**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure adequate supervision of residents and ensure interventions were implemented for residents with physically aggressive and wandering/exit-seeking behaviors for 5 of 14 sampled residents (Resident #34, #80, #81, #91 and #96) reviewed for abuse. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91 and #96 did not have supervision and interventions implemented for their behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on [DATE] at 11:52 AM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:47 PM and was validated onsite by the surveyors on [DATE] through [DATE] through observations, review of audits, meeting minutes, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property .the center must take appropriate corrective action to protect residents. The center should oversee the implementation of corrective action and evaluate whether it is effective .The Director of Nursing in conjunction with other clinical team members shall initiate or revise plan of care to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate .Appropriate steps shall be taken to prevent recurrence of the incident .The Quality Assessment and Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented as necessary . Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: provide for the safety of all concerned . Review of the medical record, revealed Resident #34 was readmitted to the facility on [DATE] with diagnoses of Sepsis, Acute Respiratory Distress Syndrome, Dementia with Behavioral Disturbances, Alzheimer's Disease, Major Depressive Disorder, Delusional Disorder, Generalized Anxiety Disorder, and Schizophreniform Disorder. Review of Resident #34's Certified Nursing Assistant (CNA) care card revealed there was no date on the care card and there were no interventions for running into other residents/staff. Review of Resident #34's Care Plan with a review date of [DATE], revealed the resident had behavior symptoms and exhibited socially inappropriate behavior. Interventions included staff were to document in the medical record the intensity, duration, and frequency of the behavior. The Medical Doctor (MD) was to assess the resident medically for signs of inappropriate behavior and encourage participation in Activities of Daily Living (ADLs). The staff were to redirect Resident #34 when exhibiting negative behaviors, refer the resident to psychiatric services as needed, administer the medications as ordered by the physician, escort the resident to a private area if needed, try to take her to a quiet and calm environment during periods of agitation, and offer activities that would change her mood and behaviors. There were no interventions noted on Resident #34's Care Plan for her aggressive behavior of running into staff and other residents with her wheelchair. Review of the Psychiatric Periodic Evaluation dated [DATE], revealed Resident #34 was up in a wheelchair (WC), going up and down the halls yelling, asking for water, and had intrusive behavior. The resident was observed almost running over people at times with her wheelchair, was agitated and aggressive, had anxiety, disinhibition, and motor disturbance. The psychiatric evaluation recommended to discontinue the Alprazolam and start Clonazepam (sedative medications) 0.5 milligrams (mg) by mouth twice daily for the anxiety. Review of the Nurse Practitioner Progress note dated [DATE] and [DATE] revealed the nurse reported Resident #34 was rolling her WC into other people. Review of the Nursing Progress Note dated [DATE], revealed Resident #34 was up in her WC, self-propelled the WC on the unit yelling and cursing loudly. Other residents were offended by the things that she yelled out. There were multiple attempts made to redirect the behavior without any success. Review of the Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated for bruising to the left upper chest and it was unknown how she got the bruise, but it was consistent with bumping into another person. Medication changes were made recently due to psychiatric (psych) recommendations. The Ativan order was discontinued, and Clonazepam 0.5 mg started two times daily for the anxiety, after the resident was noted by staff to have increased behaviors. The nurse reported the resident was rolling her WC into other people and stated .staff states that behaviors have not decreased, but have perhaps increased. Resident was using WC to bump into patients and staff. Difficult to redirect . Review of the Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated for increased behaviors. The nurses noted she used foul language and used her WC to run into other patients and staff. Review of the Progress Note dated [DATE], revealed Resident #34 continued to independently wheel herself around in her WC, and ran over staff and residents with her WC. Review of the Nurse Practitioner Progress Note dated [DATE], also revealed Resident #34 used foul language and her WC to run into other patients and staff. Review of the Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated for new .discoloration and scrapes superior to anterior side of R [right] knee. Contusion of right knee the resident noted to self propel in WC often bumping into other residents and staff. Anxiety-likely contributed to bumping into others in WC . Review of the Nurse Progress Notes dated [DATE], revealed Resident #34 was seen by the Nurse Practitioner who ordered an increase in the Xanax (sedative medication) 0.25 mg from twice a day (BID) to three times daily (TID). Review of the Nurse Progress Note dated [DATE], revealed the Nurse Practitioner evaluated Resident #34 at the psychiatric recommendation to increase the patient's Alprazolam order from Xanax 0.25 mg BID to TID due to (d/t) the resident's anxiety/agitation and reported behaviors. The reported behaviors included bumping into others in her WC. Review of the Nurse Progress Note dated [DATE], at 3:30 AM, revealed the DON .went upstairs this afternoon resident noted bumping her wheelchair into the back of another resident that was sitting in their wheelchair. The other resident did appear to notice their wheelchair had been bumped by this resident. Resident appeared unaware she had bumped into someone. Resident redirected into a less crowded area. Therapy to reevaluate chair for appropriateness. Maintenance padded some parts of residents [resident's] chair to decrease the chance of her bumping into someone and causing injury. IDT [Interdisciplinary Team] team met to discuss interventions resident placed on 1:1 [one on one observation] when oob [out of bed] in her wheelchair until therapy can assess her wheelchair . Observation on the 200 Hall on [DATE] at 5:00 PM, revealed Resident #34 rolled into the surveyor's legs with her wheelchair. The surveyor moved from that location and Resident #34 followed the surveyor for several minutes. Observation on the 200 Hall on [DATE] at 5:30 PM, revealed Resident #34 rolled her wheelchair up to the surveyor, pinning the surveyor against the wall, and stared at the surveyor, directly in the eyes. The surveyor was unable to move from her position due to the close proximity of the resident's wheelchair. After a few seconds, the resident rolled away and the surveyor walked to another area of the [NAME] side of the 200 Hall. The resident turned her wheelchair and rolled up to the surveyor once again and stared directly into the surveyor's eyes. The surveyor was unable to move until the resident rolled away in her wheelchair. Observation in the 200 East Hall on [DATE] at 12:03 PM, revealed Resident #34 rolled onto Resident #94's left foot and stopped. Resident #94 waved her on and stated under his breath, .stupid .stupid .go . Resident #34 rolled off of Resident #94's foot. Observation on the 200 Hall on [DATE] at 1:55 PM, revealed Resident #34 ran into Resident #85 in the hall and the nurse separated them. Observation on the 200 Hall on [DATE] at 2:01 PM, revealed Resident #34 ran into Resident #27. Observation on the 200 Hall on [DATE] at 2:04 PM revealed, Resident #34 threw her snack cake on the floor and rolled down the hall toward the East Nurses' Station. As she approached the corner of the hall near the East Nurses' Station, Resident #84 waved Resident #34 away from him. Resident #16 was seated in a chair and Resident #34 rolled into Resident #16. Observation on the 200 Hall on [DATE] at 2:06 PM revealed, Resident #34 rolled down the hall toward the elevator, Resident #99 was seated in a wheelchair by the elevator as Resident #34 came toward Resident #99. Resident #99 stated, .please don't hit me .please don't hit me . A staff member moved Resident #34 to the other side of Resident #99. Resident #34 turned toward Resident #99, and Resident #99 stated, .don't hit me . Resident #34 ran her wheelchair into Resident #99. A staff member took Resident #34 to her room. During an interview on [DATE] at 8:27 AM, Licensed Practical Nurse (LPN) #1 stated, .on 7/6 [2021] I saw [Named Resident #34] running over you and the other surveyor .so I called the DON and asked is there not a wheelchair guard we can put on her WC .she's getting out of hand .hurting her own self .bruises on her hand .but I really didn't get a clear response .she kind of brushed me off . Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Alcoholic Cirrhosis of the Liver with Ascites, Major Depressive Disorder, Anxiety Disorder, Hypertension, Atherosclerotic Heart Disease and History of Alcohol Abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 was assessed to have a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #80 had no cognitive impairment for decision making, had verbal behavioral symptoms that were directed toward others, threatened others, screamed at others, rejected care, and walked with supervision but required no physical help. Review of Resident #80's Care Plan dated [DATE] revealed .Behaviors: yells at others, aggressive behaviors at times, argumentative with staff at times . Review of the medical record, revealed Resident #81 was admitted to the facility on [DATE], with diagnoses of Down Syndrome, Osteoporosis, Major Depressive Disorder, Pain due to Nervous System Prosthetic Devices, Sciatica, Brief Psychotic Disorder, Restlessness and Anxiety, Anxiety Disorder, Difficulty Walking, Muscle Atrophy, and Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #81 was assessed to have a BIMS score of 2, which indicated the resident had severely impaired cognition, had poor decision making skills, required cues/supervision, had physical behaviors directed toward others which included hitting, pushing, grabbing and behaviors of pacing, disrobing, wandering, rejecting care, walked with limited assistance of 1 person, and required extensive assistance of staff for dressing and eating activities. Review of Resident #81's Care Plan reviewed [DATE], revealed .Behaviors: wandering and exit seeking .likes to disrobe through the day and wanders inappropriate places naked. Becomes agitated when staff tries to put clothes back on, family aware, can be hard to redirect him, can be combative and resist care, easily agitated when redirected, will place self on floor in various places . Review of the facility's video camera footage dated [DATE] beginning at 6:30 PM, revealed the following: At 6:30 PM and 59 seconds, Resident #81 appeared in view of the camera at the 2 East Nurses' Station hallway wearing a long t-shirt with a [NAME] emblem that reached above the knees and was not wearing pants. Resident #81 was facing the camera. At 6:31 PM and 45 seconds, Resident #80 appeared in view of the camera wearing jeans with red suspenders, a shirt, hat, and shoes. Resident #80 had his back to the camera. Resident #80 appeared to be talking to Resident #81 because Resident #80's head was moving side to side as if talking. At 6:32 PM and 4 seconds, Resident #81 took his right hand and swung at Resident #80 at his waist level and Resident #80 stepped back. At 6:32 PM and 10 seconds, Resident #80 stepped forward to the original position while he appeared to be talking as his head was moving side to side. Resident #81 took his left hand, swung at Resident #80, and hit Resident #80 on the right side of his chest. At 6:32 PM and 12 seconds, Resident #80 stepped forward and with his right open hand, shoved Resident #81 in the chest causing Resident #81 to fall back, with his body straight. There was no flexing or bending of Resident #81's body as he fell to the floor, striking his head. At 6:32 PM and 15 seconds and 6:32 PM and 16 seconds, CNA #1, CNA #2, and LPN #1 appeared in camera view responding to the incident. CNA #1 and #2 went to Resident #81's side on the floor and began to care for the resident. LPN #1 went to Resident #80 and appeared to be talking with him. Resident #80 threw up his arms and appeared to be talking with his head moving side to side. Resident #80 walked to his room alone and was seen entering the door of his room. No one escorted Resident #80 to his room. At 6:32 PM and 20 seconds, Resident #81 appeared to move his right arm. At 6:32 PM and 29 seconds, CNA #3 appeared in camera view and kneeled at Resident #81's side on the floor. Resident #81 had no pants on. At 6:32 PM and 37 seconds, CNA #4 appeared in camera view and walked around the area. At 6:32 PM and 40 seconds, Resident #81 appeared to move his left leg and toes. At 6:33 PM and 13 seconds, Resident #81 appeared to move his left arm. At 6:33 PM and 30 seconds, LPN #2 appeared in camera view and went behind the Nurses' Station. At 6:34 PM and 33 seconds, CNA #2 and CNA #3 appeared to position Resident #81 on his right side. At 6:35 PM and 34 seconds, Registered Nurse (RN) #1 appeared to take Resident #81's blood pressure on the right arm. At 6:36 PM and 30 seconds, the police appeared in camera view at the 2 East Nurses' Station, walked to Resident #80's room, and stood outside his door. There was no staff member seen on the video entering Resident #80's room. At 6:37 PM and 43 seconds, Resident #81 appeared to move his legs. At 6:38 PM and 30 seconds, facility staff applied oxygen to Resident #81 while LPN #1 was on the telephone at the Nurses' Station and pointed toward Resident #81 lying on the floor. At 6:39 PM and 17 seconds, the Emergency Medical Services (EMS) and Fire personnel appeared in camera view and assumed care of Resident #81. The resident was placed on a stretcher and was transported by EMS out of camera view. Review of the EMS Prehospital Patient Record dated [DATE] at 6:40 PM, revealed .Convulsions fall Nursing home [DATE] at 19:01 PM [7:01 PM] alert nonverbal facial grimace when head palpated, PERRLA [pupils equal, round, reactive to light accommodate] . Review of the emergency room (ER) visit note dated [DATE] at 8:19 PM, revealed .He [Resident #81] apparently was involved in altercation with another resident and was found on the floor per EMS .alert, nonverbal, [baseline nonverbal], alert/awake .CT [computerized tomography] of head bilateral acute subarachnoid hemorrhage [bleeding in the space between the brain and the tissue covering the brain] with subdural hemorrhage [a pool of blood between the brain and its covering] along the flax, right middle cranial fossa. Right tentorium and left frontal intraparenchymal hematoma [bleeding within the brain and more likely to result in death], no midline shift or herniation overall favor post traumatic etiology .subdural and subarachnoid and several contusions .needs to be monitored in neuro ICU [intensive care unit], contacted [Named Hospital] .clinical impression: intracranial hemorrhage . Review of the (Named Hospital) Emergency Department note dated [DATE] at 12:38 AM, revealed, .GCS [Glasco coma scale to assess depth and duration of coma with 9-12 assessed as moderate brain injury] 10 at baseline, vital signs stable, awake, nonverbal, roving eye movements with right sided gaze deviation .bradycardic [slow heart rate] 45 .CT no skull fracture .enlarging intraparenchymal hemorrhage [a potentially life threatening condition in which a blunt force injury causes blood to pool within the brain tissue] in the frontal lobes, subdural [under the membrane covering the brain] and subarachnoid [space between the brain and the surrounding tissue] and intraventricular hemorrhage .no evidence of acute traumatic injury to the chest .CT [computerized tomography] notable for worsening intraparenchymal hemorrhage, extensive bilateral subarachnoid and subdural hematomas. Admit trauma surgery in stable condition . Review of the (Named Hospital) Case Management Note dated [DATE], revealed .family conversation [DATE] patient made a DNR/DNI [do not resuscitate/do not intubate] as well as deferring [putting off] any neuro-surgical intervention .On night [DATE] patient [Resident #81] began having seizures, ultimately it progressed into status epilepticus [a seizure that lasted longer than 5 minutes] as patient did not regain previous GCS [Glasgow Coma Scale]. Patient declined from a respiratory status requiring NRB [nonrebreather] and Opti flow [nasal high flow oxygen] while awaiting family to arrive at hospital. After seeing [Named Resident #81] over facetime, his sister [Named Person] called and requested comfort care. Patient transitioned to Versed and Morphine drips, decreased oxygen 2 liters per nasal cannula and expired with sister [Named Person] at bedside . Review of Resident #80's Nurses' Note dated [DATE] at 8:16 PM, revealed, .Resident [Resident #80] had an altercation with another resident [Resident #81] that he shoved to the floor around 6:30 PM. when asking the resident [Resident #80] what happened he said yes I shoved him [Resident #81] to the floor he hit me .Resident [Resident #80] has been started on every 15-minute checks . Review of the medical record, revealed 15-minute observation checks were conducted on Resident #80 on [DATE] - [DATE] at 10:15 AM. At 10:15 AM, Resident #80 was placed on one on one observation by the staff. Review of Resident #80's Nurses' Note dated [DATE] at 8:05 PM, revealed, .Every 15 minute check he has been rude towards staff today because a female resident asked the nurse to please have him leave her room because he is playing loud music by her door. He said he is a grown man and can do as he wishes . Review of the medical record, revealed on [DATE] at 10:15 AM, one on one observations of Resident #80 were conducted until [DATE] at 11:00 AM, when the Administrator and DON escorted Resident #80 to the police department. During an interview on [DATE] at 3:09 PM, LPN #1 confirmed her witness statement. She stated, .I was just around the corner and came around and saw [Named Resident #81] going down [falling backwards] and I saw [Named Resident #80] throw his hands up as [Named Resident #81] fell back and I said what are you doing [Named Resident #80] said I didn't do nothing he hit me first .I made sure [Named Resident #81] was OK and told [Named Resident #80] to go to his room . During an interview on [DATE] at 4:45 PM, CNA #2 confirmed her witness statement. She stated, .We had just finished dinner tray pick up and we were just around the corner at room [ROOM NUMBER] talking about a car fire and I heard a loud thud. We ran around the corner and saw [Named Resident #81] lying on the floor and [Named Resident #80] standing near him .No, I never heard any loud talking or yelling before I heard the thud .I have not seen them [Resident #80 and Resident #81] talking or interacting before .I have heard [Named Resident #80] make a threat about [Named Resident #81] if [Named Resident #81] sat on the floor because he was agitated or walk around naked. [Named Resident #80] would say he [Resident #81] shouldn't be naked like that and if up to him [Resident #80] he would take care of him [Resident #81] .I cannot say for sure if anyone else heard it .No, I didn't tell anyone .No, I don't remember when [Named Resident #80] said it . During an interview on [DATE] at 10:17 AM, CNA #1 confirmed her witness statement. She stated, .[Named Resident #80] would yell at staff about smoke breaks .He [Resident #80] did make statements about [Named Resident #81] that [Named Resident #81] knows what he is doing when [Named Resident #81] would sit in the floor because he couldn't get his way. [Named Resident #80] would say when [Named Resident #81] walked around naked [Named Resident #80] would say the ladies don't want to see that. I told him [Resident #80] that [Named Resident #81] is not like everyone else, he don't know better .I never saw [Named Resident #80] interact with [Named Resident #81] he [Resident #80] just told me that [Named Resident #81] knows what he is doing . During an interview on [DATE] at 4:18 PM, CNA #7 stated, .I was on the elevator don't remember the date, taking [Named Resident #80] down for smoke break and I over heard him say about [Named Resident #81] that he [Resident #80] would hit him [Resident #81] .He [Resident #80] said I'm going to hit him .[Named Resident #81] had been walking down the hall naked .We immediately had put him [Resident #81] in a gown .No, I can't recall ever hearing that statement again . During an interview on [DATE] at 11:18 AM, the DON stated, .[Named Resident #81] could get argumentative with staff about smoking .I was not aware of any aggressive interactions between [Named Resident #80] and [Named Resident #81] prior to incident [[DATE]] .After the incident we placed [Named Resident #80] on every fifteen minute checks till psych [psychiatry] saw him. He had no psych issues just the incident .After the police said they were going to charge him [Resident #80] we placed him on one to one observation until he [Resident #80] went to the precinct . During a telephone interview on [DATE] at 11:45 AM, Detective #1 with the (Named) Police Department stated, .[Named Resident #80] is charged with reckless homicide . Review of the medical record, revealed Resident #91 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Depressive Episodes, Iron Deficiency Anemia, Anxiety Disorder, Hypertension, and Pain. Review of the Elopement Risk assessment dated [DATE], revealed Resident #91 was at low risk for elopement. Review of the MDS dated [DATE], revealed Resident #91 had moderate cognitive impairment and was not coded for behaviors. Review of the Nurse Progress Note dated [DATE] at 9:22 PM, revealed Resident #91 had been .very anxious and cussing at staff. Staff requested a new order for Ativan [a medication for anxiety] . Review of the Nurse Progress Note dated [DATE] at 10:56 AM, revealed Resident #91 was observed in the resident's room urinating in his roommate's water pitcher. The resident had a hematoma and fresh blood on the right temple, and a small puncture wound that was bleeding. The resident was confused and stated he fell 8 days ago. Review of the Nurse Progress Note dated [DATE] at 2:19 PM, revealed Resident #91 received an Ativan. He seemed more confused than usual. Review of the Nurse Progress Note dated [DATE] at 12:03 PM, revealed Resident #91 had increased confusion. Review of the Nurse Progress Note dated [DATE] at 9:43 AM, revealed Resident #91 had increased confusion and wanted to go to the bank. The Nurse Practitioner was made aware of the resident's increased confusion. Review of the Nurse Progress Note dated [DATE] at 4:04 PM, revealed the hospice agency was notified of Resident #91's behavior, that he thought his son was up and walking around and was yelling for the kids to come into the room. Resident #91 received Ativan for increased agitation. Review of the Nurse Progress Note dated [DATE] at 1:33 PM, revealed Resident #91 stated the doctor came and hit him 3 times in the head with a sledgehammer, was slightly confused and talking about violence to other people. Review of the Nurse Progress Note dated [DATE] at 3:33 PM, revealed Resident #91 had increased confusion and was looking for band members and a place to set up equipment. Resident #91 was administered Ativan. Review of the Nurse Progress Note dated [DATE] at 8:34 AM, revealed Resident #91 ambulated in the hallway, was redirected by staff, was alert with confused episodes, and Ativan was administered. Review of the Care Plan revised [DATE], revealed Resident #91 was care planned for Cognitive Deficits with interventions which included therapeutic activities, encourage participation in activities throughout the day; Psychotropic Drug Use with interventions which included monitor for changes in behavior and mood, observe for any signs of decline in functional or cognitive status; and Behavior Symptoms: Wandering/Risk for elopement which included interventions of Wanderguard and monitor placement, placed on every 15 minute checks for 24 hours, and to redirect away from exit doors and elevator was added on [DATE]. Review of the facility's Occurrence Report dated [DATE], revealed Resident #91 was observed by staff on the 1st floor of the facility unsupervised. The staff member assisted him back to the 2nd floor (a secured unit where if a Wanderguard is on a resident, the elevator will not move without a code. Resident #91 did not have a Wanderguard at the time of this incident). The facility's investigation revealed when the elevator arrived at the 1st floor the Occupational Therapist was waiting to go upstairs and retrieve a resident for therapy services. She observed Resident #91 exit the elevator on the 1st floor and at the time did not think anything about it. She proceeded to the 2nd floor to retrieve a resident for therapy, at which time the therapist realized that Resident #91 exited the elevator on the first floor, alone. The Social Worker returned the resident to the 2nd floor. Review of the Elopement Risk assessment dated [DATE], revealed Resident #91 was at high risk for elopement and a Wanderguard was placed on Resident #91. During an interview on [DATE] at 2:17 PM, the Occupational Therapist (OTR/L) was asked about the incident that occurred on the elevator with Resident #91. The OTR/L stated, .[Named Resident #91] never been on [therapy] case load .12:50-1 [PM] .getting on elevator, he [Resident #91] was getting off .there was no alarm going off upstairs .I proceeded to get a resident I was working with to bring him back down .while upstairs Social Worker had brought him back upstairs . Review of the medical record, revealed Resident #96 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Altered Mental Status, Cerebral Infarction, Wandering, and Insomnia due to other mental disorder. Review of the quarterly MDS dated [DATE], revealed Resident #96 was assessed with a BIMS of 2 indicating the resident was severely cognitively impaired for decision making. Resident #96 was assessed to have inattention, disorganized thinking, verbal, and physical behavioral symptoms directed toward others, rejected care, and had wandering behaviors. Review of a Nurse Progress Note dated [DATE], revealed Resident #96 was observed in Resident #74's room talking with a female resident. The female resident stated, He hit me. The only intervention was every 15 minute checks. Review of Resident #96's undated CNA Care Plan revealed the resident could become aggressive, one on one observation resolved on [DATE], and only every 15-minute checks were implemented. During an interview on [DATE] at 11:50 AM, RN #2 stated, .Today is my first day here .I received nothing really in regard to orientation .No, no one told me anything about the patient population like behaviors or specifics . During an interview on [DATE] at 12:17 PM, CNA #6 stated, .This is my third day working here .I received no orientation on the type of patients I will care for .They said here is your assignment and told me which residents were continent and who could get up .showers . During an interview on [DATE] at 12:28 PM, CNA #5 stated, .This is my first day working here .I received no orientation .They did not tell me about the type of patient or how to handle .I received no education or information on the type of patient or how to handle behaviors or dementia . Refer to F-726, F-744, F-835, and F-687. The surveyors verified the Removal Plan by: 1. Resident #80 was discharged from the facility on [DATE], return is not anticipated. 2. A facility wide baseline behavior assessment review will be conducted by the Geriatric Psychiatric Nurse Practitioner on [DATE] for all residents in the facility. The surveyors reviewed the behavior assessments. 3. A comprehensive review of the medical record and Care Plan will be conducted by the Director of Nursing and Nurse Supervisor to ensure compliance. The surveyors reviewed the Care Plans and medical records and interviewed the DON. 4. An audit was conducted of all residents with behaviors to ensure appropriate interventions were in place for noted behaviors and were care planned. This audit will be conducted monthly for 3 months and until 100% compliance. The surveyors reviewed the audits. 5. Quality Assurance Performance Improvement (QAPI) was initiated to review the effectiveness of interventions that had been in place. Failed interventions were reviewed[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, agency contract review, employee personnel file review, observation, and interview, the facility failed to ensure licensed nurses and certified nursing assistants (CNA) had the knowledge and skills necessary to assess residents, prevent abuse, and provide appropriate care to meet the residents needs for 5 of 16 sampled residents (Resident #34, #80, #81, #91, and #96) with physically aggressive and wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91, and #96 did not have supervision and interventions implemented for their aggressive behaviors. The failure of the licensed nurses and CNAs to identify behaviors and respond to those behaviors and the potential/likelihood of continued behaviors could result in serious injury to others in the facility. The failure to provide competent staff to meet resident needs, failure to provide orientation and/or training for staff, failure to oversee implementation of resident care policies and the failure to provide supervision and/or monitoring of the delivery and implementation of care could result in serious injury to others in the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-726 on [DATE] at 5:22 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-726. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 10:19 AM, and was validated onsite by the surveyors on [DATE] through [DATE] through observations, review of education provided, audits, meeting minutes, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately .provide for the safety of all concerned . Review of the facility's undated policy titled, Administering Medications, revealed .New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility .The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned . Review of agency company #1's contract dated [DATE], revealed .Obligations of Client .Supervision and Instruction, client is responsible for supervision and instruction of the Personnel regarding policies, procedures, and Client operation, specifically including, but not limited to all necessary Client safety procedures, equipment handling, and services to be rendered. Client shall remain solely liable for the safe working conditions and supervision of those entrusted to operate equipment and provide services hereunder . Review of agency company #1's Comprehensive Core Competency Certified Nursing Assistant (CNA) test dated [DATE], revealed there was no documentation on the test that included Dementia or Behaviors. Review of employee personnel files, Contract Registered Nurse (RN) #2, Contract Certified Nursing Assistant (CNA) #5 and #6, revealed the employee files had no documentation of a competency evaluation to ensure they had the knowledge skills related to care of residents with dementia, care of residents with behaviors such as physical aggression, or nursing assessment skills. Observation during medication administration on the 1 East Hall on [DATE] at 8:55 AM, Licensed Practical Nurse (LPN) #4 looked in the medication cart for artificial tears and was unable to find them. LPN #4 stated, .I will have to go get some .do you know where the med [medication] room is . Observation and interview during medication administration on the 2 East Hall on [DATE] at 11:28 AM, RN #2 stated, .hard because don't know these residents that well . RN #2 removed Gabapentin from the medication cart and put it in the cup. RN #2 realized the medication was not due and was unsure of the facility's policy regarding wasting a medication. During an interview on [DATE] at 11:50 AM, RN #2 stated, .Today is my first day here .I received nothing really in regard to orientation. Just here is the medication cart and here is the computer. I am not familiar with the system they use .No, no one told me anything about the patient population like behaviors or specifics . Observation during medication administration on the 1 East Hall on [DATE] at 12:15 PM, LPN #4 stated, .it is hard because I don't know these residents that well . During an interview on [DATE] at 12:17 PM, CNA #6 stated, .This is my third day working here .I received no orientation on the type of patients I will care for .They said here is your assignment and told me which residents were continent and who could get up .showers . During an interview on [DATE] at 12:28 PM, CNA #5 stated, .This is my first day working here .I received no orientation .They told me what rooms I had and who were incontinent .They did not tell me about the type of patient or how to handle .I received no education or information on the type of patient or how to handle behaviors or dementia . During an interview on [DATE] at 1:22 PM, the Administrator stated, .For the agency staff we usually hand them a packet up front [kept at the front desk] on abuse, fire, codes .I can't remember what else it has in it .for them to be familiar with the facility .the agency does the background checks, abuse [checks], training for abuse, resident rights .I can't think of them off the top of my head I have not looked at them in a while .We expect them [agency employee] to provide the same level of service we provide, not be abusive to the residents, to treat the residents with dignity and respect, to supplement our staff and to do everything we do .The orientation we provide is the packet. When the nurse walks them to their unit, they receive their assignment, they are shown the Nurses' Station, where they can get supplies, the clean and dirty utility rooms .they get report on their patients . Review of the packet given to agency staff on [DATE] at 1:50 PM, revealed documentation of fire, elopement, and abuse. There was no documentation of education or information on the care of residents with behaviors or dementia. During an interview on [DATE] at 1:50 PM, the Administrator stated, .No we don't have signatures that show the employee received the packet .No there is no education about behaviors, dementia or anything care related . The facility was unable to provide a contract for agency company #2. During a telephone interview on [DATE] at 10:05 AM, agency company #2's representative stated, .We provide no training prior to the staff assignments .We make sure the staff we send are licensed .We provide no training on behaviors . Review of agency company #3's contract dated [DATE], revealed .Responsibilities of Client .Provide orientation which, at minimum, includes the review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Control, and Fire and Safety .and EMR [Electronic Medical Record]/Charting (if applicable) . During a telephone interview on [DATE] at 10:10 AM, agency company #3's representative stated, .we credential our staff such as if have license .if there is special training that has to be done by the facility .no, we don't do dementia or behavior training . Review of agency company #4's contract dated [DATE], revealed .Facility obligations .Communication with Staff. Clearly communicate to Staff duties, shifts, unit assignments, and other working details during Staff's assignment .Orientation. Provide orientation to Staff for each unit to which Staff is assigned . During a telephone interview on [DATE] at 10:15 AM, agency company #4's representative stated, .We do the typical credential process .No, we haven't been told about the facility's patient population .We don't do education about dementia or behavior. We expect them [employee] to have their license. We don't do education . Observation and interview on [DATE] at 3:55 PM, revealed RN #3 (Agency Nurse) and LPN #6 (Agency Nurse) stood at the 2 East Nurses' Station talking. RN #3 and LPN #6 were notified by the surveyor that there was someone standing outside the facility door who needed to be screened to come into the facility and a resident who had completed visitation with his family and needed to be transported back to his room. RN #3 stated, We're Agency .so we don't know the code, and resumed their conversation. RN #3 and LPN #6 did not attempt to notify a facility staff member that someone was at the door who needed assistance or help the resident who needed assistance back to his room. Refer to F-600, F-744, F-835, and F-867. The surveyors verified the Removal Plan by: 1. An audit of personnel files will be conducted by the management team to determine whether all staff have received training on dementia and behaviors by [DATE]. The surveyors verified the removal plan by review of the personnel files audit, in-service sign-in sheets, and interview of staff on all shifts. 2. An audit of all facility agency contracts were conducted on [DATE] to determine whether the contracted staff have received dementia and behavior training. The surveyors verified the removal plan by review of the audits, in-service sign-in sheets, and interviews with agency staff. 3. Facility shall provide staff with the appropriate training, education and in-services regarding dementia, behaviors, identification, and management. The surveyors verified the removal plan through review of the in-service sign-in sheets, interview of staff assigned to conduct training, and interviews of staff on all shifts. 4. Dementia and behavior training will be required for all staff including agency personnel and completed quarterly for 6 months and then annually. This training will be part of the orientation process. The surveyors verified the removal plan through interviews with the DON and Human Resources (HR) Director, and review of the training program. 5. All staff including agency personnel shall complete a competency quiz to ensure knowledge and skills necessary to provide care for residents with dementia and behaviors are retained. The surveyors verified the removal plan through review of the competency quiz and interviews with staff on all shifts. 6. All staff are required to obtain a score of 100% to meet competency requirements. The surveyors verified the removal plan through review of the competency quiz and interviews with staff on all shifts. 7. Quality Assurance Performance Improvement (QAPI) will be initiated to ensure 100% compliance of dementia and behavior training for all staff. The surveyors verified the removal plan through review of audit tools developed and interview of the Administrator and DON. 8. All staff will be in-serviced prior to starting their shift. All as needed (PRN) staff and any staff on leave will not be placed on schedule until in-service has been completed. The surveyors verified the removal plan through review of the schedule, daily postings, in-service sign-in sheets, and through interviews with staff on all shifts. 9. A more in-depth training/orientation will be provided to all contract employees who work in the facility. This training will include Abuse, resident rights, fire safety, elopement, dementia, and behavior. The surveyors verified the removal plan by review of the in-service sign-in sheets, the training packet given to agency staff, and interview of agency staff on all shifts. 10. An audit of all new employee files pertaining to dementia and behavior training will be completed weekly for 4 weeks and monthly for 3 months. Results of the audit will be reviewed by the Interdisciplinary Team (IDT) in the QAPI committee meeting. Findings of noncompliance will be addressed immediately. The surveyors verified the removal plan by review of the audit tool developed by the facility for review in the QAPI committee meeting and through interview with the Administrator and DON. The facility's noncompliance at F-726 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to meet each resident's Dementia care and behavior needs for 6 of 16 residents (Resident #34, #80, #81, #91, #96, and #303) reviewed for Dementia care and behaviors. The facility's failure to provide care and services for Dementia and behaviors resulted in Immediate Jeopardy when a physical altercation occurred between Resident #80 and #81, Resident #80 willfully pushed Resident #81, Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. A physical altercation occurred between Resident #96 and Resident #74, inappropriate sexual behavior occurred between Resident #303 and Resident #36, Resident #34 ran her wheelchair into Resident #16, Resident #85, ran over Resident #94's foot, and the state surveyors, and Resident #91, a cognitively impaired vulnerable resident with a history of behaviors and had verbalized the desire to leave the facility, was found unsupervised on another floor of the facility. The facility's failure resulted in Immediate Jeopardy (IJ) for Resident Resident #34, #80, #81, #91, #96, and #303. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy for F-744 per telephone on [DATE] at 2:30 PM. The facility was cited Immediate Jeopardy at F-744. The facility was cited at F-744 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:47 PM and [DATE] at 10:19 AM, and was validated onsite by the surveyors on [DATE] through [DATE] through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: provide for the safety of all concerned . Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The resident has the right to be free from mistreatment, neglect .Abuse includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Sexual Abuse includes sexual harassment, sexual coercion, or sexual assault .Ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include temporary one on one supervision of a resident . Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Sepsis, Dementia with Behavioral Disturbance, Delusional Disorders, Major Depressive Disorder, Generalized Anxiety Disorder, Delusional Disorder, and Schizophreniform Disorder. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #34 to have moderate cognitive impairment for decision making, inattention, and disorganized thinking. Resident #34 was coded for physical behavioral symptoms and other behavioral symptoms directed toward others 1-3 days during the assessment period, was short tempered and easily annoyed. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #34 to have severe cognitive impairment for decision making, inattention, and disorganized thinking. Resident #34 was coded to have physical behavioral symptoms and other behavioral symptoms directed toward others 1-3 days during the assessment period, was short tempered and easily annoyed. Review of a Progress Note dated [DATE], revealed Resident #34 tried to hold people's hands when up in a wheelchair (WC) and some residents do not like this. Review of a Progress Note dated [DATE], revealed Resident #34 continuously wheeled around in her WC cursing and crying out for help. Review of a Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated on [DATE] for a pharmacy recommendation to attempt a Risperdal gradual dose reduction (GDR). The nurse states that she has regular behaviors of cursing and using profane language, and rolling her WC into other people. The nurse requested not to attempt GDR at this time. Resident #34 had poor insight, confusion, anxiousness, depression, agitation, inattention, abnormal heightened affect, and visual hallucinations, pulling hair, and taking off clothes. The assessment/plan revealed her Schizophrenia was stable and would attempt a GDR in the future. Review of a Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was seen for a concern of increased behaviors reported by the weekend nurse who reported the resident was rolling her WC into other people. Review of a Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was seen on [DATE] for a psychiatric recommendation to discontinue Ativan and start Clonazepam (sedative medication) 0.5 mg for anxiety. She was noted to have increased behaviors over the weekend, which included the resident rolling her WC into other people. The assessment/plan was to discontinue alprazolam and to start clonazepam 0.5 mg by mouth twice daily. Review of Progress Note dated [DATE], revealed Resident #34 was up in her WC propelling on the 2nd floor unit, yelling and cursing loudly. The other residents were getting offended by the things that she yelled out. There were multiple attempts to redirect behavior without any success. Review of Nurse Practitioner Progress note dated [DATE], revealed Resident #34 was seen for bruising to her upper chest on the left side. It was unknown how the resident obtained the bruise but was consistent with bumping into another person. A medication change was made recently at the Psychiatric Nurse Practitioner's (PNP) recommendation. An order to discontinue the Ativan and start clonazepam 0.5 mg twice daily for anxiety after the resident was noted by staff to have increased behaviors. The nurse reported the resident was rolling her WC into other people. Staff stated that behaviors have not decreased but have perhaps increased. She is still using her WC to bump into other residents and staff and is difficult to redirect. The assessment/plan was to see PNP when she was in facility the next time to see if her medication should be adjusted. Review of a Nurse Practitioner Progress note dated [DATE], revealed Resident #34 was seen related to increased behaviors. The nurses noted she used foul language and used her WC to run into other patients and staff. The assessment/plan included a Urinalysis with a Culture and Sensitivity to rule out infection, and additional blood work ordered. Review of a Nurse progress note dated [DATE], revealed Resident #34 was running over staff and residents with her WC. Review of a Nurse Practitioner Progress note dated [DATE], revealed Resident #34 was seen today for use of foul language and use of her WC to run into other patients and staff. The assessment/plan was to discontinue the clonazepam 0.5 mg by mouth twice daily and to start alprazolam (sedative medication) 0.25 mg by mouth twice daily. Review of Resident #34's Care Plan reviewed [DATE], revealed Focus Behavior Symptoms of Socially Inappropriate Behavior Resident exhibits socially inappropriate behavior. There were no interventions related to Resident #34's assessed physical behavioral symptoms on the Care Plan. Observation on the 200 Hall on [DATE] beginning at 5:00 PM, revealed Resident #34 rolled into the surveyor's legs with her wheelchair. The surveyor moved and Resident #34 followed the surveyor for several minutes. Observation on the 200 Hall on [DATE] beginning at 5:30 PM, revealed Resident #34 rolled into the surveyor with her wheelchair and stared at the surveyor, directly in the eyes. The surveyor was unable to move from her position due to the close proximity of the resident's wheelchair. After a few seconds, the resident rolled away and the surveyor walked to another area of the [NAME] side of the 200 Hall. The resident turned her wheelchair and rolled into the surveyor once again and stared directly into the surveyor's eyes. The surveyor was unable to move until the resident rolled away in her wheelchair. Observation in the 200 East Hall on [DATE] at 12:03 PM, revealed Resident #34 rolled onto Resident #94's left foot and stopped. Resident #94 waved her on and stated under his breath, .stupid .stupid .go . Resident #34 rolled off of Resident #94's foot. Observation on the 200 Hall on [DATE] at 1:55 PM, revealed Resident #34 ran into Resident #85 in the hall and the nurse separated them. Observation on the 200 Hall on [DATE] at 2:01 PM, revealed Resident #34 ran into Resident #27. Observation on the 200 Hall on [DATE] at 2:04 PM, Resident #34 threw her snack cake on the floor and rolled away down the hall toward the East Nurses' Station. As she approached the corner of the hall near the East Nurses' Station, Resident #84 waved her away from him. Resident #16 was sitting in a chair and Resident #34 rolled into Resident #16. Observation on the 200 Hall on [DATE] at 2:06 PM, Resident #34 rolled back down the hall toward the elevator, Resident #99 was sitting by the elevator in her wheelchair as Resident #34 came toward Resident #99. Resident #99 stated, .please don't hit me .please don't hit me . A staff member moved Resident #34 around to the other side of Resident #99. Resident #34 turned toward Resident #99, and Resident #99 stated, .don't hit me . Resident #34 ran into Resident #99. The staff member took Resident #34 to her room. Observation on the 200 Hall on [DATE] at 10:00 AM, revealed Resident #34 rolled her wheelchair right up on the surveyor, grabbed the surveyor's shirt with both hands, and stared in the surveyor's eyes. Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease, Hypertension, Major Depressive Disorder, Alcoholic Cirrhosis with Ascites, Alcohol Abuse, Anxiety, and Wernicke's Encephalopathy (a rapidly progressive dementia due to thiamine deficiency). Review of the Level I Pre-admission Screening Resident Review (PASRR) dated [DATE], revealed .Pt [patient] will go into SNF [Skilled Nursing Facility] given progressed dementia and alcoholism . Review of Resident #80's Care Plan dated [DATE] revealed .Behaviors: yells at others, aggressive behaviors at times, argumentative with staff at times . Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis clarification and assessment of cognitive and emotional functioning .SESSION CONTENT AND FOCUS .This patient is being treated for depression, anxiety and chronic pain. This patient was seen for treatment of depression and anxiety. He discussed his history of depression and the factors that continue to contribute to low mood. He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of Resident #80's Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis clarification and assessment of cognitive and emotional functioning .SESSION CONTENT AND FOCUS .This patient is being treated for depression, anxiety and chronic pain. This patient was seen for treatment of depression and anxiety. He discussed his history of depression and the factors that continue to contribute to low mood. He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of the quarterly MDS dated [DATE], revealed the Resident #80 was cognitively intact with verbal behaviors toward others on 1-3 days of the 7-day look back period and rejection of care behaviors on 4-6 days of the 7-day look back period. Review of a Psychiatric Periodic Evaluation dated [DATE], revealed Resident #80 was seen for depression follow up, complained of sadness since the pandemic started. He had behaviors of yelling at the nurse on [DATE] because he forgot that he had already taken his medications. He was continued on sertraline (medication) for depression. Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis clarification and assessment of cognitive and emotional functioning .SESSION CONTENT AND FOCUS .This patient is being treated for depression, anxiety and chronic pain. This patient was seen for treatment of depression and anxiety. He discussed his history of depression and the factors that continue to contribute to low mood. He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis clarification and assessment of cognitive and emotional functioning .SESSION CONTENT AND FOCUS .This patient is being treated for depression, anxiety and chronic pain. This patient was seen for treatment of depression and anxiety. He discussed his history of depression and the factors that continue to contribute to low mood. He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis clarification and assessment of cognitive and emotional functioning .SESSION CONTENT AND FOCUS .This patient is being treated for depression, anxiety and chronic pain. This patient was seen for treatment of depression and anxiety. He discussed his history of depression and the factors that continue to contribute to low mood. He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of a Nurse Progress Note dated [DATE], revealed Resident #80 had to be reminded to please stay out of a female resident's room and to see staff if he needed to go into the clean utility room. Nursing staff documented, .he said he is not supposed to be here and we treat him like an inmate . Review of a Nurse Progress Note dated [DATE], revealed Resident #80 had an altercation with another resident (Resident #81) that he shoved to the floor around 6:30 PM. He confirmed that he shoved the other resident to the floor after the other resident hit him. Resident #81 fell and hit the floor, was transferred to the hospital, and expired. Resident #80 was started on every 15-minute checks. Resident #80 was told to go to his room by staff. There was no facility staff seen on the video footage entering Resident #80's room during the time Resident #81 was on the floor receiving care. Review of a Nurse Progress Note dated [DATE], revealed the DON accompanied the police to Resident #80's room to discuss the alleged incident in which he pushed another resident and the resident fell on the floor. Resident #80 was calm and cooperative and remained on every 15-minute checks until he could be evaluated by the Psychiatric Nurse Practitioner. Review of a Nurse Progress Note dated [DATE], revealed Resident #80 continued every 15-minute checks and had been rude toward staff on [DATE] because a female resident asked the nurse to please have him leave her room because he was playing loud music by her door. Resident #80 said he was a grown man and could do as he wished. Review of a Nurse Progress Note dated [DATE], revealed a Police Detective was in the facility to speak with Resident #80 about the incident with Resident #81. Every 15-minute checks were discontinued (d/c) and he was placed on 1:1 behavior monitoring until further notice. Review of Resident #80's Psychiatric Periodic Evaluation dated [DATE], revealed, .was involved in an incident on 6/22 [2021] when another resident was hitting him so he pushed the other resident who fell to the floor and later died .states .they're trying to charge me with murder .says he has been very anxious .I'm not doing good .I could use some Ativan .shows remorse and states .it was a terrible accident .does not appear to be at a risk to himself or others at this time .continues on 1:1 [one on one] observation . Resident #80 was not evaluated by psychiatric services until [DATE], 7 days after the incident with Resident #81 occurred. Review of a Nurse Progress Note dated [DATE], revealed Resident #80 was taken to the police department by the Administrator and DON. He appeared slightly anxious when taken inside the facility. Review of the medical record, revealed Resident #81 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Pain due to Nervous System Prosthetic Devices, Sciatica, Osteoporosis, Brief Psychotic Disorder, Restlessness and Agitation, Heart Failure, Down Syndrome, and Anxiety Disorder. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 attempted to pull his shirt over his head while he stood in the hallway. His clothing was placed back on by staff. Review of the Physician's Progress Note dated [DATE], revealed Resident #81 wandered the halls. Staff stated the resident did not truly yell but had agitation. His Haldol (medication) was decreased from 2 milligram (mg) twice a day to 2 mg at bedtime and his Zyprexa (medication) was continued. Review of the Nurse Progress Note dated [DATE], revealed Resident #80 had wandering behaviors and episodes of attempting to lay or sit on the floor, he appeared anxious/agitated and had voided in the floor multiple times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 ambulated in the hall, pulled clothing over his face, and proceeded to run into wall. He was taken back to his room and was assisted to bed but before a staff member exited the room, he was back up and walked out into the hallway. Review of the Nurse Progress Note dated [DATE] at 4:15 AM, revealed Resident ran into door .he did however want to keep walking .finally coaxed into the bed and CNT [Certified Nurse Technician] sat with him until he went to sleep . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was noted sitting self down on the floor or laying his head down on the floor at intervals. Review of the Psychotherapy Progress Note dated [DATE] revealed, .Focus of Session: This patient was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Physician Progress Note dated [DATE], revealed Resident #81 had been combative and was sleeping more. The Physician noted they may want to consider decreasing the resident's medication. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was tearful and anxious, he was noted to be very still and rigid when he attempted to sit, voided in the floor, and had wandering behaviors. Review of the Nurse Progress Note dated [DATE], revealed although staff prompted Resident #81 to toilet, he was disagreeable and would frequently refuse and void in the floor. Resident #81 refused to wear pants/briefs and would frequently undress. He also had tearful, anxious moods and could be aggressive at times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 voided in the floor after toileting. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was observed walking without any clothes on and he was not receptive to redirection. He also was found in the floor, was resistant to staff helping him back up and remained in the floor for several minutes. Review of the Psychotherapy Progress Note dated [DATE] revealed, .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was alert with confusion, would lean backwards when staff attempted to assist him, attempted to remove his clothing, and voided in the floor although he was toileted multiple times. Review of the Physician Progress Note dated [DATE], revealed Resident ##81 was sometimes calm and other times was more aggressive. He was felt by the nursing staff to be too sedated, but the physician documented he was not changing his medications at this time. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was very resistant to care and attempted to hit the nurse. Review of the MDS dated [DATE], revealed Resident #81 had severe cognitive impairment for decision making and was coded for physical behavioral symptoms directed towards self and others and rejection of care behaviors on 4-6 days of the 7-day look back period, and wandered daily. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was anxious/agitated at times and attempted to lay or sit in floor. Staff intervened multiple times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had agitation and was noted to remove clothing. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 walked backwards. Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 was dressed by the CNA [Certified Nursing Assistant] and he became angry that he had to put on clothes. He threw a trash can into the hallway, then walked to Nurses' Station, and threw a computer onto the desk. CNA was unable to give him a shower due to the resident hitting and punching the CNA. Review of the Physician Progress Note dated [DATE], revealed, .At times he will agitate other residents .saw him fighting with another resident over a cane .no change in medicine today . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had self-inflicted sores to his arms. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was smiling and dancing in the hall, had urinated in the floor multiple times, and staff attempted to toilet the resident, but he refused. Review of the Psychotherapy Progress Note dated [DATE], revealed .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 sat upright on the floor next to his bed. Urine was noted on the floor around the resident. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had frequent episodes of agitation, was tearful, attempted to lay in the floor multiple times, and was resistant to care at times. Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 was up most of night wandering in the hallway. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 attempted to lay and sit in the floor multiple times, removed clothing, urinated in floor, and was agitated. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 shook his fist at one specific resident and would shoot the bird finger every time he saw that resident. His behaviors caused agitation and anxiety to the other resident. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had episodes of anxiety/agitation and removed his pants and pull-ups. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had agitation and mood changes. He was observed throwing books from the desk and attempted to pull the fire extinguisher from the wall. He required constant redirection until calmer. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was intrusive (causing disruption) and voided in the floor. He was agitated and only slept for short periods. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 voided in the floor and removed clothing. He appeared to be agitated, staff attempted to trim his nails, but he was noncompliant. Review of the Psychotherapy Progress Note dated [DATE], revealed .Focus of Session: This patient was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 was observed laying on his back on the floor. He was uncooperative at times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was up ambulating in the hallway wearing only a shirt and frequently exposed himself. He was agitated, anxious, aggressive, and turned over a table in the Dining Room. He was difficult to redirect. Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 continued to wander and could be intrusive and impulsive. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was noted with a behavioral outburst this shift with periods of agitation/anxiety, was seen pulling a handrail off of the wall, made multiple attempts to sit or lay in floor, and when he was calm would hug/wave at staff but when angry he could be aggressive. Review of the Psychotherapy Progress Note dated [DATE] revealed .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time .38 minutes . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 wandered the hall most of the day, had some agitation/anxiety, and episodes of removing his clothes. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was very active and wandering in the evening, walked as fast as he could and rammed himself into the wall a couple of times. He was also agitated and swung his fists at the nurse a couple of times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was observed lying on his back in the floor, he was noted to have increased behaviors, was more resistant and impulsive. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was noted to have agitation, anxiety, and aggressiveness, and he attempted to pull items from the walls. Staff applied his helmet multiple times, and he would remove it and throw it. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had confusion, agitation, anxiety, and aggressiveness. Staff applied his helmet multiple times, but he would remove it from his head and throw it. He tried to push the CNA cart, the nurse medication cart, and the Dining Room cart and pull off the doors. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 refused to allow staff to obtain vital signs, had aggressive and combative behaviors, randomly struck out at staff, and was difficult to redirect. His helmet was placed on him multiple times and he would take it off and throw it. He was on every 15-minute checks. Review of the Psychotherapy Progress Note dated [DATE] revealed .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Physician Progress Note dated [DATE], revealed .Patient more agitated at times. Nursing staff notes it tends to be very much at random. Some days he can do well and other days not. Patient's Haldol has been discontinued as he was placed on Zyprexa .We will increase echopraxia [Zyprexa] to 7.5 mg at bedtime .continue with 5 mg twice daily .Patient may need to return to Haldol but will observe for now . Review of the Nurse Progress Note dated [DATE], revealed Resident #81's behavior varied from hour to hour, at times he was quiet and cooperative and at other times he was intrusive with staff and residents. The resident was agitated without provocation, continued to refuse to wear shoes or socks and would remove them as soon as they were placed, and attempted to undress repeatedly throughout the day. He was noncompliant with his helmet, removed it and threw it on the floor. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had episodes of agitation, anxiety, and aggressiveness with others. Resident #81 remained on every 15-minute checks. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 wandered most of the evening. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was aggressive and combative, and staff would continue to monitor. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 continued to wander and had episodes of agitation and anxiety. Review of the Physician Progress Note dated [DATE], revealed .periods of sleeping versus walking and being agitated. No significant issues regarding contact inappropriately with other residents. Will remove close [clothes] periodically. This is ongoing/old behavior .continue Zyprexa .2.5 mg twice daily and 7.5 mg nightly . Review of the Psychotherapy Progress Note dated [DATE] revealed .Focus of Session: This patient was seen due to reports of stripping by the unit manager. The unit manager requested he be seen once

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents with behaviors and dementia. The Administration failed to provide oversight to monitor and provide a safe resident environment related to residents with behaviors and dementia. The Administration failed to provide oversight and training of staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. These failures resulted in Immediate Jeopardy for Resident #34, #80, #81, #91, #96, and #303. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91, #96, and #303 did not have supervision and appropriate interventions implemented for their aggressive and exit-seeking behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 11:52 AM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-600, F-744, F-726, F-835, and F-867. The facility was cited at F-600 and F-744 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 10:19 AM, and was validated onsite by the surveyors on [DATE] through [DATE], through observations, review of audits, meeting minutes, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property .the center must take appropriate corrective action to protect residents. The center should oversee the implementation of corrective action and evaluate whether it is effective .The Director of Nursing in conjunction with other clinical team members shall initiate or revise plan of care to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate .Appropriate steps shall be taken to prevent recurrence of the incident .The Quality Assessment and Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented as necessary . Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: provide for the safety of all concerned . Review of the undated Administrator job description, revealed, .Responsible for planning, organizing, staffing, directing, and coordinating of the facility to ensure quality care for residents; be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant .Leadership, communication, nursing home regulations and standards, budgeting, personnel and business administration, public and community relations, relations with other health-care providers, ability to handle crisis situations and make judgements and decisions .Select personnel to supervise activities of major departments and consult with them regarding problems; hire, discipline, and terminate department employees; schedule and staff department personnel; ascertain quality of performance .inter-departmental relationships .Observe activities in each department on each shift .Establish, implement, review and update facility policies pertaining to resident care, personnel .public relations, maintenance of physical plant, job descriptions, and procedure manuals .Work with department heads and supervisors to provide staff meetings, in-service training, orientation programs, employee evaluations and supervision .Be an active member of committees .set meeting dates and ascertain that copies of minutes and reports of meetings are maintained and sent to proper officials .Review and evaluate reports from the facility's committees and consultants, and document disposition and implementation of recommendations .Operate, manage, and maintain facility in accordance with established policies and procedures of the governing body .Act as a liaison with .professional and supervisory staff through meetings and reports . Review of the undated Director of Nursing Services job description, revealed, .Responsible for the overall provision of the optimal achievable quality of nursing care for all residents .Must be able to relate to and work with the ill, disabled, elderly; emotionally upset, and at times hostile people within the facility. Requires the ability to appropriately redirect and deescalate individual with inappropriate behaviors .Directs the coordination of all nursing services .Assists Administrator with ongoing updating and review of nursing policies and procedures to assure continued quality of care .Ensure that quality of care provided in the facility meets/exceeds standards .Interprets the facility's Nursing Policies and Procedures for department personnel. Ensures implementation .Makes regular rounds to assure optimal quality of care is provided .Communicates issues regarding resident care as appropriate to the Medical Director .Discusses any problems, needs or concerns which arise with the Administrator .Understands and upholds Resident's [NAME] of Rights . During an interview on [DATE] at 1:50 PM, the Administrator confirmed agency staff do not receive education or information about the facility's residents with behaviors and dementia. The Administrator confirmed agency staff are not assessed prior to the shift if they are knowledgeable and have the skill sets needed to care for the facility's patient population of behaviors and dementia. She stated, .For new agency staff before they take assignment, we don't provide education or information about anything care related .No nothing for resident's with behaviors or dementia .We give them education packet on fire, abuse, elopement . During an interview on [DATE] at 2:50 PM, the DON was asked how was the competency agency staff assessed. The DON stated, .won't know until they [agency staff] do something incorrectly .even if you do a checklist you still have to monitor them closely .we do not do medication observations with agency staff . During an interview on [DATE] at 2:43 PM, the Administrator was asked why they decided to keep Resident #80 in the facility after the resident-to-resident incident in which Resident #81 was pushed down, hit his head on the floor, began to seize, and expired. The Administrator stated, .it was an isolated incident . The Administrator confirmed Resident #80 was not placed in one-on-one monitoring until 6 days after the resident-to-resident incident occurred, when they were notified by the police detective that Resident #80 was being charged with reckless homicide. The Administrator stated, He [Resident #80] was not having any previous or current aggressive behaviors or anything that would cause us any concerns .was very calm .it was an unfortunate incident .for lack of better terms they did not match .[named Resident #81] very unsteady, smaller .when he [Resident #80] pushed him [Resident #81] .he fell .that's why we put him on q [every] 15-minute checks . The Administrator confirmed that many things could happen in 15 minutes when the resident is not being supervised. Administration failed to maintain the plan of correction to provide a safe environment and provide supervision for vulnerable residents that was submitted to the State Agency on [DATE] following an IJ that was identified for elopement. Refer to F-600, F-726, F-744, and F-867. The surveyors verified the Removal Plan by: 1. A Quality Assurance (QA) meeting was held on [DATE] to discuss the facility's new monitoring systems initiated to identify residents with behaviors and review the effectiveness of interventions. The surveyors reviewed the QA meeting sign in sheet from [DATE] and interviewed QA members. 2. The behavior log and monitoring form will be reviewed daily by nursing management and/or the Administrator to identify any adverse behaviors and appropriate interventions are in place to ensure a safe resident environment related to residents with behaviors and dementia. The surveyors interviewed nurse management about behavior log and the monitoring form to ensure staff would identify any adverse behaviors and appropriate interventions are in place. 3. Facility Administration will ensure all staff are trained regarding dementia and behaviors to ensure the staff has the necessary knowledge and skill set to care for the residents and maintain a safe environment related to residents with behaviors and dementia. The surveyors reviewed the Audit tool and interviewed staff to ensuring training regarding dementia and behaviors was provided to the staff. 4. New Hires and new agency personnel will be provided dementia and behavior training prior to the start of their shift. The surveyors interviewed the Administrator related to the education the new hires and Agency staff received regarding dementia and behaviors to ensure staff are receiving dementia and behavior training, prior to start of shift. 5. An audit of all new employee files pertaining to dementia and behavior training will be completed weekly for 4 weeks and monthly for 3 months. Results of the audit will be reviewed by the Interdisciplinary Team (IDT) in the QA committee meeting. Findings of noncompliance will be addressed immediately. The surveyors reviewed the audit tool used for new employee files pertaining to dementia/behavior training and interviewed the Administrator. 6. The Administrator and Director of Nursing were in-serviced on [DATE] by the Regional Director of Clinical Services regarding training of all staff and contracted staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. The surveyors reviewed the sign-in sheets and the education provided to the Administrator and DON, and interviewed the Administrator, DON, and staff on all shifts. 7. Administrator and DON will provide daily communication of pertinent information to include training provided to contracted and new staff for the facility. A monthly report detailing the behavior log audit and the number of new hires/ contracted staff training will be reviewed by the Regional Director of Clinical services and the Chief Operating Officer. The surveyors reviewed the daily communication log used to communicate pertinent information about residents behaviors, reviewed the sign-in sheet and the education provided to contracted and new staff by the Administrator & DON. The facility's noncompliance at F-835 continues at a scope and severity of E for the monitoring of the effectiveness of the correction actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, Registered Nurse (RN) job description review, Licensed Practical Nurse (LPN) job description review, medical record review, video camera footage review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to resident to resident abuse, failed to perform follow up on monitoring of residents with behaviors, failed to evaluate and re-evaluate interventions implemented for residents with behaviors, failed to ensure nursing staff were competent to provide care to residents with behaviors and Dementia, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to abuse, residents with Dementia and behaviors, and competent nursing staff. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI committee to ensure residents were free from abuse, interventions were developed for residents with behaviors, and staff were competent to provide care for residents with Dementia and behaviors, resulted in Immediate Jeopardy (IJ) when Resident #80 willfully pushed Resident #81 to the floor hitting is head on the floor, began having seizures, was transferred to the hospital, expired at the hospital. Resident #34 consistently rolled over other residents with her wheelchair, the facility failed to accurately assess Resident #91 for wandering/exit-seeking behaviors, after he verbalized wanting to leave the facility, exited the 2nd floor secure unit without staff supervision, was found wandering on the 1st floor of the facility, Resident #96 entered a female resident's room and struck the resident, and Resident #303 had inappropriate sexual behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and DON were notified of the Immediate Jeopardy for F-867 on [DATE] at 7:15 PM, in the admission Office. The facility was cited Immediate Jeopardy at F-600, F-726, F-744, F-835, and F-867. The facility was cited at F-600 and F-744 at a scope and severity of K, which is Substandard Quality of Care. The facility was previously cited F-600 at a scope and severity of J on a complaint survey completed on [DATE]. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 9:19 PM, and was validated onsite by the surveyors on [DATE]-[DATE], by review of the auditing tools implemented, in-service training records, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement Program, reviewed 2/2020, revealed .The [Named Facility] Quality Assurance Performance Improvement Program is demonstrated through a proactive, comprehensive, ongoing approach to improving the quality and safety of the services it delivers .The Facility employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the Facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time .It is through this collaborative approach that the organization can plan, implement, and maintain an effective, ongoing, data-driven, systematic and Facility-wide Quality Assurance and Performance Improvement program .The purpose of the Quality Assurance Performance Improvement Program is to facilitate a review of the organization's customers and employees .The Facility will maintain documentary evidence of its quality assurance and performance improvement program and be able to demonstrate its operation .Objectives .Provide a systematic mechanism for the organization's appropriate individuals and professions to function collaboratively in their performance improvement effects .Provide for an organization-wide program that assures the organization designs processes will and systematically measures, assess [assesses], and improves its performance to achieve optimal Resident health outcomes in a collaborative, interdisciplinary approach .To review and analyze collected data and indicators and recommend to the Governing Body .The program will show measurable improvement in resident health outcomes and improvement in resident safety by using quality indicators or performance measures associated with improved health outcomes .The Facility will measure, analyze, and track quality indicators, including adverse resident events, infection control and other aspects of performance that enable the Facility to assess processes of care, Facility services, and operations .The Facility will use the data collected to do the following .Monitor the effectiveness and safety of services and quality of care .Identify opportunities that can lead to improvements and changes in Resident care . Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .The Quality Assessment and Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented as necessary . Review of the facility's undated Administrator job description, revealed .Responsible for planning, organizing, staffing, directing, and coordinating the facility to ensure quality care for residents; be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant .delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures .ascertain quality of performance .Work with department heads and supervisors to provide staff meetings, in-service training, orientation programs .and supervision .Review and evaluate reports from the facility's committees and consultants, and document disposition and implementation of recommendations . Review of the facility's undated Director of Nursing Services job description revealed .Responsible for the overall provision of the optimal achievable quality of nursing care for all residents .Has background and understanding of Medicare guidelines .Assists Administrator with ongoing updating and review of nursing policies and procedures to assure continued quality of care . Review of the facility's undated Registered Nurse job description revealed .Make rounds to observe and evaluate physical, emotional, and social needs of residents .communicate with director of nursing and staff .delegate the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures .comprehensive knowledge of nursing practices .physical, psychological, social, and medical needs of residents .Recognize changes in conditions of residents during his/her shift . Review of the facility's undated Licensed Practical Nurse job description revealed .maintain records reflecting the residents' conditions .delegate the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures .Assume responsibility for residents assigned to his/her care, including regular bed checks to insure that no resident is left unattended or permitted to wander from the premises .Report incidents of suspected resident abuse immediately . Review of the facility's investigation from a resident-to-resident altercation on [DATE], revealed Resident #80 and Resident #81 had an altercation on the 200 hall. Camera footage revealed Resident #80 appeared to be talking to Resident #81. Resident #81 reached out and lightly hit Resident #80 in the chest, Resident #80 continued talking to Resident #81 and shaking his head. Resident #81 then lightly hit Resident #80 in the chest again, and Resident #80 shoved Resident #81. Resident #81 fell to the floor from a standing position, did not attempt to break his fall in any way, and hit his head on the floor. Staff responded to the scene very quickly and Resident #80 returned to his room alone without staff supervision. Video camera footage revealed Resident #81 began to seize. The police arrived at the facility prior to the arrival of Emergency Medical Services (EMS) personnel. EMS personnel transported Resident #81 to the hospital where he later expired. emergency room records revealed Resident #81 had extensive bilateral subarachnoid and subdural hematomas (acute bleeding inside the skull or brain). Resident #80 was placed on every (q) 15-minute checks. 1 on 1 monitoring of the resident was not begun until 6 days after the incident occurred. The facility staff did not have an ad hoc QAPI meeting after the incident, until surveyors from the State agency entered the building to investigate the incident and an Immediate Jeopardy was identified. The facility had a secure unit on the 2nd floor, where a code had to be entered on the elevator in order to exit the floor or the emergency stairs. The case mix of residents on that floor included residents with behaviors, psychosis, and elopement risks. During an interview on [DATE] at 1:11 PM, the Administrator confirmed the last QAPI meeting was held [DATE]. Interviews conducted with the staffing agencies revealed facility staff did not provide training of the agency staff for the care and management of dementia and behaviors. The agency expected this to be provided to the agency employees by the facility. During an interview on [DATE] at 1:22 PM, the Administrator was asked what the expectations of the agency staff were when they were practicing in this facility. The Administrator stated, To provide the same level of service we provide .to supplement our staff and to do everything we do . The Administrator confirmed they provided a packet or cheat sheet to agency staff which included abuse and fire codes, the nurse walked them to their unit, gave them their assignment, showed them where to obtain supplies, and the location of the clean and dirty utility rooms. The Administrator was asked if the facility provided any other orientation to agency staff. The Administrator stated, uh-uh [no] and shook her head from side to side. The Administrator confirmed the education was all in the orientation packet and stated, .Their agencies also do a more in-depth competency training for them. During an interview on [DATE] at 2:43 PM, the Administrator and DON confirmed they had quarterly QAPI meetings. The Administrator stated, .When we decided to bring [to the QAPI meeting] the infection control part of COVID .got together a plan .what we wanted to accomplish .Actually did it when we had a COVID outbreak .September/October .did a plan that we were going to do PPE [personal protective equipment] audits . The Administrator confirmed she did not keep quantitative and qualitative data regarding the findings. The Administrator was asked to provide the next Performance Improvement Process (PIP) they had done. The Administrator stated, We did a .kitchen sanitation . The Administrator was asked to provide her quantitative data for the PIP. The Administrator stated, .It's not filled out . The Administrator was unable to provide documented data relating to their PIP on kitchen sanitation. The Administrator was asked what PIPs the facility had in progress at the present time. The Administrator stated, Reportables .wanted to ensure they were put in and put in timely . The Administrator was asked to show the process of the PIP. The Administrator stated, I don't have that . The Administrator and DON were asked if they track the reportables to see what time the incident occurred, what staff were involved, and how they determined what was effective. The Administrator stated, .no proof .Just discussing it with you . The Administrator and DON were asked if they had conducted a Root Cause Analysis (RCA) on any issues recently. The Administrator stated, We looked at behaviors .we've identified the problem . The Administrator was asked when they identified the problem with behaviors. The Administrator stated, It was the weekend of the holiday [[DATE]rd or 4th after the State Surveyor had entered the facility to investigate the resident-to-resident incident] .talked about behaviors in morning clinical meeting .no documentation in the QA committee .were not putting it in qualitative/quantitative .you're right we haven't .I didn't really put it in the minutes .RCA .we don't have it . The Administrator was asked if behaviors were discussed prior to the survey team entering the facility. She stated, .May talk about someone having increased agitation .have the Social Worker there .get a psych [psychiatric] eval [evaluation] .bring it to the team .everybody in the morning . The Administrator confirmed she was speaking hypothetically and there was no documentation to support this. The Administrator was asked once again if the quarterly QAPI meeting included quantitative and qualitative data for the identified issues and problems. She stated, No, you did not hear in the terms you put it in. They were unable to provide data for any QA processes, PIPs, or RCA to the survey team and confirmed the QAPI team had not conducted an RCA on any issues in 2020 and 2021. The Administrator and DON were asked if they had conducted an Ad Hoc [An unplanned meeting that focused on a specific topic] QAPI meeting after the resident-to-resident incident occurred between Resident #80 and #81 on [DATE]. The Administrator stated, We didn't because it was a resident to resident .and was a fall .now once we learned that it was more to it .yes we did .with myself, [Named DON], and upward management .discussed the incident .viewing the cameras . The Administrator was asked if the QAPI committee met, did an RCA, or anything regarding the event that happened on [DATE]. The Administrator stated, Yes .had a meeting on [DATE] [16 days after Resident #81's death and also after the IJ was identified] .[Named Medical Director] involved .talked about it .put something in place for another resident . The DON stated, .talked about that incident and others we're missing the mark on . The Administrator and DON were asked if that was documented. The Administrator stated, .I haven't had time to do it .don't have qualitative or quantitative data .the root cause is we weren't looking at behaviors .identifying them as an isolated incident. The Administrator confirmed the incident was not necessarily isolated. The Administrator and DON were asked if they had a way of identifying if Resident #81 had increased behaviors. The Administrator stated, .[Named Resident #81] not on the behavior log .I did see some notes about smoking .if he didn't get his way he would get upset . The Administrator and DON were asked when the 15-minute checks were implemented and had that always been a facility policy. The DON stated, It's always just been a tool to increase monitoring for a resident for a variety of reasons .this resident needs an extra eye . The DON was asked if she had criteria for 15-minute checks or was it subjective. The DON stated, I guess we don't have criteria .the nursing team [makes the determination] . The Administrator and DON were asked for the facility QA process, who they reported to and what they had learned. The DON stated, .I don't think we're doing it like that . The Administrator was asked why they made the decision to keep Resident #80 in the facility after the resident-to-resident incident in which Resident #81 was pushed down, hit his head on the floor, began to seize, and expired. The Administrator stated, .Rationale .it was an isolated incident .[Named Resident #80] hadn't had any previous aggressive behavior . The Administrator was asked if that would not be more of a reason to put him on 1-on-1 monitoring. The Administrator stated, Well . The Administrator confirmed Resident #80 was not placed in 1-on-1 monitoring until 6 days after the resident-to-resident incident occurred and they were notified by the police detective that Resident #80 was being charged with reckless homicide. The Administrator stated, He [Resident #80] was not having any aggressive behaviors or anything that would cause us any concerns .was very calm .it was an unfortunate incident .for lack of better terms they did not match .[Named Resident #81] very unsteady, smaller .when he [Resident #80] pushed him [Resident #81] .he fell .that's why we put him on q [every] 15-minute checks . The Administrator acknowledged a lot could happen in 15 minutes. The Administrator confirmed that a QAPI meeting was not conducted until [DATE], after the IJ was called. The Administrator and DON were asked if Resident #34 had been discussed in QAPI. The Administrator stated, [Named Resident #34] has been talked about previously yelling out .says kind of inappropriate sexual things .never been maliciously intentional .just wants to get up toward you . The DON confirmed the QAPI committee had not discussed Resident #34's behaviors of running over other residents and staff while in her wheelchair. The Administrator and DON were asked how they assessed the competency of the contract agency staff and communicated that to the agency. The DON stated, .Give them a brief synopsis of our building .I guess we won't know [their competency status] until we find they aren't doing something correctly .Agency people do not get med pass [medication administration] audits .not so far .maybe something we could implement .review the documentation from the night before .make sure they sign out their MARs [Medication Administration Record] and TARs [Treatment Administration Record] . The DON was asked why there were missing pressure ulcer treatments that had not been identified by the facility staff the following day when conducting the chart audits. The DON stated, .Part of being a licensed professional .know you have to sign off your MARs/TARs .should someone have caught that .yes . The DON was asked what she had learned from her MAR/TAR reviews and how often she did those. The DON stated, Not nearly as often as I used to .try to look at them at least twice a week. The DON was asked if she did any tracking or trending of those reviews. The DON stated, I have a feeling I will be from here on out. The Administrator and DON were asked if they thought the incident between Resident #80 and Resident #81 would warrant an RCA to help with future behaviors. The Administrator stated, Yes, it would definitely be beneficial . The DON was asked about the incident where behaviors were identified for Resident #303 and the psychiatric Nurse Practitioner made recommendations for medications, but the recommendations were not followed, and there was no documentation as to why the recommendations were not implemented. The DON stated, It means there's a break somehow in the system . Refer to F-600, F-726, F-744, and F-835. The surveyors verified the Removal Plan by: 1. The facility's QAPI process will be revised to include a systematic approach to tracking and trending, quantitative and qualitative data while evaluating/reevaluating interventions, data and trends. The surveyors verified the revised QAPI process through interview of key facility personnel to determine education provided, how the audit tools developed would be used to track and trend identified issues, how the process would include the use of qualitative and quantitative data analysis, and how facility staff would evaluate/re-evaluate interventions, data, and trends. The audit tools were reviewed, and the Administrator and DON were interviewed. 2. The QAPI team met on [DATE] to discuss and develop a QAPI process that identified residents with adverse behaviors through review of medical records, staff interviews and residents already identified by psychiatric services for adverse behaviors. The surveyors reviewed the behavior assessment conducted by the Psychiatric Nurse Practitioner, the medical record/care plan review conducted by the DON, the sign-in sheet from the QAPI meeting on [DATE], and interviewed members of the QAPI team. 3. The data collection will be obtained daily through review of the behavior monitoring logs to ensure all adverse behaviors have been reported/documented. This information will be reviewed daily in the Interdisciplinary Team (IDT) meeting for a collaborative discussion. The surveyors reviewed the behavior monitoring logs, in-service sign-in sheets, and interviewed staff from all shifts regarding the in-service training received on utilization of the behavior monitoring logs and expectations for reporting of behaviors. 4. The weekly behavior management meeting, which is comprised of the IDT and the geriatric Psychiatric Nurse Practitioner, will review identified resident behavior, interventions, investigation, and the care plan to evaluate/re-evaluate interventions data and trends. This approach will provide the IDT an opportunity to determine underlying causes of behaviors. The surveyors reviewed the geriatric Psychiatric Nurse Practitioner assessments and interviewed members of the IDT to determine the education provided by the facility and the expectations for how data would be reported and covered in the weekly behavior management meeting. 5. The facility will provide all staff with the appropriate education and in-services regarding dementia identification and behavior management. This training will be conducted through lecture, handout, and measured by a competency quiz. Dementia and behavior training will be required for all staff including agency personnel and completed quarterly for 6 months and then annually. This training will be part of the orientation process. The surveyors reviewed the in-service sign-in sheets, the education provided to staff on dementia and behaviors, and the competency quiz administered. Facility staff were interviewed on all shifts to identify knowledge retention and facility expectations for logging and reporting of behaviors. 6. An audit of all new employee files pertaining to dementia and behavior training will be completed weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed by the IDT in the QA committee meeting. Findings of noncompliance will be addressed immediately. Results from the audit will be tracked and trended to ensure 100% compliance. The surveyors reviewed the audit tool and interviewed the Human Resources (HR) Director and the DON. The facility incorporated the process of compiling an employee file on all agency staff to ensure they were adequately trained on facility processes and care of residents with dementia and behaviors. The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.