Avir at Town Creek

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents reviewed for quality of care in that:<BR/>The facility did not prevent the development and worsening of two facility acquired wounds for Resident #1. <BR/>The facility failed to ensure a bed of appropriate size to prevent the developement and worsening of wounds was provided for Resident #1.<BR/>The facility failed to document weekly skin assessments for Resident #1.<BR/>The noncompliance was identified as PNC. The past noncompliance began on 12/02/24 and ended on 01/27/25. The facility had corrected the noncompliance before the survey began. <BR/>These failures could place residents with limited mobility at risk of developing facility acquired pressure injuries.<BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet indicated Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes, end stage renal (kidney) disease, and chronic ulcers of left and right feet.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition and he required assistance for ADL s. He required total assistance for toileting, hygiene, and bathing; maximal assistance for upper and lower body dressing, putting on/taking off footwear, and personal hygiene; partial assistance with sit to stand and chair/bed-to-chair transfers; touch assist with rolling from left to right, lying to sitting up, and lying to sitting on the side of the bed.<BR/>Record review of an admission observation completed by RN A of Resident #1 on 12/03/2024 at 4:23PM included a skin assessment which indicated Resident #1 was admitted to the facility with no alterations in skin integrity and no pressure injuries to sacrum, heels, hips, ankles, elbows, ears, or any other bony prominence. The same admission observation indicated Resident #1 was assessed for venous ulcers, arterial ulcers, and diabetic ulcers including assessment of lower extremities, upper and lower feet, and upper and lower toes, with no ulcers noted. <BR/>Record review of a comprehensive care plan revision on 12/11/2024 indicated Resident #1 was at risk for pressure ulcers related to impaired mobility and incontinence. Interventions were put in place including weekly skin assessments with particular attention paid to the bone prominences (areas of the body where the underlying bone is particularly close to the surface of the skin), keeping resident clean and dry, and maintaining the head of the bed at lowest degree of elevation possible.<BR/>Review of Weekly Skin assessments indicated only two skin assessments had been documented for Resident #1:<BR/>*01/09/2025 by ADON - Resident with DTI (Deep Tissue Injury) on Right and Left plantar foot;<BR/>*01/16/2025 by LVN A - DTI TO RT/LT PLANTAR (right and left sole of foot);<BR/>Record review of Resident #1's comprehensive care plan revisions on 1/09/2025 indicated Resident #1 had developed a diabetic ulcer to his left first toe, and a diabetic ulcer to his right first toe. New interventions were added including avoiding friction and shearing forces during transfer and position change, keep bony prominences from direct contact with one another with pillows, foam wedges, etc., monitor for signs of osteomyelitis (bone infection), cellulitis (soft tissue infection), sepsis (an extreme bodily reaction to infection), and wound treatment orders to clean area with normal saline and apply skin prep daily. The same care plan also included initiation of a planned weight gain program on 1/09/2025 to assist Resident #1's wound healing.<BR/>Record review of a wound care physicians Initial Wound Evaluation and Management Summary on 1/10/2025 indicated the focused wound exam revealed the presence of two Diabetic Wounds and the following new orders:<BR/>- <BR/>Site 1: Diabetic wound of the left, first toe, partial thickness. The wound measured 1cm x 1cm x Not Measurable (Length X width X Depth) due to scab covering wound. Treatment plan included applying skin prep daily for 30 days.<BR/>- <BR/>Site 2: Diabetic wound of the right, first toe, undetermined thickness. The wound measured 0.5cm x 1cm x Not Measurable due to scab covering wound. Treatment plan included applying skin prep daily for 30 days.<BR/>- <BR/>Follow-Up Evaluation by wound care provider weekly, or sooner as needed, with further intervention as indicated based on response to current treatment plan.<BR/>Record review of Resident #1's comprehensive care plan revision on 1/26/25 indicated Resident #1 had developed a new diabetic wound to his right foot. New interventions were added including using a lift sheet to move resident in bed, resident continued with weekly wound care treatments from wound care provider.<BR/>Record review of Resident #1's the most recent wound care physicians Wound Evaluation and Management Summary dated 1/31/25 indicated the following:<BR/>- <BR/>Site 1: Diabetic wound of left toe, partial thickness. The wound measured 1cm x 1cm x not measurable due to scab covering wound. Wound healing progress not at goal. Treatment plan included applying skin prep once daily for 16 days.<BR/>- <BR/>Site 2: Diabetic wound of the right, first toe, undetermined thickness. The wound measured 1.5cm x 2cm x Not Measurable due to scab covering wound. Healing progress at goal. Treatment plan includes applying skin prep once daily for 16 days.<BR/>- <BR/>Site 3: Diabetic wound of right, plantar foot full thickness. The wound measured 3.5cm x 3cm x 0.1cm. Healing progress improved as evidenced by decreased surface area. Treatment includes skin prep once daily for 30 days. No sharp debridement needed due to chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now. <BR/>During an interview on 2/03/25 at 10:10 AM, CNA B said she was familiar with Resident #1. She said his bed was not long enough for him and his feet pressed up against the footboard and hung over the edge of mattress after footboard was removed. <BR/>During an interview on 2/03/25 at 10:25 AM, LVN A said Resident #1's bed was too small because he is 6ft 8in tall and his feet were pressing and rubbing against the footboard. She said she had reported the concerns to ADM, DON, ADON. She said ADM told her that was the biggest bed available for Resident #1. She said ADON removed the footboard from the bed after Resident #1 developed diabetic wounds on his feet. <BR/>During an observation and interview on 2/03/25 at 10:30 AM, Resident #1 was observed lying in his bed in his room. His bed had no footboard, and feet were extended beyond the end of the mattress and were resting on a mattress extension attached to bedframe. Wounds to his right great toe, right sole, left great toe, and left sole were observed. The wound beds were covered over by scabbing and not visualized. Resident #1 said he was uncomfortable in the bed when he was admitted to the facility and had voiced this concern to staff, but he could not recall who he spoke to. He said he was comfortable now with the footboard being removed and mattress extension in place. He said he was uncomfortable lying flat in bed and preferred to have his head raised.<BR/>During an interview on 2/03/25 at 1:00 PM, DON said the facility identified the need for and ordered an extension for Resident #1's bed when he was admitted but they misplaced it and had to order a new one. She said Resident #1 had other interventions in place including frequent rounding and pulling him up in the bed, so his feet don't press on the footboard. She said Resident #1 had weekly skin assessments ordered and all skin assessments should have been charted in his progress notes. She said no staff had ever voiced concerns about Resident #1's feet rubbing against the footboard causing skin breakdown.<BR/>During an interview on 2/03/25 at 12:30 PM, ADM said he measured that mattress with a measuring tape, and it was 81in in length which was sufficient for Resident #1's height of 6ft 8in (80in) and additionally ordered a mattress extension. He said when Resident #1 was pulled up in his bed his feet weren't going to rub on the footboard. He said Resident #1 was mobile and slides down in the bed when he shifts positions. He said no one reported any concerns of skin break down related to resident's feet rubbing against the footboard. He said Resident #1 had a history of chronic diabetic ulcers which were one of his admitting diagnoses. He said following the first reported skin breakdown the facility put interventions in place including ordering a new mattress extension, provided an inservice to all clinical staff in which the topic of timely skin assessments was discussed, and got a referral for specialty wound clinic to assess and treat resident. He said the facility also planned to conduct further inservices and supply resident with a bariatric bed.<BR/>Review of Facility Wound Summary Report dated 1/03/2025 to 2/03/2025 indicated Resident #1 had two facility acquired Diabetic Ulcers discovered on 1/09/2025. There were no other residents with pressure related injuries in the facility. <BR/>Review of policy titled Pressure Injury/Skin Breakdown - Clinical Protocol last revised April 2024 indicated:<BR/> .Within post-acute and long-term care, pressure injuries and other chronic wounds emerge as clinical concerns, heavily influenced by patient immobility, underlying health conditions and nutritional factors. These disruptions in skin integrity can gravely impact a resident's quality of life .<BR/>And<BR/> .The licensed nurse will complete a weekly skin assessment in the progress note section of the resident chart .<BR/>It was determined these failures resulted in Resident #1 being harmed on 01/09/2025.<BR/>Facility took the following actions to correct the non-compliance:<BR/>- <BR/>Record review of the facility's In-service binder revealed an in-service titled Mandatory meeting (all clinical staff) was conducted on 1/15/25 topics of in-service topics included Skin assessments need to be done in a timely Manner. They are now schedule by day shift 6-2 and evening shift 2-10 (evening shift are for night shift).<BR/>- <BR/>During interviews with 3 CNAs and 2 LVNs on the day shift, all employees indicated they would routinely check for skin concerns. The 3 CNA's said they look at resident's skin during incontinence care and when assisting with showers and would notify their charge nurse of any concerns. The 2 LVN's said they would assess residents as ordered and chart their findings in resident progress notes.<BR/>- <BR/>Review of an invoice indicated a mattress extension was purchased on 1/27/2025 and observations of Resident #1 at various times revealed the mattress extension to be in place.<BR/>- <BR/>Referral to wound care management with visit frequency of weekly or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents were provided with a separate bed of proper size and height for the safety and convenience of the resident for 1 of 4 residents (Resident #1) reviewed for appropriate functional furniture.<BR/>The facility failed to ensure Resident #1 had a bed of proper size for his safety to prevent development and worsening of two facility acquired wounds.<BR/>The noncompliance was identified as PNC. The past noncompliance began on 12/02/24 and ended on 01/27/25. The facility had corrected the noncompliance before the survey began. <BR/>This failure could place residents at risk for discomfort, skin breakdown and a decreased quality of life.<BR/>The findings included:<BR/>Record review of Resident #1's undated face sheet indicated Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal (kidney) disease and chronic ulcers of left and right feet, and muscle wasting (atrophy) of lower right and left legs, and chronic diabetic ulcers of both feet.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition and he required assistance for ADLs. He required total assistance for toileting, hygiene, and bathing; maximal assistance for upper and lower body dressing, putting on/taking off footwear, and personal hygiene; partial assistance with sit to stand and chair/bed-to-chair transfers; touch assist with rolling from left to right, lying to sitting up, and lying to sitting on the side of the bed. He was 80 inches tall.<BR/>Record review of a comprehensive care plan revision on 12/11/2024 indicated Resident #1 had an ADL deficit related to End Stage Renal (kidney) Disease. The same care plan indicated he required the assistance of 2 people for ambulation, transfers, and bed mobility .<BR/>During an interview on 2/03/25 at 10:10 AM, CNA B said Resident #1's bed was not long enough for him, and his feet were always hanging off the bed. <BR/>During an observation and interview with Resident #1 on 02/03/25 at 10:30 AM revealed the footboard of his bed had been removed and he was lying on his back in bed with his legs and feet extended beyond the mattress, hanging over the edge. His feet were resting on a mattress extension that was attached to the end of the bed frame. His head was elevated to a semi-Fowler's position (upper body raised to a 30-45-degree angle). Resident #1 said when he was admitted to the facility, he notified staff members that his bed was too small, and it was uncomfortable. He said his feet pressed against the footboard. He said it was uncomfortable to lie flat in bed and he preferred to have his head elevated. <BR/>During an interview on 2/03/25 at 10:25 AM, LVN A said Resident #1's bed is too small because he is 6ft 8in tall and his feet were pressing and rubbing against the footboard. She said she had reported the concerns to ADM, DON, ADON. She said ADM told her that was the biggest bed available for Resident #1. She said ADON removed the footboard from the bed after resident developed diabetic ulcers on both of his feet.<BR/>During an interview on 2/03/25 at 1:00 PM, DON said the facility identified the need for and ordered a mattress extension for Resident #1's bed when he was admitted but they misplaced it and had to order a new one. She said Resident #1 had other interventions in place for comfort and safety including frequent rounding, maintaining the head of his bed in as low a position as possible to prevent sliding, and pulling him up in the bed so his feet don't press on the footboard.<BR/>During an interview on 2/03/25 at 12:30 PM, ADM said he measured that mattress with a measuring tape, and it was 81in in length which was sufficient for Resident #1's height of 6ft 8in (80in) and additionally ordered a mattress extension but it was misplaced. He said when Resident #1 is pulled up in his bed his feet aren't going to rub on the footboard. He said resident is mobile and slides down in the bed when he shifts positions. He said Resident #1 had a history of chronic diabetic ulcers which were one of his admitting diagnoses. He said he already ordered a second mattress extension which was in place on resident's bed and the facility held a mandatory in-service for all clinical staff covering bed and chair positioning. He said the facility also planned to conduct further in-services and supply resident with a bariatric bed.<BR/>Record review of facility policy titled Bed Safety indicated the following:<BR/> .The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits .<BR/> .As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs .<BR/>a. <BR/>Medical diagnoses, conditions, symptoms, and/or behavioral symptoms<BR/>b. <BR/>Size and weight .<BR/>It was determined these failures resulted in Resident #1 being harmed on 1/09/25.<BR/>Facility took the following actions to correct the non-compliance:<BR/>- <BR/>Record review of the facility's In-service binder revealed an in-service titled Mandatory meeting (all clinical staff) was conducted on 1/15/25 topics of in-service topics included positioning residents correctly in chair or bed, positioning devices in beds or chairs, and increasing visual monitoring.<BR/>- <BR/>During interviews with 3 CNAs and 2 LVNs on the day shift, all employees indicated they would assess resident's comfort and needs when rounding. The 3 CNA's said they reposition residents according to their preference and medical needs and would notify their charge nurse of any concerns. The 2 LVN's said they would ask residents comfort and pain levels during assessments and communicate any concerns.<BR/>- <BR/>Review of an invoice indicated a mattress extension was purchased on 1/27/2025 and observations of Resident #1 at various times revealed the mattress extension to be in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment 1 of 4 halls (room [ROOM NUMBER]) reviewed for environment.The facility failed to repair the window in Resident #2's room [ROOM NUMBER] that had a broken frame that had detached from the wall on 8/12/2025.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included:Record review of a Resident Face Sheet for Resident #2 dated 8/12/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can cause hallucinations and delusions), atherosclerotic heart disease (plaque buildup that causes narrowing and limited blood flow in the blood vessels), and polyosteoarthritis (joint stiffness and pain in multiple areas).Record review of a Quarterly MDS assessment dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene.Record review of a care plan for Resident #2 dated 12/31/2024 indicated she had a self-care deficit related to schizoaffective disorder with intervention for two staff to assist with bed mobility.Record review of maintenance records dated 8/12/2025 indicated there was not a request for the repair of the window in room [ROOM NUMBER].During an observation on 8/12/2025 at 10:18 AM, CNA B was in the room to provide care to Resident #2. Resident #2's bed was positioned by the window. The window frame at the bottom of the window was detached from the wall, with one screw and one nail exposed with the top of them showing that were about one-half inch out of the wall.During an observation and interview on 8/12/2025 at 10:22 AM, CNA B was in room [ROOM NUMBER]. CNA B said she did not notice the window in the room when she provided care to Resident #2 because her bed was right against the wall. She said the window frame was detached from the wall. She said if they noticed any issues they were supposed to report it to the Maintenance Supervisor by scanning a QR code that was at the nurses'desk. She said residents could be at risk for injury if the window was not repaired.During an observation and interview on 8/12/2025 at 3:03 PM, CNA C observed the window frame in Resident #2's room and said she was not aware that anything was wrong with her window. She said the window frame was detached and said she would report it to Maintenance. Resident #2 was in bed awake and said it had been repaired a while ago but was not sure how long this time it had been broken. CNA C said there was a risk for injury, or it could allow bugs into the facility if the window frame was broken.During an observation and interview on 8/12/2025 at 3:25 PM, the Maintenance Supervisor was in room [ROOM NUMBER] working on repairing the window frame. He said he had been employed at the facility for 6 weeks. He said staff usually put in work orders for him that he would check every hour daily. He said he was not aware of the window in that room until that day. He said residents could be at risk for getting cuts, scrapes, or bruises if the window frame was not repairedDuring an interview on 8/13/2025 at 2:38 PM, the SW said the department heads conducted angel rounds in the facility daily where the staff were assigned rooms to check for environment issues and any other deficiencies. He said he was assigned the hall where Resident #2 resided. He said he checked her room daily but did not check the window because the blinds were always closed and did not think there were any issues with the window. He said if staff noticed anything in the rooms that needed repair, they were to report it to the Administrator during the morning meetings. He said staff could also scan the QR codes around the facility that would notify the Maintenance Supervisor of issues that needed repair. He said there was a risk of safety concerns if repairs were not reported.During an interview on 8/13/2025 at 2:53 PM, the Administrator said the department heads in the facility were assigned rooms that they were to check daily. She said they were to check and report any environment issues. She said throughout the facility, any staff could scan QR codes to report issues that needed to be repaired directly to the Maintenance Supervisor. She said she was not made aware of Resident #2's window until yesterday 8/12/2025. She said she would in-service the staff in the facility on reporting issues to maintenance and expected the staff to communicate more. She said environment issues that were found during the angel rounds were discussed in the morning meetings daily and the window in room [ROOM NUMBER] was not discussed. Record review of a facility policy titled Homelike Environment revised February 2021 indicated, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. clean, sanitary, and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for tube feeding management (Resident #6).The facility failed to follow their policy for maintaining Resident #6's positioning while administering medications via gastrostomy tube on 8/12/2025.The facility failed to follow their policy for labeling gastrostomy tube feeding for Resident #6 on 08/12/2025.These failures placed the resident at risk for aspiration of water/feedings and reduced therapeutic effects of gastrostomy feedings by not following current clinical standards of care.Findings included: Record review of a facility face sheet dated 08/12/25indicated Resident #6 was a [AGE] year-old male that was admitted to the facility on [DATE]. He was re-admitted on [DATE] with diagnoses of tracheostomy (airway surgically created in the trachea), gastrostomy (tube placed surgically into the stomach for feeding), cerebral ischemia (decreased circulation in the brain), muscle wasting and dysphagia (inability to swallow). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 14 which indicated intact cognition and was dependent on staff for gastrostomy tube care and positioning. Record review of a comprehensive care plan revised 7/20/25 indicated Resident #6 required a gastrostomy tube (a tube placed in the stomach) for feeding and medication administration.Record review of a comprehensive care plan revised 06/20/2025 indicated: Resident requires feeding tube related to pharyngeal dysphagia. Peg- tube placed on 10/4/24. He is at risk for aspiration r/t noncompliance with positioning in bed. He will purposely scoot down in bed to a lying position. Resident will not exhibit signs of complications from feeding tube or enteral feeding solution through next 90 days.Record review of consolidated physician orders dated 08/12/2025 indicated: Enteral Administration Set & Bag - Change every 24 hours.Special Instructions: Residents name, Date, Time, and initials of nurse on feeding, Flush bag and tubing Once A Day-Enteral Feeding (Aspiration Precaution) Elevate HOB 30-45 degrees Every Shift.During an observation and interview on 08/12/2025 at 08:45 AM Resident #6 was lying supine (on back with face up) in bed with head of bed at 10 - 15 degrees elevation. Resident #6's gastrostomy tube (tube in stomach for feeding) feeding was infusing per pump with the label blank with no date, time or initials when hung. The ADON said the feeding should be labeled with date, time and initial when hung. She said there was a risk of the feeding not being changed as needed or the infusion of the feeding not administered as ordered.During an observation on 08/12/2025 at 09:00 AM Resident #6 was lying supine in bed with head of bed at 10- 15 degrees elevation. The ADON administered g-tube flushes before administration of meds and after each medication as ordered per medical doctor. Resident #6 continued to be lying supine in bed with head of bed at 10- 15 degrees elevation. Resident #6 began coughing and the ADON raised the head of bed to over 45 degrees per standard of care.During an observation and interview on 08/12/2025 at 09:10 Resident #6 nodded he was alright, smiled and coughing subsided.During an observation on 8/12/2025 at 12:00 PM Resident #6 was in the dining room participating in music activities, he was laughing and communicating with staff. Resident #6 had no negative effects observed from flushes.During an interview on 8/12/2025 at 09:30 AM the ADON said she should have raised the head of bed before beginning the flushes and medication administration. She said by not maintaining the resident in position as ordered he was at risk for aspiration of his water flushes and feedings. The ADON said that the feedings should always be labeled as required by facility policy.During an interview on 8/13/2025 at 08:30 AM the DON said she was responsible for ensuring the nursing staff followed standards of care and policies regarding g-tube feedings and positioning of residents during flushes to ensure the risk of aspiration was decreased. She said the ADON should have raised the head of bed before beginning the flushes and medication administration. She said by not maintaining the resident in fowlers position (head of head up at least 30-45 degrees) as ordered, placed the resident at risk for aspiration of his water flushes and feedings. The DON said she had already started an in-service to staff to ensure compliance with facility policies and standards of care concerning positioning of residents during gastrostomy tube feedings/flushes and labeling of gastrostomy tube feedings.During an interview on 08/13/2025 at 11:30 AM the Administrator said the DON was responsible for ensuring compliance to standards of care for feeding tubes. She said not labeling the feedings or keeping the head of bed raised could put the resident at risk for aspiration of water/feedings and reduced therapeutic effects by not following current clinical standards of care.Record review of a facility policy dated 07/01/2025 titled Flushing a Feeding Tube .Policy: It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice .5. Elevate the bed to a comfortable working height and place the patient in Fowler's position (45-60-degree elevation of the head of bed) .14. Prevent aspiration risk by keeping the head of bed elevated at a minimum of 30 degrees.Record review of a facility policy dated 07/2025 titled Care and Treatment of Feeding Tubes .Policy: It is the policy of this facility to utilize feeding tubes in accordance with clinical standards of practice, with interventions to preventcomplications to the extent possible .13. The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure all food items stored in the refrigerator and freezer were dated and labeled.These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 08/12/2025 at 8:28am-9:10am, the following undated and unlabeled items was identified by the dietary manager in the refrigerator and freezer:Freezer*1-bag of 12 premade waffles with no date or label.*3-gallon bags of precooked chicken with no date or label.*1-gallon bag of uncooked chicken no date or label.*1-gallon bag of breaded squash with no date or labelRefrigerator**9-pre-made fruit cups with no date or label.*2-5lb rolls of ground beef with no date or label.*1-6lb ham with no date or label.During an interview on 08/13/2025 at 9:55 AM with the DM he said food should be dated and labeled when it's opened and placed in a different container. He said when food comes into the facility it should be immediately dated and labeled and stored in the refrigerator, freezer or pantry. He said no dates and labels could cause the staff to cook something that is contaminated, out of date and cause illness to residents. During an interview on 08/13/2025 at 10:06 AM with Cook/Aide E she said dating and labeling should happen when storing leftovers and when food comes into to the kitchen it should be dated and labeled immediately. She said if food was not dated and labeled staff would not know the expiration date and may not be able to identity the food item. She said not dating and labeling food items could cause the staff to serve the wrong food and may cause sickness to the residents. During an interview on 08/13/2025 at 10:12 AM with Cook/Aide F, she said food should be dated and labeled upon deliver and prior to storing the food item. She said if staff opens food they should date and label the item with an open date and expiration date. She said if there was no date or label on all food products in the kitchen the staff could use expired foods and cause residents to get sick.During an interview on 08/13/2025 at 10:17 AM with the Dietitian she said food should be dated and labeled when it is received into the kitchen. She said staff should date and label food items when staff opens or removes food from its original container and when storing leftovers. She said when food was not dated and labeled correctly staff would not know the date it was delivered, the date it expires or the date it was opened. She said with no date or label to identify the item or expiration date the food could be bad and should not be served to the residents. She said if food was expired or spoiled it could cause food borne illness. During an interview on 08/13/2025 at 10:45 AM with the Administrator she said staff should be dating and labeling all foods when it was delivered in the kitchen. She said if there was left over food or if food was removed from its original container kitchen staff should apply a new label and date with the name of the item and the expiration date. She said if food was not dated and labeled the staff could serve expired foods or the wrong foods and could cause a severe allergic reaction to a resident or make residents ill. Record review of a facility policy titled Food Storage dated 10/01/2018, revised 06/01/2019 indicated, .It is the policy of this facility to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2.c. Refrigerator, food should be dated, labeled and sealed. 3.c. Freezers, Items should be labeled and dated. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food .Record review of the Food and Drug Code dated 2022 indicated.3-602 Labeling3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified inLAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, markingdevices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, anadequately descriptive identity statement; 3-201.11 Compliance with Food Law.(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 12 residents (Residents #18, #3, and #22) reviewed for ADL care.<BR/>1. <BR/>The facility failed to ensure Resident #18 had clean and trimmed nails on 3/24/25 and 3/25/25.<BR/>2. <BR/>The facility failed to ensure Resident #3 had clean and trimmed nails on 3/34/2025 and 3/25/2025. <BR/>3. <BR/>The facility failed to shave Resident #22 and she had facial hair on her chin and lip on 3/24/2025.<BR/>These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.<BR/>Findings included:<BR/>1.Record review of a facility face sheet dated 3/24/25 for Resident #18 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of dementia. <BR/>Record review of a quarterly MDS dated [DATE] for Resident #18 indicated that he had a BIMS score of 5 which indicated severely impaired cognition. He did not exhibit rejection of care. He required supervision for personal hygiene. <BR/>Record review of a comprehensive care plan dated 1/29/25 for Resident #18 indicated that he required assistance of 1 staff member for hygiene and grooming and nail care was to be performed on shower days. The care plan indicated shower days were Monday, Wednesday, and Friday. <BR/>Record review of Point Of Care History for bathing/showering dated 3/1/25 to 3/25/25 for Resident #18 indicated he received a shower on 3/24/25.<BR/>During an observation and interview on 3/24/25 at 10:10 am revealed Resident #18 was observed lying in bed and had long fingernails with a dark brown substance observed underneath them. He said it had been a while since anyone had cleaned or trimmed his nails. He said he would like for them to be cleaned and shorter, and that it would make him feel better. <BR/>During an observation on 3/25/25 at 8:51 am revealed Resident #18 was observed lying in bed with head of bed elevated, eating breakfast. His fingernails were observed to still be long and dirty.<BR/>During an observation and interview on 3/25/25 at 11:14 am CNA C said CNAs were responsible for nail care unless the resident was diabetic. She observed Resident #18's fingernails and said they needed to be cleaned and trimmed. She said she would be giving him a shower today and would clean his nails. She asked him if he would like a shower and nail care and he said yes. She said there could be a risk of bacteria and infection if nails were not kept clean and trimmed. She said she would not like to have long, dirty nails. <BR/>2. Record review of a Face Sheet for Resident #3 dated 3/25/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mix of symptoms that include seeing and hearing things and mood disorders such as depression), atherosclerotic heart disease (caused by plaque buildup that restricts blood flow to organs and parts of the body), and polyosteoarthritis (multiple areas of arthritis).<BR/>Record review of a Quarterly MDS Assessment for Resident #3 dated 1/29/2025 indicated she did not have any impairment in thinking with a BIMS of 15. She required partial/moderate assistance with personal hygiene. <BR/>Record review of a care plan for Resident #3 dated 1/29/2025 indicated she had an ADL functional status/rehabilitation potential with interventions to clean and trim finger and toenails on bath/shower days.<BR/>Record review of a point of care history for Resident #3 dated 3/1/2025-3/25/2025 indicated her shower days were on Tuesday, Thursday, and Saturday. Tasks to clean and trim fingernails and toenails on bath/shower days were documented as being done from 3/1/2025-3/25/2025.<BR/>During an observation and interview on 3/24/2025 at 9:53 AM, revealed Resident #3 was in her room sitting up in a wheelchair. She was alert to person, place, time, and situation. Her nails were about &frac12; inch to 1 inch in length and had a brown substance underneath them. She said they trimmed them sometimes and would get the goo out of them. She said she received her showers on Tuesday, Thursday, and Saturday. She said she would like her nails trimmed and cleaned.<BR/>During an observation on 3/25/2025 at 9:49 AM, revealed Resident #3 was in bed awake, and her fingernails were still long with a brown substance underneath them.<BR/>During a joint interview on 3/25/2025 at 10:20 AM, CNA A and CNA C were both present in the room of Resident #3. Both said the resident would refuse care at times and said her shower days were on Tuesday, Thursday, and Saturday and that was when the resident's nails were trimmed and cleaned but only if the resident was not diabetic and she was not. Both observed her nails and said they were long and dirty and should have been cleaned. Both said they would feel upset and gross if they did not have their nails cleaned and she used her hands to eat at times. <BR/>During an interview on 3/25/2025 at 1:35 PM, LVN D said if a resident was diabetic, then the nurse was responsible for cleaning and trimming nails, but if they were not diabetic, then the nurse aides were responsible for trimming, filing, cleaning, and soaking nails and it should be done daily. She said she was aware that nail care was not done daily and had talked to the nurse aides about it. She said if a resident refused, they could not make them. She said Resident #3 had refused in the past but was not aware of any refusals recently. She said if her nails were long and dirty it would make her feel cruddy (dirty).<BR/>During an interview on 03/25/25 at 01:47 PM, the DON said the nurse aides were responsible for doing nail care and documenting it. She said there would be a risk for infection and cross-contamination if nails were not cleaned and trimmed. She said she would not feel good if her nails were long and dirty. She said going forward she would check behind the CNAs and ensure nail care was properly done.<BR/>During an interview on 03/25/25 at 02:08 PM, the Administrator said he and the DON/ADON were responsible for ensuring ADL care was being done on the residents. He said the licensed nurses and certified nurse aides should be providing the ADL care to the residents. He said he would do in-services to ensure staff knew they were responsible for ADL care. He also said he would have the DON/ADON go behind staff to ensure compliance. He said CNAs and nurses were responsible for nail care and it should be done as needed and also on shower days. He said nail care would be added to Angel Rounds for observation that nail care was being done. He said if proper nail care was not done residents could be at risk for germs and bacteria, and it could be a dignity issue.<BR/>Record review of a facility policy titled Fingernails/Toenails, Care of revised February 2018 indicated, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. General Guidelines: 1. Nail care included daily cleaning and regular trimming .<BR/>3. Record review of a facility face sheet dated 3/24/25 revealed Resident #22 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of senile degenerative brain disorder (brain deterioration from age and disease).<BR/>Record review of a quarterly MDS assessment dated [DATE] revealed Resident #22's BIMS was not completed. Further review revealed a staff assessment for mental status (SAMS) was completed and indicated severely impaired cognitive skills for daily decision-making and required maximal assist with personal hygiene. <BR/>Record review of a comprehensive care plan dated 12/11/2024 revealed Resident #22 had an ADL self-care deficit and required dressing and grooming every shift. <BR/>During an observation on 03/24/25 at 11:46 am revealed Resident # 22 was observed with facial hair to her chin and upper lip that was approximately 1 inch long.<BR/>During an interview on 03/24/25 at 11:50 am CNA A said that Resident # 22 was seen Monday through Friday for personal care by the hospice aide. She said care that was not done by the hospice aide should be done by the facility aide. She said she had not noticed the facial hair and had not shaved Resident #22. She said by leaving hair on her face could cause her embarrassment. <BR/>During an interview on 03/24/25 at 11:54 am LVN B said that Resident #22 would sometimes refuse care, but she had allowed staff to shave her in the past. She said she had not noticed the aides were not shaving her. She said she oversaw the ADL care and helped as needed and Resident #22 should be shaved as needed to prevent embarrassment. <BR/>During an observation on 03/25/25 at 7:21 AM revealed Resident # 22 up in the dining room and the facial hair had been removed. <BR/>During an interview on 03/25/25 at 7:26 am the Hospice Aide said she had provided personal hygiene and care to Resident #22 on 3/24/25. She said that Resident #22 had on her hospice aide care plan to shave weekly, but she had not been shaving her because she would resist care. She said she told the nurse at the facility but that was several months ago. She said a female having facial hair could be embarrassing. <BR/>Record review of a hospice aide care plan report dated 3/24/2025 revealed Resident #22 was to be shaved once per week. <BR/>During an interview on 03/25/25 at 7:33 am LVN B said the staff shaved Resident #22 yesterday evening and she did well. She said Resident #22 would at times resist care, but the staff should give her time to calm down and reapproach her again. She said she would continue to monitor that ADL care was completed. <BR/>During an interview on 03/25/25 at 11:34 am the DON said that the charge nurses, ADON and herself were responsible for oversight of resident care. She said if a resident could not perform ADL's themself the staff were to provide that care to them. She said the facility staff were responsible regardless of hospice care and the facility staff should have been ensuring care was being completed. She said not providing grooming and a female resident being left with facial hair could affect their dignity and self-esteem. She said she would monitor ADL care more closely on a weekly basis. <BR/>During an interview on 03/25/25 at 2:10 pm the Administrator said that himself, the DON and ADON were responsible for ADL oversight and ADL's should be provided by the nurses and aides. He said the facility staff should be checking behind outside care aides to ensure care was provided. He said not providing ADL care could affect dignity. He said he expected all care be provided and would retrain all staff on ADL care.<BR/>Record review of a facility policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene, 2. appropriate care and services will be provided for residents who are unable to carry out ADLs independently including hygiene, 4. if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem, approach the resident in a different way or different time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 8 resident's (Resident #5) personal refrigerators reviewed for food and nutrition services.<BR/>The facility failed to ensure a personal refrigerator on 3/24/2025 and 3/25/2025 for Resident #5 did not have a plastic bag of sliced cheese dated 9/24/2024.<BR/>These failures could place residents at risk for food borne illnesses.<BR/>Findings include:<BR/>Record review of a face sheet for Resident #5 dated 3/25/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral palsy (a birth defect that caused damage to the brain), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and GERD (reflux disease). <BR/>Record review of an Annual MDS Assessment for Resident #5 dated 3/15/2025 indicated he did not have any impairment in thinking with a BIMS score of 14. He required supervision or touching assistance with eating.<BR/>Record review of a MAR for Resident #5 dated 3/1/2025-3/25/2025 indicated an order for the resident's refrigerator daily at bedtime: check for cleanliness and expiration of foods. Everything should be labeled and disposed of within 5 days .<BR/>Record review of a care plan for Resident #5 dated 1/29/2025 indicated he had ADL functional status/rehabilitation potential with interventions that included the resident required x 1 assistance with eating. <BR/>During an observation on 3/24/2025 at 9:45 AM, revealed Resident #5 was not in his room, and he had a personal refrigerator present that had a plastic bag with sliced cheese dated 9/24/24. The cheese was not in the original package.<BR/>During an observation and interview on 3/25/2025 at 9:20 AM, revealed Resident #5 was in the dining room and said he ate foods from his personal refrigerator and his best friend would get things out for him. He said the sliced cheese was purchased one day last week and his best friend made him a sandwich using the cheese yesterday, 3/24/2025. <BR/>During an observation and interview on 3/25/2025 at 9:25 AM, the Best Friend of Resident #5 said she did not prepare a sandwich for Resident #5 yesterday, 3/24/2025 and he ate a sandwich that was prepared in the kitchen. She looked in the refrigerator and said the cheese had been in the refrigerator for a long time. She said she was not sure who was supposed to check his refrigerator for expired foods.<BR/>During an observation and interview on 3/25/2025 at 10:08 AM, HSK E said she started at the facility in December 2024 and the housekeeping staff were responsible for checking the personal refrigerators for cleanliness, temperatures, and defrosted them as needed. She said they checked the refrigerators about every 2 weeks or so. She said she never checked the foods in the refrigerators because they belonged to the residents. She said she was not sure who was supposed to check the foods.<BR/>During an interview on 3/25/2025 at 10:52 AM, the HSK Supervisor said the nurses were supposed to check the personal refrigerators for expired foods. She said the housekeeping staff were to only clean and check the temperatures. She said if she saw something that was expired, she would tell the resident and then throw it away. She said if a resident ate something that was expired, it could make them sick.<BR/>During an observation and interview on 3/25/2025 at 1:35 PM, LVN D said housekeeping were responsible for checking the refrigerators in the residents' rooms for expired foods. She said Resident #5 had been known to refuse to allow staff to remove foods from his refrigerators in the past but was not aware of any recent refusals. She observed his personal refrigerator and a plastic bag of sliced cheese dated 9/24/24 was removed by her and said she would throw it away. She said residents could get sick if they ate foods that were expired.<BR/>During an interview on 3/25/2025 at 1:55 PM, the DON said she had been employed as the DON for 4 weeks. She said housekeeping was responsible for checking the personal refrigerators to make sure they were clean; temperatures were good and did not have any expired or outdated foods. She said they were to check them weekly and was not aware that Resident #5 had any foods that were expired in his refrigerator. She said if a resident ate foods that were expired it could make them sick.<BR/>During an interview on 3/25/2025 at 2:04 PM, the Administrator said he was ultimately responsible, but the nursing staff were supposed to check the personal refrigerators daily. He said he was not aware that Resident #5 had any foods that were expired in his refrigerator. He said he planned to make sure everyone was aware who was responsible for checking the personal refrigerators and they could be checked during morning rounds. He said there could be a risk for residents to get food borne illnesses if they ate foods that were beyond the expired date. <BR/>Record review of a facility policy titled Personal Resident Refrigerators revised 9/11/2023 indicated, .This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. 3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are out of compliance .

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 10 residents (Resident #4) reviewed for abuse. <BR/>The facility failed to report an incident of abuse on 10/15/2023 when LVN B told Resident #4 to stop acting like a damn fool with RN C present. LVN B was allowed to finish her shift, she continued to work with Resident #4 and did not leave the facility until 6:51 pm that day. Staff did not report the incident to the Abuse Coordinator until 10/19/2023 and the Abuse Coordinator did not report the incident to HHS until 10/19/2023. <BR/>This failure could place residents at risk of further abuse. <BR/>Findings included: <BR/>Record review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia, with agitation (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness) schizoaffective disorder, (mental disorder).<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, which indicated resident had moderate cognitive impairment. He required limited to extensive assistance of one staff for ADL care. <BR/>Record review of Resident #4 Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, which indicated resident had moderate cognitive impairment. He required limited to extensive assistance of one staff for ADL care. <BR/>Record review of Resident #4's care plan dated 10/18/2023 indicated that he had a history of schizoaffective disorder with psychosis, anxiety, major depressive disorder, recurrent, severe with psychosis. He receives psychotropic medications, (drugs that affect a person's mental state) anxiety and anti-depression medications. Interventions were to approach in a calm, slow manner, maintain a calm environment, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive.<BR/>Record review of a progress note dated 10/15/23 at 3:08PM for Resident #4 by LVN B indicated on 10/15/2023 at 3:08 PM, .Resident #4 was found lying on his right side on the floor in his bathroom and his wheelchair was by the bedside. Resident stated, I walked to the bathroom to use the bathroom and fell on the floor, the CN, (LVN B) and unit CNA assisted the resident in getting off the floor with a gait belt and walked to his wheelchair, the resident denied hitting his head, complained of right elbow discomfort and right hip discomfort, RN C assisted with the neuro check, no visible injury present at this time, notify DON, NP new order x-ray of right elbow and right hip, and emergency contact . <BR/>Record review of a self-report to HHSC dated 10/19/20223 by the Administrator indicated an incident occurred at the facility on 10/15/2023 with LVN B who told Resident #4 to stop acting like a fool with RN C present.<BR/>During an observation and interview 10/25/23 at 10:30 AM, Resident #4 was sitting in his wheelchair in the dining room on the secure unit. He was clean and well groomed. There was another resident that kept hollering out and Resident #4 made a face and grimaced whenever the other resident hollered. Attempted to interview Resident #4 and ask him a few questions and resident continues to sit with eyes closed and not answer. When asked if anyone had ever hurt him, he did not answer.<BR/>During an interview on 10/25/23 at 11:02 AM, the Administrator said LVN B, and RN C, did not like each other. He said RN C, started working for them in August, the Administrator said he had heard that something happened at another facility with LVN B. He said LVN B had worked at the facility on numerous occasions covering different shifts. He said she was already suspended, and he didn't know if it happened before or after allegation was made at his facility. He said he figured they took care of it. He said she worked agency and cannot work anywhere else because she had two allegations of abuse within a year. He said he did not hear about incident at his facility until 10/19/23. On 10/16/23 his ADON was called by the [NAME] President of Clinical Operations and told, please do not accept LVN B to work in your facility, but they did not know why. On 10/19/23 while the DON was trying to cover LVN B's shift she called RN C about working LVN B's shift. He said RN C asked whose shift she would be covering, and DON said for LVN B. RN C said the one who called a Resident #4 a damn fool. Administrator said he formally suspended LVN B, on 10/19/23. He said she has not worked at the facility since. He said incidents not being reported timely, a staff member had the ability to do it again if not reported immediately to the abuse coordinator. <BR/>During a phone interview on 10/25/23 at 11:10 AM RN C she said she had worked at the facility as the RN Supervisor on the weekends since the first of August 2023. She said Resident # 4 had fell in a bathroom on the memory care unit. RN C was called back there to assist LVN B with assessing Resident #4. She said Resident #4 was lying on the floor in the bathroom with his head under the sink. RN C began to assess resident #4 and she decided it was ok to get him up in a chair. She said LVN B told CNA P to go get her gait belt out of her bag. RN C said Resident #4 was moving around while LVN B was attempting to put gait belt on him. He jerked away and hit his head on the sink and LVN B said, stop acting like a damn fool. RN C said resident had no visible injuries. She said they notified the nurse practitioner, and she ordered an x-ray of his hip. RN C said the incident slipped her mind until 10/19/23 when the DON contacted her to work on 10/20/2023, she asked which nurse she was working for and the DON said LVN B and RN C said, oh the one that called the resident a damn fool. RN C said she should have reported the incident immediately to her DON or the abuse coordinator, which was the Administrator.<BR/>Record review of an In-Service Education on Abuse/Neglect dated 9/1/2023 indicated RN C had training and her signature was present on the sign in sheet.<BR/>Record review of an employee memorandum dated 10/19/2023 for RN C indicated she was suspended for failure to report abuse allegations in timely manner with date of violation on 10/19/2023. <BR/>Record review of a notice of termination dated 10/25/2023 for RN C indicated she was terminated for failure to report abuse/neglect in a timely manner to Abuse Coordinator.<BR/>During an interview on 10/26/23 at 3:00pm, the Administrator said he had been employed at the facility since August 14, 2023. He said if he had known about the incident when it occurred, he would have completed a self-report, suspended the employees, started in-servicing staff, conducted a head-to-toe assessment along with an emotional status assessment for each resident involved. He said by incidents not being reported timely, a staff member had the ability to do it again if not reported immediately. <BR/>Record review of a facility policy titled Abuse Prevention Program with a revised dated of 1/9/2023 indicated, .1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect. Reporting: 2. An alleged violation of abuse, neglect exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 3 residents reviewed for misappropriation of property. (Resident #6)<BR/>The facility failed to prevent a diversion (misappropriation) of Resident #6's Hydrocodone-Acetaminophen 10-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 3/14/23.<BR/>This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.<BR/>Findings include:<BR/>Record review of an undated face sheet for Resident #6 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Pressure ulcer of sacral region (bedsore to buttock region), dysphagia (trouble swallowing), chronic pain syndrome, and pneumonia (lung infection). <BR/>Record review of an Annual MDS dated [DATE] for Resident #6 indicated that he had a BIMS score of 13, indicating that he was cognitively intact. He was documented as receiving an opioid for the entire 7 day look back period.<BR/>Record review of physician's orders for Resident #6 indicated that he had an active order for hydrocodone-acetaminophen 10-325mg, 1 tablet by mouth every 6 hours dated 3/2/22.<BR/>Record review of a medication administration record for Resident #6 for the month of March 2023 indicated the resident received hydrocodone routinely at 12:00 am, 6:00 am, 12:00 pm, and 6:00 pm until his discharge on [DATE].<BR/>Record review of a police department command log #C2304113, dated 3/14/23, indicated that an officer responded to a report of theft of hydrocodone and received the following statement: .[ADM] stated she was the administrator of [facility name]. [ADM] stated that she transported a resident from [facility name] to [facility name] on 3/14/23. [ADM] stated a nurse collected all of the subject's medications and gave it to [ADM]. [ADM] stated when she got to [facility name] and they counted the medication, they were missing one tray of 30 hydrocodone pills. I asked [ADM] if she counted the narcotics before leaving the nursing home. [ADM] stated she did not know that she was supposed to count the medication before leaving the facility. She stated she had full possession of the narcotics from the time of the transport until [facility name] and that now she knows she supposed to count the medication. [ADM] stated she needed to report this theft of narcotics to the state <BR/>During an interview on 6/28/23 at 10:40 am with MA G she said she was not a regular employee of the facility and that she worked for a staffing agency. She said she helped the building when they were short-handed. She said she was working as a CNA on the day of the incident, but that the ADON had asked her to count Resident #6's hydrocodone with her because he was being transferred. She said she counted the medications with the ADON and there were 3 cards of medication for a total of 88 pills. She said the count sheet was verified to have the correct number and she circled the number on the sheet and signed off on it. She said the ADON then took the count sheet, folded it in half and rubber banded it to the 3 cards of medications. She said she could not say what happened after that because she said she did not follow the ADON around or watch the ADON go to the van. <BR/>During an interview on 6/28/23 at 11:00 am with LVN C she said that she had counted the medications that morning (3/14/23) with the oncoming ADON and the count was correct at that time. She said there was a count sheet for the medications as of the time she counted with the ADON that morning. LVN C said she had no further access to the medications after that.<BR/>During an observation and interview on 6/28/23 at 11:20 am, the Company Clinical Leader said that a breakdown in the system had occurred that day (3/14/23) because a licensed nurse should have verified the count before taking possession of the drug and accompanied the resident along with the narcotics during the transfer. She said the medication had not been found and staff had been drug tested and in-serviced on drug diversion education after the incident. She said that narcotics were no longer allowed to go with a resident without a licensed nurse signing to verify count and the count sheet and the licensed nurse retaining sole possession during the transfer. Narcotics observed in the closet of DON office under double lock.<BR/>During an interview on 6/28/23 at 11:45 am Regional Clinical Nurse said she was at the facility the day of the incident. She said that ADM and CNA H transferred Resident #6 together to another facility. She said ADM had called her upset because the receiving facility would not accept the medication. She said the ADM told her the receiving facility would not accept hydrocodone because there was no count sheet and there was a full card of 30 pills missing. The Regional Clinical Nurse said she told the ADM to return to facility with the remaining medications and she immediately searched the med carts and med room but did not locate the medication. <BR/>During an interview on 6/28/23 at 12:10 pm the DON said she was in the facility on the day of the incident. She said MA G and the ADON had counted the hydrocodone and the ADM then took possession of the medications. The ADM and CNA D then transferred the resident using the van. She said once they got to the receiving facility, it was discovered there was no count sheet and one card of 30 pills was missing. She said the remaining medications were brought back to the facility and drug tests were done on all staff involved. She said that ADM did the self-report and if any other notifications were made, they would have been done by ADM.<BR/>During an interview on 6/28/23 at 2:29 pm ADON said that she, MA G, and LVN C all 3 got Resident #6's medications together, counted the narcotic that was there, and all signed the narcotic sheet. She said there was 1 count sheet for all 88 pills, which included 3 cards: 2 cards of 30 pills and 1 card of 28 pills. She said she then attached the count sheet to the back of the 3 cards of medication and put them in a bag. She said she gave ADM the bag and ADM did not open the bag to verify. She said the bag was tied shut. She said she was unaware of any other residents missing meds. She said all staff involved had to be drug tested. She said after the incident, it was put into place that when someone was being transported to another facility, a nurse must go if they had narcotics involved. She said the facility did a self-report and notified the police.<BR/>Record review of a facility policy titled Abuse Prevention Program dated 2001 with revision date of June 2021 indicated .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .<BR/>Record review of a facility policy titled Discharge Medications dated 2001 with revision date of March 2022 indicated .6. The nurse shall complete the medication disposition record, including .i. the signatures of the person receiving the medications and the nurse releasing the medications <BR/>Record review of a facility policy titled Controlled Substances dated 2001 with revision date of April 2019 indicated .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 3 residents reviewed for misappropriation of property. (Resident #6)<BR/>The facility failed to prevent a diversion (misappropriation) of Resident #6's Hydrocodone-Acetaminophen 10-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 3/14/23.<BR/>This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.<BR/>Findings include:<BR/>Record review of an undated face sheet for Resident #6 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Pressure ulcer of sacral region (bedsore to buttock region), dysphagia (trouble swallowing), chronic pain syndrome, and pneumonia (lung infection). <BR/>Record review of an Annual MDS dated [DATE] for Resident #6 indicated that he had a BIMS score of 13, indicating that he was cognitively intact. He was documented as receiving an opioid for the entire 7 day look back period.<BR/>Record review of physician's orders for Resident #6 indicated that he had an active order for hydrocodone-acetaminophen 10-325mg, 1 tablet by mouth every 6 hours dated 3/2/22.<BR/>Record review of a medication administration record for Resident #6 for the month of March 2023 indicated the resident received hydrocodone routinely at 12:00 am, 6:00 am, 12:00 pm, and 6:00 pm until his discharge on [DATE].<BR/>Record review of a police department command log #C2304113, dated 3/14/23, indicated that an officer responded to a report of theft of hydrocodone and received the following statement: .[ADM] stated she was the administrator of [facility name]. [ADM] stated that she transported a resident from [facility name] to [facility name] on 3/14/23. [ADM] stated a nurse collected all of the subject's medications and gave it to [ADM]. [ADM] stated when she got to [facility name] and they counted the medication, they were missing one tray of 30 hydrocodone pills. I asked [ADM] if she counted the narcotics before leaving the nursing home. [ADM] stated she did not know that she was supposed to count the medication before leaving the facility. She stated she had full possession of the narcotics from the time of the transport until [facility name] and that now she knows she supposed to count the medication. [ADM] stated she needed to report this theft of narcotics to the state <BR/>During an interview on 6/28/23 at 10:40 am with MA G she said she was not a regular employee of the facility and that she worked for a staffing agency. She said she helped the building when they were short-handed. She said she was working as a CNA on the day of the incident, but that the ADON had asked her to count Resident #6's hydrocodone with her because he was being transferred. She said she counted the medications with the ADON and there were 3 cards of medication for a total of 88 pills. She said the count sheet was verified to have the correct number and she circled the number on the sheet and signed off on it. She said the ADON then took the count sheet, folded it in half and rubber banded it to the 3 cards of medications. She said she could not say what happened after that because she said she did not follow the ADON around or watch the ADON go to the van. <BR/>During an interview on 6/28/23 at 11:00 am with LVN C she said that she had counted the medications that morning (3/14/23) with the oncoming ADON and the count was correct at that time. She said there was a count sheet for the medications as of the time she counted with the ADON that morning. LVN C said she had no further access to the medications after that.<BR/>During an observation and interview on 6/28/23 at 11:20 am, the Company Clinical Leader said that a breakdown in the system had occurred that day (3/14/23) because a licensed nurse should have verified the count before taking possession of the drug and accompanied the resident along with the narcotics during the transfer. She said the medication had not been found and staff had been drug tested and in-serviced on drug diversion education after the incident. She said that narcotics were no longer allowed to go with a resident without a licensed nurse signing to verify count and the count sheet and the licensed nurse retaining sole possession during the transfer. Narcotics observed in the closet of DON office under double lock.<BR/>During an interview on 6/28/23 at 11:45 am Regional Clinical Nurse said she was at the facility the day of the incident. She said that ADM and CNA H transferred Resident #6 together to another facility. She said ADM had called her upset because the receiving facility would not accept the medication. She said the ADM told her the receiving facility would not accept hydrocodone because there was no count sheet and there was a full card of 30 pills missing. The Regional Clinical Nurse said she told the ADM to return to facility with the remaining medications and she immediately searched the med carts and med room but did not locate the medication. <BR/>During an interview on 6/28/23 at 12:10 pm the DON said she was in the facility on the day of the incident. She said MA G and the ADON had counted the hydrocodone and the ADM then took possession of the medications. The ADM and CNA D then transferred the resident using the van. She said once they got to the receiving facility, it was discovered there was no count sheet and one card of 30 pills was missing. She said the remaining medications were brought back to the facility and drug tests were done on all staff involved. She said that ADM did the self-report and if any other notifications were made, they would have been done by ADM.<BR/>During an interview on 6/28/23 at 2:29 pm ADON said that she, MA G, and LVN C all 3 got Resident #6's medications together, counted the narcotic that was there, and all signed the narcotic sheet. She said there was 1 count sheet for all 88 pills, which included 3 cards: 2 cards of 30 pills and 1 card of 28 pills. She said she then attached the count sheet to the back of the 3 cards of medication and put them in a bag. She said she gave ADM the bag and ADM did not open the bag to verify. She said the bag was tied shut. She said she was unaware of any other residents missing meds. She said all staff involved had to be drug tested. She said after the incident, it was put into place that when someone was being transported to another facility, a nurse must go if they had narcotics involved. She said the facility did a self-report and notified the police.<BR/>Record review of a facility policy titled Abuse Prevention Program dated 2001 with revision date of June 2021 indicated .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .<BR/>Record review of a facility policy titled Discharge Medications dated 2001 with revision date of March 2022 indicated .6. The nurse shall complete the medication disposition record, including .i. the signatures of the person receiving the medications and the nurse releasing the medications <BR/>Record review of a facility policy titled Controlled Substances dated 2001 with revision date of April 2019 indicated .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift

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

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

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

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 1 months (March 2023) reviewed for pharmacy services. <BR/>The facility did not have a licensed pharmacist and two witnesses initial the attached pages of controlled medication destruction inventory sheets. <BR/>This failure could put residents at risk for misappropriation and drug diversion.<BR/>Findings include:<BR/>During a record review of the facility's drug destruction log for March 17, 2023, the drug destructions for controlled drugs dated 3/17/23 indicated that the attached pages of controlled and dangerous medication destruction forms were signed only by the consultant pharmacist and did not include the initials of two witnesses.<BR/>During an interview on 06/28/23 at 10:00 a.m., the DON said she was unaware of the need for each attachment page to be witnessed by two witnesses. She said she would ensure all pages were signed and initialed appropriately going forward. She said that not following proper procedure could put residents at risk of a drug diversion or misappropriation.<BR/>During an interview on 6/28/2023 at 2:29 pm, the ADON stated she was usually only a witness with the drug destruction and present when they were destroyed with the DON and pharmacy consultant. She said she was unaware each attachment sheet must have 2 witnesses sign off as well. She said the drug destruction was the responsibility of the DON.<BR/>Record review of a facility policy titled Discarding and Destroying Medications dated 2001 with a revision date of October 2014 indicated .Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances .<BR/>Record review of 22 TAC &sect;303.1 Destruction of Dispensed Drugs accessed online 06/28/2023 at https://texreg.sos.state.tx.us/ indicated;<BR/>(a) Drugs dispensed to patients in health care facilities or institutions.<BR/>(1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. <BR/>(A) A written agreement exists between the facility and the consultant pharmacist. <BR/>(B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: <BR/>(i) name and address of the facility or institution. <BR/>(ii) name and pharmacist license number of the consultant pharmacist. <BR/>(iii) date of drug destruction. <BR/>(iv) date the prescription was dispensed; <BR/>(v) unique identification number assigned to the prescription by the pharmacy; <BR/>(vi) name of dispensing pharmacy; <BR/>(vii) name, strength, and quantity of drug; <BR/>(viii) signature of consultant pharmacist destroying drugs; <BR/>(ix) signature of the witness(es); and <BR/>(x) method of destruction. <BR/>C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es).<BR/>v) any two individuals working in the following capacities at the facility: <BR/>(I) facility administrator; <BR/>(II) director of nursing; <BR/>(III) acting director of nursing; or <BR/>(IV) licensed nurse.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 9 residents (Resident #31) reviewed for psychotropic medications (medications that affect behavior, mood, thoughts, and perception).<BR/>The facility failed to obtain a signed consent for psychotropic medications for Resident #31 that included: mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa that were administered to her.<BR/>The failure could affect residents who received psychoactive medications without informed consents and place residents at risk of receiving unnecessary psychotropic medications.<BR/>Findings included:<BR/>Record review of a face sheet for Resident #31 dated 10/1/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of manic episodes (racing thoughts, pressure speech, increased risk-taking and a decreased need for sleep), senile degeneration of brain (progressive loss of brain tissue and function), alcohol abuse with alcohol-induced psychotic disorder, anxiety, and dementia.<BR/>Record review of a Sig Change MDS dated [DATE] for Resident #31 indicated she was rarely/never understood. During the 7 day look back period she took antipsychotic, antianxiety and antidepressant medications. She received antipsychotic medications since admission.<BR/>Record review of active physician orders dated 10/1/2024 for Resident #31 indicated orders for: <BR/>o <BR/>Mirtazapine (an antidepressant used to treat major depressive disorder) 15 mg at bedtime started on 6/11/2024.<BR/>o <BR/>Risperdal (risperidone-an antipsychotic that works by changing the effects of chemicals in the brain) 1 mg at bedtime started on 6/11/2024. <BR/>o <BR/>trazodone (an antidepressant used to treat major depressive disorder) 150 mg at bedtime started on 6/29/2024.<BR/>o <BR/>Depakote (used to treat seizure disorders, certain psychiatric conditions and to prevent migraine headaches) 125 mg twice a day started on 7/1/2024. <BR/>o <BR/>clonazepam (used to prevent and control seizures) 0.5 mg three times a day started on 7/9/2024.<BR/>o <BR/>Zyprexa (used to treat severe agitation associated with certain mental/mood conditions) 5 mg daily started on 7/9/2024.<BR/>Record review of the pharmacist's medication regimen review dated 6/1/2024 and 6/24/2024 indicated Resident #31 was reviewed and did not require any recommendations.<BR/>Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antipsychotic medication Risperdal and Zyprexa with diagnosis of alcohol abuse with alcohol-induced psychotic disorder. Interventions included to assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms.<BR/>Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antidepressant medication Mirtazapine. New order for trazodone on 6/17/2024 for diagnosis of insomnia. Interventions included to administer medications as ordered and assess/record effectiveness of drug treatment.<BR/>Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antianxiety medication for treatment of anxiety, new order for clonazepam. Interventions included to assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others. Monitor for drug use effectiveness and adverse consequences.<BR/>Record review of the Resident #31's medical record indicated there were not any consents for the psychotropic medications that were ordered.<BR/>During a joint interview on 10/1/2024 at 2:07 PM, the Travel DON and the ADON both said that a previous Travel DON who was no longer employed at the facility was responsible for ensuring residents on antipsychotics had consents and appropriate documentation. The ADON said she was hired at the facility on July 23, 2024, and was responsible for antipsychotics as of last week. Both said they started an audit of the facility last week for residents on psychotropics medications and found that residents consents were scanned in different places but Resident #31 did not have any record of consents in her electronic health record. Both said on 9/26/2024 they spoke to Resident #31's RP and received verbal consent at that time and have since gotten signed consents for her medications as of 9/26/2024. Both said consents should be signed before medications were administered, complete an AIMS assessment, have target behaviors in an order along with behavior monitoring, side effects, and care planned for the medications. Both said there was a risk for adverse side effects and family not being aware if consents were not obtained before the medication was administered. Both said going forward they would monitor daily to make sure the consents were signed before psychotropic medications were given. Both said a PIP was put in place and started last week for psychotropic medications.<BR/>During an interview on 10/1/2024 at 2:19 PM, the Administrator said the DON would be responsible for ensuring residents had consents for psychotropic medications. He said he was aware of Resident #31 not having signed consents as the facility conducted an audit about a week or so ago and found some issues. He said the facility put a PIP in place at that time. He said consents for psychotropic medications should be done before the medications were given to the residents. He said there was a risk for getting something the resident or POA did not want them to have.<BR/>Record review of a Performance Improvement Plan: dated 9/23/2024 indicated they had identified concerns related to antipsychotic medications and making sure consents were obtained. <BR/>Record review of a consent for use of psychotropic medication for Resident #31 dated 9/26/2024 indicated a consent for mirtazapine by the RP for the use of the prescribed medication.<BR/>Record review of a consent for use of psychotropic medication for Resident #31 dated 10/1/2024 indicated a consent for Depakote by the RP for the use of the prescribed medications.<BR/>Record review of a consent for use of psychotropic medication for Resident #31 dated 9/26/2024 indicated a consent for clonazepam by the RP for the use of the prescribed medications.<BR/>Record review of a consent for use of psychotropic medication for Resident #31 dated 10/1/2024 indicated a consent for trazodone by the RP for the use of prescribed medications. <BR/>Record review of a consent for use of psychotropic medication form 3713 for Resident #31 dated 9/25/2024 indicated a consent for Risperdal by the RP for the use of the prescribed medications.<BR/>Record review of a consent for use of psychotropic medication form 3713 for Resident #31 dated 9/25/2024 indicated a consent for Zyprexa by the RP for the use of the prescribed medications.<BR/>Record review of a facility policy titled Psychoactive Medication dated July 2024 indicated, .Residents are not given psychotropic medications unless the drug is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the residents, as demonstrated by monitoring and documentation of the residents' response to the medication. 9. Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication (excluding an emergency). a. A consent form for antipsychotic/neuroleptic medication utilizing Texas form 3713 must be completed and signed by the residents or resident representative. Consent must be obtained in writing. b. A consent form for other psychotropic medications must be completed and signed by the resident or resident representative using the psychoactive consent form in Matrix .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure all food items stored in the refrigerator and freezer were dated and labeled.These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 08/12/2025 at 8:28am-9:10am, the following undated and unlabeled items was identified by the dietary manager in the refrigerator and freezer:Freezer*1-bag of 12 premade waffles with no date or label.*3-gallon bags of precooked chicken with no date or label.*1-gallon bag of uncooked chicken no date or label.*1-gallon bag of breaded squash with no date or labelRefrigerator**9-pre-made fruit cups with no date or label.*2-5lb rolls of ground beef with no date or label.*1-6lb ham with no date or label.During an interview on 08/13/2025 at 9:55 AM with the DM he said food should be dated and labeled when it's opened and placed in a different container. He said when food comes into the facility it should be immediately dated and labeled and stored in the refrigerator, freezer or pantry. He said no dates and labels could cause the staff to cook something that is contaminated, out of date and cause illness to residents. During an interview on 08/13/2025 at 10:06 AM with Cook/Aide E she said dating and labeling should happen when storing leftovers and when food comes into to the kitchen it should be dated and labeled immediately. She said if food was not dated and labeled staff would not know the expiration date and may not be able to identity the food item. She said not dating and labeling food items could cause the staff to serve the wrong food and may cause sickness to the residents. During an interview on 08/13/2025 at 10:12 AM with Cook/Aide F, she said food should be dated and labeled upon deliver and prior to storing the food item. She said if staff opens food they should date and label the item with an open date and expiration date. She said if there was no date or label on all food products in the kitchen the staff could use expired foods and cause residents to get sick.During an interview on 08/13/2025 at 10:17 AM with the Dietitian she said food should be dated and labeled when it is received into the kitchen. She said staff should date and label food items when staff opens or removes food from its original container and when storing leftovers. She said when food was not dated and labeled correctly staff would not know the date it was delivered, the date it expires or the date it was opened. She said with no date or label to identify the item or expiration date the food could be bad and should not be served to the residents. She said if food was expired or spoiled it could cause food borne illness. During an interview on 08/13/2025 at 10:45 AM with the Administrator she said staff should be dating and labeling all foods when it was delivered in the kitchen. She said if there was left over food or if food was removed from its original container kitchen staff should apply a new label and date with the name of the item and the expiration date. She said if food was not dated and labeled the staff could serve expired foods or the wrong foods and could cause a severe allergic reaction to a resident or make residents ill. Record review of a facility policy titled Food Storage dated 10/01/2018, revised 06/01/2019 indicated, .It is the policy of this facility to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2.c. Refrigerator, food should be dated, labeled and sealed. 3.c. Freezers, Items should be labeled and dated. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food .Record review of the Food and Drug Code dated 2022 indicated.3-602 Labeling3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified inLAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, markingdevices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, anadequately descriptive identity statement; 3-201.11 Compliance with Food Law.(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18

Based on interviews and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2024 for the third quarter April 1, 2024 to June 31, 2024)<BR/>The facility failed to submit accurate RN hours for:<BR/>04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU)<BR/>These failures could place residents at risk for personal needs not being identified and met.<BR/>The findings included:<BR/>Record review of the CMS PBJ (Payroll Based Journal) report for the third quarter of 2024 (April 1, 2024 through June 31, 2024) indicated there was no RN hours for the following dates: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU).<BR/>Record review of the monthly staffing schedules for April 2024, May 2024, and June 2024 revealed that there was a RN scheduled for most of the days in the report. Time sheets provided for proof of RN coverage on all dates except for 06/15, 06/16, 06/29, and 06/30.<BR/>During an interview on 10/01/2024 at 2:09 p.m., the Administrator said that he had been employed here since August of 2023. The Administrator stated that during the time of reporting staffing, there was not RN coverage on 6/15/24, 6/16/24, 6/29/24, and 6/30/24. He stated during that time period, the Director of Nurses at that time left the position and he did not have any other RN's on staff. The Administrator said that during that reporting period, corporate was responsible for reporting the hours. He said that hours were assessed through the payroll system and that any registered nurse hours provided by the DON, traveling corporate nurses, and agency nurses would not be reflected in the payroll system. He stated that at that time the Administrators did not review the hours being reported to ensure that all hours were captured. The Administrator stated that since that time, the company has changed the process and that he reviews the hours prior to reporting so that the report can be accurate prior to the hours being submitted to CMS (Center for Medicare and Medicaid Services) . He stated that failure to have an RN in the building could result in not having staff available to assess and recognize changes in resident condition.<BR/>In an interview with the corporate compliance officer on 10/01/2024 at 2:15 PM, she stated that on the dates that there was not an RN in the building, there was not an RN employed by the facility, and the corporate RN's were not available. She said that with the onboarding of a new DON and hiring of a weekend RN has resolved the issue of no RN coverage. The corporate compliance officer said that the tracking of RN hours has changed and that a new process has been put into place so that the facilities can make sure that information being reported is accurate. She said that the administrators were able to review hours so that any traveling nurses or corporate nurse hours are captured .<BR/>During an interview with the corporate director of data analysis on 10/02/2024 at 10:45 AM she stated that she has been with the company for 9 months. She said that she was responsible for submitting the facilities hours to the PBJ system. She stated that during the reporting period in question she obtained the hours for reporting through the company payroll system. She said that any hours that were related to the DON, traveling nurses, or agency would not be available in the payroll system. She stated that she missed the hours for the registered nurses that were in the category of the DON, travel nurses, and agency during that reporting period. She stated that it was an oversite. The director stated that a new system was now in place, that the hours that were not in the payroll system flow through a different system and the hours were captured accurately now. She said that the administrators at each facility were also reviewing the hours prior to being reported to make sure that all hours were reported accurately.<BR/>Record review of the Facility Assessment Tool dated 6/26/24 with a QAPI (Quality Assurance and Performance Improvement) committee review date of 8/19/24 indicated their plan for staff indicated one RN or LPN each 12-hour shift and a DON RN full-time Days.<BR/>Record review of a facility policy titled Staffing dated 9/28/23 read .Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 resident's reviewed for infection control (Resident #5).<BR/>The facility failed to ensure the proper handling of dirty linens for Resident #5. <BR/>This failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of an undated face sheet for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: pain, type 2 diabetes, depression, and hypertension. <BR/>Record review of a 5-day MDS dated [DATE] for Resident #5 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. She required extensive assist of 1 person for transfers.<BR/>Record review of physician orders for Resident #5 indicated a physician order dated 6/7/23 indicating that she was non-weight bearing on her right leg.<BR/>During an observation on 6/26/23 at 10:05 am in Resident #5's room revealed linens were observed in the floor, in a pile, in front of the bathroom door.<BR/>During an observation an interview on 6/26/23 at 2:30 pm revealed Resident #5 was observed sitting up in a wheelchair. She said she did not remember which staff changed her linens and put them on the floor, or how long they had been there. She said she was unable to do that for herself.<BR/>During an interview on 6/26/23 at 2:50 pm, CNA F said she was an agency employee and was assigned to care for Resident #5 today. She said she works 6am to 6pm and she said that she had not been in Resident #5's room today except to look and see if the resident was up and that Resident #5 was already up, and in her chair, when she checked. She said she had changed resident's sheets yesterday (6/25/23), but not today. She was unable to say how long the linens had been there but said the resident probably put them there. She was unable to say if the resident was able to change her own sheets. She said they were not supposed to put dirty linens on the floor because it could place residents at risk for infection.<BR/>During an interview on 6/26/23 at 3:00 pm with Regional Clinical Nurse, she said that Resident #5 did not change her own sheets as she was unable to do that due to the wound on her leg and having an IV. She said that she expected her staff to understand that it was an infection control risk to put dirty linens in the floor, and that dirty linens were to be bagged put into barrel for laundry.<BR/>Record review of a facility policy titled Laundry and Bedding, soiled dated 2001 with revision date of April 2020 indicated .All used laundry is treated as potentially contaminated until it is properly bagged and labeled for appropriate processing . and .contaminated laundry is placed in a bag or container at the location where it is used

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 resident's reviewed for infection control (Resident #5).<BR/>The facility failed to ensure the proper handling of dirty linens for Resident #5. <BR/>This failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of an undated face sheet for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: pain, type 2 diabetes, depression, and hypertension. <BR/>Record review of a 5-day MDS dated [DATE] for Resident #5 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. She required extensive assist of 1 person for transfers.<BR/>Record review of physician orders for Resident #5 indicated a physician order dated 6/7/23 indicating that she was non-weight bearing on her right leg.<BR/>During an observation on 6/26/23 at 10:05 am in Resident #5's room revealed linens were observed in the floor, in a pile, in front of the bathroom door.<BR/>During an observation an interview on 6/26/23 at 2:30 pm revealed Resident #5 was observed sitting up in a wheelchair. She said she did not remember which staff changed her linens and put them on the floor, or how long they had been there. She said she was unable to do that for herself.<BR/>During an interview on 6/26/23 at 2:50 pm, CNA F said she was an agency employee and was assigned to care for Resident #5 today. She said she works 6am to 6pm and she said that she had not been in Resident #5's room today except to look and see if the resident was up and that Resident #5 was already up, and in her chair, when she checked. She said she had changed resident's sheets yesterday (6/25/23), but not today. She was unable to say how long the linens had been there but said the resident probably put them there. She was unable to say if the resident was able to change her own sheets. She said they were not supposed to put dirty linens on the floor because it could place residents at risk for infection.<BR/>During an interview on 6/26/23 at 3:00 pm with Regional Clinical Nurse, she said that Resident #5 did not change her own sheets as she was unable to do that due to the wound on her leg and having an IV. She said that she expected her staff to understand that it was an infection control risk to put dirty linens in the floor, and that dirty linens were to be bagged put into barrel for laundry.<BR/>Record review of a facility policy titled Laundry and Bedding, soiled dated 2001 with revision date of April 2020 indicated .All used laundry is treated as potentially contaminated until it is properly bagged and labeled for appropriate processing . and .contaminated laundry is placed in a bag or container at the location where it is used

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (secured unit smoking area) reviewed for smoking safety.The facility failed to ensure paper and plastic trash were not discarded into the fire safety can on 8/12/2025.This failure could place residents at risk of injury, burns, and an unsafe smoking environment.Findings included:During an observation and interview on 8/12/2025 at 9:00 am the red fire can in the smoking area located on the secured unit was observed with a plastic liner, cigarette butts and plastic and paper trash. CNA A was outside with a resident and said everyone was responsible for the smoking area and was unsure who would have put a liner in the can, but the trash was probably placed by other staff and residents. She said the red fire can should only have cigarette butts because of fires. During an interview on 8/12/2025 at 9: 20 am the Maintenance Director said he was new and was not sure who was responsible for the fire cans in the smoking area but would find out. He said he was not sure if a liner and trash should be in the fire can but could see that it could be a fire hazard. During an interview on 8/12/2025 at 4:00 pm the Administrator said that the designated smoking areas were to be maintained by the Maintenance Director but all staff that assisted the residents to smoke should be mindful of the ashtrays and fire cans and ensure there was no trash or plastic liner in the red fire can. She said the Maintenance Director was new in his position and would see that he was trained on the smoking policy and maintenance of the smoking areas. She said that by not maintaining the smoking area fires could happen.Record review of an undated facility policy titled Resident Smoking Policy indicated, .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. 3. Safety measures for the designated smoking area will include, but are not limited to: c. Accessible metal containers with self-closing covers into which ashtrays can be emptied .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 12 (Resident #6) residents observed for care. The ADON failed to provide Resident #6 with full privacy while providing gastric tube care on 08/12/25. This failure could place residents at risk of not being treated with dignity and respect. Findings:Record review of a facility face sheet dated 08/12/25indicated Resident #6 was a [AGE] year-old male that was admitted to the facility on [DATE]. He was re-admitted on [DATE] with diagnosis of tracheostomy (airway surgically created in the trachea), gastrostomy (tube placed surgically into the stomach for feeding), cerebral ischemia (decreased circulation in the brain), muscle wasting and dysphagia (inability to swallow). Record review of a comprehensive care plan revised 7/20/25 indicated Resident #6 required a gastrostomy tube (a tube placed in the stomach) for feeding and medication administration.Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 14 which indicated intact cognition and was dependent on staff for gastrostomy tube care and positioning. During an observation on 08/12/25 at 09:00 AM Resident #6 was provided gastrostomy care by the ADON. The ADON did not pull the privacy curtain between the room and door or close the door to the hallway. Resident #6 was visible from the hallway while visitors, staff and other residents passed by the open doorway. At 09:15 AM CNA B knocked on Resident #6's door and walked in room while resident was receiving care and drew the privacy curtain around resident #6 and closed the door. During an interview on 08/12/25 at 09:30 AM the ADON said she had been trained on resident privacy and dignity. She said the privacy curtain should have been pulled to keep Resident #6 from being exposed to the hallway. She said the resident could be upset being exposed and privacy not maintained. During an interview on 08/12/25 at 09:45 AM CNA B said she had been trained on resident privacy and dignity. She said the privacy curtain should have been pulled to keep Resident #6 from being exposed to the hallway. She said the resident could be exposed and embarrassed being exposed and privacy not maintained. During an interview on 08/12/25 at 10:59 AM Resident #6 nodded his head yes, when asked if it bothered him when the staff don't pull his privacy curtain, and he felt exposed and embarrassed. During an interview on 08/13/25 at 10:53 AM the DON said she was responsible for oversight of all nursing staff and education on resident rights. She said all staff should pull the privacy curtain during care. She said by not doing so it could make a resident feel exposed, embarrassed, or rushed. She said she expected all staff to maintain resident rights and dignity.During an interview on 08/13/25 at 11:00 AM the Administrator said all employees were responsible for following resident rights and ensuring resident privacy and dignity were maintained. The Administrator said she expected all staff to always respect resident privacy and dignity. Record review of a facility policy dated 2/2021 titled Dignity indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 4 of 92 days reviewed. (April 2024, May 2024, and June 2024).<BR/>The facility did not have RN coverage for 4 days in June 2024.<BR/>This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.<BR/>Findings:<BR/>Record review of the Center for Medicare and Medicaid Services PBJ (Payroll Based Journal) report for the third quarter of 2024 (April 1 through June 31, 2024) indicated there were no RN hours for the following dates: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU).<BR/>Record review of the monthly staffing schedules for April 2024, May 2024, and June 2024 revealed that there was a RN scheduled for most of the days in the report. Time sheets provided for proof of RN coverage on all dates except for 06/15, 06/16, 06/29, and 06/30. <BR/>During an interview on 10/01/2024 at 2:09 p.m., the Administrator said that he had been employed here since August of 2023. The Administrator stated that during the time of reporting staffing, there was not RN coverage on 6/15/24, 6/16/24, 6/29/24, and 6/30/24. He stated during that time period, the Director of Nurses at that time left the position and he did not have any other RN's on staff. The Administrator said the corporate travel nurses were not available at that time. He said that they were utilizing agency registered nursing staff to provide the required 8 hours daily coverage but on those occasions the nurse had called in prior to the shift. He said that the staffing agency did not try to find replacements for the dates that the nurses called in. He stated the DON was the only RN on staff at that time and she had left. The Administrator said that he has hired a weekend RN since then. He said that he expected a licensed registered nurse to be on the schedule for 8 hours a day. He said that the DON was to provide RN coverage if there was not an RN on the schedule . He stated that failure to have an RN in the building could result in not having staff available to assess and recognize changes in resident condition.<BR/>During an interview with the corporate compliance officer on 10/1/2024 at 2:15 PM, she said that on the dates that there was not an RN in the building, there was not an RN employed by the facility, and the corporate RN's were not available. She said that with the onboarding of a new DON and hiring of a weekend RN has resolved the issue of no RN coverage .<BR/>Record review of a facility policy titled Staffing dated 9/28/23 indicated .The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 resident's reviewed for infection control (Resident #5).<BR/>The facility failed to ensure the proper handling of dirty linens for Resident #5. <BR/>This failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of an undated face sheet for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: pain, type 2 diabetes, depression, and hypertension. <BR/>Record review of a 5-day MDS dated [DATE] for Resident #5 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. She required extensive assist of 1 person for transfers.<BR/>Record review of physician orders for Resident #5 indicated a physician order dated 6/7/23 indicating that she was non-weight bearing on her right leg.<BR/>During an observation on 6/26/23 at 10:05 am in Resident #5's room revealed linens were observed in the floor, in a pile, in front of the bathroom door.<BR/>During an observation an interview on 6/26/23 at 2:30 pm revealed Resident #5 was observed sitting up in a wheelchair. She said she did not remember which staff changed her linens and put them on the floor, or how long they had been there. She said she was unable to do that for herself.<BR/>During an interview on 6/26/23 at 2:50 pm, CNA F said she was an agency employee and was assigned to care for Resident #5 today. She said she works 6am to 6pm and she said that she had not been in Resident #5's room today except to look and see if the resident was up and that Resident #5 was already up, and in her chair, when she checked. She said she had changed resident's sheets yesterday (6/25/23), but not today. She was unable to say how long the linens had been there but said the resident probably put them there. She was unable to say if the resident was able to change her own sheets. She said they were not supposed to put dirty linens on the floor because it could place residents at risk for infection.<BR/>During an interview on 6/26/23 at 3:00 pm with Regional Clinical Nurse, she said that Resident #5 did not change her own sheets as she was unable to do that due to the wound on her leg and having an IV. She said that she expected her staff to understand that it was an infection control risk to put dirty linens in the floor, and that dirty linens were to be bagged put into barrel for laundry.<BR/>Record review of a facility policy titled Laundry and Bedding, soiled dated 2001 with revision date of April 2020 indicated .All used laundry is treated as potentially contaminated until it is properly bagged and labeled for appropriate processing . and .contaminated laundry is placed in a bag or container at the location where it is used

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 resident's reviewed for infection control (Resident #5).<BR/>The facility failed to ensure the proper handling of dirty linens for Resident #5. <BR/>This failure could place residents at risk for infection.<BR/>Findings include:<BR/>Record review of an undated face sheet for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: pain, type 2 diabetes, depression, and hypertension. <BR/>Record review of a 5-day MDS dated [DATE] for Resident #5 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. She required extensive assist of 1 person for transfers.<BR/>Record review of physician orders for Resident #5 indicated a physician order dated 6/7/23 indicating that she was non-weight bearing on her right leg.<BR/>During an observation on 6/26/23 at 10:05 am in Resident #5's room revealed linens were observed in the floor, in a pile, in front of the bathroom door.<BR/>During an observation an interview on 6/26/23 at 2:30 pm revealed Resident #5 was observed sitting up in a wheelchair. She said she did not remember which staff changed her linens and put them on the floor, or how long they had been there. She said she was unable to do that for herself.<BR/>During an interview on 6/26/23 at 2:50 pm, CNA F said she was an agency employee and was assigned to care for Resident #5 today. She said she works 6am to 6pm and she said that she had not been in Resident #5's room today except to look and see if the resident was up and that Resident #5 was already up, and in her chair, when she checked. She said she had changed resident's sheets yesterday (6/25/23), but not today. She was unable to say how long the linens had been there but said the resident probably put them there. She was unable to say if the resident was able to change her own sheets. She said they were not supposed to put dirty linens on the floor because it could place residents at risk for infection.<BR/>During an interview on 6/26/23 at 3:00 pm with Regional Clinical Nurse, she said that Resident #5 did not change her own sheets as she was unable to do that due to the wound on her leg and having an IV. She said that she expected her staff to understand that it was an infection control risk to put dirty linens in the floor, and that dirty linens were to be bagged put into barrel for laundry.<BR/>Record review of a facility policy titled Laundry and Bedding, soiled dated 2001 with revision date of April 2020 indicated .All used laundry is treated as potentially contaminated until it is properly bagged and labeled for appropriate processing . and .contaminated laundry is placed in a bag or container at the location where it is used