**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #2) out of three residents reviewed for abuse, in that: The facility failed to prevent a physical altercation between Resident #1 and Resident #2 that led to Resident #2 sustaining an abrasion to his left ear, redness to the back of the left side of his head and neck, causing him to have a headache and experience dizziness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/31/23 at 3:00 PM. While the IJ was removed on 11/01/23 at 2:30 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk pain, injury, hospitalization, intimidation, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain) with behavioral disturbances, cerebral infarction (stroke), altered mental status, and violent behaviors. Review of Resident #1's quarterly MDS assessment, dated 09/25/23, reflected a BIMS score of 8, indicating a moderately impaired cognition. Review of Resident #1's quarterly care plan, revised 10/16/23, reflected he had behavioral symptoms of hitting other residents with an intervention of keeping distance between himself and other residents when he became physically abusive. Review of a progress note in Resident #1's EMR, dated 04/03/23 and documented by LVN A, reflected the following: During dinner, [Resident #1] became upset, stood up, and attempted to charge another resident. Staff immediately interfered and instructed [Resident #1] to sit back down. CN asked why he (Resident #1) attempted to do that and he replied, she is always getting to close to me. Attempted to explain to [Resident #1] this particular resident is not aware of what she is doing, therefore he is not allowed to do that to her or any other resident in this building. [Resident #1] became angry with CN and ambulated down 100 hall and sat in hallway. Review of a progress note in Resident #1's EMR, dated 08/10/23 and documented by LVN B, reflected the following: Peer to peer disagreement in the dining room. [Resident #1] had a verbal altercation with [Resident #2] over changing the channel on the TV in the dining room area. [Resident #1] rose from the chair and lunged at [Resident #2]. Nurse (LVN B) immediately ran in-between the two individuals to diffuse the situation. Review of a progress note in Resident #1's EMR, dated 08/22/23 and documented by RN C, reflected the following: With SW present, conversation with [Resident #1] regarding behaviors with [Resident #2] in the dining room where they had to be separated due to [Resident #1] threatening to hit [Resident #2]. Explained to [Resident #1] that there will be consequences if he at any point follows through with that threat and encouraged [Resident #1] to remove himself moving forward if [Resident #2] makes him feel the way he did this morning to prevent from any further threats. There was no progress note regarding an additional incident between Resident #1 and #2 on the morning of 08/22/23, as documented in the above progress note. Review of Resident #1's Psychologist's assessment, dated 08/18/23, reflected the following: A/O x2. Affect reserved and flattened in context of defected mood (despite his denial of such). Psychologist received a request from SW that [Resident #1] be seen ASAP as there had been reports of controlling and manipulative behavior. Review of Resident #1's Psychologist's assessment, dated 08/25/23, reflected the following: A/O x2. Psychologist received a request from the SW that [Resident #1] be seen ASAP as there had been reports of angry, threatening behavior. Affect became labile and defensive when asked about a recent incident where [Resident #1] threatened to break the jaw of [Resident #2]. Aggression: Physical, verbal, threatened to break the jaw of [Resident #2] Overall Treatment Progress: Slight, two separate sessions required on 08/25/23 due to inappropriate, controlling, coercive and threatening behaviors towards other residents. Review of a progress note in Resident #1's EMR, dated 10/13/23 and documented by the SW, reflected the following: [Resident #1] was in an altercation with [Resident #2] in the dining room during lunch time . Review of a progress note in Resident #1's EMR, dated 10/18/23 and documented by the SW, reflected the following: [Resident #1] left for (behavioral health hospital) . Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), unspecified dementia without behavioral disturbance, depression, and age-related physical debility. Review of Resident #2's quarterly MDS assessment, dated 10/13/23, reflected a BIMS score of 14, indicating he was cognitively intact. Review of Resident #2's quarterly care plan, revised 10/11/23, reflected he received antidepressant medication related to behavioral issues such as sadness and tearfulness with an intervention of approaching him in a calm manner and remaining positive when providing care. Review of an investigation report for the incident between Resident #1 and #2, dated 10/13/23 and completed by the DON, reflected the following: [Resident #1] was seen hitting [Resident #2] in the head in the dining room with a closed fist. Upon assessment of [Resident #2]'s head there was redness to the area behind the left side of the back of his head with a small open rea to his ear that was bleeding slightly. Review of a progress note in Resident #2's EMR, dated 10/13/23 and documented by LVN D, reflected the following: [Resident #2] was involved in an altercation with [Resident #1]. [Resident #2] is noted to have an abrasion on his left ear with redness to the left side of his neck and head. He c/o light headache and being dizzy. [Resident #2] is being sent to the ER for evaluation and treatment. Review of a progress note in Resident #2's EMR, dated 10/16/23 and documented by the SW, reflected the following: Spoke with [Resident #2] regarding anxiety and if [Resident #2] would be agreeable for psych services to see him. [Resident #2] stated not at this time, that he believed the anxious feelings would go away on their own . [Resident #2] expressed gratitude that steps were being taken to keep [Resident #1] away, and that he was starting to feel better. Observation and interview on 10/31/23 at 2:51 PM revealed Resident #2 in his bed watching television. He stated he was no longer experiencing head pain or dizziness after the incident with Resident #1. He stated it had only lasted a few days. He stated Resident #1 was a psychopath and had been antagonizing him for months. He stated on 10/13/23, Resident #1 was arguing with him about what the television and out of now where he started punching him in the back of the head. He stated he was so bad that he filed a police report. He stated he was now afraid of him and was told he would not be coming back to the facility. He stated if he did come back to the facility, he was going to have a real problem. During an interview on 10/31/23 at 8:36 AM, the DON stated she did not witness the altercation on 10/13/23 but was there to assess Resident #1 and #2. She stated she was notified Resident #1 punched Resident #2 in the back of the head. She stated they immediately moved Resident #1 to a different hallway and after Resident #2 had given his statement to the police, he was sent to the ER for further evaluation. She stated he came back the same day with no findings. She stated Resident #1 was currently at a behavioral health hospital and their plan was to find alternate placement for him. The DON stated her main concern was that Resident #1 had no remorse or saw a problem with what he did to Resident #2. The DON stated she had only been at the facility since September (2023) and had never been made aware of any prior physical/verbal aggression from Resident #1. She stated there had been nothing in his care plan regarding behaviors and if she had known he had a history, there would have been interventions in place. During an interview on 10/31/23 at 11:46 AM, the SW stated he did not see the altercation between Resident #1 and #2 on 10/13/23 but had been walking down the hall when he heard yelling in the dining room area. He stated the aides had told him Resident #1 had put his hands on Resident #1. He stated Resident #2 requested he call the police and during his interview with the police told them Resident #1 had punched him with a closed fist to his head at least three times. He stated when he interviewed Resident #1, he admitted that was what he had done, but could not give an explanation as to why. The SW stated Resident #1 had a history of verbal aggression but not physical. He stated he did not remember any incident regarding him charging at a resident in April. He stated he did remember the incident from August when Resident #1 lunged at Resident #2 but stated he had not physically touched Resident #2. He stated he followed up with Resident #2 a few days after the incident. He stated Resident #2 told him he was feeling anxious from the incident but felt better knowing that Resident #1 had been moved to a different hall. During an interview on 10/31/23 at 12:03 PM, LVN A stated she worked regularly with Resident #1 and #2. She stated Resident #1 had always been very verbally aggressive, but not exactly aggressive. She stated he would do things to intimidate residents, like run up behind them in their wheelchairs and scream. There were a few vulnerable residents that are unable to speak that she watched out for when Resident #1 was around. She stated there was an incident in April when a resident he did not like, for whatever reason, got close to him in the dining room and he got up and charged at her. She stated she intervened immediately after she saw the look in his eye. She stated she had always been fearful that Resident #1 could be physically aggressive. She stated he was always loud and cursing, got frustrated easily, and he was unpredictable. LVN A stated Resident #1 had always been annoyed by Resident #2, and it normally revolved around what channel the television was on. She stated Resident #2 was scared after the incident with Resident #1. She stated Resident #2 was more withdrawn for a few days. During an interview on 10/31/23 at 12:33 PM, CNA E stated she witnessed the incident between Resident #1 and #2 on 10/13/23. She stated Resident #2 told Resident #1 to put the TV on, they bickered back and forth, yes - no - yes - no, until Resident #1 out of nowhere went behind Resident #2 and punched him three times in the back of the head while Resident #2 just covered his head with his arms attempting to protect himself. She stated it was always Resident #1 who was the aggressor and he was always yelling about something. She stated she had always been fearful that Resident #1 would be physically aggressive with the residents. On 10/31/23 at 2:55 PM and 11/01/23 at 12:02 PM, attempts were made to contact Resident #1's Psychologist via telephone. A returned phone call was not received prior to exit. Review of the facility's undated Abuse and Neglect Policy, reflected the following: . 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard residents. . 3. Abuse if the willful infliction of injury, intimidation, confinement, or punishment that results in physical harm, pain, or mental anguish. The ADM and DON were notified on 10/31/23 at 3:00 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 11/01/23 at 12:00 PM: On 10/31/23 an abbreviated survey was initiated at (facility). On 10/31/23 the surveyor provided an Immediate Jeopardy Template (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F600 - The facility failed to keep the residents free from abuse. Resident #1 no longer at facility. Upon resident return to facility, resident will be reevaluated by psychiatry services. Behaviors will be monitored on Resident #1 and documented in clinical record using behavior monitoring forms. Should aggressive behaviors continue, resident #1 will be placed on 1:1 supervision until alternate placement arrangements can be made Residents residing in the facility had the potential to be affected by the alleged deficient practice. Action: Head to toe completed on Resident #2 with no negative outcomes. Staff Responsible: Director of Nursing/Designee Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: Psychosocial evaluation will be completed on Resident #2. Identified psychosocial needs will be addressed at the time of the evaluation and referrals made as indicated. Staff responsible: Social Services Director Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: Interviews will be completed with residents residing in the facility with Resident #1 prior to his discharge to identify any negative psychosocial effects and referrals will be made as indicated. Staff Responsible: Social Services Director/Designee Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: The Administrator and Director of Nursing will be re-educated on Abuse and Neglect policy and Behavior Management including: Need to update care plan interventions with any new interventions that are implemented in an attempt to prevent any further behaviors and maintain a safe environment. Staff Responsible: Clinical Consultant Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: The Licensed Clinical Team and Social Services Director will be reeducated on need to update care plan interventions with any new interventions that are implemented in an attempt to prevent further behaviors and maintain a safe environment. Staff Responsible: Director of Nursing/Designee Date Intiated:11/1/23 Date Completed: 11/1/23 Action: Facility staff will be reeducated on the Abuse and Neglect Policy including prevention and reporting of behaviors and maintenance of a safe environment. Facility staff not receiving this reeducation prior to this date will receive prior to next scheduled shift. This education will be presented in New Hire and agency staff orientation Staff Responsible: Director of Nursing/Designee Date Intiated:11/1/23 Date Completed: 11/1/23 Action: Incident reports and grievance reports will be reviewed Monday - Friday in morning meeting to identify resident to resident behaviors and to determine interventions have been implemented, safe environment has been maintained, allegations reported per abuse policy, and care plan has been updated. Staff Responsible: Administrator/Designee Date Intiated:11/1/23 Date Completed: ongoing, Monday - Friday Action: A review of behavior documentation, such as nurse notes, incident reports, 24 hours reports will be completed Monday through Friday during clinical review to determine if any resident had any unwanted behaviors towards other residents and to ensure interventions were in place to prevent further occurrences, and safe environment. Staff Responsible: Director of Nursing/Designee Date Intiated:11/1/23 Date Completed: ongoing, Monday - Friday Action: Three Random Residents will be interviewed validating residents feel safe and have no care concerns daily for one week, then weekly for three months validating residents feel safe and have no care concerns. Interviews will be documented on an interview sheet and maintained by the Administrator. Staff Responsible: Nursing Management Date Initiated: 11/1/23 Date Completed: 2/1/24 Action: The results of this monitoring will be presented to the Quality Assurance/Performance Improvement Committee for review and recommendation. Any identified concerns will be addressed at the time of discovery. Staff Responsible: Administrator/Designee Date Initiated: 11/1/23 Date Completed: 2/1/24 Ad Hoc QAPI will be held on 11/1/23. The Medical Director was notified of the Immediate Jeopardy on 10/31/23. The Surveyor monitored the POR on 11/01/23 as followed: During interviews on 11/01/23 from 1:17 PM - 2:22 PM with the AD, MRC, SW, one CNA, and two LVNs revealed they all stated they were in-serviced prior to their shifts on abuse and neglect, types of abuse, the protocol for handling situations of verbal and physical altercations between residents. All staff members were able to relay different types of abuse such as physical, mental, verbal, and sexual. They all stated their ADM was their Abuse and Neglect Coordinator and all suspicions of abuse or neglect should be reported to her immediately. All staff members stated that if they witnessed a verbal or physical altercation between residents that they would separate them immediately, make sure they were safe, would immediately notify their charge nurse and ADM, would check on them every 15 minutes, and would not let them be in the same area alone until they were sure the hostility had been defused. The AD and SW, whom had access to care plans, stated they would update resident behaviors in their care plan immediately. The SW stated after any resident-to-resident altercation he would arrange a care plan with the resident's RP and would notify the psychologist for a psychiatric evaluation. During an interview on 11/01/23 at 1:51 PM, the DON stated all staff had been in-serviced prior to their shifts and the in-servicing would continue until all staff had been in-serviced. She stated all residents had been interviewed utilizing a safe survey questionnaire and no concerns had arisen. She stated she would be responsible for ensuring care plans were updated after any behaviors between residents. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated 11/01/23, reflected the MD, NP, ADM, DON, and CSD were in attendance. Review of an in-service conducted by the CSD, dated 11/01/23, reflected the ADM and DON were in-serviced on the abuse and neglect policy, behavior management, care plans being updated with any new interventions that were implemented to prevent further behaviors to maintain a safe environment. Review of an in-serviced conducted by the DON, dated 11/01/23, reflected the licensed clinical team was in-serviced on the following: 1. Updating care plan interventions with behaviors. 2. The care plan interventions need to be updated at time of incident and/or time behavior was identified. 3. This will prevent further behaviors and maintain a safe environment. Review of an in-serviced conducted by the DON, dated 11/01/23, reflected all staff were in-serviced before their shifts on abuse and neglect and who to notify when behaviors were witnessed. While the IJ was removed on 11/01/23 at 2:30 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.