**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 2 of 16 residents (Residents #1 and #2) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #1 made verbal threats to other residents and was involved in multiple physical altercations with other residents. The facility failed to train staff in resident -to-resident altercations and failed to update Resident #1's care plans to include interventions for behaviors and resident altercations. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 6:21 pm. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of bodily, emotional, and psychosocial harm and neglect, including hospitalization or death. Findings included: Record review of Resident #1's face sheet undated revealed an [AGE] year-old male, on hospice, who initially admitted to the facility on [DATE] with a diagnosis including chronic obstructive pulmonary disease , heart failure, dementia, cognitive communication deficit, and episodic panic disorder . Record review of Resident #1's MDS dated [DATE] revealed a BIMS of 9 suggesting moderate cognitive impairment. He ambulated with a walker and a motorized wheelchair. Section E (Behaviors) reflected he had no behaviors. Record review of Resident #1's undated care plan revealed no care plan or interventions for behaviors or resident-to-resident altercations. Resident #1's progress note dated 04/18/2023 revealed a report of Resident #1 standing by [Resident #2]'s bed and stating that he is tired of the [Resident #2] yelling and If staff did not move the [Resident #2], Resident #1 would hit him or push him out of the bed. Resident #1 stated, I am telling you if you leave him (Resident #2) in here, he will be hurt. Resident #1's progress note dated 08/17/23 revealed Resident #1 attended 3-5 activities weekly and had some behavior issues with other residents (no description of behaviors included in progress note). Resident #1's progress notes date 08/23/23 revealed a referral sent to the APRN for psychological evaluation for Resident #1 because his FM stated during the care plan meeting that resident calls her in the evenings with more agitation. Resident #1 stated he had been getting frustrated with roommate but did not want to move at that time. Residents #1's progress notes date 10/02/23 revealed Resident #1 was heard with a raised voice in his room and when room was entered Resident #1 was standing beside his roommate's bed and Resident #1's roommate (now discharged ) was yelling back to Resident #1 who had a pair of scissors in his hand turned backwards holding, the handle with scissor part against the back side of his forearm. Resident #1 was re-directed to go with staff to sit in lobby. There was no injury to either Resident #1 or his roommate. Resident #1 was placed on 1-1 staff observation. Resident #1 changed his story about the events of the altercation several times. Resident #1 first reported he had not done anything, and he was trying to defend himself and did not get near the other resident and then stated he did try to stab the other resident. Resident #1 continued to change the version of altercation. Resident #1's progress notes date 10/03/23 revealed Resident #1 has had several episodes of telling staff that he was, going to finish the job with the white man and talked of cutting his throat. The progress note revealed that staff explained that Resident #1 couldn't do that, and the fight was over, and Resident #1 and the other man were in different rooms on opposite sides of the building. Resident #1 told the staff, I have a lot of patience and can wait. Staff progress note revealed, He [Resident #1] just grinned at me. Additional progress note on the same date revealed that the APRN did see Resident #1 as a threat. Resident #1's progress note dated 10/17/23 revealed that during Bingo Resident #1 was hit by a 3rd resident as Resident #1 was going towards a 2nd resident instigating a fight with the 2nd resident who flipped off Resident #1. As Resident #1 was instigating a fight with the 2nd resident, Resident #1 had his hands up defending himself from the 3rd resident. Additional progress notes from the same date reveal APRN recommended Resident #1 not to be allowed to go to group activities at that time and If he went to dining hall that he not be seated near other male resident and staff needed to be close by and if any further incidents, Resident #1 should be discharged . Resident #1's progress note dated 11/11/23 revealed Resident #1 was waiting to get coffee and Resident #2 moved Resident #1's coffee cup. Resident #2 yelled he has rights and was defending other residents. Resident #1 slapped Resident #2 in the back of his head. Resident #1's psychiatric progress note dated 10/17/23 revealed Resident #1 told the APRN he is not a candy ass and felt justified in defending himself and would do it again. Resident #1 admitted he was stubborn and had a history of fighting. Resident #1 said he understands the consequences of further incidents but will, not back down if he is feeling bullied. Progress note reveals that he told him former roommate he was, good with scissors after Resident #1 was in a verbal altercation with his former roommate and Resident #1 was holding scissors. Interview on 12/14/23 at 1:46 pm with the APRN revealed Resident#1 is not usually an instigator but during her conversations with Resident #1 he has said that he is not a [NAME] and if someone picks on him, he will give it back to them. He is impulsive at times and if he gets scissors again, she does not know what he will do with them. She cannot say for sure that he would not hurt anyone because of his impulsivity. She said that she sees that he has an enjoyment in these physical alterations. Interview on 12/14/23 at 3:58 pm with the Resident #2 about his altercation with Resident #1 revealed he feels trepidation getting coffee in the morning because he knows all those people are lined up for coffee and he feels exposed. He revealed he stays in his room mostly and is hyper aware of his surroundings. Interview on 12/15/23 at 1:11 pm with the ADON revealed that Resident #1's care plan should have been updated with the resident-to-resident altercations and behavioral issues because the care plan would talk about the resident and what the resident needed to be successful for themselves and other residents in the facility . Behavioral interventions should be a part of the care plan to prevent altercations between residents and to keep residents safe. It was important that everyone had the same knowledge and there should be continuity of care, so the resident gets what they need to be successful. If care plans are not up to date there are interruption of care, safety issues, and residents could be injured or die. The ADON said she had never received resident to resident altercations training at the facility. She revealed that that there was no training on identifying resident triggers. She revealed that 99% of the time there are no problems with resident behaviors but there is a 1% chance a resident could, fly off the handle and It was absolutely a problem that they were not trained in the resident-to-resident altercation policy. The ADON revealed she had only received abbreviated in-service trainings that consisted of a piece of paper with a sentence at the top of the in-service informing them either to remember to do or not to do something and to sign she had read the statement. She revealed that, while at the facility, she had never received an in-service with the entire facility resident to resident in-service policy with a discussion of how to proceed in different situations with an opportunity to ask questions. Interview on 12/15/23 at 1:51 pm with the CMA A revealed she did not feel she was trained or well prepared for the resident-to-resident altercations and had not received any resident-to-resident altercation training. She revealed it would have been important to have the training to look for the signs needed for intervention, and It was detrimental to the residents because the residents could have been seriously injured or could die without the proper interventions. She said she had access to the residents' care plans, and it would have been helpful for her to see behavioral interventions. She revealed staff need to be informed about behavioral and resident-to-resident altercations and interventions to be aware of what to look for and know what to do. She revealed that the facility has a lot of residents with behavioral issues that are not currently in the care plan and did not feel the care plans are up to date. She felt it was a recipe for disaster to have so many residents with behaviors and care plans that are not current. She feels that if the triggers that cause the behavior are not care planned with interventions behaviors could escalate to altercations harming the residents . Interview on 12/15/23 at 2:05 pm with Resident #1's Medical Director revealed he does not have a recollection if the facility called him and informed him of the resident-to-resident altercations at the facility because he gets so many telephone calls. He said he had no concerns about resident safety at the facility. He said he is marginally involved in resident care plans but revealed that resident-to-resident altercations and behaviors should be included in care plan to keep residents safe, and It could be detrimental to the safety of the residents if behaviors and resident-to-resident altercations are not included in the care plan . Interview on 12/15/23 at 2:25 pm with the DON who revealed she has been working at the facility for three days and she is responsible for the care plans and care plans are in place to identify specific interventions needed for the process of caring for the residents. The DON revealed that care plans are the process of learning about the resident and a guideline for individualized care. The DON revealed it is important to include resident-to-resident alterations in a care plan because it is detrimental to the resident if the staff did not have a guideline to care for the resident. The DON revealed harm could come to residents if the staff did not know how to approach someone with behaviors and someone could get hurt or injured or could die if the facility does not document how to proceed to protect the residents . Interview on 12/15/23 at 3:25 pm with CNA B who revealed she had access to Resident #1's care plan and she looked at it and She knew that Resident #1 had past behaviors but did not see that his behavior's had been included in his care plan. She revealed she thinks it is important to have information on resident behaviors in a care plan so staff can know at the beginning what behaviors to look for. She revealed that if Resident #1 had been care planned with interventions staff might have distanced him from other residents. She said she witnessed the coffee incident between Resident #1 and Resident #2, but she never saw the incident listed in Resident #1's care plan. It might have been helpful to include in the care plan to watch Residents #1 and #2 when they were in the dining room. She revealed there could be resident harm if the staff are not aware of resident behaviors . Interview on 12/15/23 at 4:08 pm with the ADM who revealed she has been at the facility for 30 days and the ADON is receiving training in care planning and the DON and ADM are responsible for care planning. The ADM revealed that care plans are important because they paint the picture of what the residents' needs are and where they need to go to have their needs meet. If a resident does not have a complete care plan the facility cannot meet the needs of the resident and it impacts the wellbeing of all the residents. The ADM revealed that by not having a care plan for resident-to-resident altercations, it could impact the resident involved in the altercations and other residents as well. The ADM revealed the resident behaviors and resident to resident altercations should have been included in the care plan . Review of facility resident-to-resident altercations policy dated 2016. All altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Policy interpretation and implementation 1. The facility will monitor residents for aggressive/ inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. 2. If two residents are involved in an altercation staff will: a. separate the residents, and institute measures to calm the situation; b. identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; c. notify each residen representative and attending physician of the incident; d. review the events with the nursing supervisor and director of nursing and possible measures to try to prevent additional incidents; e. Consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problems; f. make any necessary changes in the care plan approaches to any and all of the involved individuals; g. document in the resident clinical record all interventions and their effectiveness; h. consult psychiatric services is needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team; i. complete a report of incident/accident form and document the incident, findings, needed corrective measures taken and the residents medical/clinical record; j. if, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and k. report incidents, findings, and corrective measures to appropriate agencies as outlined in our facilities abuse reporting policy. Review of Facility Abuse, Neglect, and Exploitation policy dated 10/2023 revealed the facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Policy interpretation and implementation 1. The facility will develop and implement written policies and procedures that; a. Prohibit and prevent abuse, neglect, and exploitation of residence and misappropriation of resident property; and b. established policies and procedures to investigate any such allocations; and c. include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of residence property, reporting procedures and dementia management and resident abuse prevention and d. established coordination with the QAPI program. 2. The facility will designate an abuse prevention of coordinator in the facility who is responsible for reporting allegations or suspected abuse, to collect, exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight with supervision of staff to ensure that its policies are implemented as written. Abuse Prohibition Plan Components 1. Screening B. prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. a. An assessment of the individual's functional and mood/ behavior status, medical acuity, and special needs will be reviewed prior to admission. 2. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment and equipment. Employee Training A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in- services and/or assigned web- based trainings as needed. C. Training topics will include; a. Aggressive and/or catastrophic reactions of residence; b. wandering or elopement- type behaviors; c. resistance to care; d. Outbursts or yelling out; and e. Difficulty to adjusting to new routine or staff. I. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves. D. Ensuring as assessment of the resources needed to provide care and services to all residents is included in the facility assessment; E. The identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors with might lead ot conflict or neglect; Identification of abuse, neglect, and exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse -mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. The includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to; 1. Resident, staff, or family report of abuse, 2. Verbal abuse of a resident overheard, 3. Physical abuse of a resident observed, 4. Sudden or unexplained changes in behavior and/or activities such as a fear of a person or place, or feelings of guilt or shame. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation examples include but are not limited to; A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed and G. Revision to the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change because of an incident of abuse. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. No later than 24 hours of the events that [NAME] the allegation do not involve abuse and do not result in serious bodily injury. 2. Ensuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safe and open communication in the work environment prohibiting retaliation against any employee who reports a suspicious of a crime. The facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint. 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following; a. Analyzing the occurrences(s) to determine why abuse, neglect, occurred and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training staff on changes made and demonstration of staff competency after training in implemented; d. Identification of staff responsibility for implementation of corrective action; e. The expected date for implementation, and f. Identification of staff responsible for monitoring the implementation for the plan. This was determined to be an Immediate Jeopardy (IJ) on 12/14/2023 at 6:21 pm. The ADM and the DOW were notified. The ADM as provided with the IJ template on 12/14/2023 at 6:21 pm. On 12/14/2023 an abbreviated survey was initiated at the facility. On 12/14/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy to resident health and safety. The following POR was accepted on 12/15/23 at 1:36 PM: The notification of Immediate Jeopardy states as follows: F600- Free from Abuse/Neglect Action (Immediate): Resident #1 has been placed on 1:1 until resident is deemed no longer a risk to self and/or others by one or more of the following: Interdisciplinary team (IDT) which must, at a minimum, include the Administrator and the Director of Nursing, and may also include the Social Services Director and/or other IDT members as appropriate, Medical Director or designated provider, Psychiatric services, after evaluation, treatment, and release from a psychiatric or medical facility and/or Psychiatric services consulted prior to removing a resident from 1:1 supervision. This may be done in person or via telehealth services. Resident #1's care plan will be updated immediately by the Clinical Company Leader to reflect the resident's history of aggressive events. Person(s) Responsible: Administrator and/or Director of Nursing Start Date: 12/14/2023 Completion Date: 12/14/2023 Action (Identification): All residents with behaviors documented as an event and/or in the progress notes for the previous 90 days will be reviewed to ensure care plans are in place and interventions are present. If any behavioral events are identified without care plans and interventions these will be placed immediately. Person(s) Responsible: Director of Nursing and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 Action (Prevention): Administrator, Director of Nursing, Assistant Director of Nursing will be educated by the Clinical Company Leader about care planning behavioral events with meaningful interventions. Person(s) Responsible: Clinical Company Leader Start Date: 12/14/2023 Completion Date: 12/14/2023 Action (Prevention): Education provided to all staff regarding-- Abuse and Neglect: Types of abuse and when/who to report to (immediately & the administrator- abuse coordinator) Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene and deescalate. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. Nursing Staff (facility and agency) will be educated on the resident profile that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. Staff, facility and agency, assigned to the specific education, will complete prior to working their next shift. Person(s) Responsible: Administrator and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 Action (Monitoring): During daily meeting, x5 days weekly, Monday-Friday, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following behavioral events. If an incident occurs over the weekend, the Administrator and/or Director of Nursing will be notified by staff (staff will know to immediately notify through the education noted above), and interventions will be discussed and implemented, next shift staff will be notified of the interventions through report. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 Action (QAPI): Medical Director informed of the Immediate Jeopardy for F-600 and [NAME] Nursing and Rehabilitation Center's plan to remove the immediacy. At this time no other recommendations have been made. Person(s) Responsible: Administrator Start Date: 12/14/2023 Completion Date: 12/14/2023 Action (Prevention): Education provided to all staff regarding-- Abuse and Neglect: Types of abuse and when/who to report to (immediately & the administrator- abuse coordinator) Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene and deescalate. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. Nursing Staff (facility and agency) will be educated on the resident profile that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. Staff, facility and agency, assigned to the specific education, will complete prior to working their next shift. Person(s) Responsible: Administrator and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 The Surveyor monitored the POR on 12/15/23 as followed: Interview on 12/15/23 at 3:24 pm with the RDO reflected that Resident #1 had 1- 1 supervision from 6:00 pm on 12/14/23 until he was discharged with his son on 12/15/23 at 2:00 pm. Resident #1's care plan was updated prior to his discharge to reflect the resident's history of aggressive events. On 12/15/23 reviewed care plans for all residents with behaviors documented as an event and/or in the progress notes for the previous 90 days and confirmed interventions were present in the care plans. During interviews on 12/15/23 from 1:11 PM - 4:10 PM with the housekeeping supervisor, the ADON, a CNA, a CMA , and an LVN revealed they all stated they were in-serviced before their shifts on reporting abuse and were able to correctly list types of abuse and when/who to report to, how to recognize behaviors and how to intervene and deescalate residents' behaviors. They confirmed they were educated on the resident profile that contained the updated care plans and interventions following resident behavioral events. They stated all behaviors and interventions to behaviors should be resident care plans. During interview on 12/15/23 from 1:14 PM - 2:22 PM with four residents revealed they felt safe at the facility and had no concerns. Reviewed 12/15/23 in-service with the ADM, DON, and ADON regarding care planning meaningful behavioral interventions. Reviewed staff in-service dated 12/14/23 reflected staff were treained on using resident profile, resident to resident altercations, and abuse and neglect. Reviewed staff pre and posttest for the above in-services . Reviewed 12/14/23 QAPI notes with Medical Director. The ADM and DON were informed the Immediate Jeopardy was removed on 1215/23 at 5:33 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 16 residents (Residents #1 and #3) reviewed for care plans. Resident #1 and Resident #3 did not have completed comprehensive care plans for resident-to-resident behaviors and resident-to-resident altercations. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 6:21 pm. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having their care needs met. Findings included: Record review of Resident #1's face sheet undated revealed an [AGE] year-old male, on hospice, who initially admitted to the facility on [DATE] with a diagnosis including chronic obstructive pulmonary disease , heart failure, dementia, MDD, cognitive communication deficit, and episodic panic disorder . Record review of Resident #1's MDS dated [DATE] revealed a BIMS of 9 suggesting moderate cognitive impairment. He ambulated with a walker and a motorized wheelchair. Record review of Resident #1's care plan revealed no care plan or interventions for behaviors or resident-to-resident altercations. Record review of Resident #3's face sheet undated revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and with return date of 12/05/23 and a diagnosis including metabolic encephalopathy (a problem in the brain. It is caused by a chemical imbalance in the blood), congestive heart failure, disruptive mood dysregulation disorder , impulse disorder, and conduct disorder. Record review of Resident #3's MDS dated [DATE] revealed a BIMS of 15 suggesting resident was cognitively intact. Record review of Resident #3's care plan revealed no care plan or interventions for resident-to-resident behaviors or altercations. Resident #1's progress note dated 04/18/2023 revealed a report of Resident #1 standing by his roommate's bed and stating that he is tired of the roommate yelling and if staff did not move the roommate, Resident #1 would hit him or push him out of the bed. Resident #1 stated, I am telling you if you leave him in here, he will be hurt. Resident #1's progress note dated 08/17/23 revealed Resident #1 attended 3-5 activities weekly and had some behavior issues with other residents (no description of behaviors included in progress note). Resident #1's progress notes date 08/23/23 revealed a referral sent to the APRN for psychological evaluation for Resident #1 because his daughter stated during the care plan meeting that resident calls her in the evenings with more agitation. Resident #1 stated he had been getting frustrated with roommate but did not want to move at that time . Residents #1's progress notes date 10/02/23 revealed Resident #1 was heard with a raised voice in his room and when room was entered Resident #1 was standing beside his roommate's bed and Resident #1's roommate (now discharged ) was yelling back to Resident #1 who had a pair of scissors in his hand turned backwards holding, the handle with scissor part against the back side of his forearm. Resident #1 was re-directed to go with staff to sit in lobby. There was no injury to either Resident #1 or his roommate. Resident #1 was placed on 1-1 staff observation. Resident #1 changed his story about the events of the altercation several times. Resident #1 first reported he had not done anything, and he was trying to defend himself and did not get near the other resident and then stated he did try to stab the other resident. Resident #1 continued to change the version of altercation. Resident #1's progress notes date 10/03/23 revealed Resident #1 has had several episodes of telling staff that he was, going to finish the job with the white man and talked of cutting his throat. The progress note revealed that staff explained that Resident #1 couldn't do that, and the fight was over, and Resident #1 and the other man were in different rooms on opposite sides of the building. Resident #1 told the staff, I have a lot of patience and can wait. Staff progress note revealed, He [Resident #1] just grinned at me. Additional progress note on the same date revealed that the APRN did see Resident #1 as a threat . Resident #1's progress note dated 10/17/23 revealed that during Bingo Resident #1 was hit by a 3rd resident as Resident #1 was going towards a 2nd resident instigating a fight with the 2nd resident who flipped off Resident #1. As Resident #1 was instigating a fight with the 2nd resident, Resident #1 had his hands up defending himself from the 3rd resident. Additional progress notes from the same date reveal APRN recommended Resident #1 not to be allowed to go to group activities at that time and if he went to dining hall that he not be seated near other male resident and staff needed to be close by and if any further incidents, Resident #1 should be discharged . Resident #1's psychiatric progress note dated 10/17/23 revealed Resident #1 told the APRN he is not a candy ass and felt justified in defending himself and would do it again. Resident #1 admitted he was stubborn and had a history of fighting. Resident #1 said he understands the consequences of further incidents but will, not back down if he is feeling bullied. Progress note reveals that he told him former roommate he was, good with scissors after Resident #1 was in a verbal altercation with his former roommate and Resident #1 was holding scissors . Resident #3's progress note dated 10/24/23 revealed Resident #3 was angry about another male resident because Resident #3 felt he stayed too long in the shower. Later Resident #3 saw the other resident on the house phone and went up behind him and tried to hit him because Resident #3 wanted to use the phone. Review of Resident #3's event report dated 10/10/23 revealed Resident #3 became upset when he witnessed another resident throw water in the face of a staff member and Resident #3 used his cane to hit the resident in resident's face causing the resident to bleed and the resident was sent to the hospital. Interview on 12/14/23 at 1:46 pm with the APRN revealed Resident#1 is not usually an instigator but during her conversations with Resident #1 he has said that he is not a [NAME] and if someone picks on him, he will give it back to them. He is impulsive at times and if he gets scissors again, she does not know what he will do with them. She cannot say for sure that he would not hurt anyone because of his impulsivity. She said that she sees that he has an enjoyment in these physical alterations. Interview on 12/15/23 at 1:11 pm with the ADON revealed that Resident #1's care plan should have been updated with the resident-to-resident altercations and behavioral issues because the care plan would talk about the resident and what the resident needed to be successful for themselves and other residents in the facility . Behavioral interventions should be a part of the care plan to prevent altercations between residents and to keep residents safe. It was important that everyone had the same knowledge and there should be continuity of care, so the resident gets what they need to be successful. If care plans are not up to date there are interruption of care, safety issues, and residents could be injured or die. The ADON said she had never received resident to resident altercations training at the facility. She revealed that that there was no training on identifying resident triggers. She revealed that 99% of the time there are no problems with resident behaviors but there is a 1% chance a resident could, fly off the handle and It was absolutely a problem that they were not trained in the resident-to-resident altercation policy. The ADON revealed she had only received abbreviated in-service trainings that consisted of a piece of paper with a sentence at the top of the in-service informing them either to remember to do or not to do something and to sign she had read the statement. She revealed that, while at the facility, she had never received an in-service with the entire facility resident to resident in-service policy with a discussion of how to proceed in different situations with an opportunity to ask questions. Interview on 12/15/23 at 1:51 pm with the CMA revealed she did not feel she was trained or well prepared for the resident-to-resident altercations and had not received any resident-to-resident altercation training. She revealed it would have been important to have the training to look for the signs needed for intervention, and It was detrimental to the residents because the residents could have been seriously injured or could die without the proper interventions. She said she had access to the residents' care plans, and it would have been helpful for her to see behavioral interventions. She revealed staff need to be informed about behavioral and resident-to-resident altercations and interventions to be aware of what to look for and know what to do. She revealed that the facility has a lot of residents with behavioral issues that are not currently in the care plan and did not feel the care plans are up to date. She felt it was a recipe for disaster to have so many residents with behaviors and care plans that are not current. She feels that if the triggers that cause the behavior are not care planned with interventions behaviors could escalate to altercations harming the residents . Interview on 12/15/23 at 2:05 pm with Medical Director revealed he does not have a recollection if the facility called him and informed him of the resident-to-resident altercations at the facility because he gets so many telephone calls. He said he had no concerns about resident safety at the facility. He said he is marginally involved in resident care plans but revealed that resident-to-resident altercations and behaviors should be included in care plan to keep residents safe, and It could be detrimental to the safety of the residents if behaviors and resident-to-resident altercations are not included in the care plan . Interview on 12/15/23 at 2:25 pm with the DON who revealed she has been working at the facility for three days and she is responsible for the care plans and care plans are in place to identify specific interventions needed for the process of caring for the residents. The DON revealed that care plans are the process of learning about the resident and a guideline for individualized care. The DON revealed it is important to include resident-to-resident alterations in a care plan because it is detrimental to the resident if the staff did not have a guideline to care for the resident. The DON revealed harm could come to residents if the staff did not know how to approach someone with behaviors and someone could get hurt or injured or could die if the facility does not document how to proceed to protect the residents . Interview on 12/15/23 at 3:25 pm with CNA who revealed she had access to Resident #1's care plan and she looked at it and She knew that Resident #1 had past behaviors but did not see that his behavior's had been included in his care plan. She revealed she thinks it is important to have information on resident behaviors in a care plan so staff can know at the beginning what behaviors to look for. She revealed that if Resident #1 had been care planned with interventions staff might have distanced him from other residents. She revealed there could be resident harm if the staff are not aware of resident behaviors . Interview on 12/15/23 at 4:08 pm with the ADM who revealed she has been at the facility for 30 days and the ADON is receiving training in care planning and the DON and ADM are responsible for care planning. The ADM revealed that care plans are important because they paint the picture of what the residents' needs are and where they need to go to have their needs meet. If a resident does not have a complete care plan the facility cannot meet the needs of the resident and it impacts the wellbeing of all the residents. The ADM revealed that by not having a care plan for resident-to-resident altercations, it could impact the resident involved in the altercations and other residents as well. The ADM revealed the resident behaviors and resident to resident altercations should have been included in the care plan . Facility Care plans, Comprehensive Person- Centered policy dated December 2020 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally - competent and trauma-informed. Policy interpretation and implementation: 1. The interdisciplinary team in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person- centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The interdisciplinary team may include but not limited to: a. the attending physician b. a registered nurse who has responsibility for the resident c. a nurse aide who has responsibility for the resident d. a member of the food and nutrition services staff e. the resident and the resident's legal representative f. other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. The care planning process will include an assessment of the resident's strengths and needs. The comprehensive, person-centered care plan will include measurable objectives and time frames. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical/ mental, and psychosocial well-being. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights including the right to refuse treatment. Incorporate identified problem areas. Incorporate risk factors associated with identified problems and reflect treatment goals, timetables, and objectives in measurable outcomes. Identify the professional services that are responsible for each element of care. Aid in preventing or reducing decline in the resident's functional status and or functional levels. Enhance the optimal functioning of the resident by focusing on a rehabilitation program and reflect currently reorganize standards of practice for problem areas and conditions. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the end point of an interdisciplinary process. No single discipline can manage an approach in isolation and residence physician, or Primary Health provider is integral to the process. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making. When possible, interventions address the underlying sources of the problem areas not just addressing only symptoms or triggers. Care planning individual symptoms in isolation may have little if any benefit for the resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. The interdisciplinary team must review, update the residence diagnosis within the clinical software system when a diagnosis is resolved, when a new diagnosis is established and reviewed at least quarterly in conjunction with the MDS assessment schedule. The interdisciplinary team must review and update the care plan when there has been a significant change to the residence condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly in conjunction with the required MDS assessment. This was determined to be an Immediate Jeopardy (IJ) on 12/14/2023 at 6:21 pm. The ADM and the DOW were notified. The ADM as provided with the IJ template on 12/14/2023 at 6:21 pm. On 12/14/2023 an abbreviated survey was initiated at the facility. On 12/14/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy to resident health and safety. The following POR was accepted on 12/15/23 at 1:36 PM: The notification of Immediate Jeopardy states as follows: F600- Free from Abuse/Neglect Action (Immediate): Resident #1 has been placed on 1:1 until resident is deemed no longer a risk to self and/or others by one or more of the following: Interdisciplinary team (IDT) which must, at a minimum, include the Administrator and the Director of Nursing, and may also include the Social Services Director and/or other IDT members as appropriate, Medical Director or designated provider, Psychiatric services, after evaluation, treatment, and release from a psychiatric or medical facility and/or Psychiatric services consulted prior to removing a resident from 1:1 supervision. This may be done in person or via telehealth services. Resident #1's care plan will be updated immediately by the Clinical Company Leader to reflect the resident's history of aggressive events. Person(s) Responsible: Administrator and/or Director of Nursing Start Date: 12/14/2023 Completion Date: 12/14/2023 Action (Identification): All residents with behaviors documented as an event and/or in the progress notes for the previous 90 days will be reviewed to ensure care plans are in place and interventions are present. If any behavioral events are identified without care plans and interventions these will be placed immediately. Person(s) Responsible: Director of Nursing and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 Action (Prevention): Administrator, Director of Nursing, Assistant Director of Nursing will be educated by the Clinical Company Leader about care planning behavioral events with meaningful interventions. Person(s) Responsible: Clinical Company Leader Start Date: 12/14/2023 Completion Date: 12/14/2023 Action (Prevention): Education provided to all staff regarding-- Abuse and Neglect: Types of abuse and when/who to report to (immediately & the administrator- abuse coordinator) Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene and deescalate. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. Nursing Staff (facility and agency) will be educated on the resident profile that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. Staff, facility and agency, assigned to the specific education, will complete prior to working their next shift. Person(s) Responsible: Administrator and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 Action (Monitoring): During daily meeting, x5 days weekly, Monday-Friday, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following behavioral events. If an incident occurs over the weekend, the Administrator and/or Director of Nursing will be notified by staff (staff will know to immediately notify through the education noted above), and interventions will be discussed and implemented, next shift staff will be notified of the interventions through report. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 Action (QAPI): Medical Director informed of the Immediate Jeopardy for F-600 and [NAME] Nursing and Rehabilitation Center's plan to remove the immediacy. At this time no other recommendations have been made. Person(s) Responsible: Administrator Start Date: 12/14/2023 Completion Date: 12/14/2023 Action (Prevention): Education provided to all staff regarding-- Abuse and Neglect: Types of abuse and when/who to report to (immediately & the administrator- abuse coordinator) Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene and deescalate. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. Nursing Staff (facility and agency) will be educated on the resident profile that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. Staff, facility and agency, assigned to the specific education, will complete prior to working their next shift. Person(s) Responsible: Administrator and/or Designee Start Date: 12/14/2023 Completion Date: 12/15/2023 The Surveyor monitored the POR on 12/15/23 as followed: Interview on 12/15/23 at 3:24 pm with the RDO reflected that Resident #1 had 1- 1 supervision from 6:00 pm on 12/14/23 until he was discharged with his son on 12/15/23 at 2:00 pm. Resident #1's care plan was updated prior to his discharge to reflect the resident's history of aggressive events. On 12/15/23 reviewed care plans for all residents with behaviors documented as an event and/or in the progress notes for the previous 90 days and confirmed interventions were present in the care plans. During interviews on 12/15/23 from 1:11 PM - 4:10 PM with the housekeeping supervisor, the ADON, a CNA, a CMA , and an LVN revealed they all stated they were in-serviced before their shifts on reporting abuse and were able to correctly list types of abuse and when/who to report to, how to recognize behaviors and how to intervene and deescalate residents' behaviors. They confirmed they were educated on the resident profile that contained the updated care plans and interventions following resident behavioral events. They stated all behaviors and interventions to behaviors should be resident care plans. During interview on 12/15/23 from 1:14 PM - 2:22 PM with four residents revealed they felt safe at the facility and had no concerns. Reviewed 12/15/23 in-service with the ADM, DON, and ADON regarding care planning meaningful behavioral interventions. Reviewed staff in-service dated 12/14/23 reflected staff were treained on using resident profile, resident to resident altercations, and abuse and neglect. Reviewed staff pre and posttest for the above in-services . Reviewed 12/14/23 QAPI notes with Medical Director. The ADM and DON were informed the Immediate Jeopardy was removed on 1215/23 at 5:33 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.