**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights. The facility failed to provide or document sufficient preparation for an orderly transfer when Resident #1 allegedly got into an unwitnessed physical altercation with her new roommate. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk of a disruption in their care and services and denying them and their RP a voice regarding their treatment plan, worsen physical and mental conditions, cause physical and emotional injury and potential hospitalization. Findings Included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. Police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note from RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -09/09/23-General Progress Note from ADON A: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. -Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her Resident #1. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, Resident #2was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she does have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file and allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Resident #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 re-admitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A state the police or EMT decide where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she re-admitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group text that there was a resident to resident altercation with Resident #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated they police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was still there. Then a police officer arrived (same officer that transported to the behavior facility an hour earlier). ADON A asked the police officer what happened and the police officer stated they took Resident #1 to a behavioral health facility with her family member present but they would not take the resident because she was too aggressive and the police left her there with her family member. ADON A then asked the police officer why did they not take Resident #2 to Hospital PP and she could not remember what the officer's response was. ADON A stated, It was so chaotic, I was trying to bring DON up to date and keep eyes on the resident. Police then were saying this is a fine line between criminal and dementia. She [officer] was on the phone with [county jail] and she doubted they would take her in [as an arrest]. At one point, Resident #1 started to walk away and the police officer said she would follow her, she could handle it, and we never heard anything else after that. ADON A could not remember if the police officer still had the face sheet and med list from earlier. ADON A stated she and the DON walked back into the facility and she did not know what ended up happening to Resident #1. ADON A stated the facility DON and C-RN were trying to find out where Resident #1 was, but they did not consider her missing because the police were on the trail. She did not know if the police ended up picking Resident #1 on 09/09/23. ADON stated she had hoped the police officer would have come back to the facility and let them know, I should have followed them, but I didn't. ADON A stated if she could do things differently, she would have tried to go across the street and talk to Resident #1 to see what the facility could do to help her, even if it was to come back into the facility, But I was afraid to approach her, I wasn't familiar with her a whole lot. I really wish I had just talked to her. An attempt was made to contact the female police officer (name provided by ADON A) on 09/13/23 at 1:15 PM. Message was left with the station intake staff, police report number provided and HHSC investigator contact information, date and location of the incident and she stated she would look up information and send the officer an email requesting her to contact the HHSC investigator. An interview with the ADM on 09/12/23 at 5:37 PM revealed he had just found out that the police took Resident #1 to jail and had just gotten off the phone with them but could not say who he talked to or their title. The ADM stated, She is discharged at this point. An interview with the DON on 09/13/23 at 12:38 PM revealed the purpose of police coming to the facility after a resident to resident incident was just the facility protocol/ She said when the police came out, depending on the situation and what was going on, they questioned both sides and depending on how each side responds, pretty much determines if they take them or not. The DON stated the police would always leave a police report number regardless because the facility needed it for their self-report to HHSC. She said just because the police come out, did not mean they always took the resident with them to jail. The DON stated a lot of times for residents with behaviors, Hospital PP was the place of choice. The DON stated Resident #1 used to be on the 600 Hall and did not have a roommate, then was recently moved 9date unknown) to the 100 hall because there were new admissions coming in and they needed her room. They placed her with a roommate who ended up having to go out to the hospital for about a week. During that time, Resident #1 got into the altercation with Resident #3 where she slapped him and she was sent to Hospital PP for evaluation and came b[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult the resident's physician and resident representative when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician and psychiatrist was notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23 . 2. The facility failed to ensure Resident #1's RP/family member(s) were notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk of a delay in medical intervention and decline in health or possible worsening of symptoms. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected the MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement prevention daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) reflected the following problems/issues: 1) [Resident #1] has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3, no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility. So they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her to the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications. So if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues. She stated the facility was agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her with any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes. So she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service. However, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor for the facility. He did not know if Resident #1's medications had been adjusted at the hospital for the first resident to resident altercation she had with Resident #3 on 09/05/23. RN F stated, I don't know, but even if they tweak her meds, she still refuses. He stated he had been working at the facility for one month on the weekends and Resident #1 always refused her medications. RN F stated the facility could try an intramuscular medication route for Resident #1, but with her, no one will try. They could also try a gel, but she doesn't want anyone close to her., So those are the dilemmas. RN F stated when a resident began refusing medications, the charge nurse should get the doctor and family involved in the care and make a nursing progress note and document the refusals. He stated the medication aides and nurses could not force a resident to take their medications. When that happened, the doctor was notified and the nursing staff should have followed up with the psychiatrist. RN F stated, If it is not resolved, we can send her out of the facility, we can discharge for not being able to take care of the resident's needs. An interview with ADON A on 09/12/23 at 4:29 PM revealed when a resident refused their medications, especially medications for a mood disorder, they could become unstable, become easily triggered and could become harmful to themselves or others. If a resident refused medication, the medications aides were supposed to report it to the charge nurse, then the charge nurse contacted the doctor and let them know. ADON A stated, Especially with behaviors, we have to stay on top of it, we can't force them to take them but we have to at least notify the doctor and [PMHP]], who comes in twice a week. When a medication has parameters, ADON A stated it was the same protocol if the resident was refusing the vitals check, notify the doctor and document. She said the charge nurse could also attempts twice and then the ADON for that hall could try as well. ADON A stated no one had notified her Resident #1 was refusing her medications when she was placed temporarily on her hall and she just found out on 09/11/23, after the incident with Resident #2 that she had not been taking them. ADON A stated she needed to in-service the nursing staff about notifying nursing management when residents were refusing medications. ADON A stated she did not know how to run an audit of refused medications in the online e-charting system. An interview with ADON B on 09/12/23 at 5:35 PM revealed he knew Resident #1 and she had mental health issues and took medications for it. He stated Resident #1 was sometimes resistant to take her medications and be provided ADL care, and it could take multiple encouragements from different staff to get her to comply. After a resident to resident altercation with Resident #3 on 09/05/23, ADON B stated Resident #1 came back from the hospital with no new orders and was placed on his hall. The nursing staff were monitoring her for physical aggression, yelling, and cursing; ADON B said he had never known her to do that before. He stated sometimes Resident #1 would walk down the hall and laugh to herself, make noises, but never physically hit someone. ADON B stated he had never been notified that Resident #1 was refusing her medications. He stated he expected the medication aides and charges nurses to tell him when a resident refused medications. He stated they had to document the refusal and the family, doctor and/or psychiatrist had to be notified. ADON B stated he had never tried to administer medications to Resident #1 while she was recently on his floor. He had been working at the facility since January 2023, and he remembered in times past when he did have to administer medications to Resident #1 and he never had any issues and she always took them. ADON B stated when a resident refused medications, the medications could become less effective and drop below their therapeutic level and the resident could have behaviors that the medication was supposed to help them with; behaviors will rise. An interview with LVN I on 09/13/23 at 10:15 AM revealed when a resident refused medications, especially medications for a mood disorder, the medication aide should have notified the charge nurse first who could then encourage the resident on why they need the medication. LVN I stated she did a three refusal rule. For residents with dementia, LVN I stated, Your nurse techniques can be used; you have to know them. If the resident refused a third time, then the doctor needed to be notified, and the family. LVN I stated the next day in morning standup meeting with management, the charge nurse should talk about the refusal and then it should also have been documented on the 24 hour report which was reviewed by management. LVN I stated in the online e-charting system, the facility could run a report that showed what residents and what medications were refused. LVN I stated, It's simple and each nurse comes in and talks about their hall and their patients. LVN I stated MA J was her medication aide for the morning shift but she had not been notified Resident #1 refused medication when she was on her hall. An interview with MA J on 09/13/23 at 11:09 AM revealed Resident #1 was not on her hall for very long; maybe a week or two in the past 30 days. MA J stated Resident #1 refused medications. MA J stated she would walk up to Resident #1 and ask her if she was going to take her medication and Resident #1 would say no. MA J said she would tell Resident #1 okay and tell the charge nurse she tried to give it. Sometimes if MA J let Resident #1 smoke a cigarette first, she would be more amenable to taking her medications afterwards, but not always. MA J stated when Resident #1 refused medications, I would say thank you and move on. I never knew what triggered her. I would just tell the nurse I tried a couple times and she was refusing me and could you try. I have told different nurses. An interview with MA K on 09/13/23 at 11:20 AM revealed she had worked with Resident #1 before and she resisted medications and care a lot. When MA K went to pass medications, she stated she would ask Resident #1 if she was ready to take her meds, Sometimes she will say no or cuss me out. MA K stated when that happened, she would try to explain to Resident #1 what the medications were for, but Resident #1 would still say no, that MA K was not her doctor. MA K stated she would then wait a couple of hours and let Resident #1 know she still had not taken them and ask if was she ready. If Resident #1 continued to say no, MA K stated she would tell the charge nurse to see if the nurse could her to take them. MA K stated her nurse was RN L and she was not successful in getting Resident #1 to take her medications either. MA K stated if a resident was not taking their medications, then whatever they are taking medications for will start to happen, like mental issues getting worse or health issues worsening. An interview with RN L on 09/13/23 at 11:29 AM revealed Resident #1 was only on her hall for less than 24 hours, so she never really worked with her. RN L stated if a resident refused medications, if they were psychotropic medications, it could cause them to have behaviors. RN L stated for medication refusals, the medication aide was supposed to let the charge nurse. RN L stated, No one told me she [Resident #1] was refusing. She said the main thing the nurse could do was notify the doctor and RP, we can't force them. RN L stated the nurse would need to document what they had done related to notifications. An interview with ADON C on 09/13/23 at 11:40 AM revealed she was over the secured units and did not work with Resident #1, but in her experience, when a resident refused medications, the medication aides were supposed to tell the charge nurse and the charge nurse needed to try to administer. If the charge nurse could not administer to the resident, then the doctor and RP had to be notified and the medications possibly needed to be put on hold. ADON C stated if she was the charge nurse for Resident #1, she would ask her why she did not want to take them. She said when a resident had dementia, the nurses and med aides still tried to encourage them and if the continued to say no, then call the doctor and document in a nursing progress note. ADON C stated, Especially if it is pill form, because maybe change it [to liquid, crushed, in food]. ADON C stated I would have tried to get her medication in liquid form if Resident #1 was refusing to take pills because she drank a lot coffee and water, a lot of dementia residents are like that, they will not take a pill but will drink. An interview with the DON on 09/13/23 at 12:38 PM revealed she was unaware Resident #1 had been refusing her medications. The DON stated her expectation was the medication aide needed to report refusals to the charge nurse and the charge nurse notified the doctor. If Resident #1 refused her psychotropic medications for an extended period of time, the DON stated she would have talked to the doctor about it if she was aware of it. The DON said she also expected the med aides and charge nurses to try several attempts, be calm, maybe try a different staff in case the resident did not like that medication aide/nurse. An interview with the MD on 09/13/23 at 4:38 PM revealed the facility did not notify him about Resident #1 being in jail or that she was refusing her medications. He stated he only heard that she was hitting someone. The MD stated the facility was pretty good about handling resident to resident altercations and it was not typical to call the police on altercations with older residents with dementia with behaviors. The MD stated, Most of the time, we put it as acute psychosis. Might be an infection going on with the patient and they became unstable, electrolyte abnormalities, not taking meds. The MD stated he was a hospitalist by trade. So what he wanted was the facility to notify him for those types of incidents and he would have that resident directly admitted to the hospital, check them out, and stabilize them. The MD stated he was a physician at one hospital and had a contract with two hospitals for admission privileges. The MD stated, It is easy for me to navigate that process and the facility knows that. He stated if a resident freaked out during a behavioral emergency and they were not thinking clearly, then he would want the charge nurse to call him and he would admit the resident for acute psychosis for admission. The MD stated, Especially with [Resident #1] because she is an older lady, I remember her face. If she was like that, I would have had her directly admitted instead of calling police. I would have had them call EMS and from there I can then stabilized her and send her back. The MD stated that was the protocol the nurses typically followed, but it all depended on who was working at the time of an incident. The MD stated, There are nurses who are really good who can catch it [behavior] and navigate that so I can do something about it and then there are nurses who freak out and call the police. I have done it so many times, I can get the patient stabilized. An interview with the MHNP on 09/13/23 at 2:47 PM revealed she was the psychiatric nurse for the facility residents and was unaware Resident #1, who was her patient, was in jail. She stated she was not contacted nor involved with the two resident to resident altercations Resident #1 had been in during the past week. She stated Resident #1 had never been physically aggressive, She's had manic episodes where she's difficult to redirect and delusional, but she's never been violent, ever. MHNP was unaware Resident #1 had been refusing her medications. An interview with NP D on 09/14/23 at 10:38 AM revealed she remembered being notified that Resident #1 was refusing her medications but could not recall when or who notified her. She stated she told the staff to keep trying, have different people try to administer, call the family, wait and try again. NP D stated, There is only so much we can do. She said if there were no behavior problems related to the medication, then after about a month, that medication could have been discontinued. An interview with LVN O on 09/14/23 at 1:46 PM revealed she was the charge nurse working on Resident #1's hall on 09/09/23 but she did not see the resident to resident altercation between her and Resident #3. LVN O stated she remembered Resident #1's family member was present at the facility and was upset stating the facility had to give Resident #1 her medications. LVN O stated she told the family member she would look at Resident #1's medications, but she did not follow through because Resident #1 was going to be sent to the hospital. LVN O stated if a resident refused medications, she expected the medication aides to report it to her. LVN O stated she had been hearing Resident #1 was refusing medications and doses through the grapevine. LVN O stated, But me, if I heard that, I would call doctor to see if anything else I could do, and I would have at least tried to put it in food or drink and watch her take it. That morning, after all this had happened [resident to resident altercation], then I start hearing she wouldn't take it [medications]. Back there on my unit, we find a way. LVN O stated if residents do not get their psychotropic medications, they were going to act out. LVN O stated when a medication refusal happened, she would document it in a progress note and let the doctor know what had transpired and see what they wanted her to do. LVN O stated, To me, if she was not taking her medication, why not call the [family member/RP] who would have a better relationship and schedule medicine administration where [family/RP] could be present, that is what I would have done. You got to show you tried. Record review of the facility's policy titled, Change of Condition Notification, revised June 2020, reflected, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changed in the resident's condition in a timely manner; Policy: Definition: An acute change in condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physician, cognitive, behavioral, or functional domains; .Procedure: I. The Licensed Nurse will notify the resident's Attending Physician when there is an: A. Incident/accident involving the resident; B. An accident involving the resident which results in injury and had the potential for requiring physician intervention, C. A significant change in the resident's physical, mental or psychosocial status, D. A need to alter treatment significantly .II. The Licensed nurse will assess the resident's change of condition and document the observations and symptoms. III. Notifying the Physician: A. The Attending Physician will be notified timely with a resident's change in condition; B. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.IV. Emergency Situations: .A.(i) NOTE: If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director .V. Family Notification: A. The Licensed Nurse will notify the resident, the resident's responsible party, or family/surrogate decision-makers of any changes in the resident's condition as soon as possible; VI. Documentation: A. A Licensed Nurse will document the following: i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes, ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received, iii. The time the family/responsible person was contacted, iv. Update the Care Plan to reflect the resident's current status, v. The incident and brief details in the 24-Hour Report, vi. If the resident is transferred to an acute care hospital, complete an inter-transfer form, vii. Complete an incident report per Facility policy, B. A Licensed Nurse will communicate any changed in required interventions to the members involved in the resident's care, C. A Licensed Nurse will document each shift for at least seventy-two (72) hours, D. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report. On 09/14/23 at 1:45 PM, an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided with the IJ template, and a Plan of Removal (POR) was requested at that time. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. The following plan of removal submitted by the facility was accepted on 09/15/23 at 4:45 PM: Date: 09/14/2023: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 9/14/23, a complaint ad self-report survey was initiated at [Facility Name and address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Notify Physician of Changes: 1. The facility failed to intervene regarding Resident #1's change of condition. Regarding refusal of medications and behavioral and or aggressive acts. The facility failed to document, assess, and notify the physician regarding change of condition. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 1. Licensed Nurses and medication aides in serviced by the DON on the facility policy and procedure regarding documentation, assess, and notify the physician regarding change of condition. 9/14/23 2. Certified Nursing Assistant received education on reporting changes in behavior in a resident by the DON.9/14/23 3. Initiated staff interviews and established a timeline of the sequence of events by Administrator on 9/14/2023. 4. Audit of all resident's MARs completed to assure if and care planned by licensed staff on 9/14/23. In-Service conducted. 1. Change in condition. 2. Medication administration The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide. This in-service was initiated on 9/14/23 and all staff must be in-service bef[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. 1. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. 2. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect with exit-seeking behaviors by placing them at risk for injury and/or death, including vehicular accidents, falls, missing medications, and an exacerbation of their dementia and mental illness related behaviors. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 [three times], no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note written by RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family]on site. -09/09/23-General Progress Note written by ADON A: Late entry- [City] police here and will take patient and [family]to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest, and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Review of Resident #2's clinical chart post-incident revealed no documentation of the facility speaking with Resident #2's family about pressing charges. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3; she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest, and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Residents #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 re-admitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A stated the police or EMT decided where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she re-admitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group texts that there was a resident to resident altercation with Residents #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated the police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm, and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was still there. Then a police officer arrived (same officer that transported to the behavior facility an hour earlier). ADON A asked the police officer what happened and the police officer stated they took Resident #1 to a behavioral health facility with her family member present but they would not take the resident because she was too aggressive and the police left her there with her family member. ADON A then asked the police officer why did they not take Resident #2 to Hospital PP and she could not remember what the officer's response was. ADON A stated, It was so chaotic, I was trying to bring DON up to date and keep eyes on the resident. Police then were saying this is a fine line between criminal and dementia. She [officer] was on the phone with [county jail] and she doubted they would take her in [as an arrest]. At one point, Resident #1 started to walk away and the police officer said she would follow her, she could handle it, and we never heard anything else after that. ADON A could not remember if the police officer still had the face sheet and med list from earlier. ADON A stated she and the DON walked b[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of five residents reviewed for neglect policies. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. The facility did not provide Resident #1 with behavioral interventions and instead, initiated an unplanned and inappropriate transfer that led to Resident #1 being left across the street from the facility and subsequently arrested and incarcerated for a week. The facility was unaware Resident #1 had been arrested for two days and did not attempt to look for her and discharged her from the facility. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect due to policy not being developed/implemented. Findings included: Record review of the facility's police titled, Abuse Prevention and Prohibition Program, revised August 2020, reflected, .Purpose: To ensure the Facility establishes, operationalizes and maintains and Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property and crime in accordance with state and federal standards .III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs and systems .VIII. Protection: .D. If the allegation is regarding a resident to resident altercation, the residents will be separated immediately, pending the investigation .IX. Reporting/Response: .C. Reporting Requirements .ii. If the suspected physical abuse is allegedly caused by a resident who has been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator, and his/her designee, shall report to the local Ombudsman or law enforcement agency by telephone as practicably possible .v. The resident's physician and responsible party, if applicable, will also be notified of the allegation and outcome of the investigation. Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 [three times], no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note written by RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family]on site. -09/09/23-General Progress Note written by ADON A: Late entry- [City] police here and will take patient and [family]to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest, and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Review of Resident #2's clinical chart post-incident revealed no documentation of the facility speaking with Resident #2's family about pressing charges. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3; she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest, and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Residents #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 re-admitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A stated the police or EMT decided where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she re-admitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group texts that there was a resident to resident altercation with Residents #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated the police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm, and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted anoth[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Residents #1 and #4) of five residents reviewed for psychosocial concerns. 1) The facility management and staff did not observe and intervene for manifestations related to mental and psychosocial adjustment difficulties when Resident #1, who lived with dementia with behavioral disturbance and mental illness was changed to three different rooms in a week, after she had been living in a room alone for most of 2023. When Resident #1 was moved to a new hall/floor, she slapped a male resident who lived across the hall from her on 09/05/23 and then moved to a different room on a new hall/floor and placed with an unfamiliar roommate and allegedly got into an unwitnessed physical altercation with her new roommate on 09/09/23 2) The facility management and staff failed to provide adequate person-centered behavioral interventions to ensure Resident #1's safety when they failed to bring her back into the facility after a failed hospital transfer after a resident to resident altercation and she was left outside across the street and subsequently arrested by the police. 3) The facility failed to provide Resident #1 with her psychotropic medications consistently prior to her having two resident-to-resident altercations. The facility med aides and nurses were documenting Resident #1 refused her psychotropic medications consistently (including an antipsychotic, mood stabilizer and antidepressant) without notifying the charge nurses, nursing management and physician. The med aide and nurses were not completing any documentation of the refusals and what intervention/orders were put in place to maintain the resident's medication regime. Resident #1 subsequently had two resident to resident altercations and was arrested and jailed for a week. 4) The facility staff failed to document any follow up post-discharge or put any interventions in place after Resident #4 returned to the facility after being sent to the hospital for expressing suicidal ideations 5) The facility failed to provide Resident #4 with his routine anti-anxiety medication for six days. 6) The facility staff and management did not follow their Behavior Management Policy when Residents #1 and #4 had a change in mental health condition. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. These failures placed residents with a history of mental disorder or psychosocial concerns at risk of not receiving appropriate interventions, experiencing emotional distress and having psychiatric episodes Findings include: 1) Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's face sheet reflected she had three emergency contacts/RPs and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement risk daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 had a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 had impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 was an elopement risk/wanderer, 4) Resident #1 had delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 required antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 had schizophrenia and dementia, 8) Resident #1 was at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 was at risk for ADL self-care performance deficient. Interventions included anticipate and meet needs, minimize background noise when communicating, administer medications as ordered, discuss concerns about confusion, keep routine consistent and encourage participation in activities. Record review of Resident #1's therapy notes reflected she was seen on 08/24/23 by MHNP and she was noted to have ongoing intermittent odd behavior and mild delusions, but no disruption to her care. Staff denied daytime sedation and falls. Resident #1 had no aggression or agitation reported and no reports of sleep/appetite disturbance. Resident #1 was documented to have criteria for schizoaffective disorder and had a history of bipolar disorder and also has had symptoms of psychosis that included delusions, disorganized speech for at least two weeks without mood symptoms during that time. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day (antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 , no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's behavior tracking MAR for September 2023 reflected she was being monitored closely for significant behaviors including agitation, anxiety, nervousness, compulsiveness, physical/verbal aggression, combativeness, excitation/irritability, panic, hallucinations, paranoia, delusions and repetitiveness. If a new or increased behavior was noted, the physician's order and MAR reflected the nurse needed to contact the MD. Resident #1's behavior tracking MAR for September 2023 reflected she had one episode of aggression on 09/08/23 and 09/09/23. There were no other significant behaviors documented from 09/01/23 through 09/09/23. Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room talking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -09/09/23-General Progress Note: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police car because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their vehicle along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding because she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; Resident #1 then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility. They took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex [by unknown person]. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived first, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home. He stated ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been sent out before the two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember Resident #1 was still a lady and he said she slapped him. LVN I did not see her slap him and he was still yelling at Resident #1, cursing and saying 'hit me again knowing she was not in her right mind. LVN I stated Resident #3 had been upset prior to this incident when Resident #1 was moved down to his hall from upstairs and he had a vendetta with wanting her to move off his hall because she was not here all the way and made weird noises. LVN I stated Resident #3 did not like that the facility was moving people with mental illness issues onto his hall. LVN I stated Resident #1 was still wanting to try and hit Resident #3 but she and the other staff who arrived, including ADON A, separated them. LVN I stated she begged Resident #3 to stop egging Resident #1 on. She stated, He is known to instigate and pick at people. LVN O stated she called the police and told them there was an altercation between two residents. Resident #1 was sent out to Hospital PP after her shift was over and came back two days later and moved to the upstairs hall. Record review of Resident #1's discharge documentation from Hospital PP on 09/06/23 reflected she was seen due to aggressive behavior and had a mental health problem listed as the diagnosis. No other information was provided and no medication was changed or new treatments/recommendations ordered. Review of Resident #1's clinical record reflected no evidence the MHNP or MD were contacted when Resident #1 returned from [Hospital PP] on 09/06/23 to discuss possible behavioral interventions to prevent future aggressive episodes. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. RN F stated Resident #1 had been back at the facility for two days prior to the weekend on 09/09/23. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not made, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident #1 left the building and never came back that day or the following day. To his understanding, he stated Resident #1 went to the [Hospital PP] but he had no idea where the police took her and he did not follow up to find out. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. A follow up interview with RN F on 09/16/23 at 5:08 PM revealed both Residents #1 and #2 had a diagnosis of dementia. RN F. stated Resident #2 was mellow, quiet and kept to herself. He stated Resident #1 could be loud and pace around and make scary sounds. RN F stated he was never notified on 09/09/23 that Resident #1 showed back up at the facility across the street by herself. He stated if he would have been told, he would have tried to bring her back into the facility. RN F stated, I don't want to abandon her, someone has to be responsible. No one asked me to help bring her back in. RN F stated he would have tried to talk to Resident #1 because she is still my patient and I have a responsibility to try and talk with her and see what happened. An interview with LVN O on 09/18/23 at 10:48 AM revealed she was the charge nurse on 09/09/23 when Resident #1 and Resident #2 had an alleged physical altercation but she did not see it. She stated no one saw it, but CNA N heard the commotion and what sounded like a hit/slap and some arguing and reported it to LVN O. LVN O went to their room to find Resident #1 in bed and Resident #2 was in the doorway. She and CNA N separated them and then she notified RN F who was the weekend supervisor and stated he would take care of it and write an incident report and next thing I know, the police show up. LVN O did not know where they sent Resident #1 and did not know she wound up back at the facility across the street by herself. LVN O stated no one came to get her to try and assist Resident #1 to come back in the facility. She stated, I could have taken another staff out with me and tried to get [Resident #1] to come in. But no one asked. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior on 09/05/23. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' (ADON A made hand motions by her ears to demonstrate), cursing, saying random things like [TRUNCATED]

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consult the resident's physician, when the resident had an injury and had the potential for requiring physical intervention and when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #167) of six residents reviewed for resident rights. The facility failed to notify the physician when Resident #167 experienced a change of condition on 09/12/22, which included a change in appearance, lethargic behavior, and vomiting resulting in hospitalization on 09/13/22. On 09/28/22 at 2:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/30/22, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Record review of Resident #167's Quarterly Assessment, dated 09/06/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: hypertension, diabetes mellitus, cerebrovascular accident, non-Alzheimer's dementia, hemiplegia, malnutrition, anxiety disorder, depression, asthma, primary insomnia, and dysphagia. His BIMS score was a 13 out of 15, which meant the resident was cognitively intact. His functional status revealed he required limited assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, and personal hygiene. He required supervision with walking in room and eating. Record review of Resident #167's care plan, undated, revealed there were no focus, goal, interventions/tasks regarding nausea and/or vomiting. Record review of Resident #167's nursing notes revealed no entries on 09/10/22 to 09/12/22 regarding resident's change of condition. Record review of Resident #167's September 2022 physician's orders revealed he was prescribed Promethazine HCL tablet 25 mg on 09/22/21. He was ordered to receive one tablet by mouth every six hours as needed for nausea and vomiting. Record review of Resident #167's September 2022 MAR revealed the resident was only administered one Promethazine HCL tablet 25mg on 09/04/22. Observation and interview with Resident #167 on 09/12/22 at 11:22 AM revealed there was a dried brown splattered substance in his trash can and on the floor by his bed. His urinal contained approximately 300 ml of dark amber tinged urine. Resident #167 stated he did not feel well and fell asleep during the interview. Observation of Resident #167's room on 09/13/22 at 8:45 AM revealed there was a dried brown splatter substance: on his trash can, left side of the mattress and bed linen, floor and wall behind the head of his bed, the floor to the left side of his bed, and the wall located on the left side of his bed. He was observed laying in his bed. The surveyor informed LVN S of the observation. Observation of Resident #167 on 09/13/22 at 8:52 AM revealed the resident appeared to be sluggish and drowsy. He informed LVN S his stomach hurt, and he needed his urine checked. LVN S assessed Resident #167 and informed the resident his eyes appeared to be more yellowish, and urine was darker. She asked him if he had vomited this morning, if he experienced pain on any other parts of his body, and the last time he had a bowel movement. Resident #167 stated his stomach hurt, he vomited this morning, and had not had a bowel movement in a few days. She informed the resident the physician would be notified. Record review of Resident #167's nursing notes revealed on 09/13/22 he was sent out 911 due to vomiting up a substance that was brown in color. MD and ADON was notified. Per MD send out 911 for further evaluation and treatment written by LVN S. Interview with LVN S on 09/13/22 at 12:09 PM revealed Resident #167 had a change of condition since returning from the hospital on [DATE]. She stated he appeared more lethargic, his eyes were more yellow, and his urine was darker. She stated she was just made aware from his previous nurse that Resident #167 vomited on 09/12/22. She stated she last worked with Resident #167 on 09/05/22. She stated she did not make rounds on residents at the beginning of her shift on 09/13/22. She stated her shift started at 07:00 AM. She stated she was not made aware Resident #167 had vomited until contacted by the state surveyor. She stated after assessing him she notified the ADON and physician. She stated she was informed by the ADON to call 911 and have Resident #167 transferred to the hospital. Interview with ADON A on 09/13/22 at 12:42 PM revealed Resident #167 had an isolated incident of vomiting on 09/04/22 and was given his PRN medication Promethazine. She stated he was ordered labs and sent to the hospital on [DATE]. She stated he received an ultrasound on 09/08/22 and there were no abnormal results. She stated Resident #167 did not vomit on 09/12/22. She stated his urine appeared to be dark on 09/12/22. She stated Resident #167's dark colored urine has been an ongoing issue. She stated NP P was aware of his urine. She stated nurses and CNAs round on residents every 2 hours. She stated sometimes rounds were missed if the residents were not in their room. She stated the nurse was supposed to contact the nurse management of a resident's change in condition. She stated the nurse assessed the resident while the state surveyor was present, completed an SBAR, contacted the physician, and sent Resident #167 to the ER. She stated he was sent to the hospital due to vomit being brown/coffee colored and suspicion of internal bleeding. Interview with CNA R on 09/13/22 at 1:07 PM, revealed Resident #167 had been vomiting for the past two weeks. She stated his vomit and urine had been the same color for the past two weeks. She stated over the past few days Resident #167 appeared to be lethargic and not like himself. She stated she had informed nurses of the resident's change in condition. She stated she did not remember the nurses' names. She stated the last time he vomited a brown substance was 09/12/22. She noticed Resident #167 had vomited. She stated he informed her he was not feeling well. She stated she notified his nurse ADON B during the shift. She stated ADON B informed her to change his sheets. She stated she did not round on Resident #167 prior to surveyor observation on 09/13/22. She stated she had not rounded on him because she was meeting the needs of other residents on the hall. Interview with ADON B on 09/13/22 at 1:21 PM, revealed she was the acting charge nurse for Resident #167 during the 07:00 AM to 03:00 PM shift on 09/12/22. She stated she noticed he vomited during her morning medication pass around 8:30 AM to 9:30 AM. She stated she observed reddish brown stains on his bed and floor. She stated the resident informed her he felt nauseated. She stated she administered his PRN medication promethazine. She stated she did not notify the DON or physician because Resident #167 had only vomited once during her shift. She stated she shared the information verbally to the 03:00 PM to 11:00 PM nurse on 09/12/22. She stated she assessed him, took his vitals, and monitored his bowel sounds. She stated his vitals and bowel sounds were normal. She stated she did not complete a progress note regarding Resident #167's vomiting or assessment. She stated a progress note and assessment for Resident #167 should have been completed. She stated she did not know why a progress note or assessment was not completed. The surveyor attempted to contact the physician on 09/13/22 at 2:12 PM. Interview with the DON on 09/13/22 at 2:43 PM revealed, she was informed by one of the ADONs Resident #167 was nauseated on 09/04/22. She stated he had labs ordered and received medication for nausea on 09/05/22. She stated he was sent to the hospital on [DATE] due to his WBC and returned to the facility the same day. She stated he was supposed to be seen by a hematologist and oncologist per his hospital discharge paperwork. She stated Medical Records was supposed to set up Resident #167's follow up appointments with a hematologist and oncologist but had not. She stated she continued to remind Medical Records to set up Resident #167's follow up appointments. She stated she was informed by the ADONs he was sent to the hospital on [DATE] for vomiting a brown substance. She stated if Resident #167 had only vomited once she would have administered medication and monitored. She stated if Resident #167 had only vomited once the physician would not need to be notified. She stated Resident #167 vomiting a brown substance was considered a change in condition. She stated when Resident #167 had a change in condition, the nurse was supposed to assess, evaluate, listen to bowel sounds, and notify the physician. She stated the nurse should have contacted the physician and then followed the physician's orders. She stated the physician was aware the resident had a history of vomiting. Record review of the 24-hour nurse's report log on 09/13/22 revealed there was only one occasion of Resident #167 vomiting, dated 09/04/22. There was no documentation regarding him from 09/09/22 to 09/13/22. Interview with LVN T on 09/14/22 at 03:04 AM revealed, Resident #167 was still in the hospital due to vomiting the morning of 09/13/22. She stated he had a history of vomiting. She stated he vomited on 09/12/22 during the 11:00 PM to 07:00 AM shift. She stated he had complained of nausea and was administered his PRN promethazine. She stated she observed light yellow vomit on the floor by his bed. She stated she cleaned up his vomit with a towel. She stated she did not notify anyone of Resident #167 vomiting because he only vomited once during her shift. She stated she should have documented his vomiting episode. She stated she did not notify NP P or the physician. She stated she did not need to notify anyone. Record review of Resident #167's hospital paperwork, dated 09/14/22, reflected his admission date was 09/13/22 and his chief complaint was nausea/vomiting three times a day for four days. His gallbladder ultrasound revealed a mass in the right hepatic lobe measuring up to 12 cm. His assessment and plan revealed evidence of biliary obstruction 2/2 iterative growth of hepatic mass [mass causing bile blockage]. A gastroenterologist and hepatologist was consulted. Interview with NP P on 09/14/22 at 3:49 PM revealed, Resident #167 was sent to the hospital on [DATE] due to the nurse reporting jaundice like symptoms of the eyes (yellowish) and being more lethargic. He stated he ordered labs for the resident after returning from the hospital and had not seen the results. He stated he was not aware Resident #167's labs had not been completed. He stated he last saw Resident #167 the week of 09/05/22. He stated Resident #167 had a change in condition because the nurse reported the resident vomited brown stuff. He stated he informed the nurse to send Resident #167 to the hospital. He stated Resident #167 did not have a history of nausea or vomiting. He stated the facility had not reported to him Resident #167 had a history of vomiting or nausea. He stated his expectation was for the facility to contact him regarding Resident #167 vomiting on 09/12/22. He stated had the facility contacted him, he would have informed the facility to send Resident #167 to the hospital on [DATE]. Record review of Resident #167's hospital paperwork, dated 09/20/22, revealed the resident had liver cancer and bile duct cancer. Record Review of Resident #167's nurse's notes, dated 09/20/22, revealed he returned to the facility on [DATE]. Record review of the facility policy, Change of Condition Notification, dated 06/2020, revealed, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: an injury/accident; a significant change in the resident's physical, cognitive, behavioral or functional status; a significant change in treatment; and/or a decision to transfer or discharge the resident from the facility. This was determined to be an Immediate Jeopardy (IJ) on 09/28/22 at 2:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 2:30 PM. The Facility Plan of Removal was accepted on 09/30/22. The plan of removal reflected: Summary of Details which lead to outcomes On 9/12/22, annual survey was initiated at the facility. On 9/28/2022 surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Notify of Changes 1. The facility failed to notify the physician regarding Resident #167's change of condition. Identify residents who could be affected Current residents who reside at the facility who are experiencing a change of condition have the potential to be affected by this alleged deficient practice. The facility DON, ADON's and regional support staff began on 9/29/22 Thursday educating and monitoring for change of condition with residents through monitoring of progress notes, review of clinical dashboard and nurse huddles for early identification of change in condition in the last 30 days. No other residents were found to be affected by the alleged deficient practice. Identify responsible staff/ what action taken 1. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant , on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. This in-service was completed before in-servicing other staff members 2. LVN T received a 1:1 re-education on 9/29/2022 by the DON , RN, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 3. ADON B received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 4. DON initiated education on 9/14/2022 and re-educated on 9/29/2022 Licensed Nurses and Certified Nursing assistants on early identification signs of change in condition, initiation of SBAR, resident assessment and physician notification 5. Beginning 09/29/22 the facility DON, ADON'S and Regional Clinical Staff administered a post-test in conjunction with education provided to staff to confirm that education was effective and assist with identifying any further residents at risk using a change of condition post-test. Staff will be educated by 9.30.2022 and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. 6. Education will be conducted at the beginning of each shift so that no staff will provide direct care without the in-service. Staff members who are on leave, vacation, PRN, agency staff, and weekend staff who unable to attend will be identified and DON or designee will meet the staff prior to working shift to provide the education and will be taken off the schedule until training is received. 7. An emergency ADHOC QAPI meeting was held today 9/29/22 with the Inter Disciplinary Team and the facility Medical Director. In-Service conducted In-service was conducted by Director of Nursing on 9/14/2022 and re-educated on 9/29/22. The in-service is on Change of Condition, Nursing assessment, Physician notification, Documentation, and Immediate implementation of interventions. The details of the in-service include: Walking Rounds Visualizing each resident during rounds at shift change Rounding every 2 hours Identifying Changes of Condition and what is considered a change of condition Immediate physician notification of Changes of condition Immediate implementation of interventions for changes of condition Documentation of changes of condition and interventions Notification of change of condition to DON/Designee The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 9/14/2022 and re-education 9/29/22. The Administrator and/or Director of Nursing will track training attendance via staff roster provided by Human Resources. Education tracking began on 09/29/2022 and ended on 9.30.2022; and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. Implementation of Changes The changes were started by the Director of Nursing. The changes were implemented effective on 9/29/2022 and will be ongoing until all staff are re-educated. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of questionnaire. Nursing staff- Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant were trained to follow the following new process: 1. Initiation of a nursing assessment with findings documented in SBAR 2. Physician notification of change of condition 3. Continued monitoring and implementation of interventions per physician order. 4. Reporting directly to the DON 5. DON will discuss changes in conditions, interventions, and effectiveness of interventions in daily clinical meeting and any adverse findings will be reported immediately to the Medical Director. Staff were training started on 9/14/2022 and re-initiated on 9/29/2022 to identify changes that are outside of resident's baseline and to report those changes to nursing for immediate interventions. Monitoring Administrator/DON/Designee will monitor recommendation daily x 4weeks, daily x 2 weeks, daily x 1 week and monthly. All adverse findings will be reviewed by IDT team and reported to the Medical Director daily. Regional Nurse Consultant will review SBARs and progress notes with recommendations made to the Inter Disciplinary team weekly x4, bi-weekly x4 then monthly after for implementation of recommendations. All adverse findings will be reviewed monthly in Quality Assurance Performance Improvement Meeting. Facility Administrator, DON and/or Designee will monitor the staff understanding and competency with change of condition by utilizing a change of condition questionnaire with weekly staff meetings x 4 weeks to identify any further educational needs. The findings of progress notes, review of SBAR and observations with resident conditions and staff huddles will be reviewed weekly x 4 weeks during a facility IDT meeting. They will be audited by DON/ADON/ RNC and presented monthly at QAPI x 3 months then quarterly x 3 quarters. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 9/29/2022 and conducted an Ad HOC QAPI regarding change in conditions of residents, Physician notification, immediate implementation of interventions and prompt documentation of change of condition and intervention. The Medical Director was notified about the immediate Jeopardy on 9/29/2022 at 4:43pm, the Plan of removal was reviewed and accepted by the Medical Director on 9/29/2022 @ 7:40pm Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, and director of nursing, to review plan of removal on 9/29/2022. Who is responsible for implementation of process? The Administrator Director of Nursing will be responsible for implementation of New Process. The New Process/system was started on 9/29/2022. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports dated 09/29/22, 09/30/22, and 10/01/22 revealed staff were in-serviced regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. Interviews were conducted on 09/29/22 starting at 5:09 PM through 10/01/22 at 12:45 PM with LVN D, CNA R, LVN U, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, LVN CC, LVN DD, and LVN EE across all three shifts, the weekend, PRN staff, and agency staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Interview with ADON B on 10/01/22 at 1:46 PM revealed, upper management had not been hired at the facility long enough to correct anything that needed to be corrected. She stated documentation of Resident #167's change of condition would have caused the IJ not occur. She stated Resident #167 had a PRN medication, prior to that there were interventions carried out. She stated she did not know what interventions Resident #167 had. She stated interventions for Resident #167 were implemented prior to her working at the facility. She stated she had only worked at the facility for four days prior to survey on 09/12/22. She stated she did not know the facility's policies and procedures. She stated she was learning facility policy and procedures by taking incentive, talking to colleagues, CNAs, nurses, and residents. She stated the facility did not deserve an IJ. She stated the only non-compliance was failure to document in Resident #167's EMR. She stated she was re-educated on change of condition, notifying physician, entering orders, documenting, notifying RP, documenting in 24-hour report, and verbalize to the incoming nurse. She stated she was re-educated on SBAR (background, assess, and recommendation), the type of SBAR to complete, and document anything that was not the resident's baseline. Interview with the DON on 10/01/22 at 3:02 PM revealed, she supervised her staff by rounding, follow -ups, asking questions, and audits. She stated she ensured policies and procedures were followed by walking the units, talking to staff, reviewing systems in EMR, and visual rounding. She stated there was a delegation of supervision. She stated the ADONs supervise the CNAs and Nurses. She stated the ADONs follow up with the staff and the DON does an audit to ensure tasks have been completed. She stated the facility received an IJ because LVN T overshared information, ADON B provided care to Resident #167 but did not inform the incoming nurse. She stated staff had been in-served regarding change of condition, stop and watch, assess resident when a change of condition is noticed, notify physician, notify RP, document and give report, review documentation to ensure completion. She stated there was an audit tool used to follow up on residents until residents return to baseline or if it is their new baseline. She stated she looked at residents, talked to nursing staff, talked to residents, progress note review to ensure other residents had not had a change in condition. She stated she was re-educated regarding policy of change of condition, notification, and how to audit. She stated she re-educated to LVN T by discussing change of condition policy, notifying change, scenarios, change of condition form, follow physician orders, and documentation. She stated she re-educated on 09/29 to staff regarding change of condition, SBAR, quiz, asked questions. She stated she ensured agency and any new staff were in-serviced. She stated in-servicing will be conducted with oncoming staff. She stated she will monitor change of condition, monitor change of condition form, orders carried out, any new orders, audit tool, she stated regional will audit the change in condition form. She stated the EMR system will automatically trigger her a notification. She stated she will be monitoring as written in the POR. Interview with LVN T on 10/01/22 at 04:09 PM revealed, she was in-serviced regarding resident's change of condition, notifying the physician, and documenting a resident's change of condition in their EMR. She stated the reason the facility received an IJ was because the facility failed to act regarding Resident #167's change in condition. She stated the IJ would have been prevented had staff monitored Resident #167's changes in condition and notified the physician. The surveyor attempted to contact the physician on 10/01/22 at 4:15 PM. Interview with Regional Nurse Consultant on 10/01/22 at 04:20 PM revealed, she educated the DON and ADON B regarding facility policy on change in condition, notifying the physician, reviewing 24-hour report, morning meeting and talk nurses, and stand down. She stated she reviewed change in condition assessments, SBAR, talked to residents, talked to staff, reviewed dashboard in EMR, and reviewed progress notes to determine if other residents were affected by change in condition. She stated she assisted with in-servicing staff and competency test. She stated she created herself a tool to check dashboard and assessments per the POR. Interview with Administrator on 10/01/22 at 4:34 PM revealed, he ensured policies and procedures were being followed by monthly in-services, morning meeting (census, new admission) ambassador rounds (grievances, concerns, resident needs), rounds throughout the facility, corrections on the spot, infection control (face masks). He stated he supervised the DON by having afternoon stand downs, group chat with administrative staff and walked arounds with DON every Thursday. He stated the facility failed to ensure the resident received the care he needed. He stated the nurses did not document the medication and did not contact the physician. He stated fingers could be pointed at the nursing staff but all together the facility failed. He stated the documentation was not there regarding meds even though the nurse stated she did give it. He stated the MD was notified of the IJ on 09/29/22. He stated LVN T was held accountable and received a write up and education, education with nursing and every staff, every department has some interaction with the resident, ambassador program (you would see something regarding the resident), monitoring and auditing resident's change in condition, during daily QA meetings residents with change of will be discussed, each nurse will go over each resident on the hall thoroughly. The facility's Administrator was informed the Immediate Jeopardy was removed on 09/30/22 at 12:31 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one of six (Resident #167) residents reviewed for quality of care. The facility failed to assess, implement interventions, communicate, document multiple incidents of vomiting on 09/12/22, which included a change in appearance, lethargic behavior, and vomiting resulting in hospitalization on 09/13/22. On 09/28/22 at 2:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/30/22, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Record review of Resident #167's Quarterly Assessment, dated 09/06/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: hypertension, diabetes mellitus, cerebrovascular accident, non-Alzheimer's dementia, hemiplegia, malnutrition, anxiety disorder, depression, asthma, primary insomnia, and dysphagia. His BIMS score was a 13 out of 15, which meant the resident was cognitively intact. His functional status revealed he required limited assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, and personal hygiene. He required supervision with walking in room and eating. Record review of Resident #167's care plan, undated, revealed there were no focus, goal, interventions/tasks regarding nausea and/or vomiting. Record review of Resident #167's nursing notes revealed no entries on 09/10/22 to 09/12/22 regarding resident's change of condition. Record review of Resident #167's September 2022 physician's orders revealed he was prescribed Promethazine HCL tablet 25 mg on 09/22/21. He was ordered to receive one tablet by mouth every six hours as needed for nausea and vomiting. Record review of Resident #167's September 2022 MAR revealed the resident was only administered one Promethazine HCL tablet 25mg on 09/04/22. Record review of Resident #167's labs, dated 09/06/22, revealed his WBC was 21.7 (white blood count reference range 3.8-10.1), RBC 4.00 (red blood count reference range 4.40-5.80), HGB 10.1 (hemoglobin reference range 13.8-17.2), HCT 10 (hematocrit reference range 41-50), MCV 75 (mean corpuscular volume reference range 81-99), MCH 25.3 (mean corpuscular hemoglobin reference range 27-33), RDW 20.8 (red blood cell distribution width reference range 11.5-14.5), PLT 610 (platelet reference range 130-400), NE# 15.3 (neutrophil count reference range 1.8-7), LY% 13.9 (lymphocytes reference range 20-55), MO# 1.7 (monocytes high reference range 0.0-0.8), EO# 0.6 (eosinophil count reference range 0.0-0.5), BA# 0.3 (basophil reference range 0.0-0.2), IGRE 3.8 (reference range 0.0-0.5), Imm. Grans Abs. 0.8 (immature granulocyte reference range 0.0-0.1), CO2 22 (carbon dioxide reference range 23-32), BUN 27 (blood urea nitrogen reference range 6-25), and Creatinine 1.53 (reference range 0.30-1.20). Record Review of Resident #167's hospital paperwork, dated 09/06/22, revealed he had elevated white blood cell count. He was referred to a hematology and oncology specialist due to high white blood count. Observation and interview with Resident #167 on 09/12/22 at 11:22 AM revealed there was a dried brown splattered substance in his trash can and on the floor by his bed. His urinal contained approximately 300 ml of dark amber tinged urine. Resident #167 stated he did not feel well and fell asleep during the interview. Observation of Resident #167's room on 09/13/22 at 8:45 AM revealed there was a dried brown splatter substance: on his trash can, left side of the mattress and bed linen, floor and wall behind the head of his bed, the floor to the left side of his bed, and the wall located on the left side of his bed. He was observed laying in his bed. The surveyor informed LVN S of the observation. Observation of Resident #167 on 09/13/22 at 8:52 AM revealed the resident appeared to be sluggish and drowsy. He informed LVN S his stomach hurt, and he needed his urine checked. LVN S assessed Resident #167 and informed the resident his eyes appeared to be more yellowish, and urine was darker. She asked him if he had vomited this morning, if he experienced pain on any other parts of his body, and the last time he had a bowel movement. Resident #167 stated his stomach hurt, he vomited this morning, and had not had a bowel movement in a few days. She informed the resident the physician would be notified. Record review of Resident #167's nursing notes revealed on 09/13/22 he was sent out 911 due to vomiting up a substance that was brown in color. MD and ADON was notified. Per MD send out 911 for further evaluation and treatment written by LVN S. Interview with LVN S on 09/13/22 at 12:09 PM revealed Resident #167 had a change of condition since returning from the hospital on [DATE]. She stated he appeared more lethargic, his eyes were more yellow, and his urine was darker. She stated she was just made aware from his previous nurse that Resident #167 vomited on 09/12/22. She stated she last worked with Resident #167 on 09/05/22. She stated if an incident of vomiting or not informing oncoming staff of incident could delay the care the resident receives. She stated she did not make rounds on residents at the beginning of her shift on 09/13/22. She stated her shift started at 07:00 AM. She stated she was not made aware Resident #167 had vomited until contacted by the state surveyor. She stated the reddish-brown emesis could be internal bleeding. She stated after assessing him she notified the ADON and physician. She stated she was informed by the ADON to call 911 and have Resident #167 transferred to the hospital. Interview with ADON A on 09/13/22 at 12:42 PM revealed Resident #167 had an isolated incident of vomiting on 09/04/22 and was given his PRN medication Promethazine. She stated he was ordered labs and sent to the hospital on [DATE]. She stated he received an ultrasound on 09/08/22 and there were no abnormal results. She stated Resident #167 did not vomit on 09/12/22. She stated his urine appeared to be dark on 09/12/22. She stated Resident #167's dark colored urine has been an ongoing issue. She stated NP P was aware of his urine. She stated nurses and CNAs round on residents every 2 hours. She stated sometimes rounds were missed if the residents were not in their room. She stated an incident of vomiting or not informing oncoming staff of incident could delay the care the resident receives. She stated the nurse was supposed to contact the nurse management of a resident's change in condition. She stated the nurse assessed the resident while the state surveyor was present, completed an SBAR, contacted the physician, and sent Resident #167 to the ER. She stated he was sent to the hospital due to vomit being brown/coffee colored and suspicion of internal bleeding. Interview with CNA R on 09/13/22 at 1:07 PM, revealed Resident #167 had been vomiting for the past two weeks. She stated his vomit and urine had been the same color for the past two weeks. She stated over the past few days Resident #167 appeared to be lethargic and not like himself. She stated she had informed nurses of the resident's change in condition. She stated she did not remember the nurses' names. She stated the last time he vomited a brown substance was 09/12/22. She stated she noticed Resident #167's vomit on 09/12/22 during her morning rounds around 8:00 AM but did not know the specific time. She stated it had happened during the morning shift between 7:00 AM and around 8:00 AM. She stated she did not document the vomiting anywhere in her notes. She stated she informed ADON B of the resident vomiting directly after noticing. She stated there was no delay in notifying the ADON. She stated ADON B informed her to change his sheets. She stated she did not round on Resident #167 prior to surveyor observation on 09/13/22. She stated she had not rounded on him because she was meeting the needs of other residents on the hall. Interview with ADON B on 09/13/22 at 1:21 PM, revealed she was the acting charge nurse for Resident #167 during the 07:00 AM to 03:00 PM shift on 09/12/22. She stated she did not know he went to the hospital on [DATE] regarding similar issues. She stated she was unfamiliar with him because she had only been working at the facility for four days. She stated she noticed he vomited during her morning medication pass around 8:30 AM to 9:30 AM. She stated she observed reddish brown stains on his bed and floor. She stated the resident informed her he felt nauseated. She stated she administered his PRN medication promethazine. She stated she did not notify the DON or physician because Resident #167 had only vomited once during her shift. She stated she shared the information verbally to the 03:00 PM to 11:00 PM nurse on 09/12/22. She stated she assessed him, took his vitals, and monitored his bowel sounds. She stated his vitals and bowel sounds were normal. She stated she did not complete a progress note regarding Resident #167's vomiting or assessment. She stated a progress note and assessment for Resident #167 should have been completed. She stated she did not know why a progress note or assessment was not completed. The surveyor attempted to contact the physician on 09/13/22 at 2:12 PM. Interview with the DON on 09/13/22 at 2:43 PM revealed, she was informed by one of the ADONs Resident #167 was nauseated on 09/04/22. She stated he had labs ordered and received medication for nausea on 09/05/22. She stated he was sent to the hospital on [DATE] due to his WBC and returned to the facility the same day. She stated he was supposed to be seen by a hematologist and oncologist per his hospital discharge paperwork. She stated Medical Records was supposed to set up Resident #167's follow up appointments with a hematologist and oncologist but had not. She stated she continued to remind Medical Records to set up Resident #167's follow up appointments. The DON stated Medical Records was trying to locate a hematology and oncology specialist willing to take Resident #167's insurance. She stated she was informed by the ADONs he was sent to the hospital on [DATE] for vomiting a brown substance. She stated if Resident #167 had only vomited once she would have administered medication and monitored. She stated if Resident #167 had only vomited once the physician would not need to be notified. She stated Resident #167 vomiting a brown substance was considered a change in condition. She stated when Resident #167 had a change in condition, the nurse was supposed to assess, evaluate, listen to bowel sounds, and notify the physician. She stated the nurse should have contacted the physician and then followed the physician's orders. She stated the physician was aware the resident had a history of vomiting. Record review of the 24-hour nurse's report log on 09/13/22 revealed there was only one occasion of Resident #167 vomiting, dated 09/04/22. There was no documentation regarding him from 09/09/22 to 09/13/22. Interview with LVN T on 09/14/22 at 03:04 AM revealed, Resident #167 was still in the hospital due to vomiting the morning of 09/13/22. She stated he had a history of vomiting. She stated he vomited on 09/12/22 during the 11:00 PM to 07:00 AM shift. She stated he had complained of nausea and was administered his PRN promethazine. She stated she observed light yellow vomit on the floor by his bed. She stated she cleaned up his vomit with a towel. She stated she did not notify anyone of Resident #167 vomiting because he only vomited once during her shift. She stated she should have documented his vomiting episode. She stated she did not notify NP P or the physician. She stated she did not need to notify anyone. Record review of Resident #167's hospital paperwork, dated 09/14/22, reflected his admission date was 09/13/22 and his chief complaint was nausea/vomiting three times a day for four days. His gallbladder ultrasound revealed a mass in the right hepatic lobe measuring up to 12 cm. His assessment and plan revealed evidence of biliary obstruction 2/2 iterative growth of hepatic mass [mass causing bile blockage]. A gastroenterologist and hepatologist was consulted. Interview with NP P on 09/14/22 at 3:49 PM revealed, Resident #167 was sent to the hospital on [DATE] due to the nurse reporting jaundice like symptoms of the eyes (yellowish) and being more lethargic. He stated he ordered labs for the resident after returning from the hospital and had not seen the results. He stated he was not aware Resident #167's labs had not been completed. He stated he last saw Resident #167 the week of 09/05/22. He stated Resident #167 had a change in condition because the nurse reported the resident vomited brown stuff. He stated he informed the nurse to send Resident #167 to the hospital. He stated Resident #167 did not have a history of nausea or vomiting. He stated the facility had not reported to him Resident #167 had a history of vomiting or nausea. He stated his expectation was for the facility to contact him regarding Resident #167 vomiting on 09/12/22. He stated had the facility contacted him, he would have informed the facility to send Resident #167 to the hospital on [DATE]. Record review of Resident #167's hospital paperwork, dated 09/20/22, revealed the resident had liver cancer and bile duct cancer. Record Review of Resident #167's nurse's notes, dated 09/20/22, revealed he returned to the facility on [DATE]. Record review of the facility policy, Change of Condition Notification, dated 06/2020, revealed, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: an injury/accident; a significant change in the resident's physical, cognitive, behavioral or functional status; a significant change in treatment; and/or a decision to transfer or discharge the resident from the facility. This was determined to be an Immediate Jeopardy (IJ) on 09/28/22 at 2:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 2:30 PM. The Facility Plan of Removal was accepted on 09/30/22. The plan of removal reflected: Summary of Details which lead to outcomes On 9/12/22, annual survey was initiated at the facility. On 9/28/2022 surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F684 Quality of Care 1. The facility failed to intervene regarding Resident #167's change of condition. The facility failed to document, assess, and notify the physician regarding change of condition. F580 Notify of Changes 1. The facility failed to notify the physician regarding Resident #167's change of condition. Identify residents who could be affected Current residents who reside at the facility who are experiencing a change of condition have the potential to be affected by this alleged deficient practice. The facility DON, ADON's and regional support staff began on 9/29/22 Thursday educating and monitoring for change of condition with residents through monitoring of progress notes, review of clinical dashboard and nurse huddles for early identification of change in condition in the last 30 days. No other residents were found to be affected by the alleged deficient practice. Identify responsible staff/ what action taken 1. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant , on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. This in-service was completed before in-servicing other staff members 2. LVN T received a 1:1 re-education on 9/29/2022 by the DON , RN, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 3. ADON B received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 4. DON initiated education on 9/14/2022 and re-educated on 9/29/2022 Licensed Nurses and Certified Nursing assistants on early identification signs of change in condition, initiation of SBAR, resident assessment and physician notification 5. Beginning 09/29/22 the facility DON, ADON'S and Regional Clinical Staff administered a post-test in conjunction with education provided to staff to confirm that education was effective and assist with identifying any further residents at risk using a change of condition post-test. Staff will be educated by 9.30.2022 and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. 6. Education will be conducted at the beginning of each shift so that no staff will provide direct care without the in-service. Staff members who are on leave, vacation, PRN, agency staff, and weekend staff who unable to attend will be identified and DON or designee will meet the staff prior to working shift to provide the education and will be taken off the schedule until training is received. 7. An emergency ADHOC QAPI meeting was held today 9/29/22 with the Inter Disciplinary Team and the facility Medical Director. In-Service conducted In-service was conducted by Director of Nursing on 9/14/2022 and re-educated on 9/29/22. The in-service is on Change of Condition, Nursing assessment, Physician notification, Documentation, and Immediate implementation of interventions. The details of the in-service include: Walking Rounds Visualizing each resident during rounds at shift change Rounding every 2 hours Identifying Changes of Condition and what is considered a change of condition Immediate physician notification of Changes of condition Immediate implementation of interventions for changes of condition Documentation of changes of condition and interventions Notification of change of condition to DON/Designee The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 9/14/2022 and re-education 9/29/22. The Administrator and/or Director of Nursing will track training attendance via staff roster provided by Human Resources. Education tracking began on 09/29/2022 and ended on 9.30.2022; and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. Implementation of Changes The changes were started by the Director of Nursing. The changes were implemented effective on 9/29/2022 and will be ongoing until all staff are re-educated. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of questionnaire. Nursing staff- Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant were trained to follow the following new process: 1. Initiation of a nursing assessment with findings documented in SBAR 2. Physician notification of change of condition 3. Continued monitoring and implementation of interventions per physician order. 4. Reporting directly to the DON 5. DON will discuss changes in conditions, interventions, and effectiveness of interventions in daily clinical meeting and any adverse findings will be reported immediately to the Medical Director. Staff were training started on 9/14/2022 and re-initiated on 9/29/2022 to identify changes that are outside of resident's baseline and to report those changes to nursing for immediate interventions. Monitoring Administrator/DON/Designee will monitor recommendation daily x 4weeks, daily x 2 weeks, daily x 1 week and monthly. All adverse findings will be reviewed by IDT team and reported to the Medical Director daily. Regional Nurse Consultant will review SBARs and progress notes with recommendations made to the Inter Disciplinary team weekly x4, bi-weekly x4 then monthly after for implementation of recommendations. All adverse findings will be reviewed monthly in Quality Assurance Performance Improvement Meeting. Facility Administrator, DON and/or Designee will monitor the staff understanding and competency with change of condition by utilizing a change of condition questionnaire with weekly staff meetings x 4 weeks to identify any further educational needs. The findings of progress notes, review of SBAR and observations with resident conditions and staff huddles will be reviewed weekly x 4 weeks during a facility IDT meeting. They will be audited by DON/ADON/ RNC and presented monthly at QAPI x 3 months then quarterly x 3 quarters. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 9/29/2022 and conducted an Ad HOC QAPI regarding change in conditions of residents, Physician notification, immediate implementation of interventions and prompt documentation of change of condition and intervention. The Medical Director was notified about the immediate Jeopardy on 9/29/2022 at 4:43pm, the Plan of removal was reviewed and accepted by the Medical Director on 9/29/2022 @ 7:40pm Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, and director of nursing, to review plan of removal on 9/29/2022. Who is responsible for implementation of process? The Administrator Director of Nursing will be responsible for implementation of New Process. The New Process/system was started on 9/29/2022. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports dated 09/29/22, 09/30/22, and 10/01/22 revealed staff were in-serviced regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. Interviews were conducted on 09/29/22 starting at 5:09 PM through 10/01/22 at 12:45 PM with LVN D, CNA R, LVN U, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, LVN CC, LVN DD, and LVN EE across all three shifts, the weekend, PRN staff, and agency staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Interview with ADON B on 10/01/22 at 1:46 PM revealed, upper management had not been hired at the facility long enough to correct anything that needed to be corrected. She stated documentation of Resident #167's change of condition would have caused the IJ not occur. She stated Resident #167 had a PRN medication, prior to that there were interventions carried out. She stated she did not know what interventions Resident #167 had. She stated interventions for Resident #167 were implemented prior to her working at the facility. She stated she had only worked at the facility for four days prior to survey on 09/12/22. She stated she did not know the facility's policies and procedures. She stated she was learning facility policy and procedures by taking incentive, talking to colleagues, CNAs, nurses, and residents. She stated the facility did not deserve an IJ. She stated the only non-compliance was failure to document in Resident #167's EMR. She stated she was re-educated on change of condition, notifying physician, entering orders, documenting, notifying RP, documenting in 24-hour report, and verbalize to the incoming nurse. She stated she was re-educated on SBAR (background, assess, and recommendation), the type of SBAR to complete, and document anything that was not the resident's baseline. Interview with the DON on 10/01/22 at 3:02 PM revealed, she supervised her staff by rounding, follow -ups, asking questions, and audits. She stated she ensured policies and procedures were followed by walking the units, talking to staff, reviewing systems in EMR, and visual rounding. She stated there was a delegation of supervision. She stated the ADONs supervise the CNAs and Nurses. She stated the ADONs follow up with the staff and the DON does an audit to ensure tasks have been completed. She stated the facility received an IJ because LVN T overshared information, ADON B provided care to Resident #167 but did not inform the incoming nurse. She stated staff had been in-served regarding change of condition, stop and watch, assess resident when a change of condition is noticed, notify physician, notify RP, document and give report, review documentation to ensure completion. She stated there was an audit tool used to follow up on residents until residents return to baseline or if it is their new baseline. She stated she looked at residents, talked to nursing staff, talked to residents, progress note review to ensure other residents had not had a change in condition. She stated she was re-educated regarding policy of change of condition, notification, and how to audit. She stated she re-educated to LVN T by discussing change of condition policy, notifying change, scenarios, change of condition form, follow physician orders, and documentation. She stated she re-educated on 09/29 to staff regarding change of condition, SBAR, quiz, asked questions. She stated she ensured agency and any new staff were in-serviced. She stated in-servicing will be conducted with oncoming staff. She stated she will monitor change of condition, monitor change of condition form, orders carried out, any new orders, audit tool, she stated regional will audit the change in condition form. She stated the EMR system will automatically trigger her a notification. She stated she will be monitoring as written in the POR. Interview with LVN T on 10/01/22 at 04:09 PM revealed, she was in-serviced regarding resident's change of condition, notifying the physician, and documenting a resident's change of condition in their EMR. She stated the reason the facility received an IJ was because the facility failed to act regarding Resident #167's change in condition. She stated the IJ would have been prevented had staff monitored Resident #167's changes in condition and notified the physician. The surveyor attempted to contact the physician on 10/01/22 at 4:15 PM. Interview with Regional Nurse Consultant on 10/01/22 at 04:20 PM revealed, she educated the DON and ADON B regarding facility policy on change in condition, notifying the physician, reviewing 24-hour report, morning meeting and talk nurses, and stand down. She stated she reviewed change in condition assessments, SBAR, talked to residents, talked to staff, reviewed dashboard in EMR, and reviewed progress notes to determine if other residents were affected by change in condition. She stated she assisted with in-servicing staff and competency test. She stated she created herself a tool to check dashboard and assessments per the POR. Interview with Administrator on 10/01/22 at 4:34 PM revealed, he ensured policies and procedures were being followed by monthly in-services, morning meeting (census, new admission) ambassador rounds (grievances, concerns, resident needs), rounds throughout the facility, corrections on the spot, infection control (face masks). He stated he supervised the DON by having afternoon stand downs, group chat with administrative staff and walked arounds with DON every Thursday. He stated the facility failed to ensure the resident received the care he needed. He stated the nurses did not document the medication and did not contact the physician. He stated fingers could be pointed at the nursing staff but all together the facility failed. He stated the documentation was not there regarding meds even though the nurse stated she did give it. He stated the MD was notified of the IJ on 09/29/22. He stated LVN T was held accountable and received a write up and education, education with nursing and every staff, every department has some interaction with the resident, ambassador program (you would see something regarding the resident), monitoring and auditing resident's change in condition, during daily QA meetings residents with change of will be discussed, each nurse will go over each resident on the hall thoroughly. The facility's Administrator was informed the Immediate Jeopardy was removed on 09/30/22 at 12:31 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.