Every finding on record at Casas Adobes Post Acute Rehab Center

Based on clinical record review, observations, interviews, and review of the facility's policies, the facility failed to ensure 1 of 35 residents (Resident #1) received oxygen therapy in accordance with a current physician's order. The deficient practice placed Resident #1 at risk for unmonitored and potentially unnecessary medical treatment.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, and chronic pulmonary edema.Review of the admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #1 had moderate cognitive impairment. The same MDS indicated that Resident #1 was not experiencing shortness of breath but was on oxygen therapy.A physician's order, dated April 28, 2026, indicated Resident #1 was to have continuous oxygen at 2 liters per minute (lpm) via nasal cannula (NC). The order was subsequently discontinued on May 16, 2026 at 1:37 P.M. A secondary review of all current physician's orders confirmed no active orders for oxygen therapy was on file.On May 20, 2026, at 8:54 A.M., Resident #1 was observed in her bed with a NC in place and connected to an oxygen concentrator set at 2 lpm.A second observation of Resident #1 on May 20, 2026 at 1:32 P.M., confirmed Resident #1 remained in bed with her NC in place at 2 lpm. During this observation, Resident #1 stated that the oxygen helps her breathe better.An interview was conducted with a Certified Nursing Assistant (Staff #132/CNA) on May 20, 2026 at 1:54 P.M. Staff #132 shared that Resident #1 uses oxygen at 2 lpm and had used oxygen since admission.An interview was conducted with a Registered Nurse (Staff #301/RN) on May 20, 2026 at 1:59 P.M. Staff #301 shared that he was unaware of the facility's policy requiring a physician's order for a resident's oxygen use. He acknowledged that based on his experience, residents would typically need physician's orders to use supplemental oxygen. When asked if Resident #1 used oxygen, Staff #301 reviewed her clinical chart and shared that she did not use oxygen because there was no order for it. At 2:05 PM. Staff #301 and surveyor entered Resident #1's room and directly observed her using oxygen via a NC. Staff #301 then reviewed the clinical record a second time and confirmed there was no current order for oxygen use. He further stated he was unfamiliar with the facility's protocol regarding oxygen administration. An interview was conducted with a Licensed Practical Nurse Supervisor (Staff #103/LPN) on May 20, 2026 at 2:10 P.M. Staff #103 stated that residents are required to have physician's orders for oxygen use. Upon being taken to Resident #1's room, Staff #103 observed the resident using oxygen via a NC and stated that resident should have orders for its use. After reviewing Resident #1's clinical record, Staff #103 confirmed the resident did not have active orders for oxygen and stated it was not the facility's process to administer oxygen without current orders. Staff #103 added that Resident #1 did have orders for oxygen use; however, it was discontinued on May 16, 2026. Staff #103 stated that a resident receiving oxygen without a physician's order presents a risk of hypoxia. An interview was conducted with the Director of Nursing (Staff #120/DON) on May 20, 2026 at 2:22 P.M. Staff #120 stated that residents are required to have current physician's orders for oxygen use, as oxygen is considered a medication. While reviewing Resident #1's clinical record, Staff #120 noted that a new oxygen order had been entered that day at 2:22 P.M. by RN/Staff #233. Staff #120 confirmed the prior oxygen order had been discontinued on May 16, 2026, and stated she was not able to locate a progress documenting the clinical rationale for the discontinuation. Staff #120 further stated that she did not know whether a resident receiving oxygen without a current physician's order would result in an adverse reaction. An interview was conducted with Staff #233 on May 20, 2026 at 2:38 P.M. Staff #233 shared that she had entered the new oxygen orders for Resident #1 upon learning the resident was receiving oxygen without a current order. Staff #233 explained that Resident #1 was issued a Notice of Medicare Non-Coverage (NOMNC) and the therapy team had assessed the resident as no longer needing the oxygen, resulting in the discontinuation of the order. Staff #233 further explained Resident #1 should have ceased oxygen use when the order was discontinued and noted the resident was scheduled for discharge from the facility on May 22, 2026.Review of the facility's policy and procedure titled Oxygen Administration, last reviewed in April 2026, indicated that oxygen therapy is to be administered as ordered by the physician.

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure the Ombudsman's office was notified of the discharge of four residents (#150, #211, #215, and #217). The sample size was four. The deficient practice could lead to lack of post-discharge care coordination for residents.Findings Include: - Regarding Resident #217: Resident #217 was admitted on [DATE] with diagnoses that included fracture of the right lower leg, difficulty in walking, and polyneuropathy. Resident #217 was discharged on February 20, 2026. A care plan, initiated on February 8, 2026, revealed a focus for discharge to home with interventions that included coordination with the resident and the resident's family for plan of care and discharge planning. A Social Services Summary progress note, dated for February 9, 2026, revealed that the resident wanted to discharge home with her significant other. A Case Manager progress note, dated for February 17, 2026, revealed that the resident received a Notice of Medicare Non-Coverage (NOMNC) with a discharge date of February 20, 2026. A Case Manager progress note, dated February 18, 2026, revealed the resident submitted an appeal to the NOMNC provided, and the documents were uploaded in the resident chart. A Case Manager progress note, dated for February 20, 2026, revealed the resident lost the appeal and proceeded with planned discharge home. A Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also revealed that Resident #217 participated in discharge planning and had a planned discharge. There was no evidence in the resident's progress notes, dated February 2, 2026 through February 20, 2026, indicating that the facility had contacted the Ombudsman of the resident's discharge. Regarding Resident #150: Resident #150 was admitted to the facility on [DATE], with diagnoses that included fracture of the left femur, muscle weakness, major depressive disorder, and chronic kidney disease. Review of an admission Minimum Data Set (MDS), dated [DATE], indicated Resident #150 participated in a Brief Interview for Mental Status (BIMS) assessment and scored a 15, indicating he was cognitively intact. Review of an order summary revealed a physician's order, dated May 12, 2026, which indicated the resident was to be transferred to the hospital. Review of a progress note, dated May 12, 2026 at 12:43 P.M. revealed Resident #150 was sent to the hospital, directly from an orthopedic appointment, for surgery. Further review of Resident #150's clinical record revealed no documentation indicating the Ombudsman's office was notified of the resident's transfer to the hospital. Regarding Resident #211: Resident #211 was admitted to the facility on [DATE], with diagnoses that included dementia, Chronic Obstructive Pulmonary Disease (COPD), and cognitive communication deficit. He was discharged on April 19, 2026. Review of a discharge MDS, dated [DATE], revealed that a BIMS assessment was not completed; however, the same MDS indicated the staff assessment of cognitive skills for daily decision-making was noted to be severely impaired. Review of a progress note, dated April 19, 2026 at 1:58 P.M., revealed Resident #211 exhibited an increase in confusion and was reaching out in the air with his hands. The note further revealed that a family member requested that Resident #211 be sent to the hospital due to the increased confusion and medication refusal. Review of a second progress note, dated April 19, 2026 at 7:45 P.M., revealed Resident #211 was sent to the hospital upon a family member's request. Further review of the clinical record revealed no documentation indicating the Ombudsman's office was notified of the resident's discharge to the hospital. Regarding Resident #215: Resident #215 was admitted to the facility on [DATE] with diagnoses that included COPD, interstitial pulmonary disease, suicidal ideations, and major depressive disorder. The resident was discharged on February 12, 2026. Review of a Medicare 5-day MDS, dated [DATE], indicated Resident #215 participated in a BIMS assessment and scored a 04, indicating she had severe cognitive impairment. Review of a physician's order revealed Resident #215 was to be transferred to another facility on February 12, 2026. Review of a progress note, dated February 12, 2026 at 6:31 P.M., revealed Resident #215 was discharged from the facility. Further review of the clinical record revealed the resident was discharged to another facility; however, there was no documentation indicating the Ombudsman's office was notified of the discharge. An e-mail received on May 21, 2026, at 7:50 P.M. from the facility's Ombudsman confirmed that the facility had not submitted transfer and discharge reports from October 2025 through April 2026, and noted that the transfer/discharge report was submitted to her that evening. An interview was conducted on May 22, 2026 at 10:21 A.M. with Social Services Manager (SSM/Staff #2). Staff #2 shared that her assistant had recently gone out on leave and that, during that time, the task of making notifications of resident transfers and discharges to the Ombudsman's office was not being completed. Staff #2 stated she discovered the error while conducting an audit of Ombudsman notifications the prior month. Staff #2 further stated that upon review of her emails, she found the last notification made to the Ombudsman was in September 2025. Staff #2 stated she contacted the Ombudsman on May 19, 2026, and provided a list of residents who were transferred or discharged in April 2026. Staff #2 acknowledged that residents could be at risk of not being informed of available resources post-discharge if the Ombudsman was not notified of transfers and discharges. An interview was conducted on May 22, 2206 at 10:29 A.M. with the Director of Nursing (DON/Staff #120). Staff #120 stated that transfer and discharge notifications to the Ombudsman's office was not completed from October 2025 until May 19, 2026. Staff #120 further stated that Staff #2 had sent the list of April transfers and discharges on May 19, 2026, and that on May 21, 2026, Staff #2 had sent the transfers and discharges list for October 2025 through March 2026. Staff #120 stated her expectation was that the resident transfer and discharge list was to be sent to the Ombudsman's office on a monthly basis. Staff #120 was not able to identify potential risks to residents if the Ombudsman is not notified of the transfers and discharges. She added that the Ombudsman is at the facility once a month for Resident Council meetings, and that she would be notified in person if there were issues with a resident's transfer or discharge; however, Staff #120 acknowledged that a formal notification to the Ombudsman was required. Review of the facility's policy and procedure titled Criteria for Transfer and Discharge, revised/reviewed in December 2023, revealed the policy required that transfers and discharges be documented in the clinical record; however, the policy contained no language regarding the notification to the Ombudsman's office of resident transfers and discharges.

Based on clinical record reviews, staff and resident interviews, review of facility documentation, and review of facility's policy and procedures, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of the four sampled residents (#2 and #3). The deficient practice could result in placing residents at risk for physical harm, injury and psychological distress.Findings Include: Regarding Resident #2: Resident #2 was admitted on [DATE], with a diagnosis that included metabolic encephalopathy, vascular dementia, major depressive disorder, anxiety disorder, cerebral infarction, hearing loss, and respiratory failure.A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating he was severely cognitively impaired.A care plan revised on March 2, 2026 identified behavioral disturbances including yelling/screaming, using abusive language, threatening behaviors, physical aggression, pushing, punching, exit seeking, delusional thoughts, paranoia, spitting food, refusing care related to dementia/ a cerebrovascular accident. Interventions included March 02, 2026, Labs and Urinalysis ordered, psych provider to visit this week and placement in a separate unit in a secured hall for behaviors. Monitoring for psychosocial needs. A nursing note dated March 02, 2026, at 12:59 PM revealed that at approximately12:45 PM, Resident #2 was in the dining room, in a self-propelling wheelchair when Resident #2 bumped Resident #3's chair. The note revealed Resident #3 turned and asked Resident #2 what he was doing. Resident #2 then opened his hand and made contact with Resident #3 on the side of the face. Resident #3 reported that Resident #2 startled him and responded by making contact with Resident #2's right side of the face with an open hand as well. Resident #2 was wearing glasses at the time of the incident. Both residents were separated immediately, and skin checks were completed for both residents. A Sitter was placed for Resident #2, and both residents were placed on 15-minute checks. Both residents were moved to different units. Family was notified of Resident #2, the Department of Health Services, Adult Protective Services, the provider was notified, and law enforcement. A weekly skin evaluation dated March 2, 2026, revealed a skin tear on the right elbow. An IDT (Interdisciplinary Team) note dated March 3, 2026, at 10:13 AM, revealed IDT team met to review an incident on March 02, 2026, of an altercation with another resident. An interview was conducted on April 14, 2026, at 1:53 PM with Resident #2, who was unable to follow through, resulting in an unsuccessful interview. Regarding Resident #3: Resident #3 was admitted on [DATE], with a diagnosis that included adjustment disorder, bipolar disorder, anxiety disorder, schizoaffective disorder, and epilepsy. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #3 was cognitively intact. A care plan revised on March 02, 2026 identified behavioral disturbances including poor impulse control, verbally aggressive to staff, 2 of 2 Traumatic Brain Injury (TBI), impulse control. Interventions included for March 02, 2026: Labs, urinalysis, and a psych provider consult were placed. Monitor for an increase in anxiety and psychosocial needs. Assess and anticipate the resident's needs: food, thirst. toileting needs, comfort level, body positioning, and pain. Document observed behavior and attempted interventions. Give as many choices as possible about care and activities. Modify environment: Adjust room temperature to a comfortable level, reduce noise, dim lights, place familiar objects in the room, keep the door closed, etc.) Monitor/document/report to the medical doctor of danger to self and others. Place a checklist of frequently needed items to remind [NAME] and staff to review prior to staff exiting the room. Psychiatric/Psychogeriatric consult as indicated. When becomes agitated: Guide away from the source of distress; Engage calmly in conversation; If the response is aggressive, staff should walk calmly away, and approach later. A nursing note dated March 02, 2026, at 5:07 PM documented resident #3 had resident to resident altercation with resident #2. An IDT note dated March 3, 2026, at 10:20 AM, revealed the IDT team met to review the incident on March 02, 2026, of an altercation with another resident. Resident #3 resides in a secured Behavioral unit. Diagnosis: Adjustment disorder, Bipolar, Anxiety, Schizoaffective disorder, and Traumatic brain injury. All notes and event reviewed in detail. Both residents were immediately separated. The Resident #2 was placed on one-on-one and relocated to another unit. Resident #3 was placed on 15min checks for 24 hours. Labs, urinalysis, and a psych follow-up were ordered. Resident #3 was able to recall the event and is very apologetic. It was caused by impulse, and he is working hard on that. There were no events that occurred since admission. Resident #3 will be continually monitored for all the psychosocial needs. In the IDT meeting, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Charge Nurse, Activities Director, and Case Managers were present. A review of the skin Evaluation dated March 02, 2026, revealed no new skin noted. An interview was conducted on April 14, 2026, at 1:21 PM with Licensed Practical Nurse (LPN/Staff #1), who stated that she had witnessed part of a resident-to-resident altercation between Resident #2 and Resident #3. She stated this happened when she was charting on the computer. When she looked away from the computer, she witnessed Resident #3 striking out at Resident #2 in the dining room, and then she immediately got up and took Resident #2 away into a separate room and made sure he was okay. She did a skin check on Resident #2, where she found a mark over his eyebrows on the right side. She cleaned it up and put steri-strips on that injury. Staff #1 stated that when she checked Resident #3, she did not find any injuries. An interview was conducted on April 14, 2026, at 1:59 PM with Resident #3, who stated that somebody hit him in the face, and then he back-handed him and slapped him automatically. He further stated he did not mean to hit the other resident and stated he feels safe at the facility. An interview was conducted on April 14, 2026, at 2:08 PM with Certified Nursing Assistant (CNA/ staff #2), who stated that she had heard that Resident #2 and Resident #3 were involved in an altercation with each other, and she heard that both Residents were in the dining room, where Resident #2 was moving his wheelchair back and forth, and he bumped into Resident #3's wheelchair. This is when Resident #3 struck Resident #2. She stated that the activities personnel and the nurse separated them immediately. An interview was conducted on April 14, 2026, at 3:18 PM with the Activities Aide (Staff #3), who stated that there was a resident-to-resident altercation between Resident #2 and Resident #3. He stated that he witnessed Resident #2 accidentally bumped into Resident #3's wheelchair and they both made contact, then Resident #3 slapped Resident #2's face, and this happened while he was passing out snacks in the dining room. He further stated that Resident #2 probably hit Resident #3, which he did not observe, but that was what Resident #3 stated. The activities aide stated that after the incident, they were immediately separated from the situation and sent to different rooms. An interview was conducted on April 14, 2026, at approximately 3:25 PM, with the DON (Staff #5), who stated that there was a physical altercation between Resident #2 and Resident #3 in the dining room. She stated that Resident #3 was leaving the dining room when he bumped into Resident #2's wheelchair, which bumped into his chair. Resident #3 turned around, raised his voice, and Resident #3 made contact with Resident #2's face. Resident #2 was wearing glasses, and the glasses bumped into his eyes after Resident #3 made contact with his face, leaving him with a skin tear on his right eyebrow. She stated that physical abuse occurred, which did not meet her expectations or the facility's expectations. A Policy titled Abuse: Prevention of and Prohibition Against was revised in April 2025, revealing that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.

Based on clinical record reviews, facility documentation, interviews, and facility policies, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#10). The deficient practice could result medication errors and uncontrolled pain for the residentsFindings include:On March 28, 2024 the facility implemented a Quality Improvement Plan (QIP) regarding medications administered outside of parameters. The plan included inservice/education with the nursing team on medication administration, and weekly random review of the medication administration record to verify pain medications are administered per physician orders. The QIP was reviewed by the CQI committee on June 20, 2024, August 23, 2024, November 5, 2024, January 20, 2025, and May 25, 2025.On January 16, 2024, all nursing staff received in-service training regarding medication administration per parameters, pain documentation. Another in-service was conducted on March 5, 2025 regarding narcotics. Following this, on March 29, 2024 an in-service was conducted regarding medication count, narcotic waste and medication errors. Further in-services were provided to nursing staff regarding medication parameters on April 18, 2024. On May 16, 2024 an in-service was provided to nursing regarding pain medications, pain scales and again on June 20, 2024 regarding pain scales and parameters.The facility provided a daily/weekly/monthly compliance audit dated May 2024 regarding medication administration.A monthly nursing meeting conducted on August 24, 2024 for nursing staff was conducted regarding parameters and completing follow-up notes. Further nursing staff in-services were conducted January 6, 2025 for narcotics forms, and on March 20, 2025 regarding medication parameters.-Regarding Resident #10Resident #10 was admitted on [DATE] with diagnosis including hypertension, spinal stenosis, polymyalgia rheumatica, cognitive communication deficit and muscle weakness. The resident was discharged from the facility on May 19, 2024.A review of the admission MDS (minimum data set) dated March 12, 2024 revealed a BIMS (brief interview of mental status) score of 13, indicating that the resident was cognitively intact. The MDS further revealed the resident was on antidepressant, anticoagulant, opioid, and antiplatelet medications as well as injections.A review of the physician orders revealed an order for oxycodone HCI oral tablet 5 milligrams, 1 tablet by mouth every 4 hours as needed for pain level 5-10. An order for tramadol HCI oral tablet 50 milligrams, 1 tablet by mouth every 8 hours as needed for pain level 1-4.A review of the MAR (medication administration record) revealed that tramadol HCI 50 milligrams for pain level of 7 on the following dates in 2025: April 6, April 7, April 15 and April 20. Tramadol HCI 50 milligrams was administered twice for a pain level of 8 on April 11 and April 18, 2025; however, the orders indicated that tramadol is to administered for pain level of 1-4.A review of the care plan initiated on April 5, 2024 revealed that the resident had both acute and chronic pain due to chronic neck and back pain. The intervention included that pain relief should be anticipated and that there should be an immediate response to any complaint of pain. Additionally, the care plan noted to follow the pain scale as ordered.An interview was conducted on June 18, 2025 at 11:17 A.M. with certified nursing assistant (CNA/ Staff #132). Staff #132 stated that if she sees or is advised of a resident being in pain, she would ask where the pain is and attempt to make the resident more comfortable. Staff #132 stated if a resident is non-verbal she would look for signs such as grimaces, guarding or over body language that is different from their baseline. She stated that in addition to identifying, locating and assisting with non-pharmaceutical approaches, she would alert the nurse.An interview was conducted on June 18, 2025 at 11:20 A.M. with licensed practical nurse (LPN/Staff #152). Staff #152 stated that if a resident were to present with pain, she would ask where the pain was, how long it had been going on, what it felt like, and what the pain rating was. She stated that she would look in the record to see what orders were in place, administer medication according to the orders, follow-up within an hour and document the effectiveness of the medication. She stated that she would always start with the medication as ordered but if it was not effective, she would reach out to the doctor to see what course of action they wanted to take. The LPN stated that if the pain level exceeded the medication administered and administered outside of parameters then this would not be following physician's orders and the risk to the resident would be that their pain would not be controlled and it may impact the mental well-being of the resident.An interview was conducted on June 18, 2025 at 12:09 P.M. with LPN, staff #377. The LPN stated that he only worked at the facility for about 10 weeks. He stated that if a resident had reported pain, he would assess the pain level, see what's on record and administer the medication and document it in the record. Staff #377 stated that the resident has a right to refuse a medication or opt for a medication prescribed for a lower pain level, but that he would then notify the doctor. Staff #377 stated that medication refusal would be documented in the MAR and that doctor notification would be documented in the progress notes. He stated that he did not recall any incidents regarding medications at this facility and that he always administered medications as ordered. However, a review of the MAR revealed that medications had been administered outside or ordered parameters.Staff #377 stated that the risk to the resident if medications are administered outside of parameters include that the resident may need to take more of a lower and that at some time it would need to be addressed. An interview was conducted on June 18, 2025 at 12:34 P.M. with the director of nursing (DON/ Staff #51). Staff #51 stated that her expectation is that when orders are received that the nursing staff follow the orders timely and as written. The DON stated that the risk for medications being administered outside of parameters could include that pain would not be managed accordingly. Staff #51 further stated that the pain scale has since been adjusted to pain level of 1-10.A review of the policy entitled Medication Administration-Oral with a revision date of May, 2025 revealed that when administering medications that the resident's eMAR (electronic medication administration record) orders are to be identified.A review of the policy entitled Physician Orders with a revision date of August 2023 revealed that it is the policy of this facility to accurately implement orders.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that two residents did not abuse other residents. The deficient practice could result in residents being physically harmed.Findings Include: Past non-compliance was identified for this citation:In November 27, 2023 the facility conducted an in-service regarding behavioral care and charting that included implementation of a 24-hour report to monitor new behaviors, daily clinical meetings with discussion regarding new behaviors. In January 2024, the facility implemented new training in January 2024 training for all nursing staff and certified nursing assistants, using the Crisis Prevention Institute program training for all nursing staff and certified nursing assistants. On March 18, 2025, a nursing meeting was conducted on managing difficult behaviors and de-escalation. to review the changes made to the behavioral units. Following this, on March 22, 2025, all nursing staff and certified nursing assistants received in-service training on understanding dementia and mental illness. On April 2, 2024 the facility continued in-service training on trauma informed care. On June 20, 2024 an in-service was provided regarding behavioral health interventions and care plans. Further in-services on August 16, 2024 included behavior training, interventions, boundaries and de-escalation. The facility provided daily 24-hour reviews audits of progress notes for behaviors and care plan interventions during April 2024 through September 2024. The facility also provided their De-escalation Crisis plan that included steps on to ensure resident safety when a patient is disruptive, agitated, verbally aggressive and not redirectable or potentially a risk for physical aggression. - Regarding Resident #171 Resident #171 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, cognitive communication deficit, paranoid schizophrenia, anxiety, and a major depressive disorder. A care plan initiated May 11, 2020 and resolved May 21, 2020 revealed that the resident was prescribed an anti-anxiety medication related to anxiety as evidenced by restlessness. The interventions included to provide a quiet environment. A behavior care plan dated May 19, 2020 revealed that the resident takes a psychotropic medications related to schizoaffective disorder as evidenced by physical aggression. Non-pharmacological interventions included redirection, provide a quiet environment, and provide reassurance. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. A progress note dated May 3, 2023 stated that the CNA on the floor was walking in the hallway when a resident in a wheelchair slapped resident #171 in the abdomen. The resident yelled out, stop it. The resident did not have any signs of pain and there was no redness noted on the abdomen. The CNA separated them and reported it. The Sheriff's Department was contacted at 3:20 p.m., event number #230502256. The progress note dated May 3, 2023 (late entry) stated that the resident was apparently assaulted earlier by another resident. Another resident slapped him in the abdominal area. The resident denies any pain. There was no evidence of trauma noted on abdominal area. The resident will be monitored closely. A progress note dated May 28, 2023 revealed that an altercation occurred between resident #171 and another resident. The other resident made accusations that resident #171 was being inappropriate. Nursing staff stated that this was not the case and that things have been resolved. The other resident apparently hit him in the genitalia area. Resident #171 does not recall this or was able to explain it. The other resident accused him of touching himself inappropriately. The care plan dated December 1, 2023 revealed that the resident takes an anti-anxiety medication related to an anxiety disorder as evidenced by restlessness and pacing. Interventions included to use non-pharmacological interventions done: back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk/, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, provide reassurance. -Regarding Resident #50: Resident #50 was admitted to the facility on [DATE] with diagnoses that included alcohol dependence in remission, major depression, anxiety disorder, and disorientation unspecified. A behavior care plan dated March 28, 2021 revealed that the resident has behavioral disturbances which include but not limited to physical aggression, verbal aggression, repetitive questions and statements, pacing, rummaging related to dementia, and poor impulse control. It also included that the resident had a resident to resident altercation on March 28, 2021 and April 16, 2024. The interventions included to allow the resident to walk on the secure patio as able. The MDS dated [DATE] included a brief interview for mental status score of 7 indicating the resident had a severe cognitive impairment. A progress note dated May 12, 2025 revealed that the resident was slapped on his arm and back by another resident while entering the dining room. An interdisciplinary team meeting note dated May 15, 2023 stated that the team met to review an incident on May 12, 2023 of physical altercation with another resident. Resident #50 resides on a secured dementia with behaviors unit. He has a diagnoses of schizoaffective disorder, dementia with behavioral disturbances. Resident #50 walked up next to another resident while trying to enter the dining room and she hit him on his arm and then once on his back. No injuries were noted. The two residents were separated. The aggressor was placed on fifteen-minute checks for twenty-four hours, labs and urine to rule out infection. -Regarding Resident #172: Resident #172 was admitted to the facility on [DATE] and discharged [DATE]. The diagnoses included Alzheimer's disease, cognitive communication deficit, behavioral disturbance, psychotic disturbance, and bipolar disorder. The MDS dated [DATE] included a brief interview for mental status score of 1 indicating the resident had a severe cognitive impairment. It also included that the resident exhibited physical and verbal behaviors 1 to 3 days during the look-back period. The progress note dated May 3, 2023 revealed that the writer was informed by the certified nursing assistant (CNA) that the resident was in the hallway when another resident walked by and then resident #172 slapped the resident in the abdomen. The other resident yelled out stop it. The CNA separated them and reported it. The Sheriff's Office was contacted at 3:20 p.m. and the event number was #230502256. The resident was placed on fifteen-minute checks, a psych evaluation was done and a medication was adjusted. Review of the clinical record revealed that resident #172 was put on fifteen-minute checks on May 2, 2023 and May 3, 2023 due to behavioral concerns. The care plan dated May 4, 2023 revealed that the resident had behavioral symptoms which include but not limited to hitting, kicking, pinching, screaming, yelling, impulsiveness, verbal aggression, refusal of care related to bipolar diagnosis, dementia, and poor impulse control. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. It also included that when the resident becomes agitated , guide away from source of distress; engage calmly in conversation; if response is aggressive, staff should walk calmly away, and approach later. The interdisciplinary team (IDT) meeting note dated May 4, 2023 revealed that the team reviewed the incident that occurred on May 2, 2023 of a physical altercation with another resident. Resident #172 resides on a secured dementia with behaviors unit with a diagnosis of dementia with behavioral disturbances. A resident walked up next to resident #172 while in the hallway, and she hit him on his abdomen. No injuries were noted and the two residents were separated. Resident #172 was placed on fifteen-minute checks for twenty-four hours and a psych evaluation with a medication change was completed. The progress note dated May 4, 2023 revealed that the resident was alert and able to verbalize her needs, was up in her wheelchair most of the shift, and eating meals in the dining area. The resident was wandering intrusively on the unit going in and out of other rooms and getting clothes from closets. The resident gets very agitated when redirected and yells and hits staff. A progress note dated May 5, 2023 revealed that the resident was alert and up in her wheelchair wandering intrusively most of the day, grabbing at clothes form other rooms, very hard to redirect, yells and hits at staff, swinging her hands and throwing stuff. A progress note dated May 12, 2023 revealed that a staff reported the resident who was in her wheelchair slapped another male resident two times on his arm and one time on his back, while she was trying to go inside the dining room. The residents were immediately separated, and this resident was placed on fifteen-minute checks. The incident was reported to the police, case number #230512267. Review of the clinical record revealed that resident #172 was put on fifteen-minute checks on May 12, 2023 and May 13, 2023 due to behavioral concerns. An IDT meeting note dated May 15, 2023 stated that the team reviewed on May 12, 2023 of a physical altercation with another resident. Resident #172 resides on a secured dementia with behaviors unit with a diagnosis of dementia with behavioral disturbances. A resident walked up next to resident #172 while she was trying to enter the dining room, and she hit him on his arm and then once on his back. There were no injuries noted. The two residents were separated. Resident #172 was placed on fifteen-minute checks for 24 hours, labs and urine to rule out infection. A progress note dated May 28, 2023 stated that the resident has been wandering into other residents rooms this shift and taking clothes, personal belongings. The resident has also attempted to hit other residents in the dining room and was redirected multiple times. A progress note dated May 29, 2023 revealed that the nurse was charting at the nurse's station and heard yelling and immediately went to the dining room. She noted that resident #172 was in her wheelchair and yelled at the resident in room [ROOM NUMBER] A standing in front of her scratching his thing. Resident #172 yelled at the other resident stop touching yourself, reached over and slapped him in the genitalia. The five-day investigation dated May 8, 2023 revealed that on May 2, 2023 a certified nursing assistant (CNA/staff #300) was in the hallway monitoring residents and saw resident #172 slap resident #171 in the abdomen. She heard resident #171 yell and growl and immediately went to separate them. (CNA/staff #63) also witnessed resident #172 slapping resident #171 in the abdomen and went to help separate the residents. She stated that both residents were put on fifteen-minute checks. It also included that both residents have wandering behaviors. The five-day investigation dated May 19, 2023 revealed that on May 12, 2023 a resident to resident altercation occurred between resident #172 and resident #50. The investigation included a statement from (CNA/staff #160) who stated that she was helping in the hall and was asked by another worker to come into the dining room assist. When she walked into the dining room, another staff member was separating resident #50 from resident #172. CNA #160 helped to remove resident #50 from the room and called for the nurse for assistance. A second statement from a licensed practical nurse (ADON/LPN/staff #228) revealed that she was called into the dining area and a staff member reported that resident #172 hit resident #50. She helped to separate the residents and assessed them for injuries. No injuries were noted and both residents were placed on fifteen-minute checks. Based on the facility investigation and speaking with staff, it was a witnessed behavior that occurred on a dementia hall known to have wandering and demented residents. The five-day investigation dated June 1, 2023 revealed that on May 28, 2023 residents #171 and #172 were in the dining room. Resident #171 was scratching his inner thigh while being fully clothed. Resident #172 told resident #171 to stop and hit him in the genital area. Both residents were separated immediately and assessed for injury and no injuries noted for either party. An interview was conducted on June 19, 2025 at 1:59 p.m. with the Director of Nursing (DON/staff #51), who stated that when she does a five-day investigation, interviews any staff and/or residents who witnessed the incident or heard anything. She acknowledged that the five-day investigation sent into the state agency only included interviews from (CNA/staff #160) and (LPN/staff #228). She reviewed documentation in a brown box and pulled out the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities dated May 12, 2023 with the statement of Hospitality Aide (HA/staff #303). She reviewed the interview and stated that staff #303 witnessed the resident to resident altercation between resident #172 and resident #50. She also stated that she considered the altercation a form of abuse. An interview was conducted on June 19, 2025 at 12:38 p.m. with the staffing coordinator/certified nursing assistant (CNA/staff #160), who stated that she has received training on abuse and one resident can abuse another resident. She stated that staff have to keep their eyes open and be aware of the surroundings at all times. She stated that the staff on the secured units rotate watching the public areas (dining room and hallway) and the nurse will also help to monitor the residents in the dining room when she is in the dining room. She stated that there are generally more than one staff in the public areas whether it be an activities person, nurse or a CNA. She stated that she was working the day that resident #172 hit resident #50 and thinks she was standing in the doorway of the dining room, but didn't remember which staff was between the two residents. She stated that there have been a couple of incidents when she had to intervene and get between resident #172 and other residents. She stated that resident #172 has hit and grabbed other residents. She stated that one time resident #172 put her nails into another resident and thinks it was resident #50. An interview was conducted on June 19, 2025 at 1:06 p.m. with a licensed practical nurse (LPN/staff #228), who stated that she has received training on abuse and when a resident grabs or hits another resident it is abuse. She thinks that resident #172 reached out and slapped resident #50 and this was abuse. Resident #172 does reach out and slap people when they walk by in the dining room and hits the staff. She stated that there are always staff in the dining room and if the activity staff see something, the staff should report it to the licensed staff. She can see the residents from her office, but acknowledged that she might not be able to get to the residents from her office before they hit each other. She also stated that there should be a staff that monitors the hallway as well. An interview was conducted on June 20, 2025 at 8:46 a.m. via the phone with the Assistant Director of Nursing (ADON/staff #6), who stated that she has received training on abuse and resident to resident abuse can occur. She stated that resident #172 spent a lot of time in the dining room. She stated that she has never witnessed resident to resident abuse at the facility. The surveyor read staff # written statement regarding resident #172 hitting resident #171 in the genitals on May 28, 2023. Staff # acknowledged that if she wrote a statement for the five-day investigation, the statement was true. Attempted to contact (CNA/staff #300) on June 20, 2025 at 12:51 p.m. but the phone number was inaccurate. Attempted to contact (CNA/staff #63) on June 20, 2025 at 12:56 and could not leave a message due to the voicemail box not being set up. -Regarding Resident #170 Resident #170 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, schizophrenia, major depression, and anxiety disorder. The minimum data set (MDS) dated [DATE] included that the resident was not able to repeat three words back, was not able to state the current year, month, or day of the week. The care plan revealed that the resident is an elopement risk/wanderer related to disorientation to place, impaired safety awareness. The resident wanders aimlessly. Interventions included to document wandering behavior and attempted interventions. The progress note dated March 9, 2023 revealed that the resident had an encounter with another resident. She is fine and does not have any injuries. Nursing does not know what happened. She was slapped by another resident on the right side of her face. Right side of face was reddened. A nursing note dated March 9, 2023 stated that staff reported at approximately 1:30 p.m. that a male resident slapped this resident (victim) on the right side of her face in the aggressor's room. The residents were separated immediately, and the aggressor was put on fifteen-minute checks and moved to the 600 unit at 2:00 p.m. The resident was comforted, and skin check was done, right side of face reddened. Sheriff's Department was notified, case #230309188. The order summary included an order dated March 9, 2023, Change of Condition for monitoring mood and behaviors every shift for status post altercation with peer for three days. No injuries noted. Review of the Medication Administration Record (MAR) dated March 2023 revealed that the resident was being monitored for a change of condition (COC) for mood and behaviors every shift for status post altercation with peer for three days dated March 9, 2023. COC was monitored from March 9, 2023 through March 12, 2023. On March 11 and 12, 2023, the resident exhibited behavioral symptoms. -Regarding Resident #148: Resident #148 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, cognitive communication disorder, and anxiety. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment. The care plan dated April 28, 2022 revealed that the resident has behavioral disturbances with include but not limited to yelling, screaming, using abusive language, threatening behaviors, physical aggression, pushing, punching, exit seeking, delusional thoughts, paranoia related to dementia/cerebral vascular accident (CVA). Altercations occurred on: -November 8, 2022-March 9, 2023-July 27, 2023-September 22, 2023-May 2, 2024Interventions included to assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. A progress note dated March 9, 2023 revealed that staff reported at approximately 1: 30 p.m. that this resident slapped another female resident in his room. The residents were separated immediately, and this resident was put on fifteen-minute checks. The Sheriff's Department was notified, case number #230309188. This resident was moved to the 600 unit at 2:30 p.m. A progress note dated March 10, 2023 revealed that change of condition for monitoring mood and behaviors every shift for status post altercation with peer for three days. Review of the five-day investigation dated March 16, 2023 revealed that a licensed nursing assistant (LNA/staff #302) was in the soiled utility room and heard resident #148 yelling. She ran towards the room and heard a slap. Another CNA was already in the room and she assisted her with separating the residents and removed resident #170 from resident 148's room. (LNA/staff #301) was assisting another resident in the hall and heard resident #148 yelling at someone. As she approached the residents, she witnessed resident #148 slap resident #170 across the face. She immediately separated the residents and called for assistance. Another LNA was there and helped to remove resident #170 from resident #148's room. An interview was conducted on June 18, 2025 at 10:30 a.m. with a licensed practical nurse (LPN/staff #7), who stated that interviews are always conducted when an incident occurs. She stated that it is her expectation that abuse should not occur and there is a risk of physical or emotional injury. An interview was conducted on June 19, 2025 at 8:32 a.m. with the Director of Nursing (DON/staff #51), who stated that all staff receive training on abuse. She stated that all their residents have behaviors, so resident to resident altercations can occur. She stated that the behaviors for each resident would be his/her behavioral care plan and staff have access to the care plans. She stated that the public areas (dining room and hallway) on the secured units must be monitored so staff are aware of what is going on with the residents. She stated that when the staff are monitoring the public areas, she expects the residents to be within the line of sight of the staff. She stated that staff are monitoring to make sure residents do not wander into other residents rooms. - Resident # 1Resident # 148 was admitted on [DATE] with diagnoses that included vascular dementia, unspecified psychosis, anxiety disorder, and unspecified sequelae of cerebral infarction. The resident remains at the facility. The annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The Patient Health Questionnaire-2 (PHQ-2) indicated a score of 00, indicating no mood disturbance. Section D of the MDS revealed that the resident experienced no psychosis but endorsed refusal of care. The MDS indicated that the resident experienced verbal behavioral symptoms directed at others (e.g., threatening others, screaming at others, and cursing at others).The resident's care plan dated 7/10/2024 revealed potential for problems related to psychosocial well-being regarding a recent incident in the building, grief related to the death of his brother, risk of re-traumatization due to post-traumatic stress disorder (PTSD) related to military service, behavioral disturbances with 5 altercations occurring on 5/2/2024, 9/22/2023, 7/27/2023, 3/9/2023 and 11/8/2022. Interventions to address these problems included emotional support, calm reassurance, 15-minute checks, move to high acuity unit, psychiatric evaluation, and medication administration as ordered. A room move consent was identified, showing the resident was moved from room [ROOM NUMBER]-A to room [ROOM NUMBER]-14 A, and received 15-minute checks by facility staff. A review of the electronic health record confirms these checks were conducted and recorded in the tasks section of the electronic health record.A psychiatric evaluation was conducted on 5/23/24 that noted continuing hallucinations that led the resident to be verbally aggressive. No progress notes related to the incident were identified in the electronic health record. - Resident # 2 Resident # 125 was admitted on [DATE] with a diagnosis of unspecified dementia, unspecified severity with agitation, brief psychotic disorder, and other generalized epilepsy and epileptic syndromes, intractable without status epilepticus. He was discharged from the facility on 4/17/2025.The quarterly MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. The PHQ-2 revealed a score of 00, indicating no mood disturbance. Behavioral symptoms identified in the MDS included the presence of delusions, physical symptoms directed towards others, rejection/refusal of care, and wandering.The resident's care plan initiated on 1/04/2024 indicated that the resident was placed in a secured behavioral health unit and that he was at risk for cognitive function/dementia or impaired thought processes, behavioral disturbances which included delusions, exit seeking, physical aggression, medication and treatment refusals, paranoid delusions and verbal aggression related to traumatic brain injury (TBI) and dementia.No progress notes related to the incident were identified in the electronic health record.Emergency Department triage notes from the hospital, dated 5/3/2024 at 01:33 A.M., revealed the resident presented with a chief complaint that while at the care facility, he was punched in the face and fell on a chair, hitting his left anterior ribs. Reported symptoms included pain with breathing. Resident # 125 was noted to have bruises to the left anterior ribs and left eye. Emergency department physician notes revealed that the resident apparently got into a fist fight with another resident. The resident was noted to have a bandage on the left cheek, but when removed, no abrasion or laceration was present. The physician's notes indicated that resident # 125's step-daughter and medical power of attorney was contacted and confirmed that the resident's current cognitive status is that of oriented to self only, which was his baseline.Diagnostic evaluation at the hospital included a CT scan of the head/brain and maxillofacial areas that revealed no acute findings. The resident returned to the facility, and the electronic health record identified that neurological checks were completed from 5/2/2024 to 5/5/2024.A review of the facility's 5-day investigative report dated 5/9/2024 indicated that Resident # 148 and Resident # 125 were in the dining room for an activity on 5/2/2024 when Resident # 148 became verbally escalated and an altercation occurred, Resident # 148 and Resident #125 were immediately separated, and care was provided to both residents. The report indicated that neither resident recalls the incident. The report indicated that the facility provided skin checks for both residents. The facility notified physicians and emergency contacts/decision makers for both residents, and Resident #125 was transported to the hospital for evaluation and treatment. Additional interventions following the altercation revealed that Resident # 148 was moved to an alternate behavioral health unit, had a psychiatric evaluation initiated, and received medication adjustments. The facility provided staff education on de-escalation techniques.A request for the incident report related to the altercation was addressed by the facility providing an additional copy of the facility's 5-day investigative report dated 5/9/2024. An interview was conducted on 6/18/2025 at 10:25 A.M. with staff # 211, Certified Nursing Assistant (C NA), who defined abuse as physical, mental, emotional, or financial. The CNA stated that abuse can be between residents or with any other person. C NA #211 stated that any type of abuse is not permitted at the facility. The CNA stated that if abuse occurs, the staff would immediately separate the victim from the abuser, make sure they are safe, and report the abuse up the chain of command. The CNA reported that staff are provided training on abuse annually, but it may occur more often if an incident occurs. Staff # 211 reported that the risk of abuse, if it occurs, is possible injury or mental anguish. An interview with Staff # 92, Certified Nursing Assistant (CNA) was conducted on 6/18/25 at 10:34 A.M, who stated that in the event of an altercation between residents, staff would separate the residents and ensure that they are safe and report the event forward to facility leadership. CNA # 92 stated that staff receive abuse training every month during monthly meetings, with formal abuse training provided upon hire and annually. The CNA stated that if the abuse allegation concerns a staff member and a resident, the staff member would be removed from the hall/floor and suspended until an investigation has been completed. The CNA reported no awareness of recent abuse allegations between residents.An interview was conducted on 6/18/2025 at 10:30 A.M. with Licensed Practical Nurse (LPN) staff # 7 who stated that if abuse is between residents, the staff would ask them what is going on, separate them to ensure their safety and then report it to the Assistant Director of Nursing, The Director of Nursing, the Facility Administrator, the Physician, the State and Adult Protective Services (APS). The LPN stated that interventions would be to stay with the aggressor and talk with them to see if anything could be done differently, check for skin issues or injuries. Staff # 7 stated that if the residents are in the same hall, the facility would try to move them. The LPN reported that the report must be initiated immediately, but the building has 2 hours and would conduct interviews with anyone who witnessed the event and with other residents who are alert and able to respond. The LPN stated that it was her expectation that abuse should not occur, and the related risk of abuse is physical or emotional injury.An interview was conducted on 6/19/2025 at 1:15 P.M. with staff # 164, Social Services Associate, who reported that when residents are known to cause altercations with other residents, her team and all staff try to keep the residents occupied in activities and in small groups. Staff # 164 praised their activities team for their ability to redirect the resident's attention. The Social Services Associate reported that the facility provides a behavioral health program that includes de-escalation skills and positive reinforcement that support these efforts. Staff # 164 reported that the facility separates residents who are known to initiate altercations and can reshuffle staff to allow them to work by providing cares in pairs when working in resident groups. The Social Services Associate stated that they discuss care plans and reach a consensus about the resident's activities, interventions, and Behavioral Health programs, and reach out to specialized areas to assess a resident who has been repeating the same attitude of behavior in order to identify the root cause of the problem. An interview was held on 6/20/25 at 09:49 with Licensed Practical Nurse (LPN # 189) who defined resident-to-resident abuse as anything from verbal confrontation, hitting, stealing, but most commonly a verbal disagreement. The LPN stated that the overall goal of the staff and facility is to maintain the safety of residents and staff. The LPN stated that residents are observed for escalation, evidenced by restlessness or agitation, noting that staff try to 'nip it in the bud' before it escalates. LPN # 189 stated that the first steps are to try to identify the cause and address it, including pain, hunger, fatigue, or bathroom needs. The LPN stated that if an issue occurs, the residents would be separated, and if the event is more than a verbal disagreement, notification of the Director of Nursing and the Executive Director, as well as the resident's physician and family member, would begin. LPN #189 stated that the facility may initiate a room change for a resident, and the Social Services Department would be involved in obtaining consent for the move. If a move is indicated, the staff would receive notification from the unit manager before the move is started. The LPN reported that the Executive Director is considered the 'abuse coordinator' for the facility, and in any instance beyond verbal conflict, the staff would notify the abuse coordinator to ensure he meets all reporting deadlines. Staff # 189 stated that following physical conflict, the resident would be assessed for injury. If an injury was found, the abuse coordinator, the physician, and the family would be notified. Notifications would also include hospice or other agencies involved in the

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to failed to prevent resident to resident abuse with resident #55 being the aggressor and #44 being the victim. The deficient practice could result in further abuse of residents at the facility. Findings include: Resident #55, the aggressor, was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, and dementia. At the time of incident, prescribed psychotropic medications included Aripiprazole, Citalopram, Depakote, hydroxyzine, and Donepezil and memantine for dementia. Resident #55 had an order to monitor for psychosis as evidence by physical aggression and verbal threats dating back to 11/03/2022. Change in condition protocols were ordered due to an altercation with a peer on 03/01/2023, on 04/03/2023, and again later on 4/18/2024. In the Quarterly Minimum Data Set (MDS) assessment from 02/09/2023, Resident #55 scored a 01 in a Brief Interview of Mental Status which suggested severe cognitive impairment. The MDS also revealed that the resident had wandered on a daily basis in the assessment period. In the care plan originally initiated on 11/03/2022, Resident #55 had goals for a potential psychosocial well-being problem related to her Dementia, depression, and bipolar diagnoses. Interventions included if conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Also documented in the care plan, for psychotropic medications use for physical aggression and labile mood. Interventions included taking psychotropic medications as ordered, monitoring for effectiveness, and adjusting dosages as clinically appropriate. Progress notes documented the following history of resident having altercations with other residents: -03/01/2023: Resident went into another resident's room and hit him on his back while he was shaving. When staff entered room, Resident #55 had a hand raised as if to strike him again. -03/20/2023: Resident #55 it a hit roommate on the chest with the back of their hand while in the hallway. -04/04/2023: Resident #55 walked up to another resident and pushed the resident to the floor. Labs and Urinalysis was ordered. -4/14/2023: Resident #55 had two episodes of aggression. One where they pushed a staff member from behind. The second was where they were posturing at another resident in the dining room during dinner. There was no physical contact. -4/18/2023: Interdisciplinary Team (IDT) met to review incident on 4/17/23 of physical altercation with another Resident #55 was seen shaking a fist at another resident. The other resident reported Resident #55 had hit her on her back. A note timestamped 4/18/2023 05:18pm documented a medication regimen review which revealed Resident #55 may have been having exacerbated symptoms from Depakote. The day started on Depakote was a day physical aggression was seen. As dose was increased to help alleviate her aggression and labile mood, aggression slowly increased. After staffing with the psychiatric provider, Depakote was discontinued and her Aripiprazole dose increased. A discharge summary from 4/20/23 showed that resident was ultimately transferred to a behavioral care home as documented in a nursing progress note dated 04/18/2023. Regarding Resident #44, the victim: Resident #44 admitted to the facility on [DATE] and discharged [DATE] with diagnoses that included dementia and major depressive disorder. In the quarterly MDS assessment from 03/19/2023, Resident #44 scored a 05 on BIMS which suggested severe cognitive impairment. The MDS also revealed that the resident had not behaviors other than wandering during the assessment period. During an interview on 6/14/2024 at 4:45p with Licensed Practical Nurse (LPN), Staff #21, stated that to prevent resident to resident altercations the staff will try to do activities and keep residents busy. If they see the signs of agitation they can redirect with food and fluids for example for ask if they need pain medication. They will try to keep the resident happy before anything happens. If they are becoming agitated keep them a safe distance from other patients. They will also call the doctor and have the psychiatric provider take a look at their medications. She stated she was unsure if the facility does one on ones for residents. She said it is a good option, but she has not seen it here. It is not possible in her nursing opinion to prevent all resident to resident interactions. The patient could be having delusions, PTSD (posttraumatic stress disorder), or any number of other reasons including boredom. It is about anticipating their needs. In an interview on 6/14/2024 at 4:50pm with the Director of Nursing (DON), Staff #31, along with Operations Manager Staff #51, visiting DON Staff #41, and Clinical Resource Staff #61, the facility discussed the history of Resident #55's altercations with other residents. For the incident in question on 04/03/2024, the DON stated that typically in a resident to resident altercation, staff will remove the aggressor and focus on the aggressor. She stated that Resident #55 was not always the aggressor. On 4/3 after the incident, she was moved from the 500 to 800 unit. 800 is the high acuity behavioral unit and 500 unit is for dementia with behaviors. Both units are secured. A review of the electronic chart with the above-mentioned staff members revealed 5 incidents in 2023 when Resident #55 was the aggressor prior to her discharge. The dates are 4/17, 4/14, 4/3, 3/20, 3/1. The DON stated that after the incident on 3/1, the resident was placed on 15-minute checks; on 3/20/2024 she moved rooms and was placed on 15 minutes checks; after 4/3/2024 she was moved to high acuity unit from wandering dementia unit with behaviors. For residents that have repeated altercations with other resident, if they are stable and can be safe, then the facility can try to do medical clearance, have a psychiatric provider assessment, and different techniques to keep them in the least restrictive environment possible. If needed, they will do 1:1 staff. If it is needed for an extended period of time, then they are sent to a level I facility. On 4/18/24, they had a 1:1 for Resident #55. The DON stated that in August of 2023 the unit was transferred from dementia to wandering with behaviors. Wandering residents were placed on a different unit which decreased resident to resident altercations. Since January of 2024, they have placed a staff member in the hall and dining rooms. The psychiatric team is always involved whenever there is an altercation. They are on site 5 days a week. Psychiatric evaluations are done every time and then they will do a medication review, urinalysis, and labs if indicated. Behavior health counselors are on site every day, and will talk with the aggressor to adjust and provide counsel, and then the victim to make sure they are doing okay post incident. The facility has also since implemented a new activity program. It is 7 days a week and includes low and high sensory activities on the behavioral units. The DON stated she feels confident since implementing new training in January that they are taking care of residents. The incidence of resident altercations have gone way down. She said she had no concerns about Resident #55 and how her case was handled after review of the chart. Facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment last revised on 10/2023 states it is the policy of this facility that each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, [and] other residents. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm pain, or mental anguish .Willful, as used in this definition of abuse, means the individual mush have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to protect the rights of five residents (#1, #4, #2, #5, and #3) to be free from abuse from other residents. The deficient practice could lead to further abuse and residents being placed in an unsafe environment. Findings include: Regarding to resident #4 and resident #5 -Resident #5 was admitted on [DATE] with diagnoses of dementia, cognitive communication deficit, and heart disease. The quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMs (Brief Interview for Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The assessment also included that the resident had been experiencing verbal behavioral symptoms towards others, rejection of care, and wandering within the 1 - 3 days of the assessment. The progress note dated August 17, 2023 revealed a staff was with resident #5 who was laying on their left side next to their wheelchair; and that, the wheelchair was also on its side. Per the documentation, another resident (#4) was yelling in the hallway and reported that resident #5 ran over the foot of the other resident (#4) so resident #5 threw him (referring to resident #4) down. The note also included that resident #5 complained of pain in the left hand and hip. A review of the x-ray result done on August 18, 2023 revealed there was no fracture or soft tissue trauma of the left hip, left hand, humerus, radius, ulna or the forearm. -Resident #4 was admitted on [DATE] with diagnoses of dementia, muscle weakness, and cognitive communication deficit. A review of the care plan revised on August 16, 2023 included a focus area of behavioral disturbances. The goal was that resident #4 understand their verbally abusive behavior. Interventions included providing positive feedback for good behavior, anticipating the needs, and to intervene when resident showed signs of being agitated. A progress note dated August 17, 2023 revealed that staff heard resident yelling in the hallway. The documentation included that resident #4 accused resident #5 of running over his (referring to resident #4) foot with the wheelchair; and that, resident #4 threw resident #5 onto the floor. The documentation also included that resident #4 was placed on 1:1 staff supervision until the resident was transferred to the ED (emergency department). The progress note dated August 17, 2023 included resident #4 required a higher level of transfer due to his aggression; and that, resident was transported to the hospital. The discharge MDS assessment dated [DATE] revealed resident #4 had physical and verbal behaviors including rejection of care and wandering; and that, BIMs score was not completed for resident #4. An interview with certified nursing assistant (CNA/staff #8) was conducted on April 12, 2024 at 10:03 a.m. The CNA stated she saw the incident between residents #4 and #5. She stated that resident #4 went into the room of resident #5; and, she saw resident #4 lifting the wheelchair with resident #5 in it resulting in resident #5 falling to the floor. The CNA stated that resident #4 was a big and strong guy so he was able to lift the chair. Further, the CNA stated that after witnessing the incident, she separated both residents from each other and the nurse came to help out. Regarding resident #2 and #3 -Resident #2 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, and anxiety disorder. The quarterly MDS assessment dated [DATE] revealed a BIMs score of 8 indicating the resident had moderate cognitive impairment. The assessment included resident #2 had no behavioral symptoms. A review of a progress note dated September 22, 2023 at 4:04 p.m., revealed staff witnessed resident #2 grab resident #3 from behind and hit resident #3 on his left cheek. Per the documentation, resident #2 and resident #3 were separated and 1:1 staff was placed with resident #2 until he was moved to another unit. It also included that resident #3 had a scratch on the cheek. The care plan updated on September 22, 2023 revealed interventions to include 1:1 staffing until resident placed in a separate unit. Prior to the altercation, the following interventions were in place: approach resident in a calm manner, discuss resident's behavior with resident if appropriate, provide positive interactions, and administer medications as ordered. -Resident # 3 was admitted on [DATE] with diagnoses of cognitive communication deficit, metabolic encephalopathy (neurological disorder caused by chemical imbalance), and muscle weakness. The progress note dated October 10, 2023, revealed resident #3 was entering the dining room and bumped his wheelchair with another resident (#1) who then hit resident #3 on the head. The documentation included that there were no injuries noted and both residents were separated from each other and 15-minute checks were implemented. A nursing note dated October 14, 2023 at 3:08 p.m., revealed that a staff witnessed resident #3 make contact with the left lower jaw of resident #1. The documentation included immediate interventions were put into place such as a check for injury, 15-minute checks, and both residents were separated. The note also included that facility leadership, family and the sheriff department were notified. The clinical record revealed that in the days prior to the October 14, 2023 incident, resident #3 had been experiencing an increased inability to sleep, feeling more tired as usual, restlessness, and delusions; and that, resident #3 was administered medication to help them sleep. A review of the care plan updated on October 16, 2023 included a focus of behavioral disturbances. The goal was that the resident not harming himself or others. Interventions included providing verbal and physical cues to minimize their anxiety and agitation; and redirection and removing the resident them from the current environment when there were signs of agitation. The discharge MDS, dated [DATE] indicated resident #3 had a BIMs of 15 which indicated the resident was cognitively intact. The same discharge MDS assessment also indicated resident #3 had not exhibited behavioral symptoms. An interview with resident #2 was conducted on April 11, 2024 at 1:34 p.m. Resident #2 was sitting upright on his bed; and stated that he felt safe in the facility. The resident also said that staff come to see him every morning to give him the pills that he needs. In an interview with CNA (staff #3) conducted on April 11, 2024 at 2:25 p.m., the CNA said that she was working in the unit when the altercation between resident #2 and #3 took place; and that, she remembered hearing yelling as she was walking down the hall. The CNA stated that she saw resident #2 punch resident #3; and, she separated the two residents and called out for help. Further the CNA said that the behavioral manager had come into the dining room and helped defuse the situation. Regarding resident #1 and #3 Resident #1 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), dementia, and a history of strokes. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 indicating the resident had severe cognitive impairment. The assessment also included that resident had exhibited no behavioral symptoms. A review of the nursing note dated October 14, 2023 at 11:05 a.m., included that another resident (#3) was witnessed making contact with the lower left jaw of resident #1. The documentation also included that immediate interventions were put into place such as a check for injury, 15-minute checks, and both residents were separated; and that, facility leadership, family, sheriff department were notified. The weekly skin evaluation dated October 14, 2023 revealed that there were no injuries noted and that the resident did not complain of pain or discomfort in the jaw area. The interdisciplinary team (IDT) meeting note dated October 16, 2023 included that resident #1 had a verbal altercation with resident #3; and that, this resulted in resident #1 being hit on her left lower side of the face. The IDT note also included that the aggressor was resident #3; and that, laboratory test was ordered, a psychiatrist referral was placed and a referral was sent to secure alternate placement in another facility for resident #3. An interview with licensed practical nurse (LPN/staff #5) was conducted on April 11, 2024 at 2:13 p.m. The LPN stated that she mostly worked in the behavioral unit so she was familiar with the residents in those units. The LPN said that staff in the behavior unit monitor the residents and when staff notice a trigger occur, staff will attempt to remove the trigger or redirect the residents to another area of the unit. The LPN said that if a resident to resident altercation happens, staff will remove the residents from the environment and evaluate the situation then report the incident to the unit managers. Further, the LPN said that facility management often talked with staff about abuse and the behavioral team will get extra training due to the residents they work with. Another interview was conducted on April 11, 2024 at 2:25 p.m. with the CNA (staff #3) who stated that she was trained on abuse upon hire and she completes an online training class every year. Further she stated that she had to report any suspicion of abuse to her supervisor immediately even though staff had 2 hours to report it. In an interview with another LPN (staff #6) conducted on April 12, 2024 at 9:45 a.m., the LPN said that she was the unit manager for the behavioral health unit; and that, since she became the unit manager, she had increased staff training on de-escalation. The LPN said that she had been more involved in the screening process for incoming residents to determine where they would be a fit within the behavioral health units; and, this included the process of phasing out residents with dementia who wander. Further, the LPN said that she was also putting more emphasis on the activities program for residents within the unit and she had hired 1 activities staff per unit to create activities specifically for each of those units. During an interview conducted with the assistant administrator (staff #7) conducted on April 12, 2024 at 11:13 a.m., staff #7 stated that the staff training on Abuse was a topic of conversation at the monthly staff meetings, nurse meetings, behavioral health training meetings and each time there was a case of abuse in addition to their annual training. She stated that the expectation was that suspected abuse were reported to the abuse coordinator right away even when the guidelines stated that it must be reported within 2 hours. Staff #7 also said that the facility mitigated the risks of abuse in the behavioral health unit by thoroughly vetting the needs of incoming residents and looking how to cohort with others; and, the facility also has a full-time behavioral health case manager who reviews the residents' care plans and triggers. Further, staff #7 stated that each behavioral health unit has a specific level of care that they serve; and the facility had implemented a behavioral activity program that had been extremely helpful with keeping the residents busy and engaged. A review of the facility's policy titled, Abuse: Prevention of and Prohibition Against with a review date of October 2023, states Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also continues to state under the Prevention section, The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .

Based on clinical record review, staff interviews, observation of current facility practice and review of the facility's policies, the facility failed to ensure controlled medications were provided and accounted for in accordance with professional standards for 4 residents (#52, #358, #27) The deficient practice could result in diversion of resident medication. Findings include: -Resident #52 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, rheumatoid arthritis, morbid obesity, and bipolar disorder. The quarterly Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident is cognitively intact. The MDS also revealed resident #52 was on a scheduled pain regimen and also received pain medications as needed. Review of the current physician order recap revealed Oxycodone-Acetaminophen (narcotic) 5-325 milligrams (mg) every 8 hours for chronic rheumatoid arthritis. Further review of the clinical record revealed that this order was transcribed onto the MAR (medication administration record); and, the MAR revealed that this medication were documented as administered as ordered. - Resident #358, they were admitted to the facility on [DATE] with diagnoses that included Cervical Disc Disorder with Myelopathy, muscle weakness, and partial paralysis. The resident was discharged from the facility on February 27, 2024. The quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. The MDS also revealed resident #358 was on a scheduled pain regimen and also received pain medications as needed. The current physician order recap revealed Hydrocodone-Acetaminophen (narcotic) 5-325 milligrams (mg) every 6 hours as needed (PRN) for pain rated 7 though 10. A review of the February 2024 MAR revealed Hydrocodone-Acetaminophen was not administered as ordered on the evening of February 4, 2024. The controlled drug record for February 2024 revealed that on February 5, 2024 one tab of Hydrocodone-Acetaminophen was wasted at 5:00 a.m. and 5:00 p.m. The 5:00 a.m. entry had a note written as wasted and was signed by a nurse (staff #194). However, the 5:00 p.m. entry was not signed. -Resident #27, they were admitted to the facility on [DATE] with diagnoses that included paraplegia, Post Traumatic Stress Disorder (PTSD), and a personal history of transient ischemic attack. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. The MDS also revealed resident #27 did not have a scheduled pain regimen but did receive pain medications as a PRN. Resident #27's medication orders revealed they were prescribed Tramadol HCI 50 mg tablet and were to take two tablets by mouth every six hours as needed for pain rated 5 through 10. February MAR revealed there was no tramadol given to the resident during the evening of February 4, 2024 or in the early morning of February 5, 2024. The same MAR did indicate two tablets of tramadol were administered at 8:10 AM on February 5, 2024 by staff #176. A review of the controlled drug record reveals three tablets of Tramadol was administered on February 4, 2024 at 2:00 AM by staff #194. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #88) on March 27, 2024 at 8:24 AM. Staff #88 explained that when a controlled medication was to be wasted, there must be a second nurse observing the wasting of the medication. Staff #88 also indicated there was always a second nurse available at all times in the building; and that, they often get training throughout the year on controlled medication processes. An interview was conducted with LPN (staff #80) on March 27, 2023 at 8:44 AM. Staff #80 indicated that controlled medication administration should be done according to the resident's orders and if medications were to be wasted, a second nurse was needed to observe the process. Staff #80 also indicated that there was always a second nurse available in the building to waste medications and if a second nurse could not be found, a unit manager can assist. An interview was conducted with the Director of Nursing (DON/staff #51) on March 28, 2024 at 11:17 AM. When asked what the expectation of documenting the administration of controlled medications, staff #51 indicated the resident's orders must be followed and the documentation is done on the paper form and the electronic health record. When asked what the expectation of wasting controlled medications was. Staff #51 indicated that the nurses have a drug buster at the bottom of the medication carts. Medications must be wasted with another nurse present. Then staff #51 or the pharmacist would process the medications and label them accordingly for the United Parcel Service (UPS) pick-up. Staff #51 indicated the risks associated with controlled medications being wasted with one staff is that medications could be taken and abused by staff. A review of the facility policy titled Medication Administration indicated that controlled medications not administered to a resident must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record, on the line representing that dose. 49325 -Regarding Resident # 118 Resident # 118 was admitted into the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, encephalopathy, and essential hypertension. Care Plan initiated on January 26, 2024, concerning diabetes mellitus, revealed will receive diabetes medication as ordered by doctor. Review of the physician order with a start date of January 19, 2024 revealed an order for Lantus Subcutaneous Solution 100 Unit/Milliliter (Insulin Glargine) Inject 25 unit subcutaneously one time a day for Diabetes Mellitus hold if fasting blood sugar less than 110. Review of Medication Administration Records (MAR) February 2024 revealed that this medication was administered outside of the physician ordered parameters (hold if fasting blood sugar less than 110) on the following dates: -February 18 fasting blood sugar (FBS) 106 -February 21 FBS 106 - February 25, FBS 105 - March 4, FBS 106 -March 6, FBS 106 -March 17, FBS 109 -March 18, FBS 105 - March 25, FBS 109 The clinical record revealed no evidence why this was administered outside of the physician ordered parameters; and that, the physician was notified. An interview was conducted on March 28, 2024 at 03:12 PM with Registered Nurse (RN/Staff # 189) who stated medications are administered based on physician orders. Staff # 189 stated that high risk medications have parameters and if administered outside of parameters the nurse should communicate this to the doctor. Staff # 189 stated if the provider doesn't want us to administer glargine, if fasting blood sugar is less than 110, that is what the provider requested and we should be administering within ordered parameters. Staff # 189 stated with any medication given outside of the parameters there are risks. Staff # 189 stated administering Insulin Glargine outside of parameters may cause sugar levels to tank and drop too low. An interview was conducted on March 28, 2024 at 3:30 PM with the Director of Nursing (DON/Staff # 51) who stated following physician order is expected during med pass. Staff # 51 reviewed the medication administration records and progress notes regarding Insulin Glargine administration, and confirmed that there was a total of 8 administration of the medication outside of parameters. Staff # 51 stated if insulin is given outside of parameter when it is not required it may cause residents to experience lightheadedness, dizziness, and become diaphoretic. Staff # 51 stated that the administration of Insulin Glargine outside of parameters did not meet facility's expectations. Review of the facility's Policy titled, Physician Orders (revised May 2023) revealed, it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. It is the policy of this facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs. No drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. Review of the facility's Policy titled, Medication Administration - Oral (revised May 2022) revealed, it is the policy of this facility to accurately prepare, administer and document oral medications. Any irregularity in pouring or administering must be reported to the doctor. If there is any question in regard to dosage, the person in doubt should not give the drug until obtaining information which clarifies drug dosage. Review of the facility's Policy titled, Controlled Medications (revised June 2023) revealed, the Director of Nursing Services and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. A controlled medication accountability record is prepared when receiving or checking in a Schedule II, III, IV, or V medication. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the medication is actually administered. When a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record. Any discrepancy in controlled substance medication counts is reported to the Director or Nursing Services immediately.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#84) received safe monitoring of vital signs, to include weights. The deficient practice could result in the potential for complications and the resident not receiving appropriate care and treatment. Findings include: Resident #84 was admitted on [DATE] with diagnosis including end stage renal disease, type 2 diabetes, epilepsy, and major depressive disorder. A review of the MDS (minimum data set) dated March 09, 2024 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact. A review of the physician orders revealed an order dated March 21, 2024 noting that vitals and weights are to be taken before and after dialysis. Entries under the vitals section of the electronic health record revealed a weight loss of 41 pounds between the dates of March 13, 2024 and March 19, 2024. A subsequent weight gain of 20.4 pounds was noted for the time ranging from March 19, 2024 through March 27, 2024. An IDT (interdisciplinary team) notation on March 19, 2024 revealed an entry by staff #195 (dietetic technician, registered). The entry noted that there was significant weight loss in a one-week period and suggested a re-weigh for the resident; however, facility documentation did not reveal evidence of the resident having been re-weighed. An interview was conducted on March 27, 2024 at 11:02 AM with staff #80 LPN (licensed practical nurse). Staff #80 stated that as part of the assessment process for a resident on dialysis, vitals are taken, which include the resident's weight. She stated that when there is an issue with weights, either a dramatic weight gain or loss then the nurse manager would be notified. She stated that a weight change of 10 pounds or more would be cause for notification. An interview was conducted on March 27, 2023 at 11:05 AM with staff #153 CNA (certified nursing assistant). Staff #153 stated that CNA's are responsible for conducting the vitals. She stated that if she was monitoring a dialysis resident and observed any changes in weight that she would let the nurse know immediately. An interview was conducted on March 27, 2024 at 11:29 AM with staff #196 Nurse Manager. Staff #196 stated that weights are discussed on a weekly and emergent basis. She stated that if weight fluctuations were observed she would let the physician and the family know and review possible causes for the change in weight. She stated that Nurse Manager was in charge on tracking resident weights. An interview was conducted on March 27, 2024 at 11:51 AM with staff #174 LPN. Staff #174 stated that she felt a weight change of 5 pounds could be concerning and would alert the nurse manager of any chnage of 5 or more pounds. An interview was conducted on March 27, 2024 at 12:00 PM with staff #49 Nurse Manger. Staff #49 stated that fluctuations in weight will always be there with dialysis patients, and stated that staff will weigh residents prior to dialysis and even though they are weighed at the dialysis center, staff would weigh the resident again upon return to the facility. She stated that if there were any abnormalities in weight, the provider would be notified. She stated that she had been the point person for tracking the weights but stated that now the dieticians are tracking weights. She reviewed the residents record and stated that the recent weights may have a documentation error. She stated that the resident should have been re-weighed based on the dramatic change in weight, but had not been. Staff #49 stated that anything over a 5-pound weight change should be actively monitored. An interview was conducted on March 28, 2024 at 10:21 AM with staff #166 DTR (dietetic technician, registered). She stated that there had recently been a transition from an external entity to internal monitoring of resident weights. She stated that monthly monitoring is conducted, but that weights are reviewed on a daily basis for all residents on dialysis. If there is a concern regarding a resident's weight, she stated that she would ask staff to re-weigh the resident. She stated that at times it is feasible to see up to a 30-pound change in weight for a dialysis resident, she stated, however, these should still be investigated. She reviewed the residents record and stated that a change in weight as noted, should be followed up on regardless, but had not been. She stated that the expectation would be to follow-up and monitor any weight changes of 5 pounds or more. She stated that the risk of not monitoring a resident's change in weight could impact the resident's health. An interview was conducted on March 28, 2024 at 10:52 AM with staff #51 DON (director of nursing). Staff #51 stated that vitals and weights are taken prior to dialysis and documented on a flow sheet. She stated that weight changes may be contingent on each individual resident and their overall condition. She stated that the expectation would be for any recommendation to reweigh a resident, due to potential weight fluctuations, would communicated, documented and monitored. She stated that facility will be working on a more robust process to include reviewing the IDT (interdisciplinary team) notes with the new medical director. She stated that her expectations are that residents are re-weighed if there is a greater than 5% weight change. She stated that the risk to the resident could include fluid overload, shortness of breath and the need for further evaluation. A review of the policy entitled weight, with a review date of 2023 revealed that the intent of the policy was to obtain an accurate weight as part of the resident's assessment. A review of the nutrition policy reviewed on July, 2023 revealed that any resident's weight that varies from the previous reporting period by 5% in 30 days would be evaluated by the interdisciplinary team to determine the cause of the weight loss/ gain, what interventions would be required and the need for further recommendations and / or referral. However, the record revealed that the weight loss had been identified by the IDT and the recommendation noted that the resident should be re-weighed, which did not transpire per review of the electronic health record and staff interviews.

Based on observation, staff and resident interviews, and facility policy, the facility failed to ensure that one resident (#124) was free from accident hazards. The deficient practice could result in resident not taking their needed medications as prescribed and other residents gaining access to and taking the medications. Findings include: Resident #124 was admitted on [DATE] with diagnoses of dementia, bipolar disorder, and cognitive communication deficit. Review of this resident's care plan included that the resident was admitted to a secured behavior health unit for psychosis, mood disorder and dementia. This care plan also included that this resident has poor safety awareness. A physician's order dated 2/7/24 included glipizide (hypoglycemic) Oral Tablet 10 mg (milligrams) give 2 tablets by mouth in the morning for Diabetes Mellitus II. A physician's order dated 3/5/234 included seroquel (antipsychotic) Give 50 mg by mouth two times a day for bipolar disorder as evidenced by auditory hallucinations A physician's order dated 11/16/23 included depakote sprinkles delayed release 125 mg (antiseizure) give 250 mg by mouth every 8 hours for Bipolar disorder as evidenced by labile mood A physician's order dated 10/17/23 included metformin (anti-diabetic) 1000 mg give 1 tablet by mouth two times a day for Diabetes Mellitus II. However, review of the physician's orders did not include an order for self-administration. An observation was conducted on 3/25/24 at 9:49 A.M. of resident #124's bedside table which included a cup which contained: 2 tablets marked APO glp 10 (glipizide), 1 tablet marked white round 337 (Quetiapine Fumarate), 2 capsules which were blue and white marked 125 (Divalproex), and a white oval tablet marked g12 (Metformin). An interview was conducted on 3/28/24 at 9:45 A.M. with a Licensed Practical Nurse (LPN/staff #180) who said that when administering medications, you look at computer verify meds, check resident name, the 5 rights, and then you watch them take their meds. This nurse said it is not ok to leave a cup of pills at the bedside. An interview was conducted on 03/28/24 at 1:31 P.M. with a Certified Nursing Assistant (CNA/staff #172) who said that the nurses usually stay with this resident when she takes her pills but that she has found pills on the resident's bedside table before. An interview was conducted on 03/28/24 at 1:35 P.M. with an LPN (staff #108) who said that this resident was not ok to take meds on her own but that she's pretty good about it. She said that nurses should make sure she takes her medication. An interview was conducted on 03/28/24 at 4:15 P.M. with the Director of Nursing (DON/staff #51) who said that her expectation for medication administration was that staff would confirm the right resident, the right medication and the other rights, offer the medication to the patient and then watch the patient and document the administration or refusal. She said that medications left on the bedside table do not meet her expectation and that the facility had identified that issue and had started a QAPI which included assessing patients that wanted to be self administering and to let those patients who could not know that they could not leave the medications at bedside. This DON included that the nurses were educated as well. A policy titled Medication Administration - Oral, revised 5/22, revealed that it is the policy of this facility to accurately prepare, administer and document oral medications. This policy included that the person administering medication must remain with the resident until all medication has been swallowed.

Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policies, the facility failed to develop and complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident (#47). The deficient practice could result in delayed identification of potential risks and care needs of the resident. Findings include: Resident # 47 was admitted on [DATE] with diagnoses of dementia, Parkinson's Disease, and peripheral vascular disease. The admission MDS (Minimum Data Set) revealed that it was completed on November 16, 2023. Review of the clinical record revealed no evidence that a quarterly MDS assessments were completed after November 16, 2023. In an interview with MDS Coordinator (Staff # 91) conducted on March 28, 2024 at 12:50 p.m., The MDS coordinator stated that all residents should have a quarterly MDS Assessment completed to meet facility expectations regardless to what the resident had for an insurance. During the interview, a review of the electronic clinical record was conducted with the MDS coordinator who stated that a quarterly MDS assessment for resident #47 was missing and not done on time. The MDS coordinator stated that when a quarterly MDS Assessment is not completed, it is unknown whether the resident had changes in their status or if facility was able to meet the needs of the resident. The MDS coordinator stated that the resident should have come up on the schedule for an assessment; but it appeared that the schedule for this resident was cleared and did not appear on the scheduler. The MDS coordinator then proceeded to initiate a quarterly MDS dated [DATE] and stated that the quarterly assessment can still be completed but it would not be timely. An interview was conducted on March 28, 2024 at 1:23 p.m. with the Director of Nursing (DON/Staff # 51) who stated that not having a quarterly MDS Assessment completed would not meet facility expectations. During the interview, a review of the electronic record was conducted with the DON who stated that the quarterly MDS assessment for resident #47 was missing and it should have been completed in the month of February to meet facility expectations. Review of the facility's Policy titled, Resident Assessment - Accuracy of Assessment (MDS 3.0), reviewed May 2023, revealed it is the policy of this facility to ensure that the assessment accurately reflect the resident's status. The physical, mental, and psychosocial conditions of the resident determine the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medial social workers, dieticians, and other professionals in assessing the resident and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs. Review of the facility's Policy titled, Resident Assessment - Assessments, Frequency of, (revised May 2021) revealed, it is the policy of this facility that resident assessments shall be developed and reviewed on a timely basis, based on resident condition and RAI guidelines. The interdisciplinary team will document resident assessments and reviews at least quarterly. Review of the RAI manual dated October 2019 revealed that the primary purpose of the MDS assessment tool is to identify resident care problems that are addressed in an individualized care plan. The Quarterly ARD date is no later than the ARD of the previous OBRA assessment + 92 days and the completion date is no later than the ARD + 14 calendar days.

Based on closed record review, staff interview, and review of the facilitydocumentation, policies and procedures, the facility failed to protect the rights of 3 residents (#92, #71, and #1) to be free from abuse of another (#117 and #460). The deficient practice could result in residents not protected from further abuse. Findings include: Regarding resident #92 and #117 -Resident #92 was admitted on [DATE] with diagnoses of major depressive disorder, Stage 3 kidney disease, and a history of strokes. The annual MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 13 indicating the resident was cognitively intact. A review of the electronic health record revealed that on July 19, 2023 resident #117 pulled the hair of resident #92 who then pulled the hair of resident #117. The documentation included that both residents were separated and placed on 15 minute checks; and, resident #117 was moved to a different room. 49199 Based on closed record review, staff interview, and review of the facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#71) to be free from abuse of another. The deficient practice could result in residents not protected from further abuse. Findings include: Regarding resident #71 Resident #71 was admitted to the facility on [DATE] with a diagnosis of dementia. The second Resident involved in the incident has passed away. The MDS (Minimum Data Set) assessment revealed a BIMS (Brief Interview for Mental Status) revealed a score of 06 which indicated the resident had severe cognitive impairment. Review of the clinical record revealed that on July 27, 2023 at 5:45 p.m., yelling was heard from the room of resident #71 and his roommate. Per the documentation, when staff entered the room resident #71 was on the floor and his roommate was standing next to him; and that, resident #71 was yelling, holding the wrist and leg of the roommate, and was hitting at the roommate. The documentation also included that staff immediately seperated both residents and resident #71 was moved to a new room the same day of the incident. 49325 Regarding Resident # 1 and # 460: -Resident # 1 was admitted on [DATE] with diagnoses of Alzheimer's Disease, cognitive communication deficit, major depressive disorder, and unspecified psychosis. The care-plan initiated July 25, 2022 revealed interventions that included staff will assign seating away from other residents when agitated during meal times. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 2, indicating resident had severe cognitive impairment. A review of the electronic medical records revealed that on August 11, 2023 at 10:50 a.m., resident # 1 entered the dining room and saw resident #460 sitting in her favorite spot. Per the documentation, resident #1 asked resident #460 to move and as resident #460 was getting up, both residents started having a verbal altercation. The documentation also included that as staff were intervening, resident #1 bumped resident #460 with her walker and resident #460 attempted to push the walker back into Resident #1. Per the documentation, staff were physically in between both residents. -Resident # 460 was admitted to the facility on [DATE] with diagnoses that included dementia, post-traumatic stress disorder, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed Resident #460 was not assessed for a BIMS score. A review of the facility investigation dated August 18, 2023 revealed that both resident (#1 and #460) were both on a secured behavioral unit when staff reported that resident #1 walked into the dining room and resident #460 was sitting in a chair that resident #1 wanted. The report also included that resident #1 began to push her walker into Resident #460; staff witnessed the incident and immediately intervened and no injuries were noted to either resident. An interview was conducted on March 26, 2024 at 11:54 AM with behavioral health unit manager (BHUM/staff # 52) who stated that staff receive abuse in-service trainings. Staff # 52 initially stated she was not sure of how soon it was reported, although later detailed it should be right away because they have a 2-hour window. Staff # 52 stated that the first thing staff do was to ensure both residents were safe during a physical altercation as resident safety comes first. In an interview with certified nursing assistant (CNA/staff #138) conducted on March 27, 2024 at 11:44 a.m., the CNA stated that facility incorporates in-service training on abuse; and, the abuse protocol was to notify the nurse as soon as possible and make sure residents were safe. The CNA said that she was familiar with resident #1; but, she was not familiar with resident # 460 or any altercation between the two residents. An interview was conducted on March 27, 2024 at 2:35 p.m. with registered nurse (RN/staff # 49) who stated that if at any time a resident to resident make physical contact, this incident is reported. The RN said that the physical contact does not have to be purposeful to be reportable; and that, comes first. The RN further stated that residents were removed and placed on 15-minute checks whenever physical abuse was suspected. During an interview with the Director of Nursing (DON/Staff # 51) conducted on March 28, 2024 at 11:40 a.m., the DON stated that during a resident to resident altercation, the residents involved were separated and assessed for any injuries. Further, the DON said that the facility expectations on abuse was that residents were free from abuse. Review of the facility's Policy titled, Abuse: Prevention of and Prohibition Against (revised October 2023) revealed, it is the policy of this facility that each resident has the right to be free from abuse. The facility will provide oversight and monitoring to ensure its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. Policy defines abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Will, as used in this definition of abuse, means the individual must have acted deliberately. Furthermore, policy revealed that physical abuse includes but is not limited to hitting, slapping, pinching, and kicking. The facility will act to protect and prevent abuse and neglect from occurring with the facility by identifying, correcting and intervening in situations in which abuse is more likely to occur.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that five residents (#1, #3, #4, #5, #6) were free from abuse from other residents. The deficient practice could result in other residents being abused. Findings included: Regarding Resident #1 and #2: Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, cognitive communication deficit, atherosclerotic heart disease, syncope, hypertension, and mild neurocognitive disorder. A review of the quarterly MDS (minimum data set) assessment dated [DATE] for resident #1 revealed a BIMS (brief interview of mental status) score of 7, indicating moderate impact on cognition. Resident #2 was admitted on [DATE] with diagnosis including dementia, major depressive disorder recurrent, dysphagia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease. A review of the quarterly MDS (minimum data set) dated November 21, 2023 for resident #2 revealed a BIMS (brief interview of mental status) score of 3, indicating severely cognitively impaired. A review of the progress notes revealed that on November 13, 2023 at 3:52 P.M. resident #1 and resident #2 were self-propelling their wheelchairs out of the dining area, as staff were assisting other residents, words were exchanged between resident #1 and resident #2. Resident #1 accused resident #2 of running over the foot of resident #1. Resident #1 was then observed by staff hit resident #2 in the arm before staff could reach either resident. Staff were noted to have separated the residents and assisted them back to their respective rooms. Resident records revealed that skin checks were conducted and no areas of redness or injuries were observed. The progress notes further revealed that notifications of the director of nursing, family, case manager, provider, and police had transpired. Residents were placed on 15-minute intervals checks. A review of the facility investigation dated November 16, 2023 revealed that a resident to resident altercation had occurred on November 13, 2023 between resident #1 and resident #2. The investigative report revealed that resident #1 and resident #2 were self-propelling their respective wheelchairs from the dining room area and that the wheelchair of resident #2 made contact with the foot of resident #1 and then that the hand of resident #1 made contact with the arm of resident #2. The investigation cited that the residents were immediately separated and that no injuries had transpired, notifications were made, laboratory assessments ordered and the residents were placed on 15-minute interval checks. An interview was conducted on February 13, 2024 at 2:35 PM with a certified nursing assistant (CNA, staff #81). Staff #81 stated that staff receive frequent ongoing training regarding abuse and neglect. She further stated that if she were to observe an instance of abuse, whether it involved staff or another resident, she would immediately intervene, ensure the residents safety and report the issue. An interview was conducted on February 14, 2024 at 10:46 AM with behavioral health unit manager (staff #20). Staff #20 stated that unit 500, 600 and 800 are locked units and that determination to place a resident on either unit is contingent on their behaviors, documentation of behaviors, intensity of behaviors and frequency of behaviors to ensure the residents were a good fit for that unit. She stated that based on the aforementioned criteria, both resident #1 and #2 were deemed a good fit. She stated that staff received ongoing training through the facilities online learning portal as well as recent CPI [Crisis Prevention Institute] training on identifying warning signs for potential behaviors and de-escalation of behaviors. She stated that there is at least one behavioral health training for staff on a monthly basis. Staff #20 stated that the units are staffed contingent on the needs of the resident and based on the facility assessment, and that generally equated to 3 CNAs on each unit. Staff #20 stated that abuse could be verbal or physical and that the expectation was that all residents are free from abuse, whether by another resident, by staff, or other persons. Regarding Resident #3 and #9: Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety disorder, alcohol induced psychotic disorder with hallucinations, Wernicke's encephalopathy, cognitive communication deficit, unsteadiness and dysphagia. A review of the quarterly MDS for resident #3 assessment dated [DATE], revealed a BIMS score of 14, indicating cognitively intact. Resident #9 was admitted on [DATE] with diagnoses that included respiratory failure, hemiplegia, hemiparesis, symbolic dysfunction, epilepsy, major depressive disorder-recurrent, traumatic brain injury and schizophrenia. A review of the annual MDS for resident #9 revealed a BIMS score of 15, indicating cognitively intact. A review of the progress notes dated November 21, 2023 at 3:56 P.M. revealed that staff #37, a restorative nurse assistant, reported an incident between 2 residents. It was noted that resident #9 was in his wheelchair blocking the doorway and not allowing his roommate to exit the room. Resident #9 was noted to have kicked out with his foot and made contact with the abdomen of resident #3. It was noted that the 2 residents were immediately separated, vitals were obtained, skin assessments completed, no noted injuries reported and that resident #3 denied having any injuries as a result of the incident. It was further noted that 15-minute visual checks were implemented, notifications occurred, and laboratory assessments were ordered. A review of the facility investigative report revealed that a resident to resident altercation had occurred on November 21, 2023 between resident #3 and resident #9. The report revealed that resident #3 was participating in therapy with staff #37. It was noted that resident #9 was blocking the way for resident #3. Resident #3 and staff 37 asked resident #9 for room to pass and resident #9 stated no. The foot of resident #9 then made contact with the stomach of resident #3. It was further noted that both residents were immediately separated, skin checks conducted, no injuries were noted, appropriate notifications transpired, residents were placed on 15-minute skin checks, resident #9 was moved to a different room on a different hall, laboratory assessments were ordered and follow-up visits were conducted by the operations manager (staff #133). An interview was conducted on February 13, 2024 at 9:35 A.M. with resident #3. Resident #3 stated that he was trying to leave the room to meet his therapist and had asked resident #9 to move. He stated that resident #9 did not move and instead kicked him. He said that there were no injuries and that the facility had acted promptly and conducted a head to toe skin assessment and moved resident #9 to another hall. He stated that there have been no further incidents. An interview was conducted on February 14, 2024 at 3:18 P.M. with staff #37. Staff #37 stated that that resident #3 was at the door of his room wanting to go out, but resident #9 was blocking the door and would not move. She stated that as a CNA was trying to get a walker out of the way, resident #9 kicked resident #3 in the abdomen. She stated that staff separated the residents and moved the residents into separate rooms. She stated that this has been the first time that resident # 9 had ever physically acted out against another resident. She stated in any instance of physical abuse, staff intervene, insure that the residents are safe and free of injury, place the aggressor away from other residents, notify all appropriate parties and proceed with written statements of the incident. She stated that the expectation is to prevent all types of abuse; however resident #3 did suffer abuse by resident #9. Regarding Resident #4 and #5: Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, muscle weakness and cognitive communication deficit. A review of the admission MDS assessment dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. Resident #5 was admitted on [DATE] with diagnosis that included dementia, cognitive communication deficit, dysphagia, unsteadiness, muscle weakness, chronic kidney disease, anxiety disorder, major depressive disorder-recurrent, paranoid personality disorder, Parkinson's disease, and persistent mood disorder. A review of the 5-day MDS assessment dated [DATE] revealed a BIMS score of 14, indicating cognitively intact. A review of the facilities investigative report revealed that on November 26, 2023, resident #4 and resident #5 were in the dining room in the secured unit, when a nurse heard a noise. It was noted that the nurse observed resident #5 making contact, via his foot, with the wheelchair of resident #4. It was further noted that the nursing assistant escorted both residents to their respective rooms and initiated 15-min interval checks. The report revealed that post separation, skin checks were conducted and revealed an abrasion to the arm of resident #4, notifications were completed, resident #5 had an adjustment to his medications as well as a psychological evaluation. The report further revealed that neither resident recalled the incident. An interview was conducted on February 14, 2024 at 10:25 A.M. licensed practical nurse (LPN, staff #143). Staff #143 stated that she had not observed the verbal altercation between the two residents, but had herd yelling coming from the dining room and went to investigate. She stated that when she arrived in the dining room, she observed resident #5 kicking the wheelchair of resident #4. She stated that she pulled the chair of resident #4 away. She stated that she had separated the two residents and recalled that each had minor injuries. She stated that she thought resident #4 had an injury to his forearm and the resident #5 had an injury to his thumb. She stated that she could not recall if the incident occurred right after lunch or right after dinner and stated that there were either 2 or 3 CNA's (certified nursing assistants) present that day, which is normal for the facility. A review of the punch detail revealed 3 CNA's present on November 26, 2024. She further stated that the expectation is that in spite of it being a behavioral unit, abuse should not occur. Regarding Resident #6 and #7: Resident #6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anoxic brain damage, major depressive disorder recurrent, chronic kidney disease, epilepsy, and type 2 diabetes. A review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 0, indicating severely cognitively impaired. Resident #7 was admitted on [DATE] with diagnosis including metabolic encephalopathy, pneumonia, sepsis, acute respiratory failure with hypoxia, type 2 diabetes, cognitive communication deficit, dysphagia, and dementia. A review of the 5-day MDS dated [DATE] revealed a BIMS score of 01, indicating severely cognitively impaired. A review of the facility's investigative report revealed that on January 31, 2024, resident #7 was observed experiencing increased disorientation, staff intervened and attempted to direct resident #7 out of the dining room to provide de-escalation and re-orientation. It was noted as resident #7 passed resident #6 in the hall. Resident #7 made a hand gesture contacting the upper arm of resident #6. The report further revealed that skin checks were conducted-revealing no injuries, notifications were completed, resident #7 was placed on 1:1 for the remainder of his stay, additional behavioral supports were enlisted from the operations manager and the behavioral health manager. An interview was conducted on February 14, 2024 with behavioral health unit manager (LPN, staff #20). She stated that she did not witness the incident but arrived in the dining room right after it had occurred. She stated that resident #7 was noted to become restless and staff were in the process of moving him out of the dining room, when they passed by resident #6. Resident #7 hit resident #6 during the encounter. She stated that that act of hitting resident #6 was deliberate and not accidental She stated that staff were trained to utilize soft, calm approaches and coaxing when trying to remove a resident from an area if they observe a potential concern. She stated that if the resident is in the dining area, they may move the resident to another table or remove them from the dining area entirely. She stated that staff are trained, that if a resident refused to be moved, to call for assistance, keep the resident engaged and try to move the other residents around them. She stated that to her recollection, neither resident incurred any injuries from the encounter and that the appropriate follow-up had been conducted, which included an update to resident #7's care plan. She voiced no staffing concerns for the locked units and stated that her expectation was that residents are free from abuse. Review of the facility policy with a review date of January 2022 revealed that the resident has a right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy defined abuse as a willful infliction of injury. The policy further revealed that the facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#99) was free from physical abuse by other residents. The deficient practice could result in further incidents of resident to resident abuse. Findings include: Resident #99 was admitted to the facility on [DATE], with diagnoses that included dementia, schizophrenia, weakness, dysphagia, anxiety, depression, and hypertension. A behavioral care plan with a start date of June 26, 2023 revealed the resident was a wandering risk related to; disoriented to place, impaired safety awareness, and that the resident wanders aimlessly. The goal was that the resident's safety would be maintained. Interventions included assessing for fall risk, and documenting wandering behaviors and interventions. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had significant cognitive impairment. A review of the clinical record showed a progress note dated January 5, 2023 which revealed the resident was pacing on the unit, going into other people's rooms and was very hard to redirect. The note further revealed that physical assistance was required to keep the resident out of other people's rooms. A nursing progress note dated January 18, 2023 revealed an incident where the resident had wandered into another person's room, and that resident was noted standing near the doorway. That resident stated he had pushed resident #99 out of his room, causing them to fall into the side wall rail and slide to the floor. A social services progress note dated January 23, 2023 revealed resident #99 wanders the hallways constantly and is intrusive most shifts, needing constant on hand redirection from staff to keep her safe. It further revealed that she wanders into patient rooms, often taking other resident's food and laying in other resident's beds. A nursing progress note dated February 2, 2023 revealed the resident was continuing to wander into other resident's rooms all day, taking other resident's food, and was very hard to redirect again requiring physical assistance to keep her from other resident's rooms. A nursing progress note dated March 9, 2023 revealed another instance where resident #99 had gone into another resident's room, and staff were required to intervene after the resident had slapped resident #99 in his room. It was noted that the right side of the face of resident #99 was reddened after the incident, indicating a negative outcome. A nursing progress note dated April 7, 2023 revealed that resident #99 continues to wander the unit, going in and out of other resident's rooms and requiring physical assistance to keep her out of other resident's rooms. However, no care plan interventions were added for any of the documented instances of behavior. An interview with a licensed practical nurse (LPN/staff #23) was conducted on November 22, 2023 at 9:50 AM. The LPN stated the resident #99 was always in everyone's room, constantly wandering, and that problematic residents are transferred to other units if incidents keep occurring. They also stated that there were more incidences that were not documented because not everyone documents appropriately, however they stated that any time there was an incident she documented it in the progress notes. An interview with the Director of Nursing (DON/staff #49) was conducted on November 22, 2023 at 10:44 AM. The DON stated that they use multiple units to transfer residents to keep them separate from each other as incidents happen. She further stated that they have to keep track of why they are moving what residents where, and that her expectation when incidents happen is that they follow the facilities policy regarding abuse. A review of facility policy titled 'Abuse: Prevention of and prohibition against' under the section 'prevention' revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by identifying, assessing, care planning for appropriate interventions that include wandering into other's rooms/space.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#99) was free from physical abuse by other residents. The deficient practice could result in further incidents of resident to resident abuse. Findings include: Resident #99 was admitted to the facility on [DATE], with diagnoses that included dementia, schizophrenia, weakness, dysphagia, anxiety, depression, and hypertension. A behavioral care plan with a start date of June 26, 2023 revealed the resident was a wandering risk related to; disoriented to place, impaired safety awareness, and that the resident wanders aimlessly. The goal was that the resident's safety would be maintained. Interventions included assessing for fall risk, and documenting wandering behaviors and interventions. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had significant cognitive impairment. A review of the clinical record showed a progress note dated January 5, 2023 which revealed the resident was pacing on the unit, going into other people's rooms and was very hard to redirect. The note further revealed that physical assistance was required to keep the resident out of other people's rooms. A nursing progress note dated January 18, 2023 revealed an incident where the resident had wandered into another person's room, and that resident was noted standing near the doorway. That resident stated he had pushed resident #99 out of his room, causing them to fall into the side wall rail and slide to the floor. A social services progress note dated January 23, 2023 revealed resident #99 wanders the hallways constantly and is intrusive most shifts, needing constant on hand redirection from staff to keep her safe. It further revealed that she wanders into patient rooms, often taking other resident's food and laying in other resident's beds. A nursing progress note dated February 2, 2023 revealed the resident was continuing to wander into other resident's rooms all day, taking other resident's food, and was very hard to redirect again requiring physical assistance to keep her from other resident's rooms. A nursing progress note dated March 9, 2023 revealed another instance where resident #99 had gone into another resident's room, and staff were required to intervene after the resident had slapped resident #99 in his room. It was noted that the right side of the face of resident #99 was reddened after the incident, indicating a negative outcome. A nursing progress note dated April 7, 2023 revealed that resident #99 continues to wander the unit, going in and out of other resident's rooms and requiring physical assistance to keep her out of other resident's rooms. However, no care plan interventions were added for any of the documented instances of behavior. An interview with a licensed practical nurse (LPN/staff #23) was conducted on November 22, 2023 at 9:50 AM. The LPN stated the resident #99 was always in everyone's room, constantly wandering, and that problematic residents are transferred to other units if incidents keep occurring. They also stated that there were more incidences that were not documented because not everyone documents appropriately, however they stated that any time there was an incident she documented it in the progress notes. An interview with the Director of Nursing (DON/staff #49) was conducted on November 22, 2023 at 10:44 AM. The DON stated that they use multiple units to transfer residents to keep them separate from each other as incidents happen. She further stated that they have to keep track of why they are moving what residents where, and that her expectation when incidents happen is that they follow the facilities policy regarding abuse. A review of facility policy titled 'Abuse: Prevention of and prohibition against' under the section 'prevention' revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by identifying, assessing, care planning for appropriate interventions that include wandering into other's rooms/space.

Based on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure weekly weights for one resident (#12) were completed as ordered by the physician. The deficient practice could result in resident not receiving the appropriate care and treatment they need. Findings include: -Resident #12 was admitted on [DATE] with diagnoses of diabetes mellitus, end stage renal disease, and Bipolar disorder. An Admission Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 3, which indicated resident had severe cognitive impairment. A care plan initiated September 21, 2022 included the resident had a potential nutritional problem related to diabetes mellitus, poor nutritional intake, end stage renal disease, and bipolar disorder. Interventions included weekly weights for four weeks and then monthly if stable. A physician order dated September 21, 2022 included for weekly weights every 7 days during day shift for 4 weeks and to be completed on October 26, 2022. This order was transcribed onto the restorative nursing administratrion record for September and October 2022. According to the documentation weights were scheduled to be taken and recorded on September 28, October, 5, 12 and 19. However, the boxes for these dates in the record were blank and were not marked as completed. The weight summary record revealed that on October 3, 2022 the resident had a weight of 128.4 lbs (pounds). Further review of the clinical record revealed there was only 1 weight recorded; and there were no evidence of resident refusals to be weighed from September 21, 2022 through October 26, 2022. An interview was conducted on December 7, 2022 at 1:25 p.m. with the behavioral unit manager (staff #67) who stated that the Restorative Nursing Assistant (RNA) should be getting the weekly weights; and that, weights are usually in the chart under the vitals or weights section; and that, they can also be documented on the Medication Administration Record (MAR). An interview was conducted on December 8, 2022 at 8:58 a.m. with a licensed practical nurse (LPN/staff #89). During the interview, a review of the clinical record was conducted by the LPN who was not able to find the weekly weights for resident #12. Staff #89 then called for staff #67 to join the interview and to also review the resident's clinical record. Staff #67 was also not able to find the resident's weekly weights; and stated that resident #12 should have weekly weights and she was not able to find them. In an interview conducted with an RNA (staff #9) on December 8, 2022 at approximately 8:48 a.m., the RNA said she was performs weekly weights and documents weights in the clinical record. She said she cannot document resident refusals but she informs the nurse who will then document the resident refusal in the clinical record. Further, the RNA stated that resident #12 should have more weights recorded in the clinical record. During an interview with the Director of Nursing (DON/staff #138) conducted on December 8, 2022 at 2:13 p.m., the DON stated that her expectation was for nurses to follow through when they receive an order from the physician. The DON further stated that weights not obtained and recorded for resident #12 does not meet her expectations. Review of the facility's policy titled, Professional Standards included that it is their policy that services provided by the facility meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan. 47179

Based on clinical record review, staff interviews and facility documentation, the facility failed to ensure that ongoing assessment and monitoring for complications before and after dialysis was provided to one resident (#12). The deficient practice could result in resident not provided with treatment and care according to their assessed needs. Findings include: Resident #12 was admitted on [DATE] with diagnoses of end stage renal disease, traumatic brain injury, and bipolar disorder. An admission Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The assessment also included that the resident received dialysis. A physician's order dated September 21, 2022 included dialysis schedule was Tuesday, Thursday and Saturday from 8:00 a.m. through 12:00 p.m. for end stage renal disease. A care plan dated September 22, 2022 revealed the resident needed hemodialysis related to end stage renal disease. Intervention included to obtain vital signs and weight per protocol. A Dialysis Services Agreement between the facility and the dialysis provider included that the facility was responsible for pre and post dialysis weights for patients. Continued review of the clinical record revealed no evidence that pre and post dialysis weights were taken and recorded. An interview was conducted on December 8, 2022 at 8:58 a.m. with a licensed practical nurse (LPN/staff #89) who said that when a resident is on dialysis, she checks the resident's blood sugar, and blood pressure; gives reports on laboratory results, resident's blood pressure medication; administer medication as ordered by the physician. The LPN also stated that when dialysis is finished, the dialysis nurse will go over the resident's blood pressure and how many liters they removed. However, the LPN stated that staff do not take resident's weights before and after dialysis. During an interview with the the Director of Nursing (DON/staff #138) conducted on December 8, 2022 at 2:13 p.m., the DON stated that there are orders for pre and post dialysis weights. She said that resident's weights can be taken by either the certified nursing assistant on the floor or the dialysis center nurse. The DON further stated that her expectations were not met because resident #12 did not have pre and post dialysis weights. The facility policy on Pre and Post Dialysis Care included that it is their policy t assist resident in maintaining homeostasis pre- and post- renal dialysis; and assess resident daily for function related to renal dialysis.

Based on clinical record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure the clinical record was accurate and complete for regarding an advanced directive one resident (#105). The sample size was 24. The deficient practice could result in residents' clinical record not being accurate and complete. Findings include: Resident #105 admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance and end stage renal disease. A Healthcare Power of Attorney dated February 14, 2019 revealed that a designated family member was appointed as an agent for the resident. The document was signed by the resident and witnessed by two additional individuals. Review of the Advanced Directives Addendum dated August 12, 2022 revealed resident had a full code status; and, the document indicated a verbal consent was obtained from the resident's power of attorney (POA). The admission MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (brief interview for mental status) score of 10 indicating resident had moderate cognitive impairment. A physician order dated October 31, 2022 included a DNR (do not resuscitate) order. It also included limited additional interventions such as no feeding tube, no hospitalization , no antibiotics, and no intravenous therapy. The order also indicated verification with the resident's Medical Power of Attorney (MPOA). However, review of the clinical record revealed no documentation regarding the change in code status. Review of the resident's comprehensive care plan did not include an advance directive designation. Review of the resident's legal documents revealed no evidence of an orange DNR form completed to indicate the end of life preferences of the resident and/or representative. A review of the code status binder located at the 500 unit revealed that resident #105 had a full code status. On December 8, 2022 at 9:06 a.m., an interview was conducted with a licensed practical nurse (LPN/staff #117) who stated that there was a binder located in the unit that contained information on resident's code status. The LPN also stated that whenever a new admission comes, staff adds that advanced directive to the binder; and, in the clinical record as well. The LPN stated staff had to make sure that the DNR form is signed; and that, she thought the social services was involved in ensuring that all the documentation was accurate. An interview was conducted with the social services director (#87) and a social services staff (#73) on December 8, 2022 at 9:38 a.m. Staff #73 stated that if a resident's representative wanted to make a change in a resident's code status, they will ensure that all the appropriate paperwork gets filled out. Staff #73 also stated that the change in code status is communicated to nursing staff who will change all the orders and updates the clinical record. Both staffs #73 and #87 stated they were not aware there was a change in the code status of resident #105. During the interview, a review of the clinical record was conducted by staff #73 who stated she could see resident #105 had a full code status upon admission; and that, a change had taken place. Staff #73 said the change in resident's code status was transcribed by a new facility provider (staff #141). During and interview conducted on December 8, 2022 at 9:50 a.m., the Director of Nursing (DON/staff #138) stated that it was her expectation that the resident's code status will be initiated upon admission; and that, the resident was given the right to choose. She stated that when a representative wanted to change the code status, the representative can talk to social services or nursing, and this change will need to be communicated to the provider. The DON further stated that nursing will fill out a new DNR sheet that the provider must sign. Further, the DON stated that it was her expectation that the the code status match the paperwork for residents. The Advance Directives policy, revised on May 2022 included that it is their policy that the resident's choice about advanced directives will be recognized and respected. Once the advanced directive or information regarding the resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident's medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented into the resident's medical record and plan of care. Changes or revocations of a directive must be submitted to the facility in writing. The facility may require that the resident or resident representative create/execute new documents if changes are extensive. The care plan team will be informed of such changes and/or revocations so that the appropriate changes can be made in the resident assessment (MDS), care plan, and elsewhere in the clinical record.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide one resident (#84) consistent restorative nursing services according to the physician order. The deficient practice could decrease resident's ability to carry out the activities of daily living. Findings include: Resident #84 was admitted on [DATE] with diagnoses of Alzheimer's disease, dysphagia, and schizoaffective disorder. A review of care plan initiated on June 28, 2021 revealed the the resident had ADL (activities of daily living) self-care performance deficit due to impaired thought process due to Alzheimer dementia. The goal was to maintain current level of function in ADL's, transfers and mobility. Interventions included AROM (active range of motion) to BLE (bilateral lower extremities) and ambulation with 2WW (two-wheeled walker), and gait belt down corridor up to three times a week as resident is willing to participate; and, occupational, physical, and speech-language therapy evaluation and treatment per physician orders. A significant change in status MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severe cognitive impairment. A physician order dated November 15, 2022 revealed an order for restorative treatment that included ambulation around corridor with gait belt and 2WW, AROM to BLE up to three times a week as resident is willing to participate. A progress note dated November 25, 2022 included resident #84 was unable to ambulate or even stand and did participate in PROM (passive range of motion) to BLE. Per the documentation, plan was to continue restorative nursing services. Review of clinical record revealed documentation that on November 25 and December 1, 2022 restorative services were being offered to the resident. A progress note dated December 1, 2022 revealed resident #84 was unable to ambulate at this time; and had participated in PROM to BLE with no complaints. Further, the note included there had been no changes in ROM from last week; and plan was to continue with restorative nursing services. However, review of the clinical records revealed no evidence that the facility consistently provided restorative nursing services. An interview was conducted on December 7, 2022 at 11:27 a.m. with an RNA (restorative nursing assistant/staff #9) who stated that therapy writes the restorative nursing order that include what the resident might need such as ambulation or range of motion. Staff #9 stated that restorative nursing services provided to resident were on the order; and that, a meeting was conducted and attended by the Director of Nursing (DON), Assistant DON (ADON), and herself to discuss the progress of residents. Regarding resident #84, the RNA stated that resident #84 was not able to ambulate at this time, had a decline, was very weak and was only able to do passive range of motion. Further, staff #9 stated she does not know the days restorative nursing services was provided for resident #84. During an interview with the Director of Nursing (DON/staff #138) conducted on December 8, 2022 at 12:06 p.m., the DON stated that an order is prescribed for RNA services; and that, staff provide RNA services throughout the week. The DON stated that they meet on a monthly basis to go through each resident RNA plans. The DON further stated that review of the clinical record revealed no documentation that resident #84 refused or declined RNA services. A facility policy on Restorative Care revealed that restorative care will be provided to each resident according to his/her individuals needs and desires as determined by assessment and interdisciplinary care planning. Documentation of restorative services is specific to facility's documentation practices.

Based on clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure one of 5 sampled residents (#110) was informed of the risks and benefits of a psychotropic medication prior to its administration. The deficient practice could result in resident not fully informed of the risk and benefits of the use of a psychotropic drug. Findings include: Resident #110 was admitted on [DATE] with diagnoses of dementia without behavioral, psychotic, and mood disturbances, bipolar disorder and cognitive communication deficit. A physician order dated November 4, 2022 included for hydroxyzine HCl (antihistamine/antianxiety) 25 milligrams (mg) give one tablet every evening for anxiety as evidenced by restlessness. Review of the November 4 through 9, 2022 Medication Administration Record (MAR) revealed hydroxyzine HCl was first administered to the resident as ordered on November 5, 2022. However, the clinical record revealed no evidence the resident and/or her representative was informed of the risks and benefits of the use of hydroxyzine. The admission Minimum Data Set assessment dated [DATE] revealed the resident required limited one-person physical assistance for most activities of daily living and a brief interview for mental status (BIMS) score of 2 indicating severe cognitive impairment. The assessment also included the resident received antianxiety medications for 5 days during the last 7 days of the assessment. A consent for psychotropic medications dated November 11, 2022 included the risks and benefits associated with hydroxyzine HCl; and a verbal consent for the use of the medication was received from the resident's responsible party. The care plan dated November 11, 2022 included the resident was receiving antianxiety medication related to anxiety disorder as evidenced by restlessness. Goal was for the resident to be free from discomfort or adverse reactions. Interventions included to educate the resident, family/caregivers about risks, benefits and the side-effects of antianxiety medication being given. On December 7, 2022 at at 11:43 a.m., an interview was conducted with the director of nursing (DON/staff #138) who stated nursing staff was expected to obtain informed consents for psychotropic medications prior to the administration of the medication. The Psychoactive Medication policy, revised on November 2022, included that it is their policy to maintain every resident's right to be free from use of psychoactive medication. The use of psychoactive medication must first be explained to the resident, family member, or legal representative. A consent is to be obtained either from the resident or the responsible party, if the resident is unable to give. A verbal consent may be obtained if no responsible person is available. The person obtaining the consent is to sign the consent once obtained. Potential negative outcomes of psychoactive medication must be explained.

Based on observation, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that 1 of 21 sampled residents (#51) received adequate pain management. The deficient practice could result in residents having pain that may diminish their quality of life. Findings include: Resident #51 was admitted to the facility on (MONTH) 8, 2014 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 10, 2019 revealed the Brief Interview for Mental Status (BIMS) assessment could not be completed, as the resident was rarely/never understood and the resident was severely impaired with cognitive skills for daily decision making. In Section J, the documentation included the resident was on a scheduled pain medication regimen, was not on PRN pain meds and non-medication interventions for pain were not in place. Under staff assessment for pain, the documentation included the resident exhibited nonverbal sounds (crying, whining, gasping, moaning or groaning) and indicators of pain were present on 3-4 days during the last 5 days of the look back period. A Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 30, 2019 revealed a score of 9.0, indicating the resident was at very high risk. Some of the factors that contributed to the score included the resident's ability to respond meaningfully to pressure related discomfort was very limited; was only able to respond to painful stimuli and could not communicate discomfort, except by moaning or restlessness. Review of the physician orders [REDACTED]. The order had an original order date of (MONTH) 12, (YEAR). The orders also included to monitor the resident's pain level every shift using the following pain scale: 0=no pain; 1-3=mild pain; 4-6=moderate pain and 7-10=severe pain. Another physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. In addition, the documentation showed the resident's pain level was assessed every shift and was generally at 0-1. At times, the resident's pain level was assessed as follows: on (MONTH) 13, the resident's pain level was documented as a 6 on two separate shifts; on (MONTH) 14, the resident's pain level was documented as a 6 on two separate shifts; and on (MONTH) 29, the resident's pain level was a 6. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. A pain care plan dated (MONTH) 2, 2019 included a goal for the resident to verbalize adequate pain relief or ability to cope with incompletely relieved pain through the review date. Interventions included to administer [MEDICATION NAME] medication as ordered, anticipate need for pain relief and respond immediately to any complaint of pain, follow pain scale to medicate as ordered and notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. A physician's orders [REDACTED]. Cleanse with normal saline, pat dry, apply therahoney and cover with a foam dressing every Monday, Wednesday, and Friday and PRN for an unstageable pressure injury. A Skin Pressure Ulcer Weekly summary completed by the wound nurse dated (MONTH) 8, 2019 revealed the resident had an unstageable pressure injury to the vertebral, [MEDICATION NAME] area of the back which measured 3.6 cm x 4.2 cm x UTD (unable to determined depth), and the periwound area had signs of [DIAGNOSES REDACTED], but no symptoms of infection. The summary included that wound care was provided and that the resident showed signs of pain, when turning and cleansing the wound. The documentation also included the resident experienced pain related to the wound, as evidenced by grimacing, moaning/crying, guarding, irritability, anger and by being tense. Although there was documentation by the wound nurse that the resident was experiencing pain during the wound treatment, there was no clinical record documentation that the resident was administered PRN [MEDICATION NAME], prior to the wound treatment on (MONTH) 8. A quarterly MDS assessment dated (MONTH) 10, 2019 included the resident was rarely/never understood. Section J revealed the resident had pain indicated by non-verbal sounds such as; crying, whining, gasping, moaning or groaning. The MDS included that non-verbal indicators of pain were observed on 3-4 days out of 5 during the look back period. A Skin Pressure Ulcer Weekly summary dated (MONTH) 16, 2019 revealed that wound care was provided and that the resident showed signs of pain when turning and cleansing the wound; as evidenced by grimacing, moaning/crying, guarding, anger and hitting. A Skin Pressure Ulcer Weekly summary dated (MONTH) 31, 2019 revealed that wound care was provided and that the resident showed signs of pain when turning and cleansing the wound. The summary included the resident was unable to communicate pain related to the wound, however, non-verbal demonstrations of pain were documented as; grimacing, moaning/crying and guarding. Despite documentation by the wound nurse that the resident was experiencing pain during the wound treatments, there was no clinical record documentation that the resident was administered PRN [MEDICATION NAME], prior to the wound treatments on (MONTH) 16 and 31. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. The documentation also showed that the resident's pain was being assessed every shift and was generally rated at 0-1 on a 1-10 pain scale. However, on the following dates the resident's pain level was assessed as follows: on (MONTH) 13 for a pain level of 6; on (MONTH) 15 for a pain level of 7; and on (MONTH) 25 for a pain level of 5. However, further review revealed no documentation that PRN [MEDICATION NAME] was administered at any time during the month. A Skin Pressure Ulcer Weekly summary dated (MONTH) 7, 2019 revealed that wound care was provided and that the resident showed signs of pain when turning and cleansing the wound. A Pressure Ulcer Weekly summary dated (MONTH) 14, 2019 revealed wound care was provided as ordered and that the resident showed signs of pain when turning and cleansing the wound. A Pressure Ulcer Weekly summary dated (MONTH) 21, 2019 revealed that wound care was provided as ordered by the physician. The documentation included the resident was noted with an unstageable pressure injury to the [MEDICATION NAME] area of the back, which measured 3.6 cm x 4.2 cm x UTD and that slough was continuing to separate, the periwound area had signs of [DIAGNOSES REDACTED], and there were no signs or symptoms of infection. Per the summary, the resident showed signs of pain when turning and cleansing the wound, as evidenced by grimacing, moaning/crying and guarding. Again, there was no clinical record documentation that the resident was administered PRN [MEDICATION NAME], prior to the wound treatments on (MONTH) 7, 14, and 21, despite documentation that the resident was in pain. An observation of a pressure ulcer treatment for [REDACTED].#149), who stated that she was a certified wound nurse. The resident was observed in bed and as she was approached by a CNA (staff #145), she grimaced and held tightly to the blanket on her bed. When staff #145 touched the resident, she began guarding and hitting at staff #145. At this time, staff #145 assisted the wound nurse in rolling the resident onto her side. As this was being done, the resident began crying out and was slapping at staff #145. Staff #145 held the resident's hip with one hand, and restrained the resident's hands with the other. Staff #149 then donned clean gloves and began to remove the old dressing. Resident #51 cried out loudly as the old dressing was removed. As the wound nurse was removing the old dressing, she identified the black/brown substance, which was partially attached to the old dressing as eschar. As the old dressing was being removed, the eschar began tearing away from the wound bed, without fully detaching. During this time, the resident squirmed and cried out during the treatment, as staff #145 continued to hold her at the hip and hands. However, the nurse did not stop the treatment to assess the resident's pain. The nurse then changed her gloves and cleansed the area. Resident #51 cried out again and squirmed against the hold of staff #145. The wound nurse measured the wound and stated it measured 2.6 cm x 1.6 cm. The nurse then changed gloves and applied therahoney to the wound. The resident moaned and slapped at the CNA. During the above observation, staff #149 stated the resident was not provided with adjuvant pain medication prior to wound care today. She stated that she usually provides wound care to the resident during the early mornings at approximately 7:00 AM. She said she changes the dressing before the CNAs get the resident up for breakfast and before medications have been administered. Staff #149 stated the resident does not receive pain medication prior to wound care because the resident's family does not want her to have it, due to their concerns about the resident becoming over-sedated. Staff #149 stated the resident cries out whenever care is provided and that it was customary behavior for her. Review of the clinical record including the (MONTH) 2019 MAR, revealed the resident did not receive any pain medication prior to the wound treatment which was done on (MONTH) 26, 2019 at 7:37 a.m. The (MONTH) MAR indicated [REDACTED] Continued review of the (MONTH) 2019 MAR indicated [REDACTED]. However, on the following dates the resident was observed to have pain as follows: on (MONTH) 7 a pain level of 7; on (MONTH) 9 a pain level of 2 and 4; on (MONTH) 10 a pain level of 4 on three separate shifts. There was no indication that the resident had been administered PRN [MEDICATION NAME] during the month. On (MONTH) 26, 2019 at 12:27 PM, an interview was conducted with the Assistant Director of Nursing (ADON/staff #52). He stated that non-verbal residents are assessed for pain through demonstrations of behaviors such as grimacing, moaning or crying. He stated that there is a pain scale in the computer that helps the nurses evaluate by grimace (Pain Aid), and that if he noticed grimacing or signs that the resident was in pain, he would consider administering pain medication. He said he would anticipate giving an adjuvant pain medication prior to therapy, wound care, treatments, or appointments. An interview was conducted on (MONTH) 26, 2019 at 12:36 PM with a LPN (staff #17). She stated that if she were providing treatment care to a resident who was experiencing pain, she would stop the treatment and administer pain medication, or call the provider for an order, or ask to have the order changed so that it could be administered as an adjuvant. She said that it would never be ok for the resident to be in pain during the treatment process. An interview was conducted on (MONTH) 26, 2019 at 12:56 PM with the Director of Nursing (DON/staff #151). She stated that the administration of pain medication depends on how the medication is ordered, as some are ordered on a schedule. She said that if a resident was experiencing pain with a treatment or wound care, she would anticipate the nurse would look to see if the resident had an order for [REDACTED].#51, she stated that the resident's family has insisted the resident does not receive too much pain medication, due to the sedating effects. However, she agreed that if the resident were crying out in pain during treatment, it would be acceptable to stop the treatment and administer as needed [MEDICATION NAME], and come back to resume the treatment in a 1/2 hour. A Pain Management Review dated (MONTH) 27, 2019 revealed the resident was not interviewable. The document stated that the resident displayed crying, grimacing, moaning, grunting, and yelling out at baseline. It stated that when the resident is experiencing pain or needed a break in care related to possible discomfort, she tapped her fist or open palm repeatedly on the nearest surface to indicate that there may be an issue or discomfort. The note stated that interventions included, but were not limited to, taking a break from care, repositioning, calming speech, distraction, tv, and offering as needed medication. On (MONTH) 27, 2019 at 10:15 AM, an interview was conducted with a CNA (staff #145). She stated that while she provides care to residents, she definitely monitors for pain or changes in behaviors. She stated that she feels any type of pain is concerning. If a resident was non-verbal, she said she would watch for facial expressions and reactions to care. She said that if the resident always reacts to treatment as if they were in pain, she would pay attention to a more intense reaction. Staff #145 stated that she works with resident #51 on a regular basis, and has become very familiar with the resident's responses. She stated that she definitely believed the resident was in pain during her treatment. She said that resident #51 reacted per her norm at first, but during the removal of the dressing, cleaning of the wound, and application of therahoney, the resident reacted as if she were in pain. The facility's policy titled Pain Management stated it is the policy of the facility to provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Additionally, the policy stated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening to determine if the resident has been or is experiencing pain, comprehensively assessing the pain, and identifying circumstances when pain can be anticipated. The policy also stated that residents will be assessed for pain upon development of new symptoms of acute or chronic pain that have not previously been assessed, and staff should consult the physician for additional interventions if pain is not relieved by the currently ordered treatment modalities and comfort measures.

Based on clinical record review, observation, staff interviews, and review of policy and procedures, the facility failed to ensure one out of three sampled residents (#51) with a pressure ulcer received care consistent with professional standards of practice to prevent the development of an unstageable pressure ulcer and consistently received necessary treatment and services consistent with professional standards of practice. The deficient practice could result in the development and worsening of pressure ulcers. Findings include: Resident #51 was admitted to the facility on (MONTH) 8, 2014, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 10, 2019 revealed the Brief Interview for Mental Status (BIMS) assessment could not be completed, as the resident was rarely/never understood and the resident was severely impaired with cognitive skills for daily decision making. The assessment included the resident required extensive assistance with bed mobility and was totally dependent on staff for transfer, toilet use, and personal hygiene. The MDS assessment also included the resident was at risk for the development of pressure ulcers but did not have any pressure ulcers, had a pressure reducing device for the bed but not for the chair, and was not on a turning/repositioning program. A physician's orders [REDACTED]. Additional review of the clinical record revealed the resident had previously received treatment for [REDACTED]. Review of the current care plan initiated (MONTH) 6, (YEAR), revealed the resident was actual for pressure ulcer development related to immobility. The goal was for the resident to have intact skin, free of redness, blisters or discoloration by/through review target date of (MONTH) 31, 2019. Interventions included to administer treatments as ordered and monitor for effectiveness, to encourage fluid intake and assist to keep skin hydrated, Low Air Loss (LAL) mattress, and a weekly head to toe skin at risk assessment. Continued review of the current care plan revealed the resident was at risk for skin breakdown related to impaired mobility, 2/2 right-sided paralysis, and bowel and bladder incontinence. The goal was the resident will not have any skin breakdown through the next review target date of (MONTH) 31, 2019. Interventions included weekly skin assessments, reporting any red and/or open areas, pressure relieving mattress on the bed and pressure relieving device in wheelchair, and providing incontinence care following each incontinent episode. The Braden Scale for Predicting Pressure Sore Risk forms dated (MONTH) 23 and 30, 2019 revealed a score of 9.0, indicating the resident was at very high risk. Some of the factors that contributed to the score included the resident's ability to respond meaningfully to pressure related discomfort was very limited; was only able to respond to painful stimuli and could not communicate discomfort, except by moaning or restlessness. Also included was that the resident was chairfast, completely immobile, and that friction and shear were considered a problem as the resident required moderate to maximum assistance moving and complete lifting without sliding against the sheets was deemed impossible. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed the weekly skin assessments were done. Review of the physician's orders [REDACTED]. A Weekly Skin Evaluation dated (MONTH) 3, 2019 revealed no documentation of ulcers, wounds, or other skin problems. The evaluation included that there were no new skin issues noted at that time. A nursing progress note dated (MONTH) 4, 2019 revealed a Certified Nursing Assistant (CNA) reported to the nurse resident #51's back was bleeding. The note included there was redness noted to the back, mostly the mid-back, with a wound noted to the site. The note also included the wound was cleaned and covered with a foam dressing and that an order for [REDACTED]. A physician's orders [REDACTED]. Review of the Weekly Skin Evaluation dated (MONTH) 4, 2019 revealed redness was noted to the back and a wound to the mid back and that wound care was to evaluate and treat. Another physician's orders [REDACTED]. Review of the TAR for (MONTH) 2019 revealed monitoring for the LALM began on (MONTH) 7. A physician's orders [REDACTED]. A Skin Pressure Ulcer Weekly form dated (MONTH) 8, 2019 revealed for an initial evaluation of the unstageable upper mid back wound. The wound measured 3.6 centimeters (cm) x 4.2 cm, had scant amount of serous drainage, and no odor. The wound bed was described as black/brown (eschar), edges of the wound were defined, and there was peripheral tissue [MEDICAL CONDITION]. The wound was cleansed with normal saline, pat dry, covered with therahoney, and covered with a foam dressing. Also documented was that the resident experienced non-verbal signs of pain that included grimacing, moaning/crying, guarding, irritability, anger, and being tense. Additional comments included orders would be changed to a LALM, staff would use wedges to rotate the resident every 2 hours, physical therapy and occupational therapy would be informed to take a look at the wheelchair, the registered dietician would be informed if any changes of nutrients were needed, and the resident's family would be informed. A nursing progress note dated (MONTH) 8, 2019, revealed the resident's family was notified of the wound. A Dietary Quarterly Evaluation dated (MONTH) 10, 2019, revealed the registered dietician had been informed of the pressure ulcer. However, review of the clinical record revealed no documentation that care was provided for the pressure ulcer between (MONTH) 4 and 8, 2019 and no documentation that the resident was administered pain medication prior to the wound treatment on (MONTH) 8, 2019. The quarterly MDS assessment dated (MONTH) 10, 2019 revealed the resident could not be assessed for the BIMS due to the resident rarely/never being understood. The assessment included the resident had one unstageable pressure ulcer, was receiving pressure ulcer care, had moisture associated skin damage, was not on a turning/repositioning program, had a pressure-reducing device for the bed, but no pressure reducing device for the chair. The assessment also included the resident required extensive assistance for activities of daily living. A physician's orders [REDACTED]. A Skin Pressure Ulcer Weekly form dated (MONTH) 16, 2019 revealed the wound was unstageable and measured 3.6 cm x 4.2 cm x UTD (unable to determine depth), had scant amount of serous exudate, and no odor. The wound bed had black/brown eschar, defined wound edges, and peripheral tissue [MEDICAL CONDITION]. The treatment was provided and the resident showed signs of pain when turning and cleaning the wound of grimacing, moaning/crying, guarding, anger, and hitting. A nursing progress note dated (MONTH) 27, 2019 revealed the unstageable pressure ulcer treatment had been provided by the wound nurse. The Skin Pressure Ulcer Weekly form dated (MONTH) 31, 2019 revealed the unstageable pressure ulcer measured 3.6 cm x 4.2 cm, had scant amount of serous exudate, and no odor. The form included slough to the wound bed, defined wound edges, and normal surrounding tissue. The form included the treatment was provided and that the resident continued to show signs of pain when turning and cleaning the wound of grimacing, moaning/crying, and guarding. Review of the clinical record did not reveal documentation the resident was administered pain medication prior to the wound treatments on (MONTH) 16 and 31, 2019. Further review of the clinical record did not reveal a Skin Pressure Ulcer Weekly form or documentation that the wound was assessed for the week between (MONTH) 16 and (MONTH) 31, 2019. A Skin Pressure Ulcer Weekly form dated (MONTH) 7, 2019 revealed the unstageable pressure ulcer measured 3.6 cm x 4.2 cm, had scant amount of serous exudate, and no odor. The documentation included the wound bed had black/brown eschar, defined wound edges, and normal surrounding tissue. Additional comments included the resident showed signs of pain when turning and cleaning the wound. Also included was that if there are no changes to the wound bed, the family will be asked if another product can be used. A Skin Pressure Ulcer Weekly form dated (MONTH) 14, 2019 revealed the unstageable pressure ulcer measured 3.4 cm x 4.0 cm, had scant amount of serous exudate, and no odor. The wound bed had black/brown eschar, defined wound edges, and normal surrounding tissue. Additional comments included slough was beginning to separate and that the resident showed signs of pain when turning and cleaning the wound. A Skin Pressure Ulcer Weekly form dated (MONTH) 21, 2019 revealed the unstageable pressure ulcer measured 3.6 cm x 4.2 cm, had scant amount of serous exudate, and no odor. The wound bed had slough, defined wound edges, and the surrounding tissue was normal. Comments included slough is continuing to separate, the periwound area has signs of [DIAGNOSES REDACTED], and there is no signs or symptoms of infection. The documentation also included the resident continued to show signs of pain when turning and cleaning the wound of grimacing, moaning/crying, and guarding. Additional review of the clinical record revealed no documentation the resident was provided with pain medication prior to the wound treatments for (MONTH) 7, 14, and 21, 2019. Further review of the clinical record revealed no evidence that the pressure ulcer treatment was consistently provided as ordered every Monday, Wednesday, and Friday on the day shifts for (MONTH) and (MONTH) 2019. An observation was conducted of the pressure ulcer treatment on (MONTH) 26, 2019 at 7:37 AM with a Licensed Practical Nurse (LPN/staff #149) who stated she was a certified wound nurse. A CNA (staff #145) assisted the LPN by turning and holding the resident. As they rolled the resident onto her side, the resident began crying out and was slapping at staff #145. The wound nurse washed her hands, donned clean gloves, and began to remove the old dressing. As the wound nurse was removing the old dressing, she identified the black/brown substance, which was partially attached to the old dressing as eschar. As the old dressing was being removed, the eschar began tearing away from the wound bed, without fully detaching. During this time, the resident squirmed and cried out during the treatment, as staff #145 continued to hold her at the hip and hands. The nurse changed gloves and cleansed the area with normal saline. Resident #51 cried out again and squirmed against the hold of staff #145. The nurse measured the wound and stated it measured 2.6 cm x 1.6 cm. The nurse then changed gloves and applied therahoney and a foam dressing to the wound. The resident moaned and slapped at the CNA. During the observation, staff #149 stated that the pressure ulcer developed in the facility. She said the resident had been sleeping on a regular mattress, which contributed to the development of the pressure ulcer. The LPN also stated the wheelchair the resident was using contributed to the skin breakdown. She stated that the wound has decreased in size because it is healing. The wound nurse also stated that the resident was not administered pain medication prior to the treatment. An interview was conducted on (MONTH) 26, 2019 at 7:42 AM with the CNA (staff #145). The CNA stated that she is very familiar with resident #51. She stated that part of the resident's daily care is to ensure the resident is clean and dry, and repositioned at least every 2 hours. An interview was conducted on (MONTH) 26, 2019 at 12:36 PM with a LPN (staff #17). She stated that if she were providing treatment care to a resident who was experiencing pain, she would stop the treatment and administer pain medication. She said that it is never ok for the resident to be in pain during the treatment process. During an interview conducted on (MONTH) 26, 2019 at 12:56 PM with the Director of Nursing (DON/staff #151), the DON agreed that if the resident was crying out in pain during treatment, it would be acceptable to stop the treatment, administer [MEDICATION NAME], and resume the treatment in a 1/2 hour. On (MONTH) 27, 2019 at 10:15 AM, an interview was conducted with a CNA (staff #145). Staff #145 stated that she works with resident #51 on a regular basis, and has become very familiar with the resident's responses. She stated that she definitely believed the resident was in pain during her treatment. She said that resident #51 reacted per her norm at first, but during the removal of the dressing, cleaning of the wound, and application of therahoney, the resident reacted as if she were in pain. Another interview was conducted on (MONTH) 27, 2019 at 12:14 PM with the certified wound nurse, staff #149. She stated the criteria for obtaining a physician's orders [REDACTED]. The wound nurse stated that resident #51 had a regular mattress when she started working at the facility approximately 3 months ago. She said she was informed of the redness on the resident's back on (MONTH) 4, 2019 and thought it might be from shearing. The LPN stated that she was not sure it was a pressure ulcer because the wound had not opened. She stated that on (MONTH) 4, 2019 she texted the provider, as that was a customary method of communication between them. She said she wanted to talk with the provider before putting a LALM on the resident's bed as the LALM could put the resident at risk for falling. She stated that the provider did not get back to her until (MONTH) 7, 2019. The wound nurse stated that at that time she obtained an order for [REDACTED].>On (MONTH) 27, 2019 at 1:18 PM, an interview was conducted with the Assistant Director of Nursing (ADON/ staff #52). He stated that if he was unable to contact the attending physician, his process for obtaining an order would include calling the Nurse Practitioner, Team Health (an on-call service), or the Medical Director. The ADON stated that if he needed a physician's orders [REDACTED]. On (MONTH) 27, 2019 at 1:46 PM, another interview was conducted with the DON (staff #151). The DON stated that if an unstageable pressure ulcer was found on a resident, she would expect nursing to contact the physician and notify the wound nurse to do an evaluation. She stated that a LALM is not always necessary, that it depends on the location of the injury and the mobility of the resident. In regard to resident #51, she stated that the wound nurse received a telephone call at home on a Saturday regarding the injury. She stated that after the floor nurse described the injury to the wound nurse, they thought it might be a friction injury. The DON stated that the wound nurse directed the floor nurse to apply a foam dressing to the site, and that it would be good for 5 days. The DON stated that when the wound nurse reported to work on (MONTH) 7th, she assessed the injury to be a pressure ulcer and put the appropriate treatment into place, including the LALM. The facility's policy titled Wound Management stated it is the policy of the facility that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless clinically unavoidable. The policy included care and services are provided to promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present, and to prevent the development of additional, avoidable pressure ulcers. The policy also revealed the nurse is responsible for assessing and evaluating the resident's condition and is expected to take actions which include completing a weekly head to toe skin assessment with follow up as applicable. The policy included that once a wound has been identified, assessed, and documented, the nurses shall administer treatment to each affected area per the physician's orders [REDACTED]. The policy stated that in order to prevent the development of skin breakdown, the following approaches shall be implemented as appropriate: Reposition the resident. Use pressure relieving/reducing and redistributing devices (including but not limited to low air mattresses, wedges, pillows, etc.). Use transfer techniques which minimize friction and skin tears/shears as applicable (mechanical lift). If the resident is incontinent, make sure his/her skin remains clean and dry with regular pericare and toileting when appropriate. The facility's policy regarding Pain Management revealed residents will be assessed for pain and that residents who are cognitively impaired may exhibit pain through changed behaviors. The policy stated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by identifying circumstances when pain can be anticipated.

Based on closed record review, staff interviews, facility documentation and policy review, the facility failed to ensure that one resident (#289) was transferred/repositioned in a safe manner, resulting in a fractured shoulder. Findings include: Resident #289 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] under Section G, noted that the resident required extensive assistance with transfers and one person physical assistance. Review of the care plan for self-care and mobility related to weakness and debility, due to cerebral vascular accident with right hemiparesis included the resident required extensive assistance by one person for transfers. An intervention included to assist the resident as needed. A Progress Note dated August 10, 2012, revealed the resident was complaining of extreme pain to the right arm. A certified nursing assistant (CNA) was transferring the resident to her wheelchair when her right arm was injured. According to the facility incident report dated August 10, 2012, the resident stated to the nurse that her arm was already sore and the CNA picked her up and put her in the wheel chair too fast, and that afterwards her arm started hurting more. Per the report, the CNA stated that the resident asked to be repositioned in her wheelchair and the resident stood up and had her left arm on the CNA's shoulder, when she became unsteady and started to go back into the chair and grabbed the CNA with her right arm, as she went down into the chair. The report included the CNA did not use a gait belt during the repositioning procedure. An x-ray of the right shoulder was done and revealed a comminuted fracture of the right humeral head and neck, with some impaction at the fracture site and superolateral displacement of the distal fracture fragment. A physician's orders [REDACTED]. Review of the emergency department report dated August 10, 2012, revealed the resident had a right shoulder humeral neck fracture. The arm was placed in a sling and referred to outpatient follow up with orthopedics. An interview was conducted on July 9, 2013, with the CNA. The CNA stated that on July 10, 2012, she was transferring the resident to her wheelchair when her right arm was injured. She said that the resident complained of right arm pain immediately after being transferred to her wheelchair. The CNA also stated that she did not use a gait belt, as the resident did not like the gait belt. The CNA further stated that she did not tell the nurse or document anywhere that the resident did not like the gait belt. An interview was conducted on July 9, 2013, with the director of nursing (DON). The DON stated that the facility's protocol is to use a gait belt for a one person transfer. She also stated that the CNA was suspended for not using a gait belt during the transfer and given additional education on transfers. Review of the facility's policy on Transfer/Pivot revealed "...The pivot transfer is used when moving the partial weight-bearing, non-ambulatory patient from one surface to another, such as bed to wheelchair, wheelchair to toilet, or wheelchair to chair..." Additional information from the facility policy stated, "...The belt (Gait) should be available and on the CNA's person for use when needed...Place the best around the patient's waist...Over the nightgown, clothing, etc...Below the rib cage...With the buckle centered, in front...Comfortable, snug, but not tight...Grasp the belt, as you would in a strong handshake, palm up..."

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to provide emergency dental service for one resident (#129). The sample size was two. Findings include: Resident #129 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A history and physical dated August 22, 2012, included the resident was totally dependent on staff for activities of daily living and required the use of a computer board to communicate. Review of the nursing progress notes dated May 9, 2013 at 5:55 p.m. revealed the following: "Called to room by licensed practical nurse. Resident on floor lying supine. Stated resident was found face down on the floor. Blood on floor. Moaning. Blood noted on nose with two small lacerations. Nose beginning to swell. Blood coming from mouth and upper lip swelling. Vital signs taken...Resident sat himself up partially, assisted off floor and into wheelchair. No issues with range of motion noted. Nose and lip iced. Nose steri-stripped. Call to nurse practitioner (NP)to report fall and resident status. New orders to monitor closely and call for changes. status [REDACTED]. Physician orders [REDACTED]. A progress note dated May 10, 2013 at 5:45 a.m. revealed, "Resident slept well this shift...Some bleeding and swelling noted this shift from mouth. Steri-strips intact to bridge of nose and swelling noted. Ice offered, resident refused. Resident denies pain related to injuries..." A note at 12:33 p.m., documented there was an order from the NP for a dental appointment. A physician's orders [REDACTED]." Progress notes dated May 12, 2013 at 10:11 a.m., revealed the resident was waiting for a dental appointment. Progress notes dated May 13, 2013 at 1:29 p.m., revealed that the NP offered to call the dental clinic, as the resident's family member became upset when he became aware that the resident's mouth would bleed when wiped with a wash cloth. The appointment was then arranged on a first come first serve basis, for the morning of May 14. According to the appointment schedule, the facility did not request the dental appointment until May 13, four days after the injury. The documentation showed that the resident was to be seen at the dental clinic on May 14. The facility was unable to provide documentation that an appointment had been scheduled or attempted to be scheduled prior to this date. Progress notes dated May 14, 2013, at 2:29 p.m. revealed the resident was transported to the dental clinic and from there was referred to an oral surgeon. A review of the dental clinic report dated May 14, 2013, revealed that due to the complex medical history and possible orofacial trauma, aside from the dental concerns, the resident was referred to an oral surgeon. The resident was then transported to the oral surgeon's office that same day. Review of the oral surgeon report dated May 14, revealed the following, "Patient sustained a fall on Thursday May 9, 2013 in his nursing home. He sustained facial injuries resulting in bruising and abrasions of the skin overlaying the nose and upper lip. Also tooth number 8 avulsed removing with it the overlying fixed partial denture (FPD) which has teeth number 8 and 10 as abutment. The patient brought tooth #8 with the attached FPD with him in a bag. Since the injury happened five days ago it is too late to re-implant the tooth. Usually re-implanting a tooth should be done preferably within an hour or a short time after a tooth dislodgement from its socket for the best chance of survival. Recommended dental intervention, non surgical." The following day on May 15, a progress note included the resident was spitting blood onto the walls of his room and that the resident stated that he spits blood out in his sleep. A progress note dated May 16, 2013 at 10:30 a.m., documented the resident notified a family member that he was bleeding profusely from the mouth. The nursing supervisor was notified and entered the room to find the resident spitting blood on the walls and that there was blood running out of his mouth onto his gown. Per the note, the resident was wiping his mouth with a washcloth, despite the fact that he was instructed not to do so because it would dislodge clots. When efforts to stop the bleeding were unsuccessful, the resident was sent to the emergency room , where he received stitches to the gums. The resident returned to the facility at 4:45 p.m. A physician's orders [REDACTED]. Review of the NP notes dated May 17, 2013, revealed that on May 10, 2013, she wrote a stat dental consult and that when she spoke with the oral surgeon she was informed "no surgical intervention required and further dental care/needs could be administered by a general dentist." The NP further documented that the emergency room doctor informed her on May 16, 2013, that the resident received four dissolvable sutures and did not require an antibiotic. Nursing progress notes dated May 17, 2013, revealed that staff attempted to address the resident's expressed concerns that he did not feel "safe" at the facility and wanted to leave, because he did not receive the care he needed to save his teeth when he fell . When the resident told the staff that they could not come into his room, an order was obtained to send the resident out for a psychiatric evaluation. The resident was discharged at 7:00 p.m. An interview with the director of nursing (DON) was conducted on July 11, 2013. She stated that the resident had not been sent out immediately for dental care, because they were more concerned about neurological deficits/mental status changes and that the resident did not have dental coverage, because he was on Medicaid. The DON stated she did ask if the NP wanted any facial exam done and was told not at that time. In an interview on July 11, 2013, the administrator stated that it was the policy of the facility to provide emergency dental care to residents and insurance coverage should not be an issue. The facility policy regarding dental services included to assist residents with 24-hour emergency dental services.