCO) #11 were notified Immediate Jeopardy began on 08/15/23 at approximately 7:00 P.M. when Resident #119 was observed being physically abused/assaulted by Resident #40. Licensed Practical Nurse (LPN) #2 witnessed Resident #40 willfully push Resident #119 resulting in Resident #119 falling to the ground after Resident #119 wandered into Resident #40's room without staff knowledge or evidence of adequate and individualized interventions being in place as ordered. Resident #40 had a physician order and was care planned to have a stop sign across her private doorway entrance to deter other residents from wandering into her room which was not in place at the time of the incident. Resident #119 had a physician order and was care planned to have hand-held assistance during ambulation from one staff member which was not in place at the time of the incident. As a result of the incident, Resident #119 was transferred to the hospital for treatment of an acute right femoral neck fracture, superior and inferior pubic rami fractures and severe pain as evidenced by the resident shaking and crying. The resident underwent surgery for the right hip fracture but subsequently expired on 08/19/23 at 9:57 A.M. Resident #119's preliminary cause of death was respiratory failure after trauma. This affected one resident (#119) and had the potential to affect seven additional residents (#2, #28, #34, #39, #52, #54, #112 and #113) who the facility identified as residents who wandered and resided on C-Pod (the same pod as Resident #40). The facility census was 119. The Immediate Jeopardy was removed on 08/30/23 when the facility implemented the following corrective actions: • On 08/15/23 at approximately 7:00 P.M., LPN #2 immediately assessed Resident #119, administered pain medication, and an x-ray was ordered by Certified Nurse Practitioner (CNP) #10. Upon results of right hip fracture, Resident #119 was transferred to the local hospital for evaluation and treatment. The resident's responsible party and physician were notified post incident by LPN #2 on 08/15/23 at approximately at 7:00 P.M. • On 08/15/23 at approximately 7:00 P.M., Resident #40 was placed on one-to-one supervision post incident and was to remain with staff one-to-one supervision. The responsible party and physician were notified post incident on 08/15/23 by LPN #2 at approximately 7:00 P.M. • On 08/15/23 at 8:48 P.M., the DON notified the police department of the resident-to-resident abuse incident. • On 08/16/23 at 8:00 A.M., Staff Development Coordinator (SDC) #12 educated nursing staff on residents with orders for stop signs to ensure signs were in place at all times. • On 08/29/23 at 12:13 P.M., the DON educated all nursing staff to notify the DON or designee immediately if an assigned one-to-one staff member did not arrive for their shift. • On 08/29/23 at 12:54 P.M., Unit Managers (LPN #12, Registered Nurse (RN) #14 and LPN #15) audited resident orders to identify residents who wandered and needed assistance with ambulation. Resident orders, interventions, and care plans were reviewed and updated as needed. The facility implemented a plan to review audits at monthly Quality Assurance and Performance Improvement (QAPI) meetings. • On 08/29/23 at 2:00 P.M., Unit Managers (LPN #12, RN #14, and LPN #15) began auditing five residents daily, five times a week on various shifts for four weeks to ensure residents were receiving the appropriate assistance with ambulation, according to their plan of care. The audits would be reviewed at monthly QAPI meeting. • On 08/29/23 at 5:02 P.M., LPN #13, RN #14 and LPN #15 educated all in-house staff on the facility abuse policy and procedure and following resident plan of care interventions for ambulation. • On 08/29/23 at 5:27 P.M. an Ad-hoc QAPI meeting was held with the Administrator, DON, VPCO #11, Medical Director #16, RN #9, LPN #12, RN #14, Director of Maintenance (DOM) #17, LPN #18, Licensed Social Worker (LSW) #19, Social Services Assistant (SSA) #20 and Registered Dietitian (RD) #21. • On 08/29/23 at 7:00 P.M., residents known to have a history of aggression with other residents entering their room had a stop sign placed on their door to deter residents who wander from entering their room. • On 08/29/23 at 7:00 P.M., VPCO #11 educated the Administrator and DON on the facility abuse policy and procedure. • On 08/29/23 at 7:00 P.M., SDC #12, LPN #13, RN #14 and LPN #15 educated all staff on the facility abuse policy and following resident plan of care interventions for assistance with ambulation. The facility implemented a plan that no further staff would work until education was provided/completed. • On 08/29/23 at 7:00 P.M., Unit Managers (LPN #12, RN #14, and LPN #15) or designee began auditing five residents per day for four weeks with orders for stop signs in doorway to ensure placement. The audits would be reviewed at the monthly QAPI meeting. • On 08/30/23 at 8:00 A.M., the DON/designee began auditing/interviewing five staff members a week on various shifts for four weeks to ensure their knowledge of the process to location residents' ambulation plan of care. The audits will be reviewed at the monthly QAPI meeting. • On 08/30/23 at 11:15 A.M., Resident #40 was moved to another Pod where there weren't any residents who wander. Although the Immediate Jeopardy was removed on 08/30/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #119 revealed an admission date of 05/17/23 and a discharge date to the hospital on [DATE]. Resident #119 had diagnoses including Alzheimer's disease, conversion disorder with seizures or convulsions, and need for personal care. Resident #119 resided on C-Pod, a secured memory care unit. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #119 had short and long-term memory problems, had severely impaired cognitive skills for daily decision making, had inattention and disorganized thinking, wandered that significantly intruded on the privacy and activities of others and received supervision of one-person physical assistance when walking in the corridor. Review of a wandering care plan dated 05/28/23 revealed Resident #119 was a wanderer related to disease process (Alzheimer's), was disoriented to place, and had impaired safety awareness. Resident #119 wandered aimlessly with eyes closed with an intervention to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, and music. Review of the activities of daily living (ADL) care plan updated 06/01/23 revealed Resident #119 needed ADL assistance related to dementia, Alzheimer's disease and indicated ADL's might fluctuate day to day due to cognitive deficits with an intervention for the resident to transfer and ambulate with hand-held assistance of one staff. Review of the physical therapy Discharge summary dated [DATE] revealed Resident #119 was discharged from physical therapy services due to reaching maximum potential. Continued recommendations for Resident #119 included to transfer and ambulate with hand-held assistance (HHA). Resident #119's prognosis was good with consistent staff follow-through. Review of the August 2023 physician orders revealed an order (dated 08/03/23) for Resident #119 to transfer and ambulate with hand-held assist of one staff. Review of a facility SRI, tracking number 238142 dated 08/15/23 and created at 8:58 P.M. revealed the facility reported an incident of resident-to-resident physical abuse. The SRI revealed on 08/15/23 a nurse heard Resident #40 yelling, get out of my room then heard a loud noise. Upon entering the room, the nurse saw Resident #40 in her wheelchair and Resident #119 on the floor. Resident #119 was assessed to have a small bump on her head, was medicated with Tylenol for pain and was ordered a right hip x-ray. The final facility SRI investigation, reported to the State agency on 08/21/23 at 6:01 P.M. revealed the facility substantiated the physical abuse incident involving Resident #119. Review of a witness statement dated 08/15/23 and authored by State Tested Nursing Assistant (STNA) #3 included the following information: I stepped off the unit to use the restroom. When I came back, I was informed that the incident occurred. We were getting everyone ready for bed before this. I redirected Resident #119 away from Resident #40's room earlier. After everything happened, I was sitting with Resident #40. She said she didn't like anyone coming in her room. She told me that she didn't push her. She said she grabbed her hand and was trying to get her out of her room. I also heard her tell the nurse that she hated the resident that was in her room. Review of a witness statement dated 08/15/23 and authored by STNA #4 included the following information: during this incident, I was in another room with another resident when the nurse called for me and another aide. The nurse asked me to remove Resident #40 from her room. When Resident #40 was removed, she stated she didn't want anyone in her room. She wanted Resident #119 out of her room that she is not allowed. Review of a nursing note dated 08/15/23 at 8:20 P.M. revealed Resident #119's husband was notified of the resident's fall and interaction with another resident (Resident #40). The resident's husband was notified an x-ray was ordered of the right hip. Review of a radiology report, dated 08/15/23 revealed Resident #119 had an acute right femoral neck fracture with mild displacement. Review of a nursing note dated 08/15/23 at 10:06 P.M. revealed Resident #119's husband was notified of the x-ray results of an acute right femoral neck fracture with mild joint displacement. Resident #119 was to be sent to the local hospital. Review of a facility incident report for a physical incident involving Resident #119 (on 08/15/23) dated 08/16/23 at 2:58 A.M. and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when she heard resident (Resident #40) yell, hey, get out of my room! This nurse turned to enter Resident #40's room and saw Resident #40 push Resident #119 to the ground. Resident #119 fell to her right side. Resident #40 rolled towards Resident #119 with her wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119 with the wheelchair. Predisposing factors included on the incident report noted (Resident #119) was confused, gait imbalanced, had impaired memory, was ambulating without assistance, and was a wanderer. The incident report also indicated Resident #40 was to be placed on one-to-one supervision for aggressive behaviors (following the incident) and indicated a physician ordered stop sign to Resident #40's door was not in place at the time of the incident. Review of a nurse's note (for the incident that occurred on 08/15/23) dated 08/16/23 at 3:21 A.M. and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when this nurse heard another resident (Resident #40) yell, hey, get out of my room, this nurse turned to enter the room and saw resident (Resident #40) push Resident #119 to the ground. Resident #119 fell to her right side. Resident #40 rolled towards Resident #119 with her wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119 with the wheelchair. The residents were separated immediately. Resident #119 was assessed for injury. Resident #119 was guarding the right side of her head; a quarter-sized red bump was observed to the upper right forehead. Resident #119 winced upon palpation of the of the right hip. Resident #119 tolerated minimum range of motion of the right extremity. Resident #119 was shaking and crying. Resident #119 was assisted to the wheelchair via two staff assist then to bed. CNP #10 was notified. A new order was received for a two-view x-ray to the right hip STAT and an order to administer Vistaril 25 mg. As needed Tylenol was administered per order. During the x-ray, this nurse observed Resident #119's right hip beginning to swell and redden. The x-ray results were positive for an acute right femoral neck fracture. A new order was received to send Resident #119 to the local hospital via 911. Resident #119 was transported to the local hospital. Review of the nurse's note dated 08/16/23 at 3:21 A.M. revealed a call was placed to the hospital for follow-up. Resident #119 was admitted was a diagnosis of bilateral pubic rami fracture. Review of the hospital palliative nurse practitioner progress note dated 08/17/23 revealed Resident #119, a [AGE] year-old female with a past medical history of dementia (non-verbal at baseline) presented from nursing facility after being pushed by another resident. She presented as a Level 2 trauma. Computed tomography with arterial portography (CTAP) showed mild T11 compression deformity and subacute superior and inferior pubic rami fractures. She was taken to the operating room on 08/16/23 for open reduction and internal fixation (ORIF) of right femoral neck. Post-operative complications included bradycardia, altered mental status and acute hypoxic respiratory failure with CO2 (carbon dioxide) retention. Rapid Response Team (RRT) was called, and patient was transferred to the intensive care unit (ICU) for possible non-invasive ventilation. Husband presented with paperwork for patient's wishes. Palliative care had been consulted to assisted with goals of care. Discussed option to focus on Hospice with comfort as the main priority at this time. Given resident's current clinical status, resident could acutely decompensate to where she may pass quickly. Review of the hospital physician expiration summary dated 08/19/23 revealed Resident #119 was admitted (to the hospital) after fall with hip fracture. She underwent fixation of her hip the second day of her hospital stay. This was complicated by a delayed extubation in the post-anesthesia care unit (PACU), but patient returned to regular nursing floor (RNF). Then was transferred to surgical intensive care unit (SICU) for respiratory failure and hypotension, which improved with noninvasive care. Discussions with family at this time prompted change in code status to Do Not Resuscitate Comfort Care Arrest (DNR CCA) and they also talked to Hospice at this time. The resident transferred to a RNF but continued to decline. She returned to ICU for progressive respiratory failure and family opted to avoid escalating care. The resident passed away due to hypoxic respiratory failure at 9:57 A.M. Preliminary cause of death was respiratory failure after trauma. Interview on 08/28/23 at 3:03 P.M. with STNA #1 revealed Resident #119 passed away a week ago. STNA #1 stated Resident #40 wasn't normally aggressive; however, Resident #40 didn't like when people were in her room. STNA #1 was aware Resident #40 was to have one-to-one staff monitoring. Interview on 08/28/23 at 3:50 P.M. with LPN #2 revealed on 08/15/23 around 8:00 P.M., LPN #2 had completed Resident #40's skin assessment, taken her in the bathroom, got her ready for bed, administered her medications and then the resident was in bed. Resident #40 had then gotten out of bed, was in her wheelchair and was going in and out of her room retrieving towels and blankets. LPN #2 was outside of Resident #40's room at the medication cart doing medication pass when LPN #2 heard, hey, get her out of my room. LPN #2 stated there was stuff on top of the medication cart that LPN #2 had to put away since other residents were around, and LPN #2 stated, Hey [Resident #40], I'm on the way. There were two STNAs on the unit; one STNA was in the bathroom, and the other STNA was in another resident's room. LPN #2 saw Resident #40, was seated in a wheelchair, saw her reach up with her right hand and push Resident #119's left shoulder/arm while standing. Resident #119 fell to the ground, and LPN #2 heard a crack. LPN #2 attempted to get in-between the residents because Resident #40 was trying to wheel her wheelchair toward Resident #119. Resident #40 stated, Good, I'm glad she's hurt. LPN #2 assisted Resident #40 outside of the room, and one of the STNA staff then took Resident #40 to the common area to calm her down. LPN #2 stated Resident #119 was wearing her helmet and had hipsters on at the time of the incident. Resident #119 had a small red bump on her right temple below the helmet. LPN #2 touched Resident #119's hip and the resident winced. LPN #2 lifted the resident's right leg, and the leg didn't move well. Resident #119 was inconsolable, crying, shaking and in pain. The STNA staff transferred Resident #119 into a wheelchair which the LPN stated the resident tolerated well. LPN #2 administered Resident #119 Tylenol and Vistaril. During the x-ray, Resident #119's right hip was red and swollen. The x-ray results came back showing Resident #119 had a femoral neck fracture. Resident #119 was sent to the hospital. LPN #2 revealed she did not believe the Velcro stop sign was across Resident #40's doorway before Resident #119 wandered into Resident #40's room because Resident #40 was going in and out of her room. LPN #2 also revealed that Resident #119 was quiet, so Resident #119 likely wandered into Resident #40's room without LPN #2 seeing or hearing Resident #119 walking into the room. Observation on 08/28/23 at 4:25 P.M. revealed Resident #40 was sitting in the common area in a recliner with her feet propped up on a seat of a wheelchair. STNA #1 was sitting next to her. Interview, during the observation, with Resident #40 was attempted, however unsuccessful due to the resident's cognitive impairment. A follow-up interview with STNA #1 during the observation revealed Resident #40 did not have one-to-one monitoring from 6:00 A.M. to 10:00 A.M. that morning (08/28/23). STNA #1 stated she was the only STNA assigned to the unit from 6:00 A.M. to 10:00 A.M. so she was in and out of other resident rooms completing resident care and the nurse was covering another unit, so the nurse was on and off the unit. STNA #6 arrived at 10:00 A.M. for the one-to-one monitoring of Resident #40. Interview on 08/28/23 at 4:28 P.M. with LPN #2 verified there wasn't a staff member assigned to Resident #40 for one-to-one monitoring this morning (08/28/23). LPN #2 also revealed she was assigned two units (A-Pod and C-Pod) until 10:30 A.M. so LPN #2 was on and off the C-Pod unit. Interview on 08/28/23 at 4:40 P.M. with STNA #4 revealed on 08/15/23 around 8:00 P.M. or 9:00 P.M., Resident #119 walked into Resident #40's room and Resident #40 pushed Resident #119. STNA #4 did not observe the incident because of being in another resident's room; however, the nurse called STNA #4 to assist with the incident. When STNA #4 entered the room, Resident #119 was on the floor, and the nurse was trying to obtain the resident's vital signs. Observation on 08/29/23 at 8:15 A.M. revealed Resident #40 was sitting in the recliner in the common area. STNA #1 and STNA #8 had their backs turned away from Resident #40, and LPN #8 was standing at the medication cart at the nursing station looking at the computer screen. Resident #28 walked over to Resident #40 and sat beside Resident #40 in another chair. Resident #40 did not have one-to-one monitoring by staff during the observation. Interview on 08/29/23 at 8:32 A.M. with RN #9 revealed Resident #119's physician's order to transfer and ambulate with hand-held assistance by one staff member was a result of a recommendation from physical therapy. Interviews on 08/28/23 at 4:13 P.M. and 08/29/23 at 9:50 A.M. were attempted with STNA #3 (who worked the C-Pod on the evening of 08/15/23); however, unsuccessful via telephone. Interview on 08/29/23 at 8:45 A.M. and 10:25 A.M. with the DON revealed she requested Resident #40 have the one-to-one monitoring order after the resident-to-resident incident (with Resident #119) from CNP #10. The DON verified Resident #40 had a history of being aggressive towards other residents who entered her room, verified Resident #119 was known to wander and verified the incident of resident-to-resident abuse resulting in the injury to Resident #119. There were seven additional residents, Resident #2, #28, #34, #39, #52, #54, #112 and #113 who the facility identified as residents who wandered and resided on C-Pod (the same pod as Resident #40), placing these residents also at risk of a resident to resident altercation with Resident #40, should they have wandered into the resident's room. Interview on 08/29/23 at 8:48 A.M with Director of Rehabilitation #22 revealed when ambulating with Resident #119, it was the expectation for a staff member to hold one of Resident #119's hands while the other hand of the staff member was on Resident #119's gait balance. Interview on 08/29/23 at 8:50 A.M. with LPN #7 revealed Resident #119 had a known history of wandering into other resident's rooms. A follow-up interview on 08/29/23 at 12:30 P.M. with the DON verified Resident #40 was not monitored one-to-one by a staff member on 08/28/23 from 6:00 A.M. to 10:00 A.M. nor was a staff member scheduled for one-to-one monitoring of Resident #40 on 08/28/23 from 6:00 A.M. to 10:00 A.M. The DON also verified Resident #119 was ordered to have hand-held assistance by one staff member while ambulating which did not occur at the time of the resident-to-resident incident. Interview on 08/29/23 at 12:45 P.M. with Resident #119's husband/Power of Attorney revealed he received a call from the facility that a resident had pushed Resident #119 down. The nurse notified him Resident #119 sustained a knot to her head and a broken hip. At that point, he rushed to the hospital to meet Resident #119. Interview on 08/29/23 at 2:45 P.M. with CNP #10 revealed the nurse had called CNP #10 (on 08/15/23) stating a resident-to-resident altercation had occurred between Resident #40 and #119 when Resident #119 entered Resident #40's room, Resident #40 got mad and pushed Resident #119 causing Resident #119 to fall. Resident #119 was complaining of hip pain, so CNP #10 ordered an x-ray which was positive for an acute fracture. Resident #119 was sent to the hospital. CNP #10 also revealed Resident #119 was a known wanderer and had a history of taking items off the nurses' cart and taking other resident's food. Resident #40 was known to be very territorial over her room and would display verbally aggressive behaviors. CNP #10 verified she ordered the one-to-one staff monitoring of Resident #40 after the resident-to-resident altercation. Review of the nurse and STNA staff schedule from 08/28/23 revealed STNA #1 was scheduled to work on C-Pod from 6:00 A.M. to 2:00 P.M., LPN #2 was scheduled to work C-Pod from 6:00 A.M. to 2:00 P.M. There wasn't a nurse assigned to A-Pod from 6:00 A.M. to 2:00 P.M., and there wasn't a staff member assigned for one-to-one monitoring on C-Pod until 10:00 A.M. when STNA #6 was scheduled to arrive. Review of the medical record for Resident #40 revealed an admission date of 01/08/19 with diagnoses of paranoid schizophrenia, severe vascular dementia with behavioral and mood disturbance, delusional disorders, and anxiety. Resident #40 resided on C-Pod, a secured memory care unit. Review of a nurse's note dated 04/28/23 at 4:33 P.M. revealed the STNA notified this nurse Resident #52 was in Resident #40's room and Resident #40 punched Resident #52 in the stomach while staff was attempting to remove the resident from the area. Review of the interdisciplinary team (IDT) progress note dated 05/01/23 revealed the IDT team met to discuss the previous incident. Resident (Resident #52) was wandering and entered into resident (Resident #40's) room. Resident #40 hit Resident #52 in the stomach. A stop sign was placed on resident's door to deter coresidents from wandering. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was severely cognitively impaired, had disorganized thinking and inattention that fluctuated, displayed physical behaviors towards others during one to three days of the seven-day assessment reference period, displayed verbal behaviors towards others during four to six days of the seven-day assessment reference period, and displayed other behavioral symptoms not directed towards others during four to six days of the seven-day assessment reference period. Review of the physician's orders for August 2023 revealed Resident #40 had an order (dated 05/01/23) to have a stop sign on the door to her room to deter coresidents from entering the room. Review of a nurse's note dated 08/15/23 at 8:35 P.M. revealed Resident #40's daughter was notified of an altercation with Resident #119. Review of the nurse's note dated 08/16/2 at 4:08 A.M. (for the incident that occurred on 08/15/23) and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when this nurse heard Resident #40 yell, hey, get out of my room. This nurse turned to enter room and saw resident push Resident #119 to the ground. Resident #119 fell to ground in front of Resident #40. Resident #40 rolled towards Resident #119 with the wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119. The residents were separated immediately. Resident #40 was yelling, Good! I'm glad she's hurt. I hate her. Resident #40 was removed from the room until Resident #119 could be safely transferred and removed from the room. A new order for one dose of Vistaril 25 milligrams (mg), an antihistamine used to treat anxiety was noted. Resident #40 was to be placed on one-to-one supervision for aggressive behaviors and staff education regarding stop sign to door. Review of Resident #40's physical aggression care plan updated 08/16/23 revealed Resident #40 was physically aggressive or agitated related to anger and dementia. Resident #40 would strike staff when agitated. Resident #40 stuck coresident after wandering into her room on 04/29/23. Resident #40 pushed coresident, causing her to fall on 08/15/23. Interventions of a stop sign to the resident's door to deter coresidents wandering into her room, monitor and signs or symptoms of resident posing danger to self and/or others, and one-to-one supervision. Review of the facility's Abuse, Neglect and Exploitation policy, revised 10/24/22, revealed the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property and exploitation that achieves identifying, correcting, and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property was more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of residents, and assure the staff assigned had the knowledge of the individual residents' care needs and behavioral symptoms and the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after investigation and increased supervision of the alleged victim and residents. This deficiency represents non-compliance investigated under Complaint Number OH00145778.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of a facility self-reported incident (SRI), review of a police report, review of the facility Abuse policy, and interviews with facility staff and Police Officer #642 the facility failed to ensure Resident #5 was free from an incident of staff to resident physical abuse. This resulted in Immediate Jeopardy on 04/22/23 at approximately 4:00 P.M. when Resident #5 was attempting to take the phone from the nurse's station to dial 911 and State Tested Nursing Assistant (STNA) #576 attempted to remove the phone from Resident #5's hands. Resident #5 became combative with STNA #576 and STNA #576 physically pushed Resident #5 and the resident fell to the floor and hit his head. This resulted in serious life-threatening harm and injury as Resident #5 experienced profuse bleeding from this left ear without loss of consciousness requiring medical intervention. The resident was assessed to have aphasia (difficulty speaking/communicating) and a subdural hematoma as a result of the incident. The resident was re-admitted to the facility on [DATE] following hospital intervention. This affected one resident (#5) of three residents reviewed for abuse and neglect. The facility census was 123. On 04/28/23 at 2:25 P.M. the Administrator, Director of Nursing (DON), Administrator in Training (AIT) #570, Regional Director of Clinical Operations #643, and Regional Director of Human Resources #644 were notified Immediate Jeopardy began on 04/22/22 at approximately 4:00 P.M. when STNA #576 physically abused Resident #5. The resident sustained an acute injury as a result of the incident requiring hospital intervention. The Immediate Jeopardy was removed on 04/28/23 when the facility implemented the following corrective actions. • On 04/22/23 following the incident STNA #576 was immediately suspended pending investigation. The STNA subsequently resigned his position (on 04/22/23). • On 04/22/23 the Administrator notified police an incident occurred between STNA #576 and Resident #5; police report number 23-07196. • On 04/22/23 at 4:50 P.M. Resident #5's physician and daughter were notified by the floor nurse and weekend nurse supervisor with new orders obtained to send Resident #5 to the hospital. The resident returned to the facility on [DATE] with additional interventions including Speech Therapy (ST), Occupational Therapy (OT), Physical Therapy (PT) evaluation and treat orders. A psychological services evaluation on 04/24/23 with medications reviewed with an increase in Depakote (mood stabilizer) to 250 milligrams (mg) three times daily (TID). On 04/24/23 the resident's behavior care plan was reviewed and updated by Minimum Data Set (MDS) Registered Nurse (RN) #542. • On 04/23/23 skin sweeps were completed for residents on B pod by LPN #523 and RN #627 with no negative findings. • On 04/23/23 LPN #591 conducted resident interviews for residents on the B pod with no negative findings. • On 04/23/23 LPN #591 and RN #622 conducted all staff education related to the facility Abuse policy and dealing with residents with behaviors. The staff educated included ten administrative staff, 23 LPNs, 65 certified nursing assistants (CNAs), two restorative aides, three facility support advocates, nine registered nurses (RNs), five activities staff, two social services staff; eight nursing administrative staff (three LPNs, three RNs, DON, scheduler), two maintenance staff, four hospitality aides, one Med Tech, one non-cert, one medical record staff, 16 dietary staff, and 11 housekeeping staff. • On 04/23/24 MDS RN #542 reviewed the care plans for B pod residents with behaviors for appropriate interventions. Residents #5, #7, #19, #20, #22, #24, #26, #44, #53, #54, #55, #61, #62, #71, #73, #79, #83, #93, #96, #100, #102, #103, #105, and #107 were reviewed. • On 4/24/23 9:30 A.M., the nursing station phone was placed out of resident sight/camouflaged under a monitor riser/platform. • On 04/24/23 Licensed Practical Nurse (LPN) #617 contacted Resident #5's daughter to inquire about different types of activities the resident might enjoy including, but not limited to, activities done prior to facility admission. Magazines were acquired and given to the resident on 04/25/23. • On 04/24/23 an Ad hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, Administrator, DON, Administrator in Training (AIT) #570, two LPN Unit Manager (LPN #528 and #617), Scheduler #606, Licensed Social Worker (LSW) #537, Social Service Assistant (SSA) #639, MDS LPN #622, Business Office Manager (BOM) #546, Registered Dietitian #646, Maintenance #583, Activities Director #604, Certified Nurse Practitioner (CNP) #647 and MDS RN #542. Topics discussed included but were not limited to alleged abuse, skin sweeps, interviews, education approach and abuse and the State agency SRI. • Beginning on 04/25/23, the facility implemented a plan to audit five staff/week by unit managers and/or night and weekend supervisor/manager regarding approach with residents with increased behaviors. • Beginning on 04/25/23, the facility implemented a plan for facility management staff (unit managers, MDS, DON, weekend and night nurse supervisor/manager) to observe the staff interaction on the unit with residents to ensure redirection is appropriate five times a week for four weeks on different shifts. • On 04/27/23 LPN #528, LPN #516 and LPN #622 completed skin assessments for all facility residents. As a result of the of the assessments new treatment orders were implemented for two residents, Resident #24 and #100. Resident #24 had area that was ordered Dimethicone (cream) and Resident #100 had healing scabbed area on shin. • On 04/27/23 the facility implemented a plan to discuss residents with new or increased behaviors during morning clinical meetings. Staff present for meetings would include the Administrator, DON, Unit Managers (LPNs #528, #615, and #622), Registered Dietitian (RD) #646, Activities #603, Social Services #637. • On 04/28/23 Regional Directors of Operations #645 and Clinical Services RN # 643 educated/reviewed with the DON and the Administrator the facility Abuse Neglect Policy to include having a proper investigation including conclusion/disposition. The facility SRI was updated with an addendum to change the disposition on 05/01/23 to a substantiated abuse. • On 04/28/23 an Ad hoc QAPI meeting was held with the Medical Director to discuss the facility Immediate Jeopardy Abatement Plan. Staff present included the Administrator, DON, Medical Director, CNP #647, Infection Control Preventionist (ICP) DON, Weekend Supervisor/Managers LPN #591, LPN Unit Managers #528 and #617, LPN MDS #622, LSW #537, SSA #639, RN MDS #642, AIT #570, Activity Director #604 and Scheduler #606. • Interviews on 05/01/23 from 8:40 A.M. to 8:50 A.M. with HA #619, STNA #605, and Registered Nurse (RN) #594 confirmed the facility had completed further training on abuse and neglect. They were also educated on resident behaviors and how to deescalate resident behaviors safely. Although the Immediate Jeopardy was removed on 04/28/23, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #5 revealed an admission date of 03/16/23. Resident #5 had admission diagnoses including alcohol dependence with alcohol induced dementia, chronic obstructive pulmonary disease, type two diabetes mellitus, and hypertensive chronic kidney disease. The resident's diagnosis list was updated on 04/22/23 with a diagnosis of traumatic subdural hemorrhage without loss of consciousness. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/23/23 revealed Resident #5 had mild cognitive impairment. The assessment revealed Resident #5 required supervision with (staff) set-up help only for bed mobility, transfers, eating, and toilet use, supervision with one person assistance for dressing, and limited one person assistance for personal hygiene. Review of the care plan, dated 04/03/23revealed Resident #5 was at risk for falls. Interventions included to anticipate the resident's needs, be sure his call light was in reach and encourage him to use it. The care plan also revealed a focus area indicating Resident #5 exhibited behaviors related to the diagnosis of dementia with psychosis. Interventions included to provide an opportunity for a positive interaction, intervene as necessary to protect the rights and safety of others and to divert the resident's attention. In addition, the care plan also had a focus indicating Resident #5 was an elopement wandering risk related to the resident stating he would call a cab and go home. Interventions included to distract resident by offering pleasant diversions such as structured activities, food, conversation, television, or a book. Review of nursing progress note, dated 04/22/23 at 4:29 P.M. revealed Resident #5 fell in the communal area in front of the nurse's station. The note indicated STNA #576 attempted to redirect Resident #5 away from the telephone. Resident #5 hit STNA #576. During the struggle Resident #5 lost his balance and fell. Resident #5 never lost consciousness. The note indicated before the fall Resident #5 was exit seeking and becoming increasingly agitated with staff and his surroundings by threatening to call the police. Resident #5 had socks and shoes on when he fell. Resident #5 was not incontinent during the fall. This nurse stayed with Resident #5 until the paramedics arrived. Resident #5 was assessed and found to have bleeding coming from his left ear. The area was cleaned, and no lacerations were found. Approximately five minutes after the fall Resident #5 showed symptoms of aphasia. Resident #5 was sent out to the hospital. Review of the facility hospital transfer form dated 04/22/23 revealed Resident #5 was being transferred after suffering a fall. Resident #5 was observed bleeding profusely from the left side of his ear. The family and the nurse practitioner were notified with an order to send Resident #5 to the hospital for evaluation. Review of the facility SRI, tracking number 234266 dated 04/22/23 revealed the facility reported an incident of alleged abuse involving Resident #5. A witness statement from HA #619 reported STNA #576 pushed Resident #5 after STNA #576 removed the phone from Resident #5's hands and Resident #5 had begun hitting STNA #576. The SRI also revealed a witness statement from LPN #591 stating STNA #576 informed her he had pushed Resident #5 after he had removed the nurse's station phone from the resident and Resident #5 began punching him. STNA #576 also informed her Resident #5 lost his footing after the push and fell on his back hitting his head. Review of nursing progress note dated 04/23/23 at 4:43 P.M. revealed Resident #5 returned to the facility at this time. Review of hospital discharge paperwork dated 04/23/23 for Resident #5 revealed the resident had been diagnosed with a subdural hematoma. Review of local police reported, dated 04/22/23 revealed Police Officer #642 returned to the facility to review video surveillance from the incident involving Resident #5. He saw Resident #5 approach the nurse's station and grab the phone from the desk. Hospitality Aide (HA) #619 then approached Resident #5 and began talking with him. STNA #576 then came to the desk a few moments later and took the phone from Resident #5. Immediately upon getting the phone from Resident #5 he was observed striking STNA #576 with his right hand and it did appear to be a clenched fist. STNA #576 was then observed pushing Resident #5 away from him. From being pushed backwards, Resident #5 fell with his right shoe falling off. Resident #5 landed backwards and hit his head on the floor. On 04/28/23 at 10:02 A.M. interview with HA #619 confirmed he did witness the incident with Resident #5 and STNA #576 on 04/22/23. He reported he was sitting at the nurse's station when Resident #5 approached the desk and grabbed the telephone and was attempting to dial 911. HA #619 reported he was requesting Resident #5 give him back the telephone when STNA #576 approached the desk on the side Resident #5 was standing and removed the phone from the resident's hands. HA #619 then reported Resident #5 began hitting STNA #576 and STNA #576 pushed Resident #5 causing him to lose his balance and fall. HA #619 confirmed Resident #5 fell on his back and hit his head. He confirmed seeing blood when STNA #576 informed him to get the nurse. HA #619 then proceeded to get the nurse. On 04/28/23 at 10:08 A.M. an attempted interview with Resident #5 revealed no additional information was provided by the resident. At the time of the interview, the resident was observed to be sleepy and stated he was OK when asked. The resident was unable to provide any additional information related to the incident that occurred on 04/22/23. On 04/28/23 at 10:28 A.M. information obtained via an email interview with Police Officer (PD) #642 revealed the police report was still being finalized and the case was referred to the local prosecutor's office. PD #642 denied charges being filed against STNA #576. On 04/28/23 at 10:43 A.M. interview with the Administrator revealed the facility did at one time have camera footage of the incident on 04/22/23 and it had been given to the police. The Administrator indicated the facility was no longer able to retrieve the video to provide to the surveyor for review. On 04/28/23 at 11:43 A.M. interview with Licensed Practical Nurse (LPN) #591 confirmed she was the nurse HA #619 came to get the day of the incident on 04/22/23 involving Resident #5. She reported when she arrived on the unit, Resident #5 was observed on the floor bleeding from his left ear. LPN #591 asked STNA #576 what happened, and he stated to her Resident #5 was attempting to get the phone to dial 911 when he removed it from the resident's hands. Resident #5 began hitting STNA #576 and STNA #576 pushed Resident #5 off him causing him to lose his footing and fall backwards hitting his head. LPN #591 reported Resident #5 did not lose consciousness while she was assessing him, but he did suffer from aphasia which was not his baseline. LPN #591 also reported she cleaned the resident's left ear to see where the bleeding was coming from, but she was unable to locate it. LPN #591 then called 911 and notified Resident #5's nurse practitioner and family. Resident #5 was sent to the hospital for evaluation. On 04/28/23 at 12:31 P.M. interview with the Administrator and AIT #570 revealed the Administrator was notified of the incident on 04/22/23 and she immediately came into the facility. The Administrator reported she was informed Resident #5 was attempting to take the phone from the nurse's station to dial 911 when STNA #576 came over and removed the phone from Resident #5's hands. She reported Resident #5 then began hitting STNA #576 and STNA #576 moved Resident #5 away from him causing him to lose his footing and fall backwards hitting his head. The Administrator confirmed STNA #576 was removed from the unit immediately and suspended pending an investigation. She reported the staff were educated on abuse and neglect and the police were notified. The Administrator revealed English was a second language to HA #619 and STNA #576 so they might have stated Resident #5 was pushed but they really intended on stating he was moved. The Administrator reported when the investigation first started, she informed STNA #576 she would be notifying the police and the State agency of the incident and if he returned to work, he would have to answer those investigations. STNA #576 immediately resigned his position. Review of the facility policy titled Abuse, Neglect, and Exploitation, revised 10/24/22, revealed abuse was defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse was defined as including but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00142289.