Based on staff interviews, clinical record review, and facility document review, and in the course of a complaint investigation, the facility staff failed to protect a resident's right to be free from physical and mental abuse for one (1) of fifty-five (55) sampled residents (Resident #454). The scope and severity were originally cited at Immediate Jeopardy, Level IV isolated, beginning on 8/30/24, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The facility staff provided an abatement plan that was verified by the survey team through additional observations, interviews, and document reviews. The facility staff was notified that Immediate Jeopardy was removed on 4/3/25 at 5:30 PM. The findings include: For Resident #454, the facility staff failed to protect the resident's right to be free of physical and mental abuse by a licensed practical nurse (LPN) during an incident that occurred on 8/30/24 between the resident and the LPN. Resident #454's diagnosis list indicated diagnoses that included, but were not limited to, Atrial Fibrillation, Glaucoma, Seizures, Hypertension, Chronic Obstructive Pulmonary Disease, History of Falls, Dementia with Agitation, Depression, Anxiety Disorder, Heart Failure, Vascular Dementia-severe with Psychotic Disturbance, Traumatic Brain Injury, History of Suicidal Behavior, and Thyrotoxicosis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/28/24, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of the clinical record revealed the following documentation: A behavior note dated 8/30/24, that read in part, .This nurse observed resident twisting the arm of CNA (certified nursing assistant) staff and pulling the sleeve of her hoodie not letting her go, resident was allegedly trying to attack another resident according to CNA. This nurse observed resident yelling and arguing with CNA staff. This nurse removed CNA from incident and was attempting to redirect this resident by taking him in his wheelchair to a quieter area. This nurse stated very calmly to resident .let's not do this. Please don't hit women, let's go back to your room. Resident initially was agreeing to go but resident then placed feet down firmly on the ground causing the wheelchair to stop, resident then leaned backwards reaching towards this nurse. This nurse was wearing hooded clothing at the time, resident grabbed this nurse by the hood of the hoodie while leaning back. This nurse tried to pull away from him causing my clothing to rip and the wheelchair to lean back. Resident then used his fingernails to scratch this nurse's neck and then placed his left thumb into this nurses' left eye causing this nurse to let go of the wheelchair which in turn caused resident to fall from the chair. Resident assessed for injuries. Resident does have contusion to the back of head, no other injuries present. Resident denying pain and discomfort at this time, vital signs were obtained by CNA and Hospice staff. All vital signs within normal limits . An alert note dated 8/30/2024, that read in part, .This nurse contacted on call supervisor from [NAME] side of the building about resident's increase in behaviors per previous behavior notes. Hospice was contacted again to update on resident's increased behaviors and to get an ETA (estimated time of arrival) for resident's hospice nurse arrival to this facility. At this time, CNA on staff came to this nurse and reported that resident was at the nurse's station on East side yelling and grabbing at staff members and pulling on their clothing. CNA on staff reported to this nurse that resident was swinging his arms towards other staff and residents striking staff with his hands. CNA reported to this nurse that resident's wheelchair tipped backward, and resident fell to the floor striking his head on the floor. Notified on call supervisor of resident's behaviors and of his fall. Resident vital signs obtained, and resident assessed for injuries. Resident has an egg-shaped swollen area on the back of his head more towards the left of center, red/pink in color and raised approximately one inch. On call supervisor contacted [name omitted] NP (nurse practitioner) and obtained orders to send resident to the ER (emergency room at hospital) for his safety . An alert note dated 8/30/24 that read in part, .911 ambulance service transporting resident to [name omitted] (hospital) for evaluation. This nurse contacted resident's daughter [name omitted] to update her on resident's behaviors through the end of day shift. Resident's daughter notified of resident grabbing and hitting staff and attempting to harm other residents. Resident's daughter notified of resident being transported to .ER for further evaluation . A hospice visit note report dated 8/30/24, that read in part, .Facility called the on-call services and stated patient was having behaviors .The staff reported that he had hit staff members and made threats towards other residents. The patient had been in his wheelchair, one male staff member tried to get him to his room to have a place that was quiet. When he moved the chair forward the patient pushed it backwards and flipped the chair. He has a large hematoma on the back of his head. No open areas noted .Ice pack applied. Pain in that area rated a 3 out of 10 .Talked with this nurse with no behaviors noted. The facility had called 911 and the EMTs (emergency medical technicians) arrived at the facility approximately 2 (two) minutes prior to this nurse. Patient did not refuse questions from the EMT, nor was he combative during their assessment. His medication nurse [name omitted] was in patients' room during this visit. When asked by this nurse if he would take his medications, he agreed. The facility nurse was ask {sic} three different times to get patient his medications and she refused, stating, I'm not giving him his medications because he's going out .This nurse called (hospital) ER and spoke with the supervisor .to give report. She stated the patient had just arrived but seemed calm, no aggression noted. She asked the EMTs if he had any behavior during transport, they stated he had remained calm throughout their encounter .the patient's daughter was contacted, she was provided information about the event. She stated her father had never behaved in that manner, but she had noticed he had more confusion over the last few days during her phone calls . An alert note dated 8/31/24 that read in part, .Resident arrived back to this facility from (hospital) ER via ambulance stretcher transport. No paperwork was brought back with resident from that visit to the ER. EMS transport stated the hospital had called hours ago and that he had been discharged since like 12 (midnight). Resident assisted into bed and changed into clean clothing and bed sheets since the ones he had on and underneath them were drenched with urine. Resident requested to be up in wheelchair and this nurse and cna {sic} on staff assisted him up from bed into his wheelchair . A review of the hospital CT (computed tomography) report dated 8/30/24, read in part, .Findings .Small left posterior scalp hematoma . Surveyor requested and reviewed the facility reported incident (FRI) dated 8/30/24, that read in part, .On 8/30/24, it was reported that resident was having a behavioral episode and grabbed [name omitted], CNA by the right wrist and would not let her go. It was reported that [name omitted], LPN (licensed practical nurse) intervened and aggressively spoke with resident regarding his behavior and grabbed the resident's arms. (LPN) then pushed the resident in his wheelchair down the hall towards the resident's room. It was reported that resident put his feet down to stop the wheelchair from rolling forward. (LPN) then tilted the wheelchair onto the back wheels and began to push the resident down the hall. (Resident #454) began leaning back and grabbing at (LPN), scratching his neck and poked (LPN) in the left eye. (LPN) let go of wheelchair causing the resident and chair to fall to the floor .resident evaluated for injury: resident has knot to the back of his head, sent to ER for evaluation . A review of the final report of the FRI dated 9/6/24, read in part, .(Resident #454) is a resident admitted .with a diagnosis of Dementia, Depression, Anxiety Disorder .Upon further investigation after admission, it was discovered that (Resident #454) has a previous neurological and psychological history, which includes Suicidal Ideations with suicide attempt, TBI (traumatic brain injury), Vascular Dementia with associated behaviors, Paranoia, and Fixed Delusions .Upon investigation it was discovered that (Resident #454) became physically and verbally aggressive with female staff, grabbing an employee by the wrist resulting in pain and discomfort, after which another employee, [name omitted], LPN (licensed practical nurse), intervened to assist, resulting in the wheelchair in which (Resident #454) was sitting tipping backwards and (Resident #454) hitting his head on the floor. The police found no evidence to charge (LPN) with any offense and in fact advised him that he had the right to press charges against (Resident #454) for scratching his {sic} and poking him in the eye .facility elected to DNR (do not return) the AGENCY staff member as a result of the investigation . A review of the employee statements within the FRI file revealed a statement from a witness of the incident that read in part, .(LPN) grabbed (Resident #454's) arms very aggressively and put his head against his and said, We aren't doing this. He (LPN) then leaned (Resident #454) back in his wheelchair and started down the hall. (Resident #454) became combative reaching for (LPN's) face when (LPN) dropped him (Resident #454) backwards hitting his head on the floor. (LPN) then helped lift him (Resident #454) back up and walked towards the nurse's station stating, If anyone wants to report me for abuse then so be it . The file from the FRI revealed another witness statement from the incident that read in part, .(LPN) stepped between (CNA) and (Resident #454) and grabbed him (Resident #454) by his arm and pushed him up against the nurse's station and told him to calm down and (Resident #454) still wouldn't calm down so (LPN) grabbed his wheelchair and started taking him down the hall but (Resident #454) wouldn't pick his feet up so he (LPN) stomped on the pedal on the back of the chair and got him (Resident #454) on 2 (two) wheels and started down the hall and (Resident #454) started hitting (LPN) in the face and he (LPN) dropped the chair resulting in (Resident #454) hitting his head on the floor . On 3/11/25 at 12:34 PM, surveyor interviewed local long-term care ombudsman (OS#1), and she recalled resident had behaviors and dementia. She informed surveyor an aide had been bringing resident down the hall and resident did not understand about taking medications. OS#1 stated his (Resident #454's) hospice nurse came up here (to facility) to attempt to give resident his medications. The resident went to swat at the aide and the agency nurse got a hold of the wheelchair and reared it back with the resident in it to keep resident from putting his feet down. When he reared it back, the wheelchair fell over. The facility did a FRI. The hospice nurse was here by then and tried to give the resident medication, but the facility would not let her try. The aide pressed charges against the resident, but it did not go to court. The resident was moved to another facility. On 3/12/25 at 10:38 AM, administrator (ADM) informed surveyor there was enough question after the incident to not bring the LPN back into the facility. He believes the LPN tried to help the CNA, the resident was combative, and the LPN had scratches and marks from the resident, but the ADM felt it best not to let him come back. On 3/13/25 at 3:49PM , surveyor interviewed certified nursing assistant #1 (CNA #1) about the incident that occurred on 8/30/24, and she stated Resident #454 was very upset and was hitting at the computer on the nurse's desk. He was trying to grab another resident and another CNA stepped on the other side to keep him from grabbing the resident and Resident #454 grabbed the CNA's wrist. The LPN slammed the resident up against the desk and then attempted to take the resident down the hall. The resident kept putting his feet down, so the LPN reared him back on two wheels. Then the resident was grabbing at the LPN and the nurse let go of the chair. The resident fell backwards and hit his head on the floor. This information was discussed at the end of day meeting on 3/14/25 at 12:44 PM with the administrator, interim director of nursing, assistant director of nursing, and regional nurse support. The abbreviated survey was extended, and an abbreviated-extended-standard survey was conducted to include this complaint investigation from 3/11/25 through 4/8/25 and this information was discussed on 4/2/25 at 1:47 PM with the administrator and director of nursing when Immediate Jeopardy was identified by the survey team. Surveyor requested and received the facility background check that was conducted on the LPN named in the abuse allegation. The background check was completed on 5/21/24 and there were no entries/crimes disclosed on the document. Surveyor requested and received a facility policy titled, Abuse, Neglect and Exploitation that read in part, .It is the policy of [name omitted] to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Definitions .Abuse means the willful infliction of injury .intimidation .with resulting in physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse .physical abuse, and mental abuse .IV .B. Possible indicators of abuse include but are not limited to .2. Physical marks such as bruises .on a resident's body .6. Physical abuse of a resident observed. 7. Psychological abuse of a resident observed . No further information regarding this concern was presented to the survey team prior to the exit on 4/8/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and care services in accordance with professional standards of practice for twenty-one (21) of fifty-five (55) sampled residents (Resident #103, Resident #453, Resident #41, Resident #17, Resident #454, Resident #71, Resident #153, Resident #32, Resident #40, Resident #50, Resident #78, Resident #254, Resident #255, Resident #13, Resident #85, Resident #93, Resident #23, Resident #96, Resident #353, Resident #100, and Resident #55). The scope and severity were originally cited at Immediate Jeopardy, Level IV isolated for Resident #103 and Resident #453, beginning on 2/24/25, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The facility staff provided an abatement plan that was verified by the survey team through additional observations, interviews, and document reviews. The facility staff was notified that Immediate Jeopardy was removed on 4/3/25 at 6:00 PM. The findings include: 1.For Resident #103, the facility staff failed to follow the medical director's standing orders for diabetic management and administer Glucagon 1 mg (milligram) IM (intra-muscularly) during a hypoglycemic episode on 2/24/25 resulting in the resident being transferred to a higher level of care. Resident #103's diagnosis list indicated diagnoses that included, but were not limited to, Hemiplegia, Hemiparesis, Type 2 (two) Diabetes Mellitus, Dysphagia, Hypertension, Weakness, Hypokalemia, Depression, and Rectal Fistula. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/20/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review the Facility Standing Orders Diabetic Management (Blood Glucose LESS than 70) read in part, .If the patient is unresponsive or unable to swallow and does not have a feeding tube .Administer Glucagon 1 mg IM(intramuscularly) .Repeat BG (blood glucose) after approximately 10 (ten) minutes; if <70 (less than seventy) and patient still unresponsive, repeat Glucagon .After giving a second Glucagon dose, if patient is still unresponsive, call 911 and notify provider immediately .If BG remains <70 but patient is conscious, initiate interventions for the conscious patient . A review of the February 2025 MAR (medication administration record) revealed Resident #103's Humalog (75/25 Subcutaneous Suspension 100 UNIT/ML (milliliters) injection) was held on the evening of 2/23/25 due to blood glucose reported at 106. This was within parameters to be held per a medical provider's order. A review of the clinical record revealed the following documentation: A Health Status note dated 2/24/25 at 6:15 AM read in part, .BS (blood sugar) @ (at) this time 30 (thirty). Will send to ER (emergency room at hospital) . A Health Status note dated 2/24/25 at 6:30 AM read in part, .Ambulance Service here for transportation . A Health Status note dated 2/24/25 at 6:35 AM read in part, .ER called & informed of need for transfer to ER . A review of the comprehensive person-centered care plan revealed a focus, goal, and intervention that read in part, .The resident has Diabetes Mellitus .The resident will have no complications related to diabetes through the review date Observe/document/report PRN (as needed) any s/sx (signs/symptoms) of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait . On 3/13/25, surveyor requested and received the cubex inventory sheet for 2/24/25 that revealed the following: Glutose Oral Gel-On Hand-2 Glucagon Syringe-On-Hand-4 Glocose Tablets-On-Hand-1 Surveyor also requested and received the Transactions by Patient (activity for accessing the cubex) dated 2/24/25 for Resident #103 and no activity was revealed for any access to the cubex by facility staff. Regional nurse support provided surveyor with a copy of the chat with licensed practical nurse #3 (LPN#3) and the on-call provider that read, 2/24/25 6:29 AM [name omitted] (Resident #103) BG 30, not sure if they have glucagon or glucose gel in house to raise her BG. Told the nurse she better find something. Glucagon, glucose gel, juice and peanut butter, something anything. On 3/12/25 at 12:37 PM, surveyor spoke with assistant director of nursing (ADON), and she stated the process for a resident with low blood sugar would typically be to give them something. The provider would be called, and the provider would typically give an order for something to be given. On 3/12/25 at 7:58 PM, surveyor interviewed LPN#3 via phone call to the facility. LPN#3 informed surveyor the process for a resident with low blood sugar is a standing order. For blood sugar below sixty (60) the nurse is to give glucagon gel or glycogen and stated she likes glycogen better because it's an injectable and works faster. LPN#3 stated she looked everywhere and could not find either one of those medications. Surveyor inquired if she looked in the cubex (an automated medication dispensing system that is a secure, electronically controlled cabinet that stores and dispenses medications to healthcare professionals) and LPN#3 stated she and another nurse looked in the cubex and could not find any. Surveyor asked LPN#3 for the name of the other nurse, and she stated, I can't remember. She stated she sent Resident #103 out because her blood sugar was low, and she could not find anything to give her to bring the blood sugar up. LPN#3 stated she called the medical provider but did not document it because she was in such a hurry to get the resident sent out. On 3/13/25 at 8:11 PM, surveyor interviewed LPN#3 via phone call to the facility to inquire the status of Resident #103's consciousness level during the hypoglycemic incident on 2/24/25 and the nurse informed the surveyor the resident was not unconscious, but very lethargic. LPN#3 also informed this surveyor she remembered she had gone to the medication room and found glucagon gel and attempted to administer it to Resident #103 and the gel rolled-out of the resident's mouth. She stated she re-checked the resident's blood sugar, and it had gone up to 39 and then she called 911. LPN#3 then stated she called the provider first after the first blood sugar check when it was 30 and she called the resident's son. She stated she found the glucagon gel in the supply room, and it was the only one she could find. On 3/13/25 at 9:02 AM, another surveyor observed the cubex and it contained 1 container of glucose tablets, 4 IM glucagon injections and 1 tube of glucose gel. On 3/14/25 at 9:05 AM, surveyor interviewed nurse practitioner (OS#14-other staff #14), and she stated LPN#3 called her and she asked the nurse if they had any glucagon or something to give Resident #103 and she told the nurse they had to give her something. OS#14 stated she did not give an order to send the resident out. On 3/14/25 at 12:44 PM, ADON informed surveyor Resident #103's blood sugar did go up to 39 and the standing order states if the blood sugar is below 70 to send out to the ER. On 3/17/25 at 2:05 PM, surveyor interviewed licensed practical nurse #10 (LPN#10) via phone conversation and she informed surveyor LPN#3 had to send Resident #103 out that morning (2/24/25). She stated LPN#3 had given the resident glucose gel, orange juice with sugar, and peanut butter. She was unsure if LPN#3 had notified the provider but recalled hearing LPN#3 calling the family member and stated, she was in a panic. LPN#10 stated she did not witness LPN#3 administer anything to Resident #103 as she was busy with another resident at the time. This information was discussed at the end of day meeting on 3/14/25 at 12:44 PM with the administrator, interim director of nursing, assistant director of nursing, and regional nurse support. This abbreviated survey was extended, and an abbreviated-extended-standard survey was conducted to include this complaint investigation from 3/11/25 through 4/8/25 and this information was discussed on 4/2/25 at 1:47 PM with the administrator and director of nursing when Immediate Jeopardy was identified by the survey team. No further information was provided to the survey team prior to exit on 4/8/25. 2. For Resident #453 the facility staff failed to provide and/or obtain timely radiology and/or diagnostic services after a medical provider ordered a left hip x-ray on 3/8/25 due to the resident having a fall on 3/7/25 with complaints of left hip pain and the facility staff failed to notify the medical provider the x-ray ordered for 3/8/25 was delayed until 3/10/25. Resident #453 was sent to a higher level of care and diagnosed with a left hip fracture requiring surgical repair. Resident #453's diagnosis list indicated diagnoses that included, but were not limited to, Hypertension, Atrial Fibrillation, Diverticulosis, Macular Degeneration, Unsteadiness on Feet, Depression, Difficulty Walking, Weakness, Polyosteoarthritis, Dementia, Alzheimer's, Chronic Kidney Disease-Stage 2, and Nightmare Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/19/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of a medical providers orders contained an order with a start date of 3/8/25 that read in part, .Left hip X-ray one time only for Pain for 1 (one) day . A review of the MAR (medication administration record) and TAR (treatment administration record) for March 9, 2025, revealed documentation of the left hip x-ray being administered. A review of Resident #453's clinical record revealed the following documentation. A Summary for Providers-Change In Condition dated 3/7/25 read in part, .The Change In Condition/s reported .are/were: Falls .Pain Status Evaluation: Does the resident/patient have pain? Yes .called to room by staff, observed resident in the floor on her bottom at bedside .upon entering the room, resident stated i {sic} was getting up from the potty chair and when i {sic} went to get in my wheelchair i {sic} forgot to lock it and it slid back .assessment completed .no visible injuries to note, assisted resident back to bed, no s/s (signs/symptoms) of distress, resident c/o (complaint of) some pain in left upper/inner thigh, described pain as tight, no changes to ROM (range of motion) to left leg .Primary Care Provider responded with the following feedback .monitor, if pain continues call for xray {sic} .repositioned patient in bed for c/o pain . A Medication Administration note dated 3/7/25 read in part, .Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 12 hours as needed for pain .given for c/o leg pain at this time . An Evaluation Note dated 3/8/25 read in part, .New orders post fall: x ray to left leg . A review of a Post Fall Assessment dated 3/8/25, read in part, .Resident reports pain .Resident states pain is 2/10 .left leg, thigh area .New orders post fall: x-ray to left leg . A Medication Administration note dated 3/9/25 read in part, .Left hip X-ray one time only for Pain for 1 Day .scheduled, will be here on Monday (3/10/25) to do x ray . An Evaluation Note dated 3/9/25 read in part, .Resident reports pain. Resident states pain is 4/10 .in left inner thigh .No notable findings .medication administered .order for x-ray, scheduled for Monday morning . An Evaluation Note dated 3/9/2025 read in part, .Late Entry .Resident reports pain. Resident states pain is 2/10 .Tylenol given by hall nurse .reports mild discomfort . A Health Status note dated 3/10/25 read in part, .LATE ENTRY .Upon returning to resident's room. Resident was lying in bed on her back with c/o pain with her left hip. Resident rated her pain at a level 4. PRN (as needed) medications was administered per MD (medical doctor) orders. Resident's pain level reassessed at 10:45am and resident rated her pain at a 3 at that time . A Summary for Providers Change in Condition dated 3/10/25 read in part, .The Change In Condition/s reported .are/were: New or Worsening Pain .Does the resident/patient have pain? Yes .Patient c/o pain upon ROM with left hip. PRN pain medication administered .Primary Care Provider responded with the following .Recommendations: Send to (hospital name omitted) Per family request . On 3/11/25 at 11:45 AM, surveyor met with local long-term care ombudsman (OMB) and she informed surveyor about Resident #453 having a fall at the facility. OMB recalled the resident's family member had called her on Friday (3/7/25) and informed her the resident had a fall at 3:00 PM and the facility was waiting for mobile x-ray. OMB stated this happened Friday evening and the x-ray was still not done yesterday (Monday 3/10/25). OMB stated the family called her after the resident got to the hospital and informed her Resident #453 had a left hip fracture and she was not sure if it would have to be pinned or replaced. On 3/12/25 at 1:19 PM, surveyor met with complainant at facility per her request. Complainant informed surveyor she called 911 on Monday (3/10/25) so the resident could have an x-ray of her hip because she was supposed to have the x-ray on Saturday (3/8/25), but the x-ray company did not show-up. Complainant stated Resident #453 was admitted to the hospital and had a left hip fracture and required surgery for a partial hip replacement. On 3/12/25 at 3:26 PM, surveyor met with assistant director of nursing (ADON), and she stated she spoke with Resident #453's family member on 3/10/25 in-person because she was called to the resident's room to speak with her about the fall. She informed surveyor resident fell at 4:00 PM on Friday (3/7/25). ADON stated they (nurses) called the provider, and he said if pain persists to get an x-ray. The unit manager called mobile x-ray and scheduled the x-ray. Mobile x-ray were supposed to come on the 8th (3/8/25) to do the x-ray. Surveyor asked ADON the process for complaints of pain after a fall and she stated the process is to medicate, contact the provider and depending on if an x-ray was ordered to get the x-ray. She informed surveyor the timeliness of mobile x-ray getting here is dependent on factors such as weekends and weather. She agreed mobile x-ray should come when they are scheduled. ADON informed surveyor she had started an Action Plan on 3/10/25 and provided surveyor with a copy of the action plan and staff education. Surveyor informed ADON the action plan was not completed prior to survey entrance on 3/11/25. ADON agreed the nurse should not have documented the x-ray was completed on 3/9/25. On 3/12/25 at 3:38 PM, surveyor interviewed licensed practical nurse #2 (LPN#2) and she informed surveyor she was working on 3/8/25 and did call mobile x-ray to see why they had not come to x-ray the resident and was informed by mobile x-ray they could not come until Monday (3/10/25) and they were delayed because it was the weekend. LPN#2 stated she informed the family at bedside. She stated she did not call the provider; another nurse called the provider. She stated the resident was complaining of hip pain, but the pain scale was not outrageous, and the resident was moving it (the leg/hip) good. 3/13/25 at 8:14 PM, surveyor interviewed licensed practical nurse #5 (LPN#5) via phone conversation and she informed surveyor she called the on-call provider on 3/8/25. She stated she did not work on that unit on Sunday (3/9/25) and LPN#2 was working that unit, and she (LPN#2) called mobile x-ray and she (LPN#2) would have called the provider about the x-ray being delayed. This information was discussed at the end of day meeting on 3/14/25 at 12:44 PM with the administrator, interim director of nursing, assistant director of nursing, and regional nurse support. This abbreviated survey was extended, and an abbreviated-extended-standard survey was conducted to include this complaint investigation from 3/11/25 through 4/8/25 and this information was discussed on 4/2/25 at 1:47 PM with the administrator and director of nursing when Immediate Jeopardy was identified by the survey team. Surveyor requested and received the facility services agreement with the mobile x-ray company that read in part, .Mobile Imaging shall .2.3.1 make Radiology Services available for Facility patients seven days a week . Surveyor requested and received a facility policy titled, Notification of Changes with a reviewed/revised date of 12/1/22, that read in part, .The purpose of this policy is to ensure the facility promptly .consults the resident's physician .The facility must .consult with the resident's physician .when there is a change requiring such notification .Circumstances requiring notification include .1. Accidents .b. potential to require physician intervention . No further information was provided to the survey team prior to exit on 4/8/25. 3. For Resident #41 the facility staff failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure the resident received a chest x-ray on 11/18/24. Resident #41's diagnosis list indicated diagnoses that included, but were not limited to, Peripheral Vascular Disease, Acute and Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, Hypertension, Dependence on Supplemental Oxygen, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus-Type 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/18/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A medical provider orders revealed an order dated 11/18/24 that read in part, .Chest x-ray, 2-view one time only for Congestion for 1 Day .Start Date 11/18/24 . A review of the November 2024 MAR showed no evidence the x-ray was completed as ordered by the provider. A review of radiology reports revealed no evidence the x-ray was completed as ordered by the provider. Surveyor requested evidence the chest x-ray was completed. This concern was discussed on 4/7/25 at 4:59 PM at the end of day meeting with administrator, director of nursing, assistant director of nursing, regional director of clinical services, and regional vice president of operations. On 4/8/25 at 8:38 AM, director of nursing informed surveyor no evidence could be located of the x-ray report or that the x-ray was completed. Surveyor requested and received a facility policy titled, Radiology and other Diagnostic Services and Reporting with a revision date of 12/1/22, that read in part, .The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law . No further information was provided to the survey team prior to exit on 4/8/25. 4. For resident # 454 (R454), the facility staff failed to administer Seroquel per physician's order and failed to discontinue multiple medications per physician's order. R454's diagnoses included but were not limited to, anemia, atrial fibrillation, heart failure, hypertension, non-Alzheimer's dementia, seizure disorder, anxiety, depression and chronic obstructive pulmonary disease. R454's minimum data set (MDS) assessment with an assessment reference date of 8/28/24 assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. The medical record was reviewed. On 8/26/24 a hospice note read in part, . medication reconciliation completed, and adjustments made. Discontinue the following: Eliquis, folic acid, iron and atorvastatin. Decreased baclofen and gabapentin from TID (three times daily) to BID (twice daily) status, no changes in dosages. Patient agreeable to changes, previously discussed with daughter whom was also agreeable. VSS (vital signs stable) at the time of this visit. Patient reports he's not sure why he's here. Educated patient it was a safety issue for him to be home alone. Facility nurse (name omitted) updated with changes. The facility notes were reviewed. There was no nurse progress note for 8/26/24 noted in the facility documentation. The Medication Administration Record (MAR) was reviewed for August 2024. Orders were noted as active through 8/31/24 for Eliquis 5 mg twice daily, folic acid 1 mg daily, ferrous sulfate (iron) 325 mg daily and atorvastatin 10 mg at bedtime. Orders were noted as active for baclofen 10 mg three times daily and gabapentin 100 mg give 2 capsules three times daily. The MAR for September 2024 was reviewed. Orders were noted as active throughout September until R454's discharge on [DATE] for Eliquis, folic acid, ferrous sulfate, baclofen three times daily and gabapentin three times daily. On 8/29/24 a nurse progress note read, Resident exit seeking today, stating that he is going to heaven through that door. Aid informed to this nurse that resident was in the bathroom using the shower spray on himself. A hospice note for 8/29/24 read, Staff report that patient has made several attempts to get outdoors. Patient has difficulty completing conversation due to inattention. Patient seems mildly paranoid this visit. During visit patient acted aggressively toward male staff member. When this nurse asked him what he was doing patient stated, I'm going to kick his ass. Patient settled and resumed visit activities and patient made attempt to chase down male visitor for another resident. When questioned about this patient stated I know him, that man is evil. Unit manager (name omitted) states patient has exhibited this type of behavior all morning. Unit manager and patient nurse stated she may need a one on one for patient given behavior and flight risk. A hospice note dated 8/31/24 read, Nurse (name omitted) states patient has been rolling to other residents rooms, attempting to pull items off residents walls. Upon arrival patient is sitting in wheelchair, alert and oriented to person and place. States he owns this facility and has been making updates. He whispered to this nurse that those blue lights over there, indicating the call light system, that's how they listen to us. Reoriented patient that is call bell system and yes they communicate to patient for safety reasons. Reoriented patient to stay in his area as he wouldn't want other residents in his room. Patient has Seroquel (an antipsychotic medication that balances the levels of hormones in the brain to help regulate mood, behaviors and thoughts) 25 mg BID (twice daily) ordered but not on facility MAR yet. Facility has medication, order resumed as lack of Seroquel could likely be the cause of increased paranoia . This surveyor could find no record of resident being on Seroquel prior to admission to the facility. A facility nurse note dated 8/31/24 read, Hospice nurse in to see resident this shift. Hospice nurse (name omitted) talked with this nurse about increased behaviors resident has had and talked with this nurse about mentioning to the provider to change his Seroquel from two times a day to three times a day. This nurse looked for an order in this system for Seroquel and did not see one for resident to have. Hospice nurse stated that the order for resident to have Seroquel twice a day should have been put into our system on 8/29/24. Hospice wrote orders for resident to have Seroquel 25mg one tablet by mouth twice a day for paranoid behaviors. The Medication Administration Record (MAR) for August 2024 was reviewed. An entry for Seroquel 25 mg give one tablet by mouth twice daily was noted to have started on August 31, 2024. A document entitled, Client Medication Report was noted under the heading of Hospice in the medical record. Seroquel 25 mg one tablet two times daily was ordered on 8/29/24. On 3/11/25 at 2:09 PM this surveyor interviewed other # 2, a hospice staff nurse who saw the resident on 8/30/24 when the facility had called due to R454's behavior. When asked about the visit they stated, They hadn't given him his Seroquel and it was due several hours prior. I asked him if he would take it and he said he would, but I had to ask that nurse 3 times to get it. She would not get it; said she wasn't going to give it because he was going out. She finally got the medicine, and I took it in there and he took it and thanked me. Surveyor asked if they could confirm that the Seroquel was one of the medications they administered as it was not on the MAR until 8/31/24. They stated, Well it's been a long time so I can't say that I remember every pill in the cup, but I know we talked specifically about Seroquel because it was for behaviors and that's why they called me, and I know we had an order to give it twice a day I think. This surveyor asked about the orders for Eliquis, atorvastatin, folic acid, iron, baclofen and gabapentin that were discontinued or changed according to hospice on 8/26/24. They stated, I'm not sure if that was me who did that, but I know that it was done due to falls or fear of him falling. Especially the Eliquis due to bleeding risk and then the baclofen and gabapentin were supposed to be decreased because they can have sedating side effects. On 3/17/25 at 11:20 AM this surveyor interviewed Licensed Practical Nurse (LPN) # 9. When asked about R454 they stated they remembered the resident well. When asked about 8/30/24, they stated they recalled R454's behaviors and the conversation with the hospice nurse. They stated, He had refused his medications for me, and I told the hospice nurse that. Our Administrator had come in because of his behaviors and said we had to send him out to the hospital. LPN # 9 stated that they did recall giving the hospice nurse some medications to administer but could not recall what it was and could not recall if Seroquel was discussed. On 3/14/25 at 12:44 PM the survey team met with the Administrator, Interim Director of Nursing, Assistant Director of Nursing and the Regional Nurse Support. This concern was discussed with them at that time. On 3/17/25 at 11:09 AM the survey team met with the Regional Director of Clinical Services and the Regional [NAME] President of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 4/8/25 11:20 AM interviewed the current Medical Director who was not familiar with the R454. When asked if Seroquel 25 mg twice daily ordered on 8/29/24 for paranoia could have worked by 8/31/24 to control or improve behavior, he stated, It's hard to say not being familiar with the resident or the situation, but I have a hard time thinking it could have worked that quickly. I have to question if it was even an effective dose in a paranoid hospice patient. I am thinking I would have ordered a much larger dose but again, that is just thinking out loud with little information or knowledge of the resident or the situation. 5. For resident #17 (R17) the facility staff failed to follow provider orders for medications related to a change in condition. On 3/31/25 at 1:30 PM this surveyor interviewed R17 and a visiting family member. The family member stated that R17 fell ill on or around 2/5/25 with congestion and they did not feel that the staff had properly assessed or treated her. She ended up in third degree hear block and got sent out. She tested positive for flu and was so sick they were afraid to do surgery on her but really didn't have any choice she was going to die if they didn't. She was having these symptoms several days before they finally sent her out. R17's diagnoses include but are not limited to third degree heart block with cardiac pacemaker, essential hypertension, asthma and acute respiratory failure with hypoxia. The minimum data set (MDS) assessment with an assessment reference date of 2/14/25 assigned the resident a brief interview for mental status score (BIMS) of 15 out of 15 indicating intact cognition. R17 stated she did not recall a lot, I was so sick I guess, I don't remember a whole lot about it. The clinical record was reviewed. On 1/30/25 a provider progress note read in part, Staff requested patient be seen for bradycardia. Resident requested to be seen for upper respiratory infection and wheezing. The note went on to state, Plan: Suspect influenza Upper respiratory infection Possible asthma exacerbation Start DuoNebs (a combination of ipratropium and albuterol that is delivered through a nebulizer machine) every 8 hours for 5 days Start influenza protocol including guaifenesin Bradycardia Appears to be asymptomatic Not on any AV [NAME] blockers Continue to monitor and trend heart rate Consider heart rate evaluation while ambulating. A nurse progress note dated 2/1/25 at 2:46 PM read, Please note resident's (family member name omitted) came to nurse's desk and stated she wanted her mother checked for respiratory issues. Resident vitals taken and are all WNL at this time. She also stated her mother had refused breakfast and lunch and now requesting a grilled cheese sandwich from the kitchen. Kitchen prepared resident's request, and plate was taken to resident's room by this nurse and other nurse on duty. There was no other note and no nursing assessment of R17's condition documented that day. A provider note dated 2/3/25 read in part, Staff requested patient be seen for bradycardia Resident requested to be seen for upper respiratory infection and wheezing. She believes that she has the flu. Under the heading Plan, Suspect influenza Upper respiratory infection Possible asthma exacerbation Increase DuoNebs to every 6 hours for 7 days Continue influenza protocol including guaifenesin Bradycardia Appears to be asymptomatic Not on any AV [NAME] blockers Continue to monitor and trend heart rate Plan to evaluate heart rate evaluation while ambulating Obtain EKG. The medication administration records (MAR) for January and February were reviewed. There was an order on the January MAR that read, Ipratropium-Albuterol solution 0.5-2.5 (3) mg/ml 3 ml inhale orally via nebulizer every four hours as needed for SOB (shortness of breath) and wheezing with a start date of 1/30/25 at 10:28 PM. The treatment was not administered to the resident in January or February. It was discontinued on 2/3/25 when another entry on the February MAR read, Ipratropium-Albuterol solution 0.5-2.5 (3) mg/ml 3 ml inhale orally via nebulizer four times a day for cough/wheezing for 7 days. The start date was 2/3/25 at 6:00 PM. The medication was never administered according to the record and was not supposed to be as needed according to the provider notes. There was no order for guaifenesin in the record for January or February. A nurse progress note dated 2/4/25 at 1:21 PM read, Received report from (name omitted) RN at (hospital name omitted) ER. Resident being transferred to (hospital name

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For R454, the facility staff failed to appropriately assess and treat a hospice patient with a history of trauma, by involving the family in the comprehensive admission assessment and administering medications ordered by the provider for paranoia and agitation. R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. There was no mood indicators captured on the assessment and the only behavior identified was wandering which occurred one to three days during the lookback period. Under the section for preferences for customary routine and activities, R454 had many activities coded as being very important. They included listening to music, being around animals or pets, keeping up with the news, doing things in groups, participating in religious activities, having snacks and using the phone in private. R454 was coded as requiring maximum assistance for toileting, bathing, dressing, bed mobility, transfers and standing and was not ambulatory in the lookback period. No family participated in the assessment. The clinical record was reviewed. R454 had numerous entries regarding behaviors during their stay at the facility. R454 was receiving hospice services prior to admission to the facility and was admitted there due to the inability to care for themselves at home. Behaviors started a week or more after admission to the facility according to the progress notes. A note dated [DATE] at 5:03 PM read, Resident refused medications all shift after multiple attempts by staff. Resident unable to bear weight when aides in room assisting with changes. Resident using his restroom inside his room and told aides he Owned this building and I'm getting everyone fired. Resident up in wheelchair at this time at the nurse's station. A note documented at 6:52 PM read, Resident up in wheelchair rolling around the hallway on East side. Resident stopped at this nurse's cart and would not let this nurse pass by to provide patient care to other residents. Resident held up a bible in the air and stretched his arm out to both sides and stated No you're not gonna pass you are just standing there doing nothing, so you're fired. Everyone in here is gonna be fired. I own this place. Resident able to be redirected a short ways down the hallway where he stopped and talked with another resident. He grabbed a large hole punch off of the nurses' station and carried it into the dayroom and would not put it down. Resident then rolled down the hallway and grabbed the electrical cord from an oxygen concentrator. When CNA (certified nursing assistant) on staff attempted to redirect him from wrapping the cord around his hand several times, resident grabbed a fist full of CNA's hair and jerked her head downwards and was agitated at CNA's visible tattoos on her forearms. Resident stated multiple times That ink is blood and you're taking good blood away from people that need it. Resident then picked up the o2 concentrator and hit same CNA on the ankle with it. Other staff was able to intervene and place the o2 concentrator in a locked room. Resident attempting multiple times to get out of the side door down 100 hall. Hospice called and on call supervisor called and alerted of resident's behaviors. A note documented at 7:06 PM read, Resident grabbed two CNA's arms at the wrist and twisted both their arms and shook. Resident able to be redirected from twisting staff's arms after a short time. A note documented at 8:20 PM read, This nurse observed resident twisting the arm of CNA staff and pulling the sleeve of her hoodie not letting her go, resident was allegedly trying to attack another resident according to CNA. This nurse observed resident yelling and arguing with CNA staff. This nurse removed CNA from incident and was attempting to redirect this resident by taking him in his wheelchair to a quieter area. This nurse stated very calmly to resident (R454 name omitted), let's not do this. Please don't hit women, let's go back to your room. Resident initially was agreeing to go but resident then placed feet down firmly on the ground causing the wheelchair to stop, resident then leaned backwards reaching towards this nurse. This nurse was wearing hooded clothing at the time, resident grabbed this nurse by the hood of the hoodie while leaning back. This nurse tried to pull away from him causing my clothing to rip and the wheelchair to lean back. Resident then used his fingernails to scratch this nurse's neck and then placed his left thumb into this nurses' left eye causing this nurse to let go of the wheelchair which in turn caused resident to fall from the chair. Resident assessed for injuries. Resident does have contusion to the back of head, no other injuries present. Resident denying pain and discomfort at this time, vital signs were obtained by CNA and Hospice staff. All vital signs within normal limits. This surveyor reviewed the facility investigation into the [DATE] events. A statement by Certified Nursing Assistant (CNA) # 1 read in part, .that's when (nurses name omitted) stepped between (CNA) and (R454) and grabbed him (R454) by his arm and pushed him up against the nurses' station and told him to calm down. (R454) still wouldn't calm down so (nurse) grabbed his wheelchair and started taking him down the hall but (R454) wouldn't pick his feet up so he (nurse) stomped on the pedal on the back of the chair and got him (R454) on two wheels and went down the hall. (R454) started hitting (nurse) in the face and (nurse) dropped the chair resulting in (R454) hitting his head on the floor. CNA # 1 was interviewed on [DATE] and there was no change in their statement. They stated to surveyors that the nurse got in (R454's) face, like really close while he was holding his arms. This surveyor asked if he was nose to nose with resident and CNA #1 stated, yeah, it was pretty close. The facility investigation led to the termination of the nurse involved in the [DATE], incident. A hospice note dated [DATE] read in part, Facility called the on-call services and stated the patient was having behaviors and had refused his medications all day. The staff reported that he had hit staff members and made threats towards other residents. The patient had been in his wheelchair, one male staff member tried to get him to his room to have a place that was quiet. When he moved the chair forward the patient pushed it backwards and flipped the chair. He has a large hematoma on the back of his head, no open areas noted. Neuro checks WNL (within normal limits). Ice pack applied. Pain in that area rated a 3 out of 10. Patient is alert and oriented. Talked with this nurse with no behaviors noted. The facility had called 911 and the EMT's arrived at the facility approximately 2 minutes prior to this nurse. Patient did not refuse questions from the EMT nor was he combative during their assessment. His medication nurse (name omitted) was in the room during the visit. When ask by this nurse if he would take his medications he agreed. The facility nurse was asked three different times to get the patient's scheduled medications, and she refused stating, I'm not giving his medications because he's going out. The patient stated multiple times that he didn't want to go out to the hospital but remained calm the entire time. The facility administrator (name omitted) had arrived at the facility and stated it was facility policy that a patient be sent to the ER for evaluation if they exhibited aggressive behaviors. This nurse offered to stay with patient for a few hours to ensure he remained calm, but the facility staff refused, and the patient was transported out to (name of hospital omitted) ER. The hospice director was contacted and report provided. She spoke via phone with the facility administrator however the circumstances didn't change. This nurse called ER and spoke with the supervisor to give report. She stated that patient had just arrived but seemed calm, no aggression noted. She asked the EMT's if he had any behaviors during transport, they stated he had remained calm throughout their encounter including their assessment at the facility . On [DATE] at 2:09 PM this surveyor interviewed the above hospice nurse via telephone and asked about this visit. They stated, I had already been there once earlier in the day, not to see him but another patient and he was fine but that evening they called me three or four times and I had told them the first time I was coming. The last time the nurse called she said. Well now he's fell. I went to the room and the rescue squad was there. They said he was going out. I told them no; we need to try to keep him here if he doesn't want to go. The nurse was outside the door and said nobody can handle him, and he's fell and hit the back of his head. But he was fine. His vital signs were fine, no problems, no behaviors or anything. I asked the EMT's why are we taking him out? They said because the staff said he was agitated, and maybe he was but he wasn't with the EMT's or me and they hadn't given him his Seroquel. It was due several hours earlier from what I remember. I asked him if he would take it, and he said he would, but I had to ask that nurse three times to get it. She would not get it; said she wasn't going to give it because he was going out. She finally got the medicine, and I took it in there and he took it and thanked me. They said he was threatening others, but he was fine the whole time, and I offered to stay and sit with him for several hours, or as long as it took, but they would not listen and would not let him stay. He didn't want to go. When I asked him how he fell, he said, that boy did it. The administrator (name omitted) came in and I tried to talk to her too, but she put her hand up in my face, like talk to the hand you know. Our (Hospice Director) called too and tried to talk to her, but she wouldn't listen. She said the facility policy was that he had to go out. Then they gave him a 30-day discharge notice and we had to find somewhere else for him to go. On [DATE] at 10:28 AM this surveyor met with the current Administrator who started [DATE]. When asked if there was a policy that stated residents had to go to the ER when they had behaviors they stated, It's not a policy but there is a section in the admission agreement that speaks to it. I wasn't here when it all started but came just a day or so later. We found out from hospice that he had a substantial psych history that we did not know about at first and we would not have taken him if we had known. We couldn't meet his needs; he was having altercations with staff and other residents. We tried to come up with a plan, hospice arranged for him to go GIP (general in-patient hospitalization) but they didn't keep him. Surveyor asked what happened on [DATE] that caused the facility to issue R454 a 30-day discharge notice they stated, We got the new information of his history from hospice. He had attempted suicide and had some history of abuse and other serious diagnoses. When asked if there were behaviors during or after the meeting that contributed to that decision they stated, No, when we learned the extent of his history, we knew we couldn't meet his needs. This surveyor asked if the facility had any geriatric psych services available to come in and see residents and they stated that they did contract with a service. When asked if R454 had been referred for services they stated they didn't think so. There was no documentation in the record that any such services had been sought. On [DATE] at 12:20 PM this surveyor interviewed the hospice Executive Director. When asked about R454, they stated, We had a call with the facility on a Monday morning after that the GIP stay to come up with a plan. They didn't keep him under GIP because he had no behaviors, he was there overnight. He did have a psych hospitalization history, for paranoia per his daughter. The facility said if we had the proper diagnosis, we could get the proper medications in there, so we got the psych notes from 2019 when he was in the psych ward in (hospital name omitted). He had stabbed himself in the abdomen. He had major depressive disorder, major neuro cognitive disorder with delusional disorder being ruled out. He was physically and sexually abused as a child and had a brother with schizophrenia. They (facility) said if we started Zyprexa and worked together to manage him it would be fine. We agreed to increase our visits to daily and work on getting some sort of psych services in to see him. We had a plan we thought everyone felt good about. We felt really good after the call and thought things would turn around, but less than 2 hours later, I called back to tell them something else maybe about the new medication orders, and (Administrator) said they were serving a 30-day notice of discharge, and they were giving it to the patient because he had not been deemed incapacitated. I couldn't believe it. He didn't sign himself in but they were making him sign his 30 day discharge notice and were not even going to call his daughter. I don't think they would have called us either. We notified the daughter what was happening. He (Administrator) said the corporate office said to discharge him and that is what they are doing. I asked what happened did he do something else, and he said it was due to what we told them about his history. We were able to get placement for him but that is where he wanted to be and where he had community ties and support to visit him. She stated that in her professional opinion R454's death was hastened by the move and that the rapid decline could have been delayed if the facility would have worked with them to manage his behaviors instead of against them. She stated that R454's daughter had appealed the discharge but when the other facility notified them that they would take him, they decided to go ahead with the move, Because at that point, we felt like we shouldn't trust that he would be allowed to live there comfortably and if they didn't win the appeal, this bed may have been gone and he wouldn't have had a place to go. He obviously couldn't go home alone and that was apparently the facility's plan. She stated that R454 died four days after moving to the other facility. The care plan was reviewed. R454's care plan included a problem statement that read, Resident is hospice and has had an atypical change in behavior/development of behavior physically and verbally aggressive towards staff and other residents, increase anxiety, wandering into other resident's rooms and toward exit doors, etc . [DATE]-Continues with physical and verbal aggression to staff and other residents. The interventions included, Administer medications as ordered. Monitor/document for side effects and Effectiveness, Anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. IDT medication review to include hospice provider, pharmacy, etc . PRN, intervene for the safety of resident and others PRN, attempt de-escalation techniques and redirection as available and appropriate, observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes, report behaviors PRN and provide referrals PRN. There was no mention of a history of suicide, no mention of a history of physical or sexual abuse or a family history of schizophrenia. None of the preferences from the MDS assessment were incorporated into the behavior care plan. On [DATE] at 12:57 PM this surveyor interviewed the hospice social worker. When asked about R454 and the meeting on [DATE] they stated, Yes I was in that meeting, I was there in person. We all agreed, and I felt really good about the plan we came up with and we had agreed to meet again in a week and see how things were going. When I left, I thought it was really productive and that everything would work out. It was a total shock and like a slap in the face, they didn't even give it a try. They undermined everything we talked about and discussed in that meeting. She stated the team had discussed increasing the hospice visits, getting psychiatric services in and medication changes. She stated that she thought R454's behaviors were mostly verbal stuff, he talked about what he would do or what he could do, but he never hurt anyone to my knowledge. He had a rapid and significant decline that started before he left and was probably exacerbated by the move. According to hospice notes Seroquel (an antipsychotic medication that balances the levels of hormones in the brain to help regulate mood, behaviors and thoughts) 25 mg twice daily was ordered on [DATE] for anxiety and agitation but was not entered onto the facility's medication administration record (MAR) until [DATE]. Zyprexa (another antipsychotic medication) 5 mg three times daily as needed for anxiety and agitation was ordered [DATE] but not put on the MAR until [DATE] and given only one time on [DATE], and Ativan 0.5 mg every 4 hours as needed for anxiety and agitation was ordered on [DATE], not added to the MAR until [DATE] and never administered despite ongoing behaviors. A note on [DATE] at 12:00 PM read, education was attempted to be given to resident and resident grabbed nurses arm with medicine and squeezed it tightly threatening that he owns this place and He will get her and show her how it is. Nurse then went to get unit Manager while leaving resident with another nurse and told her what happened. Unit Manager then came to talk to resident, and he threatened to break her knee caps. He then told the administrator who accompanied the unit Manager he will take him outside and show him how it is because he looks wimpy. Resident continues to go into other residents' rooms and threaten them, attempting to physically assault them, and preaching the gospel because we are all sinners. This surveyor reviewed the Facility Assessment which read in part, (facility name omitted) may accept residents with, or continue to provide care for residents that may develop the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Each resident is assessed and reviewed on an individual basis. Psychiatric/Mood Disorders: Psychosis (Hallucinations, Delusions, etc.), impaired cognition, mental disorder, depression, bipolar disorder (i.e., mania/depression), schizophrenia, post-traumatic stress disorder, anxiety disorder, behavior that needs interventions. R454 was served a 30-day notice of discharge on [DATE] that read the facility could not meet his needs. The policy entitled, Behavioral Health Services with a revised date of [DATE] was reviewed. The document read in part, Policy Explanation and Compliance Guidelines: 1. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorder. 2. The facility uses the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. 3. The resident and family are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as appropriate. The care plan shall: a. Be person-centered, b. Provide for meaningful activities which promote engagement and positive, meaningful relationships; c. Reflect the residents goals for care, d. Account for the resident's experiences and preferences, and e. Maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety. On [DATE] at 12:44 PM the survey team met with the Administrator, Interim Director of Nursing, Assistant Director of Nursing and the Regional Nurse support. This concern was discussed with them at that time. On [DATE] at 11:09 AM the survey team met with the Regional Director of Clinical Services (RDCS) and the Regional [NAME] President of Operations, and this concern was discussed. No further information was provided to the survey team prior to the exit conference. Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty or has a history of trauma receives appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being for 2 of 55 sampled residents (Resident #93 and Resident #454). The survey team informed the facility on [DATE] at 1:47 PM of the Immediate Jeopardy situation for Resident #93 and Resident #454. The scope and severity were originally cited at a Level IV, isolated. On [DATE] at 6:00 PM, the Immediate Jeopardy was abated and lowered to a Level III, isolated. The findings included: 1. For Resident #93, the facility staff failed to provide appropriate treatment and services following increased symptoms of a mental disorder including auditory/visual hallucinations, delusions, threatening another resident, suicidal ideation, and ongoing psychosis. The facility failed to appropriately address a [DATE] Pre-admission Screening and Resident Review (PASARR) determining Resident #93 did not meet psychiatric stability for nursing facility placement and recommended inpatient psychiatric hospitalization. As of [DATE], Resident #93 remained in the facility without a psychiatric evaluation for inpatient treatment. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, Convulsions, Metabolic Encephalopathy, Hypertensive Encephalopathy, and Cerebral Infarction. The minimum data set (MDS) with an assessment reference date (ARD) of [DATE] assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. There were no mood indicators captured on the assessment and coded behaviors included delusions and wandering. Resident #93 was coded as requiring moderate assistance for bathing and supervision/touching assistance for toileting, dressing, personal hygiene, and walking. Resident #93 was coded as being independent with bed mobility and standing. A [DATE] Social Services Assessment and Data Collection described Resident #93 as being suspicious during interviews and expressing thoughts consistent with delusions. The assessment documented a reported history by friends of the resident having altered thoughts and behaviors. The friends stated they have tried to help him and are unaware of any family. A [DATE] 3:00 PM nursing progress note read in part Communication with resident's friend [name omitted] on this date. [Friend] states resident lived with her .prior to entering facility. [Friend] states resident has an extensive hx [history] of drug abuse .[Friend] stated she is scared of resident because he has threatened to kill her . A [DATE] 5:04 PM nursing progress note read in part Resident came into this nurses office at this time and began asking what my name is when this nurse stated her name resident begins talking irrationally and states that he knew someone by the same name but 'She's not here anymore because I killed her.' Resident began stating that the devil is in the room and that he is coming for us all. Resident continues speaking erratically until he exits room. Resident #93 was initially seen by the psychiatric nurse practitioner (NP) on [DATE]. The progress note read in part .Patient has a history of psychiatric hospitalizations, including a stay at a facility in [name omitted] and [name omitted] per his report but cannot verbalize the reasoning .Patient has a history of being in jail and penitentiaries, with four instances of being in prison. The reasons for these incarcerations are unclear, but one instance involved a threat to burn down a church .He denies any suicidal ideations stating, 'I would hurt someone else before I would hurt myself.' He states he 'would find the nearest airport and crash an airplane into this building and kill everyone.' Staff also reports that the patient asked when the next church service would be and that he would attend 'and burn the church down' .Patient is extremely delusional with paranoid thoughts and experiencing visual/auditory hallucinations. It is unclear of his history or accurate treatment .Appears Manic .Patient IS currently a danger to self/others .The patient's presentation suggests a possible psychotic disorder. He reported auditory hallucinations .He also mentioned a history of visual hallucinations .a psychiatric evaluation by an inpatient facility is warranted to further assess his mental status and confirm psychiatric history .Initiate Haldol 10 mg PO [by mouth] BID [twice a day] .Start Vistaril 25 mg PO BID PRN [as needed] x 14 days . Resident #93 was sent to the emergency room (ER) on [DATE] for evaluation/medical clearance and returned to the facility later the same day. The ER record dated [DATE] read in part .The patient appears in no acute distress .Patient has no thoughts/intents to harm self or others .Based on patient's history, exam, and evaluation, there is no indication for emergent intervention or admission .mental health symptoms appear to be from recent CVA .patient does not meet criteria for hospitalization, a TDO [temporary detention order] is not recommended, and patient is okay to be discharged back to nursing facility . On [DATE], Resident #93 reported to a physical therapy staff member that he would wrap a therapy band around his roommate's neck. On [DATE] at 9:00 AM, surveyor spoke with the Occupational Therapist (OT) who stated Resident #93 asked what would happen if he took this (referring to a therapy band) and wrapped it around his roommate's neck. OT stated that she informed the resident that was inappropriate and then he stated he was just kidding. OT stated the roommate was not present at the time. Resident #93's clinical record failed to provide evidence of any immediate actions taken to ensure the roommate's safety. On [DATE], the medical provider requested Resident #93 be moved to a room by himself. Resident #93 was moved to a private room on [DATE], two days following the statement. On [DATE] at 4:11 PM, surveyor spoke with the Social Worker (SW) regarding the Resident #93's threat towards his roommate; SW stated she was unaware of this. SW returned to the surveyor at 5:16 PM and stated the OT note does not reference this behavior and the Director of Nursing (DON) spoke to the roommate on [DATE] about a room change. Surveyor reviewed the roommate's (Resident #101) clinical record which revealed a nursing progress note dated [DATE] at 1:20 PM which read in part Writer spoke with resident today with clinical team present regarding his voice concern of his safety while staying in the room with his room mate [sic]. Resident was asked if he would liked [sic] to be moved to another room. Resident replies 'Why do I need to move? I'm ok in this room.' I asked if he still felt as if he was not safe in the room with his room mate [sic]? Resident replied 'Yes I am ok I don't need to move rooms I'm ok with him in the room.' This note failed to include if the roommate was aware of the threat made towards him on [DATE]. Surveyor was unable to interview the roommate as they had been discharged and the writer of the note no longer worked at the facility. The psychiatric NP saw Resident #93 on [DATE] and documented the resident reported experiencing hallucinations, specifically mentioning [NAME]. NP ordered Remeron 7.5 mg at bedtime. On [DATE], Resident #93 expressed thoughts of self-harm. A [DATE] 7:41 AM nursing progress note read in part Reported to this nurse that resident had been screaming and yelling most of the night by off going nurse. CNA reported to this nurse that resident stated he was going to kill his self. Spoke to resident, he state that he didn't want to live. Resident put on one to one for his safety . Resident #93 was evaluated by the PA on [DATE] via telehealth and advised that one to one supervision could be discontinued. Surveyor was unable to speak with the PA as they no longer worked for the facility. Resident #93 was seen by the psychiatric NP on [DATE], the progress note read in part .the patient's behavior remains a concern. The caregiver reports that the patient refuses to use a wheelchair or walker and often ends up crawling on the floor. The patient also exhibits signs of distress, such as yelling and crying, and calls out for their mother. The patient's behavior was particularly challenging the day before the visit, with the caregiver describing it as 'horrible' .Initiate Lexapro 10 mg every morning .Continue Remeron Resident #93 was seen by the PA on [DATE], the progress note read in part .seen today due to resident's increased behaviors and wandering. As per nursing staff, resident has wandering the hallways more frequently, and demonstrating increasing abnormal behavior. Resident mumbles incoherently often, and repeats the word mamaw or mama. When speaking to resident, he will break his incoherent speech and answer questions appropriately. He was originally admitted status-post CVA [cerebrovascular accident] with multiple areas of ischemic infarcts. When he was admitted , he did not demonstrate this type of behavior, and demonstrated more paranoia and delusional language, and even verbally aggressive speech, although resident never became physically aggressive towards any staff or residents. He was seen by the in house behavioral health provider, and stated that he was once on Haldol for his behaviors, and he was then restarted on Haldol 10mg PO BID for his behaviors. However, through close observation, Haldol appeared to make the resident withdrawn and somnolent, so this medication was slowly tapered and then discontinued. Since discontinuation, resident has become more alert, but is demonstrating more incoherent speech, repeating mamaw or mama more often, and is wondering around the hallways more often now. He continues to eat and drink, but uses his hands for eating now instead of utensils. He does not demonstrate any verbally aggressive language anymore, and has not had any seizures while in facility .His current behavioral health medications are as follows: Lexapro 10mg by mouth once daily, Mirtazapine 7.5mg by mouth at bedtime, and Divalproex Sodium oral tablet 250mg twice daily for seizure disorder/mood stabilization . At this time, plan is to refer resident to the [name omitted] Behavioral Health Facility for further behavioral health management . A Preadmission Screening and Resident Review (PASARR) Level II was completed for Resident #93 on [DATE]. The summary of findings documented in part . [Resident #93][TRUNCATED]