Every finding on record at Affinity Healthcare

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a physician's order for nursing to monitor his/her oxygenation saturations (measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) levels, which included to notify the physician if his/her saturation levels dropped below a specific percentage, the Facility failed to ensure his/her physician was notified of changes in his/her oxygen saturation levels, when Resident #1's levels fell below the physicians ordered percentage parameters on multiple occasions, and the physician was not notified.Findings include:Review of the Facility Policy titled Change in a Resident's Condition or Status dated, as last revised 02/2021, indicated that the Facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental conditions and/or status.The Policy indicated that the nurse will notify the residents attending physician or physician on call when there has been a specific instruction to notify the physician of changes in the resident's condition.Resident #1 was admitted to the Facility in April 2025, diagnoses include acute on chronic respiratory failure, dependent on continuous oxygen, obstructive sleep apnea (throat muscles relax excessively during sleep, causing the airway to collapse and breathing repeatedly stops and starts), asthma, and schizoaffective disorder.Review of Resident #1's Physician's Orders, for the month of December 2025, indicated to obtain his/her oxygen saturation level every shift and to notify the physician if his/her oxygen saturation falls below 90%.Normal oxygen saturation level is 95-100%, slightly low is 90-94%, low would-be levels below 90 % (hypoxemia, requires medical attention). Dangerously low levels are below 88% and usually indicated a need for immediate care Review of Resident #1's Oxygen Saturation Log and Medication Administration Record, dated 12/01/25 through 12/29/25, indicated the following results were obtained for Resident #1 while on three (3) liters (l) of continuous oxygen via nasal cannula (flexible device used to deliver supplemental oxygen directly into the nostrils), all of which were considered dangerously low:-12/08/25-85 %;-12/11/25-88%;-12/12/25-88%;-12/18/25-86%;-12/19/25-86%;-12/25/25-84%; and-12/28/25-87%.Review of Resident #1's Medical Record indicated that there was no documentation to support nursing staff ever notified his/her physician of the low saturation level readings, in accordance with his/her physician's order specific instruction.During an interview on 01/27/26 at 2:20 P.M., Nurse #2 said he always obtained an oxygen saturation for Resident #1 while he/she was on oxygen, however said he was unaware that the physicians order had a specific parameter indicating to notify the physician if his/her oxygen saturation was below 90%.Nurse #2 said that he never notified Resident #1's physician when his/her oxygen saturation fell below 90 %. Nurse #2 said if the physician's order states to notify the physician if the oxygen saturation goes below 90%, he should have notified his/her physician.During an interview on 01/27/26 at 1:37 P.M., the Unit Manager said she was not aware that Resident #1's Physician's Order for obtaining an oxygenation saturation every shift had a set parameter indicating to notify his/her Physician if his/her oxygen saturation registers below 90%.The Unit Manager said multiple recorded oxygen saturation levels for Resident #1 had been below 90% without any documentation to support that nursing had informed his/her PhysicianDuring an interview on 01/27/26 at 3:41 P.M., the Director of Nurses (DON) said that she was not aware of Resident #1's physician's order for obtaining an oxygenation saturation every shift had a parameter indicating to notify his/her MD if his/her oxygenation saturation fell below 90%.The DON said that it is the Facility's expectation that the nurse would have promptly notified a physician of any result not falling into the parameters set specific in the physician's order.

Based on observation, record review, and interviews, the facility failed to ensure a person-centered comprehensive care plan was developed and/or implemented for three Residents (#21, #90, and #9), out of a total sample of 25 residents. Specifically, the facility failed:1. For Resident #21, to develop and implement a potential/at risk for skin breakdown care plan and an actual skin alteration care plan for a chronic burn/wound requiring monitoring and wound care;2. For Resident #90, to implement interventions on the Activities of Daily Living (ADL) and Fall care plans specific to transfer and ambulation status; and3. For Resident #9, to develop and implement an individualized resident centered care plan for a known history of insomnia. Findings include: Review of the facility's policy titled Resident Participation-Assessment/Care Plans, dated as last revised 8/2019, indicated but was not limited to the following: -The Care Planning process will include an assessment of the resident's strengths and his/her needs. -A comprehensive care plan will be developed within seven days of completing the resident assessment. -Right to receive the services and/or items in the care plan. 1. Resident #21 was admitted to the facility in September 2025 with diagnoses which included burn of third degree (involves all layers of skin and sometimes muscle/fat under the tissue) of left lower limb and corrosion of third degree of left lower leg (chemical/corrosive substance destroyed all skin layers). Review of the Minimum Data Set (MDS) Assessment, dated 9/15/25, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Additionally, the MDS indicted he/she had a diagnosis of a third degree burn to the left lower extremity. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Principal diagnosis: Corrosion of third degree of left lower extremity except ankle and foot. -Procedures: multiple excisions and grafts over several months. -Skin: left inner thigh with healed graft with areas of scabbing and sliver of open area to groin fold, mild edema to thigh around graft. -Wound Care: Leave open to air, emphasize importance of showering and not picking wounds. Keep clean, if area opens, then apply small piece of kaltostat (alginate dressing derived from seaweed that forms a gel barrier to promote moist wound healing) with gauze and tape, change every other day, and secure with boxer briefs. All healed/scabbed areas: donor site and left thigh scar tissue apply lotion, showering 1-2 times per week is goal. -Dressing instructions: Cleanse wounds, pat dry, apply lotion, keep open to air, open areas of the wound can be covered with Kaltostat and abdominal pads. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Reason for hospitalization: leg swelling. -History of present illness: History of third degree burn to left thigh requiring multiple skin grafts presenting with left lower extremity swelling, erythema (redness), and discharge. -Hospital Course: found to have left lower extremity cellulitis (infection of the skin's deep layers causing redness, pain, swelling, and warmth). -Wound Care Instructions: 1. LEFT MEDIAL THIGH: EVERY OTHER DAY: -Cleanse with Vashe (antimicrobial) wound cleanser, [NAME] cream (moisturizer/skin protectant) to peri wound dry skin, one layer of xeroform (petroleum mesh dressing), then 6 x 6 coversite dressing (adhesive/waterproof dressing) times two to cover wound. Change every other day or as needed. Provide dressing product size appropriate to the wound measurement size. 2. LEFT INNER GROIN WOUND: DAILY: -Apply a thick layer of Coloplast Triad Hydrophilic Wound Paste (Order Number: 000035648) (zinc oxide-based paste to promote wound healing, helps naturally loosen dead tissue, protects surrounding skin, and adheres to wet or dry skin, ideal for tough to dress wounds) to open wounds two times daily and as needed (PRN) with skin care. NOTE: clean area gently and leave thin film of Triad paste then add more after gently cleansing. Provide dressing product size appropriate to the wound measurement size. Review of the of the active Physician's Orders indicated there were wound care orders for the Left Medial Thigh and the Left Inner Groin. Review of the Comprehensive Care Plan failed to indicate a care plan for the care and management of the burn/wounds had been developed and implemented. During an interview on 12/10/25 at 9:50 A.M., Nurse #1 said there was not a care plan in place, and she did not know who puts them in or updates them. During an interview on 12/10/25 at 9:57 A.M., Nurse #2 said there should be a care plan in place but there was not, and she didn't know why. She said she doesn't do the care plans normally and she thought the Unit Manager (UM) did them and updated them as needed. During an interview on 12/10/25 at 10:05 A.M., UM #2 said there should be a potential/at risk skin care plan in place and one for the wound but there were not any active skin care plans. She said she wasn't sure how it was missed. Additionally, she said there were a couple resolved care plans, but they were not specific to the burn either. During an interview on 12/10/25 at 11:31 A.M., the Director of Nurses (DON) said there should be a potential for skin breakdown and an actual skin alteration care plan for the burn/wound care in place and there is not. She said they were not in the active care plans, and the history showed a couple of resolved care plans that were skin related, but none were specific to the burn/wound care. 2. Resident #90 was admitted to the facility in June 2025 with diagnoses which include unsteadiness on feet, anoxic brain injury, dementia, and muscle wasting and atrophy. Review of the MDS Assessment, dated 10/21/25, indicated he/she scored 5 out of 15 on the BIMS indicating he/she had severe cognitive impairment. Additionally, Resident #90 was dependent on staff for activities of daily living (ADLs) and ambulated with assistance from staff without a device. Review of the medical record indicated Resident #90 had one fall in June 2025 and two falls in November 2025. Review of the Comprehensive Care Plan indicated but was not limited to the following: ADLs: Resident has an ADL deficit as evidenced by needs assistance. -Transfers: contact guard (CGA-touching) with transfers. (2/13/25) -Mobility: Stand by Assist (SBA) with ambulation. (2/13/25) -Mobility: [NAME] (6/28/22) FALLS: Resident is at risk for injuries related to fall history, decreased mobility, impaired balance, and poor safety awareness. -Staff to supervise Resident #90 when ambulating in the hallway. (11/24/25) -CGA for ambulation when the hallway is crowded. (meals, groups etc.) (11/28/25) Review of the Fall incident Report and Investigations indicated but were not limited to the following: 6/10/25 at 2:40 A.M. -Resident #90 ambulates independently on the unit without assistance. He/she was observed entering the dining room from his/her bedroom with a small amount of blood on their face. He/she can recover from the floor independently. After assessment resident was transferred to the hospital for evaluation, returning with three staples to the laceration. - An intervention related to toileting was added to the care plan. 11/20/25 at 8:30 P.M. -Witnessed fall in hallway. Resident #90 tripped while ambulating independently and fell forward to the floor. He/she said they lost their balance and fell. Small abrasion on right upper forearm. Nurse witnessed the fall and approached him/her after they fell to assess. No other staff member witnessed the fall. -The intervention added to the care plan after the fall was for staff to supervise Resident #90 when ambulating in the hallway. (11/24/25) 11/27/25 at 8:15 A.M. -It was reported Resident #90 was walking through a congested area and was witnessed losing their balance and falling to their right knee. -The intervention added to the care plan was for CGA for ambulation when the hallway is crowded. (meals, groups etc.) (11/28/25) The facility failed to implement the transfer and ambulation interventions on the care plan at the time of each fall. Specifically, Resident #90 should have had CGA with transfers, SBA with ambulation, and a walker in use at the time of the three falls and they did not. During an interview on 12/10/25 at 9:50 A.M., Nurse #1 said it was her first day at the facility and based on the care plan she did not know what Resident #90s ambulation status was or if they used a walker and would have to ask someone who knows the Resident since the care plan had conflicting information. During an interview on 12/10/25 at 9:57 A.M., Nurse #2 said she was not sure who updates the care plans because she has never done it at this facility. During an interview on 12/10/25 at 10:05 A.M., UM #2 said the care plans should be updated after a fall to reflect the most current status. She said CGA is contact guard assistance which means handheld assistance and SBA is stand by assist which means being within arm's length walking with the resident. She said adding supervision doesn't make sense because someone should have been walking next to him/her at the time of the falls and they were not. She said Resident #90 is very impulsive and just gets up, so we are constantly chasing him/her to walk with them. Additionally, she said Resident #90 does not use a walker. During an interview on 12/10/25 at 11:31 A.M., the DON said the care plan should reflect the most current transfer and ambulation status. She said they should be accurate and updated as needed. Additionally, she said adding supervision in the hallway does not make sense because the care plan already indicated SBA which is being right next to the resident but not touching them and Resident #90 does not use a walker and hasn't for a while. She said they were not following the care plan, and it will need to be reviewed. 3. Resident #9 was admitted to the facility in December 2024 with diagnoses which included insomnia. Review of the MDS Assessment, dated 9/6/25, indicated he/she scored 15 out of 15 on the BIMS indicating his/her mental cognition was intact. Review of the PHQ-9 evaluation (patient health questionnaire indicates concerns over a prior two-week period), dated 12/02/25, indicated, but was not limited to, Resident #9 was having trouble falling or staying asleep or sleeping too much; symptom frequency of 7-11 days. Feeling tired or having little energy answer indicated yes with a frequency of 7-11 days over the last two weeks. Review of the medical record failed to indicate a care plan was developed for the Resident's diagnosed insomnia. Review of the active Physician's Orders indicated but was not limited to the following: -diphenhydramine HCL 50mg, one tablet at bedtime for insomnia (8/20/25). -melatonin 3mg, one tablet by mouth at bedtime for insomnia (3/20/25). -mirtazapine 7.5mg tablet at bedtime for insomnia (10/29/25). -document hours of sleep every night shift for monitoring (12/20/24). Further review of the medical record indicated Resident #9 had a previous order for: -zolpidem tartrate tablet 5mg (a hypnotic), one tablet by mouth as needed for difficulty sleeping at bedtime from 8/25/25 to 8/31/25. During an interview on 12/10/25 at 3:37 P.M., Certified Nursing Assistant (CNA) #2 said she does not know what time the Resident goes to sleep, and when she does rounds at night, the Resident is sometimes sleeping. CNA #2 said she is not aware of any sleeping issues the Resident may have because the Resident is independent and they do not offer him/her anything in the evening unless the Resident requests something. During an interview on 12/10/25 at 3:42 P.M., CNA #3 said Resident #9 will comes out of his/her room in the evening between 7:00 P.M. and 8:00 P.M. to ask for a snack before returning to his/her room. CNA #3 said they do not provide any care to the Resident or bother the Resident unless the Resident calls for something, so he is unsure if the Resident sleeps on the 3:00 P.M. to 11:00 P.M. shift. During an interview on 12/10/25 at 5:11 P.M., the surveyor reviewed Resident #9's record with UM #3. UM #3 said Resident #9 did not have a care plan for their insomnia, but they should have a care plan that includes interventions and goals to reduce the impact of insomnia for the Resident. During an interview on 12/10/25 at 5:09 P.M., the Director of Social Services said she would think they would have a care plan for sleep if they had a diagnosis of insomnia, are experiencing symptoms of poor sleep, and Resident #9's PHQ-9 assessment did indicate trouble sleeping most days and feeling tired. The Director of Social Services said we should have identified it as a problem, have goals and interventions. There is not a care plan but there should be one to address his/her sleep disturbances and sleep. During an interview on 12/11/25 at 4:41 P.M., Physician #2 said Resident #9's insomnia is long standing and even though care plans are not a medical doctor's responsibility he knows that it is important for the information to be on a care plan so everyone can be on the same page. During an interview on 12/11/25 at 7:41 A.M., the DON said she was not fully aware of the depth of Resident #9's insomnia and treatments, but there should be a care plan for this specific problem and there is not.

Based on record review and interview, the facility failed to ensure individualized comprehensive care plans were reviewed and revised to accurately reflect care needs for one Resident (#90), out of a total sample of 25 residents. Specifically, the facility failed to ensure the comprehensive care plan was reviewed and revised after a significant change in October 2025. Findings include:Review of the facility's policy titled Change in a Resident's Condition of Status, undated, indicated but was not limited to the following:-A Significant Change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; b. impacts more than one area of the resident's health status; andc. requires interdisciplinary review to the care plan. Resident #90 was admitted to the facility in June 2025 with diagnoses which include unsteadiness on feet, anoxic brain injury, dementia, and muscle wasting and atrophy. Review of the medical record indicated Resident #90 had a significant change Minimum Dat Set (MDS) Assessment completed on 10/21/25. Review of the nursing progress notes indicated he/she had a significant change due to decline in Activities of Daily Living (ADLs), cognitive status, and increased behaviors. Review of the MDS Assessment, dated 10/21/25, indicated he/she scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. Additionally, Resident #90 was dependent on staff for ADLs and ambulated with assistance from staff without a device. Review of the Comprehensive Care Plan indicated but was not limited to the following:ADLs: Resident has an ADL deficit as evidenced by needs assistance.-Bathing: assist-Dressing: assist-Transfers: contact guard (CGA) with transfers-Eating: independent-Mobility: stand and by assist (SBA) with ambulation. -Toileting: independent; assist with occasional bladder incontinence-Mobility: [NAME] Review of the ADL flow sheets indicated Resident #90 was dependent on staff for ADLs, including bathing, dressing, and toileting. He/she was incontinent of bladder, had variable assistance with transfers and ambulation ranging from independent to minimal assistance, and was supervised with eating. During an interview on 12/10/25 at 11:10 A.M., Certified Nursing Assistant (CNA) #1 said if she does not know a resident's status, she usually asks another aide or the nurse. During an interview on 12/10/25 at 9:50 A.M., Nurse #1 said it was her first day at the facility and she would have to ask someone who knows the Resident because she was unsure of his/her actual status. Additionally, she said she does not know who updates the care plans. During an interview on 12/10/25 at 9:57 A.M., Nurse #2 said she was not sure who updates the care plans because she has never done it at this facility. During an interview on 12/10/25 at 10:05 A.M., Unit Manager (UM) #2 said the care plans should be updated on admission, quarterly, with a significant change, and as needed, like after a fall to reflect the most current status. She said the ADL care plan was not updated after the significant change in October and does not accurately reflect his/her needs. She said Resident #90 requires staff to perform ADLs, cannot toilet themselves, and does not use a walker. During an interview on 12/10/25 at 11:31 A.M., the Director of Nurses (DON) said the care plan should reflect the most current status and it does not. She said they should be accurate and updated on admission, quarterly, with a significant change, and as needed. She said Resident #90 needs staff to provide care, does walk with minimal assistance but does not use a walker and hasn't for a while. The DON said she was unsure why the care plan was not updated and it would need to be reviewed.

Based on record review and interview, the facility failed to ensure one Resident (#21), out of a total sample of 25 residents, received necessary treatment and services to promote healing of an alteration in skin integrity related to a burn of third degree (involves all layers of skin and sometime muscle/fat under the tissue) of left lower limb. Specifically, the facility failed to accurately transcribe and implement wound care orders per the hospital discharge summary and physician's orders for two months. Findings include: Review of the facility's policy titled Medication and Treatment Orders, dated as last revised 4/2018, indicated but was not limited to the following:-Orders for medications and treatments will be consistent with regulatory standards. Review of the Lippincott Manual of Nursing Practice, 11th Edition (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Resident #21 was admitted to the facility in September 2025 with diagnoses which included burn of third degree of left lower limb and corrosion of third degree of left lower leg (chemical/corrosive substance destroyed all skin layers). Review of the Minimum Data Set (MDS) Assessment, dated 9/15/25, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Additionally, the MDS indicted he/she had a diagnosis of a third degree burn to the left lower extremity. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: -Reason for hospitalization: leg swelling.-History of present illness: History of third degree burn to left thigh requiring multiple skin grafts presenting with left lower extremity swelling, erythema (redness), and discharge. -Hospital Course: found to have left lower extremity cellulitis (infection of the skins deep layers causing redness, pain, swelling, and warmth).-Wound Care Instructions: 1. LEFT MEDIAL THIGH: EVERY OTHER DAY: -Cleanse with Vashe (antimicrobial) wound cleanser, [NAME] cream (moisturizer/skin protectant) to peri wound dry skin, one layer of xeroform (petroleum mesh dressing), then 6 x 6 coversite dressing (adhesive/waterproof dressing) times two to cover wound. Change every other day or as needed. Provide dressing product size appropriate to the wound measurement size. 2. LEFT INNER GROIN WOUND: DAILY: -Apply a thick layer of Coloplast Triad Hydrophilic Wound Paste (Order Number: 000035648) (zinc oxide-based paste to promote wound healing, helps naturally loosen dead tissue, protects surrounding skin, and adheres to wet or dry skin, ideal for tough to dress wounds) to open wounds two times daily and as needed (PRN) with skin care. NOTE: clean area gently and leave thin film of Triad paste then add more after gently cleansing. Provide dressing product size appropriate to the wound measurement size. Review of the of the active Physician's Orders indicated but were not limited to the following: -LEFT MEDIAL THIGH: EVERY OTHER DAY: Cleanse with Vashe wound cleanser, [NAME] cream to peri wound dry skin, one layer of xeroform, then 6 x 6 coversite dressing times two to cover wound. Change every other day or as needed. Provide dressing product size appropriate to the wound measurement size. (10/3/25)-LEFT INNER GROIN WOUND: DAILY: Apply a thick layer of Coloplast Triad Hydrophilic Wound Paste (Order Number: 000035648) to open wounds two times daily and PRN with skin care. NOTE: clean area gently and leave thin film of Triad paste then add more after gently cleansing. Provide dressing product size appropriate to the wound measurement size. (10/3/25) Review of the Treatment Administration Records (TAR) for October, November, and December 2025 failed to indicate the treatment to the LEFT INNER GROIN WOUND was scheduled twice daily per the physician's order and the treatment was not administered as ordered. The physician's order was only scheduled PRN in the electronic medical record. Review of the Comprehensive Care Plan failed to indicate a care plan for the care and management of the burn/wounds had been developed and implemented. The surveyor was unable to observe wound care as it is done at bedtime when he/she is in bed lying down and Resident #21 declined to have it done during the day. During an interview on 12/10/25 at 9:57 A.M., Nurse #2 said the treatment is done at night and she hadn't seen his/her leg or groin in a while. She said on Admission/readmission she thinks the Unit Manager (UM) enters the physician orders in the computer. She said, in reading the order, the treatment to the groin was supposed to be done twice a day and PRN. She said the twice a day schedule was never added to the order, so it never populated for anyone to do it. She said it only had a PRN schedule. During an interview on 12/10/25 at 10:05 A.M., UM #2 said the order was transcribed wrong when they returned from the hospital. She said the order should have been scheduled twice daily and PRN and it was not. She said the directions are in the order, but they never linked a schedule to it. She said she will have to see what the provider wants to do because it has been a couple months and the treatment was never done. She said the provider is coming in today and she will have him look at the area. During an interview on 12/10/25 at 11:31 A.M., the Director of Nurses (DON) said the order is missing the twice a day schedule. She said the admission/readmission orders should be double checked for accuracy and it was missed. She said the directions are in the body of the order, but they didn't link the schedule to it, so it was never done.

Based on observation and interviews, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure appropriate holding temperatures for time/temperature control for safety (TCS) foods;2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) to prevent cross contamination; and3. Ensure kitchenettes were maintained in a clean, sanitary, and organized manner, and food was properly stored, labeled, and dated in four of four kitchenettes. Findings include:1. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to:3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.(A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; or(2) At 5 C (41 F) or less During an observation with interview on 12/9/25 at 7:40 A.M., the surveyor arrived in the kitchen after breakfast tray line began. Items on the tray line included scrambled eggs, pureed eggs, hard boiled eggs, sausage, French toast, and pancakes. Oatmeal and cream of wheat was also observed on the tray line pre-portioned in thermal bowls with lids and stacked in two layers inside a steam pan. The surveyor asked to see the completed temperature log (a monitoring process used to document the temperature of each food item being served) for breakfast. Dietary Staff #1 said he did not obtain food temperatures of the foods that morning and continued to plate food. Dietary Staff #2 said food temperatures should be obtained prior to service to ensure the food is safe to eat. Dietary Staff #2 temped the breakfast foods which were found to be above 135 Fahrenheit (F), with the exception of the oatmeal which was at 135 F, and the cream of wheat at 132 F, which was below the lowest acceptable value for temperature control for safety. On 12/9/25 at 8:37 A.M., the Food Service Director (FSD) said temperatures should be obtained for all food being served to ensure it is cooked and held at temperatures that ensure food safety compliance and Dietary Staff #1 should have obtained food temperatures for breakfast. 2. Review of the 2022 Food Code by the U.S. FDA indicated, but was not limited to: 3-302 Preventing food and ingredient contamination; (A) FOOD shall be protected from cross contamination by: (3) Cleaning equipment and utensils as specified under 4-602.11(A) and sanitizing as specified under S 4-703.11; Review of the facility's policy titled Steps to Prevent Foodborne Illness, undated, indicated but was not limited to:-Cross-contamination is the transfer of harmful bacteria to food from other foods, cutting boards, and utensils and it happens when they are not handled properly. On 12/8/25 at 11:50 A.M., the surveyor observed Dietary Staff #1 temp food on the tray line with a probe thermometer. The surveyor observed Dietary Staff #1 rinse the thermometer under the faucet, wipe the length of the probe with the gloved hand used to turn the faucet on and off, and return to the tray line to temp the next food item. Dietary Staff #1 did not wash or sanitize the probe between food items. On 12/8/25 at 11:50 A.M., the surveyor observed the FSD temp food on the tray line. The surveyor observed the FSD take the temperature of green beans, rinse the thermometer probe under running water, and return to the line to temp the French fries. During an interview on 12/8/25 at 1:15 P.M., the FSD said thermometers should be cleaned with soapy water and appropriate sanitizer between use/food items if no thermometer probe cleaners are available. 3. Review of the 2022 Food Code by the U.S. FDA indicated, but was not limited to: - 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. - 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. - 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). - 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. - 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled Food Storage, dated 4/29/20, indicated but was not limited to: -Facility uses the Date Marking Policy in conjunction with this Food Storage Policy ensuring ready-to-eat, closed, or opened foods maintain an expiration or Use-By dating system. -Dry storage items will be required to have a date (including month/date/year) in which the product was delivered or a manufacturer's printed Best By/Use By date. -Refrigerated, ready-to-eat, potentially hazardous food opened or prepared shall be clearly marked at the time of preparation to indicate the date of preparation. Ready-to-eat items shall be discarded within 72 hours of the date opened. -Food storage, to include Dry Storage, Refrigerators, Freezers, and Chemical Rooms, shall always be clean and sanitary. On 12/4/25, the surveyor made the following observations in the unit kitchenettes: 10:10 A.M. M1 Unit-one opened Glucerna drink, no label or date;-two tuna salad sandwiches, no label or date;-six packets of Ken's salad dressing, manufacturer's expiration date 8/6/25;-one opened container of applesauce, no label or date; -six boxes of packaged cookies, located in different areas of the kitchenette, no decipherable expiration date indicated. 11:00 A.M. B1 Unit-1 peanut butter and jelly sandwich, no label or date 11:21 A.M. M2 Unit-2 drawers with food packets piled and scattered about: one with mustard, relish, jam, mayonnaise, parmesan cheese, another with jam, peanut butter, barbecue sauce, salad dressing with no dates;-one opened jar of peanut butter, no date;-one opened jar of jelly, refrigerated, no date;-two Tupperware containers, refrigerated, no label or date;-one bag of frozen burritos, open to air, no label or date; -one foil-wrapped item with no label or date. 11:33 A.M. B2 Unit- one disorganized drawer with packages of cookies, cereal, jam with no dates. During an interview on 12/9/25 at 9:00 A.M., Nurse #5 said all food should be labeled and dated in the kitchenettes. If a food item is opened, it should have the date it was opened. If food is brought from outside or made in the kitchen, it should be dated and discarded after three days. During an interview on 12/9/25 at 9:15 A.M., the FSD said dietary staff visit the kitchenettes twice per day to organize, check labels and dates, and restock. Housekeeping cleans the kitchenettes. During an observation with interview on 12/9/25 at 9:00 A.M., the surveyor observed in the M1 Unit kitchenette one drawer with a punctured pack of syrup that dripped down to the drawer below, sealing it shut. The FSD was present and said kitchenettes should be maintained in a clean and sanitary condition with food stored properly which included labeling and dating and discarding food that is beyond the three-day limit, has no label or date, is expired, or the seal is compromised.

Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for one Resident (#5), out of a total sample of 25 residents. Specifically, the facility failed to ensure the percentage of lunch consumed was accurately documented after the meal was provided and fed to Resident #5 on 17 of 35 days reviewed. Findings include: Review of the facility's policy titled Charting and Documentation, undated, indicated but was not limited to the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.-Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #5 was admitted to the facility in September 2022 with diagnoses which included protein calorie malnutrition, adult failure to thrive, dysphagia (difficulty swallowing), and Huntington's Disease (HD- fatal genetic disorder causing uncontrolled movements (chorea) and cognitive decline). Review of the Minimum Data Set (MDS) Assessment, dated 11/13/25, indicated he/she was rarely/never understood, was dependent on staff for feeding, and had weight loss. Review of the Comprehensive Care Plan indicated but was not limited to the following:NUTRITION: Risk for Malnutrition related to increased nutrient/energy needs for Huntington's Disease (HD), progressive chorea, and dysphagia as evidenced by a downward trend in weight. Review of the Meal Percentage Record from 11/5/25 through 12/9/25 indicated he/she consumed 75-100% of meals daily. Further review of the Meal Percentage Record indicated on 17 of 35 days the amount consumed for lunch was documented prior to the meal being served. Specifically, the timestamped documentation was completed between 10:30 A.M. and 11:36 A.M., within minutes of the breakfast meal being documented. During an interview on 12/10/25 at 11:10 A.M., Certified Nursing Assistant (CNA) #1 said she did not know why lunch was documented before noon. She said it should be documented after lunch is over and you know how much they ate. She said she usually finishes her documentation between 1:30 P.M. and 2:30 P.M. and that is when she would document the lunch meal percentage. During an interview on 12/10/25 at 9:50 A.M., Nurse #1 said meals should be documented after the meal, but before the end of the shift. During an interview on 12/10/25 at 9:57 A.M., Nurse #2 said the meal percentage should only be documented after the meal is served and you know how much they ate. During an interview on 12/10/25 at 10:05 A.M., Unit Manager #2 said the meal percentage is documented under the task panel. She said the CNAs are supposed to complete the documentation after the meal is served or resident is fed. She said lunch should not be documented prior to 12:30 P.M. She said she can't see who did the inaccurate documentation, but they will have to investigate it because it is a lot of days. She said she is concerned that the inaccurate documentation could be with other residents too and they (CNAs) should not be guessing how much the resident will eat. During an interview on 12/10/25 at 11:31 A.M., the Director of Nurses (DON) said meal percentage should never be documented before the Resident consumes the meal. She said based on the time stamps they are documenting breakfast and lunch at the same time, which would be fine if it were later in the day, but lunch is not served until noon and the amount eaten cannot be documented prior to the resident eating.

Based on observations, interviews, and record reviews, the facility failed to provide care and services consistent with professional standards for one Resident (#9), out of a total sample of 25 residents. Specifically, the facility failed to ensure psychotropic medication recommendations for Resident #9 were communicated to and addressed by the Attending Physician. Findings include: Review of the facility's policy titled Physician Services, last revised 2/2021, indicated but was not limited to the following:-The attending physician will determine the relevance of any recommended interventions from other disciplines.-Consultive services are made available from community-based consultants.Resident #9 was admitted to the facility in December 2024 with diagnoses which included insomnia, anxiety disorder, personality disorders, depression, post-traumatic stress disorder (PTSD), unspecified psychosis, and adult physical abuse.Review of the Minimum Data Set (MDS) Assessment, dated 9/6/25, indicated he/she scored 15 out of 15 on the Brief Interview for Mental status (BIMS) indicating his/her mental cognition was intact. Review of Resident's orders indicated but was not limited to:-Mirtazapine Tablet 7.5 MG. Give 1 tablet by mouth at bedtime for Insomnia and decrease appetite (10/29/25),-Psychiatric services as needed (12/9/24). Review of Resident #9's electronic medication administration record (eMAR) for November 2025 and December 2025, indicated Resident #9 received mirtazapine medication each evening, as scheduled, except for on two occasions, which the Resident declined the medication.Review of Resident #9's medical record indicated but was not limited to the following:-On 11/5/25 a consultant psychiatric Nurse Practitioner's (NP) note indicated Resident complained that the mirtazapine was causing night terrors and recommendations were provided to hold medication due to reported night terrors.-On 11/5/25 a nurse's note indicated Resident was seen by psychiatric services with no recommendations, physician was notified and no new orders were provided.Further review of Resident #9's medical record failed to indicate recommendations to hold mirtazapine medication were communicated to and addressed by the Resident's Attending Physician.During an interview on 12/10/25 at 10:31 A.M., Unit Manager #3 and the Surveyor reviewed the behavioral health recommendation process. Unit Manager #3 said the behavioral health NP reviews each resident's recommendations and provides those recommendations on paper to him. Unit Manager #3 said once he receives the recommendation he provides those recommendations to the medical provider for approval. Unit Manager #3 said he was unable to find a copy of the recommendation to hold Resident #9's mirtazapine.During an interview on 12/10/25 at 11:30 A.M., NP #1 said the process for recommendations is to write the recommendation on paper and then provide it to the unit manager. NP #1 said recommendations are reviewed together and then the unit manager would follow up with the medical provider for approval. NP #1 said she did not know how the recommendation was missed. NP #1 said the facility should have a written recommendation.During a follow-up interview on 12/10/25 at 5:11 P.M., Unit Manager #3 said when the 24- or 72-hour reports are reviewed by him, he should have seen the NP recommendations in the late entry note the NP documented, to hold the mirtazapine, but it was overlooked.During an interview on 12/10/25 at 4:34 P.M., Physician #1 said he was not aware Resident #9 was having issues with his/her mirtazapine medication and did not receive any update or report on that from the facility since taking over the Resident's care approximately 1-2 weeks ago.During an interview on 12/10/25 at 4:41 P.M., Physician #2 said he was not notified of any recommendations to hold the mirtazapine medication for Resident #9. Physician #2 said there is no evidence of notification of the recommendation in the provider documentation and is unclear why they would not have followed such a recommendation when the goal with this Resident is to control his/her symptoms while reducing polypharmacology. During an interview on 12/11/25 at 7:41 A.M., the Director of Nursing (DON) said the process for any consultant's recommendations is for the consultant to review the recommendations with the unit manager and then those recommendations are provided to the MD/NP for approval. The DON said the recommendation was missed and we need to put something in place to ensure that does not happen again.

Based on observation, interviews, and record review, the facility failed, for one Resident (#9), out of a total sample of 25 residents, to notify the Resident's attending physician of a potential adverse effect from a newly started medication.Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, last revised 2/2021, indicated but was not limited to:The nurse will notify the Resident's attending physician or physician on call when there has been a (an):-adverse reaction to medicationResident #9 was admitted to the facility in December 2024 with diagnoses which include insomnia.Review of the Minimum Data Set (MDS) assessment, dated 9/6/25, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating his/her mental cognition was intact.During an interview on 12/10/25 at 1:46 P.M., Resident #9 said he/she cannot wake up from night terrors/nightmares that he/she is having since starting the new medication mirtazapine (for insomnia). Review of Resident #9's Physician's Orders indicated but was not limited to:-Mirtazapine Tablet 7.5 milligrams (MG). Give 1 tablet by mouth at bedtime for insomnia and decreased appetite (10/29/25),-Psychiatric services as needed (12/9/24).Review of Resident #9's electronic medication administration record (eMAR) indicated Resident #9 refused mirtazapine on the following dates:-On 11/3/25 at 8:00 P.M., indicated Resident refusal because the medication causes nightmares.Further review of Resident #9's medical record failed to indicate notification of the potential side effects to the physician.During an interview on 12/10/25 at 2:15 P.M., Nurse #4 said she recalls offering Resident #9 the newly prescribed psychotropic medication, mirtazapine 7.5mg. Nurse #4 said she thinks she only documented the side effect and not the notification to the provider and will have to review the chart.During an interview on 12/10/25 at 3:32 P.M., Nurse #4 said she reviewed the medical record for Resident #9 and was unable to find any evidence that she ever notified the Nurse Practitioner (NP) or Physician (MD) of the Resident's refusal. Nurse #4 said she did not document the notification and therefore is unsure if it ever occurred.During an interview on 12/10/25 at 4:41 P.M., Physician #2 said the staff did not make him aware of Resident #9's concerns with night terrors/nightmares while using the medication as a potential side effect.During an interview on 12/11/25 at 7:41 A.M., the Director of Nursing (DON) said she was not aware that the Resident had declined the mirtazapine medication because of a potential side effect of nightmares or night terrors. The DON said the staff should have notified the physician at that time of the potential side effect.

Based on observation, interview, and document review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure treatment carts were locked when not in direct supervision of the licensed nurse on one of four units observed.Findings include:Review of the facility's policy titled Medication Labeling and Storage, dated as revised February 2023, indicated but was not limited to the following:-The facility stores all medications and biologicals in locked compartments. Only authorized personnel have access to keys.-Compartments (including drawers, cabinets, rooms, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.On 12/9/25 at 7:39 A.M., the surveyor observed an unlocked treatment cart positioned in front of the nursing station on the M2 unit. There were no nursing staff in the vicinity of the unlocked cart. One resident was observed in the hallway unaccompanied at the time of the observation.On 12/09/25 at 7:43 A.M., the surveyor observed Nurse #5 walk up to his medication cart and bring it down the hallway and around the corner. The treatment cart remained unlocked and out of the line of sight of Nurse #5.On 12/09/25 at 7:47 A.M., the surveyor observed a staff member walk by the unlocked treatment cart while propelling a resident in a wheelchair.On 12/09/25 at 7:49 A.M., the surveyor observed a staff member stand next to the unlocked treatment cart carrying a bag of soiled linen.On 12/09/25 at 7:50 A.M., the surveyor observed Unit Manager (UM) #3 walk in front of the unlocked treatment cart and continue down the hallway. UM #3 did not lock the treatment cart.During an observation with interview on 12/9/25 at 7:52 A.M., the surveyor observed Staff Development Coordinator (SDC) and UM #3 walk by the unlocked treatment cart. The SDC approached the cart and locked it. The SDC said she locked the cart because it should be locked at all times when unattended. During an interview on 12/10/25 at 1:06 P.M., the Director of Nursing (DON) said her expectation is that the treatment carts are clean, organized and locked on the units. The DON said none of the biological medications stored inside should be available for the residents to have access to. She said the cart should not have been left unlocked and unattended on the unit for any amount of time.

Based on observation and interview, the facility failed to ensure nurse staffing information which included the current date and actual hours worked per shift for licensed and unlicensed staff including Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA), and the resident census was posted daily as required.Findings include:On 12/3/25 at 8:58 A.M., the surveyor did not observe any nurse staffing posting in the lobby, hallways or nursing units.On 12/4/25 at 9:22 A.M., the surveyor did not observe any nurse staffing posting in the lobby, hallways or nursing units.On 12/8/25 at 8:12 A.M., the surveyor did not observe any nurse staffing posting in the lobby, hallways or nursing units.On 12/9/25 at 9:39 A.M., the surveyor did not observe any nurse staffing posting in the lobby, hallways or nursing units.On 12/10/25 at 8:35 A.M., the surveyor did not observe any nurse staffing posting in the lobby, hallways or nursing units.During an interview on 12/10/25 at 12:01 P.M., the Scheduler said she has been managing the nursing schedule for the facility for the past year. The Scheduler said she completes a nursing schedule daily which includes all nurses and CNAs working for that day. The Scheduler said it is her job to complete and post the daily staffing numbers, but it has been busy, and it must have been overlooked.During an interview on 12/10/25 at 1:10 P.M., the Director of Nursing (DON) said the daily nursing staffing sheet with the resident census should be updated daily and posted in a highly visible area for everyone to see. The DON said it has not been posted in the facility as it should have been.

Based on observations, interviews and records reviewed, for one of three sampled Residents (Resident #1), who resided on a secured unit, made verbal statements to staff a desire to leave the Facility, had a Guardianship in place, and a care plan that indicated that he/she would remain within the Facility unless supervised, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to maintain his/her safety in an effort to prevent an elopement. On 6/23/25, Resident #1 exited the secure second-floor unit (B2), unsupervised and unbeknownst to staff, through a locked and alarmed door which lead to a fire escape. At the time of the elopement, three staff members working on the B2 Unit, failed to recognize that the sounding alarm had been triggered by the opening of the door leading to the fire escape and instead mistook the alarm for a malfunction. Resident #1 descended the fire escape into a secure courtyard, climbed over a fence and left the Facility grounds. Resident #1's whereabouts were unknown for approximately twelve hours, at which time he/she was located in a bar about 58 miles away. As a result, this placed the resident at risk for the likeliness of an adverse outcome that could have led to serious harm, injury, impairment or death. Findings include: The Facility Policy, titled, Elopement of a Resident, dated as last revised 2/10/25, indicated that all residents are assessed for potential elopement risk on admission and a care plan will be implemented for any resident who is at risk. Review of the Medical Record indicated that the court had appointed a permanent Guardian for Resident #1 on 12/12/23 and on 4/02/25 the court ordered a temporary Guardianship with a different individual serving as Guardian. The Medical Record indicated Resident #1's diagnoses included traumatic subarachnoid hemorrhage, history of traumatic brain injury, cognitive communication deficit, adjustment disorder and difficulty in walking. Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 4/12/25, indicated he/she had a Guardian. Review of the most recent Elopement Risk Assessment, dated 4/10/25, indicated that Resident #1 was at risk for elopement and a care plan would be developed. Review of Resident #1's Care Plan related to Elopement, dated as initiated 10/12/23, indicated he/she was at risk for elopement based on the elopement risk assessment and verbal statements indicating a desire to discharge. The Care Plan indicated a goal that Resident #1 would remain within the Facility unless supervised and remain free from harm. The Care Plan interventions included residing on a secure unit, completing an elopement risk assessment quarterly and with a significant change in status, engaging in a structured activity program based on his/her preference, evaluating need for additional supervision and safety supervision checks as indicated. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 6/23/25, indicated that at 7:30 A.M., Facility staff noted that Resident #1 was not in his/her bed and could not be located on his/her Unit. During an interview on 6/26/25 at 12:45 P.M., Resident #1 said that he/she left the faciity on [DATE], through the fire escape door and jumped the fence. Resident #1 said that he/she heard the alarm on the door sounding, however, he/she did not notice staff looking for him/her. During a telephone interview on 6/30/25 at 11:55 A.M., Nurse #1 said that she was the nurse on the B2 Unit during the 11:00 P.M. to 7:00 A.M. shift starting on 6/22/25 and ending on 6/23/25. Nurse #1 said that when she arrived to the B2 Unit shortly after 11:00 P.M., the two 11:00 P.M. to 7:00 A.M. shift Certified Nurse Aides (CNAs #1 and #2) told her they had already done a head count. Nurse #1 said that she completed paperwork in the nursing station for much of the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said around 5:00 A.M. an alarm sounded on the B2 Unit. Nurse #1 said that CNAs #1 and #2 told her that the doors on the B2 Unit were alarmed. Review of the Facility Floor Plan indicated the B2 Unit was shaped like a letter T with the resident rooms located along one long main corridor. The Floor Plan showed that off of the main corridor was a single shorter corridor which passed the nurses station and ended in a day room for residents. The Floor Plan showed doors located at each end of the long main corridor and a door in the day room which lead to an exterior fire escape. Nurse #1 said that in response to the sounding alarm, CNAs #1 and #2 showed her the doors located at each end of the B2 Unit main corridor and showed her how to use the fob to lock and unlock the door in order to pass through them. Nurse #1 said that although CNAs #1 and #2 said that the fob should reset the sounding alarm, it did not. Nurse #1 said that CNAs #1 and #2 told her that the sounding door alarm was a malfunction. Nurse #1 said that the alarm continued to sound until sometime between 6:00 A.M. and 7:00 A.M. when it stopped without explanation. Nurse #1 said she did not become aware that there was a third door on the B2 Unit which lead to a fire escape until after the 7:00 A.M. to 3:00 P.M. shift arrived to the B2 Unit and realized that Resident #1 was missing. Nurse #1 said that although she worked at the Facility through an Agency for a year, she only worked on the B2 Unit once before and she did not understand the door alarm system. Nurse #1 said although she knew that the B2 Unit was locked, she did not know Resident #1 was an elopement risk and said she was not aware of his/her care plan. During a tour on 6/26/25 at 6:15 A.M., the Surveyor with the Nurse Consultant observed that the three doors on the B2 Unit were locked. The locking mechanism on the doors were deactivated by contact with a hand held fob to allow egress. The doors can only be opened by using the fob to deactivate the door lock. In addition, if the alarm sounds at the door for any reason, the fob silences it. The Nurse Consultant said that on 6/23/25 the Security Company checked the day room door and reviewed surveillance camera footage depicting the door. The Nurse Consultant said the Security Company told the Facility that the magnetic lock on the day room door operated correctly, however, Resident #1 hip checked the door with sufficient force to overcome the magnetic lock and force the door open. The Nurse Consultant said that opening the door without a fob using with sufficient force to overcome the magnetic lock, will sound the door alarm. The Surveyor attempted to reach CNAs #1 and #2 by telephone on 6/26/25 and 6/30/25 without success. The Surveyor asked the Administrator to arrange for telephone interviews with CNAs #1 and #2, however, CNAs #1 and #2 were unresponsive to the Administrator as well. Written statements, dated 6/23/25, taken by the Director of Nurses and the Assistant Director of Nurses, to document telephone interviews of CNA #1 and CNA #2 indicated the following: - CNA #1 said that he worked the 11:00 P.M. to 7:00 A.M. shift starting on 6/22/25 and ending 6/23/25, that he did not see Resident #1 in bed and saw him/her in the bathroom, that he could not recall whether he saw Resident #1 at 5:00 A.M., that he heard the door alarm and was given the fob to deactivate the alarm by Nurse #1, that the door continued to alarm despite his attempt to deactivate it, that he did not see any resident at the alarming door and that he reported to Nurse #1 that the alarm must be malfunctioning. -CNA #2 said that she worked the 11:00 P.M. to 7:00 A.M. shift starting on 6/22/25 and ending 6/23/25, that it was her first time on the B2 Unit, that CNA #1 completed checks of the B2 residents, that she responded to a sounding door alarm with other staff, that she and other staff checked the area including the area outside of the door by the elevator, that the alarm did not stop and that Nurse #1 was aware. During a telephone interview on 6/26/25 at 1:00 P.M., the Housekeeper said that he arrived to the B2 Unit around 6:20 A.M. on 6/23/25. The Housekeeper said that as he arrived to the B2 Unit, heard a sounding alarm and said although he recognized the alarm as a door alarm, he did not know which door was alarming. The Housekeeper said that he proceeded to wash the floor on the B2 Unit, which he estimated took ten to fifteen minutes, and then entered the day room in order to wash the floor there. The Housekeeper said that once in the day room, he realized that the sounding alarm was the door in the day room which lead to a fire escape. The Housekeeper said he used his fob to deactivate the door alarm, however, he did not discuss the door alarm with any of the staff on the B2 Unit or report that he had deactivated the sounding alarm. During a telephone interview on 6/26/25 at 1:47 P.M., Nurse #2 said that on 6/23/25, she arrived to work on the B2 Unit at 7:00 A.M. and made rounds. Nurse #2 said that she could not locate Resident #1. Nurse #2 said she enlisted other staff members to assist her in looking for Resident #1 and when he/she was not located, she notified Facility leadership that Resident #1 was missing. During an interview on 6/26/25 at 6:35 A.M., the Nurse Supervisor said that she worked at the Facility during the 11:00 P.M. to 7:00 A.M. shift starting on 6/22/25 and ending on 6/23/25. The Nurse Supervisor said that shortly after 7:00 A.M. she became aware that Resident #1 was missing from the B2 Unit. The Nurse Supervisor said that she assisted with searching for Resident #1. The Nurse Supervisor said that during the overnight shift, she was not made aware that a door alarm on the B2 Unit was sounding and that staff could not deactivate the sounding alarm and thought that there was a malfunction. During an interview with the Administrator, the Director of Nurses and the Nurse Consultant on 6/26/25 at 6:53 A.M., they said that shortly after 7:00 A.M. on 6/23/25 staff reported that Resident #1 was missing from the B2 Unit. They said that the Facility was searched and the Police and Guardian were notified. The Administrator, the Director of Nurses and the Nurse Consultant said that review of video surveillance camera footage indicated that Resident #1 eloped from the B2 Unit on 06/23/25, during the 11:00 P.M. to 7:00 A.M. shift, through the door in the day room which lead to a fire escape. They said that further review of the video surveillance camera footage indicated that after descending the fire escape into the secure courtyard, Resident #1 climbed a fence and eloped from the Facility property. Review of the video surveillance camera footage obtained from two cameras, recorded on 6/23/25, viewed with the Nurse Consultant indicated the following: -at 4:49 A.M. Resident #1 walked passed the nursing station and into the day room, he/she checked the fire escape door and looked out a nearby window into the courtyard and returned to his/her room (time stamp on footage is 5:59, however per the Nurse Consultant, the time stamp is one hour ahead of the actual time of the recording at 4:49 A.M.) -at 5:08 A.M., Resident #1 walked passed the nurses station dressed in street clothes and carrying a bag, pushed open the day room door leading to the fire escape and exited through the door (time stamp on footage is 6:08, however per the Nurse Consultant, the time stamp is one hour ahead of the actual time of the recording at 5:08 A.M.) -at 5:21 A.M. Resident #1 threw his/her bag over the fence which separated the secure courtyard from the street and climbed the fence to exit the Facility property (time stamp on footage is 4:41, however per the Nurse Consultant, the time stamp on this second camera is forty minutes behind the actual time of the recording at 5:21 A.M.) Review of the Police Report, dated 6/23/25, indicated that at 7:45 A.M. the Facility notified the Police that Resident #1 was missing. The Report indicated the Police arrived at the Facility to search for Resident #1 and initiated search efforts in the community, which included pinging his/her cell phone. The Report indicated that at 6:30 P.M., Resident #1 was located in a pub, in the town in which he/she formerly resided, which was about 58 miles from the Facility. On 6/26/25, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. On 6/23/25, the Facility suspended CNA #1 and CNA #2 pending the outcome of the Facility Internal Investigation and the Agency was notified that the Facility would no longer use Nurse #1. B. Resident #1 was evaluated in the hospital emergency department on 6/23/25 and returned to the facility on 6/24/25. On his/her return, the Facility assessed him/her for Elopement, Functional Abilities and Goals and conducted a Nursing Evaluation. The Facility initiated one on one monitoring of Resident #1 by staff to ensure his/her safety and applied a Wanderguard to his/her left ankle. C. Resident #1 was seen by the Facility Nurse Practitioner and the Facility Social Worker on 6/24/25 for on-going assessment and support. D. On 6/24/25, the Facility updated interventions on Resident #1's plan of care to include use of a Wanderguard (checked for placement and function every shift), one to one monitoring by staff and on-going efforts toward discharge planning at his/her request. E. On 6/23/25, the Facility alarm company assessed the door alarms and determined they were functioning appropriately. A recommendation was made to increase the resistance of the magnetic lock on the B2 Unit day room door and implementation is planned pending equipment availability. F. On 6/23/25, all Facility staff were educated by the Staff Development Coordinator/designee on Safety Checks and Door Alarm Response Procedures. G. On 6/24/25, the Director of Nursing enhanced existing orientation materials for Agency staff to include information on the Facility physical plant and security systems. H. On 6/24/25 and on-going, the Facility initiated random audits by Leadership of staff member response times to sounding door alarms. I. On 6/24/25, the Facility conducted an ad hoc Quality Assurance Meeting to review the corrective action plan. J. The Administrator/designee is responsible for overall compliance.

Based on records reviewed and interviews for three of three sampled residents (Resident #1, #2, and #3), who all resided on a locked, secured unit (B1), were on scheduled safety checks by unit staff, and required staff supervision, both on and off the unit, the Facility failed to ensure they provided an adequate level of staff supervision, which included unit staff responding adequately to exit door alarms, to prevent an incident of elopement. On [DATE] at approximately 11:17 P.M., Residents #1, #2, and #3, exited through the locked and alarmed door of their unit undetected by staff, made their way onto the elevator, proceeded to the main entrance/exit door leading to the parking lot, exited through the front alarmed door and proceeded to walk away from the facility. Although a staff member saw the residents get off of the elevator, she did not question them or alert other staff. An off duty staff member noticed Resident #1 and #3 down the street from the facility with police, and alerted staff at the facility. Resident #2 was found several minutes later laying on the ground with his/her wheelchair on top of him/her, he/she was transferred to the Hospital Emergency Department (ED) for evaluation of chest pain, and for treatment of facial and head lacerations, both of which required sutures to close. Findings include: Review of the Facility Policy titled Safety Awareness and Building Safety, undated, indicated the following: -that all staff should ensure residents have the appropriate level of supervision if they are seen off of their unit without a staff member present. -that staff should not reset a sounding alarm without notifying a nurse supervisor and the nurse supervisor will assess the situation and determine if a Code Silver (missing person) should be activated. Review of the Facility Policy titled Elopement of a Resident, dated [DATE], indicated the following: -all residents at the facility will be provided with a secure environment, and -all residents will be assessed for the potential for elopement on admission, quarterly, and with a significant change in status. -Residents identified as an elopement risk will have their photos maintained in a confidential manner at the main entrance to the Facility and on each unit; -A care plan will be developed and implemented for every resident that is at risk for elopement; and -A licensed nurse will have visual contact with each resident at the beginning and end of each shift. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that on [DATE] at 11:45 P.M., two staff members who had left at the end of the second shift (3:00 P.M. to 11:00 P.M.), reported seeing Resident #1 and #3 outside of the Facility, three structures down, at a donut shop. The Report indicated that staff remained with the Residents and the Facility and Police were notified. Resident #1 refused to return to the Facility with staff, became aggressive and he/she was taken to the Hospital ED on a Section 12 (emergency restraint and hospitalization of persons posing a risk of serious harm by reason of mental illness). The Report further indicated that Resident #2 was not located until staff were escorting Resident #3 back to the Facility. Resident #2 was found on the ground with his/her wheelchair on top of him/her, he/she was transported to the Hospital ED for evaluation and treatment. 1) Resident #1 was admitted to the Facility in [DATE], diagnoses included Traumatic Brain Injury (TBI), schizoaffective (combination of schizophrenia and mood issues) disorder, late effects hemiparesis (muscle weakness or partial paralysis on one side of the body) due to a Cerebral Vascular Accident (CVA), late effects cognitive deficits from CVA, and substance abuse disorders. Review of Resident #1's Petition for Appointment of Guardianship, dated [DATE], indicated that his/her original Guardianship had expired, and the Facility is petitioning for a new legal guardian for Resident #1. Review of Resident #1's Care Plan titled Activities Of Daily Living (ADL), dated as last revised [DATE], indicated he/she required continual supervision with wheelchair locomotion on the unit and extensive assistance of one staff member off the unit. Review of Resident #1's Elopement Assessment, dated [DATE], indicated he/she was at moderate risk for elopement. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated that around 1:00 P.M., Resident #1 was attempting to leave the building. Review of Resident #1's Nurse Practitioner (NP) Note, dated [DATE], indicated that he/she became very aggressive, combative, attempted to assault staff, made his/her way out to the main entrance [on the ground level of the facility] seeking to exit and was sent to the Hospital ED for evaluation. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated he/she returned to the Facility around 8:00 P.M. and was placed on 5-minute safety checks. Review of Resident #1's Nurse Progress Note, dated [DATE], indicated that he/she remained under close supervision due to being at risk for elopement. During an interview on [DATE] at 11:48 A.M., Resident #1 said that on [DATE], he/she left the building and went to the donut shop down the street. Resident #1 said that he/she just kicked the door (locked and alarmed) on the unit open and went out with his/her friends (Resident #2 and #3). Resident #1 said he/she could not recall if an alarm sounded when he/she kicked the door open, and said they then made their way onto the elevator and then right out the front door. Resident #1 said that Resident #2 was far behind them (him/her and Resident #3) as they walked away from the facility and said he/she later found out that he/she ended up getting hurt. On [DATE], when approached by Police/Staff at the donut shop, Resident #1 became aggressive and violent, he/she refused to return to the facility, an order for a Section 12 was obtained and he/she was transported to the Hospital ED for evaluation. 2) Resident #2 was admitted to the Facility in [DATE], diagnoses include unspecified psychosis, alcohol abuse, late effects hemiparesis related to a cerebral vascular accident, hemochromatosis (iron overload, leading to poisoning organs), and major depression. Review of Resident #2's Medical Record indicated that he/she had a court appointed legal guardian in place since 2021. Review of Resident #2's Elopement Risk Assessment, dated [DATE], indicated he/she was not at risk for elopement. However, Resident #2's picture was in the Facility elopement book kept at the reception desk (main entrance lobby area), and he/she had a care plan in place for a risk for elopement. Review of Resident #2's Care Plan titled ADL's, indicated he/she required supervision with wheelchair mobility. During an interview on [DATE] at 11:41 A.M., Resident #2 said that he/she, Resident #1 and Resident #3 escaped from the Facility and tried to get to the donut shop down the street. Resident #2 said that Resident #1 and Resident #3 were ahead of him/her, and that he/she wiped out (fell while self propelling his/her wheelchair) before he/she could get there. Resident #2 said he/she fell out of his/her wheelchair onto the cement and started bleeding. Resident #2 said that his/her wheelchair ended up on top of him/her that it took some time before anyone found him/her. Resident #2 said he/she needed to go to the Hospital ED for stitches. Review of Resident #2's Hospital ED Discharge Summary, dated [DATE], indicated he/she had been ejected from his/her wheelchair and onto his/her face suffering road rash to his/her right upper extremity, abrasions and laceration to the right side of his/her face, and complained of chest pain. The Summary indicated Resident #2 had a one centimeter (cm) laceration to his/her right cheek requiring two sutures and a 2.5 cm laceration to his/her right forehead requiring four sutures to close. 3) Resident #3 was admitted to the Facility in [DATE], diagnoses include traumatic brain injury, psychosis, anxiety disorder, and major depression. Review of Resident #1's Physician's Orders, indicated his/her Health Care Proxy had been activated since [DATE]. Review of Resident #3's Elopement Risk Assessment, dated [DATE], indicated he/she was at high risk for elopement. Review of Resident #3's Care Plan titled ADL's, dated as last revised [DATE], indicated he/she required supervision for locomotion on and off the unit. Review of Resident #3's Care Plan titled, Risk for Elopement, dated as last revised [DATE], indicated to distract him/her from wandering, monitor location as indicated, and document wandering behaviors. During an interview on [DATE] at 4:22 P.M., Resident #3 said on [DATE], Resident #1 planned an escape, that Resident #2 was also going to escape, and at the last minute they asked him/her to go with them. Resident #3 said that he/she was pushing Resident #1 in his/her wheelchair. Resident #3 said that when they got off of their unit, he/she does not remember hearing any alarms sound and when they got to the lobby, they just walked out the front door. Review of Resident #1, #2, and #3' Facility Supervision Check Sheets, dated [DATE], indicated the following; -Resident #1 had been on 15 minute safety checks (last signed off by staff as being seen at 11:00 P.M.); -Resident #2 had been on hourly safety checks (last signed off by staff as being seen at 10:00 P.M.); and -Resident #3 had been on 15 minute safety checks (last signed off by staff as being seen at 11:00 P.M.). Review or the Facility's Logbook Documentation titled Door Safety, dated [DATE] and [DATE], indicated that the Unit B1 door had been functioning properly and verified by the Lead Maintenance Worker. During an interview on [DATE] at 1:56 P.M., the Senior/Lead Maintenance Worker, said the all alarmed doors are checked weekly, that the exit door on Unit B1 had just been checked the day of the incident ([DATE]) on his weekly rounds. The Senior/Lead Maintenance Worker, said and once the exit doors are closed, that the alarm automatically stops sounding. During multiple observations from 8:00 A.M. to 4:00 P.M. on [DATE], the Surveyor observed multiple locked and alarmed doors functioning and sounding properly. On Unit B1, the locked and alarmed door that Resident #1, #2, and #3 exited off the Unit through, was working properly, however, once the exit door is closed, the surveyor noted that the alarm stops sounding (there is no code needed to deactivate the alarm). Observations also included how visitors and/or residents get onto and off of Unit B1 (same process is also required for Units B2 and M2). In order for a visitor (non-employee) to enter the secured units, a staff member must walk to the locked door, use a fob like key device to deactivate the lock and it will then disengage the locking mechanism (including the alarm) and the door to the unit will open. The same applies when exiting the secured units, an employee must walk the visitor and/or resident to the exit door and disengage the lock (which will cancel an alarm) by using the fob like key device and the door will open. Review of the Facility's surveillance camera video (no audio available) footage from Unit B1, dated [DATE], showed the following: ( it is important to note that the Facility's video footage and real times are not synched) . -11:15:17 P.M., Resident #1 independently wheels him/herself out of his/her room into the hallway to meet with Resident #2 and #3, who are standing very close to the locked and alarmed door of their secured unit. -11:16:37 P.M., Resident #1 wheels up to the exit door on the unit and kicks it, until the door opens, Resident #1 is then pushed by Resident #3, and Resident #2 independently mobilizes his/her wheelchair behind Resident #1 and #3, as they exit the unit at 11:17:13 P.M. -11:17:51 P.M., CNA # 1 walks into view of the camera and proceeds to enter a residents room where a call light is illuminated (CNA #1 does not look in the direction of the Unit exit door). -11:19:00 P.M., CNA #1 walks across and down the hall passing Resident #1's room (observed briefly glancing in), walks past it, and then enters the room closest to the exit door. -11:19:28 P.M., CNA #1 walks back toward the nursing station and out of the cameras view. -11:17:51 P.M. to 11:19:28 P.M., during this time there are no other staff members seen on the surveillance camera on B1 responding to the exit door alarm, (which based on Senior/Lead Maintenance Worker's interview and equipment report, the alarm on B1 was functioning properly and therefore should have sounded). -11:20:36 P.M., Residents #1, #2, and #3 exit the elevator on the ground floor and encounter a CNA who was coming into the facility to work the 11:00 P.M. to 7:00 A.M. shift and there does not appear to be any type of verbal exchange between the CNA and the Residents (video has no audio). -11:23:46 P.M., the Residents are at the main entrance (rear of the building), Resident #3 pushes the Handicapped automatic release button with no effect, Resident #1 also pushes the same button, and then kicks the first inner locked alarmed door open, the outer door opens automatically, and they all exit into the parking lot. -11:24:29 P.M., Resident #3 can be seen pushing Resident #1, in his/her wheelchair across the back parking lot, they go to the far upper left portion of the parking lot and then take a right onto what is presumed to be a sidewalk. Resident #2 can be seen propelling his/her wheelchair well behind Resident #1 and #3, but he/she is unable to keep up with their pace (no staff are seen exiting the building on the surveillance footage in the time that it takes for the Residents to be out of sight from the facility grounds). During a telephone on [DATE] at 12:37 P.M., Life Enhancement Specialist (LES) #1 said that at the end of his shift, about 10:50 P.M., on [DATE], he saw Resident #1 and Resident #3 talking in Resident #1's room, so he went into the room and stayed with them until his shift ended at 11:00 P.M. LES #1 said he left Resident #1 and #3 in Resident #1's room and said after the LES workers leave at 11:00 P.M., the nursing staff take over the safety checks for the residents. During a telephone interview on [DATE] at 9:30 A.M., CNA #1 said on [DATE], she had arrived on the B1 unit around 11:00 P.M., and said she saw Resident #1 enter Resident #2's room and they were talking. CNA #1 said a few minutes later she saw Resident #1 and Resident #2 talking in the hallway, and then a few minutes after that, Resident #3 went into Resident #1's room and they (Resident #1 and #3) were talking, and Resident #2 was just standing in the hallway. CNA #1 said she went to assist another resident and had last seen all three residents in the hallway close to the exit door talking. CNA #1 said when she finished assisting her other resident, two CNA's had come up to the unit and said they found some residents outside of the Facility down the street at the donut shop. During a telephone interview on [DATE] at 1:12 P.M., CNA #2 said that on [DATE], she punched in at 11:17 P.M. for her 11:00 P.M.-7:00 A.M. shift and headed to the elevator. CNA #2 said when the elevator opened, three people (later identified as Resident #1, #2, and #3) exited the elevator. CNA #2 said she did not know the three people that exited the elevator and said she was not certain if they were residents or visitors. CNA #2 said there are some independent residents in the building that are able to use the vending machines on the ground floor. CNA #2 said that she did not speak to them and had not asked who they were. CNA #2 said sometime later, a staff member from B1 came down to her unit (M1) to report that they found a few residents down the street, CNA #2 said that was when she reported that she saw them exit the elevator, as she was getting on to the elevator. CNA #2 said that she only works on the M1 Unit, that it is not secured unit, and said she had not realized the other three units were locked/secured units. During a telephone interview on [DATE] at 1:29 P.M., CNA #3 said that she had worked the 3:00 P.M. to 11:00 P.M. shift on [DATE], left the Facility at 11:37 P.M., and as she was driving home and passed the donut shop, down the street from the facility, she observed Resident #1 and Resident #3 outside of the donut shop speaking to the Police. CNA #3 said she called CNA #4 and was advised to return to the donut shop and stay with the Residents and she (CNA #4) would inform the Facility. CNA #3 and said before she knew it, CNA #4 and two nurses arrived at the donut shop. During a telephone interview on [DATE] at 3:12 P.M., CNA #4 said that she received a call, at approximately 11:40 P.M., from CNA #3 saying there were two residents outside of the donut shop down the street from the facility. CNA #4 said she notified Nurse #1 and Nurse #2 and the three of them went to get the residents. CNA #4 said that on the way back to the Facility with Resident #3, she heard someone yelling out for help, that she looked down a side street and observed Resident #2 on the ground with his/her wheelchair on top of him/her and blood all over the ground. CNA #4 said the police called 911 and Resident #2 was sent to the Hospital ED for evaluation. During an interview on [DATE] at 3:53 P.M., Nurse #1 said that on [DATE], she was working on Unit B1, on the evening shift and had seen Resident #1 and #3 talking together in Resident #1's room. Nurse #1 said that she does not recall hearing the locked secured door on the unit alarm and said she was unaware that three residents were missing from the unit. During an interview on [DATE] at 4:10 P.M., Nurse #2 said that on [DATE] she was working, on Unit B1, for a double shift from 3:00 P.M.-7:00 A.M. and said she had not noticed anything unusual. Nurse #2 said she had observed Resident #1, #2, and #3, hanging out by Resident #1's room (which is the second room away from the exit door). Nurse #2 said she did not hear any alarms sound that night and had no idea that Residents #1, #2, and #3 had left the unit until a CNA called the Facility to inform them that she saw Resident #1 and #3 down the street outside of the local donut shop. During an interview on [DATE] at 3:16 P.M., the Director of Nurses (DON) said that it is the Facility's expectation, that if an alarm is going off in the building, the staff member responding must determine the cause of the alarm, if the reason for the alarm is unknown, staff must open the alarming door, look around, and determine the reason for the alarm sounding. The DON said that if the reason for the sounding alarm is not confirmed, staff must inform a supervisor and perform a census check on that unit. The DON said that it is the Facility's expectation that if any employee observes any resident unattended off of their unit, they must report the observation immediately to a supervisor. On [DATE], the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction (with an effective date of [DATE]) that addressed the area(s) of concern as evidenced by: A) On [DATE], the Neurological Program Director and Director of Nurses (DON) placed Resident #1, #2, and #3 on five-minute safety checks for 72 hours. Currently, Resident #1, #2, and #3 remain on 15-minute safety checks and physician's orders were obtained for Resident #1 and #2's wheelchairs to be equipped with a wander guard device (Resident #3 continues to refuse the use of a device). B) On [DATE], the Administrator and Director of Maintenance changed the facility entrance and secured unit codes, inspected all doors and all were in functioning order. The Facility also contracted for an inspection by an outside vendor who also confirmed there were no issues with door alarm function. The Administrator and Director of Maintenance continue to search for a potential additional alarm device that may enhance the system already in place. C) On [DATE], the Administrator and DON added an additional staff member stationed at the main entrance during the off-shift hours (11:00 P.M. to 7:00 A.M.), to ensure that no one is allowed to exit the Facility without staff knowledge. The staff member was placed on the daily schedule as of [DATE]. D) On [DATE], the Director of Nurse and/or designee completed new Elopement Risk Assessments for Resident #1, #2, and #3, assured their photographs were placed in the Elopement Book at the main entrance, the B1 unit and each of the Resident's care plans were updated to reflect the recent elopement. E) On [DATE], the Facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the event, develop interventions and audit tools to minimize the risk of an event of this nature from happening again. and will continue to review for compliance. F) On [DATE] and ongoing, the DON and Staff Development Coordinator (SDC) educated all staff, including the Life Enhancement Specialist (LES) regarding the revised policy for Levels of Observations, Safety Check Procedures, and the Facility's Alarm Procedures. Education included steps to take if an alarm is sounding, ensuring residents are supervised when seen off the unit, and notifying a supervisor when a resident is observed unsupervised at any time. Administrative staff will conduct random audits for five weeks or until found to be in compliance, with all staff on all units to ensure their understanding of each of the identified issues. G) On [DATE] and ongoing, the DON and SDC completed new Elopement Assessment for all residents in the facility and care plans were updated by nursing staff according to the results. H) Results of all audits and observations will be brought to and reviewed at QAPI meetings for the next three months or until compliance is achieved. I) The Administrator and/or Designee are responsible for overall compliance.

Based on interviews and record reviews, the facility failed to ensure a monthly medication regimen review was completed once per month for five out of five Residents (#3, #13, #117, #79, and #88) selected for unnecessary medication review and one out of one Resident (#94) reviewed for medication side effects. Specifically, the facility failed to have a licensed pharmacist conduct a drug regimen review for each resident in the months of May, June, July, and August 2024. Findings include: Review of the facility's pharmaceutical services contract indicated for Pharmacy Consulting Services- At the facility's written request, the Pharmacy shall arrange for a third party consultant pharmacist to provide pharmacy consulting services to the facility. The facility and such pharmacy consultant shall contract directly with each other and the Pharmacy shall have no other duties, responsibilities or liability with respect to such pharmacy consultant. During the entrance conference on 9/19/24 on 9:30 A.M., the Administrator said the facility had entered new ownership effective 4/1/24 and the Administrator and the Director of Nurses had started working at the facility in May 2024. 1. Resident #3 was admitted to the facility in January 2019. Review of the paper and electronic medical records for Resident #3 indicated a drug regimen review was completed on 4/4/24 and then again on 9/23/24. There was no documentation to indicate the drug regimen review had been conducted by a licensed pharmacist in May, June, July or August 2024. Review of the medical record on 9/24/24 indicated the pharmacist consultant had completed the drug regimen review on 9/23/24 and had recommendations. During an interview on 9/24/24 at 1:15 P.M., the Director of Nurses (DON) said the drug regimen review had just been completed and had not been reviewed by the physician at this time. 41106 2. Resident #13 was admitted to the facility in September 2022. Review of the paper and electronic medical records for Resident #13 indicated a drug regimen review was completed on 4/4/24 and then again on 9/23/24. There was no documentation to indicate the drug regimen review had been conducted by a licensed pharmacist in May, June, July or August 2024. Review of the medical record on 9/24/24 indicated the pharmacist consultant had completed the drug regimen review on 9/23/24 and had recommendations. During an interview on 9/24/24 at 11:05 A.M., Unit Manager #4 said he has not seen any pharmacy reviews for a while and he has not seen a pharmacist in the building. 46862 3. Resident #117 was admitted to the facility in November 2023. Review of the medical record for Resident #117 failed to indicate a medication regimen review was completed in May, June, July, and August 2024. During an interview on 9/24/24 at 10:17 A.M., Unit Manager #2 said the paper pharmacy reviews were in Resident #117's medical record. Unit Manager #2 reviewed the paper medical record and did not find any pharmacy reviews for May 2024, June 2024, July 2024 or August 2024. During an interview on 9/24/24 at 10:35 A.M., the DON said the facility came under new ownership in April 2024. The DON said she was not aware that the previous owner had hired a consultant pharmacist to complete pharmacy reviews, as the pharmacy did not have a pharmacist come into the facility. The DON said no pharmacy reviews were completed from May 2024 through August 2024. 49424 4. Resident #79 was admitted to the facility in June 2022. Review of the paper and electronic medical record for Resident #79 indicated a drug regimen review was completed on 4/3/24 and then again on 9/18/24. There was no documentation to indicate the drug regimen review had been conducted by a licensed pharmacist in May, June, July, or August 2024. 15214 5. Resident #88 was admitted to the facility in August 2022. During an interview on 9/25/24 at 11:36 AM, Nurse #2 said that the pharmacist reviews each resident's drug regimen monthly, and the monthly pharmacy reviews are kept in the medical record. Record review indicated that the most recent MRR by the consultant pharmacist was on 9/18/24. Further record review indicated that there were no MRRs by the consultant pharmacist from May 2024 to August 2024. During an interview on 9/24/24 at 9:45 AM, the DON said that the facility had changed ownership in April 2024 and that the monthly MRRs had not been conducted by the consulting pharmacy from May 2024 to August 2024. 6. Resident #94 was admitted to the facility in May 2021. Record review indicated that the most recent MRR by the consultant pharmacist was on 9/18/24. Further record review indicated that there were no MRRs by the consultant pharmacist from May 2024 to August 2024. During an interview on 9/24/24 at 9:45 AM, the DON said that the facility had changed ownership in April 2024 and that the monthly MRRs had not been conducted by the consulting pharmacy from May 2024 to August 2024.

Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the resident common areas (activity rooms, pub/parlor/dining rooms) were maintained in good repair (without holes, painted) and homelike on units M2 and B2. Findings include: Review of the facility's policy titled Resident Right-Safe/Clean/Comfortable/Homelike Environment, dated as last revised September 2021, indicated but was not limited to the following: -It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior During all days of survey (9/19-9/26/24), the surveyor observed the following: Unit B2: -the unit hallway had multiple areas where hand sanitizer pumps had been removed, revealing unpainted torn drywall -the dining room had a hole in the wall approximately three inches long by one and a half inches high, with crumbling dry wall. -the walls in the dining room were painted white and light blue with visible marks, nicks, food debris. -the door frame when exiting the dining room was observed with chipped paint and dark in color on the white paint with brown smudges on the right side of the door frame at eye level and at the top of the door frame. -the activity room was observed to have a medium blue paint with multiple areas of scraped off paint, revealing white wall throughout multiple levels of the room. -the wall air conditioner in the activity room had gray dust/debris on the front and top and the vent was pointed at the ceiling. The textured ceiling in front of the air conditioner had black particles of debris. -the activity room floor level baseboard heater had a gap between the tile floor and the heater, the gap had brown dirt and trash. During an interview on 9/25/24 at 3:05 P.M., Life Enrichment Specialist #1 was in the B2 unit dining room and said he was not sure how long the hole had been in the wall, but it had been there for some time. He said he was not sure if the common area rooms had been painted anytime recently. Unit M2: - the unit hallway had multiple areas of scraped off paint and areas of unpainted patches of plaster; the walls were visibly dirty and discolored with visible liquid streaks and corners with broken plaster. -the unit fire extinguisher had trash and torn up sugar packets wrappers between the extinguisher and the wall. The wall around the extinguisher was visibly dirty with dark streaks. - the pub/parlor had painting tape around the chair rail, outlets and baseboard, there was one coat (with visible bleed through) of blue paint on the lower section of the walls. The painting tape around the base board was scratched up with wear and tear. The blue paint had visible scuffs and scratches. During an interview on 9/25/24 at 3:24 P.M., Life Enrichment Specialist #2 said the staff had previously been utilizing another room for activities for residents and when they switched to using the pub/parlor the facility staff had started painting it but were unsure when it would be finished. During an interview on 9/25/24 at 4:05 P.M., the Housekeeping Manager said there was one housekeeping staff member assigned to each unit and they were responsible for dry and wet mopping resident rooms and cleaning resident bathrooms. She said there was one additional staff member who buffed the unit hallway floors. She said the unit housekeeper was responsible for wiping down the walls and high touch areas (handrails) on the units daily. She said the walls should not be visibly dirty. She said the housekeeping staff should have been cleaning under the baseboard heater in the B2 activity room and any trash that was observed between the wall and the fire extinguisher. She said the maintenance staff were responsible for cleaning the air conditioners and her staff had not noticed the debris on the B2 activity room ceiling. During an interview on 9/26/24 at 7:30 A.M., the Corporate Manager said he was responsible for plant operations and there were currently two staff in the maintenance department. He said the facility previously had a Director of Maintenance until June 2024. He said the current maintenance staff continued to work on crisis management for the facility (plumbing, electric, safety concerns) and there were not enough staff to address painting. He said the previous brand of hand sanitizer was changed which required new dispensers with a different method of installation which was why the dispensers were now in different spots, leaving unpainted exposed dry wall. He said he knew there was a hole in the B2 dining room as it was on his rounding list and that holes in walls, with the appropriate number of staff, should be fixed within a day. He said the previous Director of Maintenance, who left the facility in June (over three months prior to survey) had started painting the M2 pub/parlor and the room had not been finished.

Based on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with accepted professional standards of practice prior to administration for 1 of 4 medication carts reviewed. Specifically, the facility failed to: -For Residents #47, #82, and #117, ensure staff did not pre-pour medications and store them in the medication cart; and -Ensure Schedule II-V controlled substance medications were maintained in a separately locked, permanently affixed compartment. Findings include: Review of the facility's policy titled General Guidelines for Medication Administration, dated September 2018, indicated but was not limited to the following: -Medications are administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to administer. -Medications are administered at the time they are prepared. Medications are not prepared either in advance of medication pass or for more than one resident at a time. On 9/25/24 at 10:57 A.M., the surveyor and Nurse #1 observed the medication cart on Unit M2 and observed in the top drawer, three plastic pill cups which each contained multiple medications. Two of the pill cups were not labeled, the third cup had a piece of paper lying on top with Resident #117's first name only. During an interview on 9/25/24 at 10:59 A.M., Nurse #1 said he pre-poured the medications because the three residents come back from group at 11:00 A.M. and want their medications right away. He said Resident #82's pill cup contained oxycodone (schedule II drug). Nurse #1 said he should not have pre-poured the medication and the Oxycodone should be stored in the narcotic box (under double lock). Review of the narcotic book indicated Nurse #1 signed out the following Oxycodone but was not limited to the following: -Resident #47 had one Oxycodone 10 milligram (mg) signed out on 9/25/2024 at 11:00 A.M. by Nurse #1. -Resident #82 had one Oxycodone 15 mg signed out on 9/25/2024 at 11:00 A.M. During an interview on 9/25/24 12:11 P.M., the Director of Nurses (DON) said she expects the nurses not to pre-pour medication and all narcotics to be stored under double lock (narcotic box).

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were formulated and maintained in the medical record for one Resident (#106), out of a total sample of 25 residents. Specifically, the facility failed to ensure Advanced Directives were reviewed, documented, valid, and maintained in the medical record. Findings include: Review of the facility's policy titled Advanced Directives, dated as last revised ,d+[DATE], indicated but was not limited to the following: -Advanced directives will be respected in accordance with state law and facility policy. -Information about whether or not the resident has executed an advanced directed shall be displayed in the medical record. -The plan of care will be consistent with his or her documented treatment preferences and/or advanced directives. -Advanced Directive- a written instruction for health care, recognized by state law, relating to the provisions of health care. -Do Not Resuscitate- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy (HCP), or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. -The staff will inform emergency medical personnel of a resident's advanced directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) website (https://www.molst-ma.org) indicated but was not limited to the following: -All clinicians in any setting should talk about advanced care planning with patients and document patients' preferences as appropriate. Such discussions may result in filling out a MOLST form, if medically indicated and desired by the patient. -Filling out the MOLST form: Both Sections D and E (Patient and Clinician Signature) must be fully complete and legible for page 1 to be valid. -The MOLST form should be kept with the patient, easy to find, and taken with the patient outside of the home. -Copy the MOLST form for the patient's medical record. -MOLST requires a physician, nurse practitioner, or physician assistant signature to be valid. This signature confirms that the MOLST accurately reflects the signing clinician's discussion with the patient. --The MOLST form should be filled out and signed only after an in-depth conversation between the patient and the clinician signer. -If any section is not completed, there is no limitation on the treatment indicated in that section. -The form is effective immediately upon signature. Photocopy, fax, or electronic copies of a properly signed MOLST are valid. -Send this form with the patient at all times. -If no form is completed, no limitations on treatment are documented, full treatment may be provided. Resident #106 was admitted to the facility in February 2023 with diagnoses which included myocardial infarction, heart disease, and Parkinsons disease. Review of the Minimum Data Set (MDS) assessment for Resident #106 indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating he/she was cognitively intact. Review of the electronic medical record for Resident #106 indicated he/she made his/her own medical decisions and his/her HCP was not invoked and he/she was a Do Not Resuscitate/Do Not Intubate (DNR/DNI). Review of the Physician's Orders indicated the following: -DNR/DNI ([DATE]) Further review of the electronic medical record failed to indicate a MOLST or DNR form had been scanned into the medical record. Review of the paper medical record failed to indicate a MOLST or DNR form had been completed and maintained as part of the medical record. Review of the Comprehensive Care Plan indicated but was not limited to the following: -ADVANCED DIRECTIVES: DNR/DNI, Self-Responsible, HCP on file ([DATE]) -Follow MOLST form as ordered. ([DATE]) Review of the Nursing, Social Service, and Physician progress notes from admission through [DATE] failed to indicate a discussion regarding a MOLST had occurred, a MOLST was signed, or that the resident wished to be a DNR/DNI. Further review of the progress notes indicated but were not limited to the following: -[DATE] Social Service Note: Advanced Directives: None. Full Code and is self-responsible at this time. -[DATE] Social Service Note: Met to discuss plan of care. In attendance were social worker, unit manager, program director, and rehab director. HCP was present via phone call and resident was present. He/she has a HCP but it is not activated at this time and is a full code status. -[DATE] Nurses Note: Resident was seen by physician today. Resident consented to medication change. -[DATE] Physician Progress Note: late entry for [DATE]: seen for falls. The progress notes failed to indicate a discussion had occurred regarding advanced directives or that advanced directives were formulated, implemented, and placed in the medical record. During an interview on [DATE] at 11:15 A.M., Unit Manager #3 said there was not a MOLST in Resident #106's chart and she did not know where it was. She said the form should be in the medical record. Additionally, she said he/she has been to the hospital a few times so perhaps it went with them. She said she was unsure why the form was not in the chart or where it was and deferred further questions to the Director of Social Services. During an interview on [DATE] at 11:15 A.M., the Director of Social Services said the MOLST form was not in the medical record, and it should be. She said she did not recall reviewing one with him/her and did not know where the MOLST was. During an interview on [DATE] at 11:56 A.M., the Director of Social Services said she did not have a copy of the MOLST in the Social Service office either. She said she put a call out to the physician to inquire about the MOLST. During an interview on [DATE] at 12:45 P.M., the Director of Nurses (DON) said she spoke to the physician, and he did not recall this particular case, but usually the provider would have the discussion, document, and write the orders. She said however, there are no notes regarding this in the medical record. On [DATE] at 11:00 A.M, the surveyor observed that there was a MOLST form flagged in the chart for physician review. The MOLST form was signed/initialed by Resident #106, dated [DATE], and indicated he/she wanted to have CPR attempted and did not want to be intubated. On [DATE] at 11:03 A.M., Resident #106 was in bed sleeping and unavailable for interview. During an interview on [DATE] at 11:07 A.M., Unit Manager #3 said there should be a current/valid MOLST in the medical record. She said a new one was completed yesterday after it was pointed out that he/she did not have one. She said the physician is coming in tomorrow to review and sign it. Review of the medical record indicated Resident #106 remained a DNR/DNI status at this time. During an interview on [DATE] at 9:58 A.M., Social Worker #3 said she did not know where the MOLST was, so she went over it to have Resident #106 sign a new one and he/she wants CPR. She said she flagged it for the physician to review. Additionally, she said the MOLST should be in the medical record as it needs to go everywhere with him/her. She said usually she would scan the original into the electronic medical record and put several copies in the paper medical record. She said that way, when they are sent to the hospital, copies are easily accessible to provide to the ambulance drivers (EMTs) because without the form indicating DNR, the EMT's would provide CPR if needed. During an interview on [DATE] at 10:38 A.M., the DON said there should be a copy of the MOLST in the medical record. She said the EMTs would do CPR without a valid MOLST if they were transporting the resident and he/she went into cardiac arrest. Additionally, she said there should be a physician's progress note indicating the discussion. She said the Social Worker re-did the MOLST on Tuesday and the physician is coming in today to review it and write the orders. Review of a progress note written on [DATE] by Social Worker #3 indicated when Resident #106 was admitted to the facility there was no MOLST, but the hospital discharge summary indicated DNR/DNI. The facility was unable to provide a copy of the MOLST indicating his/her wishes for DNR/DNI status, a progress note indicating the discussion had occurred, or confirmation the order entered into the medical record on [DATE] was a valid order based on a valid MOLST.

Based on observation, record review, and staff interview, the facility failed to ensure for one Resident (#35) with a gastrostomy tube, of a total sample of 25 residents, that medications were administered in accordance with the physician's order and Professional Standards of Practice. Specifically, the facility failed to ensure Nurse #3 followed the physician's order when administering each of the Resident's medications via the gastrostomy tube (GT). Findings include: Review of the [NAME] Skill Checklist for Taylor's Clinical Nursing Skills. A Nursing Process Approach, 5th Edition, Skill 5-2 Administering Medications via a Gastric Tube, the following standard included but was not limited to the following: 10. Prepare medication. Pills: Using a pill crusher, crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup, for future comparison of information. During an interview on 9/24/24 at 9:29 A.M., the surveyor observed Nurse #3 preparing and administering medications to Resident #35. Nurse #3 said that all of the Resident's GT medications were to be crushed and administered via the GT in warm water. On 9/24/24 at 9:30 A.M., the surveyor observed Nurse #3 pouring each of the Resident's morning medications, which included the following: - Lasix (diuretic) 20 milligrams (mg) VGT (via GT) in the AM - Aspirin 81 mg VGT in AM -Docusate sodium (stool softener) 100 mg give 2 caps by mouth (sic) in the AM -Fluoxetine Hcl (hydrochloride) (antidepressant) 60 mg VGT once daily -Metoprolol (antihypertensive) 25 mg 0.5 tab VGT two times a day -Multivitamin with minerals 1 VGT once daily -Vitamin D3 25 micrograms (mcg) VGT daily During the administration of the medications, the surveyor observed Nurse #3 place all the above medications in a small plastic crushing bag, crush the medications with a pill crusher, place all of the powdered medications in a plastic medication cup, and took them to the Resident's bedside. Nurse #3 then added 5 ml of warm water to the cup of multiple crushed medications, mixed the medications in the water, administered all the medications together via the GT, and flushed the tube with an additional 5 ml of water. Review of the Medication Administration Record (MAR) indicated the physician's order for administering the Resident's GT medications as follows: -Mix each medication with 5 milliliters (ml) of water and mix each medication separately During an interview on 9/24/24 at 9:35 A.M., Nurse #3 said she failed to follow the physician's order which indicated to mix and administer each medication separately in 5 ml of water. During an interview on 9/25/24 at 8:00 A.M., the Director of Nursing (DON) said that Nurse #3 should have followed the physician's order to prepare each GT medication separately in 5 ml of water, and not mix and administer them together via the GT.

Based on record review and interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments were completed for one Resident (#106), out of a total sample of 25 residents. Specifically, the facility failed for Resident #106, to accurately code the use of anticoagulant (blood thinner to prevent blood clots) and antiplatelet (stops platelets from clumping together and forming blood clots) medications on 11 out of 11 MDS assessments reviewed. Findings include: Review of the facility's policy titled Resident Assessment Instrument, dated September 2021, indicated but was not limited to the following: -This assessment will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. -Completion of the MDS: The assessment must include at least the following: N: Medications. -The assessment will accurately reflect the resident's status. Resident #106 was admitted to the facility in February 2023 with diagnoses which included myocardial infarction, heart disease, and Parkinson's disease. Review of the most recent MDS assessment for Resident #106 indicated he/she had been taking anticoagulant medication. Review of the Physician's Orders indicated Resident #106 was not taking an anticoagulant. Further review of the Physician's Orders indicated the following: -Clopidogrel Bisulfate 75 milligrams (mg) (Plavix- antiplatelet) give one tablet by mouth one time a day (2/14/23) Further review of the MDS assessments indicated Resident #106 was: -08/18/23, taking an anticoagulant. -11/15/23, taking an anticoagulant and not taking an antiplatelet. -11/21/23, not taking an antiplatelet. -12/03/23, taking an anticoagulant and not taking an antiplatelet. -01/25/24, taking an anticoagulant and not taking an antiplatelet. -02/10/24, taking an anticoagulant and not taking an antiplatelet. -05/11/24, taking an anticoagulant and not taking an antiplatelet. -06/01/24, taking an anticoagulant and not taking an antiplatelet. -06/12/24, taking an anticoagulant and not taking an antiplatelet. -06/26/24, taking an anticoagulant and not taking an antiplatelet. -08/10/24, taking an anticoagulant and not taking an antiplatelet. During an interview on 9/26/24 at 8:37 A.M., the MDS Nurse said the MDSs are wrong. She said Resident #106 is on Plavix, which is an antiplatelet, and has never been on an anticoagulant. She said all the MDSs would need to be modified. During an interview on 9/26/24 at 10:45 A.M., the Director of Nurses (DON) said she had already spoken to the MDS Nurse and all the MDSs are wrong and would need to be modified as Resident #106 is not on an anticoagulant and only on an antiplatelet.

Based on record review, review of the rehab consultant's contract and policy, review of the American Physical Therapy Association (APTA) guidelines, review of Massachusetts law, and interviews, the facility failed to provide skilled physical therapy services in accordance with professional standards when the physical therapist is supervising the physical therapist assistant from an offsite setting and when providing telehealth physical therapy. In addition, based on observations, record review, interview, and policy review, the facility failed to implement their falls policy after Resident #107 fell . Specifically, the facility failed to: 1. Provide regularly scheduled, documented collaboration between the physical therapist and the physical therapy assistant regarding patient care; 2. For Residents #91, #17, and #117, ensure the the physical therapist performed at least a monthly onsite re-examination of the Residents and failed to include the required information and consent for telehealth visit for the discharge assessment; and 3. For Resident #107, follow their policy and document a fall occurred, investigate the fall, complete an incident report with the required information, document, and monitor the injury to the right foot. Findings include: 1. Review of the facility's contract for rehabilitative services titled, Amended and Restated Therapy Services Agreement, signed 10/25/19, indicated but was not limited to the following: -Shall provide, in accordance with the patient's applicable plans of care, federal and state laws and regulations, and the terms and conditions of this agreement, the following services: -Physical therapy, occupational therapy, speech and language therapy and the management thereof, such management including, but not limited to, periodic written therapy related educational offers offerings to providers and to inpatient and outpatients, provided in accordance with the patient's applicable plans of care and the requirements of federal and/or state laws and regulations, and the terms of exhibit B attached hereto and incorporated herein. -Make therapy personnel available at the facility 7 days per week on an as needed basis. Shall assign individual therapy personnel to provide therapy services and schedule the times at which therapy services will be provided. Review of Massachusetts Board of Health Professionals, general law 259 CMR 5.00: Physical Therapist, dated 8/7/20, indicated but was not limited to the following: 5.02: Patient Care Management 1c. All components of clinical care, and their supporting documentation, are the sole responsibility of the physical therapist. 6. Perform reexaminations and document the findings when they change in the plan of care is needed, prior to any planned discharge, in response to changes in the patient's medical status. -Summarize patient status and document reason for discharge. Ensure safe and quality care at all times, and in those situations in which a physical therapy assistant provides patient care, serve as the supervising physical therapist. -Serve as the only supervisor of physical therapy assistants. -Determine the frequency and the amount of supervision of the physical therapy assistant by regularly consulting with the physical therapist assistant to discuss the needs of the patient and the needs of the physical therapy assistant and by utilizing the following factors: 10. Provide supervision to the physical therapy assistant including at a minimum: -On site reexamination of the patient. -On site review of the plan of care with appropriate revisions or termination. 5.03: assessment and documentation of physical therapy treatment program This documentation shall be contained in the patient's ongoing treatment notes or in a formal review of the plan of care (or reevaluation). If by formal review of the plan of care or re-evaluation), it must be completed in a particular work setting by a physical therapist of record within the following timeframes: -Outpatient, rehabilitation, home health, skilled nursing facility: At least every 30 days. 5:05: Code of Ethics, Guide for Professional Conduct and Standards of Practice for Physical Therapy (1) The following documents in their most recently approved form are adopted as the ethical standards of practice. -(a) Code of Ethics for physical therapists. The APTA code of ethics delineates the ethical obligations of all physical therapists. -(C) Guide for professional conduct. The APTA guide for professional conduct provides a framework by which physical therapists may determine the propriety of their conduct and is intended to guide the professional development of physical therapy students. (e) Standards of practice for physical therapy and criteria for standards of practice for physical therapy. The APTA standards for practice and criteria for standards of practice provide foundation for assessment of physical therapy practice. Review of the American Physical Therapy Association (APTA) guideline titled, Direction and Supervision of the Physical Therapy Assistant, dated 10/26/22, indicated but was not limited to the following: A. When supervising the physical therapist assistant in any off-site setting, the following requirements must be observed: 1. There must be regularly scheduled and documented collaboration with the physical therapy assistant regarding patients and clients, the frequency of which is determined by the needs of the patient or client and the needs of the physical therapy assistant. 2. In situations which a physical therapist assistant is involved in the care of a patient or client, a supervisory visit by the physical therapist: a. Shall be made upon the physical therapist assistants request for a reexamination, when a change in the management plan or plan a care is needed, prior to any plan conclusion of the episode of care, and in response to changes to the patient or client's medical status. b. Shall be made at least once a month, or a higher frequency when established by the physical therapist, in accordance with the needs of the patient client c. Shall include: i. Onsite reexamination of the patient or client. ii. Onsite review of the plan of care with appropriate revision and termination. Review of the facility's contracted rehab services policy titled Guidelines for Using Telehealth for Assessment and Documentation, undated, indicated but was not limited to the following: -Telehealth is a delivery model that uses an interactive telecommunications system for the purpose of providing health related services at a distance. It means audio and video equipment that permits a 2-way, real time communication between a licensed therapist and a patient assisted by a therapy assistant or nurse who is located at a distant site which is not in proximity of the therapist. -In the therapy documentation, it is required to document the following: a. patient consented to telehealth visit. b. start and end times of the session delivered via telehealth. c. who was present in the session (i.e., therapist, patient, and who else may have helped facilitate the session). d. that this session was completed via telehealth. e. the originating site (where the patient and assistant are) and the distant site (where the therapist is). During an interview on 6/29/23 at 5:40 P.M., the Rehabilitation Director said they have not had a physical therapist in the building since December 2022. She said if she needs a physical therapy evaluation, she has a pool of physical therapists she can call, they do the evaluations, re-evaluations, and discharges. She said it is not ideal, but she is making it work until they hire a physical therapist for the building. During an interview on 6/30/23 at 2:40 P.M., Rehab Staff #1 said he was a physical therapist assistant (PTA) who works full-time in the facility. He said they have not had a physical therapist in the building since December 2022. He said most of the evaluations, progress notes, and discharges are done by telehealth or by the physical therapist completing assessments off-site by reviewing his notes and talking to him or the rehab manager. The surveyor asked for clarification for when the physical therapist does an evaluation, updated plan of care (recertification signed by the physician for continued physical therapy services), or discharge summary (discontinuation of physical therapy services), the resident is seen in person or by telehealth at the time of evaluation? Rehab Staff #1 said no, they don't always see the resident when completing documentation, they review my daily notes and talk to me. He said the Rehab Director calls in a physical therapist to complete the assessments, he talks to the therapist doing the notes to give them information, but he doesn't meet with them regularly or have any documentation of regularly scheduled meetings to discuss the residents. He said he pretty much works alone in the building as the only physical therapy staff member since December. During an interview on 6/30/23 at 3:31 P.M., the Rehab Director said Rehab Staff #1 is correct, sometimes the off-site physical therapist does recertification and discharge notes without doing the telehealth visit. She said they will get updated information from Rehab Staff #1 or her, and they have access to Rehab Staff #1's daily notes. She said by reading the current notes, she can't tell what documentation was completed via telehealth or in person and can't tell if the resident consented to a telehealth visit because they have not been documenting that information in the notes. She said she can't identify which documentation was completed by the therapist reviewing the physical therapy assistants notes and/or talking to him without seeing the resident. The surveyor requested a random sample of physical evaluation, Plan of Care and discharge summaries for review. During a telephonic interview on 7/5/23 at 11:56 A.M., Rehab Staff #2 (physical therapist) said she has been helping the facility for the past two months to provide physical therapy services. The Rehab Director will call her if she needs an evaluation done, updated plan of care, or discharge assessments. She said she has never been on-site at the facility, all physical therapy assessments have been done via telehealth, and/or by chart review and/or speaking with Rehab Director or Rehab Staff #1. She said she does not always see the residents when completing the assessments, but that the goal is to see them via telehealth. She said she does not include in her documentation how the resident assessment was performed (such as by telehealth, in person or by documentation review), and she did not document the resident consented to the telehealth visit. The surveyor reviewed her daily interaction forms (time sheets) dated, 6/7/23, 6/10/23, 6/11/23, 6/13/23, and 6/16/23, which indicated a total of 450 minutes of documentation time with no resident billing for assessments. Rehab Staff #2 said she was billing the facility for documentation, but she does not have a breakdown of what documentation was performed on those dates or if any specific residents were seen via telehealth. She feels she has adequate communication with Rehab Staff #1 but does not have any documentation of collaboration discussing specific residents or direct observations of him providing patient care. She said she feels Rehab Staff #1 has adequate skill set based on how long he has been a licensed physical therapy assistant and what she can see of him during a telehealth visit. During an interview on 07/03/23 at 8:16 A.M., the Administrator said he has requested a physical therapist to be in the building but has been told by the facility's contracted Rehab Company they do not have one and it is currently difficult to employ them. He said he is aware that the physical therapy assistant requires some level of supervision, he is not sure if the current supervision is adequate without having a physical therapist in the building on a regular basis. He said he will have to increase his oversight of the rehab department. In addition, he said the facility does not have a telehealth policy, they rely on the contracted rehab company's telehealth policy, which he is aware they are documenting the resident's consent to telehealth visits or the other requirements for telehealth. During a telephonic interview on 7/5/23 at 1:50 P.M., Massachusetts Board of Health Staff Member #1 said, there are no current waivers in place and Physical therapists must follow the outlined requirements listed in rules titled 259 CMR section 5.00 to provide onsite visits and oversight of physical therapy assistant. 2A. Review of Resident #91's Physical Therapy notes indicated the evaluation was completed by a physical therapist on 1/4/23, a physical therapy assistant progress note completed by Rehab Staff #1 on 3/24/23, and discharge summary completed by Rehab Staff #2, a physical therapist (PT) on 6/16/23. There were no PT progress/updated plan of care notes completed from 1/4/23 to 6/16/23 when the discharge summary was completed via telehealth. During an interview on 7/03/23 at 8:56 A.M., the Rehab Director reviewed Resident #91's physical therapy notes and said it appears the Resident did see a physical therapist since the start of care 1/4/23. She said the discharge summary was done by Rehab Staff #2 via telehealth but she can't confirm the resident was actually seen by telehealth or that the therapist just did the discharge summary looking at the PTA's notes; there is no documentation. Review of the Daily Interaction Form (timesheet), dated 6/16/23, indicated Rehab Staff #2 billed the facility for 120 minutes for documentation, and there was no resident billing for evaluation or resident time. During an interview on 7/5/23 at 11:56 A.M., Rehab Staff #2 said she can't recall if she did a telehealth heath visit with Resident #91 on 6/16/23 or she just did it by notes and talking to Rehab Staff #1. B. Review of Resident #17's physical therapy notes indicated the physical therapy evaluation was completed on 5/3/23, an updated plan of care was dated 5/31/23, but completed 7/3/23 by Rehab Staff #2. A second updated Plan of Care was dated 6/28/23, and it was also signed by Rehab Staff #2 on 7/3/23. During a telephonic interview on 7/5/23 at 11:56 A.M., Rehab Staff #2 said she completed Resident #17's two Updated Plan of Care assessments by reviewing Rehab Staff #21's notes and did not see the Resident #17 onsite or via telehealth. C. Review of Resident #117's physical therapy notes indicated the physical therapy evaluation was completed on 12/20/22, updated care plan was dated 1/17/23, additional plans of care updates were dated 2/14/23, 3/14/23, 4/11/23, and 5/9/23, all of which were completed by Rehab Staff #2 and all dated completed on 7/3/23. During an interview on 7/5/23 at 4:00 P.M., Rehab Staff #2 said she completed documentation for a few updated plans of care on 7/3/23 but she couldn't remember the resident's name. She said they were completed via chart review and she did not see the resident. During a telephonic interview on 7/5/23 at 4:14 P.M., the [NAME] President for the Contracted Rehab company said, after reviewing Resident #91, #17 and #117's physical therapy notes, the residents were not seen onsite for updated physical therapy assessments over their course of physical therapy. In addition, she said she can't confirm Resident #91's discharge summary was completed via telehealth because it wasn't documented, and Resident #17 and #117's plan of care assessments should have been completed monthly and not have all been completed on 7/3/23. She said she had no explanation for how those completed plan of care assessments could have all been completed on 7/3/23, especially if they were supposed to be done via telehealth. 3. Review of the facility's policies titled Accidents and Incidents-Investigating and Reporting, last revised 11/2017, and Assessing Falls and Their Causes, last revised 11/2018, included but was not limited to: -All accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator -The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to the hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. After a fall: - If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. - Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or a condition change, nursing staff will notify the practitioner routinely (i.e., by fax or by phone the next office day). -After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. -Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. Resident #107 was admitted to the facility in March 2021 with diagnoses which included Huntington's disease (progressive neurological disease). Review of the MDS assessment, dated 6/10/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the Resident was cognitively intact. On 6/29/23 at 2:25 P.M., the surveyor observed Resident #107 sitting in the day room on M2 Unit in his/her wheelchair, with no socks on and the right great toe was swollen and red with an open abrasion. During an interview on 06/29/23 at 02:30 P.M., Counselor #1 said Resident #107 had a fall the other day and did not tell anyone right away. She said the toe does not look good. During an interview on 6/29/23 at 5:30 P.M., Nurse #7 said Resident #107 self-reported the fall to the nurses yesterday. Nurse #7 said reviewing Resident's medical record, there is no nursing documentation about the fall, no incident report, no pain assessment, or skin assessment. Nurse #7 said Nurses #10 and #11 did write in the nurse's note that Resident #107 reported the right great toe was painful, red and swollen, but nothing about the fall. Nurse #7 said if a resident has a fall, the falls policy is you notify the doctor, start an incident report, do skin and pain assessments, perform neuro checks if they hit their head or it is unwitnessed, and you write nurse's notes to monitor the resident. During an interview on 6/29/23 at 5:45 P.M., the Rehabilitation Manager said she was aware of Resident #107's fall and she wrote a witness statement after the Resident informed her of the fall and the injury yesterday. She recommended the Resident use the wheelchair, so he/she does not walk on the right foot until the doctor looked at it. Review of a witness statement, dated 6/28/23 with time recorded of 2:35 P.M., and signed by the Rehab Director, indicated the following: - I received a call from Social Worker #2 asking for a wheelchair for Resident #107. -Resident #107 informed the Rehab Director he/she had hurt his/her foot. The right foot was bruised in multiple places, primarily on the big toe and the second toe. There was also a bruise in the top middle of the foot and the foot appeared swollen and discolored. -Resident #107 stated he/she had fallen the prior day around 10:30 A.M., in the activity room and did not tell anyone. -Rehab Director informed Nurse #11 and sent a message to the Director of Nursing to see Resident #107 immediately. During an interview with Resident #107 (with the Rehab Director present) on 6/29/23 at 6:00 P.M., Resident #107 said he/she fell really hard in the day room on Tuesday (6/26/23), and he/she didn't tell anyone until his/her toe started to swell. Resident #107 said he/she told Nurses #10 and #11, and they cleaned and bandaged his/her right big toe. Resident #107 said the toe really hurts bad now and he/she can't sleep at night. Resident #107 said he/she thinks it is broken; it hurts really bad. Review of the Nurses' Notes, dated 6/22/23 through 6/28/23, indicated the following: -On 6/28/23 at 4:15 P.M, Resident reported that his/her right foot was red and swollen and the big toe had a scrape and some serious drainage. The physician was notified and new orders to apply to the red swollen right foot/ toe abrasion normal saline wash, bacitracin and protective dressing, change daily. The physician will be in to see the resident tomorrow. -On 6/28/23 at 10:35 P.M., Resident complained of pain in the right great toe. Area inflamed and reddened Cleanse with normal saline, bacitracin ointment applied followed by a protective dressing. Tylenol was given for pain with some relief. The Resident was encouraged to stay off the foot and keep it elevated as much as possible. The Resident used a wheelchair to mobilize. Will continue to monitor. Further review of Resident #107's medical record indicated there was no further documentation of the fall, skin or pain assessments, incident report, or neurological checks. During an interview on 6/29/23 at 6:10 P.M., the Director of Nurses (DON) said she was aware Resident #107's fall, and she was concerned the toe was red and inflamed. The surveyor informed the DON there was no documentation about the fall in the medical record. The DON said she had started an investigation into the fall. The surveyor requested a copy of the investigation. During an interview on 6/29/23 at 6:25 P.M., the DON said there was no incident report completed, which would have triggered the falls investigation. She said the only documentation she could find was the Rehab Director's statement about the fall. She said the nurses were supposed to put statements in her box and they did not.

Based on observation and interview, the facility failed to ensure that dignity was provided during the dining experience for seven Residents (#9, #33, #27, #37, #51, #76 and #77), out of a total sample of 29 residents. Specifically, the facility failed to ensure that: 1. For Residents #9, #33, #37, #51, #76 and #77, staff did not provide a towel as a clothing protector while eating; 2. For Residents #9, #27, #33, #46, #51, #77, staff delivered meals to all residents seated at the table simultaneously, resulting in residents waiting an extended period of time to receive their meal while watching their tablemates eat; and 3. For Resident #51, did not stand over the Resident while feeding him/her in the dining room. Findings include: 1. On 6/27/23 at 11:50 A.M. and 6/28/23 at 11:44 A.M., the surveyor observed six Residents (#9, #33, #37, #51, #76 and #77) of seven Residents in the B-2 Unit dining room with white towels draped around their necks as clothing protectors. 2. On 6/28/23 at 11:44 A.M., the surveyor observed seven residents in the B-2 Unit dining room: two Residents (#76 and #33) were seated at one table, five Residents (#27, #37, #46, #51 and #77) were seated at another table, and one Resident (#9) was seated alone with an overbed table in front of him/her. -On 6/28/23 at 12:12 P.M., the surveyor observed Certified Nursing Assistant (CNA) #2 deliver a lunch tray to Resident #37 who was seated at a table with four other Residents (#77, #46, #27 and #51). The residents at the table sat idly and watched Resident #37 eat his/her meal. -On 6/28/23 at 12:15 P.M., Resident #46 received his/her lunch tray and began to eat. Three other residents at the table sat idly and watched Resident #37 eat his/her meal. -On 6/28/23 at 12:16 P.M., Resident #76 received his/her lunch tray and began to eat. One other resident at the table (Resident #33) sat idly and watched Resident #76 eat his/her meal. -On 6/28/23 at 12:22 P.M., Resident #77 received his/her lunch tray. Two other residents seated at the table sat idly and watched Resident #77 eat his/her meal. -On 6/28/23 at 2:25 P.M., Resident #9 received his/her lunch tray. Three other residents in the dining room sat idly while Resident #77 ate his/her meal. -On 6/28/23 at 12:29 P.M., Resident #33 received his/her lunch tray, 13 minutes after his/her tablemate (Resident #76) received his/her lunch tray. -On 6/28/23 at 12:33 P.M., Resident #27 received his/her lunch tray, 21 minutes after the first lunch tray was delivered to Resident #37. Resident #51 sat idly while watching Resident #27 eat his/her meal. -On 6/28/23 at 12:42 P.M., Resident #51 received his/her lunch tray, 30 minutes after Resident #37 received his/her lunch tray. 3. On 6/29/23 at 1:43 P.M. in the B-2 Unit dining room, the surveyor observed CNA #3 standing over Resident #51 while feeding him/her their meal. The CNA remained standing alongside the Resident feeding him/her for the duration of the meal. During an interview on 6/29/23 at 1:45 P.M., CNA #3 said she was an agency nurse and had never worked on the unit before. The surveyor asked her if she routinely stood over Residents while feeding them or did she sit alongside them. CNA #3 did not respond to they surveyor and remained standing. During an interview on 6/30/23 at 11:45 A.M., Nurse #5 said residents should be provided their meals timely, appropriate clothing protectors should be used and not bathing towels, and staff should not stand up while feeding residents their meals.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was assessed by the nursing to be at an increased risk for falls, required the use of a safety alarm while in bed and when he/she is in his/her wheelchair, the Facility failed to ensure he/she was provided with the necessary assistive device to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury, when on 1/19/23, Resident #1 fell out of his/her wheelchair, sustained a laceration to the left side of his/her face, near the eyebrow, that required sutures to repair. It was later determined that Resident #1's safety alarm was not in place at the time of the fall. Findings include: Review of the Facility Policy titled, Safety and Supervision of Residents, dated as last revised, 4/2018, indicated that the Facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The Policy further indicated the following; -the individualized, resident centered approach to safety address safety and accidents hazards for individual residents; -the interdisciplinary care team shall target interventions obtained from assessments and observations to identify any specific accident hazards or risk for individual residents; -implementing interventions to reduce accident risks and hazards in the environment, including adequate supervision and assistive devices; and -ensuring that interventions are implemented correctly and consistently. Resident #1 was admitted to the Facility in November 2021, diagnoses included left sided hemiparesis (weakness or paralysis to one side of the body) secondary to an old cerebral vascular accident (stroke), chronic obstructive pulmonary disease, vascular dementia, bulimia nervosa (eating disorder) and anxiety. Review of Resident #1's Health Care Proxy, dated 3/24/22, indicated his/her Health Care Agent was responsible for his/her healthcare decisions. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she scored a five on his/her brief interview for mental status (BIMS), indicating he/she was severely impaired cognition. Review of Resident #1's Physician's Order, dated 7/14/22, indicated to apply a motion sensor alarm to his/her wheelchair when out of bed. Review of Resident #1's Care Plan titled, Fall Risk, dated as last revised 12/17/22, indicated intervention for safety included a fall prevention monitor (alarm) in place on his/her wheelchair when sitting in it, and a bed alarm in place when in bed. Review of Resident # 1's Incident Report Form, dated 1/19/23, indicated that while the Wound Physician a Nurse were standing at the Nurses station, the Activity Technician/Mental Health Counselor (MHC) reported to them that Resident #1 had been found outside of the activity room on the floor. The Report also indicated that Resident #1 said he/she was trying to stand and that he/she had just fallen to the floor. The section of the Report describing predisposing environmental factors was left blank related to safety alarms sounding and or functioning. Review of the Hospital Discharge Summary, dated 1/19/23, indicated Resident #1 was seen the Emergency Department after a fall at the facility in which his/her head struck the floor. The Summary indicated he/she was evaluated for the potential of a closed head injury related to complaints of a headache. The Summary indicated Resident #1 sustained a facial laceration above his/her left eye, which required sutures to repair. The Summary indicated to change the bandage daily and that Resident #1's sutures would need to be removed in seven days. Review of the Nurse Progress Note, dated 1/19/23, indicated Resident #1 returned to the facility at 8:42 P.M., with stitches above his/her left eye. During an interview on 3/01/23 at 11:58 A.M., the Activity Assistant/Mental Health Counselor (MHC) said on 1/19/23, he was at the nursing station getting some information in regard to caring for another resident from the Director of Rehabilitation (DOR) and Nurse #1, when he said he heard a bang. The MHC said the three of them ran over to check on Resident#1 and saw he/she had a laceration to his/her face. The MHC said he was not sure if Resident #1 had an alarm on his/her wheelchair at the time of the fall but, said he thought he/she is supposed to have an alarm. The MHC said he does not remember hearing an alarm going off or shutting an alarm off when he reached Resident #1. During an interview on 2/15/23 at 1:43 P.M., Nurse #1 said she does not remember shutting off a chair alarm when she got to Resident #1. During an interview on 2/28/23 at 12:51 P.M., Certified Nurse Aide (CNA) #1, said Resident #1 is very confused at times and often slides out of his/her bed. CNA #1 said, as far as she knew, Resident #1 did not have alarms when in bed or when in his/her wheelchair and said he/she screams to get our attention. During an interview on 3/01/23 at 1:52 P.M., Nurse #3 said she thinks Resident #1 is always supposed to have a alarm in place, both to his/her bed and wheelchair. During an interview on 2/15/23 at 4:30 P.M., the Director of Nurses (DON) said she was unaware if Resident #1 had a wheelchair alarm in place on the day of the incident. The DON said it was the Facility's expectation to follow each Resident's Care Plan and if an intervention is no longer being utilized then to discontinue the intervention with the approval of a Physician.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from verbal and physical abuse by a staff member. On 02/04/2022, Nurse #1 witnessed Activity Technician (AT) #1 get into a verbal altercation with Resident #1, Nurse #1 also witnessed AT #1 using both of his hands, forcefully push Resident #1. Resident #1 landed on his/her back and required transport to the Hospital Emergency Department for evaluation. Resident #1 returned to the Facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Facility Policy titled, Abuse Prevention, Prohibition, and Screening, dated as revised 12/2017, indicated that all residents have the right to be free from all forms of abuse and to be treated with respect and dignity. The Policy's definition of Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt, pain, or mental anguish. -Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteer staff, family members, friends, or other individuals; -Staff will maintain a manner of courtesy and respect towards residents; and -Staff will refrain from all actions that could be considered abuse. Resident #1 was admitted to the Facility in September 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 1/15/22, indicated he/she with a Brief Interview for Mental Status (BIMS) score of 13, indicative of being cognitively intact. Review of the report submitted by the Facility via the Health Care Facility Reporting Systems (HCFRS), dated as submitted 2/04/22, indicated that Resident # 1 reported that he/she was pushed to the ground by AT #1 over requesting a second cup of coffee. The Report indicated Resident #1 was assessed by nursing staff and was sent to the Hospital Emergency Department for evaluation. Review of the Police Department Incident Report, dated 2/04/22, indicated that an altercation between Resident #1 and AT #1 was witnessed by a staff member, Nurse #1, and the facility was to perform an internal investigation. Review of the final report submitted by the Facility via the HCFRS, dated 2/08/22, indicated the incident was witnessed by a staff member, Nurse #1, and AT #1 was terminated as of 2/08/22. Review of Facility's Incident Report, dated 2/04/22, indicated that at approximately 8:05 A.M., Resident #1 was found on the floor in his/her bedroom, by the Assistant Director of Nurses (ADON), laying flat on his/her back complaining of both right arm/wrist pain and back pain. The Report also indicated; Resident #1 said he/she requested a second cup of coffee from Activity Technician (AT) #1. Resident #1 reported that AT #1 ignored his/her request and he/she then asked AT #1 again. Resident #1 said that was when AT #1 came into his/her room and began yelling at him/her. The Report indicated Resident #1 reported that AT #1 was standing nose to nose to him/her, and that he/she pushed at AT #! to get him to back away. The Report indicated Resident #1 said that AT #1 shoved him/her to the ground. Review of Hospital Emergency Department Discharge Summary, dated 2/04/22, indicated Resident #1 endured a closed fracture of the distal end of his/her right radius (large bone in forearm), a displaced fracture of styloid process of the right ulna (one of two bones that make up the forearm), and a closed compression fracture (bone in spine weakens or crumbles) lumbar spine (lower back region of spinal column)at level one. Review of Nurse # 1's written witness statement, dated 2/04/22, indicated she heard a verbal argument escalating between Resident #1 and AT #1 in the hallway of the B2 unit. The Statement indicated AT #1 escorted Resident #1 back to his/her room and the argument continued. The Statement indicated Nurse #1 heard Resident #1 ask AT #1 to back up and that Resident #1 told her he/she has pushed AT #1, causing AT #1 to take two steps back. The Statement indicated she (Nurse #1) heard AT #1 chuckle and then witnessed as AT #1 forcefully pushed Resident #1 with both of his hands causing Resident #1 fall to the floor landing on his/her back. The Statement indicated Resident #1's right wrist was visibly deformed. During an interview on 2/23/22 at 9:45 A.M., Resident #1 said that on 2/04/22 around 8:00 A.M., Activity Technician (AT) #1 was pushing the coffee cart around his/her unit. Resident #1 said he/she asked AT#1 for a second cup of coffee and said AT#1 ignored his/her request two times. Resident #1 said he/she said to the AT#1, you do not have to ignore me. Resident #1 then said, AT#1 came to the doorway of his/her room and positioned himself nose to nose with him/her (Resident #1). Resident #1 said he/she placed his/her right hand up between their upper bodies and pushed against AT#1 to get him to back away from him/her. Resident #1 said, AT#1 then hauled off and pushed me back with two hands. Resident #1 said his/her feet left the ground and he/she landed hard on his/her back. Resident #1 said he/she had the wind taken out of him/her, hit his/her head, hurt his/her back, and could tell that his/her right arm was broken because of the pain and the position it was in after the fall. During an interview on 2/24/22 at 3:53 P.M., the Interim Assistant Director of Nurses (ADN) said she was aware of a verbal altercation that had occurred between AT #1 and another staff member in the past. The ADON said she had spoken to AT #1 regarding his verbally aggressive behavior. The ADON said if AT #1 was unhappy about something then the entire staff would be aware of it, as he displayed it in his behavior. During an interview on 2/24/22 at 12:55 P.M., AT #2 said he had worked with AT #1 only once a week. AT #2 said AT #1 could be short tempered at times. AT #2 said the unit Resident #1 resides on is a Traumatic Brain Injury (TBI) unit and said the amount of resident behaviors is great. AT#2 said, Resident #1 is pleasant, kind and rarely gives anyone trouble. AT #2 said Resident #1 can be forgetful and ask the same questions or tell the same stories repeatedly, usually based around his/her finances and coffee. During an interview on 2/24/22 at 2:45 P.M., the Assistant Neurological Program Director (ANPD) said she had given two verbal warnings and one written warning to AT #1, all involving verbal altercations with staff. Review of the Facility's Progressive Corrective Action Report, dated 2/08/22, indicated that Activity Technician #1 was witnessed engaging in a verbal and physical altercation with Resident #1. The Report indicated AT #1, by his own admission, pushed Resident #1's hands away and said Resident #1 stumbled to the floor. The Report indicated Resident #1's fall resulted in harm and medical intervention. The Report also indicated that AT #1's actions resulted in two Group I infractions. The Report defined Group I infractions as a serious violation of company policy and procedure or employee misconduct that may justify immediate discharge without regard to the employee's length of service or prior conduct. The Infractions included; a) Any Malicious conduct or abuse-physical, verbal, emotional-or neglect of a resident or co-worker, and b) Blatant disregard of the residents safety or failure to report a resident accident or injury promptly. Review of the Police Department Incident Report, dated 2/24/22, indicated that on 2/18/22, Resident #1 had decided to press assault and battery charges against AT #1, and the Police have requested that AT #1 be summonsed to court for one count of assault and battery on a person [AGE] years or older, causing serious bodily injury.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) the Facility failed to provide required assistive devices that were in good working condition when, on 10/28/20, a staff member placed a smoking apron on Resident #1 that had a tear in it, Resident #1's lit cigarette fell through the tear, and Resident #1 sustained a 0.2 centimeter (cm) by 0.2 cm burn to his/her left upper chest area which required a topical treatment to be applied twice daily, until 11/22/20, when the area was assessed as being healed. Findings include: The Facility Smoking Policy, dated as revised November 2017, indicated that the Facility shall establish and maintain safe resident smoking practices. The Policy indicated any smoking related privileges, restrictions and concerns shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues. Resident #1's most recent Quarterly Minimum Data Set Assessment, dated 10/10/20, indicated that his/her cognitive patterns were moderately impaired. Resident #1's Smoking Evaluation, dated 10/8/20, indicated Resident #1 was safe to smoke with supervision and protective smoking equipment. Review of Resident #1's care plan related to his/her wish to smoke and assessment as a supervised smoker, dated as initiated 7/25/18, indicated the addition of a safety intervention, dated 1/8/20, that Resident #1 to wear a smoking apron at all times while smoking. During an interview at 11:45 A.M. on 11/24/20, Resident #1 said that he/she burnt his/her chest while smoking. Resident #1 said that he/she was wearing a bib (smoking apron) and said he/she still got burnt. Resident #1 said that he/she did not really know how the burn occurred. During an interview at 1:25 P.M. on 12/2/20, Mental Health Counselor (MHC) #3 said that he assisted Resident #1 with smoking on 10/28/20. MHC #3 said that he placed a smoking apron on Resident #1 and assisted him/her with lighting the cigarette. MHC #3 said that a few moments later, while he was lighting another resident's cigarette, he saw that Resident #1 dropped the cigarette and the cigarette fell through the tear in the top of Resident #1's smoking apron and burned his/her shirt. MHC #3 said that Resident #1 did not seem to realize that the cigarette had fallen and MHC #3 said he ran over and pulled the cigarette off of Resident #3's chest. MHC #3 said that he could see a pink area on the skin on Resident #1's chest and he immediately brought Resident #1 to the nurse. Review of the Incident Note, dated 10/28/20 at 3:30 P.M., indicated that Resident #1 was assessed following an incident in which a cigarette fell through a tear in a smoking apron and Resident #1's sustained a burn. The Note indicated that Resident #1's physician was notified and ordered [MEDICATION NAME] ointment to be applied to the area and nursing to assess for pain every shift. The Facility Internal Investigation indicated the burn measured 0.2 by 0.2 centimeters. Review of Resident #1's Treatment Administration Records (TAR), dated 10/28/20 through 11/22/20, indicated nursing to apply [MEDICATION NAME] to left upper chest area burn twice daily for prevention and to monitor area. The TAR indicated the treatment was discontinued on 11/22/20, when the burn was assessed as being healed. Review of the Incident Note, dated 10/30/20 at 12:03 A.M., indicated that the burn on Resident #1's chest had an intact blister and Resident #1 denied pain and treatment was applied as ordered. Review of the Incident Note, dated 10/30/20 at 3:33 P.M., indicated that Resident #1 had an intact, fluid filled, raised area on his/her chest, surrounded by pink tissue without warmth. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 10/31/20 at 4:37 P.M., indicated that the fluid filled areas on Resident #1's chest area remained intact and the surrounding tissue was pink. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 11/1/20 at 10:05 P.M., indicated that burn on Resident #1's chest area was flattening and without drainage or sign of infection. The Note indicated Resident #1 denied pain and was monitored. Review of the Nurses Note, dated 11/2/20 at 4:14 P.M., indicated that the area on Resident #1's chest was dark pink and slightly moist with a scant amount of serous drainage. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 11/3/20 at 3:15 P.M., indicated that the area on Resident #1's chest remained pink and moist with intact, fluid filled areas and a scant amount of serous drainage. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 11/4/20 at 3:37 P.M., indicated that the area on Resident #1's chest was pink and with intact fluid filled sacs and a scant amount of serous drainage. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 11/5/20 at 3:45 P.M., indicated that the area on Resident #1's chest was pink and with few, intact, fluid filled sacs and a scant amount of serous drainage. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 11/6/20 at 3:41 P.M., indicated that the area on Resident #1's chest was pink and with few, intact, fluid filled sacs and a scant amount of serous drainage. The Note indicated Resident #1 denied pain and treatment was applied as ordered. Review of the Nurses Note, dated 11/7/20 at 4:24 P.M., indicated that the area on Resident #1's chest was dry and forming a scab. The Note indicated Resident #1 denied pain and treatment was applied as ordered. During an interview at 2:00 P.M. on 11/24/20, the Director of Nurses said she assessed Resident #1 after he/she sustained a burn on 10/28/20. The Director of Nurses described the area as flat and red and said that Resident #1 denied pain and seemed unaware that he/she was burned. On 11/24/20, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Resident #1 was reassessed for smoking safety on 10/29/20 and his/her care plan reviewed. B) Resident #1's burn was monitored until 11/22/20 when it was determined healed and monitoring discontinued. C) MHC #3 was educated on 10/29/20 about the importance of inspecting smoking aprons prior to use and not allowing a resident to use a worn or damaged smoking apron. D) Central supply inventoried all of the Facility aprons on 10/29/20 and, on 11/1/20 fifteen new aprons were purchased and replaced all aprons showing wear and tear. E) An audit tool was developed on 11/3/20 for the mental health counselors to document the condition of each resident's smoking apron daily and to ensure smoking aprons were stored hung up to avoid wear and tear at folds. E) On 11/18/20, all Mental Health Counselors were trained on the daily audit tool and the expectation that smoking aprons would be inspected by staff before being placed on a resident and never used if by a resident if worn or damaged. F) The Facility smoking procedure was updated to include a quarterly review of the entire inventory of smoking aprons by Activity staff to ensure an adequate number of smoking aprons in good condition. G) The Director of Nurses said that mental health counselor's completed daily audit tools were checked during nursing rounds, and the corrective action would be reviewed during the Quality Assurance meeting in December 2020. H) The Director of Nurses and/or her designee are responsible for overall compliance.

Based on records reviewed and interviews, for two of five sampled residents (Resident #4 and Resident #5), the Facility failed to prevent and protect Resident #4 and Resident #5 from being physically abused by Resident #3. - On 10/05/19, Resident #3 walked over to Resident #5, hit him/her in the face, and pushed him/her, causing him/her to fall to the floor. Resident #5's left eyebrow was bruised, swollen, and he/she reported buttocks pain. - On 10/06/19, Resident #3 threw a can of sardines at Resident #4 and hit him/her in the face with his/her fist. Findings include: The Facility's Level of Supervision Policy, dated (MONTH) (YEAR), indicated that five-minute safety checks are generally considered for residents who present moderate risk of harm to self or others and have demonstrated general stability in behavioral symptoms. The Facility's Abuse Policy, dated (MONTH) (YEAR), indicated residents have the right to be free from physical abuse. The Facility's Resident to Resident Altercation Policy, dated (MONTH) (YEAR), indicated staff will monitor residents for aggressive/inappropriate behaviors towards other residents and all altercations, including those that may represent resident-to-resident abuse. 1. Resident #3 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident #3's Behavioral Plan of Care (P[NAME]), dated 05/23/19, indicated he/she had the potential to display physical aggression due to his/her diagnosis. The Behavioral P[NAME] indicated staff interventions included five-minute safety checks and to position Resident #3 at least three arms-length (approximately five feet or greater) away from other residents. Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had mild cognitive impairment and had physical behavioral symptoms directed at others. Resident #5 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident #5's Falls Plan of Care, dated 01/25/19, indicated he/she was at risk for falls. Resident #5's Pain Plan of Care, dated 01/25/19, indicated he/she had an alteration of comfort related to [MEDICAL CONDITION]. Resident #5's Plan of Care, dated 08/09/19, indicated he/she had the potential to be a victim in situations due to his/her diagnosis. Resident #5's Quarterly MDS, dated [DATE], indicated he/she was cognitively intact, was able to make him/herself understood, and was able to understand others. The Facility's Investigation, dated 10/05/19, indicated that Resident #3 and Resident #5 were in the dining room at approximately 6:20 [NAME]M. The Investigation indicated Resident #5 said he/she had been wiping down tables when Resident #3 walked over to him/her, hit him/her in the face, and pushed him/her, causing him/her to fall to the floor. The Investigation indicated Resident #5's left eyebrow was bruised, swollen and he/she reported buttocks pain. Review of the Facility's Internal Investigation indicated there was no documentation to support whether or not staff had completed Resident #3 five minute safety checks around the time of the incident, how long Resident #5 and Resident #3 were left alone in the dining room unattended by staff and how the facility ensured Resident #3 remained three arms lengths away from other residents, for safety. Review of the Police Department's Incident Report, dated 10/06/19, indicated that at 7:53 [NAME]M. on 10/05/19, an officer was dispatched to the Facility in response to an altercation between two residents. The Report indicated that Resident #5 accidentally backed into Resident #3 and Resident #3 reacted by punching Resident #5 and striking him/her above the left eye. The Report also indicated that when Resident #3 punched Resident #5, it caused Resident #5 to fall down. The Report indicated Resident #5 had a swollen eye which appeared to be bruising. Resident #5's Nurse Progress Note, dated 10/05/19, indicated that at approximately 6:20 [NAME]M., Nurse #6 saw Resident #5 standing in the dining room crying. The Note indicated Resident #5 said that he/she (later identified as Resident #3) had punched him/her in face and he/she fell on to the floor, landing on his/her buttocks. The Note indicated Resident #5 had a bump and swelling on his/her left eyebrow. The Surveyor interviewed Nurse #6 at 4:00 P.M. on 10/21/19. Nurse #6 said she walked into the dining room and said she saw Resident #5 and Resident #3 to be the only two people in the dining room, and that Resident #5 was crying. Resident #5's Psychiatric Consult, dated 10/07/19, indicated Resident #5 reported another resident (later identified as Resident #3) grabbed his/her shoulder, struck his/her face, and pushed him/her. The Consult indicated Resident #5's left eye was positive for ecchymosis and [MEDICAL CONDITION]. Resident #5's Social Service Progress Note, dated 10/07/19, indicated that Resident #5 said he/she was in the dining room and a peer (later identified as Resident #3) came over to him/her, grabbed his/her shirt, punched him/her a few times on the left side of his/her face. The Note indicated Resident #5 said he/she tried to get Resident #3 to let go of him/her and that Resident #3 pushed him/her off, and he/she fell to the floor. The Surveyor interviewed the Social Worker (SW) at 1:15 P.M. on 10/22/19. The SW said she met with Resident #5 and confirmed the information written in the Social Service Progress Note, dated 10/07/19. The SW said Resident #5 reported pain in his/her buttocks, back of his/her head, face, and legs following the physical assault by Resident #3. The SW said she saw a bruise on the left side of Resident #5's face during their conversation. The Surveyor interviewed Resident #5 at 9:30 [NAME]M. on 10/21/19. Resident #5 said that a few weeks ago, Resident #3 hit him/her in the face, which cause his/her face to become black. Resident #5 said he/she was in pain because he/she was hit in the face and fell to the ground. 2. Resident #4 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Resident #4's Quarterly Minimum Data Set, dated dated [DATE], indicated he/she was cognitively intact. Resident #4's Plan of Care, dated 08/09/19, indicated he/she was at risk for victimization by others due to his/her behaviors. The Facility's Investigation, dated 10/06/19, indicated that Nurse #1 responded to yelling coming from Resident #3 and Resident #4's bedroom. The Investigation indicated that Resident #4 told staff that Resident #3 threw sardine at him/her and hit him/her in the face. Resident #3's Nurse Progress Note, dated 10/06/19, indicated Nurse #1 responded to yelling from Resident #3 and Resident #4's bedroom and Nurse #1 saw Resident #4 covered in oil. The Note indicated Resident #4 said Resident #3 threw a sardine (can)at him/her and hit him/her. The Surveyor interviewed Nurse #1 at 1:40 P.M. on 10/21/19. Nurse #1 said she was the first person to respond to Resident #4's yelling. Nurse #1 said she saw that Resident #4 had sardine oil on his/her body, bed sheets, and the floor and wall. Nurse #1 said Resident #4 said Resident #3 threw a can of sardines at him/her and she said Resident #4 was upset. Resident #4's Psychiatry Consult, dated 10/07/19, indicated Resident #4 said he/she asked his/her roommate (later identified as Resident #3) to close the bathroom door when using the bathroom. The Consult indicated Resident #4 said Resident #3 responded by throwing multiple objects at him/her and he/she said the incident left abrasions on his/her face and a bruise on his/her body. The Surveyor interviewed the Psychiatric Nurse Practitioner (NP) at 4:19 P.M. on 11/16/19. The Psychiatric NP said that when she met with Resident #4 on 10/07/19, he/she had a bandage on his/her forehead. The Psychiatric NP said Resident #3 and unidentified staff members said Resident #3 had a bruise and an abrasion on his/her forehead from the incident on 10/06/19. The Surveyor interviewed Resident #4 at 9:50 [NAME]M. on 10/21/19. Resident #4 said that his/her old roommate, Resident #3, hit him/her in the head with a can of sardines and also hit him/her in the head with his/her fist. The Surveyor interviewed the Administrator at 11:40 [NAME]M. on 10/22/19. The Administrator said that after the incident on 10/05/19, Resident #3 should have been placed on a one-to-one level of supervision, rather than the five-minute safety checks.

Based on observations, records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2 and Resident #3), despite previous incidents involving resident to resident altercation the locked behavioral unit, the facility failed to ensure adequate supervision was provided by staff to prevent additional resident-to-resident physical altercations, and maintain resident safety. -At approximately 11:13 A.M. on 06/13/19, staff witnessed Resident #1 hit Resident #2 in the right side of his/her face. Resident #2 had a bruise on his/her face at the time of the incident. -At approximately 12:45 P.M. on 06/13/19, Resident #1 got up from his/her bed, walk over to his/her roommate, Resident #3, and hit him/her in the face. Staff responded to Resident #1 and Resident #3's bedroom and saw the residents wrestling with each other, or words to that effect. Resident #3 had a superficial area on his/her lip with minor swelling. -At approximately 7:15 A.M. on 06/14/19, Resident #2 punched Resident #1 in the face while they were in the dining room. Resident #1, who had a fork in his/her hand, used the fork to retaliated against Resident #2, which left a four centimeter laceration on Resident #2's face. Findings include: The Facility's Policy, Resident to Resident Altercations, dated (MONTH) (YEAR), indicated that staff will monitor residents for aggressive and/or inappropriate behaviors towards other residents and all altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. The Facility's Policy, Accidents and Incidents - Investigating and Reporting, dated (MONTH) (YEAR), indicated all accidents or incidents involving residents, employees, etc., occurring on our premises shall be investigated and reported to the Administrator. Resident #1's medical record Face Sheet indicated he/she was admitted to the Facility in (MONTH) (YEAR); [DIAGNOSES REDACTED]. Resident #1's Plan of Care titled Unspecified Activities CP, dated as revised 5/23/19 , indicated he/she had the potential to display verbal and physical aggression, as well as sexually and socially inappropriate behaviors. The Plan of Care indicated staff should position Resident #1 at least three arms lengths away from other residents. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/08/19, indicated Resident #1 was cognitively intact and independent with activities of daily living. Resident #2's medical record Face Sheet indicated he/she was admitted to the Facility (MONTH) (YEAR); [DIAGNOSES REDACTED]. Resident #2 was responsible for making his/her own health care decisions. Resident #2's Quarterly MDS Assessment, dated 03/23/19, indicated he/she was cognitively intact and independently with activities of daily living. Resident #2's Plan of Care titled Unspecified Activities CP, dated as revised on 01/10/19, indicated he/she had a history of [REDACTED]. Resident #3's medical record Face Sheet indicated he/she was admitted to the Facility in (MONTH) (YEAR); [DIAGNOSES REDACTED]. Resident #3's Petition for Appointment of Guardian for an Incapacitated Person, dated 10/29/18, indicated he/she had a court appointed Guardian to admit him/her to a nursing Facility and treat him/her with antipsychotic medications in accordance with a treatment plan. Resident #3's Clinician's Affidavit as to Competency and Treatment, dated 03/29/19, indicated he/she was unable to make informed decisions due to Dementia and [MEDICAL CONDITION]. Resident #3's Quarterly MDS Assessment, dated 05/11/19, indicated he/she had severe cognitive impairment and required extensive assistance from one staff member for toileting, hygiene care, and dressing. Resident #3's Plan of Care titled Unspecified Activities CP, dated as last revised on 09/12/18, indicated he/she had [DIAGNOSES REDACTED]. 1. The Facility's Investigation, dated 06/13/19, indicated that at approximately 11:13 A.M. on 06/13/19, staff witnessed Resident #1 walk past Resident #2, who was sitting in the dining room, and he/she turned around and hit Resident #2 on the right side of his/her face. The Investigation indicated Resident #2 stood up from his/her chair after Resident #1 hit him/her and began having a [MEDICAL CONDITION]. The Investigation indicated Resident #1 was escorted back to his/her room for a low stimulus environment and placed on five-minute safety checks. Resident #2's Incident Report, dated 06/13/19, indicated Resident #2 had a bruise on his/her face at the time of the incident. Review of Resident #1's Nursing Progress Note, dated 06/13/19, indicated he/she punched a peer (later identified as Resident #2) in the face and staff responded by directing Resident #1 to his/her bedroom. The Note indicated Resident #1 left his/her bedroom and went into the hallway, but was told to return to his/her bedroom and he/she complied. Review of Resident #2's Nursing Progress Note, dated 06/13/19, indicated he/she was punched in the right side of his/her face by a peer (later identified as Resident #1), stood from his/her chair and began having a [MEDICAL CONDITION]. The Note indicated that after Resident #2 recovered from having a [MEDICAL CONDITION], he/she began ambulating in the hallway looking for his/her peer (Resident #1), but was redirected with good effect. The Surveyor interviewed Mental Health Counselor (MHC) #1 at 11:20 P.M. on 06/27/19. MHC #1 said that at approximately 11:30 A.M. on 06/13/19, she saw Resident #1 try to verbalize something and then he/she hit Resident #2, who was sitting in a wheelchair. MHC #1 said Resident #1 hit Resident #2 on the right side of his/her face. MHC #1 said Resident #2 tried to stand from his/her wheelchair after Resident #1 hit him/her in the face, but as soon as Resident #2 began to stand, he/she had a [MEDICAL CONDITION]. The Surveyor interviewed Nurse #1 at 9:30 A.M. on 06/27/19. Nurse #1 said she was at the nursing station at the time of the incident between Resident #1 and Resident #2. Nurse #1 said she did not see the physical altercation but said she could hear noises while standing at the nursing station. Nurse #1 said following the physical altercation, Resident #1 was placed on five minute safety checks. The Surveyor interviewed Resident #2 at 1:45 P.M. on 06/27/19. Resident #2 said that on 06/13/19, he/she was sitting down and Resident #1 slapped him/her. Resident #2 said staff intervened during the incident and then he/she had a [MEDICAL CONDITION]. 2. The Facility's Investigation, dated 06/13/19, indicated at approximately 12:45 P.M. on 06/13/19, Resident #4 called for staff because he/she saw Resident #1 get up from his/her bed, walk over to his/her roommate, Resident #3, and hit him/her in the face. The Investigation indicated staff responded to Resident #1 and Resident #3's bedroom to separate the residents and saw Resident #1 and Resident #3 wrestling with each other, or words to that effect. The Investigation indicated Resident #3 had a superficial area on his/her lip with minor swelling. The Investigation indicated Resident #3 was offered a room change to another unit which he/she accepted. The Investigation indicated Resident #3 received medication with poor effects and remained in his/her room with staff until he/she was calm and then was maintained on five-minute safety checks. Resident #3's Incident Report, dated 06/13/19, indicated he/she had an abrasion to his/her face at the time of the incident. The Surveyor interviewed Resident #4 at 2:10 P.M. on 06/27/19. Resident #4 said he/she was sitting in the hallway, looking into Resident #1 and Resident #3's bedroom. Resident #4 said he/she saw Resident #1 beating the dog[***]out of Resident #3; Resident #1 hit Resident #3 in the face a lot, or words to that effect. Resident #4 said he/she yelled fight, fight so staff would come help. Resident #4 said he/she has seen other residents fight on the unit and he said, this place is horrible, or words to that effect. The Surveyor interviewed Mental Health Counselor (MHC) #4 at 2:10 P.M. on 06/27/19. MHC #4 said he heard Resident #4 yell, fight, fight, or words to that effect, so he responded to Resident #1 and Resident #3's bedroom and separated the residents. MHC #4 said he could not recall the details of the physical altercation. MHC #4 said Resident #1 was placed on a one-to-one supervision level for the remainder of the day. Review of Resident #1's Nursing Progress Note, dated 06/13/19, indicated staff found him/her on the floor with his/her roommate. The Note indicated Resident #1's roommate (Resident #3) said, Resident #1 hit me, or words to that effect. The Note indicated Resident #1 was brought into a small activity room on the Unit and given [MEDICATION NAME] (antipsychotic medication) intramuscular. Review of Resident #3's Nursing Progress Note, dated 06/13/19, indicated staff entered his/her room and found Resident #1 and Resident #3 on the ground. The Note indicated Resident #3 said, Resident #1 punched me, or words to that effect. The Note indicated Resident #3 had swelling and a small open area on his/her lips, which was treated with Tylenol for the pain and ice for swelling. The Surveyor interviewed the Director of Nursing (DON) at 3:30 P.M. on 06/27/19. The DON said that following the physical altercation between Resident #1 and Resident #3, Resident #1 was given [MEDICATION NAME] (antipsychotic medication) intramuscular. The DON said staff reported that Resident #1 had an good evening and slept though most of the night. 3. The Facility' Investigation, dated 06/14/19, indicated that at approximately 7:15 A.M. on 06/14/19, Resident #2 punched Resident #1 in the face while they were in the dining room. The Investigation indicated Resident #1 used a fork he/she has in his/her hand to retaliated against Resident #2, which left a four-centimeter scratch on Resident 2's face. The Investigation indicated Resident #2's scratch was treated with pressure dressing and ice to stop the bleeding. The Report indicated Resident #2's supervision level was increased. The Investigation indicated that following the incident, staff stayed with Resident #1 until he/she was transferred to the hospital via a Section 12 Order (allows an individual to be brought against his or her will to a hospital for evaluation/treatment for [REDACTED]. Review of Resident #1's Nursing Progress Note, dated 06/14/19, indicated he/she was involved in a physical altercation which required staff to intervene. The Note indicated the other resident (Resident #2) was bleeding. The Note indicated Resident #1 was immediately escorted out of the common area and brought to his/her room. Review of Resident #2's Nursing Progress Note, dated 06/14/19, indicated Nurse #4 was called to the activity room, where she saw Resident #2 sitting in his/her wheelchair and he/she was bleeding profusely. The Note indicated Resident #2 said, I punched him/her (Resident #1) in the face and I didn't know he/she had a fork in his/her hand, and said he/she ripped my face off with it, or words to that effect. The Note indicated Resident #2 sustained a four centimeter superficial laceration to the left side of his/her face. Review of Resident #2's Psychiatric Consultation Note, dated 06/14/19, indicated Resident #2 was angry after Resident #1 hit him/her on 06/13/19. The Note indicated that on 06/14/19, Resident #2 struck Resident #1; therefore Resident #1 retaliated with a fork, causing a laceration under Resident #2's left eye. The Note indicated Resident #2 said staff told him/her to stay away from Resident #1 and that staff told him/her the incident on 06/14/19, was his/her fault. The Note indicated Resident #2 had good insight into his/her involvement in the altercation. The Surveyor interviewed Resident #2 at 1:45 P.M. on 06/27/19. Resident #2 said he/she wanted to get back at Resident #1 so he/she waited for the moment when it was just the two of them. Resident #2 said he/she hit Resident #1, then Resident #1 tried to stab him/her with a pen, but he/she blocked the pen. Resident #2 said Resident #1 picked up a fork and stabbed him/her in the face which was when staff intervened and separated them. Resident #2 said he/she is not scared of Resident #1 as he/she can take care of himself/herself. Resident #2 said, I don't know where in the mind Resident #1 is, so I don't know if Resident #1 is going to do something again, or words to that effect. The Surveyor interviewed Mental Health Counselor (MHC) #3 at 3:05 P.M. on 06/27/19. MHC #3 said on 06/14/19, at the beginning of his shift, he walked by the nursing station and saw Resident #1 move and Resident #2 try to go after him/her in the dining room. MHC #3 said he hurried over to speak with Resident #2 and noticed he/she was holding a chair and had blood on his/her face. The Surveyor interviewed Nurse #1 at 9:30 A.M. on 06/27/19. Nurse #1 said, on 06/14/19, around breakfast time, she was at the nursing station receiving the morning shift report and heard an altercation in the dining room. Nurse #1 said staff reported Resident #2 walked up to Resident #1 and slapped him/her on the face and in return, Resident #1 stabbed Resident #2 in the face with a fork. Nurse #1 said Resident #2 was placed on five minute safety checks and Resident #1 was sent to the hospital via a Section 12 Order Order (allows an individual to be brought against his or her will to a hospital for evaluation/treatment for [REDACTED]. Review of the Situation, Background, Assessment, and Recommendation (SBAR) Note, dated 06/14/19, indicated Resident #1 received [MEDICATION NAME] (antipsychotic medication) intramuscular with little to no effect. Resident #1 had little remorse for the past 3 resident-to-resident physical altercations and was transferred to the hospital via a Section 12 Order. The Surveyor interviewed the Director of Nursing (DON) at 3:30 P.M. on 06/27/19. The DON said she was on the resident care unit at 7:15 A.M. on 06/14/19 to obtain updates about the two previous incidents. The DON said she was on the unit at the time of the resident-to-resident physical altercation but did not see the incident. The DON said MHC #3 was the first staff member to intervene in the physical altercation between Resident #1 and Resident #2. The DON said Resident #1 was not on a one-to-one level of supervision at the time of the incident, but he/she was placed with a staff member until he/she was transferred to the hospital via a Section 12 Order. The Surveyor interviewed the Physician at 10:20 A.M. on 06/27/19. The Physician said Resident #1 acts on impulses due to his/her [DIAGNOSES REDACTED]. the Physician said Resident #2 is typically a gentle person and he/she was just in the wrong place at the wrong time.

Based on records reviewed, observations and interviews, the Facility failed to ensure there were sufficient staff scheduled on the 11:00 P.M. to 7:00 AM. shift to meet the needs of residents, with known histories which include history of falls, and physical, verbal, and inappropriate behaviors, on two of three locked Behavioral Units (B1 and B2). Each unit had a census of 33 residents and staffed by only 1 Nurse and 1 Certified Nurse Aide. Findings include: A) Review of Facility staff schedules in (MONTH) (YEAR), indicated the Facility was staffed with 1 Nurse and 2 Certified Nurse Aides on the 11:00 P.M. to 7: 00 AM shift on all four units, including locked Behavioral Units B1 and B2. During March, 2019, staffing levels were reduced to 1 Nurse and 1 Certified Nurse Aide on B1 and B2. Surveyor #1 interviewed the Staffing Coordinator at 10:14 A.M. on 4/30/19. The Staffing Coordinator said that in (MONTH) 2019 she was instructed by the Facility's Corporate Office to cut staffing on the 11:00 P.M. to 7:00 A.M. shift to cut staffing on the 11:00 P.M. to 7:00 A.M. shift from 1 Nurse and 2 CNAs to 1 Nurse and 1 CNA. Surveyor #1 and Surveyor #3 interviewed the Administrator at 2:45 P.M. on 5/20/19. The Administrator said she had recently been instructed by Head Office to reduce each Department Budget by ten percent. The Administer said as a Registered Nurse and a Licensed Nursing Home Administrator, she would not feel safe working on the Locked Behavioral Units by herself with only 1 CNA on the 11:00 P.M. to 7:00 A.M. or words to that effect. Surveyor #1 interviewed Nurse #2 at 3:30 P.M. on 4/29/19, Nurse #3 at 7:20 A.M. on 4/30/19, Nurse #4 at 9:08 A.M. on 4/30/19, CNA #1 at 12:15 P.M. on 4/30/19, CNA #2 at 3:35 P.M. on 4/29/19, CNA # 3 at 8:00 A.M. on 4/30/19, CNA #4 at 8:20 A.M. on 4/30/19, CNA #5 at 8:33 A.M., CNA #6 at 8:50 A.M. on 4/30/19 and CNA #7 at 1:00 P.M. on 4/30/19. Nurse #2, Nurse #3, and Nurse #4 and said they routinely worked the 11:00 P.M. to 7:00 A.M. shifts on B1 and B2. Nurse #2, Nurse #3 and Nurse #4 said that while they are made to punch in and out for breaks during the 11:00 P.M. to 7:00 A.M. shift, they are not allowed to leave the Unit as that would leave only 1 CNA alone to deal with difficult residents with aggressive behaviors placing both residents and CNAs at risk for harm or words to that effect. Nurse #2, Nurse #3, Nurse #4 and Nurse #6 said they can not always help the CNAs to provide care or perform safety checks on residents because of the type of resident and the number of residents who wander and need constant redirection during the night. CNA #2, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6 and CNA #7 said they routinely worked the 11:00 P.M. to 7:00 A.M. shifts on B1 and B2. CNA #2, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6 and CNA #7 said that while they are made to punch in and out for breaks during the 11:00 P.M. to 7:00 A.M. shift, they are not allowed to leave the Unit. CNA #2, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6 and CNA #7 said they can not provide incontinence care and repositioning to those residents who require 2 person assistance with care and said they could not routinely perform safety checks on residents with changes in behaviors as there were not enough staff assigned on the 11:00 P.M. to 7:00 A.M. shift. CNA #5 said he/she had worked at the Facility for more than years and said that since the change in staffing schedules in (MONTH) 2019, this was the first time he/she is afraid to come to work. CNA #5 said because of the type of violent and physical residents residing on B1 and B2, he/she was afraid because of the shortage of staff and lack of supervision on the 11:00 P.M. to 7;00 A.M. shift or words to that effect, that someone, either resident or staff, is going to get seriously injured. The Administrator said staff are required to punch out for breaks but because of not enough staff on the 11:00 P.M. to 7:00 A.M. shift, staff can not leave the unit and are required to take a break on unit because otherwise, only 1 staff member would be left to oversee residents which was not safe and against Labor laws or words to that effect. B) For 5 of 13 sampled residents (Residents #4, #8, #11, #12 and #13) the Facility failed to ensure there was sufficient staff scheduled to provide supervision for the prevention of falls on the 11:00 P.M. to 7:00 A.M. shift. 1. Residents #4 was admitted to the Facility's B2 Unit in (MONTH) 2012, and his/her [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) Assessment, dated 3/13/19, indicated Resident #4 was severely cognitively impaired. A Fall Risk Care Plan, dated as revised on 3/19/19, indicated Resident #4 was identified at high risk for potential falls, and staff were to ensure his/her call light and personal items were within reach, remind Resident #4 to request assistance prior to transfer or ambulation, and ensure he/she was wearing appropriate footwear when ambulating or mobilizing in his/her wheelchair. A Nurse Progress Note, dated 4/10/19, indicated at 1:15 A.M. Resident #4 was found seated on the floor on his/her buttocks. The Progress Note indicated Resident #1 did not complain of pain or injury at that time, however, at 5:25 A.M. he/she presented with increased confusion and slurred speech and was transferred via 911 emergency services to the Hospital Emergency Department for evaluation. A computerized tomography (CT) scan Report, dated 4/11/19, indicated Resident #4 had a displaced, mildly comminuted acute fracture of his/her left ischiopubic ramus (fractured pelvis). Surveyor #1 interviewed Nurse #6 at 7:53 A.M. on 5/2/19 and at 4:30 A.M. on 5/8/19. Nurse #6 said on the night of Resident #4's fall, she found him/her sitting on the floor in the hallway as she was leaving the Unit to punch out on the time clock for a break. Nurse #6 said she did not know how Resident #4 had fallen or how long he/she had been sitting on the floor or words to that effect. Review of a Resident Head Count Report, dated 4/10/19, indicated that on the 11:00 P.M. to 7:00 A.M. shift, there were 33 three residents; 17 residents were on 15 minute security checks, 1 resident was on 5 minute safety checks, 18 residents were incontinent of bowel and bladder and 5 residents required 2 person assistance with all care. Nurse #6 said a lot of residents who reside on the locked unit stay awake and wander around the unit during the night and require a lot of attention. Nurse #6 said she and CNA #3 were unable to perform safety checks as required, were unable to change or provide incontinence care to residents, and had no back up coverage if a Resident to Resident and/or a Resident to Staff altercation occurred. Nurse #6 said she did not feel safe working on the 11:00 P.M. to 7:00 A.M. shift since staffing levels were reduced beginning (MONTH) 2019. 2. Resident #8 was admitted to the Facility's Facility's B1 Unit in (MONTH) 2019, and his/her [DIAGNOSES REDACTED]. An Admission MDS Assessment, dated 2/1/19, indicated Resident # 8 was severely cognitively impaired, and required 1 person physical assistance with ambulation and wheelchair locomotion. Resident #8's Care Plan, dated 02/21/19, indicated he/she was at a high risk of falls and required continuous supervision when out of bed. A Nurse Progress Note, dated 3/17/19, indicated at 11:40 P.M. Resident #8's roommate called staff to his/her room where Resident #8 was found lying on the floor, and on assessment he/she had skin tears on his/her right elbow, forearm and back of hand. At Approximately 5:20 A.M. on 05/08/19, Surveyor #3 observed Resident #8, who appeared disheveled with his/her hospital gown falling off and exposing his/her left shoulder, sitting in a locked wheelchair in the dining room. pushed into a corner with the back side and right side of the wheelchair against the adjourning walls and a table was placed directly in front of Resident #8. Resident #8 smelled of urine, she/she was sweating and was wiggling in his/her wheelchair. Resident #8 was not in view of the nurses station and there was no call light within reach of Resident #8 in the event that he/she needed to contact staff. Surveyor #3 interviewed CNA #9 at 6:10 A.M. on 05/08/19. CNA #9 said due to the type of residents residing on the unit and the lack of staff, she was unable provide constant supervision on Resident #8 and did not want him/her to fall which is why she sat Resident #8 up in the dining room. CNA #9 said Resident #8 sat up in his/her wheelchair throughout the night, almost every night, so that staff could observe him/her. CNA #9 said she feels bad because Resident #8 and other residents do not receive the care that they should be receiving, including turning and repositioning and incontinence care or words to that effect, due to lack of staff. Although Resident #8 was unable to be interviewed due to cognitive impairment, the reasonable person's concept would apply. Specifically, that a reasonable person would suffer psychosocial and emotional harm from being placed in a room alone with wheelchair positioned such that the adjacent furniture prevented him/her from exiting the room at will. 3. Resident #11 was admitted to the Facility's B2 Unit in (MONTH) 2013, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 1/21/19, indicated Resident #11 was severely cognitively impaired, required 2 person physical assistance with bed mobility and transfers, was non-ambulatory and was totally dependent on 1 person for wheelchair mobility. A Fall Risk Care Plan, dated as revised on 1/29/19, indicated Resident #11 required 2 person assistance with all care, he/she slept in an enclosed bed at night which staff were to monitor closely for safety, he/she was non-ambulatory and required a clip belt while in his/her wheelchair. An Incident Report, dated 4/7/19, indicated at approximately 5:40 A.M. the nurse responded to a noise in the hallway and looked up to see Resident #11 walking in the hallway unassisted but was unable to reach him/her on time, and Resident #11 fell . The Incident Report indicated that contributing environmental factors to Resident #11's fall was poor lighting. The Incident Report indicated Resident #11 appeared at baseline and had no injuries, but on inspection of his/her enclosed bed, the zippers were partially unzipped. Surveyor #1 and Surveyor #3 interviewed the Administrator at 2:55 P.M. on 5/20/19. The Administrator said to the best of her recollection the Assistant Director of Nurses (ADON), who no longer works at the Facility, worked the 11:00 P.M. to 7:00 A.M. shift on 4/7/19. The Administrator said the ADON reported there was a lot of activity that night and a lot of resident to resident altercations. The Administrator said the Interdisciplinary team were unable to determine how Resident #11 got out of bed and into the hallway, and how long he/she had been there, as he/she was non-ambulatory and needed 2 person assistance to get out of bed and into a wheelchair or words to that effect. The Administrator said the best scenario she could come up with was that Resident #11 was yelling to get out of bed, and another resident went into his/her room, unzipped the enclosed bed and helped Resident #11 out of bed or words to the effect. 4. Resident #12 was admitted to the Facility's B1 Unit in (MONTH) 2019, and his/her [DIAGNOSES REDACTED]. An Admission MDS Assessment, dated 3/28/19, indicated Resident #12 was severely cognitively impaired, required extensive assistance of 2 persons for bed mobility and transfer, and extensive assistance of 1 person for wheelchair mobility. A Fall Risk Care Plan, dated 3/21/19, indicated Resident #12's bed was to be kept in the lowest position with floor mats on both side of bed when in bed, he/she was to wear a helmet at all times and staff were to encourage him/her to use the call light to for assistance. A Nurse Progress Note, dated 3/22/19, indicated Resident #12 was redirected multiple times during the 11:00 P.M. to 7:00 A.M. shift as he/she showed signs of [MEDICAL CONDITION] and was trying to walk around with an unsteady gait and was intrusive trying to climb into other residents' beds. The Nurse Progress Note indicated at approximately 3:30 A.M. the nurse responded to a loud noise and found Resident #12 on the floor in the doorway of his/her room on his/her knees and resting his/her arms on a wheelchair in front of him /her. 5. Resident #13 was admitted to the Facility's B2 Unit in (MONTH) 2012, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 3/30/19, indicated Resident #13 was severely cognitively impaired and required 1 person physical assistance with bed mobility, transfers, ambulation, wheelchair mobility and toilet use. A Fall Risk Plan of Care, dated as last revised on 8/10/16 (approximately 2 and 1/2 years prior to the most recent MDS Assessment) indicated Resident #13 had poor safety awareness related to a [MEDICAL CONDITION], and staff were to initiate safety checks as needed. An Incident Report, dated 5/15/19, indicated at approximately 2:30 A.M., a loud noise was heard from the high side of the hallway, and when Nurse #6 responded, she found Resident #13 laying on the floor in the bathroom with a broken toilet tank cover broken in pieces surrounding him/her. The Incident Report indicated that on assessment, Resident #13 had sustained an abrasion on his/her left elbow and a laceration on his/her right lower leg. C) The Facility failed to ensure there was sufficient staff scheduled on the 11:00 P.M. shift to ensure residents were assisted with care or remained free from confinement for the convenience of staff. On 5/8/19, Surveyor #1 and Surveyor #4 entered the Facility at approximately 4:15 A.M. On B1 and B2 units, fouls odors were detected, residents were observed roaming around the units, some were yelling and swearing, and others were banging their heads and arms on doors and walls. Surveyor #1 was approached by one resident, who was dressed only in a pair of underpants, with his/her arms outstretched and said I'm hungry, have you any food or words to that effect. Resident #8 was observed in an unsupervised dining room. Resident #8 was sitting in a locked wheelchair which was pushed against a wall in the corner of the back right area of the dining room which was not in of view from the nurse's station. Resident # 8 was disheveled with his/her nightwear falling off and exposing the left shoulder. CNA #9 said Resident #8 was placed there as there were not enough staff on the unit to safely supervise Resident #8. At approximately 4:30 A.M. CNA #3 was observed sleeping in the tub room, at which time Resident #9's call light was ringing. Nurse #6 said although CNA #3 had punched out earlier for break, she was not able to take a break at that time because of the number of behavioral residents roaming the hallways throughout the night. Nurse #6 said she later gave CNA #3 permission to take a break and relax in the tub room as she had to provide early morning care to residents, to the best of her ability, without any help. Nurse #6 said Resident #9's call light was ringing through out the night and said she removed his/her wheelchair because he/she insistently tries to get out of bed, but is a danger to others and can't be safely supervised until full staff, including nursing and mental health counselors arrive for the 7:00 A.M. to 3:00 P.M. shift. Although Resident #9 was unable to be interviewed a reasonable person would experience psychosocial and emotional harm from having wheelchair removed from his/her access causing him/her to be restricted to his/her bed. Resident #9 was heard by survey staff to be screaming and yelling out while in bed during the survey and told staff he/she wanted to get out of bed. Res #10 was observed in an enclosed veil bed, he/she was disheveled and smelled of stale urine, and was heard yelling and screaming consistently. Nurse #6 said Resident #10 was a 2 person assist for care but there was not enough staff to get him/her up and keep him/her safely supervised on the overnight shift. At Approximately 5:20 A.M. on 05/08/19, Surveyor #3 observed Resident #8, who appeared disheveled with his/her hospital gown falling off and exposing his/her left shoulder, sitting in a locked wheelchair in the dining room. pushed into a corner with the back side and right side of the wheelchair against the adjourning walls and a table was placed directly in front of Resident #8. Resident #8 smelled of urine, she/she was sweating and was wiggling in his/her wheelchair. Resident #8 was not in view of the nurses station and there was no call light within reach of Resident #8 in the event that he/she needed to contact staff. The Surveyor interviewed CNA #9 at 6:10 A.M. on 05/08/19. CNA #9 said due to the type of residents residing on the unit and the lack of staff, she was unable provide constant supervision on Resident #8 and did not want him/her to fall which is why she sat Resident #8 up in the dining room. CNA #9 said Resident #8 sat up in his/her wheelchair throughout the night, almost every night, so that staff could observe him/her. CNA #9 said she feels bad because Resident #8 and other residents do not receive the care that they should be receiving, including turning and repositioning and incontinence care or words to that effect, due to lack of staff. 1. Resident #8 was admitted to the Facility's Facility's B1 Unit in (MONTH) 2019, and his/her [DIAGNOSES REDACTED]. An Admission MDS Assessment, dated 2/1/19, indicated Resident # 8 was severely cognitively impaired, and required 1 person physical assistance with ambulation and wheelchair locomotion. Resident #8's Care Plan, dated 02/21/19, indicated he/she was at a high risk of falls and required continuous supervision when out of bed. At Approximately 5:20 A.M. on 05/08/19, Surveyor #3 observed Resident #8, who appeared disheveled with his/her hospital gown falling off and exposing his/her left shoulder, sitting in a locked wheelchair in the dining room. pushed into a corner with the back side and right side of the wheelchair against the adjourning walls and a table was placed directly in front of Resident #8. Resident #8 smelled of urine, she/she was sweating and was wiggling in his/her wheelchair. Resident #8 was not in view of the nurses station and there was no call light within reach of Resident #8 in the event that he/she needed to contact staff. 2. Resident #9 was admitted to the Facility's B2 Unit in (MONTH) 2014, and his/her [DIAGNOSES REDACTED]. An Annual MDS Assessment, dated 1/25/19, indicated Resident #9 was alert and oriented, and required 2 person physical assistance with bed mobility, and 1 person physical assistance with transfers and wheelchair locomotion. A Behavioral Care Plan, dated as revised on 1/28/19, indicated Resident #9 had the potential for verbal agitation and behaviors which would quickly escalate into physical aggression as evidence by violent and sexually inappropriate behaviors towards others. A Facility Investigation File, dated 5/3/19, indicated Resident #9 reported to day shift staff that he/she had been assaulted by his/her roommate during the 11:00 P.M. to 7:00 A.M. shift. At approximately 4:30 A.M. on 5/8/19, Surveyor #1 heard Resident #9's call light ringing, and heard yelling and screaming coming from his/her room. Nurse #6 said Resident #9 had been on the call light throughout the night and said that he/she wanted to get out of bed. Nurse #6 said she had removed Resident #9's wheelchair, as she did most nights, so that he/she could not get out of bed. Nurse #6 said Resident #9 chases other residents with his/her wheelchair and is a danger to him/herself and others'' or words to that effect. Nurse #6 said there are no mental health staff assigned on the 11:00 P.M. to 7:00 A.M. shift to help with Resident #9's psychotic and intrusive behaviors. Nurse #6 said that with only 1 Nurse and 1 CNA on 11:00 P.M. to 7:00 A.M. shift, it was impossible to safely supervise Resident #9 if he/she was out of bed or words to that effect. Nurse #6 said Resident #9 remains in his/her room every night until the 7:00 A.M. to 3:00 P.M. shift arrive at which time his/her wheelchair is returned and the assigned mental health staff on that shift can supervise him/her. 3. While Resident #9's call light continued to ring, unanswered, Surveyor #1 heard yelling and screaming from the direction of Resident #10's room. Upon opening the door to Resident #10's room, Surveyor #1 observed Resident #10 in an enclosed veil bed, and he/she appeared disheveled and smelled of stale urine. Nurse #6 said Resident #10 required 2 people to assist him/her with care on the 11:00 P.M. to 7:00 A.M. shift. Nurse #6 said CNA #3 was sleeping in the tub room. on a scheduled break and said she (Nurse #6) was the only staff member on the unit at that time and was unable to provide direct care to residents as she was consistently interrupted by residents who were out of bed during the night and wandered around the unit. Nurse #6 said the stale urine odor was because most residents who required incontinence care were changed only once on the 11:00 P.M. to 7:00 A.M. as there was not enough staff to supervise those residents with behaviors who did not sleep during the night and required a lot of attention or words to that effect. 4. Nurse #6 said that with only 1 nurse and 1 CNA on the 11:00 P.M. to 7:00 A.M. shift, it was impossible to complete safety checks rounds and safely supervise all residents. Nurse #6 said she was unsure how many residents were on safety checks. Nurse #6 said there was a board in the activity room with a list of residents who were on safety checks but said she had not had time to check this during the night, and was unable to provide documentation to support that safety checks had been performed throughout the night. At approximately 4:45 A.M. on 5/8/19, Surveyor #1 and Nurse #6 entered the activity room on B2 and reviewed the safety check list board. At that time there were 11 residents who were on scheduled 15 minute safety checks and 5 residents on 5 minute safety checks related to recent charges in behavior. Nurse #6 said these safety checks had not been performed during the night. CNA #2, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6 and CNA #7 said they typically filled in and checked off safety behavior sheets at the end of their shifts without actually performing the safety checks or words to that effect, as they did not have time to perform them as ordered due to lack of staff.

Based on records reviewed, interviews and observations, for 3 of 13 sampled residents (Residents #3, #7 and #11 and for 3 of 5 non-sampled residents (Residents A, B and D), the Facility failed to ensure it provided adequate supervision during smoking activities; for 1 of 13 sampled residents (Resident #3), failed to monitor for risk of elopement; and for 1 of of 13 sampled residents (Resident #11) and 1 of 5 non-sampled residents (Resident D), failed to ensure necessary equipment was in place while in bed to prevent accidents. - Resident #3's plan of care included that he/she smoke with other residents during designated supervised smoking breaks and that he/she wore a code alert bracelet to alert staff in the event he/she tried to leave the Facility unsupervised. During 3 observations throughout this survey, Resident #3's code alert was heard sounding, staff did not respond and did not go to check where Resident #3 was, and Resident #3 was discovered by the Surveyors, outside alone smoking. - The Facility's smoking Policy indicated residents were not allowed to hold smoking materials unless under direct supervision of staff. Resident #3, Resident #7, non-sampled Resident A and non-sampled Resident B were observed with smoking materials on their person, outside smoking unsupervised. - Resident #11 who slept in an enclosed bed, fell in the hallway during the night. The Incident report indicated on inspection of his/her enclosed bed, the zippers were partially unzipped. The Administrator said the Interdisciplinary team were unable to determine how Resident #11 got out of bed and into the hallway, and how long he/she had been there, as he/she was nonambulatory and needed 2 person assistance to get out of bed and into a wheelchair or words to that effect. - Non-sampled Resident D's Care Plan indicated he/she was to be placed in an enclosed bed, with protective netting, with two bolsters on either side, due to involuntary movements. On 5/2/19, non-sampled Resident D was discovered by Surveyor #4 trapped between the bed frame and the net of the enclosed bed. Non-sampled Resident D's head and shoulders were observed sticking out from underneath and his/her face was pressed against the protective netting, just above the bed frame. There were no bolsters in non-sampled Resident D's bed to prevent him her from rolling out of the bed. Findings include: A.) The Facility's Smoking Policy, dated (MONTH) (YEAR), indicated that residents will be evaluated to determine ability to smoke safely with or without supervision; any smoking related privileges, restrictions, and concerns shall be noted on the care plan; any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a responsible person at all times while smoking; residents who have independent smoking privileges are not permitted to keep cigarettes or other smoking articles in their possession; and residents without independent smoking privileges may not have or keep any smoking articles, except when they are under direct supervision. The Facility's Daily Time Table Smoking Hours Schedule, dated as last revised on 4/22/15, indicated staff were to supervise smoking breaks for residents residing on Main 1 Unit at 9:30 A.M., 11:30 A.M., 1:00 P.M., 2:30 P.M. and 7:00 P.M. 1. Resident #3 was admitted to the Facility in (MONTH) (YEAR), and his/her [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set, dated dated [DATE], indicated that Resident #3 was cognitively intact. A Smoking Care Plan, dated 2/6/19, indicated that while Resident #3 could smoke independently, he/she was to go outside with other Residents from Main 1 at scheduled supervised smoking times to decrease the amount of time he/she sets off the safety alarm. The Care Plan indicated Resident #3 was educated on safe smoking practices and oriented to the Facility's designated smoking area and smoking times. A Smoking Evaluation, dated 2/27/19, indicated that while Resident #3 could smoke independently he/she was encouraged to go outside with other smokers at designated smoking times. The Facility's Elopement Policy, dated 1/2017, indicated staff shall investigate and report all missing residents, and if an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. An Elopement at Risk Evaluation record, dated 2/27/19, indicated Resident #3 could ambulate independently and was identified at high risk for potential elopement as he/she had history of substance abuse and frequently expressed the wish to leave the Facility. An Elopement Risk Assessment, dated as revised on 2/28/19, indicated Resident #3 was to have a code alert bracelet on his/her ankle to alert staff in the event he/she tried to leave the Facility unsupervised. An Elopement Care Plan, dated as revised on 2/28/19, indicated Resident #3 had a history of [REDACTED]. The Nurse Practitioner Note, dated 03/31/19, indicated Resident #3 had psychotic or borderline psychotic symptoms, a paranoid manner and paranoid process, poor insight to problems, restlessness, and limited judgement. At approximately 7:14 A.M. on 04/29/19, Surveyor #1 exited the elevator on the first floor and heard a safety alarm sounding on Main 1. Directly opposite the elevator was an open glass door leading to a fenced in court yard where Surveyor #1 observed Resident #3 alone and smoking independently, without supervision. Resident #1 had a security code bracelet placed on his/her left ankle. Surveyor #1 entered the Main 1 Unit at approximately 7:16 A.M. and observed staff, including Unit Manager #1, standing around the nurses station talking to each other. Although the alarm was audible at the nurses station, no staff member responded to the alarm. When Surveyor #1 brought to the attention of staff that the safety alarm was sounding, Unit Manger #1 said the alarm was most likely triggered by Resident #3, who was an independent smoker who set off the alarm with his/her code bracelet, as he/she liked to go outside early each morning for a cigarette break. Unit Manager #1 said it was her understanding that Resident #3 and other residents assessed as independent smokers, could carry their own cigarettes and light their cigarettes from an electric lighter located in the designated smoking area in the courtyard. Unit Manager #1 turned off the security alarm at approximately 7:24 A.M. but did not go outside to check if Resident #3 was in the smoking area, and did not assign any other staff member to look for Resident #3. At approximately 7:32 A.M. Surveyor #1 observed Resident #3 return to his/her care unit, which again sounded the safety alarm. Surveyor #1 observed a Housekeeping staff member turn off the alarm within 15 seconds. Resident #3 was not approached by staff and was not asked to return his/her cigarettes, Resident #3 returned to his/her room with the cigarettes, and said that damn alarm is always going off or words to that effect. Surveyor #1 interviewed Resident #3 at 7:34 A.M. on 4/29/19. Resident #3 said the alarm was a nuisance, was always going off and said he/she wanted to leave the Facility or words to that effect. Resident #3 said he/she kept his/her own cigarettes on his/her person. At approximately 6:30 A.M. on 5/8/19, Surveyor #1 and Surveyor #3 exited the elevator on the first floor and heard a safety alarm sounding to the left, on Main 1 Unit. Surveyor #1 and Surveyor #3 exited the door to the designated smoking area and observed Resident #3 unsupervised smoking a cigarette. A chair was placed against a locked gate leading to the street. Resident #3 said he/she wanted to get away from this place or words to that effect. Surveyor #1 and Surveyor #3 re-entered the building and alerted staff on Main 1 Unit that Resident #3 was outside smoking unsupervised. Surveyor #1 and Surveyor #3 observed a staff member turn off the safety alarm but she did not go outside to check on Resident #3 at that time. At approximately 6:40 A.M. on 5/8/19, Surveyor #1 and Surveyor #3 took the elevator, directly opposite the door leading to the smoking area, which was unlocked and accessible to residents, staff and visitors, and led to the ground floor level. Surveyor #1 and Surveyor #3 exited the elevator on the ground floor, and were able to exit the Facility from an opened exit door leading to the parking lot with access to a busy main street. At approximately 7:30 A.M. on 5/8/19, Surveyor #1 and Surveyor #3 again heard a safety alarm sounding on Main 1 unit, and went outside to the designated smoking area. Surveyor #1 and Surveyor #3 observed Resident #3 smoking unsupervised. Resident #3 then picked up a stubbed out cigarette butt off the ground and relit it using the electronic cigarette lighter in the patio area. The safety alarm stopped sounding, however, no staff came out to check if Resident #3 was outside. 2. At 11:15 A.M., 1:30 P.M. and 3:25 P.M. on 4/29/19, Surveyor #1 observed Resident #7, non-sampled Resident A and non-sampled Resident B, smoking in the designated smoking area. No staff were present during all three observations and all three residents had their own pack of cigarettes. Non sampled Resident B was wearing a smoking apron and in addition to having cigarettes on his/her person, he/she had a blue lighter which he/she pulled from his/her pants pocket to light cigarettes. This was not consistent with the Facility's Smoking Policy. Surveyor #1 interviewed Nurse #5 at 1:37 P.M. on 4/30/19. Nurse #5 said that while Resident #7, non-sampled Resident A and non-sampled Resident B could smoke independently, without physical assistance from staff, but were supposed to smoke only at supervised designated smoking times. Nurse #5 said he was unsure if residents were allowed to carry their own cigarettes, but said he was sure they were not supposed to carry lighters. Nurse #5 said non-sampled Resident B wore a safety apron as he/she had a history of [REDACTED]. B.) Resident #11 was admitted to the Facility's B2 Unit in (MONTH) 2013, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 1/21/19, indicated Resident #11 was severely cognitively impaired, required 2 person physical assistance with bed mobility and transfers, was non-ambulatory and was totally dependent on 1 person for wheelchair mobility. A Fall Risk Care Plan, dated as revised on 1/29/19, indicated Resident #11 required 2 person assistance with all care, he/she slept in an enclosed bed at night which staff were to monitor closely for safety, and he/she was non-ambulatory. An Incident Report, dated 4/7/19, indicated at approximately 5:40 A.M. the nurse responded to a noise in the hallway and looked up to see Resident #11 walking in the hallway unassisted but was unable to reach him/her on time, and Resident #11 fell . The Incident Report indicated Resident #11 appeared at baseline and had no injuries, but on inspection of his/her enclosed bed, the zippers were partially unzipped. Surveyor #1 and Surveyor #3 interviewed the Administrator at 2:55 P.M. on 5/20/19. The Administrator said to the best of her recollection the Assistant Director of Nurses (ADON), who no longer works at the Facility, worked the 11:00 P.M. to 7:00 A.M. shift on 4/7/19. The Administrator said the ADON reported there was a lot of activity that night and a lot of resident to resident altercations. The Administrator said the Interdisciplinary team were unable to determine how Resident #11 got out of bed and into the hallway, and how long he/she had been there, as he/she was nonambulatory and needed 2 person assistance to get out of bed and into a wheelchair or words to that effect. The Administrator said the best scenario she could come up with was that Resident #11 was yelling to get out of bed, and another resident went into his/her room, unzipped the enclosed bed and helped Resident #11 out of bed or words to the effect. C.) Non-sampled Resident D was admitted to the Facility in (MONTH) 2008, and his/her [DIAGNOSES REDACTED]. A Plan of Care, dated 3/27/19, indicated non-sampled Resident D was placed in an enclosed bed (a protective netting which goes around the bed and zips shut to prevent a resident from falling out of bed) with two bolsters on either side, due to involuntary movements. At approximately 11:20 A.M. on 5/2/19, while conducting a Life Safety tour with the Director of Maintenance, Surveyor #4 observed that from just below the shoulders non-sampled Resident D's body was trapped underneath the mattress, and his/her head and shoulders were sticking out from underneath the mattress. Non-sampled Resident D's face was pressed up against the protective netting, just above the bed frame. No staff where present in the room. The Director of Maintenance alerted staff who then freed non-sampled Resident D from the entrapped bed. Surveyor #1 interviewed Certified Nurse Aide (CNA) #8 at 12:30 P.M. on 5/2/19. CNA #8 said she washed and dressed non-sampled Resident D and got him/her out of bed at approximately 7:30 A.M. that morning. CNA #8 said the bolsters on non-sampled Resident D's bed were soiled and wet, so she left them out for housekeeping to wash. CNA #8 said later in the morning non-sampled Resident D was getting restless. CNA #8 said she checked with housekeeping who told her the bolsters for non-sampled Resident D's bed were still wet and not ready to be returned. CNA #8 said she put non-sampled Resident D back to bed without the bolsters, which were used to prevent him/her from getting stuck between the bed frame and the net of the enclosed bed.

Based on records reviewed, interviews and observations, for 2 of 13 sampled residents (Residents #8 and #9) the Facility failed to ensure that residents were free from restraints and confined for the convince of staff. -At approximately 5:20 A.M. on 05/08/19, Resident #8 was observed in the dining room, where he/she sat in a locked wheelchair that was placed into a corner with the back side and right side of the wheelchair against the adjourning walls and a table was placed in front of Resident #8. CNA #9 said she did this most nights because Resident #8 was at risk for falls, was always moving and there were not enough staff on the 11:00 P.M. to 7:00 A.M. shift to supervise him/her. -At approximately 4:30 A.M. on 05/08/19, Resident #9 was yelling/screaming from his/her room with his/her call light on. Nurse #6 said she removed Resident #9's wheelchair from his/her room every night to prevent Resident #9 from getting out of bed. Nurse #6 said Resident #9 was a danger to himself/others, was known to chase after other residents in his/her wheelchair and there not not enough staff on the 11:00 P.M. to 7:00 A.M. shift to supervise him/her. Although Resident #8 was unable to be interviewed due to cognitive impairment, the reasonable person's concept would apply. Specifically, that a reasonable person would suffer psychosocial and emotional harm from being placed in a room alone with wheelchair positioned such that the adjacent furniture prevented him/her from exiting the room at will. Although Resident #9 was unable to be interviewed a reasonable person would experience psychosocial and emotional harm from having wheelchair removed from his/her access causing him/her to be restricted to his/her bed. Resident #9 was heard by survey staff to be screaming and yelling out while in bed during the survey and told staff he/she wanted to get out of bed. Findings include: The Facility's Use of Restraint Policy, dated (MONTH) 2019, indicated that restrains shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated each resident has the right to be free from involuntary seclusion. The Policy indicated that involuntary seclusion includes the separation of a resident from other residents or confinement to his/her room (with or without roommates) against the resident's will. A) Resident #8 was admitted to the Facility in (MONTH) 2019, and his/her [DIAGNOSES REDACTED]. An Admission Minimum Data Set Assessment, dated 2/1/19, indicated Resident #8 was severely cognitively impaired and required 2 person physical assistance with bed mobility and transfers, and 1 person physical assistance with ambulation and wheelchair mobility. Resident #8's Care Plan, dated 02/21/19, indicated he/she was at a high risk of falls and required continuous supervision when out of bed. At approximately 5:20 A.M. on 05/08/19, Surveyor #3 observed Resident #8, who appeared disheveled with his/her hospital gown falling off and exposing his/her left shoulder, sitting in a locked wheelchair alone in the dining room. Resident #8's wheelchair was pushed into a corner with the back side and right side of the wheelchair against the adjourning walls and a table was placed in front of Resident #8. Resident #8 smelled of urine and appeared agitated as he/she kept moving in his/her wheelchair (placed his/her arms on the wheelchair arm rests and would attempt to push his/her body up and/or reposition his/her bottom in the chair). Resident #8 was not in view of the nurses station and there was no call light within reach of Resident #8 in the event that he/she needed to contact staff. The Surveyor interviewed CNA #9 at 6:10 A.M. on 05/08/19. CNA #9 said she had placed Resident #8 up against the wall in the dining room approximately one hour earlier because he/she was a high fall risk and had a history of [REDACTED].#9 said due to the type of residents residing on the unit and the lack of staff, she was unable provide constant supervision for Resident #8 and did not want him/her to fall, which is why she sat Resident #8 up in the dining room. CNA #9 said Resident #8 had sat up in the dining room every night this week. Resident #8 was not interviewed due to his/her impaired cognitive status. B.) Resident #9 was admitted to the Facility in (MONTH) 2014, and his/her [DIAGNOSES REDACTED]. An Annual MDS Assessment, dated 1/25/19, indicated Resident #9 was alert and oriented, and required 2 person physical assistance with bed mobility, and 1 person physical assistance with transfers and wheelchair locomotion. A Behavioral Care Plan, dated as revised on 1/28/19, indicated Resident #9 had the potential for verbal agitation and behaviors which would quickly escalate into physical aggression as evidence by violent and sexually inappropriate behaviors towards others. At approximately 4:30 A.M. on 5/8/19, Surveyor #1 heard Resident #9's call light ringing, and heard yelling and screaming coming from his/her room. Surveyor #1 interviewed Nurse #6 at 4:32 A.M. on 5/8/19. Nurse #6 said Resident #9 had been ringing the call light throughout the night and said that he/she wanted to get out of bed. Nurse #6 said she had removed Resident #9's wheelchair, as she did most nights, so that Resident #9 could not get out of bed. Nurse #6 said Resident #9 chases other residents with his/her wheelchair and is a danger to him/herself and others, and is very difficult to supervise. Nurse #6 said Resident #9 remains in his/her room every night until the 7:00 A.M. to 3:00 P.M. shift arrive at which time his/her wheelchair is returned and the assigned mental health staff on that shift can supervise him/her. Resident #9 was not interviewed due to his/her psychotic behaviors.

Based on records reviewed, observations, and interviews, for two of 17 sampled residents (Resident #4 and Resident #6), the facility failed to prevent, protect and ensure Resident #4 was free from abuse when on 07/06/19, Resident #6 physically assaulted Resident #4 on two separate instances, resulting in his/her face being swollen and bruised. -At 3:26:47 P.M. on 07/06/19, Resident #4 was in the hallway near Resident #6 and Unidentified Resident #1 and Unidentified Resident #2 for approximately 34 seconds, when Resident #6 maneuvered his/her wheelchair towards Resident #4 and hit him/her approximately 20 times on his/her head and body. -At 3:27:52 P.M. on 07/06/19, staff walked away from Resident #6 and Resident #4. Resident #6 wheeled himself/herself down the hallway towards Resident #4, for approximately 15 seconds and came within approximately five feet of Resident #4, before staff intervened. -At 3:30:51 P.M. on 07/06/19, Resident #4 wheeled his/her wheelchair down the hallway where Resident #6 sat in his/her wheelchair. Resident #6 was seen saying something to Resident #4. Resident #4 was trying to wheel himself/herself down the hallway and grabbed the wall for assistance to wheel his/her wheelchair past and/or away from Resident #6. -At 3:31:04 P.M. on 07/06/19, Resident #6 wheeled himself/herself towards Resident #4, grabbed his/her wheelchair, and hit Resident #4 in the face. Findings include: The Facility's Resident to Resident Altercation Policy, dated (MONTH) (YEAR), indicated staff will monitor residents for aggressive/inappropriate behaviors towards other residents and all altercations, including those that may represent resident-to-resident abuse. Resident #4's Face Sheet indicated he/she was admitted to the Facility in (MONTH) 2012 and had a court appointed Guardian to make his/her healthcare decisions. Resident #4's Plan of Care, dated 03/19/19, indicated he/she had the potential to be victimized related to [MEDICAL CONDITION] and a language barrier. Resident #4's Discharge Minimum Data Set (MDS) Assessment, dated 06/03/19, indicated he/she had some difficulty in making decisions in new situations. Resident #6's Face Sheet indicated he/she was admitted to the Facility in (MONTH) (YEAR); [DIAGNOSES REDACTED]. Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 06/15/19, indicated he/she was cognitively intact and had a history of [REDACTED]. Resident #6's Plan of Care, dated 05/31/19, indicated he/she has a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder, which has the potential to manifest in verbal and physical aggression and socially inappropriate behaviors. Resident #4's Nursing Progress Note, dated 07/06/19, indicated that staff heard screaming in the hallway and Nurse #1 saw a Mental Health Counselor (later identified as Mental Health Counselor #1) run in the hallway to separate the aggressor (later identified as Resident #6) from the victim (later identified as Resident #4). The Note indicated Resident #6 kept pulling Resident #4's hair and punched him/her in the face nine times. The Note indicated Resident #4 tried to move away but he/she couldn't because Resident #6 continued to hold his/her hair and punch him/her in face. The note indicated the aggressor managed to hit the victim two separate times. The note indicated Resident #4 was on observation and Resident #6 was assigned a one-to-one staff member for safety supervision. Surveyor #2 interviewed Nurse #1 at 11:45 A.M. on 07/24/19. Nurse #1 said Resident #6 hit Resident #4 in the head several times. Nurse #1 said Resident #6 hit Resident #4 in the head a second time, after staff had separated the residents after the first incident. The Police Incident Report, dated 07/06/19, indicated Nurse #1 said she witnessed Resident #6 physically assaulting Resident #4. The Report indicated Nurse #1 said Resident #6 grabbed Resident #4 and began punching him/her in the face. The Report indicated that staff broke up the fight and separated the two residents. Review of the Resident Care Unit, Security Camera Footage (without audio), dated 07/06/19 at 3:25:06 P.M. (later identified as 2:35 P.M.). The security camera footage was facing the unit exit/entrance doors. Resident #6, unidentified Resident #1 and unidentified Resident #2 sat in their wheelchairs at the end of the hallway near the unit entrance/exit door. Resident #4, who was in a wheelchair, left his/her room and entered the hallway near the unit entrance/exit door. At 3:26:47 P.M. Resident #4 was in the hallway near Resident #6 and the unidentified Resident #1 and unidentified Resident #2 for approximately 34 seconds, when Resident #6 maneuvered his/her wheelchair towards Resident #4 and hit him/her approximately 20 times on his/her head and upper body. The video showed a staff member (later identified as Nurse #1) responded to the incident and grabbed Resident #6's wheelchair and moved him/her down the hallway, approximately 10 feet away from Resident #4. Nurse #1 walked back over to Resident #4. An Unidentified Staff Member #1 came in view of the video camera and stood in the hallway near Resident #6. Nurse #1 moved Resident #4 down the hallway, closer to the unit entrance/exit doors. Unidentified Staff Member #2 moved the Unidentified Resident #1 down the hallway, away from the unit door and out of view of the security camera footage. Unidentified Resident #2 remained in the hallway, near Resident #4 and the unit doors. All staff members walked down the hallway, away from Resident #4 and Unidentified Resident #2 who stayed near the unit doors. All staff members walked past Resident #6, who sat approximately 20 feet away from Resident #4 while remaining facing Resident #4. All staff members walked down the hallway, away from the unit doors, and out of view of the security camera footage. Once all the staff members walked away from Resident #4, past Resident #6, and out of view of the security camera footage, at 3:27:52 P.M., Resident #6 wheeled his/herself down the hallway towards Resident #4, for approximately 15 seconds and came within approximately five feet of Resident #4, before Unidentified Staff Member#1 and Unidentified Staff Member #2 walked down the hall near Resident #6 and Resident #4 to intervene. At 3:28:11 P.M. Unidentified Staff Member #2 wheeled Resident #6 into his/her bedroom and Unidentified Staff Member #1 wheeled Resident #4 into his/her bedroom. Resident #6 and Resident #4's bedrooms are diagonally across the hall from one another. Unidentified Resident #2 still remained in the hallway near the unit doors and next to Resident #6's bedroom door. At 3:28:28 P.M. unidentified staff member #1 and Unidentified Staff Member #2 walked down the hallway, away from the unit doors and out of view of the security camera footage. At 3:28:59 P.M. Resident #4 wheeled himself/herself out of his/her bedroom, down the hallway, away from the unit doors and Resident #4 was seen pointing at his/her face and then went out of view of the security camera footage. At 3:30:45 P.M. Resident #6 wheeled his/herself out of his/her bedroom and down the hallway, away from the unit doors. At 3:30:51 P.M. Resident #4 became in view of the security camera footage and wheeled his/her wheelchair down the hallway where Resident #6 sat in his/her wheelchair. Resident #6 was seen saying something to Resident #4. Resident #4 was trying to wheel himself/herself down the hallway and grabbed the wall for assistance to wheel himself/herself past and/or away from Resident #6. No staff member was present or in view of the security camera. At 3:31:04 P.M. Resident #6 wheeled himself/herself towards Resident #4, grabbed Resident #4's wheelchair, pulled Resident #4 toward him/her and hit Resident #4 in the face. Unidentified Resident #3 came out of his/her bedroom, entered the hallway, and was seen pointing at and saying something to Resident #6. At 3:31:14 P.M. Nurse #1 and Unidentified Staff Member #3 came into view of the security camera footage and responded to the residents. Unidentified Staff Member #3 wheeled Resident #4 back into his/her bedroom and then left him/her in the bedroom. Nurse #1 was seen talking to Resident #6. Nurse #1 wheeled Resident #6 down the hallway, away from the unit doors and out of view of the security camera footage. Resident #4's Social Service Note, dated 07/08/19, indicated the Social Worker interviewed him/her using an interpreter line for his/her preferred language. The Note indicated Resident #4 said he/she was in the hallway and a peer (later identified as Resident #6) started attacking him/her. The Note indicated Resident #4 said it was unfortunate that this had to happen to him/her, but it is part of his/her destiny; he/she had been at the Facility for many years and had never caused trouble to anyone. The Note indicated Resident #4 said he/she was afraid to go out of his/her room and does not want to go out of his/her room. Resident #4's physician progress notes [REDACTED]. The Note indicated Resident #4 had ecchymosis and [MEDICAL CONDITION] on the right side of his/her face, slight swelling to his/her left knee, Surveyor #2 interviewed Social Worker (SW) #2 at 12:25 P.M. on 07/23/19. SW #2 said that when she met with Resident #4 on 07/08/19, he/she was very upset and crying. SW #2 said she offered Resident #4 a room change, but he/she declined to change rooms because he/she was familiar with the staff on the unit and vice versa. At approximately 6:15 A.M. on 07/11/19, Surveyor #1 observed a large bruise on Resident #4's right eye and on the side of his/her face. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 12:05 P.M. on 07/11/19. Nurse #3 said she was helping complete five-minute safety checks for Resident #6. Nurse #3 said she just saw Resident #6 a second ago and he/she was in his/her bedroom. Nurse #3, Surveyor #1, and Surveyor #2 walked to Resident #6's bedroom and he/she was not in there. Nurse #3 found Resident #6 sitting at a table in the dining room. Nurse #3 said Resident #6 was so fast and sneaky. Nurse #1 said she worked on 07/06/19, when Resident #6 kept pulling and punching Resident #4. Nurse #1 said the incidents happened directly under the Facility security camera. Surveyor #1 and Surveyor #2 interviewed the Administrator at 2:00 P.M. The Administrator said she had not watched the security camera footage prior to watching the footage with Surveyor #1 and Surveyor #2. The Administrator said the security camera footage was approximately an hour off real time.

Based on records reviewed, observations, and interviews, for two of 17 sampled residents (Resident #4 and Resident #6), the facility failed to prevent, protect and ensure Resident #4 was free from abuse when on 07/06/19, Resident #6 physically assaulted Resident #4 on two separate instances, resulting in his/her face being swollen and bruised. -At 3:26:47 P.M. on 07/06/19, Resident #4 was in the hallway near Resident #6 and Unidentified Resident #1 and Unidentified Resident #2 for approximately 34 seconds, when Resident #6 maneuvered his/her wheelchair towards Resident #4 and hit him/her approximately 20 times on his/her head and body. -At 3:27:52 P.M. on 07/06/19, staff walked away from Resident #6 and Resident #4. Resident #6 wheeled himself/herself down the hallway towards Resident #4, for approximately 15 seconds and came within approximately five feet of Resident #4, before staff intervened. -At 3:30:51 P.M. on 07/06/19, Resident #4 wheeled his/her wheelchair down the hallway where Resident #6 sat in his/her wheelchair. Resident #6 was seen saying something to Resident #4. Resident #4 was trying to wheel himself/herself down the hallway and grabbed the wall for assistance to wheel his/her wheelchair past and/or away from Resident #6. -At 3:31:04 P.M. on 07/06/19, Resident #6 wheeled himself/herself towards Resident #4, grabbed his/her wheelchair, and hit Resident #4 in the face. Findings include: The Facility's Resident to Resident Altercation Policy, dated April 2018, indicated staff will monitor residents for aggressive/inappropriate behaviors towards other residents and all altercations, including those that may represent resident-to-resident abuse. Resident #4's Face Sheet indicated he/she was admitted to the Facility in September 2012 and had a court appointed Guardian to make his/her healthcare decisions. Resident #4's Plan of Care, dated 03/19/19, indicated he/she had the potential to be victimized related to [MEDICAL CONDITION] and a language barrier. Resident #4's Discharge Minimum Data Set (MDS) Assessment, dated 06/03/19, indicated he/she had some difficulty in making decisions in new situations. Resident #6's Face Sheet indicated he/she was admitted to the Facility in September 2018; [DIAGNOSES REDACTED]. Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 06/15/19, indicated he/she was cognitively intact and had a history of [REDACTED]. Resident #6's Plan of Care, dated 05/31/19, indicated he/she has a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder, which has the potential to manifest in verbal and physical aggression and socially inappropriate behaviors. Resident #4's Nursing Progress Note, dated 07/06/19, indicated that staff heard screaming in the hallway and Nurse #1 saw a Mental Health Counselor (later identified as Mental Health Counselor #1) run in the hallway to separate the aggressor (later identified as Resident #6) from the victim (later identified as Resident #4). The Note indicated Resident #6 kept pulling Resident #4's hair and punched him/her in the face nine times. The Note indicated Resident #4 tried to move away but he/she couldn't because Resident #6 continued to hold his/her hair and punch him/her in face. The note indicated the aggressor managed to hit the victim two separate times. The note indicated Resident #4 was on observation and Resident #6 was assigned a one-to-one staff member for safety supervision. Surveyor #2 interviewed Nurse #1 at 11:45 A.M. on 07/24/19. Nurse #1 said Resident #6 hit Resident #4 in the head several times. Nurse #1 said Resident #6 hit Resident #4 in the head a second time, after staff had separated the residents after the first incident. The Police Incident Report, dated 07/06/19, indicated Nurse #1 said she witnessed Resident #6 physically assaulting Resident #4. The Report indicated Nurse #1 said Resident #6 grabbed Resident #4 and began punching him/her in the face. The Report indicated that staff broke up the fight and separated the two residents. Review of the Resident Care Unit, Security Camera Footage (without audio), dated 07/06/19 at 3:25:06 P.M. (later identified as 2:35 P.M.). The security camera footage was facing the unit exit/entrance doors. Resident #6, unidentified Resident #1 and unidentified Resident #2 sat in their wheelchairs at the end of the hallway near the unit entrance/exit door. Resident #4, who was in a wheelchair, left his/her room and entered the hallway near the unit entrance/exit door. At 3:26:47 P.M. Resident #4 was in the hallway near Resident #6 and the unidentified Resident #1 and unidentified Resident #2 for approximately 34 seconds, when Resident #6 maneuvered his/her wheelchair towards Resident #4 and hit him/her approximately 20 times on his/her head and upper body. The video showed a staff member (later identified as Nurse #1) responded to the incident and grabbed Resident #6's wheelchair and moved him/her down the hallway, approximately 10 feet away from Resident #4. Nurse #1 walked back over to Resident #4. An Unidentified Staff Member #1 came in view of the video camera and stood in the hallway near Resident #6. Nurse #1 moved Resident #4 down the hallway, closer to the unit entrance/exit doors. Unidentified Staff Member #2 moved the Unidentified Resident #1 down the hallway, away from the unit door and out of view of the security camera footage. Unidentified Resident #2 remained in the hallway, near Resident #4 and the unit doors. All staff members walked down the hallway, away from Resident #4 and Unidentified Resident #2 who stayed near the unit doors. All staff members walked past Resident #6, who sat approximately 20 feet away from Resident #4 while remaining facing Resident #4. All staff members walked down the hallway, away from the unit doors, and out of view of the security camera footage. Once all the staff members walked away from Resident #4, past Resident #6, and out of view of the security camera footage, at 3:27:52 P.M., Resident #6 wheeled his/herself down the hallway towards Resident #4, for approximately 15 seconds and came within approximately five feet of Resident #4, before Unidentified Staff Member#1 and Unidentified Staff Member #2 walked down the hall near Resident #6 and Resident #4 to intervene. At 3:28:11 P.M. Unidentified Staff Member #2 wheeled Resident #6 into his/her bedroom and Unidentified Staff Member #1 wheeled Resident #4 into his/her bedroom. Resident #6 and Resident #4's bedrooms are diagonally across the hall from one another. Unidentified Resident #2 still remained in the hallway near the unit doors and next to Resident #6's bedroom door. At 3:28:28 P.M. unidentified staff member #1 and Unidentified Staff Member #2 walked down the hallway, away from the unit doors and out of view of the security camera footage. At 3:28:59 P.M. Resident #4 wheeled himself/herself out of his/her bedroom, down the hallway, away from the unit doors and Resident #4 was seen pointing at his/her face and then went out of view of the security camera footage. At 3:30:45 P.M. Resident #6 wheeled his/herself out of his/her bedroom and down the hallway, away from the unit doors. At 3:30:51 P.M. Resident #4 became in view of the security camera footage and wheeled his/her wheelchair down the hallway where Resident #6 sat in his/her wheelchair. Resident #6 was seen saying something to Resident #4. Resident #4 was trying to wheel himself/herself down the hallway and grabbed the wall for assistance to wheel himself/herself past and/or away from Resident #6. No staff member was present or in view of the security camera. At 3:31:04 P.M. Resident #6 wheeled himself/herself towards Resident #4, grabbed Resident #4's wheelchair, pulled Resident #4 toward him/her and hit Resident #4 in the face. Unidentified Resident #3 came out of his/her bedroom, entered the hallway, and was seen pointing at and saying something to Resident #6. At 3:31:14 P.M. Nurse #1 and Unidentified Staff Member #3 came into view of the security camera footage and responded to the residents. Unidentified Staff Member #3 wheeled Resident #4 back into his/her bedroom and then left him/her in the bedroom. Nurse #1 was seen talking to Resident #6. Nurse #1 wheeled Resident #6 down the hallway, away from the unit doors and out of view of the security camera footage. Resident #4's Social Service Note, dated 07/08/19, indicated the Social Worker interviewed him/her using an interpreter line for his/her preferred language. The Note indicated Resident #4 said he/she was in the hallway and a peer (later identified as Resident #6) started attacking him/her. The Note indicated Resident #4 said it was unfortunate that this had to happen to him/her, but it is part of his/her destiny; he/she had been at the Facility for many years and had never caused trouble to anyone. The Note indicated Resident #4 said he/she was afraid to go out of his/her room and does not want to go out of his/her room. Resident #4's physician progress notes [REDACTED]. The Note indicated Resident #4 had ecchymosis and [MEDICAL CONDITION] on the right side of his/her face, slight swelling to his/her left knee, Surveyor #2 interviewed Social Worker (SW) #2 at 12:25 P.M. on 07/23/19. SW #2 said that when she met with Resident #4 on 07/08/19, he/she was very upset and crying. SW #2 said she offered Resident #4 a room change, but he/she declined to change rooms because he/she was familiar with the staff on the unit and vice versa. At approximately 6:15 A.M. on 07/11/19, Surveyor #1 observed a large bruise on Resident #4's right eye and on the side of his/her face. Surveyor #1 and Surveyor #2 interviewed Nurse #3 at 12:05 P.M. on 07/11/19. Nurse #3 said she was helping complete five-minute safety checks for Resident #6. Nurse #3 said she just saw Resident #6 a second ago and he/she was in his/her bedroom. Nurse #3, Surveyor #1, and Surveyor #2 walked to Resident #6's bedroom and he/she was not in there. Nurse #3 found Resident #6 sitting at a table in the dining room. Nurse #3 said Resident #6 was so fast and sneaky. Nurse #1 said she worked on 07/06/19, when Resident #6 kept pulling and punching Resident #4. Nurse #1 said the incidents happened directly under the Facility security camera. Surveyor #1 and Surveyor #2 interviewed the Administrator at 2:00 P.M. The Administrator said she had not watched the security camera footage prior to watching the footage with Surveyor #1 and Surveyor #2. The Administrator said the security camera footage was approximately an hour off real time.

Based on records reviewed and interviews for 1 of 13 sampled residents (Resident #7), the Facility failed to ensure they were not discharged improperly. On 5/01/19, Family Member #1 contacted 911 to have Resident #7 evaluated at hospital. The Facility refused to allow Resident #7 to return to the Facility from the hospital. The Administrator said Resident #7 was considered discharged for failure to pay an outstanding bill he/she owed the Facility. Findings include; The Facility's Policy titled, Discharging a Resident without a Physician's Approval, dated (MONTH) (YEAR), indicated that should a resident or representative request an immediate discharge: -the resident's Attending Physician will be promptly notified, -the discharge must be recorded in the resident's medical record, -if the resident or representative insists on being discharged without the approval of the attending physician, the resident and/or representative must sign a Release of Responsibility Form and should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. Resident # 7 was admitted to the Facility in (MONTH) (YEAR) and his/her [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 02/23/19, indicated Resident #7 made his/her own health care decisions and preferred to communicate in the Greek language. A Social Service Note, dated 04/22/19, indicated the Director of Social Work met with Resident #7 again to discuss a letter from his/her health insurance denying his/her stay at the Facility as of 04/20/19. A Nurse Progress Note, dated 5/01/19, indicated Resident #7 was transferred to the hospital after his/her spouse called 911. A Physician order [REDACTED].#8 wrote a telephone order that Resident #7 may transfer to the hospital. A Nurse Progress Note, dated 05/03/19, indicated Nurse #8 documented that the physician was aware Resident #7's spouse called 911 to transfer Resident #7 to the hospital for no clinical reason; however, the Note indicated a Physician had not actually given an Order to transfer Resident #7 to the hospital on [DATE]. Surveyor #3 interviewed Nurse #8 at 11:57 A.M. on 05/08/19. Nurse #8 said he did not speak to a physician to obtain an order to transfer Resident #7 to the hospital. Nurse #8 said he wrote the Physician Order, dated 05/02/19, to allow Resident #7 to transfer to the hospital. Surveyor #3 reviewed the Notice of Intent Not to Readmit Resident Following hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice, dated 05/01/19, indicated the reason for the decision not to readmit Resident #7 was due to a failure and appropriate notice to pay for (or have failed to have Medicare//Medicaid pay) your stay at the nursing facility, which was faxed to the hospital by the Administrator. Surveyor #3 interviewed the Nursing Supervisor at 3:30 P.M. on 05/22/19. The Nursing Supervisor said the Administrator told him on 05/01/19, not to readmit Resident #7 if the hospital tried to send him/her back to the Facility. The Nursing Supervisor said the Administrator told him that a Notice of Intent Not to Readmit Resident #7 to the Facility had been faxed to the hospital. The Nursing Supervisor said Resident #7 returned to the Facility from the hospital during the 3:00 P.M. to 11:00 P.M. shift, but he was unsure of the exact time. The Nursing Supervisor said he directed the Emergency Medical Technicians to take Resident #7 back to the hospital because the Facility would not allow Resident #7 to return to the Facility. Surveyor #3 interviewed the Administrator at 1:20 P.M. on 05/08/19. The Administrator said Resident #7's discharge did not involve a physician as it was a resident-initiated discharge. The Administrator said the Facility's corporate office advised her not to readmit Resident #7 from the hospital due to the discharge being against medical advice and failure to pay for his/her stay at the Facility. There was no documentation to indicate the Facility notified Resident #7's physician regarding a request for transfer/discharge, obtained a signed Release of Responsibility Against Medical Advice or documented such refusal to sign in Resident #7's medical record. This was not consistent with the Facility's Policy or the Administrator's statement.

Based on records reviewed and interviews, for two of 10 sampled residents (Resident #9 and Resident #10), the Facility failed prevent a resident-to-resident altercation which resulted in Resident #9 falling, hitting his/her head on the floor, sustaining a [MEDICAL CONDITION], which resulted in Resident #9 requiring transfer to the Hospital Emergency Department, where he/she received two staples to close the laceration on the top of his/her head. Findings include: 1. Resident #9 was admitted to the facility 2/9/18, [DIAGNOSES REDACTED]. Resident #9's Admission Minimum Data Set (MDS) Assessment, dated 2/16/18, indicated Resident #9 was cognitively intact and required extensive assistance of one staff member for ambulation. The Care Plan, dated 2/12/18, indicated Resident #9 displayed verbal and physical aggression with a history of threatening behaviors due to [DIAGNOSES REDACTED]. The Care Plan, dated 2/20/18, indicated Resident #9 was at high risk for falls due to gait and balance problems related to [MEDICAL CONDITION]'s Disease and required a safe environment and prompt response to all requests for assistance. 2. Resident #10 was admitted to the facility 2/3/14, [DIAGNOSES REDACTED]. Resident #10's Minimum Data Set (MDS) Assessment, dated 12/23/17, indicated Resident #10 was severely cognitively impaired. The Care Plan, dated 10/25/17, indicated Resident #10 was at high risk for falls related to gait and balance problems, runs in the hallway at night very delusional and required increased supervision on the 11:00 P.M. -7:00 A.M. shift. A Nurse Progress Note, dated 3/13/18, indicated Resident #9 came into Resident #10's room, Resident #10 asked Resident #9 to get out of his/her room, Resident #9 refused and Resident #10 pushed Resident #9 and Resident #9 fell . A Nurse Progress Note, dated 3/13/18, indicated Resident #9 was found lying on the floor with both legs straight, right arm straight and left arm over stomach and he/she sustained a 2 centimeter (cm) laceration on the top of his/her right side of head and wound continued to bleed. The Note indicated Resident #9 was transferred to the hospital for evaluation and treatment. A Risk Management Incident Report, dated 3/13/18, indicated Resident #9 was found lying on the floor and stated that he/she was pushed by another resident and fell . The Report indicated Resident #9 sustained a 2 cm laceration on top of his/her left side of head and Resident #9 was transferred to the hospital for evaluation and treatment. The Hospital's Emergency Department Report, dated 3/13/18, indicated that Resident #9's [DIAGNOSES REDACTED]. The Facility's Incident Report Form, dated 3/19/18, indicated that, at approximately 5:40 A.M. on 3/13/18, Resident #9 was observed on the floor in the hallway, outside of Resident #10's room and he/she had sustained a laceration on the top of his/her head. The Report indicated that Resident #9 stated that he/she had been pushed by Resident #10, and Resident #10 confirmed that he/she had pushed Resident #9, stating that Resident #9 was in his/her room and when he/she asked Resident #9 to leave, he/she did not leave, so Resident #10 pushed Resident #9, which caused Resident #9 to fall down and hit his/her head. The Report indicated that Resident #9 said the reason he/she was in Resident #10's room, was because he/she was looking for CNA #3. Surveyor #1 interviewed Certified Nurse Aide (CNA) #3 at 3:36 P.M. on 5/2/18. CNA #3 said, that at approximately 5:30 A.M. on 3/13/18, she went to check in on Resident #9 in his/her room and Resident #9 said words to the effect, get out of my room! CNA #3 said she went to check on his/her roommate, that Resident #9 got up, grabbed the back of her shirt and pushed her into the hallway and yelled, words to the effect, go outside! CNA #3 said Resident #9 was running after her so she ran into Resident #10's room and that Resident #9 followed her into Resident #10's room. CNA #3 said Resident #10 tried to protect her and he/she told Resident #9 that he/she was not supposed to be in this room, and said words to the effect, get out of my room!. CNA #3 said Resident #9 tried to fight with Resident #10, that Resident #10 pushed Resident #9 and he/she fell and hit his/her head on the floor. CNA #3 said Resident #10 said to her, words to the effect, now you are safe. CNA #3 said then reported this to Nurse #6. CNA #3 said she was afraid of Resident #9 and wanted to get away from him/her, and that is why she ran into Resident #10's room. Surveyor #1 interviewed Nurse #6 at 4:00 P.M. on 5/2/18. Nurse #6 said, and Nurse's Note, dated 3/13/18, indicated the following; at approximately 5:40 A.M. on 3/13/18, Certified Nurse Aide (CNA) #3 checked on Resident #9 and he/she was upset for being woken up and chased after CNA #3, who then ran into Resident #10's room for safety and closed the door; Resident #9 opened the door and Resident #10 told Resident #9 to get out of his/her room; Resident #9 insisted on getting into the room, and therefore Resident #10 pushed Resident #9 and he/she fell to the floor and sustained a two centimeter laceration on the left side of the scalp; Resident #9 was transferred to the hospital, and he/she required two staples to close his/her [MEDICAL CONDITION].

Based on records reviewed and interviews, for two of 10 sampled residents (Resident #9 and Resident #10), the Facility failed to follow their in-service policy and assure that all staff received the mandatory training for essential skills prior to being scheduled to work on their Behavioral Rehabilitation Unit, when Certified Nurse Aide (CNA) #3 was assigned to the unit, without prior training and when Resident #9's behavior escalated CNA #3 was unable to respond appropriately, which triggered a resident to resident altercation, and Resident #9 sustaining a [MEDICAL CONDITION]. Findings include: The Facility's Neurorehabilitation Program Staff Training Policy, undated, indicated that it is the policy of the Neurorehabilitation program to provide mandatory training of essential skills at critical times prior to and during employment. The Policy indicated that the purpose of the training is to prepare staff working within the Neurorehabilitation Program for the special needs of the residents, specialized assessment and treatment protocols and the policies and procedures of the unit. The Policy indicated that this training is in addition to the general facility orientation and training and is specifically designed to train the staff to meet the needs of this patient population. The Facility's B2 Behavioral Rehabilitation Unit Policies Checklist for Float Staff, undated, indicated that if a resident is beginning to escalate, a staff member must intervene, in a non-challenging tone of voice, redirect the resident to leave the area and/or ask for assistance. The Facility's Incident Report Form, dated 3/19/18, indicated that, at approximately 5:40 A.M. on 3/13/18, Resident #9 was observed on the floor in the hallway, outside of Resident #10's room and he/she had sustained a laceration on the top of his/her head. The Report indicated that Resident #9 stated that he/she had been pushed by Resident #10, and Resident #10 confirmed that he/she had pushed Resident #9, stating that Resident #9 was in his/her room and when he/she asked Resident #9 to leave, he/she did not leave, so Resident #10 pushed Resident #9, which caused Resident #9 to fall down and hit his/her head. The Report indicated that Resident #9 said the reason he/she was in Resident #10's room, was because he/she was looking for CNA #3. Surveyor #1 interviewed Certified Nurse Aide (CNA) #3 at 3:36 P.M. on 5/2/18. CNA #3 said, that at approximately 5:30 A.M. on 3/13/18, she went to check on Resident #9 in his/her room and Resident #9 said words to the effect, get out of my room! CNA #3 said she went to check on his/her roommate and then Resident #9 got up, grabbed the back of her shirt, pushed her into the hallway and yelled, words to the effect, go outside! CNA #3 said Resident #9 was running after her so she ran into Resident #10's room and that Resident #9 followed her into Resident #10's room. CNA #3 said Resident #10 tried to protect her and he/she told Resident #9 that he/she was not supposed to be in the room, and said words to the effect, get out of my room!. CNA #3 said Resident #9 tried to fight with Resident #10, that Resident #10 pushed Resident #9, who then fell and hit his/her head on the floor. CNA #3 said Resident #10 said to her, words to the effect, now you are safe. CNA #3 said then reported this to Nurse #6. CNA #3 said she was afraid of Resident #9, wanted to get away from him/her, and that is why she ran into Resident #10's room. CNA #3 said she started work at the Facility in (MONTH) (YEAR) but usually worked on another unit and said she did not get any safety training before she went to work on the Neurobehavioral Unit. Surveyor #1 interviewed Nurse #6 at 4:00 P.M. on 5/2/18. Nurse #6 said, and Nurse's Note, dated 3/13/18, indicated the following; that at approximately 5:40 A.M. on 3/13/18, Certified Nurse Aide (CNA) #3 checked on Resident #9, he/she was upset about being woken up, chased after CNA #3, who then ran into Resident #10's room for safety and closed the door; Resident #9 opened the door, Resident #10 told Resident #9 to get out of his/her room; Resident #9 insisted on getting into the room, and therefore Resident #10 pushed Resident #9 and he/she fell to the floor and sustained a two centimeter laceration on the left side of the scalp; Resident #9 was transferred to the hospital, and he/she required two staples to close the laceration. Surveyor #1 interviewed the Assistant Neurobehavioral Program Director at 4:15 P.M. on 5/2/18. The Program Director said that she usually conducts the Safety Care Training for staff upon hire but, in this case, CNA #3 did not show up for the Safety Care training for working with neurobehavioral residents. The Program Director said CNA #3 was trained in the Safety Care course one to two weeks after the incident, which occurred on 3/13/18. Surveyor #1 interviewed the Staff Development Coordinator (SDC) at 3:50 P.M. on 5/2/18. The SDC said that Safety Care Training was done for everyone and they try to do it right away or at least within the first 90 days of hire. The SDC said that he found out after the incident on 3/13/18, that CNA #3 retreated, did not call for help and did not know the proper technique because she had not been trained in the Safety Care Training Program. The SDC said after this incident, CNA #3 went through the Safety Care Training Program. The SDC said words to the effect, It must have been one of the training's that we pushed off. The SDC said CNA #3 did not have the Safety Care Training prior to the Resident-to-Resident incident on 3/13/18, and said that he was not aware that CNA #3 was put up on the Behavioral unit to work, and said, words to the effect, she fell through the cracks. The SDC said that the Facility keeps a list of employees who have had the Safety Care Training, but that the Facility needs to sharpen the process. The Certificate of Accomplishment, dated 3/26/18, indicated that CNA #3 received education on safety care by Assistant Neurobehavioral Program Director on 3/26/18, 13 days after the incident occurred, six months after CNA #3 was hired.

Based on records reviewed, interviews, and observations for 3 of 5 sampled residents (Resident #1, Resident #2, and Resident #3) the Facility failed to provide adequate supervision to ensure safety and prevent injury, and as a result: - On 9/6/16, Resident #1, who was severely cognitively impaired, was transported by a Transportation Company at 12:00 P.M., to his/her Physician's appointment unaccompanied by a Facility staff member and eloped. The Physician's office contacted the Transportation Company at approximately 3:00 P.M., to transport Resident #1 back to the Facility. The Transportation Company notified the Facility, at approximately 5:00 P.M., that they could not locate Resident #1 at the Physician's office. Resident #1 was found by Emergency Medical Services, sitting on a street curb in another city, at approximately 3:30 A.M., more than 10 hours later, and was transferred to the Hospital Emergency Department where he/she was treated for [REDACTED]. Resident #1 was transferred to second hospital where he/she was admitted to the Intensive Care Unit. -On 9/6/17, Resident #2, who had a [DIAGNOSES REDACTED].#3 who had a [DIAGNOSES REDACTED].M. Resident #3 had a physician's orders [REDACTED].M. to 7:00 A.M. Certified Nurse Aide (CNA) #1 said Resident #3 was on her assignment when the incident occurred and said she did not conduct five minute safety checks for Resident #3 during her 11:00 P.M.-7:00 A.M. shift. Findings Include: 1. Resident #1 was admitted to the Facility in July 2017, [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 5 (scores of 0-7 indicates severe cognitive impairment). Resident #1's Plan of Care related to cognition, dated 7/14/17, indicated that Resident #1 had impaired cognitive function, dementia or impaired thought processes related to impaired decision making, psychotropic drug use, and toxic metabolic [DIAGNOSES REDACTED]. Resident #1's Plan of Care related to Advanced Directives, dated 7/13/17, indicated that Resident #1 a legal guardian who was responsible for making medical decisions for Resident #1. The Resident Event Report Worksheet, dated 9/7/17, indicated that at 4:00 P.M. on 9/6/16, Resident #1 eloped from Hospital grounds. The Worksheet indicated that the incident resulted from a policy variance with a hand written notation that indicated no escort. The Nurse Progress Note, timed at 11:43 P.M. and dated 9/6/17, indicated that Resident #1 left the Facility at noon to go to a Physician's appointment and at 5:00 P.M. the Transportation Company called the Facility to inform them that Resident #1 could not be located at the Physician's office. The Ambulance Report, dated 9/7/17, indicated that at 3:39 A.M., which was more than 10 hours after Resident #1 eloped from his/her Physician's appointment, Resident #1 was found outdoors sitting on a curb on a city street. The Report indicated Resident #1 told Emergency Medical Service staff that he/she had been drinking alcohol and was tired. Resident #1 was transported by Ambulance to the Hospital Emergency Department. The Hospital Emergency Department Report, dated 9/7/17, indicated that Resident #1 was found on the ground and was minimally responsive. The Report indicated that it had been raining most of the day and night. The Report indicated Resident #1's body temperature was hypothermic (low body temperature) at 90.0 degrees (98.6 degrees is average normal body temperature), and he/she was intoxicated. The Report indicated Resident #1 was warmed, administered intravenous fluids, and transferred to the Intensive Care Unit at another Hospital. The Hospital Discharge Summary, dated 9/11/17, indicated that, on 9/6/17, Resident #1 met a friend at a bar and went to a second bar where he/she stayed and slept for a while, and then walked around in the rain for approximately five hours until Emergency Medical Services found him/her. The Summary indicated that Resident #1 was found to be hypothermic in the setting of alcohol intoxication and environmental exposure and was placed on rewarming protocol and his/her body temperature returned to normal on 9/8/17. The Surveyor interviewed the Unit Manager at 1:18 P.M. on 10/24/17. The Unit Manager said Resident #1 should have had a staff member accompany him/her to the Physician's appointment because Resident #1 had short term memory issues, he/she was fairly new to the Facility, and they really did not know him/her well. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 10/24/17. Nurse #1 said that Resident #1 was assigned to her on 9/6/17 and said she did not know if Resident #1 needed a staff member to accompany him/her to the Physician's office. Nurse #1 said although she did not feel that Resident #1 was safe to go alone, she did not verify if Resident #1 needed an escort with the Director of Nursing. The Surveyor interviewed that Director of Nursing (DON) at 3:20 P.M. on 10/24/17. The DON said Resident #1 should not have been sent to the physician's appointment alone. 2. The Policy titled, Accidents and Supervision to Prevent Accidents, dated 4/28/11, indicated that the Facility identifies patient behaviors through risk evaluations that potentially pose a risk to the patient, other patients, and patient-to-patient altercations. The Policy indicated that the Facility communicates the interventions of mitigating potential hazardous risks to relevant staff, assigning responsibility for implementing and documenting interventions. Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #2 was admitted to the Facility in May of 2016 and had [DIAGNOSES REDACTED]. Resident #2's Plan of Care related to behaviors, revised 7/27/17, indicated that he/she had the potential for verbal and physical aggression and his/her safety status was adjusted to five minute checks. Resident #3's Annual Minimum Data Set (MDS), dated [DATE], indicated that Resident #3 was admitted to the Facility in January of 2013 and had [DIAGNOSES REDACTED]. Resident #3's Plan of Care for behaviors, revised 9/08/17, indicated that he/she demonstrated intrusiveness, agitation, physical aggression, and safety checks were to be adjusted as indicated. The Resident Event Report Worksheet, dated 9/6/17, indicated that at 5:40 A.M. a resident to resident altercation occurred between Resident #2 and Resident #3 in the dining room and Resident #2 sustained a laceration to his/her left upper and lower eye lid. The Report indicated that the circumstances related to the event were unknown. The Nurse Progress Note, timed at 7:34 A.M. and dated 9/6/17, indicated that Resident #3 had been physically aggressive, the altercation was unwitnessed, that Resident #3 hit Resident #2 in the face with a brush, and Resident #3 had laughed when approached by staff. The Nurse Progress Note, timed at 7:54 A.M. and dated 9/6/17, indicated that Resident #2 had been in the dining room all night and, at approximately 5:40 A.M., Nurse #1 observed that his/her left upper and lower eye lid was bleeding and first aid was applied. The physician's orders [REDACTED].#3 to have constant staff observation from 7:00 A.M. to 7:00 P.M. and five minute safety checks from 7:00 P.M. to 7:00 A.M. The Surveyor interviewed Nurse #3 at 1:02 P.M. on 10/24/17. Nurse #3 said she worked on the 11:00 P.M. to 7:00 A.M. shift on 9/6/17, but had not witnessed the resident to resident altercation between Resident #2 and Resident #3. Nurse #3 said she could not recall if either resident required increased supervision at the time of the incident and said she was unsure if Resident #3's supervision status was documented anywhere on the unit. The Surveyor interviewed CNA. #1 at 3:05 P.M. on 10/25/17. CNA #1 said she worked the 11:00 P.M. to 7:00 A.M. on the night that Resident #2 and Resident #3 had the resident to resident altercation. CNA #1 said both Resident #2 and Resident #3 were on her assignment that night, but said she did not witness the incident. CNA #1 said she did not know Resident #3 was on five minute checks and said she did not do five minute safety checks on the 11:00 P.M. to 7:00 A.M. shift. CNA #1 said she thought that the five minute safety checks resumed when the Mental Health Counselors came in for their 7:00 A.M. shift. This was not consistent with Resident #3's Physician orders. The Survey interviewed the Neuro-Rehabilitation Program Director at 2:45 P.M. on 10/24/17. The Neuro-Rehabilitation Director said Facility Mental Health Counselors perform safety observations from 7:00 A.M. until 11:00 P.M. and during the 11:00 P.M. to 7:00 A.M. shift, the CNA's were supposed to complete safety observations as ordered, document their checks on the Observation Sheets used by Mental Health Counselors, and then the completed sheets from the night shift were forwarded to her. Constant Observation Sheets for Resident #3, dated 9/5/17 and 9/6/17, listed Resident #3's behavior of concern as aggression. The Observation sheets were initialed at 15 minute intervals and not at five minute intervals from 7:00 A.M. through 7:00 P.M., as ordered by the Physician. The time slots for 7:15 P.M. to 6:45 A.M. were blank. The Facility was unable to provide documentation for completed five minute Observation Sheets for Resident #3. The 15 minute observation intervals were not consistent with physician's orders [REDACTED].

Based on record review and staff interview, the facility failed for 1 resident (#7) of a total sample of 24 residents, to ensure that each resident receive proper care and treatment for [REDACTED]. Findings included: Resident #7 was admitted with [DIAGNOSES REDACTED]. The resident's initial Minimum Data Set Assessment (MDS) completed 12/10/12, indicated that the resident was cognitively intact and needed extensive assistance from facility staff to complete the activities of daily living. The resident was coded with an existing stage 4 pressure area of the left buttock. On 12/6/12 the resident was visited by a wound care consultant per order of the primary care physician. Review of the physician wound consultant evaluation identified a left buttock stage 4 pressure area that measured 4 x 1.0 x 4.3 cm (length x width x depth) and had heavy serosanguinous drainage. Following surgical debridement of muscle, a wound vac (closed drainage vacuum system) at negative pressure was initiated. The wound consultant recommended to measure and record the wound vac output drainage every three days. Review of the 12/6/12 treatment administration record included an order for [REDACTED]. The care plan for the resident's wound vac was incomplete and contained no plan/approaches. Review of nurse's notes and the treatment record revealed problems with the wound vac functionality beginning on 12/7/12 when the wound vac tubing was blocked and was shut off through the night without further assessment. Treatment sheets and nurses notes indicated that the wound vac dressing was changed 12/8/12, 12/9/12 and 12/10/12. On 12/11/12 the 7-3 nurse documented that the wound vac dressing was replaced because of air leaking, and on 12/13/12, the 7-3 staff documented the wound vac was found turned off. New physician orders [REDACTED]. If unsuccessful - remove dressing and sponge- normal saline wash and pack dressing with calcium alginate (used for moist wound management) and dry protective dressing." The frequency to which this alternate treatment was to be completed was not clarified. On 12/25/12 the 11-7 nurse documented that the wound vac was not functioning. There was no documented evidence that the wound was packed with the calcium alginate (the alternate treatment) per the physician order. Review of the nurses' notes and treatment sheets indicated that the wound vac was not functioning properly beginning on the 3-11 shift on 12/31/12 and continuing on 1/1/13, 1/2/13 and 1/3/13. Review of the nurse's notes during this time frame indicated that the wound was packed daily, however, there was no clarification with the physician regarding the frequency to which this alternate treatment was to be completed. No wound treatment observations were available for review during this time. The 1/3/13 physician wound consultant evaluation documented that the stage 4 pressure wound had deteriorated due to the wound vac not working. Following surgical debridement of the muscle, the wound consultant recommended to resume the wound vac and measure and record the output every three days. The wound consultant also recommended using calcium alginate packing twice daily until replacement of the wound vac. At of time of record review on 1/9/13, none of the 1/3/13 wound consultant recommendations resulted in new treatment orders. Unit Manager #2 was interviewed on 1/9/13 at 4:15 P.M. and 1/10/13 at 8:40 A.M. regarding the plan for monitoring the resident's stage 4 wound and the wound vac. Unit Manager #2 was unable to explain why the 1/3/12 physician wound consultant's recommendations were not addressed. Unit Manager #2 could provide no evidence that the physician was made aware that the resident's wound vac remained out for a prolonged time and was unable to explain how often the resident's wound was to be packed when the wound vac was out. Unit Manager #2 reviewed the treatment administration record for 12/3/12 through 1/8/12 and said that staff had not monitored and measured the wound vac output every three days as recommended by the physician wound consultant. Unit Manager #2 said the care plan did not identify approaches for the wound vac. Unit Manger #2 added that the resident's wound vac was accidentally dislodged by the nurse's aide (CNA) while transferring the resident on 1/7/13 and on 1/9/13. Review of the care card provided no guidance to CNA staff identifying that the resident had a wound. On 1/9/13 at 3:45 P.M. the Director of Nurses (DON) was asked about the facility's wound program. The DON said that the wound care physician visits the facility weekly (normally on Thursdays) for wound care rounds and is accompanied by the ADON (Assistant Director of Nurses) (the designated "wound champion") and the respective Unit Manager. The Physician Wound Consultant completes a comprehensive wound evaluation and recommends treatment. The wound champion is responsible to ensure all new orders and recommendations are validated by the primary physician and transcribed. For resident's not followed by the wound consultant, the ADON and Unit Managers are responsible for weekly measurements. The DON said that wound champion is responsible to monitor and report to facility management on the status of wound healing progress via skin committee weekly logs outlining pressure and non- pressure wounds. Review of the 1/4/13 skin committee weekly log, which is used to track and update facility management on the status of pressure wounds and inaccurately documented that the stage 4 wound progress had improved. The Director of Nurses said that the current weekly wound documentation was not comprehensive and inaccurate. The DNS said that she was unaware of the extent of ongoing problems with the resident's wound vac or the deterioration of the resident's wound. The DNS said that the wound vac vendor was contacted to complete education for licensed staff.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was free from involuntary seclusion. Resident #2 and Resident #3 said that on the night of 2/27/12 at approximately 2:30 A.M., they heard Resident #1 yelling in his/her bedroom, while his/her bedroom door was tied shut. Resident #2 and Resident #3 said they saw Certified Nurse Assistant (CNA) #1, with Nurse #1 present, tie Resident #1's bedroom door knob to the handrail with a johnny. Findings include: The Face Sheet indicated that Resident #1's admitted was June, 2009. The [DIAGNOSES REDACTED]. The resident profile, which was updated in July, 2010, indicated that Resident #1 resisted personal care and was verbally inappropriate. The resident profile indicated that Resident #1 required continual monitoring and supervision while ambulating independently on the unit. The Surveyor interviewed the Program Manager at 2:15 P.M. on 4/9/12. The Program Manager said all staff assigned to Resident #1's unit have been educated on the neuro behavioral program that included De-Escalation Techniques. The Program Manager said De-Escalation Techniques included: maintain safety, avoid making the situation worse, or making the resident more agitated. The Program Manager said staff assigned to Resident #1's unit was educated on the neuro behavioral program and psychiatric emergencies. Psychiatric emergencies required staff to notify Unit Manager #1, Physician #1, or the Psychiatrist when it had been determined that physical or further interventions were needed to maintain safety. The plan of care, updated 7/16/10, indicated that Resident #1 had the potential to become agitated and interventions included: a low stimulus environment while re-directing with conversation, folding linen, organizing paperwork, involving him/her with his watch collection, and providing Resident #1 with a favorite movie or music which had the potential of calming him/her. The plan of care, updated 3/10/11, indicated that Resident #1 had behavioral problems, and approaches included: assess mood and behavior, reassure frequently and intervene as needed, administer medications as needed, and notify physician if symptoms do not improve, The Quarterly Minimum Data Set assessment (MDS), completed on 12/28/11, indicated that Resident #1 had problems with [MEDICAL CONDITION] and had behaviors that included wandering. The MDS indicated that Resident #1 received antipsychotic medications and antianxiety medications. The MDS indicated that Resident #1 had no restraints used. Resident #1 was not interviewed due to impaired cognitive status. The Surveyor interviewed Resident #2 at 9:15 A.M. on 4/9/12. The Surveyor interviewed Resident #3 at 9:00 A.M. on 4/9/12. Resident #2 and Resident #3 said that on the night of 2/27/12 they heard Resident #1 yelling in his/her bedroom, while his/her bedroom door was tied shut. Resident #2 and Resident #3 said they saw Certified Nurse Assistant (CNA) #1, with Nurse #1 present, tie Resident #1's bedroom door knob to the handrail with a johnny. Resident #2 said he/she told Nurse #1 that the johnny securing the door to the handrail better be untied when Resident #2 and Resident #3 returned from smoking. Resident #2 and Resident #3 said when they returned from smoking about 20 minutes later, Resident #1's bedroom door remained tied shut while Resident #1 yelled for help behind the closed door. Resident #2 and Resident #3 said they untied the johnny from Resident #1's bedroom door knob, opened Resident #1's bedroom door, and calmed down Resident #1. Resident #2 and Resident #3 said that at about 2:30 A.M. on 2/27/12, CNA #1 with Nurse #1 present tied Resident #1's bedroom door knob to the hand rail with a johnny. Resident #2 and Resident #3 said Nurse #1 left Resident #1 confined in his/her bedroom for approximately 20 minutes. Resident #2 and Resident #3 said they removed the johnny because Resident #1 was yelling for help from behind his/her bedroom door. Resident #2 said he/she reported the incident to the day shift staff and was pleased that Nurse #1 and CNA #1 were terminated. The Surveyor interviewed CNA #1 at 10:30 A.M. on 4/9/12. CNA #1 said he held Resident #1's door shut while Nurse #1 tied one end of the johnny to Resident #1's bedroom door knob and the other end of the johnny to the wall handrail while Resident #1 remained in his/her bedroom with the bedroom door secured shut. The Surveyor interviewed Nurse #1 at 9:30 A.M. on 4/9/12. Nurse #1 said she did not recall tying the door knob to the handrail, but told CNA #1 to secure Resident #1's bedroom door shut with him/her in the bedroom, because Resident #1 had attempted to elope from the Facility. There was no record that an assessment was completed prior to confining Resident #1 or that there were physicians' orders authorizing the confinement of Resident #1. The Surveyor interviewed CNA #2 at 6:45 A.M. on 4/9/12. The Surveyor interviewed CNA #3 at 7:00 A.M. on 4/9/12. CNA #2 and CNA #3 said they observed CNA #1 and Nurse #1 escort Resident #1 into his/her bedroom. CNA #2 and CNA #3 said they had not observed Resident #1 confined to his/her bedroom because they were doing rounds on another wing at the time of the incident. CNA #2 and CNA #3 said Resident #1 seemed his/her usual self following the incident. The Surveyor interviewed Unit Manager #1 at 7:15 A.M. on 4/9/12. The Surveyor interviewed the Program Director at 11:45 A.M. on 4/9/12. Unit Manager #1 and the Program Director said Resident #2 reported the incident at approximately 8:00 A.M. on 2/27/12, the Director of Nurses was notified, and an internal investigation was initiated. Unit Manager #1 said Resident #1 was calm on the morning of 2/27/12 and was unable to recall the incident. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M. on 4/9/12. The DON said Resident #1 seemed calm on the morning of the incident, had no memory of the incident, and staff observed no untoward effect following the incident. The DON said Physician #1 was notified of the incident, and gave no new orders. The investigation summary, dated 3/8/12, indicated Resident #2 reported that she saw CNA #1, with Nurse #1 present, tie one end of the johnny to Resident #1's bedroom door knob and the other end of the johnny to the handrail which prevented the door from opening. The DON said Nurse #1 and CNA #1 were terminated for the involuntary seclusion of Resident #1.

Based on record review, observation and interview, the facility failed for 1 resident (#15) of a total sample of 24 residents, to ensure that each resident received proper care and treatment for [REDACTED]. The findings included: Resident #15 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 6/27/10 indicated that the resident had severe cognitive impairment and required extensive assistance from facility staff to complete activities of daily living. The facility failed to address the resident's ongoing unplanned weight loss while usually eating 100% of food served. No strategies were developed to prevent further weight loss. Upon admission to the facility on [DATE], the resident's weight was 150.2 pounds. Per a dietary assessment, completed 3/30/10, the resident's ideal body weight was 138.6 to 169.4, and the resident's usual body weight was 156 pounds. The resident's diet order from admission included a regular diet with puree texture, lactose free, nectar thick liquids at room temperature. The resident was to have water on the tray at all meals, a sippie cup for fluids and a lip plate. The resident's plan was to have soy milk and regular yogurt with meals and pudding with medications. Because the resident did not like mashed potato, the resident was served double portion meat and double portion vegetables. During interview with the food manager on 9/2/10 at noon, replacing the potato for a resident on a puree diet was very difficult because the textures of other starches available would put the resident at risk for choking. The goal weight, as indicated on the original care plan, dated 4/1/10, was that the resident's weight remain at 150 pounds +/- 5 pounds. On 5/3/10 the weight was 150 pounds. On 5/17/10 the weight was 147.7. On 5/26/10 the resident's weight was 147 pounds. On 5/31/10 the weight was 144 pounds. Near the 5/31/10 weight, a staff person wrote "weight with chair (scale)." Per interview with the dietician on 9/3/10 at 10 AM, the resident was weighed with a Hoyer previously. In June the weights were 140 pounds (6/7/10), 145 pounds (6/14/10), 143.1 pounds (6/21/10) and 143 pounds (6/28/10.) A dietary assessment, completed 6/27/10 noted that the resident had lost 7 pounds in the 3 months since admission (4.7% in 90 days.) The dietician noted that the resident ate 100% of his meals, supplements and fluids. The plan was to follow the resident at the weekly weight meeting and that the resident not go below 143 pounds. Although the resident was losing weight while eating 100 % was not addressed. Upon request to view the minutes of the weight variance meeting as it pertained to Resident #15, the facility could only provide evidence that the resident was discussed on 6/10/10 and 6/24/10. On 6/10/10 the weight difference was attributed to the switch to the chair scale. On 6/24/10 the weight loss to 143.1 pounds was noted, and the plan was to "continue with the plan of care." The resident had a significant, unplanned weight loss of 8.2% in the 3 months from 5/3/10 (150.1 pounds) to 8/8/10 (137.8 pounds). Despite this weight loss, the resident was not discussed at the weight variance meeting; nor were interventions developed to address this weight loss. In July, the resident's weights were 140.12 pounds (7/5/10), 141.2 pounds (7/12/10), 139 pounds (7/20/10) and 139.8 pounds (7/22/10.) The resident was not weighed between 7/22/10 and 8/8/10. In August the weights were 137.8 pounds (8/8/10), 136.2 pounds (8/16/10), 138.9 pounds (8/23/10) and 139 pounds (8/30/10.) Per interview with the unit manager on 9/1/10 at 3 PM, no reassessment of the resident's weights or notification to the physician was made following the resident's additional weight loss. Per interview with the dietician on 9/3/10 at 10 AM, the facility policy was to reweigh for weight variances of 3 pounds or greater and report the weights to the dietician and physician. There was no evidence that the weights were checked and reported as required Per observation of the resident at lunch on 8/31/10, 9/1/10 and 9/2/10 the resident ate 100% of the meal and 100% of the yogurt. Per review of the dietary intake sheets, the resident's usual intake was 100% for meals and snacks. Only on rare occasions did the resident take less than 80%.