**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for Resident #1 with two staff members for bed mobility during incontinent care to prevent a fall with injury on 9/19/2024 which resulted in Resident #1 having complaint of pain to the right knee. An x-ray was conducted on 09/19/2024 with the results of evidence of acute fracture of the right distal femur (bone in the upper leg) requiring hospitalization for surgical intervention. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 09/19/2024 and ended on 09/24/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and harm due to the lack of supervision provided by the facility. Findings included: Record review of the face sheet for Resident #1 indicated she was initially admitted on [DATE], was [AGE] years old female with diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease, muscle weakness, muscle wasting, cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), dementia (loss of cognitive functioning), and morbid obesity. Record review of the MDS state optional assessment dated [DATE] indicated Resident #1 required 2 staff members for bed mobility. Her BIMS indicated she was cognitively intact with a score of 14. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1 was able to understand and make her needs known. She required substantial/maximal assistance with the helper doing more than half the effort. Her BIMS indicated she was cognitively intact with a score of 14. Record review of the care plan dated 12/28/2024 indicated Resident #1 had an ADL self-care performance deficit. Resident #1 required 2 staff for assistance with bed mobility, with start date of 08/16/2024. Record review of the physician's orders September 2024 for Resident #1 indicated she had an order for Acetaminophen Tablet 650 mg, give 1 tablet by mouth every 4 hours as needed for general discomfort related to right knee pain with start date of 08/24/2024. Record review of the Kardex (electronic care task utilized by care staff) dated 09/19/2024 indicated Resident #1 required 2 staff for bed mobility. Record review of the nurse progress notes for Resident #1 authored by LVN D indicated on 09/19/2024 at 07:45 a.m., CNA A had reported to LVN D that while getting things ready to change the resident and while waiting on help to change the resident, Resident #1 slid off the bed feet first, so she guided the resident to floor and informed nurse of the incident. The CN performed a head-to-toe assessment and the resident denied pain or hitting her head. Resident #1 was able to move all extremities. The CN provided care to a skin tear to the left toe and Resident #1 was assisted back to bed using a mechanical lift and 3 staff members. Record review of the MAR for September 2024 indicated Resident #1 received 3 doses of Tylenol 650 mg 1 tablets on 09/19/2024 at 8:14 a.m., 4:24 p.m., and 8:29 p.m. for pain and it was effective. Record review of the nurse progress note authored by LVN H for Resident #1 indicated on 09/19/2024 at 4:40 p.m. the resident had an x-ray of her right hip for pain. Record review of the nurse progress note authored by LVN X for Resident #1 indicated on 09/20/2024 at 11:19 a.m. the resident was admitted to local hospital for a closed distal right femur fracture (lower leg bone fracture that occurs without leaving any open wound in the skin) and surgery was scheduled for later that evening. Record review of an x-ray report dated 09/19/2024 indicated Resident #1 had evidence of an acute fracture of the right distal femur (bone in the upper leg) and diffuse osteopenia (a condition of lower-than-normal bone mineral density that may lead to a condition in which bones become weak and brittle) is present. Record review of the nurse progress note authored by LVN D for Resident #1 indicated on 09/20/2024 at 12:02 a.m. the facility received x-ray report which reflected an acute fracture (a break in a bone that occurs due to sudden, one-time injury, typically from direct impact or fall) of the distal femur (bone in the upper leg). Notified the on-call physician of the x-ray report and was ordered to send Resident #1 to the local ER for evaluation. Resident #1 transferred to local hospital via ambulance. Record review of the hospital records dated 09/20/2024 indicated Resident #1 had a distal femur fracture that required surgical intervention. On 09/24/2024 a right femur fluoroscopic (is a medical imaging procedure that uses several pulses (brief bursts) of an X-ray beam to show internal organs and tissues moving in real time on a computer screen) indicated a previous exam showed a fracture of the distal right femur extending into the right knee joint. There had been placement of a plate along the medial aspect (toward the middle or center) with multiple screws and alignment was normal. Impression revealed: Open reduction internal fixature (a surgical procedure used to repair severe bone fractures by realigning and stabilizing the broken bones with hardware such as plates and screws) of right femur fracture. Record review of the facility's investigation report dated 09/26/2024 indicated on 09/19/2024 Resident #1 had a fall from bed requiring head to toe assessment. Resident #1 assisted back to bed using Hoyer lift and 3 staff members. Resident #1 began to complain of hip and knee pain and mobile x-ray ordered. Resident #1's x-ray results showed an acute fracture of the distal femur (upper bone of leg). Resident #1 was transported via ambulance via stretcher to the local hospital related to acute fracture of the distal femur with surgical intervention scheduled for 09/20/2024. The investigation interviews led to CNA A admitting on 09/19/2024 she provided incontinent care alone to a Resident #1 which required 2 persons assistance for incontinent care resulting in Resident #1 falling and having a significant injury. CNA A was suspended and terminated related to this incident. Facility staff in-serviced on following Kardex for required assistance with each resident and on identifying abuse and neglect. Record review of the nurse progress notes authored by LVN X for Resident #1 indicated on 10/01/2024 at 1:19 p.m., the resident was back in facility after she was hospitalized at the local hospital for a right femur fracture with surgical intervention. Resident #1 had a surgical incision to right knee with 14 staples intact. Assist x 2 staff with all ADL's and transfers. Record review of the physician's orders October 2024 for Resident #1 indicated she had an order for Acetaminophen Tablet 650 mg, give 1 tablet by mouth every 4 hours as needed for general discomfort related to pain with start date of 08/24/2024 and Tramadol 50 mg, give 1 tablet every 8 hours as needed for pain with start date of 10/04/2024. Record review of the MAR for October 2024 indicated Resident #1 received 1 dose of Tylenol 650 mg 1 tablet on 10/01/2024, 10/02/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/06/2024, 10/10/2024, 10/15/2024, 10/18/2024, and 10/20/2024 for pain and it was effective, and she received 1 dose of Tramadol 50mg 1 tablet on 10/05/2024, 10/06/2024, 10/07/2024, 10/11/2024, 10/14/2024, 10/16/2024, 10/22/2024 and 10/27/2024 for pain and it was effective. Record review of the Kardex dated 10/01/2024 indicated Resident #1 required 2 staff for bed mobility. Record review of CNA A's personnel file indicated that she was terminated on 09/19/2024 for failing to follow safety protocols and notation showed the employee did not follow the facility's safety protocol with a two-person assistance to turn and reposition a resident in bed and the failure resulted in the resident having a significant injury. Record review of an in-service dated 09/20/2024 indicated nursing staff were retrained on the use of the Kardex system and the Kardex must be followed at all times. If the Kardex indicated that a resident required 2 people for transfer, bed mobility, etc., then staff must have 2 people assisting. Mechanical transfers must always be completed with 2 staff members, no exceptions. During an interview on 06/03/2025 at 9:30 a.m., Resident #1 said she did not remember much about the day she fell. She said she recalled having to go to the hospital and have surgery from a broken leg after the fall. During an interview on 06/03/2025 at 1:05 p.m., LVN H said Resident #1 had always been 2 staff with turning her and for her care. She said Resident #1 required a mechanical lift with 2 staff for transfers. LVN H said the Kardex, and care plan identified care needs and assistance required. During an interview on 06/03/2025 at 1:15 p.m., LVN C said when staff reposition Resident #1 they must use 2 staff. LVN C said the Kardex, and care plan identified care needs and assistance required. During an interview on 06/03/2025 at 1:30 p.m., CNA G said she knew to use 2 staff with Resident #1. She said when giving incontinent care or bed mobility and use a mechanical lift with 2 staff members for transfer out of bed. CNA G was able to correctly identify residents requiring 2 persons assist on her assigned hall and Kardex system to identify if resident required 1 or 2 persons assist. CNA G said if a resident requires a 2 persons assistance always find another staff member to help with care. During an interview on 06/03/2025 at 1:40 p.m., CNA F said she knew to use 2 staff with Resident #1. She said when giving incontinent care or bed mobility and use a mechanical lift with 2 staff members for transfer out of bed. CNA F was able to correctly identify residents requiring 2 persons assist on her assigned hall. CNA F said the Kardex identified care required and assistance needed. CNA F said if a resident requires a 2 persons assistance always find another staff member to help with care. During an observation on 06/03/2025 at 2:00 p.m., revealed CNA G and CNA F provided incontinent care to Resident #1 on her back and pulled her up in the bed and repositioned. Both staff were present the entire time care was provided, and supplies required were obtained prior to the start of care, and adequate assistance/supervision was provided from start to finish. During an interview on 06/03/2025 at 2:45 p.m., CNA A said she had been oriented about the Kardex system. CNA A said on 09/19/2024 she was making her last rounds around 4:30 - 5:00 a.m. alone and was going to provide incontinent care. She said while she was changing Resident #1's brief, she turned her over towards her and the resident rolled off the bed, landed on her feet but her knees buckled because she can't walk/hold her weight and she guided/assisted Resident #1 to the floor. She said Resident #1 was a 2 person assist with task but because the facility was always short staffed, she had to provide the care by herself. She said Resident #1 was a large lady and she should have had someone assist her while providing care. She said that the Kardex provided if the resident required 1 or 2 persons to assist with care and Resident #1 was a 2 person assist and she should have requested help or waited on help. She said, If care would not have been provided would have got in trouble and now got terminated for the incident. Record review of staffing schedule for nursing on 09/18/2024 indicated the 6:00 p.m. to 6:00 a.m. shift had 3 LVNs and 6 CNAs scheduled. An attempted telephone interview on 06/03/2025 at 3:45 p.m. with LVN D, was unsuccessful. During an interview on 06/03/2025 at 6:10 p.m., CNA Q said Resident #1 required 2 staff members for bed mobility and mechanical lift with 2 staff members for transfers. He said he looked at the Kardex and provided care as directed on the Kardex. During an interview on 06/03/2025 at 6:10 p.m., CNA R said Resident #1 required 2 staff members for bed mobility and mechanical lift with 2 staff members for transfers. She said she looked at the Kardex and provide care as directed on Kardex. CNA R was able to correctly identify residents requiring 2 persons assist on her assigned hall. During an interview on 06/03/2025 at 6:35 p.m., the ADON/LVN B said CNA A was terminated on 09/20/2024 due to failing to follow facility safety protocol. The ADON said all the nursing staff were retrained on the Kardex system to ensure all staff knew about the residents who needed 2 staff for bed mobility. The ADON said his expectation was for the staff to get help in turning the residents who required 2 staff members per Kardex or care plan. During interviews on 06/03/2025 at 8:00 a.m. to 7:00 p.m. and 06/04/2025 at 7:00 a.m. to 3:00 p.m., 14 CNAs (CNA F, CNA G, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA U, CNA V and CNA Y), and 8 LVNs (ADON/LVN B, LVN C, LVN D, LVN E, LVN H, LVN J, LVN T and LVN W) revealed all the staff were retrained on the Kardex system and said the program indicated how many staff was required for eating, transfer, bed mobility and ambulation. During an interview on 06/04/2025 at 9:00 a.m., the Administrator said she expected the staff to use the Kardex system and get help when help was needed or required. The facility policy revised July 2017 titled Safe Lifting and movement of Residents indicated the Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include Resident's preferences for assistance; Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability; Cognitive status; Whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged . On 06/04/2025 at 10:28 a.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 09/19/2024 and ended on 09/24/2024. The facility had corrected the noncompliance before survey began.

**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 4 of 14 residents (Resident #2, #3, #4 and #5) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2, #3, #4, and #5 were free of abuse from Resident #1. -On 07/10/24 Res #1 hit Res #3's head. -On 07/21/24 Res #1 hit Res #2 in the TV room. -On 07/22/24 Res #1 pushed Res #2 in the TV room. Res #2 sustained a head injury and was sent out to the ER for treatment. -On 09/02/24 Res #4 alleged Res #1 hit her. -On 11/24/24 Res #1 punched Res #3 in the forehead and chest. -On 12/28/24, Res #1 hit Res #5 in the face in the dining room The facility did not review, update, or implement interventions to include adequate supervision and continued to leave Resident #1 alone and unsupervised with other residents. An Immediate Jeopardy (IJ) was identified on 02/26/25 at 2:00 p.m. The IJ template was provided to the facility on [DATE] at 2:15 p.m. While the IJ was removed on 02/27/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of physical abuse from other residents. Findings included: 1. Record review of Resident #1's face sheet dated 02/20/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizophrenia (chronic mental disorder), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin), convulsions (sudden, violent, irregular movement of a limb or of the body), latent syphilis (a stage of syphilis infection where the bacteria (Treponema pallidum) remains in the body without causing any noticeable symptoms), and OCD (unwanted thoughts and fears, or obsessions). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she was admitted to the facility with a serious mental illness, she was able to make herself understood and understood others, and she had mild cognitive impairment (BIMS-9). Record review of Resident #1's care plan dated 04/09/24 indicated she sometimes displayed verbally aggressive behavior. Interventions included social services to evaluate and visit with me, activity staff to visit with me, provide diversional activities, and remove me from public area when behavior is disruptive and unacceptable. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of Resident #1's care plan dated 06/12/23 indicated Resident #1 had potential to be physically aggressive by resident to resident altercations related to history of harm to others. Interventions included administer medications as ordered, labs as ordered by physician, monitor, document, and report PRN any sign or symptom of resident posing danger to self and others, and nursing staff to notify abuse coordinator, police, Ombudsman, MD, RP and psych, and psychiatric/psychogeriatric consult as indicated. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of Resident #1's care plan dated 04/20/24 indicated Resident #1 had a behavior problem related to schizophrenia and OCD. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of progress note dated 07/10/24 at 10:00 a.m., completed by LVN B indicated she was sitting at the desk charting and heard a loud noise. LVN B heard HSK Z say Resident #1 hit Resident #3 in the back. Resident #1 and Resident #3 were standing at the double doors of the secure unit. Resident #3 was crying and there was some redness to her upper back. MD A, Administrator, Ombudsman, NP K, (named police department), and DON notified. LVN B did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of IDT progress note dated 07/16/24 completed by the DON for Physical Aggression that occurred on 07/10/24 indicated Resident #1 was still showing signs of aggression and was sent out to behavior hospital on [DATE]. The IDT note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of facility investigation dated 07/17/24 indicated Resident #1 was discharged to behavioral hospital on [DATE]. The facility confirmed Resident #1 hit Resident #3. Psych notification ordered 15 minute monitoring and labs. Resident #1 remained on 15 minute monitoring and continued to show signs of aggression until discharged to behavior hospital. Staff were trained on abuse/neglect/exploitation on 07/10/24. Monitoring sheets dated 07/10/24-through 07/12/24 indicated Resident #1 was on 15 minute monitoring. The investigation did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note dated 07/18/24 at 1:45 p.m., completed by LVN A indicated Resident #1 returned to the facility from the behavior hospital. LVN A did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note date 07/19/24 at 12:48 p.m., completed by LVN B indicated Resident #1 refused to let her roommate use the bathroom in their shared room. Resident #1 told the CNA to fuck off when she told Resident #1 her food was in the room. Record review of Resident #1's progress note dated 07/21/24 at 9:12 a.m., completed by LVN B indicated at 6:15 a.m. LVN B was at the medication cart. Resident #1's roommate stated Resident #1 hit another resident in the chest. There was no redness or complaint of pain from the other resident. Resident #1 was separated from the other resident. Critical monitoring started. Message left for NP/MD. Administrator and DON notified. (named police department) notified. NP K and RP notified. LVN B did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note dated 07/22/24 at 08:32 a.m., completed by LVN A indicated Resident #1 pushed another resident down in the TV room. Administrator, DON, (named police department), and Ombudsman notified. Resident #1 on 1-1 at this time. (named police department) arrived at 7:20 to talk to Resident #1. Resident refused to tell (named police department) what happened or why it happened. RP notified. Record review of Resident #1's IDT Behavior Health Review dated 07/23/24 indicated Resident #1 was sent to behavioral hospital on 7/10/24 and returned back to the facility on [DATE]. Resident #1 came back with no new orders. Labs drawn and received critical ammonia level. New orders for Lactulose 15 ml tid x 5 days. Educated staff on recognizing agitation and de-escalate behaviors. Interventions care planned for all events. Emergency care plan set up with family related to behaviors and possible discharge from the generation unit. Psych NP involved and received no medication change. 07/21/24 Resident #1 was placed on q 15 min behavioral monitoring due to behavioral and MD and psych notified. Psych stated they would see the resident on visit. 07/22/24- Resident #1 placed one to one and sent out to the behavioral related to physical aggression. There was no resident specific intervention implemented to prevent and protect other residents from Resident #1's aggression towards others. The note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors upon her return to the facility. Record review of the facility investigation dated 07/24/24 indicated Resident #1's roommate came to LVN B and said Resident #1 hit another resident in the chest. There was no redness or open areas noted to the other resident's chest and no complaint of pain. Residents were separated immediately. Psych was notified and Resident #1 was place on q 15 minute behavioral monitoring. Staff was inserviced on abuse and neglect and improving resident behavior. Behavior monitoring to continue for 72 hours post allegation with Q 15 min for first 24 hours. There were no specific interventions noted to prevent Resident #1's aggression toward others. The investigation did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of facility investigation dated 07/29/24 indicated Resident #1 was noted sitting in the television room on 07/22/24 when another resident reported to LVN A that Resident #1 had pushed Resident #2 to the floor. Residents were separated immediately. Resident #2 sustained a 1 inch laceration to the back of her head. Psych stated to do an q 15 min behavioral monitoring. Resident #1 placed on one on one and sent to behavioral hospital. Resident #2 sent out to medical center for evaluation and treatment Upon Resident #2 returned with 6 staples noted to the back of her head. In-services provided on abuse and neglect and notifying abuse coordinator/administrator with any allegation of abuse, neglect or misappropriation. In-service completed on behavior monitoring and interventions to use to dissuade physical altercation behaviors. Emergency care plan held with family. Behavior monitoring to continue for 72 hours post allegation with Q 15 min for the first 24 hours. There were no specific interventions noted to prevent Resident #1's aggression toward others. Record review of IDT Event Review dated 09/03/24 for Physical Aggression initiated on 09/02/24 indicated Resident #4 reported to the nurse that Resident #1 hit her on the back of the head while she was coming out of their shared room. There was no injury. Residents were immediately separated and place on behavior monitoring q-15 minute monitoring for 72 hours. Orders received to send Resident #1 to hospital for psych evaluation. Resident #1 transferred to another room. Psych NP visited on 09/03/24 and received order to send Resident #1 out to behavioral hospital. Resident returned from hospital and was transferred to behavior hospital. The note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note dated 11/24/24 at 11:25 a.m., completed by LVN B indicated LVN B was standing at the medication cart with her back turned away from the residents and heard a CNA shout no. CNA reported Resident #1 hit Resident #3 forehead and chest. The residents were separated. There were no injuries. Administrator, psych NP, family, RP, ombudsman, named police department and physician notified. Record review of facility investigation dated 11/29/24 indicated psych ordered 15 minute behavioral monitoring for 72 hours. The facility confirmed Resident #1 abused Resident #3. Record review of Resident #1's progress note dated 12/28/24 at 8:00 a.m., completed by LVN A indicated CNA was standing in the doorway monitoring residents in the dining room when she witnessed Resident #1 getting up from a table and went to another table and struck Resident #5 in the face. Staff separated residents. Resident #1 was on 1-1 monitoring. Administrator, DON, ADON, were notified immediately. (named police department) was called. Ombudsman was notified. On call was notified and gave new orders to send Resident #1 out for evaluation. Psych was called. Resident was transported to ER for evaluation. Record review of Resident #1's progress note dated 12/29/24 at 2:55 a.m., completed by LVN AA indicated Resident #1 returned to the facility. Resident RP and MD notified of Resident #1's return. Will continue to monitor resident for behaviors and all other concerns. LVN AA did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of IDT Event Review dated 01/03/25 for physical aggression initiated on 12/28/24 indicated Resident #1 was unable to say what happened or why. Resident #1 was sent to ER for evaluation. She returned with no new orders. Psych indicated discontinue 1-1 and begin 15-minute monitoring for 72 hours. Psych would see resident next facility visit. The note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors upon her return to the facility. Record review of the facility investigation dated 01/03/25 indicated Resident #1 and Resident #5 were in the dining room on 12/28/24 at 7:57 a.m. Resident #1 walked over to Resident #5 and struck him in the face. Residents were separated. Residents were assessed. There were no injuries. Resident #5 asked why Resident #1 hit him. Resident #1 was place on 15 minute monitoring and transferred to the ER for evaluation and treatment. Resident #5 did not provoke Resident #1. Staff were in-serviced on abuse and neglect. Staff were in-serviced on improving resident behaviors (resident-to resident altercations)-redirect any resident that is causing agitation towards another resident. Separate residents immediately before/after an altercation and monitor each resident. 2. Record review of Resident #2's face sheet dated 02/25/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnosis included IDD (intellectual or developmental disorder), anxiety (a feeling of fear, dread, and uneasiness), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin), depression (mental health condition), and delirium due to known physiological condition (state of acute mental confusion and disorientation caused by an underlying medical condition). Record review of Resident #2's annual MDS dated [DATE] indicated was usually able to make herself understood and understood others, had severe cognitive impairment (BIMS-5), had verbal behavioral symptoms directed at others that put her at risk for physical illness or injury and significantly interfered with the resident's participation in activities or social interactions. She had wandering behaviors that significantly intruded on privacy or activities of others. Record review of Resident #2's care plan dated 12/14/23 indicated she was an elopement risk/wanderer related to a history of wandering. Interventions included admit to secure unit, identify pattern of wandering, and intervene as appropriate. Record review of an incident report dated 07/22/24 completed by LVN A indicated an un-named resident notified LVN A Resident #2 was pushed down by another resident. Resident #2 was crying and lying on the floor of the activity room. Resident #2 had bleeding and a 1 inch laceration to the back of her head. Resident #2 was sent to the ER for evaluation and treatment. Record review of Resident #2's hospital records dated 07/22/24 indicated she was admitted due to a fall caused by being pushed by another resident. She had a laceration to the back of her head. It was repaired with 6 staples. 3. Record review of Resident #3's face sheet dated 02/26/25 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included schizoaffective disorder-bipolar type (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), anxiety (a feeling of fear, dread, and uneasiness), cognitive communication deficit (problems with communication), and dementia (loss of cognitive functioning). Record review of Resident #3's annual MDS assessment dated [DATE] indicated she was sometimes able to make herself understood and usually understood others, and she had severe cognitive impairment (BIMS-00). Record review of Resident #3's care plan dated 07/30/21 indicated Resident #3 had cognitive impairment and required cues and redirecting. Interventions included repeating information, allowing time for response, and assist as needed with tasks. Record review of Resident #3's care plan indicated she had a history of inappropriate/disruptive behavior. Interventions included activities, administer medications, and monitor and document behavior. Record review of Resident #3's care plan dated 04/28/22 indicated she wandered aimlessly and significantly intruded on privacy and activities. Interventions included offering diversions, activities, food, conversation, television or books. Record review of progress note dated 07/10/24 at 4:15 p.m., completed by LVN B indicated she was charting at the desk in the hall and heard a loud noise. LVN B heard HSK Z say Resident #1 hit Resident #3 in the back. Both residents were standing at the secure unit double doors. There was some redness noted to Resident #3's upper back. Residents were separated for safety. 4. Record review of Resident #4's face sheet dated 02/26/24 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included schizophrenia (mental health disorder), major depressive disorder (mood disorder), mild cognitive impairment (stage between normal aging and dementia), anxiety (a feeling of fear, dread, and uneasiness), and dementia (loss of cognitive functioning). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, and she had severe cognitive impairment (BIMS 6). Record review of Resident #4's care plan dated 09/20/24 indicated she had the potential for physical aggression. Interventions included critical behavior monitoring, separate resident from other resident, and intervene before agitation escalates. Record review of IDT Event Review dated 09/03/24-Physical Aggression Received on 09/02/24 indicated Resident #4 reported Resident #1 hit her on the back of the head. Residents were separated and assessed with no injuries or pain. Resident #4 stated she was o.k. and no distress was noted. Resident #4 was transferred to another room. 5. Record review of Resident #5's face sheet dated 02/26/25 indicated he was an [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (loss of cognitive functioning and cognitive communication deficit (problems with communication). Record review of Resident #5's quarterly MDS assessment indicated he was able to make himself understood and understood others and had severe cognitive impairment (BIMS-3). Record review of Resident #5's care plan dated 07/19/23 indicated he had impaired cognition related to dementia. Interventions included cue, reorient and supervise as needed. During an observation on the secure unit on 02/20/25 at 11:00 a.m., Resident #1 was asleep in her room with the door closed. There were other residents observed walking in the hall, in their rooms, or in the TV room and dining room. There was no staff observed near Resident #1 or her room. During an interview on 02/20/24 at 11:30 a.m., CNA G said on 12/28/24, Resident #1 was leaving the dining room and then she turned around and hit Resident #5 in the face. She said she redirected Resident #1 to her room and called for the nurse. She said there was nothing happening at the time of the incident. She said there was no warning before Resident #1 hit Resident #5. She said there was no specific interventions to prevent Resident #1's aggression towards others. She said staff could only watch and intervene and separate before and after the aggression. During an interview on 02/20/25 at 1:12 p.m., CNA G said she was working on 07/22/24 when Resident #1 pushed Resident #2 to the floor in the TV room. She said she was not working the day before when Resident #1 hit Resident #2 and was not aware of the incident. She said she was not aware Resident #1 was being monitored. She said Resident #1 was no on 1-1 monitoring for behavior. She said she was busy with other resident care and LVN A was at the medication cart in the hallway. During an interview on 02/20/25 at 1:20 p.m., CNA H said she was assisting other residents in the shower and did not observe Resident #1 push or hit Resident #2 on 07/22/24. She said she was not aware Resident #1 was on 15 minute monitoring. She said after Resident #1 pushed Resident #2 the residents were separated. She said Resident #1 was in her own room after the incident. During an interview on 02/20/25 at 1:23 p.m., LVN A said the aides were taking care of the residents and as they got each resident ready for the day, each resident was brought to the TV room. She said Resident #1 was already in the TV room. She said she was busy passing medications and heard a bump and then Resident #4 said Resident #1 pushed Resident #2 to the floor. She said she went to the TV room and and separated the residents. She said Resident #1 refused to say what happened and refused to leave the TV room. She said one aide stayed with Resident #1 while they moved the other residents. She said Resident #2 had a 1 inch laceration to the back of her head and was sent out to the hospital. She said Resident #1 was on 15 minute monitoring that started from 07/21/24. She said Resident #1 eventually went to her room and and stayed in in her room until a referral and transfer to to a behavioral hospital on [DATE]. During an interview on 02/21/25 at 9:30 a.m., the DON said the facility had attempted to discharge Resident #1 to another facility but no facility would accept her due to her aggressive behaviors. She said Resident #1 resided on the secure unit. She said there was 1 nurse on shift (6a-6p and 6p-6a 7 days/week), 2 aides (6a-2p,2p-10p, and 10p-6a 7 days/week) and 1 activity staff/CNA (8a-5p Monday through Friday). She said said staff was increased to protect the residents from aggressive behavior. She said Resident #1 was assessed for any medical issues, removed and separated from other residents, and had psychiatric interventions after each behavior. She said Resident #1 was sent to the ER and then, if necessary, referrals were obtained to send her to a behavioral hospital. She said Resident #1 may have been on 1-1 prior to being sent out to the behavior hospital. She said if there was no additional signs of aggression or behaviors the monitoring was reduced. During an interview on 02/21/25 at 12:22 p.m., SW J said she was employed with the facility since December 2024 and had not attempted to find alternative placement for Resident #1. She said she was aware the previous SW had attempted to find alternative placement for Resident #1 but was not successful due to her behaviors. During an interview on 02/24/25 at 12:30 p.m., LVN C said the IDT discussed interventions for the incident that occurred on 07/22/24 when Resident #1 pushed Resident #2. She said there were no new specific interventions to protect other residents from Resident #1's aggression added to the care plan. She said she did not know why interventions were not added. She said she was responsible for adding the interventions to the care plan. She said the monitoring intervention was already in place. During an interview on 02/25/25 at 1:34 p.m., LVN B said there were no residents who were said they were afraid or acted as if they were afraid of Resident #1. She said staff have to watch and be on the look out for Resident #1 was she is walking past or by other residents because her aggression and behaviors were unpredictable. During an interview on 02/25/25 at 1:40 p.m., Activity Staff C said she was not aware of any residents or staff who were afraid of Resident #1. She said staff would attempt to keep Resident #1 separate from other residents to avoid aggressions. During an interview on 02/25/25 at 1:45 p.m., Resident #5 said he was not afraid of anyone. He said he did not get hit by anyone or remember anyone hitting him. During an interview on 02/25/24 at 3:48 p.m., NP F said it was her first psych visit with Resident #1 was on 12/23/24. And she was in the process of reviewing her medications for possible adjustments. She said it would be her expectations the facility would implement 1-1 after resident to resident aggression until the resident was calm then go to 15 minute monitoring. She said moods were not predicable and behaviors would happen. She said she did not know what interventions were available to prevent the behaviors. She said the resident may need a referral to a behavior hospital if the behavior was not caused by a medical issue. During an interview on 02/25/25 at 4:30 p.m. LVN B said staff knew to be aware of Resident #2 wandering around Resident #1 and to keep them separate. She said she was usually in the hall monitoring to keep residents away from resident #1. During an interview on 02/25/25 at 4:34 p.m., CNA I said Resident #1's behaviors were unpredictable. She said staff were aware of her behaviors and monitored other residents to keep them away from Resident #1. She said she was not aware of any specific interventions to prevent Resident #1's behaviors. She said she was standing in the hall on 11/24/24 and she saw Resident #1 used her right hand/fist and hit Resident #3 on her forehead and her chest. She said she told the charge nurse and the residents were separated. During an interview on 02/25/25 at 5:40 p.m., the DON said Resident #1 was not monitored every 15 minutes for behaviors upon her return from the behavior hospital. She said Resident #1 was monitored for 72 hours just as every new admission was monitored. She said there was no policy related to resident behavior monitoring. During an interview on 02/26/25 at 8:30 a.m., Resident #4 said she saw Resident #1 push Resident #2 in the TV room. She said Resident #2 fell and hit her head. She said Resident #2's head was bleeding. She said Resident #2 was not doing anything to Resident #1. She said there was no staff in the TV room. She said LVN A was in the hall with the medication cart. She said she told LVN A that Resident #1 pushed Resident #2 and the staff came running fast to take care of Resident #2. She said she did not know if any other residents were afraid of Resident #1 except Resident #2. She said Resident #2 would come and sit by her (Resident #4) if Resident #1 would be in the same room. During an observation on the secure unit on 02/26/25 at 9:00 a.m., Resident #1 was in her room, dressed and sitting on her bed. She said she was fine and had no complaints. There was no signs of distress or agitation. There were other residents observed walking in the hall, in their rooms, or in the TV room and dining room. There was no staff observed near Resident #1 or her room. During an interview on 02/26/25 at 9:10 a.m., LVN A said Resident #1 was in the TV room. She said Resident #2 walked into the TV room. She said she heard a loud noise from the TV room and then Resident #4 came and told her (LVN A) that Resident #1 had pushed Resident #2 to the floor. She said Resident #1's behaviors were unpredictable. She said at the time of the incident on 07/22/24, Resident #1 was on 15 minute monitoring from 07/21/24. During an interview on 02/26/25 at 10:00 a.m., the Administrator said Resident #1 was constantly redirected due to her behaviors. She said staff were aware they had to be attentive to Resident #1 due to her history of aggressive behaviors and her risk of aggressive behavior. She said the facility was doing everything possible to prevent behaviors including activities and medications changes. She said she was not aware Resident #1 was left alone in the TV room on 07/22/24. She said she was not going to say whether or not Resident #1 should have been left alone with other residents. During an interview on 02/26/25 at 10:15 a.m., LVN C said behavior interventions should be on Resident #1's care plan. She said the interventions should have included educating staff, redirection, and activities. She said resident specific interventions should be on the Kardex and available for all staff. During an interview on 02/26/25 at 10:20 p.m., the DON said Resident #1's was compulsive and her behaviors could not be anticipated. She said the facility had previously attempted to find alternate placement but was not successful due to her aggressive behavior. During an interview on 02/26/25 at 11:00 a.m., CNA G said she was not aware Resident #1 was being monitored for behaviors or that anyone should have been watching her on 07/22/24. She said other residents were at risk of Resident #1's aggressive behaviors because the behaviors were unpredictable. She said staff had to watch Resident #1 and keep her separate from other residents or keep other residents away from being too close to Resident #1. During an interview on 02/26/25 at 11:00 a.m. CNA H said she was not aware Resident #1 was being monitored for behaviors or that anyone should have been watching her on 07/22/24. She said Resident #1 had unpredictable aggressive behaviors. She said all residents had to be keep away from Resident #1 for their protection. During an interview on 02/26/25 at 11:00 a.m., LVN A said she was aware of Resident #1 being on 15 minute monitoring but was not aware of the reason for the monitoring. She said she would look to see where Resident #1 was and what she was doing and document on the sheet. She said on 07/22/24 after the incident, Resident #1 refused to say anything. She said Resident #2 said Sorry mama help. She said Resident #1's behaviors were unpredictable and all other residents on the secure unit were at risk from her aggressive behaviors. During an interview on 02/26/25 at 2:47 p.m., NP K (previous psychiatric provider) said Resident #1's behaviors were unpredictable and she was a danger to others. She said it was her opinion Resident #1 was not appropriately placed in the facility. She said she was aware the facility had attempted to find alternate facility placement and was not successful. She said Resident #1 really needed placement in a state facility. She said Resident #1's medications never really worked and were always being adjusted but nothing ever worked to prevent the unpredictable behaviors. Review of the facility's Abuse and Neglect Policy dated 04/2021 indicated 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 resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; . 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. 10. Protect residents from any further harm during investigations. An Immediate Jeopardy/Immediate Threat was identified on 02/26/25 at 2:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 14 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA D had assistance from another staff member during incontinent care on 01/13/24 which resulted in Resident #1 rolling off the bed and being transferred to the hospital where she was diagnosed with a small left anterior frontal scalp hematoma. The noncompliance was identified as PNC. The Immediate Jeopardy began on 01/13/24 and ended on 01/15/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for falls resulting in injury, pain, and hospitalization. Findings included: Record review of Resident #1's face sheet dated 03/11/24 indicated she was a [AGE] year-old female admitted [DATE], and her diagnoses included quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food status, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record review of Resident #1's MDS assessment dated [DATE] indicated she was rarely/never understood, had severely impaired cognitive skills, and was totally dependent with two+ persons physical assist for bed mobility, transfers, and toilet use. Record review of Resident #1's care plan dated 05/23/22 (revised 05/09/23) indicated she was totally dependent on two staff for bed mobility, toilet-use, bathing/showering, dressing, and transfers. Record review of Resident #1's [NAME] (electronic care task utilized by care staff) dated 03/11/24 indicated she was totally dependent on two staff for bed mobility, toilet-use, bathing/showering, dressing, and transfers. Record review of Resident #1's progress note dated 01/13/24 at 10:30 p.m., completed by LVN C, indicated CNA D approached the nurse station and requested assistance with Resident #1. CNA D stated Resident #1 had fallen on the floor. Resident #1 was lying face up, awake and alert, and responded to stimuli. There was a hematoma on the left side of her forehead. The physician, family member, DON, and Administrator (abuse coordinator) were notified. Resident #1 was transported to the hospital for evaluation and treatment. Record review of Resident #1's progress note dated 01/14/24 at 3:04 a.m., completed by RN E indicated hospital reported Resident #1 was stable. CT results were pending. Record review of Resident #1's progress note dated 01/14/24 at 4:33 a.m., completed by RN E indicated the hospital reported Resident #1's CT showed no irregularities and would be transported back to the facility. Record review of Resident #1's progress note dated 01/14/24 at 5:40 a.m., completed by RN E indicated Resident #1 returned to the facility. She had a slightly raised area to the middle left side of her forehead. Record review of Resident #'s hospital CT record dated 01/14/24 indicated a small left anterior frontal scalp hematoma. Record review of the facility's investigation report dated 01/16/24 indicated on 01/13/24 at 10:30 p.m., CNA D provided incontinent care to Resident #1 by herself. CNA D attempted to reposition Resident #1 in her bed. Resident #1 rolled off the bed and fell on to the floor. Resident #1 sustained a small hematoma to the left side of her forehead. Resident #1 was transferred to the hospital for treatment. Resident #1 returned to the facility on [DATE]. At 5:40 a.m. Resident #1's CT dated 01/14/24 indicated no irregularities. During an interview on 03/11/24 at 10:30 a.m., the Administrator said CNA D was providing incontinent care to Resident #1 without a second staff on 01/13/24. She said Resident #1 fell off the bed and sustained a small hematoma to the left side of her forehead. She said there was no reason for CNA D to provide Resident #1's incontinent care without a second staff. She said the facility was not short staffed. She said CNA D did not request assist for any of the other CNA on shift or any of the nurses on shift. She said it was her expectation CNA D and all staff would follow the care guide on Resident #1's [NAME]. She said Resident #1 could have sustained a more serious injury. She said CNA D was suspended pending the facility's investigation. She said CNA D was trained during her orientation to provide care per Resident #1's [NAME] care guide. She said CNA D and all staff were retrained on following resident care guide on 01/14/24 and 01/15/24. During an interview on 03/11/24 at 12:18 p.m., CNA D said she provided incontinent care to Resident #1 without a second staff to assist on 01/13/24. She said she did not see any available CNA to ask for assistance. She said she did not ask any of the nurses for assistance. She said she went to reposition Resident #1 in the bed and Resident #1 rolled off the bed on to the floor. She said she went to the nurse station to report the fall and get assistance to put Resident #1 in bed. She said LVN C assessed Resident #1 and checked for injuries. She said Resident #1 had a small bump and bruise on her left forehead area. She said Resident #1 was crying. She said EMS arrived at the facility and transported Resident #1 to the hospital. She said she was trained on the [NAME] and resident care guide. She said she thought Resident #1 was a 1-person or a two-person assist. She said she was told by CNA E during her orientation that if she felt comfortable, she could do Resident #1's care by herself. She said she did not check the [NAME] to verify Resident #1's level of care or assistance required for ADLS. During an interview on 03/11/24 at 2:03 p.m., CNA F said she was retrained to follow the [NAME] resident care guide after Resident #1 fell off her bed on 01/13/24. She said she had performed Resident #1's incontinent care by herself and without staff second staff on previous occasions but Resident #1 had not fallen off the bed. She said CNA D did not ask other staff for assistance on 01/13/24. She said she did not know why CNA D had performed Resident #1's care without a second staff. She said CNA D said she was a new staff and did not feel comfortable without a second staff. She said there was other staff available to assist with Resident #1's care but CNA D had not asked anyone for assistance. During an interview on 03/13/24 at 10:30 a.m., the Administrator said all staff were trained on the [NAME] during orientation. She said the [NAME] was not specifically listed on the check-off list. She said it was added as a separate check off and skills packet to the orientation packet after Resident #1 fell from her bed on 01/13/24. During an interview on 03/13/24 at 10:30 a.m., the RNC said the facility started retraining staff on 01/14/24 and 01/15/24 to use the [NAME] to ensure they provide the required level of care for each resident. She said all staff were retrained and passed a test and were able to access the [NAME] and provide the required level of care. The surveyor attempted to contact LVN C for an interview on 03/11/24 1:29 p.m. She did not respond. The surveyor attempted to contact RN E for an interview on 03/11/24 at 1:31 p.m. She did not respond. Record review of the facility's Safety and Supervision of Residents policy dated 2001 (revised July 2017) indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Systems Approach to Safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. On 03/13/24, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 01/14/24-01/15/24 involving Resident #1 by: Observations of staff on 03/11/24 and 03/13/24 providing care indicated no observed concerns. During interviews on 03/11/24 from 9:30 a.m. through 4:00 p.m., and 03/13/24 from 9:30 a.m. through 2:20 p.m., 5 LVN's (on all shifts) 10 CNA's (on all shifts) and the ADON said they received training prior to the incident and after the incident on 01/13/24 from the DON and the RNC regarding resident abuse, neglect, rights and resident [NAME] care levels. The nursing staff verbalized understanding of the trainings and were able to give examples of resident [NAME] care levels, they would ask for assistance if required, they would report any non-compliance of care level to the Administrator, DON, or charge nurse. Interviews conducted on 03/11/24 and 03/13/24 with 3 residents who required 2 person assist with ADLS indicated they had no complaints or concerns with their care and always had two staff as required. They would report to the Administrator or the DON if staff attempted to provide care without a second staff. Record review of staff re-training dated 01/14/24 and 01/15/24 indicated all facility nursing staff were retrained on the residents' [NAME] and level of care and continued to 3/07/24 with new hires. The facility tested and competency assessed all nursing staff for [NAME] and level of care on 01/15/24. All nursing staff passed the test and check off skills for the [NAME] and resident care system. Record review of the auditing and monitoring of three random residents and staff conducted by the Administrator and DON weekly from 01/14/24 through 03/13/24 indicated no additional issues or concerns related to resident care were identified. The facility retrained CNA D on 01/18/24, related to the [NAME], level of care and 2-person required for bed mobility for the [NAME] system and to check for proper assist level. As of 03/13/24, the facility continued to randomly monitor 3 staff per week to ensure staff provide the required level of care. Record review of QAPI notes dated 01/2024 showed a meeting was held to discuss the incident with Resident #1 on 01/13/24. Members present included the Administrator, DON, Medical Director, MDS Coordinator, and ADON A and ADON B. The interventions and plan for correction included: retraining all CNAs and LVNs and new hires on 2-person assist and how to check the [NAME]. Record review of the staff in-services dated 01/14/24 through 01/15/24 included: 2-person assist and how to check the [NAME]. The noncompliance was identified as PNC. The Immediate Jeopardy began on 01/13/24 and ended on 01/15/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 27 residents (Resident #s 5 and 10) reviewed for abuse in that: 1. On 6/12/23, after LVN A was hit by Resident #5, LVN A assaulted Resident #5. She pushed Resident #5 hard against a wall, elbowed her in the face, and scratched her face. LVN A continued to work in the facility from the time of the incident (approximately 5:16 p.m.) until 9:11 p.m. on 06/12/23 and from 6 a.m. until 9:30 a.m. on 06/13/23. 2. On 7/24/23 CNA B restrained Resident #10 by the wrists, put her hands around Resident 10's neck, and was rough with her during care. CNA B worked from the time of the incident (approximately 5:16 p.m.) until 10:03 p.m. An Immediate Jeopardy (IJ) situation was identified on 10/31/23. The IJ template was provided to the facility on [DATE] at 2:32 p.m. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #5's face sheet dated 10/27/23 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and latent syphilis a period when there are no visible signs or symptoms of syphilis; a multisystem chronic infection caused by treponema pallidum. It can cause psychiatric disorders including depression, mania, psychosis, personality changes, delirium and dementia). Record review of Resident #5's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate impaired cognition (BIMS score 7). She had hallucinations and delusions. She had physical and verbal behavioral symptoms directed at others every 1-3 days. She had other behavioral symptoms not directed at others every 1-3 days. She required supervision for all ADLS. Record review of Resident #5's care plan dated 06/12/23 (revised 07/06/23) indicated she had the potential to be physically aggressive related to a history of harm to others. Interventions included, assess and anticipate resident's needs and monitor/document, report PRN any signs or symptoms of Resident #5 posing danger to self and others. Record review of Resident #5's care plan dated 12/27/21 (revised 03/27/23) indicated Resident #5 sometimes displayed verbally aggressive behavior. Interventions included, do not argue, discuss options for appropriate channeling of anger, praise for demonstrating desired behavior, and talk with Resident #5 when her behavior was disruptive. Record review of the incident report dated 06/12/23 at 6:05 p.m., completed by LVN A, indicated Resident #5 went in the shower room and began taking other residents' clothing and snacks. LVN A asked for the clothing and Resident #5 got upset and began to use foul language. LVN A offered snacks provided by the facility and Resident #5 did not want the snacks. Resident #5 took several sodas from other resident's supply and went to her (Resident #5's) room. LVN A entered Resident #5's room, retrieved the soda and exited the room. During the narcotic count on 6/12/23 at 5:19 p.m. with LVN E, Resident #5 swung and hit LVN A and pulled her hair. CNA F and CNA G pulled Resident #5 off LVN A and lowered her (Resident #5) to the floor. Resident #5 noted to have scratches near left eye. No other injuries noted. Physician, ADON C, and Administrator H were notified. Record review of Resident #5's progress noted dated 06/13/23 at 10:53 a.m., completed by RNC I indicated Resident #5 was assessed with noted scratches/abrasions below right eye and 3 scratches to left eyelid. A police officer was at the facility to speak to Resident #5. Resident #5 indicated she was in a fight but was not able to give a reason. Record review of the facility's investigation dated 06/19/23, completed by Administrator H indicated On 06/12/23 at approximately 5:14 p.m., Resident #5 went into the shower room where extra snacks and clothes were stored and got several snacks, sodas, and clothes, which did not belong to her. LVN A attempted to retrieve the snacks from Resident #5 by offering alternates. Resident #5 declined the offer and went to her room. LVN A followed Resident #5 to her room. Resident #5 threw a trashcan at LVN A. LVN A entered Resident #5's room and retrieved the snacks. LVN A went to the nurse's desk and began med count with LVN E. Resident #5 walked past LVN A, went to the nurse's desk, picked up the phone, and acted as if she was talking to someone. After a few minutes, Resident #5 walked back to her bedroom. As she passed LVN A she swung and hit LVN A. LVN A then grabbed Resident #5's wrists and pushed Resident #5 up against the wall. Resident #5 began struggling and grabbed LVN A's hair. LVN E, CNA F and CNA G attempted to get Resident #5 to release LVN A's hair. Resident #5 went limp and CNA F, CNA G and LVN E lowered Resident #5 to the floor. During the struggle it does appear LVN A's elbow came into contact with Resident #5's face. The staff were finally able to separate LVN A and Resident #5. The facility finds this incident as confirmed due to the video. Video review documentation completed by Administrator H indicated 06/12/23 Camera is three hours off-everything occurred in the 1700 (5:00 p.m.) hour, but camera time shows 1500 (3:00 p.m.) 15:16:08 (actual real time 5:16 p.m.) LVN A walked from nurse station on Hall 100 to Resident #5's room. 15:16:17 (actual real time 5:16 p.m.) LVN A goes into Resident #5's room. 15:16:20 (actual real time 5:16 p.m.) LVN A backs out of Resident #5's room. 15:16:22 (actual real time 5:16 p.m.) Resident #5 grabs her trashcan and throws it at LVN A. 15:16:24 (actual real time 5:16 p.m.) LVN A goes back into Resident #5's room. 15:16:29 (actual real time 5:16 p.m.)LVN A come out of room, closes Resident #5's door and walks toward nurse station. Several staff and residents can be seen walking the hall and interacting. 15:17:30 (actual real time 5:17 p.m.) Resident #5 comes out of her room, carrying a dress, and walking toward the nurse's station. 15:17:42 (actual real time 5:17 p.m.)Resident #5 continues to walk out to the nurse's station. 15:17:54 (actual real time 5:17 p.m.) Resident #5 walks past LVN A, turns around, says something, and then walks to phone at the nurse's station. LVN A and LVN E continue counting meds. 15:18:06 (actual real time 5:18 p.m.) Resident #5 gets on the phone. 15:19:37 (actual real time 5:19 p.m.) Resident #5 hangs up the phone and begins walking back towards her room. 15:19:40 (actual real time 5:19 p.m.) Resident #5 walks past LVN A, swings at LVN A and hits LVN A. 15:19:42 (actual real time 5:19 p.m.) LVN A grabs Resident #5's hands, charges her, backs Resident #5 to the wall. 15:19:43 (actual real time 5:19 p.m.) Resident #5 crosses LVN A's arms in the struggle. 15:19:45 (actual real time 5:19 p.m.) Resident #5 and LVN A continue to struggle. Resident #5 has moved from the wall-her back is now to the camera. LVN E, CNA F, and CNA G attempt to separate Resident #5 and LVN A. 15:19:47 (actual real time 5:19 p.m.) Struggle continues, Resident #5 begins to go to the floor as the struggle continues. 15:19:48 (actual real time 5:19 p.m.) It appears as Resident #5 lands on the ground, LVN A's elbow made contact with Resident #5's face, LVN A's hand can be seen coming off Resident #5's face. 15:19:49 (actual real time 5:19 p.m.) It appears LVN A and Resident #5 are physically separate except for Resident #5's right hand, which is extended to LVN A. 15:19:51 (actual real time 5:19 p.m.) CNA in maroon scrubs picks LVN A up and separates her from Resident #5 who is on the floor on her back. The surveyor was unable to review the video during the investigation as it was not available. The facility requested a copy of the video from the police however it was not available prior to exit. During an interview on 10/26/23 at 3:35 p.m., Resident #5 did not recall an altercation with any staff. During an interview on 10/26/23 at 1:45 p.m. the Administrator indicated she was the Abuse Coordinator. She said all allegations of abuse were reportable as soon as possible to any supervisor such as the charge nurse, the DON, or ADON and herself (the administrator). During an interview on 10/27/23 at 10:27 a.m., Administrator H said she was the previous administrator of the facility and was the abuse coordinator. She said all staff were trained on abuse and neglect and reporting. She said the incident between LVN A and Resident #5 was not reported to the state on 06/12/23 because she was not aware of the abuse until she reviewed the video of the incident on 06/13/23. She said neither LVN A nor LVN E reported the incident as abuse. She said LVN E, CNA F, and CNA G did not report the incident between Resident #5 and LVN A as abuse. She said the video was reviewed with CNA F and CNA G and their recollection of the event and statements did not match the video. She said LVN A escalated the situation and should not have reacted the way she did with Resident #5. She said LVN A should have de-escalated the situation. She said LVN E, CNA F, and CNA G should have reported the incident immediately to the DON and (Administrator H). She said staff was retrained after the incident regarding residents with dementia. During an interview on 10/27/23 at 10:37 a.m., RNC I said the initial report on 06/12/23, by LVN A, was she was attacked by Resident #5. The incident was reported to the State Agency after she and Administrator H reviewed the video. She said the written statements from the staff did not match what was seen on the video. She said LVN A was interviewed but got upset and said she was only trying to defend herself. She said all staff were trained to work with residents with dementia on the unit. She said staff were retrained after the incident. During an interview on 10/27/23 at 11:38 a.m., CNA F said on 6/12/23 at approximately 5:15 p.m., Resident #5 went into the bathroom and took another resident's snacks and drinks. She said Resident #5 gave the snacks back when she was told the CNA would get her snacks from the machine, but she took the drinks to her room. She said LVN A went into Resident #5's room and retrieved the drinks. She said Resident #5 came out of her room, got on the phone and said, I am going to fuck up that bitch. She said she was helping another resident and then heard a loud noise and saw Resident #5 had LVN A's hair in her hand. She denied seeing LVN A hit Resident #5 on 06/12/23. During an interview on 10/27/23 at 12:25 p.m., LVN E said on 06/12/23 Resident #5 went into the shower room and took snacks and drinks that belonged to other residents. She said LVN A came on to start her shift at 6:00 p.m. She said LVN A went into Resident #5's room and retrieved the drinks. She said they began counting medications and she heard a noise and LVN A had Resident #5 pushed up and retrained against the wall and then she brought Resident #5 to the ground and was on top of her. She said she and CNA F and CNA G removed LVN A from the situation. She said Resident #5 had scratches and discoloration on her face. She said LVN A called and reported the incident. She said she was trained on behaviors and working with residents with dementia before and after the incident. She said all allegations or incidents of abuse were supposed to be reported to the Administrator immediately. She said she did not report the incident as abuse to the Administrator. She said she did not think of the incident as abuse when it happened. She said when she reviewed the video, the incident looked like LVN A assaulted Resident #5. She said all staff to resident and resident-to-resident abuse was reportable to the Administrator and DON immediately. The surveyor attempted to contact LVN A on 10/30/23 at 12:00 p.m. The cell number provided was not in service. During an interview on 11/06/23 at 12:45 p.m., CNA G said she saw LVN A walk out of Resident #5's room on 06/12/23. She said Resident #5 went to the phone and said she was going to call the law next time you (LVN A) put your hands on me. She said Resident #5 walked past LVN A and hit her face. She said LVN A pushed Resident #5 up against the wall and said, you got the wrong one. She said LVN A hit Resident #5 and then Resident #5 pulled LVN A's hair. She said their hands were hitting at each other. She said she and CNA F pulled LVN A and Resident #5 apart. She said Resident #5 went to her room. She said all allegations or incident of abuse were reportable to the charge nurse, DON, or Administrator immediately. She said she did not report the incident as abuse. She said she was trained prior to the incident and after the incident on dementia and behaviors. She said LVN A agitated Resident #5 instead of dealing with her in a calm manner. Record review of LVN A's personnel file included the following: Disciplinary Form dated 06/13/23- On 06/12/23, resident (Resident #5) walked past (LVN A), swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. LVN A was suspended. Disciplinary Form dated 06/20/23- On 06/12/23, resident (Resident #5) walked past (LVN A) , swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. Employee handbook, page 12 states abuse and/or neglect of residents is prohibited. LVN A was terminated on 06/20/23. LVN A was notified by phone. Record review of the police Offence Report dated 06/13/23 indicated that on 06/12/23 at 5:19 p.m. LVN A intentionally caused a disabled individual (Resident #5) bodily injury. 2. Record review of Resident #10's face sheet dated 11/01/23 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (episodes of mania and sometimes depression), homicidal ideations (thinking about, considering, or planning a homicide), suicidal ideations (suicidal thoughts or ideas), cerebral infarction (stroke), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #10's MDS dated [DATE] indicated she was sometimes able to make herself understood, was usually able to understand others, was able to recall the location of her room and that she was in a nursing home, had severely impaired cognitive skills for daily decision making, had no behaviors, required supervision and limited assist for most ADLS, and used a walker for mobility. Record review of Resident #10's care plan dated 03/27/23 indicated Resident #10 had a history of physical aggression of pulling a staff member's hair related to poor impulse control. Interventions included assess and anticipate resident's needs. Record review of an incident report dated 07/25/23 completed by LVN L indicated a CNA (unknown who) asked Resident #10 why did you scratch that girl last night? Resident #10 grabbed her own throat. The CNA asked, that girl grabbed you by the throat? Resident #10's roommate came out of the bathroom and stated, the staff was kind of abusive with her last night, like rough. The CNA asked, who the girl (Resident #10) scratched? Yeah, I could hear them from over here, the roommate stated. Resident #10 unable to explain verbally but grabbed her throat as if choking. Resident #10 was assessed with no injuries noted. Family and physician notified. Record review of the facility's investigation dated 07/28/23 indicated CNA B was suspended and terminated on 07/25/23. CNA B denied any wrongdoing but did state Resident #10 was agitated and scratched her face and she placed a firm grip on Resident #10's wrists to prevent from being hit. CNA B was terminated for placing a firm grip on Resident #10's wrist. During an interview on 10/30/23 at 12:11 p.m., CNA Z said she was passing by Resident #10's room on 07/24/23 sometime after the evening meal. She said Resident #10 motioned for her (CNA Z) to go into the room. CNA B was rough handling Resident #10 and she (CNA Z) told CNA B not to do that and that she would go and get someone. She said she told RN L something was going on and they walked back to Resident #10's room. She said CNA B was walking toward them and said Resident #10 had scratched her face. She said CNA B told ADON D Resident #10 scratched her face. She said ADON B said she would have to report the incident to the abuse coordinator. She said the incident occurred on 07/24/23 after the supper meal. She said LVN L should have reported the abuse to the administrator immediately. She said she was called to the facility on [DATE] to write a statement. The surveyor attempted to contact CNA B on 10/30/23 at 12:33 p.m. There was no answer, and a message was left with surveyor contact information. During an interview on 10/30/23 at 1:15 p.m., the DON said she became aware in morning report on 07/25/23 that Resident #10 was pointing and grabbing at her neck. She said the facility investigated and reported to the state when they were made aware of the incident. She said LVN L did not report the incident of CNA B rough handling Resident #10 on 07/24/23. She said the Administrator terminated CNA B on 07/25/23 due to grabbing Resident #10's wrists. During an interview on 10/30/23 at 1:15 p.m., ADON D said she was in the facility on 07/24/23 when she was made aware of Resident #10 scratching CNA B. She said she was not working when CNA B reported she was scratched. She said she was not aware of any abuse, so she did not report the incident to the DON or the Administrator immediately. During an interview on 10/30/23 at 1:20 p.m., the administrator said she terminated CNA B for grabbing Resident #10's wrists during care on 07/24/23. During an interview on 10/31/23 at 10:22 a.m., the surveyor asked Resident #10 if any staff had been mean or hurt her. Resident #10 placed her hands around her neck as if choking. When asked if she was o.k. and to give a thumbs up for yes or a thumbs down for no she indicated thumbs up. When asked if someone put their hands around her neck and to give thumbs up for yes or thumbs up for no, Resident #10 indicated thumbs up. When asked if she was afraid of any of the staff Resident #10 shook her head no. During an interview on 10/31/23 at 12:40 p.m., Resident #10's roommate said CNA B was rough with Resident #10 on 07/24/23. She said CNA B said oh, you trying to hit me? Better not hit me. She said she could hear Resident #10 and CNA B struggling and fighting. She said the privacy curtain was pulled and she could not see but she could hear what was going on. She said she heard CNA B leave the room and shut the door. She said CNA B was abusive to Resident #10. During an interview on 11/01/23 at 4:55 p.m., LVN L said she did not write up an incident report, call the DON, or the Administrator on 07/24/23 after CNA Z made her aware of CNA B being rough with Resident #10. She said CNA B came out of Resident #10's room and said Resident #10 scratched her. She said CNA B had a scratch under her left eye. She said she should have documented and reported immediately. She said she was trained to report abuse immediately to the administrator. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 (revised April 2021) indicated 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 resident's symptoms.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: a. facility staff; b. other residents; .9. Investigate and report any allegations within the timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. This was determined to be an Immediate Jeopardy (IJ) on 10/31/23 at 2:32 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/312/23 at 2:50 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 11/02/23 at 6:30 a.m. and reflected the following: Immediate action: . A facility audit was completed by the DON/Designee on 11/1/223 of all incident reports and progress notes from 10/26/2023 to 10/31/2023 to determine if any other incidents occurred that required HHSC reporting. Other incidents prior to 10/26/23 had already been presented to state surveyor. One incident was identified to have occurred 10/31/23 that met guidelines for resident-to-resident abuse. Procedure for resident safety was followed, investigation initiated, and incident reported to HHSC within 2-hour reporting window. The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents are free from abuse to address changes including education, daily chart reviews and IDT discussions. DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there are no incidents that could meet the qualifications of abuse and discuss any concerns with abuse coordinator immediately. In-services completed with Administrator by Regional Nurse Consultant on 11/1/23 at 2 pm related to recognizing possible abuse and neglect, abuse prevention and the administrator's responsibilities related to investigating and reporting to all required entities. Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant and Medical Director on 10/29/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: * In-services completed with Administrator by Regional Nurse Consultant on 11/1/23 at 2PM related to recognizing possible abuse and neglect, abuse prevention and the administrator's responsibilities related to investigating and reporting to all required entities. *In-services to include all staff initiated by DON/Designee on 10/31/23 related to abuse recognition, abuse reporting, employee responsibilities in reporting abuse and resident safety and working with residents with escalating behaviors. This training will be validated by completion of a post-training test, dated and signed by each employee. *Interviews initiated by DON/Designee 11/1/23 to include a sample of residents and staff to determine if any cases of unreported abuse or suspected abuse are identified. Education to be completed with all staff working 10/31/2023 by Regional Nurse Consultant. Staff who did not receive the training will receive this training by the DON and/or designee prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. On 11/02/23 at 3:02 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 11/02/23 from 8:00 a.m. though 2:45 p.m. and included 6 LVNs, 12 CNAs, 4 housekeeping/laundry staff, 4 dietary staff, and 2 ADONs who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Record review of the facility monitoring system (implemented on 10/28/23) indicated the facility audited progress notes and incident reports daily. During an interview on 11/02/23 at 2:11. p.m., the Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately. During observations of staff and resident interactions on 11/02/23 from 8:00 a.m. though 2:45 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 11/2/23 at 3:02 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 27 residents (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) reviewed for abuse. The facility failed to ensure the abuse coordinator and/or designee implemented the facility policy to report immediately to HHSC withing two hours of an allegation or incident of alleged abuse: 1. The facility failed to report immediately to the abuse coordinator and failed to report to HHS on 6/12/23, after LVN A was hit by Resident #5, LVN A assaulted Resident #5. She pushed Resident #5 hard against a wall, elbowed her in the face, and scratched her face. LVN A continued to work in the facility from the time of the incident (approximately 5:16 p.m.) until 9:11 p.m. on 06/12/23 and from 6 a.m. until 9:30 a.m. on 06/13/23. 2. The facility failed to report immediately to the abuse coordinator and failed to report to HHS on 7/24/23, after CNA B restrained Resident #10 by the wrists, put her hands around Resident 10's neck, and was rough with her during care. CNA B worked from the time of the incident (approximately 5:16 p.m.) until 10:03 p.m. 3. The facility failed to report 7 incidents of resident-to-resident abuse between 06/21/23 and 10/22/23. On 6/21/23 Resident #5 hit Resident #4. On 7/15/23 Resident #8 hit Resident #4. On 8/12/23 Resident #9 was holding Resident #4's wrist in bed while standing over her, telling her to shut up. On 8/23/23 Resident #1 hit Resident #3. On 9/1/23, 9/13/23 Resident #1 hit Resident #2. On 10/22/23 Resident #6 hit Resident #7. 4. The facility failed to report injury of unknown origin on 09/22/23. Resident #11 was found with bruises on his neck. An Immediate Jeopardy (IJ) situation was identified on 10/31/23. The IJ template was provided to the facility on [DATE] at 2:32 p.m. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 (revised April 2021) indicated 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 resident's symptoms.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: a. facility staff; b. other residents; .9. Investigate and report any allegations within the timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. Record review of the facility's policy Abuse, neglect, Exploitation, or Misappropriation-reporting and Investigating dated 2001 (revised September 2022) indicated All reports of resident abuse (including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicions must be reported immediately to the administrator and other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for survey/licensing the facility; b. The local/state ombudsman, c. The resident's representative; . e. law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or serious bodily injury. 1. Record review of Resident #5's face sheet dated 10/27/23 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and latent syphilis a period when there are no visible signs or symptoms of syphilis; a multisystem chronic infection caused by treponema pallidum. It can cause psychiatric disorders including depression, mania, psychosis, personality changes, delirium and dementia). Record review of Resident #5's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, had moderate impaired cognition (BIMS score 7). She had hallucinations and delusions. She had physical and verbal behavioral symptoms directed at others every 1-3 days. She had had other behavioral symptoms not directed at others every 1-3 days. She required supervision for all ADLS. Record review of Resident #5's care plan dated 06/12/23 (revised 07/06/23) indicated she had the potential to be physically aggressive related to a history of harm to others. Interventions included assess and anticipate resident's needs and monitor/document, report PRN any signs or symptoms of Resident #5 posing danger to self and others. Record review of Resident #5's care plan dated 12/27/21 (revised 03/27/23) indicated Resident #5 sometimes displayed verbally aggressive behavior. Interventions included do not argue, discuss my options, praise for demonstrating desired behavior, and talk with Resident #5 when her behavior was disruptive. Record review of incident report dated 06/12/23 at 6:05 p.m., completed by LVN A, indicated Resident #5 went in the shower room and began taking other residents' clothing and snacks. LVN A asked for the clothing and Resident #5 got upset and began to use foul language. LVN A offered snacks provided by the facility and Resident #5 did not want the snacks. Resident #5 took several sodas from other resident's supply and went to her (Resident #5's) room. LVN A entered Resident #5's room, retrieved the soda and exited the room. During the narcotic count on 6/12/23 at 5:19 p.m. with LVN E, Resident #5 swung and hit LVN A and pulled her hair. CNA F and CNA G pulled Resident #5 off LVN A and lowered her (Resident #5) to the floor. Resident #5 noted to have scratches near left eye. No other injuries noted. Physician, ADON C, and Administrator H were notified. Record review of Resident #5's progress noted dated 06/13/23 at 10:53 a.m., completed by RNC I indicated Resident #5 was assessed with noted scratches/abrasions below right eye and 3 scratches to left eyelid. A police officer was at the facility to speak to Resident #5. Resident #5 indicated she was in a fight but was not able to give a reason. Record review of the facility's investigation dated 06/19/23 indicated On 06/12/23 at approximately 5:14 p.m., Resident #5 went into the shower room where extra snacks and clothes were stored and got several snacks, sodas, and clothes, which did not belong to her. LVN A attempted to retrieve the snacks from Resident #5 by offering alternates. Resident #5 declined the offer and went to her room. LVN A followed Resident #5 to her room. Resident #5 threw a trashcan at LVN A. LVN A entered Resident #5's room and retrieved the snacks. LVN A went to the nurse's desk and began med count with LVN E. Resident #5 walked past LVN A, went to the nurse's desk, picked up the phone, and acted as if she was talking to someone. After a few minutes, Resident #5 walked back to her bedroom. As she passed LVN A she swung and hit LVN A. LVN A then grabbed Resident #5's wrists and pushed Resident #5 up against the wall. Resident #5 began struggling and grabbed LVN A's hair. LVN E, CNA F and CNA G attempted to get Resident #5 to release LVN A's hair. Resident #5 went limp and CNA F, CNA G and LVN E lowered Resident #5 to the floor. During the struggle it does appear LVN A's elbow came into contact with Resident #5's face. The staff were finally able to separate LVN A and Resident #5. The facility finds this incident as confirmed due to the video. Video review documentation completed by Administrator H indicated 06/12/23 Camera is three hours off-everything occurred in the 1700 (5:00 p.m.) hour, but camera time shows 1500 (3:00 p.m.) 15:16:08 (actual real time 5:16 p.m.) LVN A walked from nurse station on Hall 100 to Resident #5's room. 15:16:17 (actual real time 5:16 p.m.) LVN A goes into Resident #5's room. 15:16:20 (actual real time 5:16 p.m.) LVN A backs out of Resident #5's room. 15:16:22 (actual real time 5:16 p.m.) Resident #5 grabs her trashcan and throws it at LVN A. 15:16:24 (actual real time 5:16 p.m.) LVN A goes back into Resident #5's room. 15:16:29 (actual real time 5:16 p.m.)LVN A come out of room, closes Resident #5's door and walks toward nurse station. Several staff and residents can be seen walking the hall and interacting. 15:17:30 (actual real time 5:17 p.m.) Resident #5 comes out of her room, carrying a dress, and walking toward the nurse's station. 15:17:42 (actual real time 5:17 p.m.)Resident #5 continues to walk out to the nurse's station. 15:17:54 (actual real time 5:17 p.m.) Resident #5 walks past LVN A, turns around, says something, and then walks to phone at the nurse's station. LVN A and LVN E continue counting meds. 15:18:06 (actual real time 5:18 p.m.) Resident #5 gets on the phone. 15:19:37 (actual real time 5:19 p.m.) Resident #5 hangs up the phone and begins walking back towards her room. 15:19:40 (actual real time 5:19 p.m.) Resident #5 walks past LVN A, swings at LVN A and hits LVN A. 15:19:42 (actual real time 5:19 p.m.) LVN A grabs Resident #5's hands, charges her, backs Resident #5 to the wall. 15:19:43 (actual real time 5:19 p.m.) Resident #5 crosses LVN A's arms in the struggle. 15:19:45 (actual real time 5:19 p.m.) Resident #5 and LVN A continue to struggle. Resident #5 has moved from the wall-her back is now to the camera. LVN E, CNA F, and CNA G attempt to separate Resident #5 and LVN A. 15:19:47 (actual real time 5:19 p.m.) Struggle continues, Resident #5 begins to go to the floor as the struggle continues. 15:19:48 (actual real time 5:19 p.m.) It appears as Resident #5 lands on the ground, LVN A's elbow made contact with Resident #5's face, LVN A's hand can be seen coming off Resident #5's face. 15:19:49 (actual real time 5:19 p.m.) It appears LVN A and Resident #5 are physically separate except for Resident #5's right hand, which is extended to LVN A. 15:19:51 (actual real time 5:19 p.m.) CNA in maroon scrubs picks LVN A up and separates her from Resident #5 who is on the floor on her back. The surveyor was unable to review the video during the investigation as it was not available. The facility requested a copy of the video from the police however it was not available prior to exit. During an interview on 10/26/23 at 3:35 p.m., Resident #5 did not recall an altercation with any staff. During an interview on 10/26/23 at 1:45 p.m. the Administrator indicated she was the Abuse Coordinator. She said all allegations of abuse were reportable as soon as possible to any supervisor such as the charge nurse, the DON, or ADON and herself (the administrator). She said all allegations of abuse were reportable to the state within two hours. She said the reporting time was clarified by the quality monitors who were in the facility at the time of the surveyor's entrance. During an interview on 10/27/23 at 10:27 a.m., Administrator H said she was the previous administrator of the facility and was the abuse coordinator. She said all staff were trained on abuse and neglect and reporting. She said the incident between LVN A and Resident #5 was not reported to the state on 06/12/23 because she was not aware of the abuse until she reviewed the video of the incident on 06/13/23. She said neither LVN A nor LVN E reported the incident as abuse. She said LVN E, CNA F, and CNA G did not report the incident between Resident #5 and LVN A as abuse. She said the video was reviewed with CNA F and CNA G and their recollection of the event and statements did not match the video. She said LVN A escalated the situation and should not have reacted the way she did with Resident #5. She said LVN A should have de-escalated the situation. She said LVN E, CNA F, and CNA G should have reported the incident immediately to the DON and (Administrator H). She said all abuse allegations were reportable to the state within two hours. She said staff was retrained after the incident regarding residents with dementia. During an interview on 10/27/23 at 10:37 a.m., RNC I said the initial report on 6/12/23, by LVN A, was she was attacked by Resident #5. The incident was reported to the State Agency after she and Administrator H reviewed the video. She said the written statements from the staff did not match what was seen on the video. She said LVN A was interviewed but got upset and said she was only trying to defend herself. She said all staff were trained to work with residents with dementia on the unit. She said staff were retrained after the incident. She said all allegations of abuse were reportable to the state within two hours. During an interview on 10/27/23 at 11:38 a.m., CNA F said on 6/12/23 at approximately 5:15 p.m., Resident #5 went into the bathroom and took another resident's snacks and drinks. She said Resident #5 gave the snacks back when she was told the CNA would get her snacks from the machine, but she took the drinks to her room. She said LVN A went into Resident #5's room and retrieved the drinks. She said Resident #5 came out of her room, got on the phone and said I am going to fuck up that bitch. She said she was helping another resident and then heard a loud noise and saw Resident #5 had LVN A's hair in her hand. She denied seeing LVN A hit Resident #5. During an interview on 10/27/23 at 12:25 p.m., LVN E said on 06/12/23 Resident #5 went into the shower room and took snacks and drinks that belonged to other residents. She said LVN A came on to start her shift at 6:00 p.m. She said LVN A went into Resident #5's room and retrieved the drinks. She said they began counting medications and she heard a noise and LVN A had Resident #5 pushed up and retrained against the wall and then she brought Resident #5 to the ground and was on top of her. She said she and CNA F and CNA G removed LVN A from the situation. She said Resident #5 had scratches and discoloration on her face. She said LVN A called and reported the incident. She said she was trained on behaviors and working with residents with dementia before and after the incident. She said all allegations or incidents of abuse were supposed to be reported to the Administrator immediately. She said she did not report the incident as abuse to the Administrator. She said she did not think of the incident as abuse when it happened. She said when she reviewed the video, the incident looked like LVN A assaulted Resident #5. She said all staff to resident and resident to resident abuse was reportable to the Administrator and DON immediately. During an interview on 10/27/23 at 12:56 p.m., the DON said all allegations of abuse were reportable to the Administrator immediately. She said all allegations or incidents of abuse were reportable to the state within 2 hours. During an interview on 10/27/23 at 1:39 p.m., the Administrator said up until 10/26/23, allegations or incidents of abuse were reported to the state when it was malicious, willful, or had injury. The surveyor attempted to contact LVN A on 10/30/23 at 12:00 p.m. The cell number provided was not in service. During an interview on 11/06/23 at 12:45 p.m., CNA G said she saw LVN A walk out of Resident #5's room on 06/12/23. She said Resident #5 went to the phone and said she was going to call the law next time you (LVN A) put your hands on me. She said Resident #5 walked past LVN A and hit her face. She said LVN A pushed Resident #5 up against the wall and said you got the wrong one. She said LVN A hit Resident #5 and then Resident #5 pulled LVN A's hair. She said their hands were hitting at each other. She said she and CNA F pulled LVN A and Resident #5 apart. She said Resident #5 went to her room. She said all allegations or incident of abuse were reportable to the charge nurse, DON, or Administrator immediately. She said she did not report the incident as abuse. She said she did not think of the incident as abuse. She said she was trained prior to the incident and after the incident on dementia and behaviors. She said LVN A agitated Resident #5 instead of dealing with her in a calm manner. Record review of LVN A's personnel file included the following: Disciplinary Form dated 06/13/23- On 06/12/23, resident (Resident #5) walked past (LVN A), swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. LVN A was suspended. Disciplinary Form dated 06/20/23- On 06/12/23, resident (Resident #5) walked past (LVN A) , swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. Employee handbook, page 12 states abuse and/or neglect of residents is prohibited. LVN A was terminated on 06/20/23. LVN A was notified by phone. Record review of the police Offence Report dated 06/13/23 indicated that on 06/12/23 at 5:19 p.m. LVN A intentionally caused a disabled individual (Resident #5) bodily injury. 2. Record review of Resident #10's face sheet dated 11/01/23 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (episodes of mania and sometimes depression), homicidal ideations (thinking about, considering, or planning. a homicide), suicidal ideations (suicidal thoughts or ideas), cerebral infarction (stroke), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #10's MDS dated [DATE] indicated she was sometimes able to make herself understood, was usually able to understand others, was able to recall the location of her room and that she was in a nursing home, had severely impaired cognitive skills for daily decision making, had no behaviors, required supervision and limited assist for most ADLS, and used a walker for mobility. Record review of Resident #10's care plan dated 03/27/23 indicated Resident #10 had a history of physical aggression of pulling a staff member's hair related to poor impulse control. Interventions included assess and anticipate resident's needs. Record review of an incident report dated 07/25/23 completed by LVN L indicated a CNA (unknown who) asked Resident #10 why did you scratch that girl last night? Resident #10 grabbed her own throat. The CNA asked, that girl grabbed you by the throat? Resident #10's roommate came out of the bathroom and stated the staff was kind of abusive with her last night, like rough. The CNA asked, who the girl (Resident #10) scratched? Yeah, I could hear them from over here, the roommate stated. Resident #10 unable to explain verbally but grabbed her throat as if choking. Resident #10 was assessed with no injuries noted. Family and physician notified. Record review of the facility's investigation dated 07/28/23 indicated CNA B was suspended and terminated on 07/25/23. CNA B denied any wrongdoing but did state Resident #10 was agitated and scratched her face and she placed a firm grip on Resident #10's wrists to prevent from being hit. CNA B was terminated for placing a firm grip on Resident #10's wrists. During an interview on 10/30/23 at 12:11 p.m., CNA Z said she was passing by Resident #10's room on 07/24/23 sometime after the evening meal. She said Resident #10 motioned for her (CNA Z) to go into the room. CNA B was rough handling Resident #10 and she told CNA B not to do that and that she would go and get someone. She said she told RN L something was going on and they walked back to Resident #10's room. She said CNA B was walking toward them and said Resident #10 had scratched her face. She said CNA B told ADON D Resident #10 scratched her face. She said ADON B said she would have to report the incident to the abuse coordinator. She said the incident occurred on 07/24/23 after the supper meal. She said LVN L should have reported the abuse to the administrator immediately. She said she was called to the facility on [DATE] to write a statement. The surveyor attempted to contact CNA B on 10/30/23 at 12:33 p.m. There was no answer and a message was left with surveyor contact information. During an interview on 10/30/23 at 1:15 p.m., the DON said she became aware in morning report on 07/25/23 that Resident #10 was pointing and grabbing at her neck. She said the facility investigated and reported to the state when they were made aware of the incident. She said LVN L did not report the incident of CNA B rough handling Resident #10 on 07/24/23. She said the Administrator terminated CNA B on 07/25/23 due to grabbing Resident #10's wrists. During an interview on 10/30/23 at 1:15 p.m., ADON D said she was in the facility on 07/24/23 when she was made aware of Resident #1 scratching CNA B. She said she was not working when CNA B reported she was scratched. She said she was not aware of any abuse, so she did not report the incident to the DON or the Administrator immediately. During an interview on 10/30/23 at 1:20 p.m., the administrator said she terminated CNA B for grabbing Resident #5's wrists during care on 07/24/23. During an interview on 10/31/23 at 10:22 a.m., the surveyor asked Resident #10 if any staff had been mean or hurt her. Resident #10 placed her hands around her neck as if choking. When asked if she was o.k. and to give a thumbs up for yes or a thumbs down for no she indicated thumbs up. When asked if someone put their hands around her neck and to give thumbs up for yes or thumbs up for no, Resident #10 indicated thumbs up. When asked if she was afraid of any of the staff Resident #10 shook her head no. During an interview on 10/31/23 at 11:46 a.m., the COO indicated he trained the Administrator on 10/27/23 regarding reporting abuse to the state as required. He said the prior training was after the most recent provider training when there was a team discussion and the CNO reviewed the provider meeting information. He said there was a lot of confusion because each state has different reporting requirements. He said as company, abuse was an area of focus and there has been a lot of training. He said all newly hired employees were provided information on abuse, abuse prevention and abuse reporting. He said it was the company's expectations the facility would follow the guidelines and resident to resident abuse was reported within two hours to the state as required. During an interview on 10/31/23 at 12:40 p.m., Resident #10's roommate said CNA B was rough with Resident #10. She said CNA B said oh, you trying to hit me? Better not hit me. She said she could hear Resident #10 and CNA B struggling and fighting. She said the privacy curtain was pulled and she could not see but she could hear what was going on. She said she heard CNA B leave the room and shut the door. She said CNA B was abusive to Resident #10. During an interview on 11/01/23 at 4:55 p.m., LVN L said she did not write up an incident report, call the DON, or the Administrator on 07/24/23 after CNA Z made her aware of CNA B being rough with Resident #10. She said CNA B came out of Resident #10's room and said Resident #10 scratched her. She said CNA B had a scratch under her left eye. She said she should have documented and reported immediately. She said she was trained to report abuse immediately to the administrator. 3. Record review of the incident report dated 06/21/23, completed by LVN J indicated during medication count Resident #4 was standing behind the nurses when Resident #5 became agitated and hit Resident #4 in the chest. Resident #4 was assessed with no injuries. Record review of incident report dated 07/15/23 and completed by LVN K indicated Resident #4 was standing at the TV trying to change the TV channels and Resident #8 slapped her arm and left an imprint. Resident #4 was assessed with no additional injuries. Resident #8 was removed from the area. Record review of incident report dated 08/12/23, completed by LVN O, indicated Resident #9 was standing over her roommate's bed (Resident #4) and holding her by the wrist and yelling I told you to shut up. Resident #9 was unable to explain what happened. Resident #9 has issues with communications and her words come out wrong. She was showing aggression through actions and cursing but her words did not make sense. Residents were immediately separated. Resident #9 was sent to ER for evaluation. Resident #4 had no injuries. Record review of incident report dated 08/23/23, completed by LVN P indicated Resident #1 hit Resident #3 on top of his head with his fist. Resident #3 was redirected and educated to not assault others. Resident #3 had redness on top of his head. Resident #3 received pain medication. Record review of an incident report dated 09/01/23, completed by LVN P, indicated Resident #1 hit Resident #2 on the forehead. There was no swelling and Resident #2 did not complain of pain. Record review of an incident report dated 09/13/22 completed by LVN Q indicated Resident #1 hit Resident #2 on the back of his head. Resident #2 was assessed and had no injuries. Resident #1 was removed from the area. Record review of incident report dated 10/22/23, completed by LVN, indicated Resident #6 was standing over Resident #7 (who was attempting to sleep. Resident #6 was turning Resident #7's light on and off. Resident #7 asked Resident #6 to stop turning his light on and off. Resident #7 hit Resident #6 in the chest. Resident #7 was moved to another room for his safety. The police and ambulance were called. Resident #6 was transferred to the hospital for a psychological evaluation. Resident #7 indicated he was hit. There were no observed injuries. Record review of Resident #1's face sheet dated 10/30/23 indicated Resident #1 was a [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was able to make himself understood and understood others. He had severe cognitive impairment (BIMS score 3), no behaviors, and required varying levels of assistance for ADLS. Record review of Resident #1's care plan dated 09/14/23 indicated Resident #1 had the potential to be physically aggressive related to dementia. Interventions included behavior monitoring and separating residents. Record review of Resident #2's face sheet dated 10/30/23 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #2's MDS dated [DATE] indicated he was usually able to make himself understood and usually understood others. He had severe cognitive impairment (BIMS score of 5). He had no behaviors. He required various levels of assistance for all ADLS. Record review of Resident #2's care plan dated 03/02/22 indicated Resident #2 utilized psychotropic medications for behavioral management. Interventions included monitor for effectiveness. Record review of Resident #3's face sheet dated 11/9/23 indicated he was an [AGE] year old male, admitted on [DATE], and his diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), cognitive communication deficit (difficulty with thinking and how someone uses language), and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Record review of Resident #3's MDS dated [DATE] indicated he was able to make himself understood and understood others. He had severe cognitive impairment (BIMS score of 6). He had no behaviors and required various levels of assist for all ADLS. Record review of Resident #3's care plan dated 02/10/22 indicated Resident #3 used antipsychotic medications related to paranoid personality disorder. Interventions included administer medications and monitor for effectiveness. Record review of Resident #4's face sheet indicated she was a [AGE] year-old female admitted on [DATE] and her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychotic disorder with hallucinations, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #4's MDS dated [DATE] indicated Resident #4 was sometimes able to make herself understood and understand others. She had a BIMS score of 00 (severe cognitive impairment). There were no behaviors noted. Record review of Resident #4's care plan dated 11/05/21 indicated Resident #4 had a history of displaying socially inappropriate/disruptive behavior. Interventions included monitor and document behaviors and remove from public area. Record review of Resident #6's face sheet indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included frontal temporal neurocognitive disorder (the result of damage to neurons in the frontal and temporal lobes of the brain), alcohol induced persisting amnestic disorder (a mental disorder associated with chronic ethanol abuse and nutritional deficiencies characterized by short term memory loss, confabulati[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult the physician with a significant change in resident physical status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 17 residents (Resident #1) reviewed for change of condition. The facility failed to notify the MD or NP of Resident #1's abnormal lab and x-ray results that indicated dehydration, kidney failure, and possible pneumonia to obtain treatment interventions after a change of condition in a timely manner. The facility failed to notify the MD or NP of Resident #1 (who had a history of weight loss) refusing to eat. Resident #1 was admitted to hospital on [DATE] with diagnoses of altered mental status and pneumonia, placed on hospice services on 06/01/23, and expired on 06/04/23. An Immediate Jeopardy (IJ) situation was identified on 06/02/23 at 12:29 p.m. While the IJ was removed on 06/04/23 at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delay of appropriate medical treatment and a worsening of a resident's condition, including death. Findings included: Record review of a face sheet dated 05/31/23 indicated Resident #1 was a [AGE] year-old male resident admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behaviors and agitation, diverticulitis (condition that affects the large intestine), depression (constant feeling of sadness and loss of interest), insomnia (a common sleep disorder that can make it hard to fall asleep), dysphagia (swallowing difficulties), cognitive communication deficit (difficulty with thinking and how someone uses language), severe protein-calorie malnutrition, and anemia (the body does not have enough healthy red blood cells). Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and understand others, had BIMS score of 3 (severe cognitive impairment), required extensive/total physical assist of one staff for all ADLS, utilized a wheelchair for mobility, and was incontinent of bowel and bladder. Record review of a care plan dated 12/09/22 (revised 04/28/23), indicated Resident #1 had dehydration or potential fluid deficit related to dementia. Interventions included obtain and monitor lab/diagnostics work as ordered. Report results to MD and follow up as indicated. Monitor/document and report as needed any signs and symptoms of dehydration including fatigue and weight loss. Record review of a care plan dated 12/09/22 (revised 04/28/23), indicated Resident #1 had an alteration in gastrointestinal status related to diverticulitis in his intestine. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a care plan dated 12/09/22 (revised 04/28/23), indicated Resident #1 had a diagnoses of anemia. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a NP progress note dated 05/26/23, completed by NP D, indicated Resident #1 was positive for fatigue (staff reports resident has been very weak for one week and history of a fall) and unintentional weight loss. The NP progress note indicated Resident #1 was positive for not eating for a week. The NP progress note indicated Resident #1 had a normal respiratory rate and pattern with no distress and normal breath sounds with no rales, rhonchi, wheezes, or rubs. The NP progress note indicated Resident #1's vital signs were blood pressure 110/72, pulse 68 beats per minute, and respirations 20 breaths per minute. The NP progress note indicated Resident #1 was ordered CBC (complete blood count), BMP (basic metabolic panel, LFT (liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views. Record review of Resident #1's physician orders dated 05/26/23 indicated CBC(complete blood count), BMP(basic metabolic panel, LFT(liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views was ordered. Record review of progress note dated 05/26/23 at 2:35 p.m., completed by ADON B, indicated new orders per NP D included CBC, BMP, LFT, Lipid panel today, and chest x-ray 2 views. Diagnoses included HLD (hyperlipidemia-an imbalance of the cholesterol levels in the blood that can lead to serious heart conditions), weight loss, anorexia (decrease in appetite and/or food intake in old age). Record review of lab results dated 05/26/23 indicated the collection as 05/25/23 at 4:55 p.m. and reported on 05/26/23 at 10:21 p.m. -TSH-10.80 (high)-Reference range 0.40-4.50 -HCT (red blood cells)-45.3-Reference range 34.1-44.9-high -PLT (platelet)-80-Reference range 182-369-low -RDW (red cell distribution width)-17.2-Reference range 11.7-14.4 -high -Sodium-151-Reference range 136-145-high -Chloride-112-Reference range 98-107-high -BUN (blood urea nitrogen test reveals important information about how well kidneys are working)-71-Reference range 3-23-high -Creatinine-2.20-Reference range 0.60-1.20-high -Cholesterol-221.0-Reference range 0.0-199.0-high -Triglycerides-162-Reference range 40-149-high The report had no signature or date to indicate the report was reviewed. Record review of an x-ray report dated 05/26/23 for Resident #1 indicated diffuse opacity is seen in bilateral upper lungs. This is likely secondary to pulmonary edema (excessive fluid in the lungs), atelectasis (complete or partial collapse of a lung) and/or pneumonia (infection in the lungs). The report had no signature or date to indicate the report was reviewed. Record review of Resident #1's meal intake dated 05/27/23 indicated his intake was 0-25% for breakfast., refused lunch and 0-25% for supper. His meal intake on 05/28/23 was 0-25% for breakfast., 0-25 % for lunch and refused for supper. Record review of Resident #1's fluid intake dated 05/27/23 his fluid intake was 120 ml for breakfast, refused for lunch, and 120 ml for supper. His fluid intake for 05/28/23 was 120 ml for breakfast, 120 ml for lunch, and 0 ml for supper. Record review of a 24-hour shift report dated 05/26/23 indicated to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated 05/27/23 indicated continue to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated 05/28/23 indicated no information related to Resident #1. There was no information related to labs or the results for Resident #1. Record review of the fax confirmation page dated 05/28/23 at 4:04 p.m. indicated the fax for Resident #1's abnormal lab results and chest x-ray were not successfully sent to the specified recipient (was the wrong fax number). Record review of a progress note dated 05/29/23 at 10:30 a.m., completed by LVN E indicated she called the on-call number to report Resident #1's abnormal labs and x-ray. Record review of a progress note dated 05/29/23 (three days after the lab results had been reported to the facility) at 11:53 a.m., completed by LVN E indicated on-call NP Q ordered Resident #1 to be sent out for IV ABT and fluids. Record review of a progress note dated 05/29/23 at 6:27 p.m., completed by LVN E indicated Resident #1 was admitted to the hospital for hyperkalemia (high potassium), AMS, dehydration and pneumonia. Record review of hospital records dated 05/29/23 indicated Resident #1 was admitted for hyperkalemia, AMS, dehydration and pneumonia. During an observation and interview at the hospital on [DATE] at 3:11 p.m., Resident #1 was asleep and unresponsive in the hospital. LVN F said Resident #1 had been admitted to hospice services and was on comfort care. She said Resident #1's prognoses was poor. During an interview on 05/31/23 at 1:30 p.m., LVN E said on 5/29/23 ADON A asked her to follow up on the labs that were drawn on 05/26/23. She said she called the hospital to get the on-call number and called on-call NP Q. She said she told NP Q about Resident #1's lab results and the chest x-ray showing possible pneumonia. She said NP Q ordered Resident #1 to be sent to the hospital. LVN E said if abnormal lab results or x-rays were not addressed immediately there could be a delay of medical care. She said she was not aware of the percentage of food intake or lab results in the residents' dashboard of the electronic chart. During an interview on 06/02/23 at 12:57 p.m., LVN E said she was not aware of a dashboard for lab results. She said if lab results were critical the lab would call directly to the facility. She said if she did not check for results then she would not know lab results or x-ray results were available. She said the hospital said the on-call physician was NP Q. She said the labs and x-ray were done on a holiday weekend. She said Resident #1's family tried to feed him fast food and asked why the facility was sedating him. She said she told them he had not been sedated. She said they wanted her to force feed him. She said he drank ensure and liked it. During an interview on 06/02/23 at 3:00 p.m., ADON A said on 05/29/23 he found Resident #1's lab results had not been reviewed or addressed as they should have been on 05/26/23, when the results were sent to the facility. He said he asked LVN E on 05/29/23 to follow-up on the results. He said nursing staff should have notified the MD or on-call NP immediately of Resident #1's abnormal lab results and chest x-ray on 5/26/23. He said the nursing staff should have notified the MD or on-call NP of Resident #1 not eating or drinking adequate amounts. He said Resident #1 had delay of medical treatment and care due to the failure to notify the physician or NP. During an interview on 06/02/23 at 3:19 p.m., RN C said the MD should be notified if a resident has not eaten for two days. She said missed meals were documented in the kiosk (where CNAs document the residents' meal intake) and would trigger in the dashboard (in the electronic record). The nurses should have checked the dashboard for any alerts and notify the MD as needed. She said labs and lab results were supposed to be checked daily in the dashboard. She said the nurses were supposed to review, notify the MD, then check off the results as reviewed. During an interview on 06/03/23 at 2:14 p.m., Resident #1's roommate said Resident #1 would eat when LVN E fed him. He said he would mostly eat his breakfast then the tray would sit on the bedside table for a while until staff picked the tray up and take it from the room. During an interview on 06/03/23 at 2:17 p.m. LVN E said none of the aides had reported to her Resident #1 was not eating or drinking. During an interview on 06/03/23 at 2:34 p.m., CNA K said she assisted Resident #1 to eat his meals. She said she told LVN G Resident #1 would not open his mouth to eat and was drinking very little water or juice. She said he would sometimes eat oatmeal for breakfast with a lot of sugar. She said she tried to feed Resident #1 all meals and snacks on 5/27/23 and 5/28/23 but he would not eat. CNA K said she told the family Resident #1 would not eat. She said the family went to talk to the nurse. During an interview on 06/04/23 at 10:03 a.m., LVN R said she was not aware of the dashboard or Resident #1's abnormal lab results or chest x-ray. She said she was not told Resident #1 was not eating or drinking as he should. She said she was not aware of the alerts on Resident #1's dashboard. She said she did not notify the physician or NP of the abnormal results or that Resident #1 was not eating because she was not aware of the issues. During an interview on 06/04/23 at 10:30 a.m., RN C said the nurses should have been checking the dashboard and monitoring the labs and the results. She said management was not monitoring and there was no system in place when management was not in the facility on weekends. She said a delay of physician notification of abnormal lab results and chest x-rays could result in delay of medical care. She said the nurses should have notified the MD or the on-call NP about Resident #1 not eating. During an interview on 06/05/23 at 8:18 a.m., Resident #1's family member indicated he expired on 06/04/23. During an interview on 06/05/23 at 11:31 a.m., LVN G said NP D ordered labs and chest x-ray for Resident #1 on 05/26/23. She said she told NP D on Friday (05/26/23) that Resident #1 was not doing well and NP D went to see Resident #1 and ordered labs. LVN G said NP D asked her how many days Resident #1 had been like this and LVN G told NP D she could not say. She said she did not know to check the dashboard to see if the lab results were available for review. She said ADON B gave her the lab results and chest x-ray to report to MD H on Sunday 05/28/23. She said she called the hospital for the on-call number and was given a fax number. She said the hospital indicated they would notify the on-call NP to call the facility. She said the on-call NP never called the facility. She said she did not follow-up to call the on-call NP again. LVN G said she texted NP D, who was Resident #1's physician's NP and was not on-call. NP D told her did not see the text from LVN G until 05/30/23. She said she did not call the medical director. She said not reporting/communicating abnormal results could result in a further decline in resident health and delay medical care. She said she did not call the MD or the NP to report Resident #1 was not eating or drinking as he should. She said she should have reported Resident #1 not eating or drinking for two days as a change of condition to the MD or NP. During an interview on 06/05/23 at 1:50 p.m., ADON B said on 05/28/23 she found Resident #1's abnormal lab results and chest x-ray had not been reviewed. She said she asked LVN G to call the on-call NP and fax the results. She said she was not aware the on-call NP did not call back to the facility. She said she was not aware the fax was not sent successfully. She said there was a delay of medical intervention due to the abnormal labs and chest x-ray not being addressed timely. She said the staff should have followed up and communicated the results of the abnormal results with the physician or NP. During an interview on 06/05/23 at 1:55 p.m., NP D said the on-call physician or NP should have been informed of Resident #1's abnormal labs immediately. She said the facility nursing staff should have followed up with the on-call physician or NP if they did not receive a call back. She said she most likely would have ordered Resident #1 be sent to the hospital for fluids and ordered a second set of labs. During an interview on 06/06/23 at 1:09 p.m., the Medical Director said the facility nursing staff should have called the on-call number and followed up when the on-call NP did not call regarding Resident #1's abnormal results. He said the delay could result in further decline of health and delay of medical services. He said the facility staff should have called him (the medical Director) if they had not received a call back from the on-call NP. He said the delay of notification of abnormal results could result in a decline in health and even death. An attempted interview was made to contact MD H on 06/02/23 at 12:24 p.m. and on 06/06/22 at 12:52 p.m. MD H did not respond. Record review of the facility policy Change in Resident's Condition or Status dated 2001 (revised 02/2021) indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).3. Prior to notifying the physician or healthcare provide, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Record review of the facility's Interact SBAR form dated 2014 indicated Laboratory Tests/Diagnostic Procedures (*report why the test or procedure was done) . Report immediately . Blood/urea/nitrogen (BUN) >60 mg/dl . X-ray new or suspected finding (e.g., fracture, pneumonia, CHF) . Appetite, Diminished -no oral intake 2 consecutive meals. This was determined to be an Immediate Jeopardy (IJ) on 06/02/23 at 12:29 p.m. The Administrator, Regional Nurse Consultant, and CNO were notified of the IJ and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on 06/02/23 at 12:29 p.m. The following Plan of Removal was submitted and accepted on 06/03/23 at 7:02 p.m.: Action Taken to Address Immediate Jeopardy Condition: On 06/02/23, regional nurse consultant (RNC) and ADON conducted a 100% lab result audit from 05/02/2023 to current to ensure all labs ordered had been verified and carried out. The facility identified 12 labs, which were not sent to the physician and 4 labs waiting for physician response. Physicians were notified of any issues identified. All results were reviewed in an emergency/as needed (ad hoc) QAPI with IDT Team 06/02/23, which identified diagnostic testing results not reported to physician in timely manner and MD was not notified of change of condition, timely. Facility Plan to ensure compliance quickly. 1. Diagnostic testing policy & procedure and physician notification policy was reviewed by Regional Nurse Consultant (RNC) and ADONs on 06/02/2023 prior to initiating training for licensed nursing staff. All licensed nurses currently on shift, were in-service by Regional Nurse Consultant/designee 06/20/23 on: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them with the resident's primary PCP. -Nurses are to document in the nurse's notes as well as any interventions that are ordered by the PCP.- RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification to the physician/responsible party by 06/03/23 at 6:15pm*. For example, if a resident is refusing to eat or drink on more than two consecutive occurrences. - RNC/ADON/designee in-serviced CNAs on documenting residents' intake in the POC by 06/03/23 at 6:15pm*. - RNC/ADON/designee in-serviced nurses by 06/03/23 at 6:15pm* to contact medical director if primary MD does not respond: -routine - within 24 hours -abnormal - within 24 hours -critical - within 2 hours - The Regional Nurse Consultant (RNC)/ADON/designee performed training to other licensed nurses prior to their shift on all the above items. This will be completed by 06/03/23 at 6:15pm*. - ADON/DON/designee was trained by the Regional Nurse Consultant on 06/02/23 on following up with nurses notifying the PCP of abnormal labs. A monitoring tool was developed where the ADON/DON/designee will track the abnormal labs 5 days a week in the clinical meeting and review for missing/late notifications to clinician/Responsible Party. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 2. Emergency/as needed (ad hoc) QAPI completed on 06/02/2023 at 1:50pm. MDS Coordinator, Regional Nurse Consultant, Administrator, Medical Director, Human Resource, ADON, Activity Director, Rehab Director, and Dietary Manager attended emergency/as needed (ad hoc) QAPI. 3. Licensed nurses present completed 4 question communication test on 06/02/23 to ensure comprehension of education provided. All licensed nurses will complete the test prior to returning to work. This will be completed by 06/03/23* at 6:15pm. 4. DON/ADON/designee will be monitoring all labs/x-rays, daily, to ensure they have been reviewed and PCP has been notified, effective 06/01/23. This process will be completed on weekends by the weekend supervisor/designee. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 5. Staff will not be able to work until they have been trained on reviewing the lab results process by completing the following in-services: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them per facility protocol with the resident's primary PCP. -Nurses are to document in the nurse's notes and any interventions ordered by the PCP. -When there is a dashboard alert that a resident has eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician if warranted based on assessment. -Physician Notification of lab results, follow-up, or concerns. Nurses must notify MD/NP within 2 hours if lab order was unable to be carried out for any reason. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee. -Nurses/staff who do not work after the 06/03/23 will be trained prior to their next shift. 6. All Processes will be in place by 06/03/23 at 6:15pm. On 06/04/23 at 11:45 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's ad-hoc QAPI meeting minutes dated 06/02/23 (included the Medical Director) indicated the IJ failures were identified and discussed. Action plans for improvement were developed with monitoring and evaluating systems in place. Record review of the facility's chart audit dated 06/03/23, indicated the facility had completed 100% chart audit and notified the physicians of any changes or lab results as required. Record review of facility audit indicated 12 abnormal lab results with no physician notification. They were sent to physician for review and response. All results were reviewed by Ad HOC QAPI that included the medical director on 6/2/23. Record review of the facility's lab monitoring dated 06/01/23 through 06/05/23 indicated all lab results had been addressed. Record review indicated all nursing staff were in-serviced on the facility's policy for diagnostic testing and procedure and physician notification. Record review indicated the RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification. RNC/ADON/designee in-serviced CNAs on documenting residents' meal intake in the electronic record and reporting missed or refused meals immediately to the charge nurse. Record review of communication test results dated 06/02/23 and 06/03/23 indicated all nurses tested passed with a score of 100%. Interviews conducted on 06/04/23 from 9:00 a.m. through 11:40 a.m. with the interim DON, two ADONs, 2 RNs, and 10 LVNS, who worked all shifts, indicated they were trained and able to correctly state the protocols for physician notification when there was a change of condition or a need to alter treatment for a resident, report abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change of condition, and ensuring the physician received the lab results. They were knowledgeable and were aware to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results, any unreviewed results to address them with the resident's primary PCP, document in the progress notes and interventions that are ordered by the PCP. They were to contact medical director if primary MD does not respond for routine labs- within 24 hours, abnormal labs- within 24 hours, and critical labs- within 2 hours. They were aware if a dashboard alerted a resident had eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician as warranted based on assessment. They were aware they must notify MD/NP within 2 hours of lab orders not completed for any reason. They were aware they must also notify the Administrator and the DON/designee. They were aware the DON/designee would monitor for compliance. Interviews conducted with 7 CNAs from all shifts indicated they were aware to document correct intake in the electronic record and to notify the charge nurse after each meal if a resident is not eating or drinking. Record review of an in-service dated 06/02/23 indicated the interim DON and two ADONs were trained to follow up on lab results and physician notification with a new monitoring tool. Interviews conducted with the interim DON and two ADONs indicated they were responsible for ensuring all lab results were reviewed and followed up per the new monitoring tool. They would review the monitoring tool at clinical meeting Monday through Friday for missing/late notifications to clinician/Responsible Party. The interim DON/designee was aware to monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results would be reviewed by the IDT team to determine if monitoring could be decreased. An Immediate Jeopardy (IJ) situation was identified on 06/02/23 at 12:29 p.m. While the IJ was removed on 06/04/23 at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 17 residents (Resident #1) reviewed for quality of care. The facility failed to notify the MD or NP of Resident #1's abnormal lab and x-ray results that indicated dehydration, kidney failure, and possible pneumonia to obtain treatment interventions after a change of condition in a timely manner. The facility failed to notify the MD or NP of Resident #1 (who had a history of weight loss) refusing to eat. Resident #1 was admitted to hospital on [DATE] with diagnoses of altered mental status and pneumonia, placed on hospice services on 06/01/23, and expired on 06/04/23. An Immediate Jeopardy (IJ) situation was identified on 06/02/23 at 12:29 p.m. While the IJ was removed on 06/04/23 at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delay of appropriate medical treatment and a worsening of a resident's condition, including death. Findings included: Record review of a face sheet dated 05/31/23 indicated Resident #1 was a [AGE] year-old male resident admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behaviors and agitation, diverticulitis (condition that affects the large intestine), depression (constant feeling of sadness and loss of interest), insomnia (a common sleep disorder that can make it hard to fall asleep), dysphagia (swallowing difficulties), cognitive communication deficit (difficulty with thinking and how someone uses language), severe protein-calorie malnutrition, and anemia (the body does not have enough healthy red blood cells). Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and understand others, had BIMS score of 3 (severe cognitive impairment), required extensive/total physical assist of one staff for all ADLS, utilized a wheelchair for mobility, and was incontinent of bowel and bladder. Record review of a care plan dated 12/09/22 (revised 04/28/23), indicated Resident #1 had dehydration or potential fluid deficit related to dementia. Interventions included obtain and monitor lab/diagnostics work as ordered. Report results to MD and follow up as indicated. Monitor/document and report as needed any signs and symptoms of dehydration including fatigue and weight loss. Record review of a care plan dated 12/09/22 (revised 04/28/23), indicated Resident #1 had an alteration in gastrointestinal status related to diverticulitis in his intestine. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a care plan dated 12/09/22 (revised 04/28/23), indicated Resident #1 had a diagnoses of anemia. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a NP progress note dated 05/26/23, completed by NP D, indicated Resident #1 was positive for fatigue (staff reports resident has been very weak for one week and history of a fall) and unintentional weight loss. The NP progress note indicated Resident #1 was positive for not eating for a week. The NP progress note indicated Resident #1 had a normal respiratory rate and pattern with no distress and normal breath sounds with no rales, rhonchi, wheezes, or rubs. The NP progress note indicated Resident #1's vital signs were blood pressure 110/72, pulse 68 beats per minute, and respirations 20 breaths per minute. The NP progress note indicated Resident #1 was ordered CBC (complete blood count), BMP (basic metabolic panel, LFT (liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views. Record review of Resident #1's physician orders dated 05/26/23 indicated CBC(complete blood count), BMP(basic metabolic panel, LFT(liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views was ordered. Record review of progress note dated 05/26/23 at 2:35 p.m., completed by ADON B, indicated new orders per NP D included CBC, BMP, LFT, Lipid panel today, and chest x-ray 2 views. Diagnoses included HLD (hyperlipidemia-an imbalance of the cholesterol levels in the blood that can lead to serious heart conditions), weight loss, anorexia (decrease in appetite and/or food intake in old age). Record review of lab results dated 05/26/23 indicated the collection as 05/25/23 at 4:55 p.m. and reported on 05/26/23 at 10:21 p.m. -TSH-10.80 (high)-Reference range 0.40-4.50 -HCT (red blood cells)-45.3-Reference range 34.1-44.9-high -PLT (platelet)-80-Reference range 182-369-low -RDW (red cell distribution width)-17.2-Reference range 11.7-14.4 -high -Sodium-151-Reference range 136-145-high -Chloride-112-Reference range 98-107-high -BUN (blood urea nitrogen test reveals important information about how well kidneys are working)-71-Reference range 3-23-high -Creatinine-2.20-Reference range 0.60-1.20-high -Cholesterol-221.0-Reference range 0.0-199.0-high -Triglycerides-162-Reference range 40-149-high The report had no signature or date to indicate the report was reviewed. Record review of an x-ray report dated 05/26/23 for Resident #1 indicated diffuse opacity is seen in bilateral upper lungs. This is likely secondary to pulmonary edema (excessive fluid in the lungs), atelectasis (complete or partial collapse of a lung) and/or pneumonia (infection in the lungs). The report had no signature or date to indicate the report was reviewed. Record review of Resident #1's meal intake dated 05/27/23 indicated his intake was 0-25% for breakfast., refused lunch and 0-25% for supper. His meal intake on 05/28/23 was 0-25% for breakfast., 0-25 % for lunch and refused for supper. Record review of Resident #1's fluid intake dated 05/27/23 his fluid intake was 120 ml for breakfast, refused for lunch, and 120 ml for supper. His fluid intake for 05/28/23 was 120 ml for breakfast, 120 ml for lunch, and 0 ml for supper. Record review of a 24-hour shift report dated 05/26/23 indicated to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated 05/27/23 indicated continue to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated 05/28/23 indicated no information related to Resident #1. There was no information related to labs or the results for Resident #1. Record review of the fax confirmation page dated 05/28/23 at 4:04 p.m. indicated the fax for Resident #1's abnormal lab results and chest x-ray were not successfully sent to the specified recipient (was the wrong fax number). Record review of a progress note dated 05/29/23 at 10:30 a.m., completed by LVN E indicated she called the on-call number to report Resident #1's abnormal labs and x-ray. Record review of a progress note dated 05/29/23 (three days after the lab results had been reported to the facility) at 11:53 a.m., completed by LVN E indicated on-call NP Q ordered Resident #1 to be sent out for IV ABT and fluids. Record review of a progress note dated 05/29/23 at 6:27 p.m., completed by LVN E indicated Resident #1 was admitted to the hospital for hyperkalemia (high potassium), AMS, dehydration and pneumonia. Record review of hospital records dated 05/29/23 indicated Resident #1 was admitted for hyperkalemia, AMS, dehydration and pneumonia. During an observation and interview at the hospital on [DATE] at 3:11 p.m., Resident #1 was asleep and unresponsive in the hospital. LVN F said Resident #1 had been admitted to hospice services and was on comfort care. She said Resident #1's prognoses was poor. During an interview on 05/31/23 at 1:30 p.m., LVN E said on 5/29/23 ADON A asked her to follow up on the labs that were drawn on 05/26/23. She said she called the hospital to get the on-call number and called on-call NP Q. She said she told NP Q about Resident #1's lab results and the chest x-ray showing possible pneumonia. She said NP Q ordered Resident #1 to be sent to the hospital. LVN E said if abnormal lab results or x-rays were not addressed immediately there could be a delay of medical care. She said she was not aware of the percentage of food intake or lab results in the residents' dashboard of the electronic chart. During an interview on 06/02/23 at 12:57 p.m., LVN E said she was not aware of a dashboard for lab results. She said if lab results were critical the lab would call directly to the facility. She said if she did not check for results then she would not know lab results or x-ray results were available. She said the hospital said the on-call physician was NP Q. She said the labs and x-ray were done on a holiday weekend. She said Resident #1's family tried to feed him fast food and asked why the facility was sedating him. She said she told them he had not been sedated. She said they wanted her to force feed him. She said he drank ensure and liked it. During an interview on 06/02/23 at 3:00 p.m., ADON A said on 05/29/23 he found Resident #1's lab results had not been reviewed or addressed as they should have been on 05/26/23, when the results were sent to the facility. He said he asked LVN E on 05/29/23 to follow-up on the results. He said nursing staff should have notified the MD or on-call NP immediately of Resident #1's abnormal lab results and chest x-ray on 5/26/23. He said the nursing staff should have notified the MD or on-call NP of Resident #1 not eating or drinking adequate amounts. He said Resident #1 had delay of medical treatment and care due to the failure to notify the physician or NP. During an interview on 06/02/23 at 3:19 p.m., RN C said the MD should be notified if a resident has not eaten for two days. She said missed meals were documented in the kiosk (where CNAs document the residents' meal intake) and would trigger in the dashboard (in the electronic record). The nurses should have checked the dashboard for any alerts and notify the MD as needed. She said labs and lab results were supposed to be checked daily in the dashboard. She said the nurses were supposed to review, notify the MD, then check off the results as reviewed. During an interview on 06/03/23 at 2:14 p.m., Resident #1's roommate said Resident #1 would eat when LVN E fed him. He said he would mostly eat his breakfast then the tray would sit on the bedside table for a while until staff picked the tray up and take it from the room. During an interview on 06/03/23 at 2:17 p.m. LVN E said none of the aides had reported to her Resident #1 was not eating or drinking. During an interview on 06/03/23 at 2:34 p.m., CNA K said she assisted Resident #1 to eat his meals. She said she told LVN G Resident #1 would not open his mouth to eat and was drinking very little water or juice. She said he would sometimes eat oatmeal for breakfast with a lot of sugar. She said she tried to feed Resident #1 all meals and snacks on 5/27/23 and 5/28/23 but he would not eat. CNA K said she told the family Resident #1 would not eat. She said the family went to talk to the nurse. During an interview on 06/04/23 at 10:03 a.m., LVN R said she was not aware of the dashboard or Resident #1's abnormal lab results or chest x-ray. She said she was not told Resident #1 was not eating or drinking as he should. She said she was not aware of the alerts on Resident #1's dashboard. She said she did not notify the physician or NP of the abnormal results or that Resident #1 was not eating because she was not aware of the issues. During an interview on 06/04/23 at 10:30 a.m., RN C said the nurses should have been checking the dashboard and monitoring the labs and the results. She said management was not monitoring and there was no system in place when management was not in the facility on weekends. She said a delay of physician notification of abnormal lab results and chest x-rays could result in delay of medical care. She said the nurses should have notified the MD or the on-call NP about Resident #1 not eating. During an interview on 06/05/23 at 8:18 a.m., Resident #1's family member indicated he expired on 06/04/23. During an interview on 06/05/23 at 11:31 a.m., LVN G said NP D ordered labs and chest x-ray for Resident #1 on 05/26/23. She said she told NP D on Friday (05/26/23) that Resident #1 was not doing well and NP D went to see Resident #1 and ordered labs. LVN G said NP D asked her how many days Resident #1 had been like this and LVN G told NP D she could not say. She said she did not know to check the dashboard to see if the lab results were available for review. She said ADON B gave her the lab results and chest x-ray to report to MD H on Sunday 05/28/23. She said she called the hospital for the on-call number and was given a fax number. She said the hospital indicated they would notify the on-call NP to call the facility. She said the on-call NP never called the facility. She said she did not follow-up to call the on-call NP again. LVN G said she texted NP D, who was Resident #1's physician's NP and was not on-call. NP D told her did not see the text from LVN G until 05/30/23. She said she did not call the medical director. She said not reporting/communicating abnormal results could result in a further decline in resident health and delay medical care. She said she did not call the MD or the NP to report Resident #1 was not eating or drinking as he should. She said she should have reported Resident #1 not eating or drinking for two days as a change of condition to the MD or NP. During an interview on 06/05/23 at 1:50 p.m., ADON B said on 05/28/23 she found Resident #1's abnormal lab results and chest x-ray had not been reviewed. She said she asked LVN G to call the on-call NP and fax the results. She said she was not aware the on-call NP did not call back to the facility. She said she was not aware the fax was not sent successfully. She said there was a delay of medical intervention due to the abnormal labs and chest x-ray not being addressed timely. She said the staff should have followed up and communicated the results of the abnormal results with the physician or NP. During an interview on 06/05/23 at 1:55 p.m., NP D said the on-call physician or NP should have been informed of Resident #1's abnormal labs immediately. She said the facility nursing staff should have followed up with the on-call physician or NP if they did not receive a call back. She said she most likely would have ordered Resident #1 be sent to the hospital for fluids and ordered a second set of labs. During an interview on 06/06/23 at 1:09 p.m., the Medical Director said the facility nursing staff should have called the on-call number and followed up when the on-call NP did not call regarding Resident #1's abnormal results. He said the delay could result in further decline of health and delay of medical services. He said the facility staff should have called him (the medical Director) if they had not received a call back from the on-call NP. He said the delay of notification of abnormal results could result in a decline in health and even death. An attempted interview was made to contact MD H on 06/02/23 at 12:24 p.m. and on 06/06/22 at 12:52 p.m. MD H did not respond. Record review of the facility policy Change in Resident's Condition or Status dated 2001 (revised 02/2021) indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).3. Prior to notifying the physician or healthcare provide, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Record review of the facility's Interact SBAR form dated 2014 indicated Laboratory Tests/Diagnostic Procedures (*report why the test or procedure was done) . Report immediately . Blood/urea/nitrogen (BUN) >60 mg/dl . X-ray new or suspected finding (e.g., fracture, pneumonia, CHF) . Appetite, Diminished -no oral intake 2 consecutive meals. This was determined to be an Immediate Jeopardy (IJ) on 06/02/23 at 12:29 p.m. The Administrator, Regional Nurse Consultant, and CNO were notified of the IJ and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on 06/02/23 at 12:29 p.m. The following Plan of Removal was submitted and accepted on 06/03/23 at 7:02 p.m.: Action Taken to Address Immediate Jeopardy Condition: On 06/02/23, regional nurse consultant (RNC) and ADON conducted a 100% lab result audit from 05/02/2023 to current to ensure all labs ordered had been verified and carried out. The facility identified 12 labs, which were not sent to the physician and 4 labs waiting for physician response. Physicians were notified of any issues identified. All results were reviewed in an emergency/as needed (ad hoc) QAPI with IDT Team 06/02/23, which identified diagnostic testing results not reported to physician in timely manner and MD was not notified of change of condition, timely. Facility Plan to ensure compliance quickly. 1. Diagnostic testing policy & procedure and physician notification policy was reviewed by Regional Nurse Consultant (RNC) and ADONs on 06/02/2023 prior to initiating training for licensed nursing staff. All licensed nurses currently on shift, were in-service by Regional Nurse Consultant/designee 06/20/23 on: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them with the resident's primary PCP. -Nurses are to document in the nurse's notes as well as any interventions that are ordered by the PCP.- RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification to the physician/responsible party by 06/03/23 at 6:15pm*. For example, if a resident is refusing to eat or drink on more than two consecutive occurrences. - RNC/ADON/designee in-serviced CNAs on documenting residents' intake in the POC by 06/03/23 at 6:15pm*. - RNC/ADON/designee in-serviced nurses by 06/03/23 at 6:15pm* to contact medical director if primary MD does not respond: -routine - within 24 hours -abnormal - within 24 hours -critical - within 2 hours - The Regional Nurse Consultant (RNC)/ADON/designee performed training to other licensed nurses prior to their shift on all the above items. This will be completed by 06/03/23 at 6:15pm*. - ADON/DON/designee was trained by the Regional Nurse Consultant on 06/02/23 on following up with nurses notifying the PCP of abnormal labs. A monitoring tool was developed where the ADON/DON/designee will track the abnormal labs 5 days a week in the clinical meeting and review for missing/late notifications to clinician/Responsible Party. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 2. Emergency/as needed (ad hoc) QAPI completed on 06/02/2023 at 1:50pm. MDS Coordinator, Regional Nurse Consultant, Administrator, Medical Director, Human Resource, ADON, Activity Director, Rehab Director, and Dietary Manager attended emergency/as needed (ad hoc) QAPI. 3. Licensed nurses present completed 4 question communication test on 06/02/23 to ensure comprehension of education provided. All licensed nurses will complete the test prior to returning to work. This will be completed by 06/03/23* at 6:15pm. 4. DON/ADON/designee will be monitoring all labs/x-rays, daily, to ensure they have been reviewed and PCP has been notified, effective 06/01/23. This process will be completed on weekends by the weekend supervisor/designee. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 5. Staff will not be able to work until they have been trained on reviewing the lab results process by completing the following in-services: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them per facility protocol with the resident's primary PCP. -Nurses are to document in the nurse's notes and any interventions ordered by the PCP. -When there is a dashboard alert that a resident has eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician if warranted based on assessment. -Physician Notification of lab results, follow-up, or concerns. Nurses must notify MD/NP within 2 hours if lab order was unable to be carried out for any reason. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee. -Nurses/staff who do not work after the 06/03/23 will be trained prior to their next shift. 6. All Processes will be in place by 06/03/23 at 6:15pm. On 06/04/23 at 11:45 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's ad-hoc QAPI meeting minutes dated 06/02/23 (included the Medical Director) indicated the IJ failures were identified and discussed. Action plans for improvement were developed with monitoring and evaluating systems in place. Record review of the facility's chart audit dated 06/03/23, indicated the facility had completed 100% chart audit and notified the physicians of any changes or lab results as required. Record review of facility audit indicated 12 abnormal lab results with no physician notification. They were sent to physician for review and response. All results were reviewed by Ad HOC QAPI that included the medical director on 6/2/23. Record review of the facility's lab monitoring dated 06/01/23 through 06/05/23 indicated all lab results had been addressed. Record review indicated all nursing staff were in-serviced on the facility's policy for diagnostic testing and procedure and physician notification. Record review indicated the RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification. RNC/ADON/designee in-serviced CNAs on documenting residents' meal intake in the electronic record and reporting missed or refused meals immediately to the charge nurse. Record review of communication test results dated 06/02/23 and 06/03/23 indicated all nurses tested passed with a score of 100%. Interviews conducted on 06/04/23 from 9:00 a.m. through 11:40 a.m. with the interim DON, two ADONs, 2 RNs, and 10 LVNS, who worked all shifts, indicated they were trained and able to correctly state the protocols for physician notification when there was a change of condition or a need to alter treatment for a resident, report abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change of condition, and ensuring the physician received the lab results. They were knowledgeable and were aware to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results, any unreviewed results to address them with the resident's primary PCP, document in the progress notes and interventions that are ordered by the PCP. They were to contact medical director if primary MD does not respond for routine labs- within 24 hours, abnormal labs- within 24 hours, and critical labs- within 2 hours. They were aware if a dashboard alerted a resident had eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician as warranted based on assessment. They were aware they must notify MD/NP within 2 hours of lab orders not completed for any reason. They were aware they must also notify the Administrator and the DON/designee. They were aware the DON/designee would monitor for compliance. Interviews conducted with 7 CNAs from all shifts indicated they were aware to document correct intake in the electronic record and to notify the charge nurse after each meal if a resident is not eating or drinking. Record review of an in-service dated 06/02/23 indicated the interim DON and two ADONs were trained to follow up on lab results and physician notification with a new monitoring tool. Interviews conducted with the interim DON and two ADONs indicated they were responsible for ensuring all lab results were reviewed and followed up per the new monitoring tool. They would review the monitoring tool at clinical meeting Monday through Friday for missing/late notifications to clinician/Responsible Party. The interim DON/designee was aware to monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results would be reviewed by the IDT team to determine if monitoring could be decreased. An Immediate Jeopardy (IJ) situation was identified on 06/02/23 at 12:29 p.m. While the IJ was removed on 06/04/23 at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.