**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 7 of 12 (Resident #'s 2, 3, 4, 5, 6, 7, and 8) residents reviewed for abuse, neglect, and misappropriation of property. 1.The facility did not implement their policies and procedures related to interventions for resident-to-resident altercations after Resident #1 hit Resident #2 twice on the arm. Resident #1 then hit and spit on Resident #3, 30 minutes later. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:37 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because (e.g.) all staff had not been trained on Abuse/Neglect, Resident-to-Resident Altercations, and 1:1 monitoring of the aggressors. 2.The facility did not implement their policies and procedures related to investigation and reporting allegations of misappropriation of property when Activity Director A: * took money via cash app from Resident #4 in the amount of $1,150.00 dollars; * took cash money from Resident #5 in the amount of $100.00 dollars. * attempted to take cash money from Resident #6 in the amount of $100.00 dollars. * took cash money from Resident #7 in the amount of $25.00 dollars. * took cash money from Resident #8 in the amount of $20.00 dollars. This failure could place residents at risk for abuse, neglect, misappropriation of property, and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of the facility's policy dated [DATE] titled: Abuse Prevention Program 2. Out resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by center management. Findings of abuse investigations will also be reported. Policy interpretation and implementation: 3. Develop and implement policies and procedures to aid our center in preventing abuse, neglect, or mistreatment of our residents. 7. Protect residents during abuse investigations. Investigations: 6. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Response: 1. C. Should the results indicate that abuse occurred, appropriate authorities will be notified. 1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia without behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and pseudobulbar affect (inappropriate laughing or crying). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated residents' cognition was moderately impaired. She required extensive assistance of 1 staff for ADL care. Record review of Resident #1's care plan dated [DATE] revealed she had behavioral symptoms as evidenced by cussing at someone not there and hears voices. Interventions were to keep distance between resident and others during delusional periods. Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia without behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and hypertension (high blood pressure). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, which indicated residents' cognition was mildly impaired. he required limited assistance of 1 staff for ADL care. Record review of Resident #2's care plan dated [DATE] revealed he had cognitive loss/dementia as. Interventions were to approach in a calm manner. Record review of Resident #3's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. His diagnoses included hepatic encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood), psychotic disorder (loss of contact with reality), and viral hepatitis (infection that causes liver inflammation). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated residents' cognition was severely impaired. he required supervision to limited assistance of 1 staff for ADL care. Record review of Resident #3's care plan dated [DATE] revealed he had behavioral symptoms and has socially inappropriate/disruptive behavioral symptoms. Interventions were to assess whether the behavior endangers the resident and/or others, intervene if necessary. During an interview and observation on [DATE] beginning at 10:38 AM CNA D observed about to exit the secured unit. She said LVN N had told her she no longer had to do 1:1 monitoring with Resident #1. She said Resident #1 rolled into the dining room on Sunday [DATE] at 04:45 PM and hit Resident #2 twice on the right arm. She said Resident #1 and Resident #2 were immediately separated. She said a little while later Resident #1 rolled up to Resident #3 in the hallway of the secured unit and hit and spit on Resident #3. She said sometime after the second incident Resident #1 was put on 1:1 monitoring. She said she came in at 06:00 AM this morning on [DATE] and was told she no longer had to do 1:1 monitoring with Resident #1 so she was going to ask the ADON. During an interview on [DATE] at 10:50 AM CNA O said she works for an agency and had Been coming to this facility for about 3 weeks. She said she works All over the building and that was her 2nd day on the secured unit. She said there is always 2 CNAs on the unit. She said she had not received any in-services or training before working on the secured unit. She said yesterday [DATE] Resident #1 hit and spit on 2 residents. Said she was on the war path, and she went over and hit Resident #2 on the shoulder twice then went over to Resident #3 and hit him and spit on him. She said Resident #1 then sat at the table and cussed everyone out. She said on [DATE] her behavior was horrible, but that was her behavior sometimes. She said she reported to her charge nurse and wrote out witness statements. She said that is the only altercation she had witnessed. During an interview on [DATE] at 11:08 AM LVN N Said Resident #1 has sun downers in the evenings and said Resident #1 hit Resident #2 twice on the right arm and then went back and hit Resident #3 and spit on him in the hallway. She said Resident #1 gets very delusional in the evenings but has never hit anyone before [DATE]. She said the ADON asked her what Resident #1 was doing that morning, she said she was asleep. She said the ADON told her to take Resident #1 off 1:1 monitoring that morning since Resident #1 was not having any behaviors. Then the ADON told the CNA to keep Resident #1 on 1:1. She said the ADON came back and told her since state was in the building to go ahead and keep Resident #1 on 1:1 monitoring. She said she did not know if the situation has been reported to the administrator. She said she had received in-servicing over the last several weeks regarding resident-to-resident altercations. She said 2 CNAs were to be on the secured unit at all times. During an interview on [DATE] at 11:20 AM the DON said she was notified that Resident #1 had hit Resident #2 and spit on Resident #3. She said this behavior is out of the normal for Resident #1. She said she was called and told of the incident but was not in the building at the time. She said she assumed Resident #1 was put on 1:1 immediately. During an interview on [DATE] at 11:33 AM the ADON said she was called by the 6p-6a nurse and told of the incident and instructed the nurse to put Resident #1 on 1:1 monitoring on [DATE] at 06:16 PM. She said there was some confusion and she had told LVN N they would discuss taking resident off of 1:1 on the morning of [DATE]. During an interview on [DATE] at 02:52 PM LVN P said at 03:20 PM on [DATE] Resident #1 rolled up to the table and hit Resident #2 on the arm two times. She said staff separated and then 30 minutes later she rolled up to Resident #3 in the hallway hit him and spit on him. She said she called the family, MD, DON. She said the DON said she would call the Current Administrator and report it to her. She said the DON did not give her any instructions for any interventions at that time, she said she was only told to separate, assess, and notify. She said after she gave report to the oncoming nurse, that nurse called the ADON, and that nurse was instructed by the ADON to place resident on 1:1 supervision at 06:16 PM. Said she works 6am-6pm and the incident happened at 03:20 PM. LVN P said she left at 06:35 PM and Resident #1 was not on 1:1 monitoring. During an interview on [DATE] at 1:30 PM the Current Administrator She said she had been notified on Sunday [DATE] by the DON that Resident #1 had hit 2 residents on the secured unit. She said she did not feel like there was willful intent due to Resident #1's cognition, so she did not feel like she had to report it as abuse. Record review of event report dated [DATE] at 04:45 PM reveal per CNA, Resident #1 was in a wheelchair and rolled up to another resident working on a crossword puzzle in the dining room and proceeded to hit the resident in the right arm. Resident #1 also began cussing at Resident #2. The two residents were immediately separated. No injuries noted to either resident. Resident #1 was also involved in an incident following the previous incident in which she was rolling to her room and spit on another resident and attempted to hit the other resident. The two residents were immediately separated. The event report also revealed that physical and verbal behavioral symptoms were exhibited by Resident #1 occurred daily. Interventions documented were redirection and separation. Record review of event report dated [DATE] at 03:46 PM revealed per CNA Resident #2 was sitting at the dining room table reading a book when Resident #1 in a wheelchair rolled up next to him and proceeded to hit him in his right arm. Resident #2 held up his hands when he was being struck. Staff immediately separated the two residents. Resident #2 was assessed with no injuries noted. Resident #2 denied any pain or discomfort. Record review of event report dated [DATE] at 06:30 PM revealed Resident #3 was standing in the hallway and was approached by another resident who spit on him and attempted to hit him. Residents were separated immediately. No injuries noted to this resident. Record review of 15-minute checks dated [DATE] revealed 1:1 monitoring of Resident #1 began at 8:00 PM on [DATE]. Record review of facility policy dated [DATE] titled Resident-to-Resident Altercations. 2. If two residents are involved in an altercation, staff will: D. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents. F. Make any necessary changes in the care plan approaches to any or all of the involved individuals. G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as 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. K. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. The facility Administrator was notified on [DATE] at 05:37 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on [DATE] at 12:14 PM and included: Action: Resident #1 has been placed on 1:1 (as of [DATE]). Resident #1 will remain on 1:1 until deemed no longer a danger to self or others by Physician/Physician Extender/Psych Services and discussed with the IDT- Administrator, Director of Nursing, Social Services Director and MDS Coordinator. Resident #1 and Resident #2 received head to toe assessment by the Director of Nursing and a safe survey performed by the Assistant Director of Nursing. Resident #3 is out of the facility on an unrelated matter at this time. No concerns with skin or psychosocial wellbeing noted during assessments/surveys. Responsible Person(s): Director of Nursing and Assistant Director of Nursing Date: [DATE] by 5PM Action: Activity Director was suspended pending investigation. Responsible Person(s): Administrator Date: [DATE] Action: Self reports submitted to CII on [DATE] for the resident-to-resident altercation and the misappropriation allegations. Facility investigations have been implemented. Responsible Person(s): Administrator Date: [DATE] Action: Police notified of allegations. Responsible Person(s): Administrator Date: [DATE] Action: Progress notes and event reports reviewed for all residents for the previous 30 days to identify any other resident-to-resident abuse that the facility failed to implement the abuse/neglect policy and/or resident-to-resident policy. No other concerns identified. Responsible Person(s): Clinical Company Leader and Survey Resource Date: [DATE] by 6PM Action: The Director of Nursing reviewed the incident and proper interventions have been implemented. Resident #1 has been placed on 1:1 and will remain on 1:1 until deemed safe to self and others. Responsible Person(s): Director of Nursing Date: [DATE] by 6PM Action: Resident safe surveys misappropriation performed on all residents. Resident safe surveys abuse/neglect performed on all residents. Any residents unable to answer for abuse/neglect survey had a skin assessment performed. Responsible Person(s): Administrator, Director of Nursing, and/or Designee Date: [DATE] by 12PM Action: Residents were educated on not giving money to any staff other than the designated employee for resident shopping. Activity Director #2 received education on when purchasing items for residents the receipt must be turned into the Business Office Manager and change counted and verified by the business office manager and returned to the residents. Responsible Person(s): Administrator, Activity Director #2, and BOM. Date: [DATE] by 12PM Action: Administrator and Director of Nursing educated regarding Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC). Key Takeaway: Appropriate interventions following a resident-to-resident altercation to decrease the probability of another incident and what to self-report and when (any type of abuse- 2 hours). Responsible Person(s): Regional Resource Nurse Date: [DATE] by 5PM Action: Department Head education regarding: Abuse/Neglect, Resident-to-Resident, and 1:1 Monitoring of the aggressor. Key Takeaway: Department Heads will understand that taking a resident off 1:1 is an IDT decision (IDT: including but not limited to a Physician/Physician Extender/Psych Services, Administrator, Director of Nursing, Social Services Director, MDS Coordinator) and the resident has been deemed no longer a safety risk to themselves or others by the Physician/Physician Extender/Psych Services. Abuse and Neglect Policy with an emphasis on resident-to-resident abuse and misappropriation. Resident-to-Resident Altercation Policy Misappropriation of resident property Responsible Person(s): Survey Resource and Clinical Company Leader Date: [DATE] by 5PM Action: All staff educated regarding Abuse/Neglect, Resident-to-Resident Altercations, and 1:1 monitoring of the aggressors, misappropriation. Key Takeaway: Residents who are aggressors towards other residents will be immediately placed on 1:1 and the abuse coordinator will be immediately notified. If staff feel as if the abuse coordinator is not reacting appropriately to the allegation they will be educated to call the corporate compliance line. Misappropriation- not accepting electronic transfers from residents, not taking any money or items from residents. Tests to ensure competency will be completed for all staff. Facility staff and temporary staff will be trained/tested prior to working their next shift. Responsible Person(s): Administrator, Director of Nursing, and/or Designee Date: [DATE] by 12PM Action: Administrator, Business Office educated 1:1, and all staff have been educated on: If center personnel purchases items on behalf of residents, the center must obtain a signature from the resident upon return to the center, with items. The actual receipt must be signed. If the resident is unable to sign, signatures from two witnesses are required for the withdrawal or purchased items. The witnesses can be any person(s) except the person(s) responsible for accounting for the trust fund, that person's supervisor, or the person(s) that accepts the withdrawn funds, merchandise, or services. Anyone in the business office, administrator or the employee doing the shopping cannot sign as a witness Employees do not accept cash via any electronic funding app, such as CashApp, Venmo, [NAME], or any other funding app. Business Office Employees do not do any shopping on behalf of the resident Employees cannot accept gifts of any kind from a resident Employees cannot withdraw funds from an ATM for the resident using the residents' personal ATM Card. The resident or family member are responsible for ATM withdrawals. Responsible Person(s): Survey Resource and/or Designee Date: [DATE] by 12PM Action: Ad Hoc QAPI performed with Administrator, Director of Nursing, and Medical Director. ANE policy and procedure reviewed with no changes. Responsible Person(s): Administrator Date: [DATE] by 12PM On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on [DATE] at 03:00 PM the Surveyor confirmed Resident #1 was on 1:1 monitoring. Record review of education provided to the DON and Current Administrator on Abuse, neglect, misappropriation. Record review of education provided to the Department heads on Abuse/neglect, Resident to resident altercations, misappropriation. Record review of education provided to all staff on Abuse/neglect, Resident to resident altercations, misappropriation, and Resident Funds. Record review of Survey Resource and Clinical Company Leader Progress Notes and event reports. Record review of 35 Safe Surveys completed by staff with no concerns noted. Record review of Ad hoc Qapi completed on [DATE] at 07:53 PM. Interviews on [DATE] from 12:00 PM through [DATE] 03:00PM with the Business Office Manager, SW, DON, ADON, LVN A, LVN B, LVN C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, Medication Aide J, housekeeper K, Housekeeping Supervisor, Housekeeper L, Housekeeper M, and Maintenance Man who worked the shifts of 6:00 AM-6:00 PM, 6:00 PM-06:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff expressed understanding of the importance of reporting abuse to the DON and Current Administrator, and how to use the compliance hotline if needed. While the IJ was removed on [DATE] at 03:20 PM, he facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on resident abuse, neglect, misappropriation and following facility policy. 2.Record review of Resident #4's electronic face sheet, dated [DATE], indicated Resident #4 was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses including functional quadriplegia (completely immobile), Hypertension (high blood pressure), and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #4 was understood by others and understood others. Resident #4 had a BIMS of 13, which indicated the resident was cognitively intact. Record review of the care plan, dated [DATE], indicated Resident #4 had impaired decision making as evidenced by his poor decision making with interventions that included: 1. Determine if decisions made by Resident #4 endanger the resident or others and intervene if necessary. 2. Give objective feedback when inappropriate decisions are made. Record review of the nursing progress note, dated [DATE], indicated Resident #4 had discharged home from the facility. Record review of Resident #5's electronic face sheet, dated [DATE], indicated Resident #5 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizophrenia (seeing or hearing things that do not exist), Hypertension (high blood pressure), personal history or traumatic brain injury, and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #5 was understood by others and usually understood others. Resident #5 had a BIMS of 11, which indicated the resident's cognition was mildly impaired. Record review of the care plan, dated [DATE], indicated Resident #5 had psychosocial well-being problems: Resident #5 had absence of personal contact with family/friends related to homelessness. Interventions included: Assess for factors that may impede the resident's ability to interact with others. Record review of Resident #6's electronic face sheet, dated [DATE], indicated Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (disorganized thinking and seeing or hearing things that do not exist), Hypertension (high blood pressure), and other reduced mobility. Record review of the MDS, dated [DATE], indicated Resident #6 was understood by others and usually understood others. Resident #6 had a BIMS of 15, which indicated the resident's cognition was intact. Record review of the care plan, dated [DATE], indicated Resident #6 had cognitive loss/Dementia: Resident #6 had impaired decision making related to schizophrenia, major depressive disorder, and anxiety. Interventions included: Encourage to verbalize feelings, concerns, and fears. Clarify misconceptions. Record review of Resident #7's electronic face sheet, dated [DATE], indicated Resident #7 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (disorganized thinking and seeing or hearing things that do not exist), chronic obstructive pulmonary disease (breathing related problems), and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #7 was understood by others and usually understood others. Resident #7 had a BIMS of 09, which indicated the resident's cognition was mildly impaired. Record review of the care plan, dated [DATE], indicated Resident #7 had hallucinations related to paranoid schizophrenia. Interventions included: assign a consistent staff member. Establish a trusting relationship with resident. Record review of Resident #8's electronic face sheet, dated [DATE], indicated Resident #8 was a [AGE] year-old female who was admitted to the facility on [DATE] and expired in the facility on [DATE] with diagnoses including schizoaffective disorder (disorganized thinking and seeing or hearing things that do not exist), hemiplegia following a cerebral infarction (not able to move to move the left side of the body following a stroke) and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #8 was usually understood by others and usually understood others. Resident #8 had a BIMS of 09, which indicated the resident's cognition was mildly impaired. Record review of the care plan, dated [DATE], indicated Resident #8 had behavioral symptoms and often accused staff/residents of stealing her money, and forgot she bought items such as tobacco products. Interventions included: maintain a calm environment and approach to the resident. During an interview on [DATE] at 03:50 PM Activity Director A said she does work as a CNA occasionally. She said she remembers Resident #4 and said he was a special resident that relied on her a lot. She said someone gave Resident #4 her personal cell phone number and would call her personally, she said that was not a typical practice. She said later after it became a habit of Resident #4 calling her, she stopped answering his calls. She said she reported it to the Previous Administrator. She said Resident #4 did give her money to go get things for him from the store, such as skoal, snacks. She said Resident #4 ordered from store a lot and had things delivered. She said Resident #4 never gave her money in exchange for care she provided for him. She said she does not know how much money he gave her total, but that sometimes he would give it to her twice weekly. She said the most amount of money he gave her at 1 time was 100-120 dollars. She said sometimes Resident #4 give her cash, sometimes she would take his debit card and sometimes he would cash app her. She said she never used any money he gave her for any personal reasons. She said over the course of 2 years he gave her 500-600 dollars to go and buy things for him. She said he had her buy him cell phones and phone cards. She said she was always in the position of activity director. She said as the activity director she does shopping for the residents. Normally she has a witness when she exchanges money and stuff she went and bought for the residents. She said normally it would be the ADON, or whatever CNA was working that day. During an interview on [DATE] at 04:17 PM the ADON said Activity Director A is allowed to go to the store for residents. She said if the activity director went to the store for the resident, she is supposed to bring the residents item and a receipt for the item back with her and give the receipt to the BOM. She said the only person that is allowed to shop for the residents is the activity director. She Said she only knows of there being a paper trail if the resident has a trust fund. She said if the resident gave cash, then there would not be a paper trail. She said Resident #8 was confused and made accusations frequently. She said Resident #7 also would make accusations frequently. She said she remembers Resident #4 giving money to the Activity Director A to get skoal but other than that he ordered things from the store and had it delivered to the door. She said she never witnessed Activity Director A give Resident #4 any items she had bought for him or any change from shopping she had done for him. She said Resident #4 had the cell phone numbers to the DON, Previous Administrator, and Activity Director A. She said that Resident #4 complained about his care while he was there and only wanted certain ones to care for him. She said Resident #4 never tried to pay her for providing care. She said Resident #4 wanted care from certain staff and would refuse care by other staff and thought if he refused then the ones he wanted would come and do the care. During an interview and observation on [DATE] beginning at 08:40 AM, Resident #7 said she gave Activity Director A 25.00 dollars for some new socks and shoes. Resident #7 said she had not received the socks and shoes or her 25.00 dollars. During an interview on [DATE] at 08:48 AM the Regional Accounts Manager said in June of 2022 Resident #4 made a $300 dollar payment to the facility and that Activity Director A was able to go and talk the resident in to making. She said Resident did make another 500-dollar payment on [DATE] using his atm card. She said the process for staff going to the store for residents is they are to bring a receipt back and sign a form with the resident stating the resident had received the requested items and change from there purchase. She said under no circumstances are any staff allowed to withdraw any money from a resident's bank account using there debit card. During an interview on [DATE] at 09:10 AM with Resident #4 via phone, he said he had given Activity Director A 1,150.00 dollar via cash app, and Activity Director A had taken his ATM card and withdrew an additional 1000.00 dollars from his bank account. Resident #4 said Activity Director A had agreed to take care of him while he was at the nursing facility if he paid her. He said the agreement was he would pay her 50.00 to 100.00 dollars every couple of weeks, and she would make sure he was cared for. He said Activity Director A had given him Activity Director A's personal cell phone number to call her when he needed care. He said if Activity Director A was at work and he needed care he would call her cell phone and she would come and provide care, if she was not at work then he would call her, and she would call the facility and have someone go to his room to provide the care. He said Activity Director A would occasionally go to the store for him, but all of those purchases were made with Resident #4's debit card and never with cash app. He said Activity Director A would occasionally ask to borrow money from him that was never paid back. He said most of the time when he needed something from the store, he would order it online and have it delivered to the facility. He said he discharged from the facility on [DATE] and received a call from Activity Director A in [DATE], he said she told him that he still owed her 100.00 dollars for taking care of him, so he sent her 100.00 dollars on [DATE] via cash app. Resident #4 said he does not feel like it was right and now wants his money back. During an interview on [DATE] at 09:50 AM the BOM said they have a process they started in august of 2022 they are supposed to follow when going to the store for residents due to multiple complaints of residents not getting there change or items. She said there is a form that is to be filled out, and the employee is supposed to bring the receipt back with the items purchased and the change. She said the resident and the employee are supposed to sign the form stating the resident received the items and change from the transaction. She said that Resident #6 came to her in February of 2023 and wanted to withdrawal 100.00 dollars from her trust fund, which was out of the normal for her, so it made her suspicious. She said Resident #6 took the money to the social worker/activity director A office and Activity Director A was not there so the resident gave the money to the SW and asked him to give it to the Activity Director A. The SW intercepted the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 3 of 5 residents reviewed for accidents and supervision. (Resident #1, Resident #2, and Resident #3) 1. The facility failed to adequately provide supervision for Resident #1 and Resident #2. On 04/05/2023 Resident #1 wandered into Resident #2's room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1's right mid arm. 2. The facility failed to adequately provide supervision for Resident #2 and Resident #3. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3's left forearm. 3. The facility failed to adequately provide supervision for Resident #2 and Resident #3. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. This failure placed all residents in the secured unit at risk of injury and death. Findings included: 1. Record review of an admission Record, not dated, for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admission date of 07/10/2018 and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady but was able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that resident had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist/psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). The resident had a history of throwing liquids at other residents. Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resided on the secure unit. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavior health hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 5. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nurse progress notes for Resident #2 dated 04/05/2023 at 10:33 PM written by LVN A indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 who wandered into her room. Resident #2 then grabbed Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of an event report dated 04/05/2023 indicated Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. The event report indicated Resident #2 was placed on one-on-one supervision. The event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 at 4:01 PM written by LVN C indicated: Resident was sitting in chair in common room when another resident rolled up in their wheelchair reached out with their arm and this resident stabbed her with a pen. Resident #2 was placed on 1 on 1 supervision for 72 hours. Record review of an event report dated 04/15/2023 at 3:47 PM completed by LVN C indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: The behavioral health hospital returned a call to the facility. They denied the resident for their services at this time. They stated, We may have availability on Monday. On-call, the ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 at 1:22PM completed by LVN B indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at this time and Resident #2 was redirected to her room. Nurse Practitioner notified of incident no new orders for Resident #2 received at that time. Record review of an event report date 06/27/2023 at 9:29 AM completed by the regional clinical nurse indicated: Resident #2 pushed another resident sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. 2. Record review of an admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admission date of 10/18/2021 and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNAs were present on the hall and assisting other residents. LVN A witnessed Resident #1, and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admission date of 05/28/2021 and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10 AM revealed the TV/dining area with 6 residents and 1 can; 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a Bible with papers inside and a pen. Resident #3 was sitting up in her wheelchair 5-6 feet away from Resident #2 with her head down. Resident #1 was observed lying in bed in his room with eyes closed. During an observation and interview on 06/26/2023 at 10:05 AM revealed Resident #2 sitting up in chair in the common area. She said it was year 2025 but they kept telling her it was 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer any more questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. She said she had been coming to the facility for about 3 weeks and ever since there had only been one CNA that worked on the secured unit per shift. She said there was a CNA that worked on the hall outside of the secured unit that could come and occasionally help if needed. She said Resident #2 only got aggressive if someone went into her room but had not seen any physical aggression by Resident #2. She said Resident #2 did not get aggressive unless someone got in her personal space. She said she had 15 residents on the secured unit. She said if she witnessed a resident to resident altercation she would separate the residents for safety and notify the DON and Administrator. During an interview on 06/26/2023 at 10:22 AM LVN B said she had worked at the facility for about 2 months and was the nurse for the secured unit and the backside of 200 hall. Said she was not able to always be in the secured unit. She said on 05/25/2023 Resident #3 rolled her wheelchair past Resident #2 and Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. She said Resident #2 and Resident #3 are both combative, so they have had to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they tried to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and she had seen an improvement in her behaviors. LVN B said when she worked, she has 1 CNA in the unit. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting where resident could be seen the whole time. She said Resident #2 wrote on paper a lot. She said Resident #3 went past Resident #2 and Resident #2 stabbed Resident #3 with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to Resident #3's arm and first aid was provided to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and the ADON, DON and provider was notified of the incident. She said Resident #2 and Resident #3 were watched to make sure they were not in the same area. She said both Resident #2 and Resident #3 can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in-services that were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the Administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the ADM said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he had known Resident #2 for a long time due to seeing her at a previous facility. He said he had never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 had a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. The Psychologist said you cannot educate the other residents of the secured unit because they would not understand or remember the education. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party of Resident #2 said he was notified of an incident regarding Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services; he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear to another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral health hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. The Social Worker said he attempted to send Resident #2 out to a behavioral hospital previously, but the resident's guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said the Psychologist was who the facility had a contract with, and they also had a contract with another counseling provider. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents did wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she had worked for the facility as needed for 1 year. She said there was one CNA that works on the secured unit and covers the backside of 200 hall outside of the unit. She said the nurse normally stepped into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and Resident #1. She said Resident #1 wandered into Resident #2's room and Resident #2 threw water on Resident #1 and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that if anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral health hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 Resident #1 wandered into Resident #2's room and Resident #2 threw water on and grabbed Resident #1's wrist causing a skin tear. She said Resident #2 did not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023 the behavioral health hospital would not accept the resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral health hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. The DON said she did not feel like 1 CNA was enough staff on the secured unit. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as 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. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a [Provider name]Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment Record review of a facility policy titled Abuse Prevention Program with a revised date of 01/09/2023 indicated: .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by the DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. Resident #2 remained in the facility at the time of surveyor exit. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM The facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and the MD. Timeline for completion: 06/28/2023 at 3:00 PM. The facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete the safe survey will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. The safe surveys and head to toe skin assessments had been completed and documented at time of surveyor exit. The facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, all staff will understand they cannot leave the secured unit unattended through education, and the Administrator and Director of Nursing will ensure the secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. The facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. An ad hoc QAPI meeting with the Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation an interview on 6/28/2023 at 9:40 AM in the secured unit revealed MA E was present. MA E said she was assigned to provide 1 on 1 with Resident#2 and today was her first day of work. She said the facility started 1 on 1 with Resident #2 as of midnight last night, 6/28/2023. She said she had to complete 15-minute check documentation on her. Observation of the secured unit on 06/28/23 at 3:00 pm revealed there were 2 certified nurse aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the Activity Director on the unit at this time. CNA E was observed documenting on Q15 minute monitoring sheet. Record review of the Q15 minute monitoring sheet dated 06/28/2023 indicated resident had not had any behaviors for that day. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, the Business Office Manager, Social Worker, Activity Director, Certified Occupational Therapist, DON, ADON, LVN C, MA E, MA G, and CNA D, CNA I, CNA H, CNA K were able to verbalize the procedure when a resident-to-resident altercation occurred, Resident #2's current staffing, behavioral health training, when a resident needed a psychiatric consult, and the abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM revealed attendees consisting of the Administrator, Company Clinical Leader, Regional Clinical Nurse and the Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and 1. Resident place on 1 on 1(Q15 minute checks) to be documented on form provided to staff. 2. Referral made to psych services. 3. Staff trained on abuse policy and resident to resident altercation policy. 4. Staff educated on event reporting to be completed at time of event. 5. Care plans were updated. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring, to be documented on a documentation sheet provided to staff, referrals made to psych services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of the abuse prevention program. The in-service attendees included nurses, CNAs, MAs, the Business Office Manager, housekeeping, and the Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of abuse and neglect. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of psychiatric referrals sent to the psych services provider for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the

**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 for 2 of 5 residents (Resident #1 and Resident #3) reviewed for Resident Abuse. 1. The facility failed to protect Resident #1 from abuse by Resident #2. On 04/05/2023 Resident #1 wandered into Resident #2's room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1's right mid arm. 2. The facility failed to protect Resident #3 from abuse by Resident #2. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3's left forearm. 3. The facility failed to protect Resident #3 from abuse by Resident #2. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: 1. Record review of an admission Record, not dated, for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admission date of 07/10/2018 and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady, but was able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that resident had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist/psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). The resident had a history of throwing liquids at other residents. Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resided on the secure unit. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavior health hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 5. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nurse progress notes for Resident #2 dated 04/05/2023 at 10:33 PM written by LVN A indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 who wandered into her room. Resident #2 then grabbed Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of an event report dated 04/05/2023 indicated Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. The event report indicated Resident #2 was placed on one-on-one supervision. The event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 at 4:01 PM written by LVN C indicated: Resident was sitting in chair in common room when another resident rolled up in their wheelchair reached out with their arm and this resident stabbed her with a pen. Resident #2 was placed on 1 on 1 supervision for 72 hours. Record review of an event report dated 04/15/2023 at 3:47 PM completed by LVN C indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: The behavioral health hospital returned a call to the facility. They denied the resident for their services at this time. They stated, We may have availability on Monday. On-call, the ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 at 1:22PM completed by LVN B indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at this time and Resident #2 was redirected to her room. Nurse Practitioner notified of incident no new orders for Resident #2 received at that time. Record review of an event report date 06/27/2023 at 9:29 AM completed by the regional clinical nurse indicated: Resident #2 pushed another resident sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. 2. Record review of an admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admission date of 10/18/2021 and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNA's were present on the hall and assisting other residents. LVN A witnessed Resident #1 and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admission date of 05/28/2021 and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10 AM revealed the TV/dining area with 6 residents and 1 can; 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a Bible with papers inside and a pen. Resident #3 was sitting up in her wheelchair 5-6 feet away from Resident #2 with her head down. Resident #1 was observed lying in bed in his room with eyes closed. During an observation and interview on 06/26/2023 at 10:05 AM revealed Resident #2 sitting up in chair in the common area. She said it was year 2025 but they kept telling her it was 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer any more questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. She said she had been coming to the facility for about 3 weeks and ever since there had only been one CNA that worked on the secured unit per shift. She said there was a CNA that worked on the hall outside of the secured unit that could come and occasionally help if needed. She said Resident #2 only got aggressive if someone went into her room but had not seen any physical aggression by Resident #2. She said Resident #2 did not get aggressive unless someone got in her personal space. She said she had 15 residents on the secured unit. She said if she witnessed a resident to resident altercation she would separate the residents for safety and notify the DON and Administrator. During an interview on 06/26/2023 at 10:22 AM LVN B said she had worked at the facility for about 2 months and was the nurse for the secured unit and the backside of 200 hall. Said she was not able to always be in the secured unit. She said on 05/25/2023 Resident #3 rolled her wheelchair past Resident #2 and Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. She said Resident #2 and Resident #3 are both combative, so they have had to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they tried to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and she had seen an improvement in her behaviors. LVN B said when she worked, she has 1 CNA in the unit. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting where resident could be seen the whole time. She said Resident #2 wrote on paper a lot. She said Resident #3 went past Resident #2 and Resident #2 stabbed Resident #3 with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to Resident #3's arm and first aid was provided to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and the ADON, DON and provider was notified of the incident. She said Resident #2 and Resident #3 were watched to make sure they were not in the same area. She said both Resident #2 and Resident #3 can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in-services that were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the Administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the ADM said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he had known Resident #2 for a long time due to seeing her at a previous facility. He said he had never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 had a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. The Psychologist said you cannot educate the other residents of the secured unit because they would not understand or remember the education. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party of Resident #2 said he was notified of an incident regarding Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services; he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear to another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral health hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. The Social Worker said he attempted to send Resident #2 out to a behavioral hospital previously, but the resident's guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said the Psychologist was who the facility had a contract with, and they also had a contract with another counseling provider. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents did wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she had worked for the facility as needed for 1 year. She said there was one CNA that works on the secured unit and covers the backside of 200 hall outside of the unit. She said the nurse normally stepped into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and Resident #1. She said Resident #1 wandered into Resident #2's room and Resident #2 threw water on Resident #1 and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that if anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral health hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 Resident #1 wandered into Resident #2's room and Resident #2 threw water on and grabbed Resident #1's wrist causing a skin tear. She said Resident #2 did not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023 the behavioral health hospital would not accept the resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral health hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. The DON said she did not feel like 1 CNA was enough staff on the secured unit. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as 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. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a [Provider name]Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment Record review of a facility policy titled Abuse Prevention Program with a revised date of 01/09/2023 indicated: .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by the DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. Resident #2 remained in the facility at the time of surveyor exit. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM The facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and the MD. Timeline for completion: 06/28/2023 at 3:00 PM. The facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete the safe survey will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. The safe surveys and head to toe skin assessments had been completed and documented at time of surveyor exit. The facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, all staff will understand they cannot leave the secured unit unattended through education, and the Administrator and Director of Nursing will ensure the secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. The facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. An ad hoc QAPI meeting with the Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation an interview on 6/28/2023 at 9:40 AM in the secured unit revealed MA E was present. MA E said she was assigned to provide 1 on 1 with Resident#2 and today was her first day of work. She said the facility started 1 on 1 with Resident #2 as of midnight last night, 6/28/2023. She said she had to complete 15-minute check documentation on her. Observation of the secured unit on 06/28/23 at 3:00 pm revealed there were 2 certified nurse aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the Activity Director on the unit at this time. CNA E was observed documenting on Q15 minute monitoring sheet. Record review of the Q15 minute monitoring sheet dated 06/28/2023 indicated resident had not had any behaviors for that day. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, the Business Office Manager, Social Worker, Activity Director, Certified Occupational Therapist, DON, ADON, LVN C, MA E, MA G, and CNA D, CNA I, CNA H, CNA K were able to verbalize the procedure when a resident-to-resident altercation occurred, Resident #2's current staffing, behavioral health training, when a resident needed a psychiatric consult, and the abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM revealed attendees consisting of the Administrator, Company Clinical Leader, Regional Clinical Nurse and the Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and 1. Resident place on 1 on 1(Q15 minute checks) to be documented on form provided to staff. 2. Referral made to psych services. 3. Staff trained on abuse policy and resident to resident altercation policy. 4. Staff educated on event reporting to be completed at time of event. 5. Care plans were updated. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring, to be documented on a documentation sheet provided to staff, referrals made to psych services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of the abuse prevention program. The in-service attendees included nurses, CNAs, MAs, the Business Office Manager, housekeeping, and the Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, CMAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of abuse and neglect. The in-service attendees included nurses, CNAs, CMAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of psychiatric referrals sent to the psych services provider for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The facility continued to monitor and in-service staff to ensure all were in-serviced on abuse/neglect, resident-to-re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 2 of 5 (Resident #1 and Resident #3) of residents reviewed for incidents. The facility failed to ensure the residents right to be free from abuse, neglect, misappropriation, of resident property and exploitation. The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 threw water on and then grabbed Resident #1 causing a skin tear to Resident #1's arm. The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 Stabbed Resident #3 in the arm with a pen. The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 pushed Resident #3 out of her wheelchair and onto the floor. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. These deficient practices could affect any resident and contribute to further abuse. Findings included: 1. Record review of an admission Record, not dated, for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admission date of 07/10/2018 and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady, but was able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that resident had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist/psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). The resident had a history of throwing liquids at other residents. Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resided on the secure unit. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavior health hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 5. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nurse progress notes for Resident #2 dated 04/05/2023 at 10:33 PM written by LVN A indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 who wandered into her room. Resident #2 then grabbed Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of an event report dated 04/05/2023 indicated Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. The event report indicated Resident #2 was placed on one-on-one supervision. The event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 at 4:01 PM written by LVN C indicated: Resident was sitting in chair in common room when another resident rolled up in their wheelchair reached out with their arm and this resident stabbed her with a pen. Resident #2 was placed on 1 on 1 supervision for 72 hours. Record review of an event report dated 04/15/2023 at 3:47 PM completed by LVN C indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: The behavioral health hospital returned a call to the facility. They denied the resident for their services at this time. They stated, We may have availability on Monday. On-call, the ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 at 1:22PM completed by LVN B indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at this time and Resident #2 was redirected to her room. Nurse Practitioner notified of incident no new orders for Resident #2 received at that time. Record review of an event report date 06/27/2023 at 9:29 AM completed by the regional clinical nurse indicated: Resident #2 pushed another resident sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. 2. Record review of an admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admission date of 10/18/2021 and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNA's were present on the hall and assisting other residents. LVN A witnessed Resident #1 and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admission date of 05/28/2021 and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10 AM revealed the TV/dining area with 6 residents and 1 can; 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a Bible with papers inside and a pen. Resident #3 was sitting up in her wheelchair 5-6 feet away from Resident #2 with her head down. Resident #1 was observed lying in bed in his room with eyes closed. During an observation and interview on 06/26/2023 at 10:05 AM revealed Resident #2 sitting up in chair in the common area. She said it was year 2025 but they kept telling her it was 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer any more questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. She said she had been coming to the facility for about 3 weeks and ever since there had only been one CNA that worked on the secured unit per shift. She said there was a CNA that worked on the hall outside of the secured unit that could come and occasionally help if needed. She said Resident #2 only got aggressive if someone went into her room but had not seen any physical aggression by Resident #2. She said Resident #2 did not get aggressive unless someone got in her personal space. She said she had 15 residents on the secured unit. She said if she witnessed a resident to resident altercation she would separate the residents for safety and notify the DON and Administrator. During an interview on 06/26/2023 at 10:22 AM LVN B said she had worked at the facility for about 2 months and was the nurse for the secured unit and the backside of 200 hall. Said she was not able to always be in the secured unit. She said on 05/25/2023 Resident #3 rolled her wheelchair past Resident #2 and Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. She said Resident #2 and Resident #3 are both combative, so they have had to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they tried to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and she had seen an improvement in her behaviors. LVN B said when she worked, she has 1 CNA in the unit. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting where resident could be seen the whole time. She said Resident #2 wrote on paper a lot. She said Resident #3 went past Resident #2 and Resident #2 stabbed Resident #3 with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to Resident #3's arm and first aid was provided to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and the ADON, DON and provider was notified of the incident. She said Resident #2 and Resident #3 were watched to make sure they were not in the same area. She said both Resident #2 and Resident #3 can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in-services that were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the Administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the ADM said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he had known Resident #2 for a long time due to seeing her at a previous facility. He said he had never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 had a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. The Psychologist said you cannot educate the other residents of the secured unit because they would not understand or remember the education. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party of Resident #2 said he was notified of an incident regarding Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services; he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear to another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral health hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. The Social Worker said he attempted to send Resident #2 out to a behavioral hospital previously, but the resident's guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said the Psychologist was who the facility had a contract with, and they also had a contract with another counseling provider. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents did wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she had worked for the facility as needed for 1 year. She said there was one CNA that works on the secured unit and covers the backside of 200 hall outside of the unit. She said the nurse normally stepped into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and Resident #1. She said Resident #1 wandered into Resident #2's room and Resident #2 threw water on Resident #1 and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that if anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral health hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 Resident #1 wandered into Resident #2's room and Resident #2 threw water on and grabbed Resident #1's wrist causing a skin tear. She said Resident #2 did not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023 the behavioral health hospital would not accept the resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral health hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. The DON said she did not feel like 1 CNA was enough staff on the secured unit. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as 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. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a [Provider name]Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment Record review of a facility policy titled Abuse Prevention Program with a revised date of 01/09/2023 indicated: .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by the DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. Resident #2 remained in the facility at the time of surveyor exit. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM The facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and the MD. Timeline for completion: 06/28/2023 at 3:00 PM. The facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete the safe survey will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. The safe surveys and head to toe skin assessments had been completed and documented at time of surveyor exit. The facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, all staff will understand they cannot leave the secured unit unattended through education, and the Administrator and Director of Nursing will ensure the secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. The facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. An ad hoc QAPI meeting with the Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation an interview on 6/28/2023 at 9:40 AM in the secured unit revealed MA E was present. MA E said she was assigned to provide 1 on 1 with Resident#2 and today was her first day of work. She said the facility started 1 on 1 with Resident #2 as of midnight last night, 6/28/2023. She said she had to complete 15-minute check documentation on her. Observation of the secured unit on 06/28/23 at 3:00 pm revealed there were 2 certified nurse aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the Activity Director on the unit at this time. CNA E was observed documenting on Q15 minute monitoring sheet. Record review of the Q15 minute monitoring sheet dated 06/28/2023 indicated resident had not had any behaviors for that day. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, the Business Office Manager, Social Worker, Activity Director, Certified Occupational Therapist, DON, ADON, LVN C, MA E, MA G, and CNA D, CNA I, CNA H, CNA K were able to verbalize the procedure when a resident-to-resident altercation occurred, Resident #2's current staffing, behavioral health training, when a resident needed a psychiatric consult, and the abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM revealed attendees consisting of the Administrator, Company Clinical Leader, Regional Clinical Nurse and the Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and 1. Resident place on 1 on 1(Q15 minute checks) to be documented on form provided to staff. 2. Referral made to psych services. 3. Staff trained on abuse policy and resident to resident altercation policy. 4. Staff educated on event reporting to be completed at time of event. 5. Care plans were updated. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring, to be documented on a documentation sheet provided to staff, referrals made to psych services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of the abuse prevention program. The in-service attendees included nurses, CNAs, MAs, the Business Office Manager, housekeeping, and the Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of abuse and neglect. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of psychiatric referrals sent to the psych services provider for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The fac[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being 1 of 3 resident (Resident #2) reviewed for behavioral health. 1. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 04/05/2023 Resident #1 wandered into Resident #2's room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1's right mid arm. 2. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3's left forearm. 3. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. The facility failed to immediately provide psychological services for Resident #2 following 3 separate residents to resident altercations on 04/05/2023, 04/15/2023 and 05/25/2023. On 02/28/2023 an order for a psych consult was written for Resident #2 to be evaluated and treated. Resident #2 was not evaluated until 06/08/2023 by psychological services. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. These failures affected residents living in the facility at risk of not receiving behavioral health services, increased anger and behaviors, inflicting harm on others, anxiety and decline in quality of life. The findings included: 1.Record review of an admission Record not dated for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admission date of 07/10/2018 and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She requires limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that Resident #2 had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). History of throwing liquids at other residents. Interventions included avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resides on the secure unit. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist /psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavioral hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 04/16/2023 reflected Resident #2 had episodes of anxiety. Interventions included: Psychologist/Psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 1. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021 2. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023 Record review of nurse progress notes for Resident #2 dated 04/05/2023 indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 that wandered into her room. Resident #2 then grabbed the Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of event report dated 04/05/2023 indicated: Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. Event report indicated Resident #2 was placed on one-on-one supervision. Event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: Resident #2 was sitting in chair in common room when Resident #3 rolled up in wheelchair reached out with arm and Resident #2 stabbed Resident #3 with a pen. Resident #2 had been placed on 1 on 1 supervision for 72 hours. Record review of event report dated 04/15/2023 indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: Behavioral Hospital returned a call to the facility. Denies the resident for their services at this time. States, We may have availability on Monday. On-call, ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident #2 had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at that time and Resident #2 was redirected to her room. The Nurse Practitioner was notified of incident and no new orders for Resident #2 were received at that time. Record review of event report date 06/27/2023 indicated: Resident #2 pushed Resident #3 sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. . Record review of an admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admission date of 10/18/2021 and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNAs were present on the hall and assisting other residents. LVN A witnessed Resident #1, and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admission date of 05/28/2021 and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10am observed TV/dining area with 6 residents and 1 CNA, 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a bible with papers inside and a pen. Resident #2 was not on any special supervision at that time. During an observation and interview on 06/26/2023 at 10:05 AM observed Resident #2 sitting up in chair in the common area, said it was year 2025 but they keep telling her its 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer anymore questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. Said she had been coming to the facility for about 3 weeks and said ever since she had been coming, there had only one CNA that worked on the secured unit per shift. She said there is a CNA that worked on the hall outside of the secured unit that can come and occasionally help if needed. She said Resident #2 only gets aggressive if someone goes into her room but has not seen any physical aggression. She said Resident #2 does not get aggressive unless someone gets in her personal space. She said she has 15 residents on the secured unit. During an interview on 06/26/2023 at 10:22 AM LVN B said she has worked at the facility for about 2 months and is the nurse for the secured unit and the backside of 200 hall. Said she is not able to always be in the secured unit. She said on 05/25/2023 another resident rolled her wheelchair past Resident #2 and Resident #2 pushed the other residents out of her wheelchair causing that resident to fall onto the floor. She said Resident #2 and the other resident are both combative, so you have to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they try to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and has seen an improvement in her behaviors. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting there the whole time. She said Resident #2 writes on paper a lot. She said the other went past Resident #2 and Resident #2 stabbed the other with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to the other resident's arm and provided first aid to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and ADON, DON and provider was notified of the incident. She said Resident #2 and the other resident were watched to make sure they were not in the same area. She said both Resident #2 and the other resident can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in services were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the Administrator said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he has known Resident #2 for a long time due to seeing her at a previous facility. He said he has never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 has a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party said he was notified of an incident of Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services, he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear on another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. He said attempted to send Resident #2 out to a behavioral hospital previously, but the residents guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said Psychologist was who the facility had a contract with, and they also had a contract with another counseling company. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents do wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she has worked for the facility as needed for 1 year. She said there is one CNA that works on the secured unit and also covers the backside of 200 hall outside of the unit. She said the nurse normally steps into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and another resident. She said another resident wandered into Resident #2's room and Resident #2 threw water on that resident and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that is anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 another resident wandered into Resident #2's room and Resident #2 threw water on and grabbed the other resident's wrist causing a skin tear. She said Resident #2 does not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023, the behavioral hospital would not accept resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as 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. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a Senior Living Properties Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Senior Living Properties Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment . The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM Facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and MD. Timeline for completion: 06/28/2023 at 3:00 PM. Facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. Facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, All staff will understand they cannot leave the secured unit unattended through education, Administrator and Director of Nursing will ensure secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. Facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. Ad hoc QAPI meeting with Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 6/28/2023 at 9:40 AM in the secured unit MA E was present said she was assigned to provide 1 on 1 with Resident #2 and today was her first day of work. She said the facility started 1 on 1 with Resident # as of midnight last night 6/28/2023. She said she had to complete 15-minute checks on her. Observation of secured unit on 06/28/23 at 3:00 pm revealed that there were 2 Certified nurse's aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the activity director on the unit at this time. CNA E observed documenting on Q15 minute monitoring sheet. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, Business office manager, Social Worker, Activity Director, certified occupational therapist, DON, ADON, 1 LVN, 2 MA's, and 4 CNA's were able to verbalize the procedure when a resident-to-resident altercation occurs, Resident #2's current staffing, behavioral health training, when a resident needs a psychiatric consult, and abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM had attendees of Administrator, company clinical leader, Regional clinical nurse and Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and several things were put in place. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring to be documented on documentation sheet provided to staff, referrals made to Senior Psych Services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of abuse prevention program. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of abuse and neglect. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of psychiatric referrals sent to Senior Psych Care for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The facility continued to monitor and in-service staff to ensure all were in-serviced on abuse/neglect, resident-to-resident altercations, behavioral health training, staffing of the secured unit and psychiatric consults.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 580 Based on record review and interviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) of a medication error for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to inform the Physician, NP, or DON when Resident #1 received the wrong medications on 1/4/2023. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk not receiving appropriate care and interventions and/or death. Findings included: Record review of Resident #2's Face Sheet dated January 2022 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmission date of 9/2/2020. Resident #2's diagnoses included schizoaffective disorder bipolar type, (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior)., major depressive disorder, and human immunodeficiency virus (a virus that attacks the body's immune system.) Record review of Resident #2's Physician orders dated January 2022 indicated the following medications were to be administered daily to Resident #2 between 7:30 p.m. and 10:00 p.m. Cogentin 1 mg- used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs Prolixin 10 mg- used to treat certain types of mental/mood conditions: (psychotic disorders; schizophrenia) Haldol 5 mg- used to treat certain types of mental/mood conditions: schizophrenia, schizoaffective Isentress 400 mg- used to treat human immunodeficiency virus infections Toprol 25 mg- used to treat symptoms used to treat chest pain, heart failure and high blood pressure Seroquel 500 mg- used to treat certain types of mental/mood conditions: Schizophrenia, Bipolar disorder, sudden episodes of mania or depression associated with Bipolar Disorder Risperdal 3 mg- used to treat certain types of mental/mood disorders; Schizophrenia, Bipolar, irritability associated with autistic disorder Glucophage 1000 mg- used to control blood sugar Eskalith 300 mg- mood stabilizer used to treat or control the manic episodes of Bipolar disorder (manic depression) Record review of Resident #1's Face Sheet dated January 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmission date of 1/6/2023. Resident #1's diagnoses included polyosteoarthritis, (when five or more joints are affected with joint pain), unspecified intellectual disabilities, (when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills), diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania and lows (depression), epilepsy, (a brain disorder that causes recurring, unprovoked seizures.), hypertension ( when blood pressure is too high), and peripheral vascular disease (a slow and progressive circulation disorder). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 9 for cognitive awareness, which indicated she was moderately impaired. The MDS indicated Resident #1 required supervision with set up assistance for transfers, walking in the room or corridor, dressing, eating, toileting, and personal hygiene. Record review of a Facility Event Report dated 1/5/2023 at 9:36 p.m. indicated on 1/4/2023 Resident #1 was given the wrong medications. Resident #1 was sent to the ER. Record review of the nursing progress notes for Resident #1 revealed there were no entries documented on 1/4 or 1/5 2023 by RN A. Record review of a nursing progress note written by LVN B and dated 1/5/2023 at 10:34 a.m. indicated Resident #1 was lying in bed, appeared to be lethargic (lacking mental and physical alertness and activity). with limited speech, and non-reactive pupils. Resident #1 had to have more help than normal. Her BP was 121/63. The Nurse Practitioner was notified and ordered Resident #1 to be sent to the ER for evaluation and treatment. Record review of a nursing progress note written by LVN C dated 1/6/2023 at 3:48 p.m. indicated Resident #1 returned to from the ER related to altered mental status. Resident #1's diagnoses included a UTI and dehydration. Resident #1's mood was pleasant. The NP was notified. Record review of a nursing progress note written by LVN D dated 1/6/2023 at 10:.00 p.m. indicated Resident #1's orientation was within normal baseline with a slightly unsteady gait. Record review of Resident #1's Medication Administration Record dated 1/1/2023-1/7/2023 indicated the following medications were to be administered daily to Resident #1 between 7:30 p.m. and 10:00 p.m. Claritin 10 mg- an antihistamine that treats symptoms such as itching, runny nose, watery eyes, and sneezing from hay fever and other allergies Depakote 500 mg- used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder) Keppra 1,000 mg- used to treat certain types of seizures Lorazepam 1mg- used to treat anxiety Magnesium 400 mg- used to treat vitamin D deficiency Metformin 500 mg-used to control high blood sugar Vimpat 100 mg- used to prevent and control seizures RN A signed off the medications as being given to Resident #1 on 1/4/2023. Record review of #1's Hospital Discharge summary dated [DATE] revealed Resident #1 was admitted on [DATE] and discharged back to nursing facility 1/6/2023. Discharge diagnoses included acute urinary tract infection, acute renal failure syndrome (sudden and sustained deterioration of the kidney function) and altered mental status. Hospital course reflected: On 1/6/2023 in discussion with family members it was revealed the patient was given up to 6 medications that were belonging to the patient's neighbor (Resident #2), with most of them being psychiatric with a heavily sedating effect. Upon evaluation in the morning, patient was found alert and orient x3, answering questions appropriately, speaking in full sentences, minimal confusion/disorientation noted in the early morning hours which resolved by the afternoon. Deemed stable for discharge. The hospital record indicated a drug screen was done on 1/5/2023 at 11:10 a.m. The results reflected the resident was negative for methadone, cocaine, THC (psychoactive component in marijuana), barbiturates, benzodiazepines, opiates, amphetamines, and PCP, (Phencyclidine, a sedative narcotic). Record review of a facility Event Report dated 1/5/23 at 9:36 p.m. indicated on 1/4/2023 Resident #1 was given the wrong medications. Resident was sent to the ER. Record review of a Facility Event Summary Report dated from 8/1/2022 to 1/9/20233 indicated that the facility had 1 reported medication error during this period, with date of occurrence 1/4/2023. During an interview on 1/7/2023 at 10:37 a.m. the ADON said RN A worked the 6 p.m.-6 a.m. shift on 1/4/2022. The ADON said RN A did not report the med error until she came to work on 1/5/2022 for her 6 p.m.-6 a.m. shift and found out Resident #1 had been sent to the hospital. The ADON said RN A had 2 med cups with pills, one for Resident #1 and one for Resident #2, who were roommates. The ADON said RN A realized at some point she had given the wrong medicine to Resident #1, which actually belonged to Resident #2. The ADON said the DON was notified at some time around 9:33 p.m. on 1/5/2023. The ADON said Resident #1 usually questioned her meds before taking them. During an interview on 1/7/2023 12:30 p.m. Resident #1 said she was doing well. Resident #1 stated she had returned from the hospital 1/6/2023 and went to the hospital because of too much sugar, and my sugar was high. All the candy I ate at Christmas made my sugars go up, is what the doctor told me. Resident #1 said she took medications in the morning and in the evening and had never had any problems getting the right ones. During an interview on 1/7/2023 12:34 p.m. Resident #2 stated she received medications in the morning and in the evening. Resident #2 said she had problems 2 different times getting the right medications. Resident #2 said she received meds on 1/4/2023, and when she looked at them, she asked the nurse what they were, as they did not look right. Resident #2 said she could not pinpoint the time frame for the first event, but said it was the same nurse, RN A. Resident #2 said RN A gave her meds to her roommate and that was why she went to the hospital. Resident #2 said she did not take any of the meds that were not hers. Resident #2 said RN A was nice and told her she was daydreaming when she was giving the meds. Resident #2 said her roommate is confused at times. During an interview on 1/7/2023 12:40 p.m. the RNC said she was aware of the medication error on 1/4/2022. The RNC said training was started immediately, and that RN A would be called in on this date and suspended until the investigation was completed. During an interview on 1/7/2023 1:45 p.m. RN A stated on 1/4/2022, 6 p.m.-6 a.m. shift she was getting ready to give meds to both Resident #1 and Resident #2. RN A said she got 2 med cups out, filled 1 cup with medications and scooted it back under the computer, filled the other med cup with medications and scooted it back as well. RN A said she went into Resident #1's room, called her name and told her she had her meds. RN A said Resident #1 sat up in bed and she gave Resident #1 the med cup. RN A said Resident #1 looked at the pills and took them. RN A said she walked out of the room and got distracted. RN A said on the evening shift, they were the secretary, they had to answer phones, and the door, and answer call lights so it was 1-2 hours before she went back to give Resident #2 her meds. RN A said she grabbed the other cup of pills that were locked in the med cart, in the same cup she had previously filled. RN A said she handed Resident #2 the cup and Resident #2 looked at the pills said, These don't look right. RN A said she immediately thought oh no what did I do?. RN A said she and Resident #2 went to the med cart. RN A said she looked at the cup and knew she had just given Resident #1 Resident #2's meds. She said she told the resident she did not know what had happened, but she was going to get rid of the meds and start over. RN A said she poured new meds and gave them to Resident #2. RN A said she realized she gave the wrong meds to Resident #1, when Resident #2 said her pills did not look right. RN A stated she did not do what she should have; she should have called the doctor but did not because Resident #1 slept all night. RN A said the next day, 1/5/2023 around 6:30 p.m. she returned to work and saw that Resident #1 had been sent to the hospital. The DON was in the building, and RN A told her what she had done, and was told to complete an incident report. RN A said she probably passed meds to 4-5 residents prior to the incident involving Resident #1 but did not remember for sure. RN A said she did not give any more meds after the incident. RN A said Resident #1 slept all night with no issues noted. RN A said she did not normally fill 2 med cups at one time and had every intention of going back to give Resident #2's meds sooner. RN A said she did not put the residents' names on the medication cups. RN A said she had not made this mistake before, and no other resident had looked at their pills prior to taking them and stated they were the wrong medications. During an interview on 1/9/2023 at 10:22 a.m. LVN B stated she worked the 6:00 a.m.-6:00 p.m. LVN B stated on 1/5/2023 she went into Resident #1's room either during or after breakfast. LVN B stated Resident #2 said she had to help Resident #1 from the bathroom. LVN B stated Resident #1 was lying in her bed. LVN B called Resident #1 by her name and Resident #1 said huh? and nothing else. LVN B stated Resident #1 seemed lethargic. LVN B stated she got the DON and they did an assessment and Resident #1's blood pressure was 103 over something but could not remember exactly but said it was low. LVN B stated a neuro exam was done, and Resident #1's pupils were not reactive. LVN B stated she notified the NP and an order was received to transfer Resident #1 to the hospital. LVN B stated Resident #1 was admitted to the hospital with altered mental status diagnosis. LVN B said she was off the next 3 days and was unsure what all had transpired. LVN B said she passed medications in the morning and had a couple in the afternoon. LVN B said when passing meds, she addressed the resident by name, checked vital signs, pulled medications, and went in the room to administer them. LVN B said on the computer system there was a picture of each resident. She said she also verified the resident by the name on the door, and by addressing them by name. LVN B stated when she put meds in the med cup, there was a place on the electronic medication record to put a check mark by the medication to keep track of what has been put in med cup. LVN B stated she did not click on the given button until the resident had taken the medication in case they refused or were unable to take it for some reason. LVN B stated she only dispensed medications for 1 resident at a time. LVN B stated if she would happen to give the wrong medication to a resident, she would immediately notify the Dr., NP., Administrator and DON. During an interview on 1/9/2023 at 1:57 p.m. The NP stated she had been made aware of the medication error on Resident #1 on 1/5/2022. The NP said there was no harm, no lingering side effects, or no treatments/testing that would be necessary. The NP said she had asked the staff to monitor Resident #1's vital signs and report any changes. The NP said there were no issues with Resident #1 not receiving the actual medications she was prescribed, as they were just 1 series of doses. The NP stated that RN A was not following policies, the right patient, the right med, the right dose. The NP felt RN A needed remediation and reported to the Board of Nursing. Record review of the facility policy Adverse Consequences and Medication Errors, with a revision date of April 2014 indicated, a medication error is defined as the preparation of administration of drugs which are not in accordance with physician orders . In the event of a significant medication related error or adverse consequence, immediate action is taken, as necessary to protect the resident's safety and welfare. Significant is defined as requiring hospitalization . The attending physician is notified promptly of any significant error or adverse consequence. The Plan of Removal was accepted on 9:15 a.m. on 1/10/2023, and included the following: Plan of Removal F760 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 1/9/23, for F760 Free of Significant Med Error Action Item: The resident was sent to hospital on 1/5/23 for assessment. Person Responsible: DON Timeline for completion: 1/10/23 Action Item: Medication administration records were reviewed for all other residents with no other errors identified. Person Responsible: RN Regional Nurse Consultant Timeline for completion: 1/10/23 Action Item: Medication administration training, education and competencies including Medication Administration Policies, Adverse Consequences and Medication Errors, Notification of med error to DON/Physician and med error investigations were completed with the nurses on 1/9/23 by the Regional Nurse Consultant. New nursing staff will complete competency prior to working the floor. Person Responsible: Nursing and administration Timeline for completion: 1/10/23 Action Item: medication administration observations will be completed on weekly basis for all shifts until substantial compliance has been achieved. Person Responsible: DON Timeline for completion: 1/10/23 Verification of the Plan of Removal was as follows: a. Reviewed in-service training on 1/7/23 and 1/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on medication administration, error prevention, medication administration policies reviewed. Guidelines for notifying physicians for clinical problems, as well as notifying the NP, and DON. b. Competency Assessment/skills check off for Administering Oral medications was initiated, for all nursing staff, on all shifts. Six had been completed. c. Interviews conducted 1/10/2023 between 11:25 a.m. and 11:43 a.m. revealed LVNs B, F, and G all stated they worked the 6:00 a.m.-6:00 p.m. shift, and had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of reporting med errors immediately and the proper procedure for medication administration, and proper resident identification. An Immediate Jeopardy (IJ) was identified on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-servicing and monitoring interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 760 Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents reviewed for pharmacy services. (Resident #1) RN A administered Resident #2's medication to Resident #1, resulting in Resident #1 experiencing an altered mental status requiring transfer to local hospital for evaluation. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk for a serious decline in health, hospitalization and/or death. Findings included: Record review of Resident #2's Face Sheet dated January 2022 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmission date of 9/2/2020. Resident #2's diagnoses included schizoaffective disorder bipolar type, (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior)., major depressive disorder, and human immunodeficiency virus (a virus that attacks the body's immune system.) Record review of Resident #2's Physician orders dated January 2022 indicated the following medications were to be administered daily to Resident #2 between 7:30 p.m. and 10:00 p.m. Cogentin 1 mg- used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs Prolixin 10 mg- used to treat certain types of mental/mood conditions: (psychotic disorders; schizophrenia) Haldol 5 mg- used to treat certain types of mental/mood conditions: schizophrenia, schizoaffective Isentress 400 mg- used to treat human immunodeficiency virus infections Toprol 25 mg- used to treat symptoms used to treat chest pain, heart failure and high blood pressure Seroquel 500 mg- used to treat certain types of mental/mood conditions: Schizophrenia, Bipolar disorder, sudden episodes of mania or depression associated with Bipolar Disorder Risperdal 3 mg- used to treat certain types of mental/mood disorders; Schizophrenia, Bipolar, irritability associated with autistic disorder Glucophage 1000 mg- used to control blood sugar Eskalith 300 mg- mood stabilizer used to treat or control the manic episodes of Bipolar disorder (manic depression) Record review of Resident #1's Face Sheet dated January 2022 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmission date of 1/6/2023. Resident #1's diagnoses included polyosteoarthritis, (when five or more joints are affected with joint pain), unspecified intellectual disabilities, (when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills), diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania and lows (depression), epilepsy, (a brain disorder that causes recurring, unprovoked seizures.), hypertension ( when blood pressure is too high), and peripheral vascular disease (a slow and progressive circulation disorder). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 9 for cognitive awareness, which indicated she was moderately impaired. The MDS indicated Resident #1 required supervision with set up assistance for transfers, walking in the room or corridor, dressing, eating, toileting, and personal hygiene. Record review of a Facility Event Report dated 1/5/2023 at 9:36 p.m. indicated on 1/4/2023 Resident #1 was given the wrong medications. Resident #1 was sent to the ER. Record review of the nursing progress notes for Resident #1 revealed there were no entries documented on 1/4 or 1/5 2023 by RN A. Record review of a nursing progress note written by LVN B and dated 1/5/2023 at 10:34 a.m. indicated Resident #1 was lying in bed, appeared to be lethargic (lacking mental and physical alertness and activity). with limited speech, and non-reactive pupils. Resident #1 had to have more help than normal. Her BP was 121/63. The Nurse Practitioner was notified and ordered Resident #1 to be sent to the ER for evaluation and treatment. Record review of a nursing progress note written by LVN C dated 1/6/2023 at 3:48 p.m. indicated Resident #1 returned to from the ER related to altered mental status. Resident #1's diagnoses included a UTI and dehydration. Resident #1's mood was pleasant. The NP was notified. Record review of a nursing progress note written by LVN D dated 1/6/2023 at 10:.00 p.m. indicated Resident #1's orientation was within normal baseline with a slightly unsteady gait. Record review of Resident #1's Medication Administration Record dated 1/1/2023-1/7/2023 indicated the following medications were to be administered daily to Resident #1 between 7:30 p.m. and 10:00 p.m. Claritin 10 mg- an antihistamine that treats symptoms such as itching, runny nose, watery eyes, and sneezing from hay fever and other allergies Depakote 500 mg- used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder) Keppra 1,000 mg- used to treat certain types of seizures Lorazepam 1mg- used to treat anxiety Magnesium 400 mg- used to treat vitamin D deficiency Metformin 500 mg-used to control high blood sugar Vimpat 100 mg- used to prevent and control seizures RN A signed the medications as being given to Resident #1 on 1/4/2023. Record review of #1's Hospital Discharge summary dated [DATE] revealed Resident #1 was admitted on [DATE] and discharged back to nursing facility 1/6/2023. Discharge diagnoses included acute urinary tract infection, acute renal failure syndrome (sudden and sustained deterioration of the kidney function) and altered mental status. Hospital course reflected: On 1/6/2023 in discussion with family members it was revealed the patient was given up to 6 medications that were belonging to the patient's neighbor (Resident #2), with most of them being psychiatric with a heavily sedating effect. Upon evaluation in the morning, patient was found alert and orient x3, answering questions appropriately, speaking in full sentences, minimal confusion/disorientation noted in the early morning hours which resolved by the afternoon. Deemed stable for discharge. The hospital record indicated a drug screen was done on 1/5/2023 at 11:10 a.m. The results reflected the resident was negative for methadone, cocaine, THC (psychoactive component in marijuana), barbiturates, benzodiazepines, opiates, amphetamines, and PCP, (Phencyclidine, a sedative narcotic). Record review of a written statement by RN A dated 1/7/2023 indicated the following: On 1/4/23 I mistakenly gave the wrong medications to Resident #1. I was not alerted till I went to give meds to the roommate, and she stated she did not recognize her meds in the cup I gave her. So, I destroyed the meds and repoured in front of the patient and gave her meds at the med cart. I did not notify DON/ADON at this time. Record review of RN A's disciplinary record dated 1/7/2023 indicated the date of violation was 1/4/2023. The rule infracted was medications being given to the wrong resident. RN A was suspended pending an investigation. During an interview on 1/7/2023 at 10:37 a.m. the ADON said RN A worked the 6 p.m.-6 a.m. shift on 1/4/2022. The ADON said RN A did not report the med error until she came to work on 1/5/2022 for her 6 p.m.-6 a.m. shift and found out Resident #1 had been sent to the hospital. The ADON said RN A had 2 med cups with pills, one for Resident #1 and one for Resident #2, who were roommates. The ADON said RN A realized at some point she had given the wrong medicine to Resident #1, which actually belonged to Resident #2. The ADON said the DON was notified at some time around 9:33 p.m. on 1/5/2023. The ADON said Resident #1 usually questioned her meds before taking them. During an interview on 1/7/2023 12:30 p.m. Resident #1 said she was doing well. Resident #1 stated she had returned from the hospital 1/6/2023 and went to the hospital because of too much sugar, and my sugar was high. All the candy I ate at Christmas made my sugars go up, is what the doctor told me. Resident #1 said she took medications in the morning and in the evening and had never had any problems getting the right ones. During an interview on 1/7/2023 12:34 p.m. Resident #2 stated she received medications in the morning and in the evening. Resident #2 said she had problems 2 different times getting the right medications. Resident #2 said she received meds on 1/4/2023, and when she looked at them, she asked the nurse what they were, as they did not look right. Resident #2 said she could not pinpoint the time frame for the first event, but said it was the same nurse, RN A. Resident #2 said RN A gave her meds to her roommate and that was why she went to the hospital. Resident #2 said she did not take any of the meds that were not hers. Resident #2 said RN A was nice and told her she was daydreaming when she was giving the meds. Resident #2 said her roommate is confused at times. During an interview on 1/7/2023 12:40 p.m. the RNC said she was aware of the medication error on 1/4/2022. The RNC said training was started immediately, and that RN A would be called in on this date and suspended until the investigation was completed. During an interview on 1/7/2023 1:45 p.m. RN A stated on 1/4/2022, 6 p.m.-6 a.m. shift she was getting ready to give meds to both Resident #1 and Resident #2. RN A said she got 2 med cups out, filled 1 cup with medications and scooted it back under the computer, filled the other med cup with medications and scooted it back as well. RN A said she went into Resident #1's room, called her name and told her she had her meds. RN A said Resident #1 sat up in bed and she gave Resident #1 the med cup. RN A said Resident #1 looked at the pills and took them. RN A said she walked out of the room and got distracted. RN A said on the evening shift, they were the secretary, they had to answer phones, and the door, and answer call lights so it was 1-2 hours before she went back to give Resident #2 her meds. RN A said she grabbed the other cup of pills that were locked in the med cart, in the same cup she had previously filled. RN A said she handed Resident #2 the cup and Resident #2 looked at the pills said, These don't look right. RN A said she immediately thought oh no what did I do?. RN A said she and Resident #2 went to the med cart. RN A said she looked at the cup and knew she had just given Resident #1 Resident #2's meds. She said she told the resident she did not know what had happened, but she was going to get rid of the meds and start over. RN A said she poured new meds and gave them to Resident #2. RN A said she realized she gave the wrong meds to Resident #1, when Resident #2 said her pills did not look right. RN A stated she did not do what she should have; she should have called the doctor but did not because Resident #1 slept all night. RN A said the next day, 1/5/2023 around 6:30 p.m. she returned to work and saw that Resident #1 had been sent to the hospital. The DON was in the building, and RN A told her what she had done, and was told to complete an incident report. RN A said she probably passed meds to 4-5 residents prior to the incident involving Resident #1 but did not remember for sure. RN A said she did not give any more meds after the incident. RN A said Resident #1 slept all night with no issues noted. RN A said she did not normally fill 2 med cups at one time and had every intention of going back to give Resident #2's meds sooner. RN A said she did not put the residents' names on the medication cups. RN A said she had not made this mistake before, and no other resident had looked at their pills prior to taking them and stated they were the wrong medications. During an interview on 1/9/2023 at 9:35 a.m. the DON stated that on 1/4/2023, RN A did not say anything to her about a medication error. The DON stated on the morning of 1/5/2023 LVN B told her Resident #1 was not looking like herself. The DON stated Resident #1's blood pressure was low (could not remember exactly what it was) and her heart rate went from 60 to 40 beats per minute when aroused. The DON said neuro checks were done and Residents #1's pupils were pinpoint and fixed. The DON said Resident #1 went out to the hospital. The DON said she had called the hospital around 10:00 a.m., and the hospital did not have an update at that time. The DON said the hospital called back later in the day on 1/5/2023 saying Resident #1 was diagnosed with a drug overdose. The DON said she immediately looked at her meds and was puzzled all day, as to what medications Resident #1 had taken to cause a drug overdose. The DON said the hospital did not tell her what, if anything tested positive on the drug screen, or confirm a specific drug. The DON stated the hospital thought it was an overdose based on Resident #1's symptoms of being lethargic. The DON stated Resident #1 was diagnosed with a UTI and encephalopathy (brain disease, damage, or malfunction). The DON said RN A came back to work on 1/5/2023 6p.m.-6a.m. shift. The DON said when RN A saw that Resident #1 was sent to the hospital, she came into her office and said, I think I gave [Resident #2's] medications to [Resident #1]. The DON stated RN A was asked why she was just now reporting it, and never said anything before. The DON said RN A said, I wasn't going to say anything. DON stated she asked RN A why, and RN A said, I don't know. The DON stated RN A said she had 2 med cups of meds, and she gave Resident #1 medications, and when she went to give her roommate, Resident #2, her meds, Resident #2 said the pills were not her medications. The DON stated RN A said she did not give Resident #1 her correct medications, and she had clicked the given button before any meds were given, so the medication administration record reflected the medications Resident #1 was supposed to be given, were not. The DON stated after RN A reported this information to her on 1/5/2023, she notified the Administrator, the RNC, and the NP. The DON stated on 1/6/2022 when Resident #1 returned from the hospital, she was alert and oriented, as she was prior to the event. The DON said she talked to Resident #1 and asked her why she did not look at her meds before taking them, as she usually did. The DON said Resident #1 stated, I was already in bed, and I trusted her. The DON sated Resident #1 said she did not want to get RN A in trouble. The DON stated RN A said after the incident she did not have any more medications to pass. The DON stated RN A should not have signed the medications as being given until after they were administered. The DON stated RN A should only pass medications to 1 resident at a time, according to best practices. She stated RN A should have reported the incident immediately even if she wasn't sure she had made a mistake so Resident #1 could have been sent out for any possible adverse drug reactions. The DON stated she had started in-service training on medication pass, identifying and reporting med errors when she found out the medication error had occurred on 1/5/2023. DON stated she planned to do competency check offs on all nursing staff this week. She stated she also asked staff to do a double check before passing any and all meds; to double check med orders and the right resident. During an interview on 1/9/2023 at 10:22 LVN B stated she worked the 6:00 a.m.-6:00 p.m. LVN B stated on 1/5/2023 she went into Resident #1's room either during or after breakfast. LVN B stated Resident #2 said she had to help Resident #1 from the bathroom. LVN B stated Resident #1 was lying in her bed. LVN B called Resident #1 by her name and Resident #1 said huh? and nothing else. LVN B stated Resident #1 seemed lethargic. LVN B stated she got the DON and they did an assessment and Resident #1's blood pressure was 103 over something but could not remember exactly but said it was low. LVN B stated a neuro exam was done, and Resident #1's pupils were not reactive. LVN B stated she notified the NP and an order was received to transfer Resident #1 to the hospital. LVN B stated Resident #1 was admitted to the hospital with altered mental status diagnosis. LVN B said she was off the next 3 days and was unsure what all had transpired. LVN B said she passed medications in the morning and had a couple in the afternoon. LVN B said when passing meds, she addressed the resident by name, checked vital signs, pulled medications, and went in the room to administer them. LVN B said on the computer system there was a picture of each resident. She said she also verified the resident by the name on the door, and by addressing them by name. LVN B stated when she put meds in the med cup, there was a place on the electronic medication record to put a check mark by the medication to keep track of what has been put in med cup. LVN B stated she did not click on the given button until the resident had taken the medication in case they refused or were unable to take it for some reason. LVN B stated she only dispensed medications for 1 resident at a time. LVN B stated if she would happen to give the wrong medication to a resident, she would immediately notify the Dr., NP., Administrator and DON. During an interview on 1/9/2023 at 10:41 a.m. the ADON said new employees spent 3 days with staff orienting on the med cart. The ADON said she frequently helped administer medications on the floor. The ADON said she looked at the residents' MAR, looked at the pills, and the label on them. The ADON said she made sure she had the right resident. The ADON said she would ask the resident their name if able, she looked at the name on the door, and the picture in Matrix (facility computer system) on the electronic MAR. The ADON stated she only filled meds for 1 resident at a time. She said she checked the residents' medications off by clicking on the prepare button as she put the medication in the pill cup but did not click the given button until after the resident took the meds. The ADON said all staff had been trained/or would be receiving training, including the Mobile Dispatch nurses (nurses working for an inner agency through the corporate office), on the process of reporting med errors, and medication administration. The ADON said RN A did not pay attention to what she was doing, and she did not report a possible med error which should have been reported immediately. During an interview on 1/9/2023 at 10:57 a.m. LVN E stated she usually worked the secured unit. LVN E said she had received training on medication administration/reporting errors. LVN E stated when she passed medications, she first cleaned the cart, then got ice or pudding to have available if needed. She stated she usually got the vital signs on all residents done first. LVN E stated she got medications together and would verify the resident by their picture in the computer. She stated she also asked the resident their name. She stated she would click the prep button and checks off the meds as she put them in the med cup. She stated she then would click the given button after the resident took their medications. LVN E stated if by chance she would give a wrong medication, she would immediately notify the physician, and DON. During an interview on 1/9/2023 at 1:57 p.m. the NP stated she had been made aware of the medication error involving Resident #1 on 1/5/2022. The NP said there was no harm, no lingering side effects, or no treatments/testing that would be necessary. The NP said she had asked the staff to monitor Resident #1's vital signs and report any changes. The NP said there were no issues with Resident #1 not receiving the actual medications she was prescribed, as they were just 1 series of doses. The NP stated RN A was not following policies regarding med pass which included the right patient, the right med, the right dose. Record Review of the facility policy Adverse Consequences and Medication Errors, with a revision date of April 2014 indicated, a medication error is defined as the preparation of administration of drugs which are not in accordance with physician orders . In the event of a significant medication related error or adverse consequence, immediate action is taken, as necessary to protect the resident's safety and welfare. Significant is defined as requiring hospitalization . The attending physician is notified promptly of any significant error or adverse consequence. Record Review of the facility policy Administering Medications, with a revision date of April 2019 indicated Medications are administered in a safe and timely manner as prescribed. Medication errors are document, reported, and reviewed . The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The individual administering the medications verifies the resident's identity before giving the resident his/her medications . The individual administering the medication document in the resident's electronic record after administering the medication . The RDO, RNC, DON, and ADON were notified of an IJ on 1/9/2023 at 4:20 p.m. A copy of the IJ Template was emailed to the RDO and RNC 1/9/23 4:52 p.m. and a Plan of Removal was requested. The Plan of Removal was accepted on 9:15 a.m. on 1/10/2023, and included the following: Plan of Removal F760 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 1/9/23, for F760 Free of Significant Med Error Action Item: The resident was sent to hospital on 1/5/23 for assessment. Person Responsible: DON Timeline for completion: 1/10/23 Action Item: Medication administration records were reviewed for all other residents with no other errors identified. Person Responsible: RN Regional Nurse Consultant Timeline for completion: 1/10/23 Action Item: Medication administration training, education and competencies including Medication Administration Policies, Adverse Consequences and Medication Errors, Notification of med error to DON/Physician and med error investigations were completed with the nurses on 1/9/23 by the Regional Nurse Consultant. New nursing staff will complete competency prior to working the floor. Person Responsible: Nursing and administration Timeline for completion: 1/10/23 Action Item: medication administration observations will be completed on weekly basis for all shifts until substantial compliance has been achieved. Person Responsible: DON Timeline for completion: 1/10/23 Verification of the Plan of Removal was as follows: a. Reviewed in-service training on 1/7/23 and 1/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on medication administration, error prevention, medication administration policies reviewed. Guidelines for notifying physicians for clinical problems, as well as notifying the NP, and DON. b. Competency Assessment/skills check off for Administering Oral medications was initiated, for all nursing staff, on all shifts. Six had been completed. c. Interviews conducted 1/10/2023 between 11:25 a.m. and 11:43 a.m. revealed LVNs B, F, and G said they worked the 6:00 a.m.-6:00 p.m. shift, and had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of reporting med errors immediately and the proper procedure for medication administration, and proper resident identification. An Immediate Jeopardy (IJ) was identified on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-servicing and monitoring interventions.