Every finding on record at Castle Peak Senior Life and Rehabilitation

Based on interviews, record review and observations, the facility failed to ensure residents were free from accidents or hazards for one (#1) of four residents reviewed for accidents hazards out of seven sample residents. Specifically, the facility failed to ensure Resident #1 was provided a hot beverage without injury. Resident #1, was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified cataract, unspecified macular degeneration (loss in central vision of the eyes), disorientation, unspecified, and restlessness and agitation. On 11/12/25 Resident #1 was provided a hot beverage dispensed from the facility's coffee machine and then heated in the microwave for an additional 30 seconds, per the resident's request, by a staff member. Resident #1 was visually impaired and could not find the opening on the lid to drink the hot beverage. The resident attempted to remove the lid, causing the beverage to spill on her arm and leg, which resulted in second degree burns to the resident's skin.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 3/9/26 to 3/10/26, resulting in the deficiency being cited as past non-compliance with a correction date of 12/11/25. I. Incident on 11/12/25On 11/12/25 Resident #1 requested a physical therapy assistant (PTA) to make her tea, which was dispensed from the hot water out of the coffee machine, very hot. The PTA heated up the tea in the microwave for an extra 30 seconds. The PTA secured a lid on the coffee cup and placed the cup on on Resident #1's bedside table. Resident #1 attempted to remove the lid but had difficulty finding the opening to drink out of due to her macular degeneration. Resident #1 spilled the hot tea on herself, resulting in a burn. Resident #1 was assessed and it was determined that she received second degree partial thickness burns to her arm and leg. The nurse practitioner determined the burns from the hot tea covered a 6% (percent) total body surface area. II. Facility plan of correctionThe plan of correction the facility implemented in response to Resident #1's burn incident on 11/12/25 was provided by the NHA on 3/10/26 at 5:40 p.m. The plan of correction documented the following:A. Immediate action to correct the deficient practice Resident #1's hot liquid burn sites were measured, the nurse practitioner was notified, assessed the injuries and treatment orders were written on 11/12/25.Staff interviews were conducted beginning on 11/12/25 regarding residents' physical and visual needs when consuming hot beverages independently for further evaluation for adaptive equipment. An audit was completed revealing no other residents were in need of an occupational therapy (OT) evaluation for adaptive equipment. Staff were informed to notify leadership if any new identified evaluations were needed.Multiple forms of education were provided to staff related to the incident beginning on 11/12/25. The hot liquid dispensers in the facility were reviewed to ensure temperatures were within acceptable ranges on 11/12/25. Signs were placed near the microwaves and in the kitchen to remind staff not to use microwaves to heat liquids beginning on 11/12/25. The Hot Beverage policy was reviewed by the interdisciplinary team (IDT) at the quality assurance performance and improvement meeting on 11/13/25.B. Systematic changesThe home office clinical team, the regional director of nutrition and the regional director for the facility were notified of the incident and assisted the facility to identify the root cause of the incident and create a follow-up plan.Resident #1 was evaluated by OT on 11/17/25 to determine the type of adaptive equipment for safe consumption of hot/warm liquids with her visual impairment. Resident #1 was provided with a specialized hot beverage cup to promote independence and safety when consuming hot beverages on 11/17/25.The facility identified other residents at potential risk related to hot beverages and vision impairment. The identified residents were assessed by OT for the need for adaptive equipment on 12/11/25. One other resident was determined to benefit from adaptive equipment during hot beverage consumption. Education was added to the new hire orientation to include contract staff and the therapy department on 2/25/26.C. MonitoringA monthly audit of the hot liquid dispensers in the kitchen and the kitchenettes was conducted by the dietary manager beginning on 11/12/25 and completed on 2/27/26.III. Facility policy and procedureThe Hot Beverage policy, revised 1/10/25, was provided by the dietary manager (DM) on 3/10/26 at 4:35 p.m. The policy read, Hot beverages will be served at a palatable, safe temperature. All hot beverage machines will be set to manufacturer's established temperature recommendations to enhance quality, palatability, and safety of beverages served. Hot beverage machines will be serviced as needed and, established temperature settings per manufacturer's recommendations will be verified. (The facility) must maintain the set temperature of the machine and may not request the manufacturer to increase for any reason due to safety of the residents. If the temperature of hot beverages is not considered palatable for any reason, pour another fresh cup and do not use the microwave to reheat. Report concerns with safety/decline managing hot beverages to director of food and nutrition/IDT (interdisciplinary team)/therapy for review and any possible intervention/updates to plan of care. IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] discharged home on [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified cataract, unspecified macular degeneration, disorientation, unspecified, restlessness and agitation.The 10/7/25 minimum data set (MDS) assessment documented Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment indicated the resident was independent with eating and drinking. According to the MDS assessment, Resident #1 had adequate vision and did not use glasses or other corrective lenses. B. Record reviewThe activities of daily living (ADL) care plan , initiated 9/27/25, documented Resident #1 could feed herself independently but required set up assistance. The care plan interventions, initiated on 11/12/25, directed staff to encourage her to leave the lid on cups/mugs containing hot liquids, use the call light to request staff assistance for removing/replacing lids on hot liquids and provide her education on the risk for burns when reheating liquids in the microwave. According to the care plan, staff were to offer to provide the resident a hot beverage of her choice by use of the kitchen dispensing equipment.The skin integrity care plan, initiated 9/27/25, identified Resident #1 was at risk for alterations in her skin integrity related to incontinence of bladder and bowel, decreased activity, immobility, cognitive impairment, hip fracture and need for assistance with ADLs. The care plan documented Resident #1 had a burn to her right forearm and right thigh related to hot liquids (11/12/25). The care plan directed staff to provide treatment orders per her physician (11/13/25), change the dressing daily and provide the resident with a spill proof cup (11/17/25). The vision care plan, initiated 11/13/25, documented Resident #1 had a vision impairment related to cataracts, macular degeneration and diplopia (double vision). According to the care plan, Resident #1 wore an eye patch and glasses. The 11/12/25 skin assessment documented Resident #1 sustained a burn to her right lower arm and right posterior thigh when she removed the lid from a coffee container. The burn on her arm measured 8 centimeters (cm) by 5 cm. The burn to her thigh measured 12 cm by 22 cm. The burns were described as bright red and blanchable (a red or discolored area of skin that turns pale or white when pressed before quickly returning to its red color when pressure is removed). The assessment documented the resident had a burn related broken blister on her arm. The 11/12/25 nurse practitioner (NP) note documented Resident #1 was seen by the NP due to a partial thickness burn from spilling hot tea on her right forearm and right thigh. According to the note, the resident rated her level of pain as 3 out of 10 and denied numbness, tingling, fevers or chills.The 11/12/25 skin progress note documented OT notified the registered nurse (RN) that Resident #1 had spilled hot water on her right arm and right posterior thigh. The RN assessed the resident's skin. At the time of the assessment, the resident's skin was bright red without blistering. The RN applied an ice pack with a barrier to both affected areas. The RN retrieved wound orders from the NP and a broken blister to the resident's arm was noted during the wound care. The 11/13/25 nursing note identified staff apologized for the burn incident to Resident #1 and reviewed a plan with the resident and her representative. According to the note, the resident and the resident's representative were informed that liquids could not be heated more than the set temperature on the coffee machine. The note documented a spill resistant cup had been ordered for the resident to help prevent a future occurrence. The 11/17/25 nursing note documented communication from OT to the nursing department related to the new cup for Resident #1. The note directed staff to provide Resident #1 with new blue insulated mugs for hot liquids, adding the milk prior to bringing the beverage to the resident so she did not need to remove the lid herself and placing the handle on the right side of her, per her preference. The 11/27/25 nursing note documented Resident #1's burn wound on her right forearm measured 3.5 cm by 2.5 cm and the right thigh burn wound measured 2.5 cm by 1 cm. The note identified both wounds presented with scabbing and the presence of epithelial tissue (tissue that appears pink or pearly white and wrinkles when touched; occurs in the final stages of healing) without infection.V. Staff interviewsRN #4 was interviewed on 3/9/26 at 5:09 p.m. RN #4 said she was newer to the facility but had learned during the facility's on boarding orientation that nothing was reheated. She said if the resident needed something warmed up, the item would go back to the kitchen. RN #1 was interviewed on 3/9/26 at 5:10 p.m. RN #1 said the facility did an performance improvement plan and an education with all staff to ensure they knew not to reheat items in the microwave. RN #5 was interviewed on 3/9/26. RN #5 said all staff knew not to reheat items for the residents. RN #1 and the director of nursing (DON) were interviewed together on 3/10/26 at 1:05 p.m. RN #1 said Resident #1 was assessed by the wound care nurse on 11/12/25. She said she assessed Resident #1's skin after the resident spilled a hot beverage on herself. She said the top layer of Resident #1's skin was red and partially removed from the burn initially and then blisters formed and broke. RN #1 said she investigated the 11/12/25 incident. She said Resident #1 wanted her tea hotter than the hot water dispensed from the kitchenette's coffee machine and requested the PTA to heat her tea. She said the PTA heated up the tea in the microwave without checking the temperature of the beverage and served it to Resident #1. She said the resident spilled the tea on herself, resulting in burns. She said the NP identified the burns as covering 6% of Resident #1's body with partial thickness. RN #1 said all the staff were educated not to reheat drinks or soups provided by the facility, in the microwave. She said the dietary manager (DM) made sure the coffee machines were set at 160 degrees fahrenheit (F). RN #1 said the facility determined the root causes of the 11/12/25 incident. She said the tea was heated up hotter than it was originally dispensed from the coffee machine. She said Resident #1 had impaired vision and removed the lid on accident trying to find the hole on top of the lid to sip out of. She said the hot tea spilled on the resident when she attempted to take the lid off. RN #1 said the facility ordered and provided Resident #1 with specialized cups with lids that she would not be able to easily remove the lid. She said the facility continued to monitor and treat the resident until she discharged home a couple weeks later. She said Resident #1's burns were scabbed over and almost healed when she was discharged . The DM was interviewed on 3/10/26 at 3:26 p.m. The DM said the facility followed manufacturer's recommendations of setting the coffee machine temperature at 160 degrees F. He said the coffee machine vendors set the temperatures of the coffee machines. He said coffee and tea were served out of the kitchenettes on the first and second floor. The DM said drinks and soups should not be reheated. He said staff should dispense new coffee or hot water for tea instead of reheating the drinks in the microwave if the coffee or tea was not warm enough when it was served. He said the facility used a lid over their hot beverages because it looked nicer and was harder to spill on the residents. The DM was interviewed a second time on 3/10/26 at 4:35 p.m. The DM said the review of manufacturer's recommendations identified the manufacturer recommended the brewing and dispensing temperature of the hot liquid to be 180 degrees F, but the facility had chosen to not set the machine brewing/dispensing temperature above 160 degrees F for safety of the residents. The NHA was interviewed on 3/10/26 at 6:38 p.m. The NHA said the facility had safety measures in place to decrease the risk of resident burns. She said the facility special ordered cups for Resident #1 and other residents who were assessed for the new cups with safety lids after the 11/12/25 incident. The NHA said the facility preferred to have the coffee machine settings to dispense liquids at 160 degrees F. RN #1 and the DON were interviewed together a second time on 3/15/26 at 7:00 p.m. RN #1 said the facility audited all residents who had visual impairments to determine if those residents would be appropriate for specialized cups with handles and lids that could not be easily removed. She said the residents that were determined to be at risk for spills related to the visual impairments were provided the cups if deemed necessary and their care plans were updated to help prevent a similar occurrence. The DON said there were not set guidelines for how hot beverages should be served but the facility strived for beverages to be at 160 degrees F or below. RN #1 said staff was not allowed to reheat any food or drink that had been provided by the facility. She said if a family member brought in an item, the staff could reheat the item but staff needed to use their best judgement to ensure the item was not too hot.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#2) of three residents out of seven sample residents.Specifically, the facility failed to maintain documentation to indicate a thorough investigation was completed after an allegation of verbal abuse towards Resident #2 by the director of nursing (DON).Findings include:I. Facility policy and procedureThe Occurrence Reporting-Vulnerable Adult policy, revised October 2022, was provided by the nursing home administrator (NHA) on 3/10/26 at 6:09 p.m. The policy read in pertinent part, All reports of suspected/alleged resident abuse, neglect, exploitation of residents, mistreatment, injury of unknown source and/or misappropriation of resident property shall be promptly and thoroughly investigated. All interviews related to the investigation shall be conducted in private. The investigation may include, but is not limited to: physical examination of the resident and environment; examination of the resident by a licensed nurse or physician (If sexual abuse is suspected, call the police immediately. Do not bathe/wash the resident or wash the resident's clothing or linen. Do not take items from the area in which the incident occurred.); interview the person(s) reporting the incident; interview the alleged victim; interview any potential witnesses to the incident. Interview the alleged perpetrator; interview other residents to whom the alleged perpetrator provides care or services; review the completed documentation. If witness reports are obtained, they may be in writing; witnesses should sign and date such reports; document the results of the investigation; log the incident on the event summary or other log; use the event summary or other log for ongoing review and analysis of abuse incidents and the implementation of changes to prevent future occurrences of abuse. The results of all investigations must be reported to the administrator (or his or her designated representative) and state agency and to other officials in accordance with state law within 5 (five) working days of the incident. If the alleged violation is verified appropriate corrective action must be taken. If an employee is found to have perpetrated the incident, follow the employee handbook.II. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included cerebral vascular accident (CVA - stroke), hemiparesis, spastic hemiplegia of the left side, coronary artery disease, hyperlipidemia, depression, attention-deficit hyperactivity disorder (ADHD), lower back pain and muscle weakness. The 3/4/26 minimum data set (MDS) assessment documented Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment revealed Resident #2 exhibited verbal behavioral symptoms directed towards others including yelling and cursing. Resident #2 required set up and clean up assistance with eating. Resident #2 was independent with oral and personal hygiene, toileting, bathing and dressing. Resident #2 used a wheelchair for mobility.B. Resident interviewResident #2 was interviewed on 3/9/26 at 2:26 p.m. Resident #2 said she communicated with the NHA regarding moving her personal belongings to her new room on 12/19/25 at 6:00 p.m. Resident #2 said in her email, she told the staff she was not physically able to move her items and needed assistance. Resident #2 said this was an accommodation because she was told by the NHA that she misinterpreted or misunderstood previous in-person conversations.Cross-reference F558 for failure to provide reasonable accommodations of needs.Resident #2 said nobody came to her room on 12/19/25 to let her know they were ready at 6:00 p.m. Resident #2 said she emailed the NHA to let her know no staff members had arrived. Resident #2 said she found out the DON was waiting in the hallway and Resident #2 said she was upset nobody told her they were ready to start moving. Resident #2 said she felt the DON was worked up the moment she entered Resident #2's room. Resident #2 said she recorded the argument between her and the DON. Resident #2 said the DON stood between Resident #2 and the door with her hands on her hips. Resident #2 said the DON told her she would move the facility provided furniture but Resident #2 needed to move her own personal belongings. Resident #2 said she felt that asking her to move her own items despite knowing her left side was paralyzed was asking her to perform impossible tasks. Resident #2 said she felt cornered in her room and the facility staff were attempting to provoke an emotional response from her. Resident #2 said when she told the DON she was not able to move her items, the DON argued with her and the facility told her it was not their problem. Resident #2 said she began to argue with the DON that the facility needed to provide accommodations for her. Resident #2 said she and the DON each began to talk over each other until the DON and Resident #2 were yelling. Resident #2 said she asked the DON to stop yelling at her and instead communicate with her in writing. Resident #2 said the DON asked her over and over if she was going to move her stuff and when she asked the DON to follow her accommodations, the DON mocked her, asking Resident #2 if she was unable to hear. Resident #2 said she felt the DON's tone was demeaning and the DON mocked her disabilities. Resident #2 became tearful and said she felt the facility was trying to blame her for the problems because they wanted to find a way to evict her from the facility.Resident #2 was interviewed again on 3/9/26 at 5:56 p.m. Resident #2 said registered nurse (RN) #3 witnessed the argument between her and the DON. Resident #2 said she sent an email with the recording of the argument and a written statement to the NHA the evening of 12/19/25. Resident #2 said she told the NHA in her email that she felt mocked and provoked by the DON. Resident #2 said no facility staff members followed up with her regarding the argument, and she did not know if anyone ever investigated her concerns regarding the DON. C. Record reviewResident #2's behavior care plan, revised 2/27/26, revealed Resident #2 had a behavior care plan related to behaviors of yelling or lashing out at staff with inappropriate language. Interventions included following the resident's preference to communicate with Resident #2 via email instead of in-person, reminding resident #2 her speech was inappropriate when Resident #2 yelled or cursed at staff, and following up on Resident #2's concerns in a timely manner. Resident #2's abuse prevention care plan, revised 2/27/26, revealed Resident #2 was at risk for abuse or neglect related to Resident #2's physical impairment, history of disruptive behavior, misinterpreting information and verbally lashing out at staff. The care plan documented Resident #2 was alert and oriented and would be able to report suspected abuse. Interventions included conducting supportive rounds as needed, abuse prevention observations completed by the social services director (SSD) on admission, annually and with significant changes; and staff observations for signs and symptoms of abuse such as fear or resistance to allowing a staff person, family or visitor to assist them.On 3/10/26 at 11:36 a.m. the NHA provided copies of email communications between Resident #2 and the NHA. The emails revealed the following:The DON's email, dated 12/19/25 at 7:48 p.m., revealed the DON contacted the NHA about the argument with Resident #2. The email documented the DON claimed she was at the facility at 5:50 p.m. per the NHA's request to assist with overseeing the transfer of Resident #2's belongings to her new room. The email documented the DON told staff they were not to move any of Resident #2's personal belongings. The email documented the DON waited in the common area for Resident #2. The email documented the nurse went into Resident #2's room to administer medication and Resident #2 did not mention moving to the nurse. The email documented the DON received a text message from the NHA stating Resident #2 emailed the NHA indicating no staff members were at the facility to coordinate the move. The email documented Resident #2 claimed she also needed the facility provided furniture moved to her new room. The email documented the DON went to obtain a cart. The DON's email documented the DON and RN #3 entered Resident #2's room together, and the DON told Resident #2 that she heard the resident needed assistance moving some furniture. The email documented the DON told Resident #2 she would only move the furniture items and, per the previous email sent by the NHA, Resident #2 needed to move her own personal belongings. The email documented Resident #2 became angry and told the DON she was not able to move her belongings and talked about her disability. The email documented Resident #2 asked the DON why she did not come to her room when she arrived. The email documented the DON asked if Resident #2 was going to move her items and Resident #2 told the DON her questions needed to be in writing. The email documented the DON asked Resident #2 why she wanted the DON to come to her room if she was not allowed to talk to her. The email documented the DON asked Resident #2 several times if she was going to move tonight (12/19/25), during which Resident #2 kept talking over the DON, repeating that the DON had to communicate with Resident #2 in writing. The email documented the DON claimed she repeated the question louder so Resident #2 could hear her. The email documented Resident #2 told the DON she was shouting and the DON told Resident #2 she was talking loudly, but not screaming. The email documented Resident #2 continued to repeat she wanted communication in writing until the DON and RN #3 left the room. Resident #2's email, dated 12/19/25 at 8:46 p.m., revealed Resident #2 contacted the NHA about the argument with the DON. The email documented Resident #2 claimed the DON addressed Resident #2 in an infantilizing and confrontational manner, standing with her hands on her hips and repeatedly demanding to know whether or not Resident #2 was moving her items, despite Resident #2's documented physical and cognitive CVA-related disabilities. The email documented Resident #2 claimed the DON repeatedly mocked Resident #2's request for written communication and Resident #2 claimed the mockery appeared intended to provoke a reaction.Resident #2's email, dated 12/20/25 at 10:09 a.m., documented Resident #2 contacted the NHA again regarding the argument. The email documented Resident #2 requested she no longer speak with facility administration without the ombudsman or a dedicated representative present due to the argument with the DON. The email documented Resident #2 told the NHA she felt the DON's behavior was verbally abusive.-However, despite Resident #2 indicating that she felt the DON had been verbally abusive, the facility did not report the resident's allegation to the State Agency.Cross-reference F609 for failure to report an alleged violation.A written statement, dated 12/20/25, was provided by the NHA on 3/10/26 at 11:36 a.m. The written statement revealed the NHA interviewed RN #3. The written statement documented RN #3 confirmed he was present during a conversation that occurred on 12/19/25 betweenThe DON and Resident #2. The written statement documented there was an email summary written by the DON in regards to that conversation and RN #3 was included on thesummary. The written statement documented RN #3 had nothing further to add.-However, there was no documentation provided by the facility regarding what specific questions RN #3 was asked in the interview related to what occurred between the DON and Resident #2.-Review of Resident #2's electronic medical record (EMR) and the email correspondence between the NHA and Resident #2 revealed no additional documentation of an investigation or further communication between the NHA and Resident #2 regarding Resident #2's claim of possible verbal abuse.-The facility was unable to provide documentation to indicate a thorough investigation of the incident between the DON and Resident #2 was completed, to include an interview with Resident #2 about the incident, interviews with other residents regarding their interactions with the DON, interviews with other staff members to see if they overheard the incident on 12/19/25, or documentation of the NHA's review of the audio recording sent to him by Resident #2 and discussion of the recording and the written statements with the regional corporate director and the corporate compliance officer (see NHA interview below). III. Staff interviewsThe SSD was interviewed on 3/10/26 at 10:22 a.m. The SSD said he did not communicate directly with Resident #2 in most situations. The SSD said Resident #2 had a history of contentious relationships with staff and attempts to manipulate situations. The SSD said almost all communication between Resident #2 and the facility's administration went through the NHA. The SSD said this was an intervention to reduce misunderstandings between the facility staff and Resident #2. The NHA was interviewed on 3/10/26 at 11:36 a.m. The NHA said Resident #2 had a long history of distrust toward the facility staff and behaviors of cursing, yelling, and belittling staff members. The NHA said email communication was requested as an accommodation by Resident #2, and all communication between the NHA and Resident #2 occurred via email. The NHA said Resident #2 previously attempted to email multiple staff members, attempting to find different answers from different staff, so communication between the facility's administration and Resident #2 was primarily completed by the NHA to reduce misunderstandings between staff and Resident #2. The NHA said she asked the DON to stay and oversee the transfer of Resident #2's personal belongings on 12/19/25. The NHA said she received an email from Resident #2 indicating no staff members had arrived to assist with the relocation of the resident's belongings to her new room. The NHA said she messaged the DON to confirm she was available to assist with oversight of the move. The NHA said she received an email from Resident #2 and the DON later that night (12/19/25) about the argument that occurred between them. The NHA said she listened to the audio recording of the conversation provided by Resident #2, as well as reviewing the written statements by Resident #2 and the DON. The NHA said she additionally spoke with RN #3 to see if he agreed with the written statement completed by the DON. The NHA said she had the regional corporate director and the corporate compliance officer review the written statements from the DON and Resident #2 and the audio recording of the argument. The NHA said the regional corporate director and the corporate compliance officer felt both the DON and Resident #2 were arguing with each other, and the DON's speech was loud and direct, however the three of them (the NHA, the regional corporate director and the corporate compliance officer) decided the verbal abuse was not substantiated. The NHA said after speaking with the corporate compliance officer and the regional corporate director, she asked the DON to listen to the audio recording and then provided education to the DON.-However, there was no documentation provided of the steps that the NHA indicated were taken in response to the allegation of verbal abuse made by Resident #2. The DON was interviewed on 3/10/26 at 4:12 p.m. The DON said she was asked by the NHA to oversee the relocation of Resident #2's personal belongings to her new room on 12/19/25. The DON said she was in the dining area of the facility at approximately 5:45 p.m., talking with another resident and waiting for Resident #2. The DON said at some point, she received a text message from the NHA asking if she was on the unit. The DON said the NHA told her Resident #2 claimed no staff members were available and Resident #2 needed assistance with moving furniture. The DON said she got the cart to move furniture from storage, then the DON and RN #3 entered Resident #2's room with the cart. The DON said she did not remember her exact words, but she said she told Resident #2 she was there to oversee the move. The DON said Resident #2 asked why the DON did not meet with Resident #2 when she arrived. The DON said she did not remember exactly how, but at some point Resident #2 stated to her that the Americans with Disability Act (ADA) requirements required staff to communicate with Resident #2 in writing. The DON said at first she was confused by what Resident #2 said because she thought she was referring to her hemiparesis and told Resident #2 that it was not related to her hearing. The DON said she then understood it was not related to her hearing, and once she understood, she said she asked Resident #2 if she planned to move her items tonight (12/19/25). The DON said Resident #2 continued to tell her she (the DON) needed to make her requests in writing. The DON said she and Resident #2 continued to go back and forth repeating themselves, getting progressively louder until the DON and RN #3 left the room. The DON said after the conversation with Resident #2, she documented her recollection of the events and sent them in an email to the NHA with RN # 3 carbon copied (cc) in the email. The DON said within the next day or two, she met with the NHA in her office. The DON said she listened to the audio recording from Resident #2 with the NHA. The DON said she did not remember the specifics in the audio recording, but she remembered she felt bad about how the conversation went. The DON said she should not have kept repeating herself and she should not have allowed Resident #2 to escalate her feelings. The DON said she had participated in unrelated abuse investigations with the NHA. The DON said the facility had a checklist to ensure they completed a thorough investigation of abuse allegations. The DON said a thorough investigation typically included interviews with additional staff or residents to gather evidence, ensure other residents were not affected, and rule out a possible pattern or additional allegations. The DON said phrases that would prompt additional investigation when interviewing staff or residents would include fear of retaliation or lack of care for reporting and staff members unwilling to discuss situations. The DON said residents using words, such as intimidated or provoked, when referring to staff would also prompt additional investigation questions. The NHA was interviewed again on 3/10/26 at 5:01 p.m. The NHA said she felt she adequately investigated Resident #2's allegation of verbal abuse. The NHA said when she reviewed the written statements and audio recording, she said if she were in the same situation as the DON, she probably would have left the resident's room earlier. The NHA said she did not interview Resident #2 in person because her written statement served as the interview. The NHA said when she spoke with RN #3, she asked him if he saw the email from the DON and if he had anything to add, which he said he did not. The NHA said she did not ask RN #3 additional questions about the event. The NHA said she did not complete the additional steps of the facility's abuse investigation checklist, including interviews of additional staff members and residents because after reviewing the initial information with her regional corporate director and corporate compliance officer, they did not substantiate the event as verbal abuse. IV. Facility follow-upOn 3/11/26 at 9:20 a.m., the NHA sent an email to communicate the facility's decision to re-initiate the investigation of Resident #2's allegation of verbal abuse on 12/19/25. -However, the facility failed to thoroughly investigate the allegation of abuse at the time it occurred.

Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#2) of three residents out of seven sample residents.Specifically, the facility failed to report an allegation of verbal abuse towards Resident #2 by the director of nursing (DON) to the State Agency.Findings include:I. Facility policy and procedureThe Occurrence Reporting-Vulnerable Adult policy, revised October 2022, was provided by the nursing home administrator (NHA) on 3/10/26 at 6:09 p.m. The policy read in pertinent part, Report all alleged violations and substantiated incidents immediately, but no later than 2 (two) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury to the state agency and all other agencies as required.II. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included cerebral vascular accident (CVA - stroke), hemiparesis, spastic hemiplegia of the left side, coronary artery disease, hyperlipidemia, depression, attention-deficit hyperactivity disorder (ADHD), lower back pain, muscle weakness. The 3/4/26 minimum data set (MDS) assessment documented Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment revealed Resident #2 exhibited verbal behavioral symptoms directed towards others including yelling and cursing. Resident #2 required set up and clean up assistance with eating. Resident #2 was independent with oral and personal hygiene, toileting, bathing and dressing. Resident #2 used a wheelchair for mobility.B. Resident interviewResident #2 was interviewed on 3/9/26 at 2:26 p.m. Resident #2 said the DON was sent by the NHA on the evening of 12/19/25 to oversee the moving of her (Resident #2) belongings into a new room. She said when the DON came to her room, the DON stood between Resident #2 and the door with her hands on her hips. Resident #2 said the DON told her she would move the facility provided furniture but Resident #2 needed to move her own personal belongings. Resident #2 said she felt that asking her to move her own items despite knowing her left side was paralyzed was asking her to perform impossible tasks. Resident #2 said she felt cornered in her room and the facility staff were attempting to provoke an emotional response from her. Resident #2 said when she told the DON she was not able to move her items, the DON argued with her and the facility told her it was not their problem. Resident #2 said she began to argue with the DON that the facility needed to provide accommodations for her. Resident #2 said she and the DON each began to talk over each other until the DON and Resident #2 were yelling. Resident #2 said she asked the DON to stop yelling at her and instead communicate with her in writing. Resident #2 said the DON asked her over and over if she was going to move her stuff and when she asked the DON to follow her accommodations, the DON mocked her, asking Resident #2 if she was unable to hear. Resident #2 said she felt the DON's tone was demeaning and the DON mocked her disabilities. Resident #2 became tearful and said she felt the facility was trying to blame her for the problems because they wanted to find a way to evict her from the facility.Resident #2 was interviewed again on 3/9/26 at 5:56 p.m. Resident #2 said registered nurse (RN) #3 witnessed the argument between her and the DON. Resident #2 said she sent an email with the recording of the argument and a written statement to the NHA the evening of 12/19/25. Resident #2 said she told the NHA in her email that she felt mocked and provoked by the DON. Resident #2 said no facility staff members followed up with her regarding the argument, and she did not know if anyone ever investigated her concerns regarding the DON. Cross-reference F610 for failure to investigate an alleged violation.C. Record reviewResident #2's careplan, revised 2/27/26, revealed Resident #2 had a behavior care plan related to behaviors of yelling or lashing out at staff with inappropriate language. Interventions included following the resident's preference to communicate with Resident #2 via email instead of in-person, reminding Resident #2 her speech was inappropriate when Resident #2 yelled or cursed at staff, and following up on Resident #2's concerns in a timely manner. Resident #2's abuse prevention care plan revealed Resident #2 was at risk for abuse or neglect related to Resident #2's physical impairment, history of disruptive behavior, misinterpreting information and verbally lashing out at staff. The care plan documented Resident #2 was alert and oriented and would be able to report suspected abuse. Interventions included conducting supportive rounds as needed, abuse prevention observations completed by the social services director (SSD) on admission, annually and with significant changes; and staff observations for signs and symptoms of abuse such as fear or resistance to allowing a staff person, family or visitor to assist them.On 3/10/26 at 11:36 a.m. the NHA provided copies of email communications between Resident #2 and the NHA. The emails revealed the following:The DON's email, dated 12/19/25 at 7:48 p.m., revealed the DON contacted the NHA about the argument with Resident #2. The email documented the DON claimed she was at the facility at 5:50 p.m. per the NHA's request to assist with overseeing the transfer of Resident #2's belongings to her new room. The email documented the DON told staff they were not to move any of Resident #2's personal belongings. The email documented the DON waited in the common area for Resident #2. The email documented the nurse went into Resident #2's room to administer medication and Resident #2 did not mention moving to the nurse. The email documented the DON received a text message from the NHA stating Resident #2 emailed the NHA indicating no staff members were at the facility to coordinate the move. The email documented Resident #2 claimed she also needed the facility provided furniture moved to her new room. The email documented the DON went to obtain a cart. The DON's email documented the DON and RN #3 entered the room together, and the DON told Resident #2 that she heard the resident needed assistance moving some furniture. The email documented the DON told Resident #2 she would only move the furniture items and per the previous email sent by the NHA, Resident #2 needed to move her own personal belongings. The email documented Resident #2 became angry and told the DON she was not able to move her belongings and talked about her disability. The email documented Resident #2 asked the DON why she did not come to her room when she arrived. The email documented the DON asked if Resident #2 was going to move her items and Resident #2 told the DON her questions needed to be in writing. The email documented the DON asked Resident #2 why she wanted the DON to come to her room if she was not allowed to talk to her. The email documented the DON asked Resident #2 several times if she was going to move tonight (12/19/25), during which Resident #2 kept talking over the DON, repeating that the DON had to communicate with Resident #2 in writing. The email documented the DON claimed she repeated the question louder so Resident #2 could hear her. The email documented Resident #2 told the DON she was shouting and the DON told Resident #2 she was talking loudly, but not screaming. The email documented Resident #2 continued to repeat she wanted communication in writing until the DON and RN #3 left the room.Resident #2's email, dated 12/19/25 at 8:46 p.m., revealed Resident #2 contacted the NHA about the argument with the DON. The email documented Resident #2 claimed the DON addressed Resident #2 in an infantilizing and confrontational manner, standing with her hands on her hips and repeatedly demanding to know whether or not Resident #2 was moving her items, despite Resident #2's documented physical and cognitive CVA-related disabilities. The email documented Resident #2 claimed the DON repeatedly mocked Resident #2's request for written communication and Resident #2 claimed the mockery appeared intended to provoke a reaction.Resident #2's email, dated 12/20/25 at 10:09 a.m., documented Resident #2 contacted the NHA again regarding the argument. The email documented Resident #2 requested she no longer speak with facility administration without the ombudsman or a dedicated representative present due to the argument with the DON. The email documented Resident #2 told the NHA she felt the DON's behavior was verbally abusive.-However, despite Resident #2 indicating that she felt the DON had been verbally abusive, the facility did not report the resident's allegation to the State Agency.III. Staff interviewsThe NHA was interviewed on 3/10/26 at 11:36 a.m.The NHA said Resident #2 had a long history of distrust toward the facility staff and behaviors of cursing, yelling, and belittling staff members. The NHA said she received an email from Resident #2 and the DON later that night (12/29/25) about the argument that occurred between them. The NHA said she listened to the audio recording of the conversation provided by Resident #2 as well as reviewing the written statements by Resident #2 and the DON. The NHA said she additionally spoke with RN #3 to see if he agreed with the written statement completed by the DON. The NHA said she had the regional corporate director and the corporate compliance officer review the written statements and the audio recording. The NHA said the regional corporate director and the corporate compliance officer felt both the DON and Resident #2 were arguing with each other, and the DON's speech was loud and direct, however the three of them (the NHA, the regional corporate director and the corporate compliance officer) decided the verbal abuse was not substantiated. The NHA said after speaking with the corporate compliance officer and the regional corporate director, she asked the DON to listen to the audio recording and then provided education to the DON. The NHA said she did not report Resident #2's allegation of abuse to the State Agency because she had already investigated the situation and decided it was not substantiated, so she did not need to report it.

Based on record review and interviews, the facility failed to provide reasonable accommodations for one (#2) of three residents out of seven sample residents.Specifically, the facility failed to provide timely accommodations for moving Resident #2's personal belongings during a room change. Findings include:I. Facility policy and procedureThe Room Change policy, revised April 2025, was provided by the nursing home administrator (NHA) on 3/10/26 at 7:18 p.m. The policy read in pertinent part, A resident may request a room transfer at any time. The resident's request for transfer will be honored if there is an available bed on an appropriate unit and if the resident is able to comply financially with any potential private room differential. Environmental services staff or designee will assist the resident to pack their belongings prior to the room change. A nursing assistant or designee will bring the resident to the new room at the time of the room change and will introduce the resident to any new staff, as indicated. Nursing staff will assist the resident to unpack belongings and get settled into the new room.II. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included cerebral vascular accident (CVA - stroke), hemiparesis, spastic hemiplegia of the left side, coronary artery disease, hyperlipidemia, depression, attention-deficit hyperactivity disorder (ADHD), lower back pain and muscle weakness. The 3/4/26 minimum data set (MDS) assessment documented Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment revealed Resident #2 exhibited verbal behavioral symptoms directed towards others including yelling and cursing. Resident #2 required set up and clean up assistance with eating. Resident #2 was independent with oral and personal hygiene, toileting, bathing and dressing. Resident #2 used a wheelchair for mobility.B. Resident interviewResident #2 was interviewed on 3/9/26 at 5:56 p.m. Resident #2 said she reported her concerns about witnessing a housekeeper mixing cleaning chemicals in her bathroom to the NHA. Resident #2 said the NHA offered her a room change, but she initially declined until the room was inspected for chloramine gas exposure (a hazardous gas caused by mixing bleach and ammonia based cleaning solutions). Resident #2 said on the night of 12/15/25, she reported irritation to her nose and eyes and refused to go back to her room. Resident #2 said the night staff offered her a new room and wheeled her into it. Resident #2 said she was told she needed to either return to her previous room or move into the new room, but the facility would not assist her with moving her personal items and told her she needed to move them herself or arrange for someone else to move them. Resident #2 said she could not move the items herself because she could not move her left side. Resident #2 said she felt like she should not have to pay to move her own items because the facility offered her the room change. Resident #2 said she was allowed to go back to her previous room when she was supervised by staff, but the majority of her personal items remained in her previous room until the facility hired a moving company on 1/27/26 to move her belongings to the new room.C. Record reviewThe progress note, dated 12/16/25 at 4:13 a.m., documented Resident #2 complained of an increased smell of ammonia and bleach in her room on 12/15/25 at 9:00 p.m. The progress note documented Resident #2 said she was being poisoned and could no longer stay in her room due to the smell. The progress note documented Resident #2 declined a nursing assessment or transport to the local area emergency room. The progress note documented staff assisted Resident #2 into a new room so she could get some sleep.The progress note, dated 12/19/25 at 1:05 p.m., documented the floor nurse and a certified nurse aide (CNA) responded to Resident #2's call light. The progress note documented Resident #2 asked staff to bring her toiletries and a plant from her old room to her new room. The progress note documented the CNA told Resident #2 the staff were not allowed to move her items, they were only allowed to accompany Resident #2 to her previous room and accompany Resident #2 while she moved the items. The progress note documented Resident #2 agreed and was escorted to her previous room to acquire the aforementioned personal items. The progress note, dated 1/3/26 at 5:27 p.m., documented a nurse and a CNA entered Resident #2's room to administer her morning medications. The progress note documented Resident #2 requested staff to get socks from her room. The progress note documented the nurse explained to Resident #2 that staff were not allowed to go into her room, but could accompany Resident #2 into her room. The progress note documented Resident #2 agreed and was wheeled by staff to her previous room. The progress note documented Resident #2 gathered some of her own belongings, including a plant, and brought them to her new room. Resident #2's care plan, revised 2/27/26, revealed Resident #2 had a behavior care plan related to behaviors of yelling or lashing out at staff with inappropriate language. Interventions included following the resident's preference to communicate with Resident #2 via email instead of in-person, reminding Resident #2 her speech was inappropriate when Resident #2 yelled or cursed at staff and following up on Resident #2's concerns in a timely manner. On 3/10/26 at 11:36 a.m. the NHA provided copies of email communications between Resident #2 and the NHA. The emails revealed the following:The email, dated 12/11/25 at 4:01 p.m., revealed the NHA replied to Resident #2's concerns related to the facility inspection of Resident #2's reported concern of chemical exposure. The email revealed the NHA offered a room change to Resident #2 as an accommodation.The email, dated 12/12/25 at 9:33 a.m. revealed Resident #2 declined the offer to change rooms at this time. The email revealed Resident #2 did not want to transfer rooms because she filed a complaint and wanted to preserve the state of the room until the room was investigated for chemical exposure. The email revealed Resident #2 was willing to cooperate with a room transfer immediately after the investigation was complete. The email, dated 12/18/25 at 11:32 a.m, revealed the NHA contacted Resident #2 regarding occupying two rooms at the same time. The email documented the NHA informed Resident #2 that no permanent room change was approved. The email documented Resident #2 relocated to a new room on her own initiative; it was not authorized as a permanent assignment. The email documented the NHA had previously offered an alternative room as a potential accommodation, which Resident #2 declined. The email documented attempts to allow a plumber into Resident #2's initial room were also declined by Resident #2. The email documented a county examiner inspected her previous room on 12/18/25, based on the resident's reports of chemical exposure, and did not substantiate the complaint of a chemical exposure. The email documented Resident #2 needed to choose which room to occupy by 12/18/25. The email documented if Resident #2 chose to move to the new room permanently, the move needed to be completed by 12/22/25. The email, dated 12/18/25 at 1:12 p.m., documented the NHA contacted Resident #2 regarding the room change. The email documented Resident #2 chose to permanently move to the new room. The email documented that due to ongoing concerns raised by Resident #2 related to the handling of personal property and previous misunderstandings regarding staff involvement, Resident #2's personal belongings should be moved by a family member, authorized representative or a third-party mover of Resident #2's choice and expense. The email documented facility staff would be available to assist with coordination of access to the room, and overall safety during the room change; however, staff would not directly handle the resident's personal belongings unless otherwise agreed upon in advance and documented. The email documented the approach was intended to respect Resident #2's expressed concerns and to prevent further distress or misunderstandings.The email, dated 12/18/25 at 4:38 p.m., documented Resident #2 replied to the NHA. The email documented Resident #2 felt the initial room transfer was initiated by the facility and not Resident #2. The email documented Resident #2 was willing to oversee the transfer of her items on 12/19/25 at 6:00 p.m., requesting night shift staff oversee the process.The email, dated 12/19/25 at 9:58 a.m., documented the NHA responded to Resident #2. The email documented the facility's stance on the resident's room relocation was that the relocation was not facility-directed because there was no environmental hazard, which was confirmed by multiple outside sources. The email documented the facility was providing the room change as an accommodation to the resident. The email documented the facility was willing to provide access to Resident #2's old room and oversight for the relocation of Resident #2's personal belongings, however, the facility staff would not physically handle or move personal property. The email documented the NHA informed Resident #2 the packing, transport, and placement of belongings remained Resident #2's responsibility.The email, dated 12/22/25 at 3:17 p.m., documented the NHA provided Resident #2 with a notice of non-compliance with room assignments and personal property requirements. The email documented Resident #2 had previously informed the facility she planned to move her personal belongings on Friday, 12/19/25, shortly after 6:00 p.m. The email documented the move did not occur, and Resident #2's belongings remained in her previous room. The email documented the NHA reiterated to Resident #2 how the facility would be able to accommodate her request to move to a different room. However, the facility did not move or transport residents' personal property. The email documented Resident #2 was responsible for coordinating the relocation of her personal belongings to her new room.The email, dated 1/21/26 at 10:59 a.m., documented the NHA informed Resident #2 the facility had hired a moving company to complete the move of Resident #2's personal belongings to her new room on 1/27/26.-However, the move to the new room did not occur until 39 days after Resident #2 agreed to the permanent transfer to her new room on 12/19/25.III. Staff interviewsThe social services director (SSD) was interviewed on 3/10/26 at 10:22 a.m. The SSD said Resident #2 was the only resident to have initiated a room change since he started in his position at the facility two years prior. The SSD said he was informed of Resident #2's room change, but was not directly involved in the room change. The SSD said Resident #2 had a history of contentious relationships with staff and attempts to manipulate situations. The SSD said almost all communication between Resident #2 and the facility's administration staff went through the NHA. The SSD said this was an intervention to reduce misunderstandings between the facility staff and Resident #2. The SSD said the records documented Resident #2's room was officially changed on 1/27/26. The SSD said he knew Resident #2 was occupying the room prior to 1/27/26, but he did not know why the room change was not officially changed when Resident #2 first occupied the new room. The SSD said the facility's room change policy indicated the environmental services staff would assist with the packing of residents' belongings and nursing staff would assist with unpacking the belongings. The SSD said the facility's policy did not specify who would physically move the personal belongings from one room to another, but he assumed environmental services staff or nursing staff would typically assist with moving; or the maintenance department might assist with moving furniture.The NHA was interviewed on 3/10/26 at 11:36 a.m. The NHA said Resident #2 had a long history of distrust toward the facility staff and behaviors of cursing, yelling and belittling staff members. The NHA said email communication was requested as an accommodation by Resident #2 and all communication between the NHA and Resident #2 occurred via email. The NHA said Resident #2 previously attempted to email multiple staff members, attempting to find different answers from different staff, so communication between facility administration and Resident #2 was primarily completed by the NHA to reduce misunderstandings between staff and Resident #2. The NHA said typically, when a resident wanted to change rooms or units due to a change in resident status, the facility requested family assistance with the room transfer. The NHA said the purpose of requesting family assistance was to reduce the incidence of items becoming lost or misplaced. The NHA said if the family was unable to assist, the facility staff would assist with transferring the resident's items, and the maintenance staff may assist with transferring large items or furniture. The NHA said sometimes previous residents had to wait for a room to become available, but once the room was available, room move transfers took less than a week to coordinate. The NHA said she told Resident #2 the facility was not willing to transfer any of Resident #2's personal belongings because of previous accusations by Resident #2 of staff losing, stealing, or mishandling her items. The NHA said she offered ways to schedule a date to move Resident #2's items, and allowed Resident #2 into her previous room to retrieve her own belongings whenever she requested. The NHA said she did offer to accommodate Resident #2's concerns by offering a room change, but Resident #2 declined. The NHA said when Resident #2 refused to go back to her room during the night of 12/15/25, staff probably did assist her into the new room because they were wanting to provide good customer service. The NHA said despite staff assistance, she still considered the room change as initiated by Resident #2 and not by the facility.The director of nursing (DON) was interviewed on 3/10/26 at 4:12 p.m. The DON said the facility usually asked residents' families to assist with moving residents' items to reduce the odds of items going missing, but sometimes the family was not available or physically able to assist. The DON said Resident #2 had a long standing history of accusing different staff members of improper care, losing and mishandling her property. The DON said Resident #2 would email different staff members with questions and try to use the differing responses against the facility. The DON said the facility never expected Resident #2 would be physically able to move her personal belongings, but they were hoping Resident #2 would reach out to family or hire a company for assistance. The DON said she was not sure if the facility provided the resident with a list of moving companies or attempted to assist Resident #2 with finding assistance prior to the NHA hiring the moving company at the end of January 2026.The NHA was interviewed again on 3/10/26 at 5:01 p.m. The NHA said she never expected Resident #2 would be physically able to move her own items. The NHA said Resident #2 was young for their resident population and in a difficult situation. The NHA said she knew that Resident #2 was not frequently in contact with her family. The NHA said she did not remember if she ever provided Resident #2 with any informational resources on moving services. The NHA said she did not want to offend Resident #2's cognitive abilities to manage her items. The NHA said she knew Resident #2 was resourceful and was hoping she would reach out to someone for assistance. The NHA said when she saw no progress was made on Resident #2's behalf after several weeks, she contacted the moving company on 1/21/26 to move Resident #2's items on 1/27/26. The NHA said the facility covered the cost of the moving company.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents was provided the care and services necessary to ensure a safe discharge from the facility to the community out of three sample residents.Specifically, the facility failed to:-Allow Resident #1 to return to the facility after an unplanned discharge to the hospital;-Provide documentation from Resident #1's physician, including the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #1 for readmission after he was stabilized at the hospital and ready to return to the facility. Findings include:I. Facility policy and procedureThe Discharge Notice Requirements policy and procedure, revised 4/28/25, was provided by the director of nursing (DON) on 8/20/25 at 1:40 p.m. It read in pertinent part, The facility must document in the resident's record the basis for the discharge. If the basis of the discharge is the facility's inability to meet the resident's needs, the resident's record must show that the facility based this determination on the resident's assessment and status at the time of the proposed return to the facility, not on the resident's needs at the time when he/she was transferred to an acute care facility; and how the resident's needs are distinctly different from other residents' needs. More specifically, the facility can not discharge a resident based on the claim that the facility cannot meet the resident's needs if there are other residents with similar needs whose needs are being met by the facility. If the basis of the discharge is because the facility can not meet the resident's needs, the resident's behavior creates a danger to individuals in the facility, the resident's physician must document the basis for the discharge. The physicians' documentation must show the specific needs the facility can not meet; the facility's efforts to meet the resident's needs; and how and why the discharge location is better equipped to meet the resident's needs. The resident's record should show the receiving location's willingness and capacity to care for the resident.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 7/23/25. According to the July 2025 computerized physician order (CPO), diagnoses included dementia with mood disturbances, Parkinson's disease, Alzheimer's disease and adjustment disorder with anxiety.The 6/30/25 minimum data set (MDS) assessment revealed Resident #1 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment indicated Resident #1 had behavioral symptoms that were directed toward others. B. Record reviewAn elopement assessment, dated 3/27/25, revealed the resident had an elopement risk of six, which indicated the resident was at risk for elopement.A progress note, dated 7/20/25, revealed that on 7/19/25 at approximately 1:18 p.m. the medical director (MD) declined readmission of Resident #1 from the emergency department. The involuntary discharge was necessary to protect the welfare of other residents. The note documented Resident #1 had displayed increasingly unpredictable behaviors over the past few weeks. The behaviors included attempting to have sex with another dementia resident who was unable to consent, eloping from the facility and physically striking a certified nurse aide (CNA). Resident #1 was previously evaluated and interventions such as a one-to-one sitter and starting Depakote (anti-seizure medication used for behaviors) were implemented. The MD documented in her medical opinion, Resident #1 required inpatient geriatric psychiatric treatment until his behaviors stabilized. The MD documented it was unsafe to have Resident #1 in proximity of the other vulnerable residents at the facility and Resident #1 was involuntarily discharged .-There was no documentation to indicate the facility reassessed the resident after he was stabilized at the hospital.-The facility failed to document the needs the receiving facility was going to provide for the resident that the current facility was unable to provide.-Review of Resident #1's electronic medical record (EMR) did not reveal the facility completed a discharge summary for Resident #1.III. Resident #1's representative interviewThe resident's representative was interviewed on 8/20/25 at 2:10 p.m. The representative said the resident was admitted to the hospital because the facility refused to readmit the resident once he was medically cleared. The representative said the facility did not help the resident find an alternate facility. The representative felt the resident was abandoned by the facility. The representative said the resident had no behaviors at the hospital.IV. InterviewsThe case manager from the hospital was interviewed on 8/20/25 at 2:00 p.m. The case manager said the facility left Resident #1 in the hospital's care and did not help the resident find a different facility to be discharged to. She said no one from the facility reassessed Resident #1 when he was medically cleared and there was no reason for the hospital to keep the resident. She said she felt the resident was dumped at the hospital. She said Resident #1 displayed no behaviors of any type while he was in the hospital, so she was confused as to why the facility refused to readmit the resident.The DON was interviewed on 8/20/25 at 2:30 p.m. The DON said when Resident #1 was first admitted to the facility, the family said he was able to go on walks outside the facility by himself. She said during the resident's admission, she found out the resident fell outside by himself a day later when he complained of shoulder pain and explained he fell the day before. The DON said the resident was located a mile away from the facility and was hitchhiking to another state to see his ex-wife. She said there was a second incident where the resident was found a half mile away from the facility and he told the staff he wanted to go to another state. She said the resident was found naked in a female resident's room and she was unable to consent. The DON said the resident also struck a CNA in the face. She said no one from the facility reassessed the resident and she was not aware someone needed to reassess the resident when he was medically cleared prior to discharging him. The DON said the receiving facility for Resident #1 was the hospital. She said she was not aware that the hospital was not an acceptable discharge location.

Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints for one (#1) of three residents out of five sample residents. Specifically the facility failed to: -Ensure Resident #1 had physician's orders for the placement of a wanderguard; and, -Obtain consent to move Resident #1 to the secured unit, which prevented the resident from activities that met his interests. Findings include: I. Facility policy and procedure The Physical Restraint policy, revised 10/14/22, was provided by the director of nursing (DON) on 6/16/25 at 4:05 p.m. The policy read in pertinent part, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the residence body that the individual cannot remove easily and which restrict freedom of movement or normal access to one's body. It is the policy of the facility to use restraints only under the following conditions; as a last resort after a trial period where less restrictive measures have been undertaken and proven unsuccessful; with a physician's order and only when necessary to prevent injury to the resident or others, based on a physical, functional, emotional, and medication assessment; with the consent of the resident and his or her representative; when benefits of the restraint outweigh the risks. The Wandering Resident policy, revised 3/10/25, was provided by the DON on 6/16/25 at 4:05 p.m. The policy read in pertinent part, The facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan which addresses the unique factors contributing to their wandering behavior or elopement risk. Residents with a signaling device on will be escorted by staff, volunteers or another responsible person when they leave their unit/neighborhood. The Dementia Care policy, revised 3/10/25, was provided by the DON on 6/16/25 at 4:05 p.m. The policy read in pertinent part, A systematic process will be used including input from interdisciplinary team (IDT) members to provide holistic care for residents with dementia. Gather information on resident's past and current physical, functional and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related to complications and functional impairments. Monitor for safety including wandering and need for electronic monitoring. Create individualized approaches in the care plan with measurable goals and specific interventions for management of behavioral symptoms/ behavioral expressions. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease without dyskinesia (movement disorder), without mention of fluctuations, unspecified dementia, specified severity, with mood disturbance and other behavioral disturbances, Alzheimer's disease, anxiety disorder, abnormal involuntary movements, tremors, abnormalities of the gait and mobility, difficulty in walking and generalized muscle weakness. The 3/31/25 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He did not use a mobility device for ambulation but needed supervision with most of his activities of living (ADL). The MDS assessment documented Resident #1 did not have inattention or disorganized thinking. The MDS assessment indicated it was very important to Resident #1 to go outside to get fresh air and participate in his favorite activities was very important to him. According to the MDS assessment Resident #1 did not have wandering behavior, a physical restraint or alarm. B. Resident representative interview Resident #1's representative was interviewed on 6/17/25 at 10:34 a.m. The representative said he Resident #1 left the facility to hitch hike out of state to see his spouse. She said the facility placed a wanderguard on him and had him go to the memory care secured unit during the day. She said he was not assessed for the memory care unit. She said he was now permanently on the secured unit. The representative said she and the resident's power of attorney (POA) wanted Resident #1 to have the least restrictive environment possible. She said he was used to being very independent when he was at home. The representative said she did not think the facility was providing personalized activities for Resident #1. She said walking was very important to him but the staff was not taking him on walks routinely. She said the staff were letting the resident go on the patio and not taking him for walks. Resident #1's POA was interviewed on 6/17/25 at 11:00 a.m. The POA said after Resident #1 tried to hitch-hike, the facility placed a wanderguard on Resident #1 and put him in the secured unit during the day. She said she did not agree to having Resident #1 on the secured unit and away from him from his room and personal items during the day. She said his communication skills were impaired due to aphasia (difficulty with language communication) and she was worried that he would not be able to fully communicate when he would want to go back to his room outside of the secured unit. She said the facility said they were going to have him go to the secure unit during the day without her consent. The POA said she was notified on the evening of 4/12/25 that the facility put a wanderguard on Resident #1 after his elopement on 4/12/25. She said she felt the facility should have educated him and assessed him before using a wanderguard. The POA said walks were very important to Resident #1. She said when he walked, he still felt some independence. She said he loved doing anything outside. C. Observations Resident #1 was in the secured memory care unit on 6/16/25, between 5:30 p.m. and 6:00 p.m., watching television. On 6/17/25 at 10:05 a.m. Resident #1 was in a lounge chair in the day room sleeping on the secured unit. At 11:35 a.m. he was independently drawing in the day room while a certified nurse aide (CNA) visited with him on the secured unit. At 11:58 a.m. the CNA read the newspaper to him on the secured unit. At 1:15 p.m. the resident was in his room resting on the secured unit. D. Record review The wander/elopement risk care plan, initiated 4/14/25, identified Resident #1 was at risk for elopement due to history of leaving the facility to travel out of state. The 4/17/25 interventions directed staff to monitor his calls with his spouse that could trigger his behaviors to travel out of state and ensure the resident's wanderguard was in place and functioning appropriately. Review of nursing progress notes identified Resident #1 eloped from the facility on 4/12/25. The facility placed a wanderguard on the resident and placed him on the secured unit during the day for memory care programming. The April 2025 CPO for a wanderguard was provided by the DON on 6/18/25 at 5:37 p.m. a A physician's order directed staff to place a wanderguard on Resident #1 one time between 6:30 p.m. and 10:00 p.m., ordered and discontinued on 4/12/25. -The April 2025 CPO identified the resident did not have physician's orders for the wanderguard after 4/12/25, however, the resident wore a wanderguard until he was placed on the memory care unit full time on 6/9/25 (see interviews below). The June 2025 CPO revealed a physician's order that directed staff to verify placement of the wanderguard device on Resident #1 every shift and check the device daily to confirm that it was working, ordered on 6/9/25 and discontinued on 6/17/25 (during the survey). -The 6/9/25 wanderguard physician's order for verification of the placement and confirmation that it was operational were added to the physician's orders after the resident was moved to the secured memory care unit and after the wanderguard was taken off of the resident (see interviews below). The June 2025 medication administration record (MAR) documented on 6/9/25 through the day shift on 6/17/25, the staff checked Resident #1's wanderguard daily to confirm that it was in working order and verify placement of the wanderguard device on the resident every shift. -However, according to the DON, the resident did not have a wanderguard after he was moved to the secured memory care unit on 6/9/25 (see interview below). The 3/27/25 activity assessment documented Resident #1's preferred program style was one-to-one, independent leisure and small groups. The assessment identified his past interests as walking to the store, biking, fishing, rafting, watching specific television shows and going to church. According to the activity assessment, the resident felt health, walks and church provided him life enjoyment, a meaningful daily routine and were very important to him. -The March 2025 activity participation record did not identify Resident #1 was offered or participated in group or individual leisure activities from the time of his admission on [DATE] to 3/31/25. The 4/11/25 progress note documented Resident #1 went for a walk on 4/11/25 and fell outside. According to the note, the resident was reminded to just walk around the facility. Review of the April 2025 progress notes identified Resident #1 eloped from the facility on 4/12/25. Review of participation records and progress notes between the time he admitted (3/26/25) and the time he eloped on 4/12/25, revealed he went on one walk and attended one activity. The April 2025 activity participation record documented Resident #1 was offered and participated in bingo on 4/2/25 prior to his 4/12/25 elopement. The participation record identified the resident was offered and participated in a walk and live music on 4/16/25, a drumming activity on 4/22/25, an afternoon stroll on 4/23/25 and watched a documentary and went on a walk on 4/28/25. The April 2025 participation record indicated the resident was offered and participated in seven activities in April 2025, which included three walks for the month, after he eloped. The May 2025 activity participation record documented Resident #1 was offered and participated in one or more walks on 5/6/25, 5/13/25, 5/16/25, 5/21/25, 5/22/25, 5/23/25, 5/29/25 and 5/31/25. The participation record identified the resident had eight days out 31 days that he received a walk. The participation recorded identified the resident was offered seven bingo or card games, one social on the patio and live music twice. Review of the May 2025 progress notes identified the resident wanted more opportunities for walks outside and attempted to take himself outside. The 5/17/25 nursing note documented Resident #1 triggered the wanderguard alarm when he went out the front door. The note documented that the resident said he only wanted to walk outside. -The note did not identify that the resident was provided a walk outside. The 5/21/25 nursing note documented Resident #1 triggered the wanderguard when he attempted to get on the facility elevator. The nurse reminded Resident #1 that he needed supervision to go for a walk off the unit. According to the note, the resident was told no one was available to take him on a walk. The resident then returned to his room. The 5/26/25 nursing note documented Resident #1 attempted to walk out of the facility. The note identified the resident said he just wanted to have a walk outside. According to the note, the nurse and three other staff members convinced Resident #1 to go to the memory care unit. The resident went to the memory care unit for 30 minutes, watched television and had a snack. The resident then said he wanted to go back to his room to sleep. -The note did not identify the resident was later provided a walk outside. The physician communication log identified Resident #1 had a written physician's order for placement on the secured unit on 6/9/25. The 6/10/25 activity progress note identified the activity director (AD) walked with Resident #1 outside for 30 minutes on 6/10/25. According to the note, the resident enjoyed the walk and the company. The 6/11/25 activity progress note identified Resident #1 received two walks on 6/11/25 and watered the flowers. According to the note, the resident was in a good mood and enjoyed the walks. III. Staff interviews The social services director (SSD) was interviewed on 6/17/25 at 12:20 p.m. The SSD said the nursing staff requested the physician's order for a wanderguard. He said the wanderguard was usually tried as an intervention before the resident was placed on the secured memory unit. The SSD said Resident #1 had a wanderguard and the nursing staff would try to have him go to the memory care unit for activities. He said if Resident #1 wanted to go back to his room on the non-secured side of the facility, the staff would assist him back to his room. The DON was interviewed on 6/17/25 at 12:33 p.m. The DON said a wanderguard would be implemented on a resident if the resident attempted to leave the facility and would not be able to find their way back. She said if the facility felt a resident needed a wanderguard, the facility would notify the family and the physician and get orders. The DON said the staff would make sure the wanderguard was in place and in good working order. She said Resident #1 no longer had a wanderguard on. The DON said Resident #1 was allowed to go outside of the facility on walks independently and with staff. The DON said he was just asked to let staff know when he was leaving. She said the resident did not have any restrictions before he attempted to hitchhike out of state on 4/12/25. The DON said after the elopement, the staff was very concerned about his safety. The DON said a wanderguard was placed on the resident and he was placed on the memory care unit during the day and offered supervised walks. The DON said the resident was brought to the secured memory care unit during the day and ultimately moved to the secured due to his wander risk and benefit for more activity programming. The activity assistant (AA) was interviewed on 6/17/25 at 3:22 p.m. The AA said Resident #1 liked games like bingo, cards and balloon bat and going on walks. She said the facility had religious services but not the denomination he preferred. She said the facility might be able to find someone to minister to him from his church. The DON was interviewed again on 6/18/25 at 1:18 p.m. The DON said sometimes a wanderguard would be placed on a resident in an emergency without a physician's order but the facility would then get an order. The DON was interviewed a third time on 6/18/25 at 3:46 p.m. The DON said a wanderguard was placed on Resident #1 after he eloped (on 4/12/25). She said he was provided day programming on the secured memory care unit from 4/13/25 to 5/30/25. The DON said starting on 5/30/25, he remained on the non-secured side of the facility. She said he continued to wear his wanderguard until he was moved to the secure memory care unit full time on 6/9/25. She said when a resident moved to the secured unit, the wanderguard would come off. The DON reviewed the wanderguard orders and said she did not know why Resident #1 had wanderguards orders for just one day on 4/12/25 or had orders to verify placement of the wanderguard when he was placed on the secured unit on 6/9/25. She said she would have to follow up. The AD was interviewed on 6/18/25 at 4:25 p.m. The AD said there was limited record of Resident #1's activity participation and walks in March 2025, April 2025 and May 2025. She said he may have engaged in and been offered more walks and activities but she could not say for sure because it was not documented. The AD said she knew he walked and watched television before he eloped on 4/12/25 but she did not know how often. The DON was interviewed a fourth time on 6/18/25 at 5:37 p.m. The DON said the nurse manager entered the wanderguard physician's orders incorrectly and it should not have been just for one day. She said the nurse manager must have misunderstood what the physician ordered. The DON said Resident #1 should have had active orders for the duration of use. The DON said the nurse manager should have additionally entered in the orders to verify placement and working condition of the wanderguard. She said the nurse manager must have not understood the full process of putting in a wanderguard order. The DON said she would provide education to the nurse manager. The DON said on 6/9/25 she noticed Resident #1 did not have complete orders for the wanderguard so she added the 6/9/25 physician's orders and discontinued the orders on 6/17/25.

Based on observations, record review and interviews, the facility failed to ensure two (#10 and #35) of five residents out of 23 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #10 was admitted to the facility for long-term care on 4/6/18 with diagnoses of dementia, stroke, and seizure disorder. Upon admission, the resident weighed 117 pounds (lbs). On 7/30/24, Resident #10 weighed 145.6 lbs. On 9/3/24 the resident weighed 126 lbs. Resident #10 sustained a 18.6 lbs (12.8%) weight loss from 7/30/24 to 8/27/24 in one month, which was considered severe weight loss. Due to the facility's failure to accurately assess and implement nutrition interventions timely the resident's weight continued to decline. Additionally, Resident #35 admitted on [DATE] with a diagnosis of gastroesophageal reflux disease (GERD), arthritis and thyroid disorder. Upon admission, the resident weighed 107 lbs. On 8/1/24 the facility discontinued the oral nutritional supplement that was prescribed to the resident, due to weight gain. However, the resident had lost 1.6 lbs from 7/23/24 to 7/30/24, in one week. The resident continued to have gradual weight loss and on 9/10/24 the resident weighed 106 lbs, which indicated the resident had lost eight pounds (7%) from 8/6/24 to 9/10/24, in one month, which was considered severe. After the resident sustained severe weight loss, the facility failed to implement person centered nutritional interventions to address the weight loss. Findings include: I. Facility policy and procedure The weight measurement policy, reviewed 3/28/24, was provided by the nursing home administrator (NHA) on 9/19/24 at 1:12 p.m. It documented in pertinent part, Weigh the resident at approximately the same time of day. A re-weigh is needed in these circumstances: if the present weight of the resident is plus or minus five pounds from the previous weight, or if the resident weighs 100 pounds or less and the present weight is plus or minus three pounds from the previous weight. Update the resident care plan with all changes of orders, goals, and interventions. The hydration policy, reviewed 3/27/24, was provided by the NHA on 9/19/24 at 1:12 p.m. It read in pertinent part, The nutrition services professional, nursing staff, and physician will assess factors that may be contributing to inadequate intake. Orders for medications that may exacerbate dehydration ( diuretics) will be reviewed and held if medically appropriate. Nursing will monitor fluid intake and the nutrition services professional will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and related factors are resolved. II. Resident #10 A. Resident status Resident #10, over the age of 65, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included dementia, stroke, and seizure disorder. The 9/3/24 minimum data set (MDS) assessment revealed the resident could not complete the brief interview for mental status (BIMS) score assessment because she was rarely or never understood. The resident was dependent on the nursing staff for all care. The assessment documented the resident had no signs or symptoms of swallowing disorders. The assessment documented the resident was 62 inches (5 foot, 2 inches) tall. The assessment documented the resident weighed 126 pounds. The assessment documented the resident had experienced 10% or more weight loss in the last six months. The assessment documented the resident was not on a physician-prescribed weight loss regimen. B. Observations During a continuous observation on 9/16/24, beginning at 11:58 a.m. and ending at 1:13 p.m. the following was observed: At 11:58 a.m. Resident #10 was observed in a reclining chair in the living room area. The resident sat alone in the recliner chair until she was assisted one on one by an unidentified staff member which began at 12:21 p.m. The unidentified staff member assisted Resident #10 with eating lunch which included tomato soup with crackers, bread, and another unidentified food item that was covered with plastic wrap. Resident #10 ate 25-50% of her tomato soup and none of her bread during the lunch observation. At 12:31 p.m. the unidentified staff member removed the lunch tray from Resident #10. The unidentified staff member did not offer the resident the bread or the unidentified food item. That food remained covered in plastic wrap. -Resident #10 was not offered any alternate food option. C. Record review The nutrition care plan was initiated on 4/6/18 and revised 9/5/24. The care plan documented a goal of maintaining Resident #10's weight and maintaining intakes greater than 50%, implemented on 6/5/24. Interventions included encouraging the resident to drink fluids and providing an easy to chew texture. -A review of the comprehensive care plan revealed there were no new or revised interventions implemented after the resident sustained severe weight loss on 9/3/24. Resident #10's weights were documented in the electronic medical record (EMR) as follows: -On 7/30/24, the resident weighed 145.6 lbs; -On 8/6/24, the resident weighed 140.4 lbs; -On 8/13/24, the resident weighed 131.7 lbs; -On 8/20/24, the resident weighed 139.4 lbs; -On 8/27/24, the resident weighed 127 lbs; and, -On 9/3/24, the resident weighed 126 lbs. -The resident lost 18.6 lbs (12.8) from 7/30/24 to 8/27/24, in one month, which was considered severe. The nutritional assessment, dated 9/4/24, documented the resident had not experienced weight loss or weight gain. The assessment documented the resident had not had a significant weight change due to a prescribed weight change regimen. The assessment documented Resident #10 had no food allergies and the resident's spouse preferred Glucerna protein shakes and evening snacks offered to the resident. The assessment documented Resident #10 was often assisted at mealtimes by her spouse. The assessment documented that Resident #10 required no new interventions at this time. -However, Resident #10 sustained a 19.6 lbs (13.46%) from 7/30/24 to 9/3/24, which was considered severe. -Review of the resident's EMR did not reveal a physician's prescribed weight loss regimen or indication of why the resident's weight loss was desired. The nutritional quarterly progress note, dated 9/4/24, documented the resident lost 14 pounds in 30 days or less. The progress note documented no new interventions were necessary at this time, and the resident was receiving treatment for a urinary tract infection. -The facility failed to implement a person centered nutritional intervention after Resident #10 sustained a 19.6 lbs (13.46%) from 7/30/24 to 9/3/24, which was considered severe. The care conference note, dated 9/12/24, documented Resident #10 had lost 16 pounds since the last care conference, which concerned the facility. The resident's spouse requested the facility explore potential supplements and the facility documented that the resident enjoyed protein drinks. It documented Resident #10 was falling asleep during meals. -However, the facility failed to implement or trial oral nutritional supplements after the resident had sustained weight loss. The nutrition at risk meeting note, dated 7/17/24, documented the resident had a BMI of 26.5, was eating 75-100% of all meals, required assistance at meals and the resident's spouse was often present at meals. The nutrition at risk meeting note, dated 8/7/24, documented the resident had a BMI of 26.5, was consuming 75-100% of all meals, required assistance at meals and the resident's spouse was often present at meals. -However, on 8/6/24 the weighed 140.4 pounds, which indicated the resident had a BMI of 25.7. The nutrition at risk meeting note, dated 8/28/24, documented the resident had a BMI of 26.5, was consuming 75-100% of all meals, required assistance at meals and the resident's spouse was often present at meals. -However, on 8/27/24 the resident weighed 127 pounds, which indicated the resident had a BMI of 23.2. -The nutrition at risk meetings failed to identify that Resident #10 sustained a 18.6 lbs (12.8%) weight loss in one month, from 7/30/24 and 8/27/24, which was considered severe. -The facility failed to implement person centered nutritional interventions to address the resident's weight loss. The nutrition at risk meeting note, dated 9/18/24, documented the resident had a BMI of 23.1, was consuming 51-75% of all meals, required assistance at meals and the resident's spouse iwa often present at meals. III. Resident #35 A. Resident status Resident #35, over the age of 65, was admitted to the facility on [DATE]. According to the September 2024 CPO, diagnoses included GERD, arthritis and thyroid disorder. The 7/26/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident was independent with eating. The resident required supervision or touching assistance with bathing, dressing, personal hygiene and toileting. The assessment documented the resident was 56 inches (4 foot, 8 inches) tall. The assessment documented the resident weighed 118 pounds. The assessment documented the resident did not have a swallowing disorder. The assessment documented the resident had not experienced weight loss or weight gain in the last six months. -However, the resident had sustained a 11.8 lbs (10.01%) weight loss in less than three months, which was considered severe weight loss. B. Record review The nutrition care plan, initiated on 4/24/24 and revised on 7/30/24, documented the resident was at a minimal nutritional risk with consistent food intake greater than 50%. The care plan documented the resident could eat independently and make her needs known. The interventions included maintaining the resident's weight, encouraging fluid intake, monitoring food and fluid intake at meals and providing snacks available daily. -A review of the comprehensive care plan did not reveal documentation indicating interventions were reviewed or implemented to reduce or prevent weight loss after the resident sustained severe weight loss on 9/10/24. Resident #35's weights were documented in the EMR as follows: -On 6/12/24, the resident weighed 113.2 lbs; -On 6/12/24, the resident weighed 113.2 lbs; -On 5/28/24, the resident weighed 107 lbs; -On 6/4/24, the resident weighed 112.8 lbs; -On 6/11/24, the resident weighed 114.2 lbs; -On 6/12/24, the resident weighed 113.2 lbs; -On 6/25/24, the resident weighed 114.6 lbs; -On 7/2/24, the resident weighed 113.6 lbs; -On 7/9/24, the resident weighed 114.6 lbs; -On 7/16/24, the resident weighed 115.6 lbs; -On 7/23/24, the resident weighed 117.8 lbs; -On 7/30/24, the resident weighed 116.2 lbs; -On 8/6/24, the resident weighed 114 lbs; -On 8/13/24, the resident weighed 111.4 lbs; -On 8/20/24, the resident weighed 113 lbs; -On 8/27/24, the resident weighed 112 lbs; -On 9/3/24, the resident weighed 109 lbs; and, -On 9/10/24, the resident weighed 106 lbs. -The resident lost 8 lbs (7%) from 8/6/24 to 9/10/24, in one month, which was considered severe. The nutritional assessment, dated 7/24/24 documented the resident had no food allergies and had not experienced weight loss. The assessment documented the resident was asleep during the assessment. A physician's order, dated 8/1/25, documented the protein supplement (Ensure) was discontinued. A physician's visit note, dated 8/1/24, documented Resident #35's protein supplement (Ensure) was discontinued because the resident had experienced weight gain. -However, Resident #35 had lost 1.6 lbs from 7/23/24 to 7/30/24. Resident #35 had not experienced significant weight gain. The resident's weight fluctuated up and down a pound or two at each weigh-in (see the weight record above) and by 9/10/24 the resident had experienced a significant weight loss. -A review of the resident's EMR did not reveal documentation indicating the resident was on a prescribed weight loss regimen. IV. Staff interviews Certified nursing aide (CNA) #1 was interviewed on 9/18/24 at 5:59 p.m. CNA #1 said Resident #35 did not regularly require assistance with eating. CNA #1 said Resident #35 usually ate what was in front of her as long as the staff helped her identify what the food items were because of her poor vision. CNA #1 said Resident #10 was difficult to assist with eating because she often fell asleep during meals and it was a time consuming task for the nursing staff. CNA #1 said she knew Resident #10 had lost weight but could not say how much weight she had lost. CNA #1 said she did not know what the facility could do to prevent further weight loss for Resident #10. The registered dietitian (RD) was interviewed on 9/19/24 at 11:16 a.m. The RD said she was in the building one day per week to assess resident nutritional needs. The RD said if she identified weight loss in a resident, she would perform a comprehensive assessment of the resident to identify the root cause for the weight loss. The RD said if a resident experienced weight loss the resident would not always receive new interventions. The RD said she would have to look at the whole picture to determine if a resident needed a nutritional intervention. The RD said she did not expect the nutritional plan of care to be updated if a resident experienced weight loss. The RD said interventions such as nutritional supplements could be considered in residents with weight loss. The RD said residents should be seated in the dining room for meals because the social aspect of meals helped the residents eat more. The RD said she did not know if additional food or supplements should be added or considered for residents experiencing consistent weight loss. The RD said she did not know if any interventions were added, reviewed, or changed for Resident #10 after she sustained severe weight loss between 7/30/24 and 9/3/24. The RD said she did not have documentation indicated Resident #35 was on a weight loss regimen. The RD said she did not often manage weight loss regimens in the facility. The RD said she thought Resident #35 had recently increased her prescribed dose of thyroid medication which was the cause of Resident #35's weight loss. -However, review of Resident #35's EMR did not reveal documentation regarding the reasoning for Resident #35's weight loss. The RD said she did not know if Resident #35 should receive protein supplements or not. The RD said she did not know if interventions were added, reviewed, or changed for Resident #35 to help reduce or prevent her severe weight loss between 7/30/24 and 9/3/24. The RD said Resident #35 was not reviewed in the nutrition at risk meeting. The director of nursing (DON) was interviewed on 9/19/24 at 1:41 p.m. The DON said if a resident was experiencing weight loss, the facility worked to identify why the resident was losing weight and how the facility could prevent it. The DON said all residents experiencing weight loss were reviewed in the nutrition at risk committee. The DON said she reviewed the nutrition at risk committee meeting notes between 7/17/24 and 9/18/24 for Resident #10. The DON said the weights documented for Resident #10 on the nutrition at risk committee meeting notes did not match documented weights in the EMR. The DON said the facility could have done more to help reduce or prevent Resident #10's severe weight loss, such as considering supplements, diet changes, or working with the nursing staff to improve her intake. The DON said Resident #35 was not identified as at risk in the nutrition at risk committee. The DON said Resident #35 should have been discussed in the nutritional at risk committee because she experienced significant weight loss. The DON said the facility could have done more to help reduce or prevent Resident #35's severe weight loss if she had been identified in the committee. The DON said she was concerned about the accuracy of the information being brought to the nutrition at risk committee because of documentation inaccuracies seen in Resident #10.

Based on record review and interviews, the facility failed to ensure one resident (#5) out of five residents reviewed were free from significant medication errors out of 23 sample residents. Specifically, the facility failed to ensure, for Resident #5: -Antibiotics were started as ordered; -The correct antibiotic was given as ordered; -The physician was notified when the antibiotics were not available; and, -Timely identification and notification of a significant medication error. Findings include: I. Facility policy and procedure The Medication Administration policy, last reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:14 p.m. The policy read in pertinent part, Medications will be administered to residents as prescribed by the primary MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant). Staff will follow the six rights of medication administration. Right resident, right medication, right dose, right dosage form, right frequency and right route. Medications will be given one hour before or one hour after scheduled medication unless there is a specific order or indication otherwise. Expired or discontinued medications will be promptly removed from the medication cart and disposed of per medication disposition policy. The Notification of Physician and Resident Representative policy, last reviewed [DATE], was provided by the NHA on [DATE] at 1:14 p.m. The policy read in pertinent part, Primary physicians, residents, and the resident representative, consistent with their authority, will be updated with resident condition changes as soon as possible. The names of those contacted will be documented in the progress notes. The policy identified the physician needed to be contacted as soon as possible when: A need to alter treatment significantly, for example need to discontinue or change existing form or treatment due to adverse consequences, or to begin a new form of treatment. A significant medication error. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE] and readmitted on [DATE] According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), unspecified otitis externa (inflammation of the ear canal), right ear and unspecified otitis externa. The [DATE] minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) of 10 out of 15. The resident did not exhibit disoriented thinking or inattention. -The MDS assessment indicated the resident was on an antibiotic during the lookback period. B. Resident interview Resident #5 was interviewed on [DATE] at 3:29 p.m. He said he had an ear ache since [DATE]. He said he was supposed to get ear drops for it on [DATE] but was told the ear drops were coming from an out of town pharmacy and would not arrive until tonight ([DATE]). Resident #5 was interviewed a second time on [DATE] at 2:59 p.m. He said he was now getting the ear drops for his ear ache but his ear was hurting over the weekend and had to ask for tramadol (a synthetic opioid pain reliever). C. Record review The [DATE] physician progress note identified Resident #5 was seen by the medical director (MD) on [DATE] at 3:15 p.m. The resident had right ear pain that was described as deep. According to the note, the resident had a diagnosis of otitis externa to the right ear which was recurrent and improved with treatment. The MD prescribed cortisporin (antibiotic ear drops). The [DATE] medication administration record (MAR) revealed Resident #5 had physician's orders for the antibiotic treatment of neomycin-polymyxin-HC (ear) drops three times a day, ordered on [DATE] and discontinued on [DATE]. -According to [DATE] MAR, Resident #5 received the ordered antibiotic until the discontinue date of [DATE]. The [DATE] MAR revealed Resident #5 had a physician's order for for cortisporin-TC (neomycin-colist-hc-thonzonium) ear drops to be given twice a day for seven days, ordered on [DATE] and ending on [DATE]. According to the [DATE] MAR, Resident #5 did not receive the cortisporin antibiotic ear drops for both scheduled doses on [DATE] and [DATE] and one scheduled dose on [DATE]. -The missed doses were documented as unavailable, not administered and waiting for delivery from the pharmacy. -However, the cortisporin was documented on [DATE] as administered by registered nurse (RN) #2 between the hours of 7:00 a.m. and 10:00 a.m. (see interviews below). -Review of Resident #5's electronic medical record (EMR) did not reveal documentation indicating the resident's physician was notified of the missed doses on [DATE], [DATE] and [DATE]. A [DATE] email between the director of nursing (DON) and the nursing staff was provided by corporate consultant (CC) on [DATE] at 3:50 p.m. The email was created on [DATE] (during survey period). The email read in pertinent part, When a medication order is received that the resident should start right away such as an antibiotic or narcotic, check the stat safe list and use that until the medication arrives. when you fax in order to the pharmacy, please enter the time the order was faxed on the physician order sheet. Please communicate on report any medications that should be arriving. night shift, during your chart check, please be the second set of eyes and know any medications that should be arriving. compare this to the medications that come in. If a medication does not arrive as expected, please document in the progress notes:' X medication order was faxed to the pharmacy at X time. Medication did not arrive in tonight's shipment. Will pass on to the next shift to contact the pharmacy and the provider.' Pass this on to the day nurse. The day nurse will be responsible for calling the pharmacy and checking on this. you will document in the progress notes the status of the medication as well as any follow-up that is needed. The day nurse will contact the provider to see if the provider would like to order a different medication. The information will be passed on to the next shift. This will continue until the medication is received. The DON directed the staff to document each step of the process. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:37 p.m. LPN #1 said the MD ordered the cortisporin ear drops for Resident #5's ear infection on Friday [DATE] for a start date on [DATE]. LPN #1 said the pharmacy was notified of the order on [DATE]. He said the antibiotics were ordered from a pharmacy that was out of town and it was common for a medication not to arrive till the following Monday when it was ordered late on a Friday. LPN #1 said the antibiotic did not arrive until Monday night ([DATE]). He said Resident #5 received his first dose of the cortisporin antibiotic on Tuesday morning ([DATE]). The infection preventionist (IP) was interviewed on [DATE] at 1:01 p.m. The IP reviewed Resident #5's MAR and said the antibiotic was scheduled twice a day starting on [DATE] but the MAR was not clear when the resident received it and she would need to refer to the DON for clarification. The DON was interviewed on [DATE] at 1:11 p.m. The DON reviewed Resident #5's MAR. She said the resident should have received the antibiotic starting on [DATE] but according to the notes on the MAR, the antibiotic was not available to give. The [DATE] administration of the antibiotic must have been marked as received in error because the antibiotic did not arrive until [DATE]. She said she would contact RN #2 to find out what happened and provide education to her. The DON said she was not sure why the medication did not arrive until [DATE]. She said she was not made aware of a concern. The DON reviewed Resident #5's progress notes and said she did not know if the pharmacy was contacted to determine why the late delivery. She said she had not been informed that it was common for a medication ordered on Friday not to arrive until monday. She said the physician's orders needed to be given to the pharmacy by 3:00 p.m. to receive the following day but no one complained to her that the medication would not arrive the following day. She said she did not know if the MD was notified that the antibiotic was not given on [DATE] as ordered and he did not have his first dose until [DATE]. The DON said it could be more difficult to reach the MD if the concern was not urgent but she should have been contacted. The DON said she did not see any notes identifying the resident complained of pain related to his ear. The CC was interviewed on [DATE] at 3:11 p.m. The CC said the facility was in process of notifying the MD to inform her of the delay in antibiotics for Resident #5. She said RN #2 would be educated on the charting error and the pharmacy would be contacted. The CC said the DON was still in process of trying to identify why the antibiotic was marked as administered when it was not available. The MD was interviewed on [DATE] at 3:13 p.m. The MD said she was informed today ([DATE]) that there was a delay over the weekend to give Resident #5's the antibiotic ear drops. She said she put in a PRN (as needed) order for the drops on [DATE] once she heard the risk of not getting the medication over the weekend so that they would be available to him if it happens again. She said she was not contacted until [DATE] and would have preferred to be contacted if the resident did not receive his medication, especially if the resident was experiencing discomfort. She said she could have ordered through the local pharmacy for an easy pickup. The DON was interviewed again on [DATE] at 5:47 p.m. The DON said she sent out an email to nursing staff on documentation and what to do when a medication was not available as ordered. She said she was trying to figure out how the medication error occurred. She said once she learned what happened she would know what her next steps were. The DON was interviewed again on [DATE] at 12:31 p.m. The DON said she spoke to RN #2. She said RN #2 remembered giving Resident #5 his antibiotics on [DATE]. The DON said RN #2 named off a discontinued antibiotic (neomycin-polymyxin administered three times a day). She said the discontinued antibiotic was also ear drops but it was discontinued on [DATE]. She said the cortisporin (neomycin-colist-hc-thonzonium administered twice a day) was ordered on [DATE] and was the ear drop RN #2 should have been administered. She said the discontinued antibiotics were not removed for the nursing medication cart and RN #2 gave Resident #5 the wrong antibiotic. She said the discontinued antibiotic was later removed by a night nurse on [DATE] but after the discontinued antibiotic was given on [DATE]. The DON said she was concerned with RN #2 accuracy of medication administration. She said RN #2 did not review the orders close enough to ensure the resident did not receive an discontinued antibiotic and that was giving him the correct antibiotic. The DON said education would be provided to RN #2. She said the education would include the rights of medication administration (see above in policy) and online training. She said he education would be completed prior to RN #2 administering medications. The DON said RN #2 would then be monitored during medication pass to ensure accuracy. The DON said she was concerned that the staff did not inform her of delays with receiving medications over the weekends. She said the nurses should have communicated to her. She said after speaking with the staff it was identified as a long standing concern. The DON said she would discuss her concerns with the NHA and the pharmacy. She said it was not appropriate for a medication to be ordered on a Friday and not able to start till its next scheduled dose on a Tuesday morning. The DON said the pharmacy concern would also be discussed in the quality assurance and performance improvement (QAPI) meeting. The DON said she would speak to the MD with an immediate plan to mitigate the receival of weekend medications ordered on a Friday.

Based on record review and interviews, the facility failed to ensure two (#14 and #37) of five residents reviewed were free from unnecessary psychotropic medications out of 23 sample residents. Specifically, the facility failed to ensure as-needed psychotropic medications for Resident #14 and Resident #37 had an identified end date from the prescriber. Findings include: I. Facility policy and procedure The Psychotropic Medication Monitoring policy, reviewed 3/4/24, was received from the nursing home administrator (NHA) on 9/19/24 at 11:09 a.m. It read in pertinent part,Residents who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. II. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), stroke and respiratory failure. The 8/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) assessment score of nine out of 15. She was dependent on staff for eating, oral care, bathing, toileting, dressing and personal hygiene. B. Record review A review of the September 2024 CPO revealed the resident had a physician's order for Haloperidol (antipsychotic medication) 1 milligram (mg) per 0.5 milliliter (mL) oral syrup every six hours as needed, ordered on 7/25/24. -The antipsychotic medication was ordered by the medical director (MD) and did not have a a stop date. -The antipsychotic medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. III. Resident #37 A. Resident status Resident #37, over the age of 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included non-traumatic brain dysfunction, anxiety disorder, and Alzheimer's disease. The 8/30/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS assessment score of zero out of 15. She required moderate assistance with bathing, dressing, and personal hygiene. She required supervision or touching assistance with eating and oral hygiene. B. Record review A review of the September 2024 CPO revealed the resident had a physician's order for Haloperidol (antipsychotic medication) concentrate 2 milligrams (mg) per milliliter (mL), administer one mL every six hours as needed for agitation, ordered on 8/16/24. -The antipsychotic medication was prescribed by the MD without a stop date. -The antipsychotic medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. IV. Staff interviews The medical director (MD) was interviewed on 9/19/24 at 9:59 a.m. The MD said that as-needed psychotropic medications have a maximum prescribing time of 14 days for the order. The MD reviewed the September 2024 CPO for Resident #14 and Resident #37. The MD said Resident #14's Haloperidol should have had a stop date and it was incorrect to order the medication without one. The MD said Resident #37's ordered Haloperidol did not have a stop date either, which was also incorrect. The MD said it was important to have stop dates for as-needed psychotropic medications to ensure we are using psychotropic medications only when necessary. The MD said it was the responsibility of the MD to ensure as-needed psychotropic medications are prescribed appropriately. The MD said it should not be the responsibility of the nursing staff to ensure psychotropic medications are prescribed correctly in the CPO. The MD said she would address the incorrect psychotropic medication orders on 9/19/24. The director of nursing (DON) was interviewed on 9/19/24 at 1:41 p.m. The DON said as-needed psychotropic medications cannot be ordered for more than 14 days.

Based on record review and interviews, the facility failed to ensure one (#145) of 23 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #145's vital signs were taken after the resident sustained an unwitnessed fall in her room. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 9/23/24, : In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor patients closely for 48 hours after a fall. IV. Resident #145 A. Resident status Resident #145, under the age of 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), renal insufficiency, and chronic obstructive pulmonary disease (COPD). The 9/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision or touching assistance with car transfers and was independent with all other cares. The assessment documented Resident #145 had no rejections of care. B. Record review The fall care plan, initiated on 9/5/24 and reviewed on 9/16/24. The plan of care documented nursing staff would check vital signs and assess Resident #145 for injuries if she should experience a fall. The plan of care included an intervention to document the circumstances and possible cause of the fall. The fall incident report, dated 9/10/24, documented that Resident #145 experienced an unwitnessed fall on 9/9/24. The fall report documented the resident was found in her bathroom at 6:45 a.m. sitting on the floor with her legs crossed. The fall report documented Resident #145 experienced pain in her coccyx (tailbone). The fall report documented the nurse believed the resident may have become hypotensive (low blood pressure) as a reason for the fall. The fall event documentation included a prompt to attach all vital signs and a progress note that included a summary of the fall. -The fall event documentation failed to include documentation indicating the resident's vital signs were obtained. Vital sign documentation was reviewed between 9/9/24 and 9/12/24. -The facility failed to record vital signs after the resident experienced an unwitnessed fall on 9/9/24 until 8:18 a.m. on 9/11/24. C. Resident interview Resident #145 was interviewed on 9/16/24 at 3:02 p.m. Resident #145 said she fell in the bathroom about a week ago which caused her pain in her tailbone. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/18/24 at 10:18 a.m. LPN #1 said when a resident fell they must be assessed immediately. LPN #1 said vital signs and a full head-to-toe assessment should be completed to ensure the resident was not injured. The director of rehabilitation (DOR) was interviewed on 9/19/24 at 10:39 a.m. The DOR said if a resident had an unwitnessed fall, she would get a nurse to assess the resident and obtain vital signs. The DOR said it was important to obtain a set of vital signs quickly to ensure the resident did not need additional care or services. Certified nursing aide (CNA) #2 was interviewed on 9/19/24 at 10:49 a.m. CNA #2 said if a resident had an unwitnessed fall, she would get the nurse immediately to assess the resident while she obtained vital signs on the resident. CNA #2 said CNAs and nurses could obtain vital signs after a resident experiences a fall. The director of nursing (DON) was interviewed on 9/19/24 at 1:41 p.m The DON said if a resident experienced an unwitnessed fall she would expect the nursing staff to assess the resident. The DON said the assessment included vital signs, a neurological assessment and a resident assessment to ensure there are no physical injuries from the fall. The DON said it was important for the nursing staff to consider all possibilities of how the resident fell . The DON reviewed the fall report for Resident #145 documented on 9/10/24. The DON said that vital signs should have been taken when Resident #145 fell to ensure a low heart rate or a low blood pressure were not the cause of the fall.

Based on record review and staff interviews, the facility failed to ensure one (#23) of three residents reviewed for abuse out of 23 sample residents was kept free from abuse. Specifically, the facility failed to: -Prevent Resident #22 from slapping Resident #23; -Thoroughly investigate a resident to resident altercation between Resident #22 and Resident #23; and, -Put interventions in place to prevent future resident to resident altercations between Resident #22 and Resident #23. Findings include: I. Facility policy and procedure The Vulnerable Adult policy, reviewed 10/20/23, was provided by the nursing home administrator (NHA) at 10:15 a.m. The policy documented in pertinent part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. This includes but is not limited to freedom from corporal punishment, and voluntary seclusion in any other physical or chemical restraint not required to treat resident symptoms. Physical abuse includes hitting, slapping, pinching, and kicking. Resident to resident altercations must be reported in accordance with regulations including willful actions resulting in physical injury, mental anguish, or pain. All residents of the facility are considered vulnerable adults. Therefore, the interdisciplinary team evaluates the vulnerability of each resident and develops interventions as part of the resident plan of care. The interdisciplinary team assesses, develops care plans, and monitors residents with needs and behaviors that might lead to abuse, conflict, or neglect, exploitation of residents. These residents' needs and behaviors may include communication disorders, those that require heavy nursing care and or totally dependent, a history of aggressive behavior, behaviors such as entering other residents' rooms, and/or self-injurious behavior. The facility will initiate an investigation immediately upon identification of possible abuse, neglect, exploitation of residents, mistreatment, injuries of unknown source, resident to resident verbal or physical altercations, and or misappropriation of property. All reports of suspected/alleged resident abuse, neglect, exploitation of residents, mistreatment, injuries of unknown source and/or misappropriation of resident property shall be properly and thoroughly investigated. All interviews related to the investigation shall be conducted in private. The policy identified the procedure to investigate all suspected and allegations of resident abuse as the following: -Collect data and document the investigation findings; -Conduct a physical examination of the resident and the environment; -Review documentation and the resident medical record for events leading up to the incident; -Interview the person(s) reporting the incident; -Interview the alleged victim; -Interview any potential witnesses to the incident; -Interview the alleged perpetrator; -Interview other residents to whom the alleged perpetrator provides care or services; and, -Review the completed documentation. According to the policy, if witness reports were obtained, witnesses should sign and date such reports. Staff should analyze the incident/occurrence to determine what changes were needed, if any, to the policies and procedures to prevent further occurrences. II. Resident to resident altercation between Resident #22 and Resident #23 on 9/9/24 The NHA provided the file containing the facility' s abuse investigation of the 9/9/24 incident between Resident #22 and Resident #23 on 9/17/24 at 5:41 p.m. The investigation file included: -The progress notes for both residents on the incident; -Care plans for both residents; -A summary of the situation; -A witness statement from certified nurse aide (CNA) #3; and, -An abuse reporting flow sheet. The 9/9/24 nursing progress note for Resident #22 documented in pertinent part, This RN (registered nurse) was called to the dining room by CNA (certified nurse aide) stating that another resident got too close for this resident and this resident slapped the other resident (Resident #23) on the hand. This RN did have a conversation with this resident to tell her it was not okay to be mean to others just for being too close to them. If she is not comfortable with others that are close to her, then she needs to ask staff to move other residents away from her. It is determined that this resident due to her dementia, lacked willful intent and had no intention of causing harm. This RN will add the behavior to her care plan so we can continue to monitor. The 9/9/24 nursing progress note for Resident #23 documented in pertinent part, This RN was called out to the dining room by CNA staff stating that another resident (Resident #22) slapped at this resident' s hand for being too close. Resident (#23) was assessed, but no injury or c/o (complaints of) pain to the area are noted. This resident is very active all over the MC (memory care) unit, and does tend to upset others by touching them or in this instance, by being too close to them. This incident lacked willful intent, as the other resident had no intention of hurting this resident. Will continue to monitor and report to the next shift to monitor for any bruising. No further issues or concerns at this time. The 9/9/24 at 4:00 p.m. summary of the situation documented Resident #23 was standing near and possibly touching something of Resident #22' s. CNA #3 saw Resident #22 slap Resident #23' s hand. The CNA went over to the resident and guided Resident #23 away from Resident #22. The CNA then told Resident #22 not to hit the other residents. The unit manager was also asked to speak with Resident #22. The summary read the behavior was known and care planned for Resident #22 and Resident #23. Resident #23 repeatedly picked up items. The summary documented due to the known behaviors of both residents, the staff monitored them. According to the summary, it was determined Resident #22' s action was willful to stop Resident #23 from touching her belongings but not willfully to harm her. The summary documented there was no pain or physical injury and Resident #23 returned to her baseline behaviors, showing no signs of psychological or emotional harm. The incident would not be reported. The documentation was completed and the care plans were reviewed. The witness statement for CNA #3 documented she saw Resident #22 slap Resident #23' s hand and told her to get away. Resident #23 stayed next to Resident #22 so the CNA intervened. She moved Resident #23 away from Resident #22. According to the statement, CNA #3 told Resident #22 to please not hit other residents and Resident #23 responded that the other resident needed to leave her stuff alone. CNA #3 told Resident #22 to let staff know if Resident #23 was touching her items and the staff would intervene. -The investigation did not include interviews with Resident #22 and Resident #23 to determine if they felt safe. -The investigation did not include interviews with other residents to ask if they felt safe and free from abuse. -The investigation did not include interviews with other staff members on the memory care unit as part of the investigation process to determine abuse or ask if the staff had any concerns with abuse or insight of how to prevent future resident to resident altercations between Resident #23 and Resident #22. -The investigation did not include what the residents were doing just before the altercation took place and if staff attempted to redirected the residents away from each prior to Resident #22 hitting resident #23. III. Resident #22 A. Resident status Resident #22, age greater than 65, was admitted on [DATE], with an initial admitted [DATE]. The resident resided in the secured memory care unit. According to the September 2024 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity without behavioral disturbances, major depressive disorder, anxiety disorder and unspecified convulsions. The 7/10/24 minimum data set (MDS) assessment documented Resident #22 had severe cognitive deficits with a brief interview for mental status (BIMS) score of six out of 15. Resident #22 did not have upper or lower extremity limitations in range of motion and did not use a mobility device. According the MDS assessment, Resident #22 had inattention thinking. She did not have physical or verbal behavioral symptoms directed at others or rejections of care. The resident did not have wandering behaviors. B. Record review The behavior care plan for Resident #22, initiated 8/1/23, documented Resident #22 called staff and residents derogatory names and was overprotective of her belongings and had caused a skin tear to another resident' s hand by yanking her phone from the resident. According to the care plan, Resident #22 tended to slap at people' s hands or arms when she did not like what the person was doing or if someone got too close to her. Resident #22' s care planned intervention added on 9/9/24,, after the resident to resident altercation, read Please move other residents away from me if I feel like they' re too close so that I do not hit or slap them. The abuse prevention care plan for Resident #22, revised on 7/15/24, documented Resident #22 had no known history of abuse or neglect. She was at risk for abuse and neglect due to her vulnerable status living in a nursing facility. According to the care plan, Resident #22 was not alert and oriented and may not be able to report abuse/neglect. Her short term goal was to remain safe and free from abuse. The abuse prevention intervention was for staff to complete an abuse prevention observation per facility protocol. The resident profile (a staff communication sheet) for Resident #22, initiated 9/9/24, was provided by the corporate consultant (CC) on 9/19/24 at 3:57 p.m. The resident profile directed staff to move other residents away from Resident #22 if Resident #22 felt they were too close so she did not hit or slap them. IV. Resident #23 A. Resident status Resident #23, age greater than 65, was readmitted on [DATE], with an initial admitted [DATE]. The resident resided in the secured memory care unit. According to the September 2024 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity with and without behavioral disturbances, major depressive disorder, vascular dementia with history of anxiety, and transient cerebral ischemic attack (reduced blood to the brain), unspecified. The 7/8/24 minimum data set (MDS) assessment documented Resident #23' s cognition was severely impaired with a staff assessment for mental status. According the MDS assessment, Resident #23 had short and long term memory problems. She had behaviors of inattention and disorganized thinking. Resident #23 did not have physical or verbal behavioral symptoms directed at others or rejections of care. Resident #23 did not have upper or lower extremity limitations in range of motion and did not use a mobility device. Resident #23 did not have upper or lower extremity limitations in range of motion and did not use a mobility device. The MDS assessment documented the resident wandered daily. B. Record review The abuse prevention care plan for Resident #23, revised on 7/8/24, documented Resident #23 had no known history of abuse or neglect. She was at risk for abuse and neglect due to her vulnerable status living in a nursing facility. According to the care plan, Resident #23 was not alert and oriented and may not be able to report abuse/neglect. Her short term goal was to remain safe and free from abuse. The abuse prevention intervention was for staff to complete an abuse prevention observation per facility protocol. The skin integrity care plan intervention for Resident #23, initiated 8/4/23, documented Resident #23 liked to pick up other residents' and staff things such as a cell phone and walk around with the items. The intervention directed staff to keep items that she should not pick up out of the common area or put away. According to the care plan intervention, Resident #23 did not always agree to return the picked up items. -Review of Resident #23' s care plan did not identify new care plan interventions put in place to prevent future resident to resident altercations after the 9/9/24 incident. The abuse reporting flow sheet identified a resident to resident altercation must be reported if the action was a willful act such as hitting or slapping and resulted in physical injury, mental anguish or pain. -The review of the investigation and Resident #23' s electronic medical record (EMR) did not identify concerns. Review of Resident #23' s EMR and progress notes between 9/10/24 and 9/17/24 for Resident #23 did not document or identify behavior monitoring that was put in place after the 9/9/24 resident to resident altercation, such as monitoring for fearfulness to determine a component of potential abuse. On 9/18/24 and 9/19/24 (during the survey period), the progress notes documented the resident was not showing signs of fear, retreating or nervousness. The resident profile for Resident #23, dated 9/19/24 (during the survey period and 10 days after the altercation), was provided by the CC on 9/19/24 at 4:35 p.m. The profile directed staff to give Resident #23 a piece of paper or other objects to keep in her hands so her hands were preoccupied in order to prevent her from touching other residents and their property. -The resident profile intervention for Resident #23 was created during the survey period and 10 days after the altercation (see interviews below). A 9/18/24 email to the nursing staff from the director of nursing (DON) was provided by the CC on 9/18/24 at 3:11 p.m. The email read This is a follow-up from the incident between Resident #23 and Resident 22 last week. Because trauma can appear at a later time, please monitor Resident #23 for emotional distress for 72 hours. CNAs please let the nurse know if you see any signs of distress such as fearfulness, retreating nervousness or any other behavioral change. nurses there' s an order to document this in the progress notes, thank you. -The email was provided to the nursing staff during the survey period and nine days after the resident to resident altercation. A 9/18/24 general order for Resident #23 was provided by the CC on 9/18/24 at 3:11 p.m. The order directed staff to document the resident' s behavior in progress notes every shift for three days and assess for any change in behavior such as fearfulness, retreating, nervousness or any other change in behavior. -The order was created on 9/18/24 at 2:40 p.m., during the survey period, and nine days after the resident to resident altercation. V. Staff interviews The social service director (SSD) was interviewed on 9/18/24 at 8:55 a.m. The SSD said the facility wanted to keep the residents safe and put measures in place to help ensure the residents feel safe. He said the interdisciplinary team (IDT) would identify risk factors that lead to potential abuse. He said his role in an abuse investigation was to interview the residents. He said if an incident of abuse or potential abuse occurred in the memory care unit he would interview 10% of the residents in the memory care unit. The SSD said he would ask the residents basic questions to determine if they felt they were safe. He said most residents with memory problems could still say if they felt safe or not. The SSD said the nursing management would interview the staff. He said behavior monitoring would be initiated by the nursing staff to help determine if there were changes in the behavior of a resident. He said if a resident was having cognitive or behavioral changes related to altercations, the facility would look at how their medications were affecting them, contact their physician and care plan accordingly. He said the facility may refer the concerns to a mental health specialist. The SSD said behavior monitoring was important because it could take time to process trauma and trauma could present differently for everyone. The NHA was interviewed on 9/18/24 at 11:07 a.m. The NHA said the provided abuse investigation file for Resident #22 and Resident #23 was what was completed for the investigation. She said the director of nursing (DON) might have additional information. The DON was interviewed on 9/18/24 at 1:24 p.m. The DON said she was the facility' s abuse coordinator. She said if there was an allegation or suspicion of potential abuse,, staff involved would be interviewed. She said staff who worked directly with the residents involved on both shifts would be interviewed. The DON said the staff would be asked if they were aware of any potential abuse, had seen abuse or had concerns for residents' safety. She said she would want to make sure staff were aware of the reporting protocol. She said the interviews would be documented and reviewed to help determine if there was abuse or suspicion of abuse. She said after the investigation she would write up an investigation summary. The DON said she would report an incident to the State Agency if abuse was determined. The DON said pain would be monitored and documented in progress notes and on a weekly pain assessment. She said if there was pain reported, it would be on the pain log. She said the facility would watch for mood and behavior changes such as fearful reactions. The DON said the monitoring would be in progress notes for 72 hours for consistency. She said if monitoring residents after an incident was not in the progress notes, it probably was not documented. The DON reviewed the EMRs for Resident #22 and Resident #23 and said there was not 72 hour documentation of behavior monitoring after the 9/9/24 incident, but she said she said nothing was reported as a change. The DON said she did not feel a more complete investigation was necessary because staff saw what happened. She said staff knew the way Resident #22 and Resident #23 were. The DON said it was normal behavior for both residents that resulted in the altercation. She said Resident #23 got in other residents' personal space and Resident #22 did not want others in her personal space. The DON said additional interviews were not completed because these were typical typical behaviors the residents exhibited. The DON said she did not feel there was more that could have been investigated. The DON said the facility ruled out the abuse concern because it was the residents' normal behavior and there was not a negative outcome and residents were separated at the time. She said the residents did not have pain, injury or psychological harm after the incident. The DON said the incident was communicated in staff huddles that were not documented. She said the staff were reminded to supervise Resident #22 and Resident #23 related to the incident and their normal behaviors. She said there was no no new intervention put in place put in place for Resident #23 because it was it was her usual behavior to reach for things and it and it was already care planned. She said there had been no other problems on any other . She said there had been no other problems on any other days except for 9/9/24. CNA #5 was interviewed on 9/18/24 at 2:05 p.m. CNA #5 said she had worked on the memory care unit for a few months. She said if there was a resident to resident altercation, she would redirect the residents away from each other and report the incident. She said she would tell the residents that the behavior was incorrect and encourage them to respond to each other in a more positive manner. CNA #5 said Resident #23 could get agitated when staff tried to help her get dressed but she was not aware of any problems or incidents with other residents. She said Resident #22 liked to have her own personal space. She said if a resident tried to take her or her family member' s napkin, she would try to hit their hand. She said Resident #23 got into other residents' personal space so staff tried to tell her to move on when she was in another resident' s personal space. She said nothing had been reported to her about an incident between Resident #23 and Resident #22. CNA #3 was interviewed on 9/18/24 at 2:13 p.m. CNA #3 said she witnessed Resident #22 hit the left hand of Resident #23. She said after the incident she redirected her not to get too close to Resident #22. She said she reminded Resident #22 that Resident #23 did not know what she was doing. She said she said she was not aware of other interventions other than talking to Resident #22 and reminding her that other residents were confused. The activity director (AD) was interviewed on 9/19/24 at 9:30 a.m. The AD said when Resident #22 was in the common area, other residents should not get too close to her or or reach for her items. The AD said to help prevent any problems, she would try to sit with Resident #22 Resident #22 in an activity or take her to other activities outside of the memory care unit. The AD said Resident #23 should not be near Resident #22 because she did not have an understanding of personal space. The AD said she was not aware of any resident to resident alterations between Resident #22 and Resident #23. She said usually found out about incidents in morning meetings and zoom communication. She said when there was an altercation, staff usually asked if activities staff were available to help redirect residents. The CC was interviewed on 9/19/24 at 4:33 p.m. The CC said she spoke to the memory care staff on the afternoon of 9/19/24 and learned Resident #23 liked to hold pieces of paper. She said the staff was looking into independent activities the resident could do with her hands to help deter her from trying to reach for other resident' s items. The CC said the intervention would be added to the care plan and the resident' s profile. The NHA was interviewed a second time on 9/19/24 at 4:33 p.m. The NHA said she was no longer the abuse coordinator but the facility should still be following the same abuse investigation process. The NHA said every morning, resident progress notes were reviewed to identify if any concerns were documented and needed to be addressed. She said if there were any allegations or concerns of potential abuse, the facility would interview everyone to figure out what happened. The NHA said the facility would look at the root cause using the five whys method to help determine what caused the incident. She said if lack of training was a factor, then the facility would set up the needed training. The NHA said when an investigation file was given to her, she needed to be able to see from the investigation what actually happened and what were the interventions to stop this from happening again. She said if a staff member was involved, the facility needed to provide them with education. The NHA said it was important to do those things to be able to rule out if it was abuse or not and to prevent it from happening again.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#26 and #29) of five residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to: -Conduct a thorough investigation was completed after an unwitnessed fall with injury for Resident #26; -Ensure appropriate and effective preventive fall measures and communication, were in place to prevent recurrence of a fall for Resident #26; and, -Investigate Resident #29's skin conditions and implement preventative measures. Findings include: I. Resident #26 A. Facility policy and procedure The Fall Assessment and Managing Fall Risk policy, last reviewed 10/17/22, was provided by the facility on 3/16/23. The policy identified procedures the facility should incorporate to manage the risk for falls. According to the policy, the facility should initiate appropriate interventions to minimize risk of falls and/or risk of injury from falls and include it in the resident's care plan. The policy identified the following steps if the resident fell : -An event form would be completed; -Each fall was to be investigated as soon as possible to determine what the resident was doing when the fall occurred and any contributing factors. -Interventions were updated in the care plan based on the review of the fall. -A fall event and associated documentation would be reviewed by the interdisciplinary team (IDT) the following day for appropriate interventions and the interdisciplinary team would make recommendations/changes as needed to the care plan. -Falls were tracked and analyzed and reported to the quality assessment performance improvement committee. -Staff nurses were responsible for making safety rounds throughout their shift to ensure compliance with safety devices as indicated on the residents plan of care. The fall prevention protocol, undated, was provided by the facility on 3/16/23 at 2:15 p.m. According to the protocol, every time there was a fall, the nurse would document what happened, what the resident was trying to do, and conduct a follow up assessment. B. Resident status Resident #26, age 71, admitted on [DATE]. He resided in the secured/memory care unit. According to the February 2023 observation detail report, diagnoses included unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance and anxiety, transient cerebral ischemic attack (stroke) and major depressive disorder. The 2/2/23 minimum data set (MDS) assessment identified Resident #26 had moderate cognitive impaired as indicated in the staff assessment for mental status. The resident exhibited short and long term memory loss. Resident #26 was independent with bed mobility, transferring, walking in her room, corridor and locomotion on the unit. The resident required limited assistance from one person with personal hygiene and dressing. She required supervision from one staff member with toileting. The MDS assessment did not identify the resident had a history of falls. C. Record review The falls care plan, initiated on 5/13/23, read Resident #26 was at risk for falls due to dementia, decreased mobility, generalized weakness, and her psychotropic medication use. The fall interventions, last initiated on 5/13/23, read staff were to encourage the resident to wear gripper socks or shoes when she was up; monitor for side effects from psychotropic medication use; place her bed by wall; and observed for changes in gait, steadiness, mobility, judgment and coordination and notify the resident's physician/nurse practitioner/physician assistant, with concerns as indicated. -The care plan did not identify the resident had a recent fall as indicated in the below records. -The care plan did not identify new interventions after the resident fell to prevent the recurrence of the fall with injury. The review of the progress notes prior to the below 2/6/23 nursing note and notes on 2/6/23, did not identify a change in the resident's condition on and before 2/6/23. According to the 2/2/23 social service note, the resident had not exhibited any mood or behavior changes and she was active and friendly. Progress notes on 2/4/23, 2/5/23, and 2/6/23 identified the resident was negative for COVID. The 2/6/23 life enrichment note read the resident continued to enjoy dancing and going for walks. The 2/6/23 nursing note read on 2/6/23 at 7:15 a.m. Resident #26 was found in her bed with blood on her sleeve and pillow. The resident's lower lip was bleeding, swollen and had an abrasion to the lower lip. The wound/abrasion measured 0.2 centimeters (cm) by 0.2 cm. According to the note, the resident denied any incident or fall and she continued to be her usual active self around the unit. -The nursing note did not identify who found the resident, or when the resident was last seen without injury and what she was doing. The note did not identify the resident had low energy levels as identified in the below stand up tool as a potential factor of the fall. The 2/6/23 wound management assessment was initiated. The wound was identified to be on the resident's left lower lip. According to the assessment the wound was identified at 7:45 p.m. The 2/6/23 nurse practitioner (NP) note read Resident #26 was seen by the for follow up on her lower lip swelling with a laceration. The NP noted the resident was found this morning (2/6/23) in bed with blood on her pillowcase and bed sheets. There were no other cuts or bruises on her skin. According to the NP note, Resident #16 reported pain in lower lip but was unable to recall if she fell , hit her lip on something, or what caused her injury. The 2/7/26 morning stand-up tool was provided by the facility on 3/16/23. The stand up tool identified the resident had abrasion and swelling to her left lower lip. The stand up tool read the interdisciplinary team (IDT) reviewed a change of condition for Resident #26. The tool read: COVID testing due to an outbreak. Low energy levels and 'not herself. ' Concluded unwitnessed fall. -The morning stand up tool did not provide additional investigative information related to the unwitnessed fall such as; when the fall occurred; when was the resident last seen without injury to determine time frame; what was she wearing on her feet when she was found in bed; was she incontinent at the time she was found; how the injury was determined to be caused by the fall; what environmental factors did the IDT looked at; and, how to prevent the fall from reoccurring based on investigative findings. The 2/8/23 nursing note read the swelling to Resident #26's lips were improving and bacitracin (antibiotic) was applied. According to the note, the resident complained of pain when applying the bacitracin and refused to keep ice on her lips. The 2/15/23 wound management assessment for Resident #26's lip was black and red in color. The wound measured 0.4 cm by 0.4 cm. According to the assessment, swelling has decreased and there was no drainage noted and no evidence of an infection. The wound was resolving well and improving. The 2/23/23 wound management assessment for Resident #26's lip was black in color. The wound measured 0.2 cm by 0.2 cm. According to the assessment, swelling has decreased and there was no drainage noted and no evidence of an infection. The wound was resolving well and improving. The 2/14/23 psychotropic pharmacy meeting note read Resident #26 identified the resident had a recent fall. -The psychotropic meeting note did not identify when the resident fell . The review of the record did identify additional details of the unwitnessed fall including an event form or other investigative tools/assessments/notes used to identify pertaining details, factors and measures taken immediately after the fall. D. Staff interview The director of nursing (DON) was interviewed on 3/15/23 at 9:31 p.m. She said after a resident fell , staff would initiate a huddle to identify the root cause of the fall and implement immediate interventions. The DON said a fall event report would be completed. She said the IDT would meet the following morning and review the fall. The DON they would discuss any changes to the care plan and add interventions. She said the care plan was one of the main communication sources for staff as a resident care directive and therefore she said she trained staff to look at the care plan. The DON said injuries would also be investigated to identify what occurred and how to prevent it from happening again. The DON was interviewed on 3/15/23 at 10:46 a.m. she said the facility did not have any investigations pertaining to injuries of unknown origin for Resident #26 and she had not had any falls. The DON was interviewed with the corporate consultant (CC) on 03/16/23 at 1:59 p.m. The DON said staff had noticed a change in condition. She was showing an increase in weakness and lethargy. On 2/7/23 the IDT met (as identified on the morning standup tool) and discussed the resident's change in condition. She said the resident most likely had a fall trying to get out of bed and the resident had recently had weakness potentially impacting her ambulation. She acknowledged the resident was found in her bed and not on the floor. The DON identified a fall event form was not done. The DON said staff working on the overnight shift did not see the resident wandering or anyone else wandering in her room. She said the nights were pretty quiet and staff would have been at the nurse's station and would do two hour rounding. The DON said she did not know when Resident #26 was last observed by staff prior to finding her in bed with an injury to her lip. The DON said the room was looked at and they did find any environmental factors that could cause the injury to her lip and was not blood on the hard surfaces on the bed. She said they determined the injuries were a result of the fall. The CC said the facility missed the storytelling in the documentation related to the facility's findings and conclusion to the unwitnessed fall. The DON said she felt the facility did their due diligence to identify the fall but did not have the supporting documentation. The CC said the nurse should have opened an event when the injuries were identified. The CC said they could not show a thorough job was done in relation to the unwitnessed fall. 47351 II. Resident #29 A. Resident status Resident #29, age 94, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included pneumonia, acute on chronic respiratory failure, metabolic encephalopathy, obstructive/reflux uropathy, and presence of foley catheter. According to the 1/16/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment, memory problems, and an inability to complete a brief interview for mental status (BIMS) score. The resident required extensive assistance for bed mobility, transfers, toileting, and personal hygiene. B. Wound observation Wound observations were conducted on 3/16/23 at 3:15 p.m. in the presence of the medical director. Four skin tears were observed on the residents left forearm, left shin/calf, right forearm, and right anterior wrist. A bruise on the right shin was also observed at 1.5 inches below the right knee to one inch above the right ankle. C. Resident representative The resident's representative was interviewed 3/13/23 at 1:49 a.m. He stated he did not know how the swollen red area on the right anterior wrist happened, only that she was taking antibiotics for it. He asked a staff member what occurred but the staff person did not know. D. Record review The comprehensive plan of care, initiated on 2/10/23 and revised on 2/22/23, identified the potential for alteration in skin integrity related to overall Braden scale score of 15. The CPO on 3/14/23 revealed an order to apply steri-strips to the resident's left forearm skin tear. According to the electronic and paper records of skin condition from 1/10/23 to 3/16/23, the resident had a total of seven skin altercations. The resident was admitted to the facility with a pressure ulcer to the left heel and bruising to the right shin. The investigation regarding the skin conditions identified in the observation (see above) were requested from the wound care nurse on 3/16/23. In response, received an interdisciplinary team (IDT) morning report dated 2/25/23 that did not address the left forearm skin tear. Rather it documented the right arm bruise was in alignment with possible hoyer (mechanical) lift bump into sling or lift surfaces. E. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 9:16 a.m. RN #2 stated the resident's dressing change occurred late evening with a shower and/or before bedtime. RN #2 said the right forearm skin tear occurred while transferring the resident from bed to lift when the sling caught the resident's arm causing the skin to tear. Certified nurse assistant (CNA) #3 was interviewed on 3/16/23 at 10:24 a.m. CNA #3 reported the resident received a shower yesterday and was transferred by hoyer lift with support of RN #2 and licensed practical nurse (LPN) #2. CNA #3 said LPN #2 did a skin assessment after the resident was showered and noticed bruising to the right shin. CNA #3 reported the resident was tall and bruising may have occurred with lifting since the resident's skin was fragile. The wound care nurse (WCN) was interviewed on 3/16/23 at 1:25 a.m. The WCN stated the left lower arm skin tear occurred on 3/12/23 while RN #2 transferred the resident using the lift and the sling strap rubbed against the resident's left arm resulting in a 0.6 x 0.6 skin tear. The skin tear did bleed and was cleaned and covered with a dressing. The wound care nurse reported she did receive an email about the event. The WCN said she was unaware of the wound on the right forearm. The WCN stated the resident crossed her left leg over the right leg and may have caused the bruising to the right shin. She said there was no investigation completed on the right shin bruising due to the bruising was present on admission.

Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for two (#16 and #18) of five residents reviewed for dementia care out of 19 sample residents. Specifically, the facility failed to: -Ensure Resident #16 was provided meal assistance with dignity and opportunity to achieve her highest level independence as possible with appropriate staff support; and, -Ensure Resident #18 was provided opportunities for meal assistance on 3/14/23 to promote meal intake. Findings included: I. Facility standards The Food and Nutrition Services policy, last reviewed on 1/16/23, read in pertinent part: Individuals will be provided with nourishing, palatable, attractive meals that meet daily and special nutritional needs. Individuals will be provided with services to maintain or improve eating skills. The dining experience will enhance the individual's quality of life and be supportive of the individual's needs during dining. According to the policy staff would assist residents as needed to assure adequate intake of food and fluids at the time of meals. The residents would be assisted promptly and in a timely manner after the meal arrives. The Dignity, Customer Delivery and Respect education was conducted on 3/15/23 and 3/16/23 with staff, was provided by the facility on 3/16/23. The following reminders were provided to staff: It is important to have a positive attitude when we are serving residents. They can tell when we are upset, angry or withdrawn as they read that as ' attitude ' ; not wanting to help them ect: and it makes them sad. We are all humans, but when we come to work, kindly try to wear a smile on your face and support the residents. Speak and smile with your eyes. Always, ask (the) resident if they need help with anything else at the time of each care task, that way they do not call you back or feel you are abrupt with them. II. Resident #16 A. Resident status Resident #16, age 81, was admitted on [DATE]. The resident resided in the secured memory care unit. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, and muscle weakness. The 2/14/23 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for a mental status. The resident had short term and long term memory loss. The assessment did not identify the resident had inattention or disoriented thinking. According to the MDS assessment, Resident #16 required extensive physical assistance from one person with bed mobility, transferring, locomotion on and off the unit, dressing, toileting and personal hygiene. The MDS assessment identified Resident #16 required limited assistance from one person with eating. The MDS assessment indicated Resident #16 was highly involved in the activity and staff were to provide guided maneuvering of her limbs (arms/hands) or other non-weight bearing activities. B. Observation Observations on memory care unit during meal service were conducted on 3/13/23, between 5:10 p.m. and 5:30 p.m. Between 5:20 p.m. and 5:22 p.m. Certified nurse aide (CNA) #1 was observed standing next to Resident #16. The CNA placed three bites of the dinner meal in the mouth of Resident #16 while she stood on the right side of Resident #16. She did not sit down to assist the resident or face the resident. Observations on memory care unit during meal service were conducted on 3/14/23, between 5:05 p.m. and 5:51 p.m. Residents were served their dinner meal at 5:12 p.m. Between 5:21 p.m. and 5:51 p.m. CNA #1 was observed providing one-on-one meal service with Resident #16. CNA #1 placed a fork in the hand of Resident #16. The CNA guided her hand with the fork to the resident ' s mouth. The resident took a couple of bites. The CNA took the fork out of the resident ' s hand and handed her a spoon. The resident did not take the spoon. The resident put her hand on her plate, she placed the pasta in mouth with her hand. CNA #1 said to the resident Don ' t grab your food like that. The resident was observed chewing her food when the CNA attempted serve Resident #16 another bite while the resident was still chewing. Resident #16 backed her head away from the spoon by her mouth. The resident continued to chew as CNA #1 attempted to give her a sip of juice from her lidded cup. She told Resident #16 Come on, take a sip of juice. The CNA placed the cup spout into the resident's mouth, holding it for a few seconds. Resident #1 attempted to reach the cup with her left hand but then pulled her head back to stop drinking. -At 5:41 p.m. the resident attempted to eat her meal without utensils. CNA #1 place the spoon again in the resident hand. The resident had difficulty self guiding her spoon to her mouth. CNA #1 said to the resident, Come put it in your mouth. The resident attempted again but as the spoon was midway to her mouth, the CNA placed the cup to the resident ' s lips to take another sip. The resident set the spoon down and the CNA proceeded to feed the resident without offering to place the spoon in the resident ' s hand again or offer guided hand assistance. For the remainder of the meal observation, CNA #1 continued to provide total meal assistance for the resident. CNA #1 frequently placed the spoon in the resident ' s mouth while the resident was still chewing the previous bite. -At 5:47 p.m. the resident refused to take another bite as she continued to chew her previous bite. The CNA told the resident to take a drink while the resident was still chewing her food. The CNA placed the cup to the resident ' s mouth and said You ready, no, why, alright take a drink, come on take a drink. The resident took a sip of the juice and the CNA continued to assist the resident. On 3/15/23 at 12:15 p.m. Resident #16 was served a hamburger on a bun cut in quarters. -At 12:19 p.m. CNA #7 asked the resident if was going to try her burger. The resident asked the CNA what the food was. The CNA placed the cut hamburger in the resident ' s hand. Resident #16 placed the hamburger back down on the plate. -At 12:26 p.m. the resident picked up the hamburger patty and proceeded to independently eat several bites of it. Between 12:26 p.m. and 1:14 p.m. Resident #16 continued to independently feed herself by eating each cut section of the bun and patty. She took small bites and allowed herself time to chew her food before taking another bite. -At 1:02 p.m. another staff member attempted to collect the resident ' s plate. CNA #7 told the another staff that Resident #16 was still eating and to leave the plate. -At 1:14 p.m. the observation of the meal service concluded as Resident #16 continued to eat her meal at her own pace. Resident #16 was observed during the dinner meal on 3/15/23. The resident was provided her dinner at 5:19 p.m. CNA #5 was observed providing meal assistance to the resident. -At 5:26 p.m. Resident #16 pushed her plate away from her. The activity director (AD) observed and place the meal back in front of Resident #16. On the direction of the AD, CNA #5 sat in the chair in between Resident #16 and another resident. Between 5:26 p.m. and 5:32 p.m. CNA #5 ' s back was toward Resident #16 with knees and feet facing the other resident. The CNA turned her shoulder, reached back and picked up Resident #16 ' s fork and quickly placed the fork in Resident #16 ' s mouth. Resident#16 pulled back in surprise. The CNA turned back around to directly face the other resident again. No additional guidance was given to Resident #16. -At 5:32 p.m. Resident #16 began to wipe the table with her napkin and did not focus on her meal. No staff offered her guidance or assistance with her meal. CNA #5 ' s back was toward the resident. -At 5:35 p.m. CNA #5 turned slightly around, reaching behind herself, picked up the fork upside down and placed the fork in the resident ' s mouth. -At 5:36 p.m. the CNA used the same motion to assist the resident again with another bite. C. Record review The CPO, initiated on 10/21/21, identified memory care was required due to dementia with behavioral disturbances and history of fall with pathological fracture secondary to osteoporosis. According to the CPO, Resident #16 was unable to safely care for herself. The nutrition care plan, initiated 5/17/18, read Resident #16 had a declining cognition and activities of daily living (ADLs) as evidenced by the need for a secured unit for safety. Interventions included one on one assistance with all meals to prevent aspiration and choking. According to the care plan, the resident needed verbal cueing, and at times, physical assistance. The cognition care plan, read Resident #16 had potential/actual alteration in her cognition due to her dementia. According to the care plan, staff should provide her with reminders, reorientation, and cues as needed. Staff should provide a calm consistent routine for the resident when providing care. III. Resident #18 A. Resident status Resident #18, age 89, was admitted on [DATE]. The resident resided in the secured memory care unit. According to the March 2023 CPO, diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type two diabetes mellitus with other specified complications. The 12/6/22 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for a mental status. The resident had short term and long term memory loss. The assessment did not identify the resident had inattention or disoriented thinking. According to the MDS assessment, Resident #18 required extensive physical assistance from one person with bed mobility, transferring, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS assessment identified Resident #18 supervision from one person with eating. The MDS assessment identified Resident #18 required oversight, encouragement and cueing with eating. B. Observation Observations during the meal service for Resident #18 were conducted on 3/13/23, 3/14/23, and 3/15/23 during the dinner meal, and on 3/15/23 during the lunch meal. Three out four of the meals, the resident was provided with a combination of guided and total meal assistance from staff members providing one to one assistance. The resident was not provided meal assistance during the dinner meal on 3/14/23. On 3/14/23 at 5:12 p.m. residents were served their meals. Staff sat next to residents and proceeded to provide meal assistance. No staff sat next to Resident #18. -At 5:35 p.m. Resident #18 remained sitting in front of her meal. There were no bites taken off her plate. Her head was down and her eyes were closed. Staff did not attempt to arouse her or encourage her to eat. They did not offer her assistance. -At 5:45 p.m. the resident lifted her head up. Staff did not attempt to encourage and offer her assistance. -At 5:51 p.m. the resident ' s head was down with her plate of food still in front of her. The resident was not offered assistance to eat her meal. The staff did not offer the resident another meal option if she did not want to eat her provided meal. Staff did not offer to lay down the resident if she was too tired to eat. C. Record review The nutritional care plan, initiated on 9/8/22, read the resident had a low body mass index (BMI) and may benefit from cueing. The cognition care plan, initiated on 9/9/22, read the resident had actual alteration in cognition related to diagnosis of dementia. She displayed confusion/disorientation and has difficulties maintaining focus. According to the care plan, staff should use cueing and redirection for assisting the resident to maintain her highest level of cognitive function. IV. Staff interview CNA #7 was interviewed on 3/15/23 at 12:58 p.m. She said Resident #18 needed assistance with her meals. She said sometimes Resident #18 did not like the food offered so they needed to offer her other choices of food that she might like, but staff needed to encourage and assist her to eat. CNA #8 was interviewed on 3/15/23 at 1:06 p.m. He said Resident #16 usually just needed encouragement and cueing related to some confusion. He said she usually did not need feeding assistance. The CNA said she tended to eat more after everyone else was finished with their meal. He said it was all about her pace of eating. The CNA said she could use utensils but finger foods seem to work best for her. CNA #8 said staff would usually only feed her if she was struggling with the utensils. He said Resident #16 mainly needed time to eat and allow her to go at her pace. The registered dietitian (RD) was interviewed on 3/16/23 at 9:41 a.m. She said Resident #16 could usually feed herself if she was placed correctly at a table, set her up with her condiments, and had her hamburger cut in quarters. The RD said she has most often observed Resident #16 eat hamburgers. She said if Resident #16 was provided a meal that required a utensil, staff may need to place the food on the fork and place it in her hand as one as one assistance but she could usually feed herself. She said if Resident #16 needed more meal assistance such as total meal assistance by placing the food in her mouth, staff should be sitting next to her, not standing next to her. The RD said she has had to provide on the spot education with staff because she had also observed them standing during meal assistance on occasion. The RD said staff should first provide the resident cueing and then if needed hand over hand guided assistance with a utensil before they attempted to totally feed her. The RD said Resident #16 usually needed cognitive cueing to get her started with her meal. The RD said Resident #16 gets her meals served cut up but she could look into if the resident was appropriate for more finger foods to help with Resident #16 ' s independence. The RD said staff should provide her with time to eat her meal and allow her to do one task at a time. She said a lot of tasks at one time when eating, could be overwhelming for Resident #16 and add to her confusion. She said staff needed to give her time to chew, allow her to go at her pace and avoid any potential choking risks. She said the speech therapist has also posted signs to remind staff on cueing and pacing needs. The RD said she would observe a dinner meal in the near future with Resident #16. She said would look if staff needed continued training with cueing, meal task sequencing, and pacing during meals. The RD said Resident #18 has had some weight fluctuations but there had not been any significant weight loss for her. She said Resident #18 has had a decline in meal intake but was maintaining her weight though snacks and a dietary supplement. The RD said she has been focusing on food preferences for Resident #18. The RD said staff should provide the resident one to one set up, ongoing cueing and assistance as needed. The RD said staff should try to arouse her if she dozed off during a meal and cue her to help stay alert. The RD said most of the staff training would need to come from nursing for their staff and she would do on the spot training when she saw concerns. She said the training focus could include cueing, pacing, attempting to wake. The director of nursing (DON) was interviewed with the corporate consultant (CC) on 3/16/23 at 3:17 p.m. The CC with the DON said the goal for residents with eating was for them to be as independent as possible. The staff should start with cueing and prompting, as then as needed place finger foods or utensils in their hand and guide them to their mouth with hand over hand assist. The CC said staff try to encourage Resident #18 to do as much as she can for herself but she still needed to have some sit with her and encourage her to eat. She said Resident #18 takes a while to eat. They said the staff should try to keep encouraging residents to eat during meals. They said staff should have attempted to wake or have her lay down if she was too tired. The CC and the DON said the facility trained staff to provide meal assistance with dignity. The DON said Resident #16 was variable in her meal assistance needs and needed encouragement to take her time. Staff should have her take a sip and take a bite alternating. Staff should also be properly facing the resident during meal assistance. The DON said they have ongoing training with staff. She said she would remind staff to slow down and not stand during meal assistance. She said she would also speak to CNA #1 about her choice in words such as come on during meals. She said every resident was different with different needs and they were going to follow the best practice for each resident. The DON and nursing home administrator (NHA) was interviewed on 3/16/23 at 5:32 p.m. The DON said the facility would be having a skills day at the end of March 2023. She said the hands-on training would include dining assistance. She said she would continue to revisit dignity through staff conversations. The NHA said the facility would continue to conduct facility wide audits and if concerns were identified, would do on the spot training.

Based on observations, record review and interview, the facility failed to ensure a resident with mental and psychosocial adjustment, received appropriate treatment to attain the highest practicable mental and psychosocial well-being for one (#26) of two residents reviewed for mood and behavior out of 20 sample residents. Resident #26 expressed a preference not to have male caregivers providing activites of daily living (ADL) care. A request of the Resident #26's preference not to have male caregivers was documented on 7/31/21. Resident #26 required two assistance for most of her ADLs. Two CNAs for both the day and night were scheduled on the unit where the resident resided. The review of the schedule between August 2021 and 11/30/21 identified at least one male staff member, on at least one shift, was scheduled to work with the resident on almost a daily basis. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Between 7/11/21 and 11/30/21, the resident had documented seven incidents of verbal or physical aggression with and yelling/screaming (combative behavior) towards her caregivers. Of those seven incidents, the resident had six incidents that occurred when a male caregiver (registered nurse or certified nurse aide) was scheduled and or provided assistance with ADL care. According to both interviews and progress notes, the resident often directed her aggression towards the male caregiver. Cross-reference to F609 failure to report abuse, and F610 failure to investigate abuse. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, dated 5/31/19, was provided by the facility on 12/2/21. The policy read in pertinent part: (Named corporation) recognizes the resident's right to a quality of life that supports privacy, confidentiality, independent expression, choice, and decision making consistent with the State law and Federal regulations. (Named corporation) recognizes the resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside of the facility II. Resident #26 status Resident #26, age 84, was admitted on [DATE], with an initial admitted [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/18/21 minimum data set (MDS) assessment documented Resident #26 had severe cognitive deficits with a brief interview for mental status (BIMS) score of five out of 15. According the MDS, Resident #9 did not have inattention, or disorganized thinking. The MDS identified under [CONDITION(S)], revealed the resident had both hallucinations and delusions. The MDS did not indicate the resident had verbal, physical behaviors directed at others during the MDS look back period, however, she did exhibit other behavioral symptoms not directed at others. The MDS revealed her behavioral symptoms put her at risk for significant illness or injury and significantly interfered with her care. The MDS indicated rejections of care. Resident #26 required extensive assistance of two or more staff for bed mobility, transfers, dressing, and toileting. She requires extensive assistance from one staff member for personal hygiene and locomotion on and off the unit. The resident required supervision of one staff member. III. Resident interview Resident #26 was interviewed on 11/29/21 at 2:46 p.m. Resident #26 said she did not want to have male staff work with her. The resident said males urinate on her. She said she was not afraid of them but if she had a weapon, she would kill them. She said she did not like to talk about it but tells the female staff who were nice to her. IV. Staff interviews On 11/29/21 at 3:02 p.m. the nursing home administrator (NHA) was informed of statements made by Resident #26 on 11/29/21 at 2:46 p.m. The NHA said she was not aware of the resident expressing similar concerns with staff or any one urinating on her. The NHA said the resident had hallucinations. Certified nurse aide (CNA) #2 was interviewed on 12/1/21 at 9:37 a.m. CNA #2 said Resident #26 had combative behavior but has only seen combative behavior with the resident when she was working with male staff. CNA #2 said Resident #26 had told her she did not want male caregivers. The CNA said she had reported the resident's concern to the nurse and was told they were working on it. CNA #2 said it was tough with staffing because there were sometimes only male CNAs working at night. CNA #6 was interviewed on 12/1/21 at 10:14 a.m. The CNA said Resident #26 could be crabby and feisty in the morning. The CNA said the resident did not like male CNAs. She said she had seen the resident at night verbally aggressive towards the male CNAs. She said she swears, and yells out rape. She said she had not reported because the nurses had heard it too. CNA #6 said just how she gets sometimes when a male CNA was working with her. When it is just me, she is fine. The social service director (SSD) was interviewed on 12/1/21 at 10:27 a.m. She said if a resident expresses fear she would advocate for them and forward the concern to the appropriate department head. She said she would follow up with the Resident #26 and make sure staff were working on the resident's concern. The SSD said Resident #26 had not expressed to her that she was afraid of any person. She said Resident #26 had told her a male doctor was on her ceiling but she did not express fear. The SSD said she tried to redirect her and offer active listening. The SSD said she had been aware of Resident #26's preference to only have female staff for the past couple of years. She said she had reminded the staff, including the DON, that the resident should only have female caregivers or another person in the room with her during care. The SSD said the resident had not had changes in her behavior. She said the resident could be combative with care. She said the resident did not like to be changed or showered. The SSD said she has not identified patterns in the resident's behavior, it was based on if Resident #26 was in a good mood or if she did not want to do something. The SSD said if the resident did not want to get changed or showered, staff should reproach with a different caregiver. She said the resident could also be offered coke or chocolate but that would be difficult when she received activities of daily living care (ADLs). She said she responded to some staff more than others. She said she did better when staff could get her out of her delusionary state. The SSD said the resident's son said the resident was a loner and her independence was important to her. She said the son was not aware of any past trauma history. The SSD said maybe the resident felt invaded. She said she was not aware the resident was yelling rape until recently during a dicussion with the NHA and the nurse manager. She said she interviewed staff and residents during an abuse investigation. The SSD said she would advocate more for the resident to help meet her preferences of who takes care of her. The SSD said, CNA #9 said, he did not know why Resident #26 hated him. He said the resident had hit him in the stomach in August 2021. He said he reported it to his supervisor and was told not to work with her. The nurse manager (NM) was interviewed on 12/1/21 at 2:36 p.m. The NM said she was the facility's former director of nursing (DON). The NM said she was aware of Resident #26's combative behavior. She said of the past six to eight months, the behaviors had become more frequent. She said she contributed the change in behaviors to be associated with the decrease in her son's visits and staff changes. The NM said behaviors were tracked on the medication administration and treatment administration record (MAR and TAR) if the resident was on an associated medication. She said Resident #26 did not receive psychiatric medications so her behaviors would be charted in the progress notes by exception. She said the resident had ups and downs based on mood and staff. The NM said the resident had always had hallucinations. She said last Spring 2021 was the last time she heard Resident #26 express a concern with male staff. She said no changes were made to the staff schedule at that time. The DON was interviewed on 12/1/21 at 2:53 p.m. She said some days Resident #26 did not like male CNAs, some days she did not like female CNAs. The DON said she was not aware of the resident's preference to not work with male CNAs. She said she would have changed the schedule so the resident did not have fear. She said moving forward, the staff schedule would be changed for the resident to not have male caregivers. The SSD was interviewed again on 12/2/21 at 9:34 a.m. She said Resident #26 had hallucinations but her delusions have been only during care, which created the fear. She said the resident's provider was aware. She said staff had now been instructed to leave the room if she was yelling and reproach with potentially different caregivers. She said staff should provide a thorough explanation to the resident of what and how they were going to provide care with her. She said only during care, the male caregivers seem to bother her. The SSD said she helped ensure resident rights were protected. She said she was not aware of the resident's documented preference on 7/31/21 that she did not want male caregivers (see progress notes below). The SSD said staff did not always communicate concerns with her as they should. The SSD said she would make it a new habit to review all residents' progress notes daily. The SSD said she would speak to the nurse practitioner (NP) about outside psychiatric and or behavioral health counseling/therapy services. The NP was interviewed 12/2/21 at 11:11 a.m. The NP said she met with the resident on 12/2/21. The resident refused the exam with the NP, stating it would be more touching. She said the resident was offered therapy/counseling but refused. She said the resident was offered psychiatric services early in her year but she refused. She said she would make the referral again for a psychiatric evaluation and contact her son. CNA #4 was interviewed on 12/2/21 at 12:45 p.m. He said he last worked with Resident #26 on 11/28/21. He said she used slurs towards him. He had been off work for a couple of days and returned on 12/2/21. He said she was informed on 12/2/21 when he started his shift, not to work with Resident #26. V. Record review A. Daily staff schedule The August 2021 staff schedule identified 26 days out of 31 days, a male CNA was assigned to her unit. The September 2021 staff schedule identified 26 days out of 30 days, a male CNA was assigned to her unit. The October 2021 staff schedule identified 27 days out of 31 days, a male CNA was assigned to her unit. The November 2021 staff schedule identified 17 days out of 30 days, a male CNA was assigned to her unit. B. Care plan The mood and behavior care plan, initiated 5/8/18, revised on 11/30/21, indicated Resident #9 had an actual/potential alteration in behavior related to living in long term care (LTC) and being away from her support system. The care plan indicated the resident also had actual/potential alteration in her psychosocial well-being due to not wanting to be in LTC and wanted to return to her home in California. The care plan identified Resident #9 resisted cares, hit, scratched staff and called staff names during cares. She had visual hallucinations that were not disturbing to her according to the care plan. The care plan also indicated she made false accusations regarding males doing inappropriate things to her and prejudice towards people of color. Her short term care plan read the resident would accept redirection as needed and would not exhibit an increase in behavioral symptoms in the next 90 days. According to the care plan she would demonstrate cooperation and compliance. Interventions included: -The intervention initiated on 5/8/18 read to monitor for behaviors such as resisting care. -The intervention initiated on 5/8/18 read to provide her with opportunities to express my feelings; offer emotional support and listening. Refer to outside resources as needed such as counseling. -The intervention initiated on 7/11/21 directed staff to assign regular caregivers as able. -The intervention initiated on 7/11/21 read to record changes in behavior and notify the provider as needed. -The intervention initiated on 7/11/21 read to refer to a psychologist/psychiatrist as appropriate. -The intervention initiated on 7/14/21 read when the resident became aggressive, make sure she was safe, leave the room and return later. -The intervention initiated on 7/22/21 directed staff not to argue with the resident. -The intervention initiated on 11/29/21 (during survey) read Resident #26 prefers male caregivers. (Clarified with the DON as an error. She said the care plan should have read the resident preferred female caregivers and she would correct the error.) -The intervention initiated on 11/30/2021 two staff with personal cares d/t (due too) accusations and hallucinations/delusions -The intervention initiated on 11/30/21 directed staff to explain all cares to the resident prior to performing, especially incontinent cares. The psychosocial care plan, initiated on 3/13/21, directed staff to provide support and allow the resident to express her feelings, fears, and concerns. C. Progress notes Between 7/11/21 and 11/30/21, the resident had documented seven incidents of verbal or physical aggression with and yelling/screaming towards her caregivers. Of those seven incidents, the resident had six incidents that occurred when a male caregiver was scheduled and or provided assistance with ADL. According to both interviews and progress notes, the resident often directed her aggression towards the male caregiver. The nursing progress note on 7/11/21 read the registered nurse (RN) assisted the CNA in cleaning and changing Resident #26. According to the note, The resident was very aggressive, hitting the RN (male) and the CNA. The resident was screaming and yelling help. The note indicated they attempted to calm her down and reassure her that they were trying to help her get clean. The note identified the resident calmed down after she was completely cleaned and changed. No injuries were noted. The nursing progress note on 7/31/21 read when the CNAs were attempting to give Resident #26 a bed-bath, the resident became verbally and physically aggressive towards male CNA. According to the note, the male CNA was repositioning the resident to prevent her from falling over the edge of the bed when the resident used a closed fist and forcefully struck the male CNA in the center of his chest with a back-handed swing. The male CNA left the room. The note identified Resident #26 remained emotionally upset, continuing to yell That stupid man, no men should be changing a woman. The resident stated she was only comfortable with female caregivers. She calmed down and the volume of her voice returned to normal level and pattern. The 8/3/21 social service progress note read during a routine safety audit, Resident #26 reported she did not feel safe at the facility. Staff asked her why and the resident said Her thinking. When asked what they could do as staff to make her feel safe? She responded they could move her to her home in California. The nursing progress note on 8/6/21 11:19 p.m. read Resident #26 was combative during peri cares. According to the note, the resident swore and swung at staff and attempted to bite the CNA. The staff completed the care and the resident went to sleep. The behavior progress note on 9/28/21 at 9:40 p.m. read the resident scratched the CNA and was yelling and screaming during a shower. The resident was cleaned, changed and assisted to bed. The note indicated she was calm after care. The behavior progress note on 10/19/21 at 5:50 a.m read at 10:00 p.m. (10/18/21), Resident #26 was yelling and swearing at one of the CNAs while the resident was getting changed. During the morning rounds (10/19/21), Resident #26 started to yell and hit the CNA while she was getting changed. The provider was notified via the communication log. The nursing progress note on 10/19/21 read a CNA reported to the nurse at approximately 9:30 p.m. a bruise to the right arm of Resident #29. The nurse assessed and confirmed the bruise. According to the progress note, the resident stated a male doctor caused the bruise. (Cross-references F610 fail to conduct a thorough and timely investigation.) The 11/20/21 at 2:28 a.m. combative behavior note read Resident #26 was in the process of being changed by the CNA when she started to yell. LPN #3 attempted to assist the CNA but the resident was upset at male CNA stating that he touched her inappropriately. Resident #23 was screaming, cursing and scratching at the male CNA. LPN #3 was able to calm the resident down by removing the male CNA from the room and having the female CNA assist in performing peri-care. The resident was apologized to and the resident was content by the end of the conversation. (Cross-references F610 fail to conduct a thorough and timely investigation.) The nursing note on 11/20/2021 at 11:51 a.m. read Resident #26 agreed to her bath due to urine getting on the sheets, she then voiced that she was not happy with the care here. The resident completed the shower and insisted on getting out as soon as possible. Resident #26 agreed CNA #9 could assist. According to the nursing note CNA #9 assisted with the Hoyer lift only and tried to stay out of the resident's vision. According to the note, the resident saw CNA #9 and became angry and threw the wash cloth. D. Facility follow-up The NP note on 11/30/21 read Resident #26 was seen on 11/30/21 in follow up to her request not to have male aides in her room. According to the note, the resident was unable to tell the NP if there was a particular incident that happened with male aides at the facility. The resident stated, No more male aides in my room, they are so much stronger than us. The note indicated the resident's son said the resident had been having increased visual and auditory hallucinations when he visited. The plan indicated by the NP was to not have male CNAs work with Resident #26. The NP assured the facility would only use female aides to provide care for her. The NP note read the resident was unable to provide details why she did not want male CNAs however, her statement alluded to perhaps experiencing an incident in the past with a male, and therefore not wanting males CNAs in her room in general. According to the NP note the resident's statement of no more male aides in her room, they are much stronger than us was reported and is being investigated. The NP indicated the resident was having increased hallucinations and requested hallucinations added to her diagnoses.

Based on interviews, observations, and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one (#20) of two residents reviewed for nutrition status services of 20 sample residents. Specifically, the facility failed to ensure Resident #20 had interventions in place to prevent significant weight loss. Resident #20 experienced significant weight loss of 11.34% within a two month time frame, which was considered significant weight loss. The registered dietitian (RD) had a history with the resident as she had been previously admitted in April 2021, where she experienced a 10 lb (pound) weight loss in seven months. The facility waited until Resident #20 experienced significant weight loss this admission before implementing interventions such as Ensure shake, eating in dining room, and cuing assistance during meals to prevent weight loss. Staff did not follow recommendations to assist the resident with meals, and a family member had to enter the facility to support the resident with eating. Findings include: I. Facility policy and procedure The Nutritional Intervention Program policy, last revised 1/5/21, was provided by the nurse manager (NM) on 11/30/21 at 4:39 p.m. It read: Residents requiring nutrition beyond current intake will be offered nutrient dense products to treat a nutritional problem or as a preventative measure against malnutrition. The purpose of this program is to provide the resident with additional nutrition when the resident is unable to meet his/her nutritional needs through diet alone. The Weight Measurement-Resident policy, last revised 6/17/2020, was provided by the NM on 11/30/21 at 4:39 p.m. It read: Each resident will be weighed monthly unless more frequently by physician. II. Resident status Resident #20, age 92, was admitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/13/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Resident #20 required extensive assistance with activities of daily living (ADL) and used a wheelchair for mobility. She required supervision and verbal cues with eating. She was not on a physician prescribed weight gain program. III. Record review The resident had a baseline care plan initiated 10/8/21 and revised 11/2/21 that read in pertinent part: Eating: The resident was at risk for decline in her ability to feed herself due to patellar fracture, decreased mobility, generalized weakness, history of falling, ataxia, dementia, history of [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], depression, and anxiety. It documented that the resident was independent with eating and only required set up. Nutritional status: Resident #20 had unintended weight loss related to inadequate oral intake. Weight gain was desirable with a desired intake of 50-75% of most meals. A CPO dated 10/12/21-11/3/21 documented: Weekly weights for four weeks after admission, then monthly weights unless otherwise specified by physician. A RD progress note dated 10/17/21 documented in pertinent part: Resident #20 had no nutritional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20 was familiar to the RD from a past admission (April 2021) with 10 lb weight loss in seven months. Oral intake was less than desired with an average of 50% of meals eaten. There were no signs or symptoms of dehydration or weight changes at that time. Staff to continue routine nutrition monitoring and need for any additional interventions. A nurse practitioner (NP) progress note dated 10/19/21 documented in pertinent part: Resident #20 needs assistance with feeding. A nursing progress note dated 10/21/21 documented in pertinent part: Resident #20's daughter came to assist the resident with dinner. The resident did not eat much for breakfast or lunch. The resident's daughter was hoping she would be able to get Resident #20 to eat more. A nursing progress note dated 10/22/21 documented in pertinent part: Resident #20 was not eating much at all, even with staff assistance. A nursing progress note dated 10/24/21 documented in pertinent part: Resident #20's appetite remained poor despite encouragement from staff. A CPO dated 11/9/21 ordered weekly weights to be performed for Resident #20. A nursing progress note dated 11/30/21 documented in pertinent part: The RD was made aware of Resident #20 ' s weight loss and wrote orders for an ensure shake twice a day. The NP was also updated. A RD progress note dated 11/30/21 documented in pertinent part: Resident #20 had experienced a seven percent weight loss in 30 days and would be monitored weekly for nutrition risk. RD discussed nutrition concerns with the resident's daughter. The plan was for the staff to provide an ensure shake twice a day and to encourage snacks and preferred foods and fluids. A CPO dated 11/30/21 ordered ensure plus twice a day for Resident #20. According to the vital signs report the following weights were documented for Resident #20: -10/6/2021 148.2lbs, -10/26/21 148 lbs, -11/2/21 146.8 lbs, -11/9/21 142.8 lbs, -11/16/21 135 lbs, -11/24/2021 137.6 lbs, -11/30/2021 131.4 lbs. Resident #20 had an overall weight loss of 16.8 lbs since admission. Resident #20 experienced an 11.34% of weight loss within two months. IV. Observations Resident #20 was observed in her room on 11/29/21 at 12:11 p.m. The resident was confused, and non-interviewable. She had been sat up for lunch, however was not assisted or cued throughout the meal. She had one bite of banana gone and had not eaten any of her sandwich. The resident said she was just picking at her food. On 11/30/21 at 9:04 a.m. Resident #20 was observed in her room sitting up in her bed in her pajamas. There was an empty yogurt in front of her. On 12/1/21 at 9:00 a.m. Resident #20 was observed in her room with breakfast placed in front of her. She was not being assisted with the meal and there did not appear to be any food consumed from the plate. On 12/1/21 at approximately 5:00 p.m. Resident #20 was observed eating in the dining room with her daughter assisting her. V. Staff interviews The director of nursing (DON) was interviewed on 11/30/21 at 1:17 p.m. She said she had just been informed of Resident #20's weight loss. She said some days the resident will eat and some days she would not, she said the daughter said she did the same thing at home. She said that they did have staff that cue the resident to eat. The RD was interviewed on 11/30/21 at 1:36 p.m. She said the facility had a nutrition meeting for each resident once a week. She said that she generally tried to catch weight loss trends before they were significant. She said Resident #20 had shown up on her list of residents with significant weight loss to discuss on that day. She said that she would revise the care plan to document that the resident needed cuing assistance and should eat in the dining room rather than her room. She said that she had started the resident on a nutritional supplement shake twice daily. She said she would call the resident's daughter and let her know about weight loss concerns and the interventions that would be put in place. The nurse practitioner (NP) was interviewed on 11/30/21 at 3:45 p.m. She said that she had thought all residents had standing orders to eat in the dining room and did not realize that Resident #20 was eating in her room without assistance. She said she would put orders in for Resident #20 to be assisted by staff with each meal for cuing and to eat in the dining room.

Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for one (#9) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility failed to ensure Resident #9 was free from physical abuse from a staff member. Resident #9 was dependent on staff for care and cognitively impaired. Resident #9 was struck in the eye when a staff member threw chocolate at her. The action resulted in a hematoma (bruising) to her right eyelid and was given ice and Tylenol for the pain (see the nurse practitioner's note). The resident reported feeling fearful and per certified nurse aide #8 statement the resident was crying after the incident. Findings include: I. Facility policy and procedure The Abuse Prohibition-Occurrence Reporting policy, last reviewed 10/5/21, was provided by the facility on 11/30/21. The policy read in part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property and exploitation All residents of the facility are considered vulnerable adults due to their physical or mental disability or dependence on institutional services. (Named corporation) attempts to establish an environment that is as homelike as possible and includes cultures and environment that treat each resident with respect and dignity .The facility provides ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. If a staff member at any time displays suspect or inappropriate behavior, the supervisor must intervene and take appropriate action. II. Resident status Resident #9, age 75, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/24/21 minimum data set (MDS) assessment documented the resident had severe cognitive deficits with a brief interview for mental status (BIMS) score of three out of 15. According to the MDS, the resident required limited assistance of one person for bed mobility, transfers, personal hygiene and walking in her room. She requires extensive assistance from one for locomotion on and off the unit, dressing, and toileting. She did not have behaviors or rejections of care. An anticoagulant medication was not coded. III. Record review A. Care plan The abuse prevention care plan, revised 9/21/21, read Resident #9 had no known history of abuse or neglect. She was at risk for abuse/neglect due to vulnerable status living in the facility, had difficulty communicating, and needed assistance with activities of daily living (ADLs). According to the care plan, she was not alert and oriented and may not be able to report abuse/neglect. The cognition care plan, revised 9/21/21, read Resident #9 had an actual alteration in cognition related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Progress notes The 10/19/21 at 6:58 a.m. nurse progress note read the registered nurse (RN) was informed by a certified nurse aide (CNA) on 10/19/21 at 6:45 a.m. Resident #9 had bruising to her right eye. The resident informed the CNA the guy hit her last night (10/18/21). The resident was assessed by the nurse and confirmed the bruise. The resident told the RN the guy threw candy at me yesterday and hit me in the eye. The RN informed the RN manager on call. The 10/19/21 at 9:28 a.m. nurse progress note read a second RN was informed by the resident a male CNA hit her in the eye with a piece of chocolate the night prior after dinner. The resident said she was sitting up in her bed and he threw the candy from her doorway, striking her in the eye. The administrator, social services, the resident's family, nurse practitioner (NP), and the police department were notified of the findings. The 10/19/21 NP note read the NP assessed Resident #9's right eye injury. The NP described the injury as a hematoma. The resident was provided ice and Tylenol for pain and swelling. The NP reassured the resident this type of injury is unacceptable. According to the NP note, the CNA had been terminated and the incident had been reported to the State agency. An optometry referral was provided. The 10/19/21 social service director (SSD) note read social services and the director of nursing (DON) did a full investigation. According to the note, the resident has not had a change in psychosocial status since the allegation of abuse occurred but reported having fear. The note indicated the resident did not exhibit additional signs and symptoms of fearful behavior. She is able to recall recent events. The resident had moderate depression but there was no change in her depression from the month prior. Social services continued to provide emotional support, active listening, and validation. C. Abuse investigation An investigation of alleged physical abuse was initiated on 10/19/21. According to the investigative record, the incident occured on 10/18/21 at 6:00 p.m. The facility was informed of the incident on 10/19/21 at 8:45 a.m. The facility implemented facility safety measures including removal of the alleged assailant from the staff schedule pending the investigation. Statements were gathered from the alleged assailant and the witness of the incident. Other staff and residents were interviewed for any knowledge of the incident. The allegation was reported to police. Five staff were interviewed separate from the staff involved in the incident, five family members were interviewed and 27 residents were interviewed between 10/19/21 and 11/4/21. All staff were interviewed on abuse and neglect reporting and resident rights to prevent/report abuse and were reminded of staff on guidelines related to abuse and neglect. The facility presented staff with abuse and neglect in service and emphasized the different kinds of abuse to report any suspicion immediately. The appropriate authorities and State Agencies were notified. According to the investigation, Resident #9 reported to CNA #6 that sometime after dinner on 10/18/21 a male CNA entered her room and before leaving he threw a piece of chocolate candy at her striking her in the face. The incident resulted in a bruise to her right eyelid. According to the summary of the investigation, when the resident was interviewed, she began crying and stated that she was scared of him and did not want to be blamed for anything. In the course of the investigation, CNA #7 was identified as the alleged assailant and CNA #8 was aware of the incident and did not report it. The facility became aware of the incident the following morning (10/19/21) after the resident presented with bruising to her right eye. Based on the findings of the investigation, both CNA #7 and CNA #8 were terminated. Included in the investigation was a handwritten statement from CNA #7 and CNA #8. According to CNA #7's statement, he tossed the chocolate at the resident as he was exiting the room. The resident was trying to sit up at the time, resulting in the chocolate hitting her eye. The statement revealed the resident began to cry after she was hit in the eye. According to CNA #8's handwritten statement, CNA #7 and CNA #8 conducted resident rounds together. CNA #8 identified CNA #7 as very frustrated, with I guess everything going on. CNA #8 entered the room of Resident #9. The resident was crying and CNA #7 told CNA #8 he did not mean to hit her in the eye. CNA #8 left the room and proceeded to finish her rounds. The facility substantiated the allegation of physical abuse. IV. Staff interview The nursing home administrator (NHA) was interviewed on 11/29/21 at 3:02 p.m. The NHA said staff report all allegations of abuse, neglect, and mistreatment. She said anything deemed as reportable that meets the criteria would be reported and investigated. The DON or the nurse on call submitted the reportable allegations. The DON was interviewed on 12/1/21 at 2:53 p.m. The DON reviewed the facility's abuse protocol. She said staff should report immediately any suspected abuse, even if it was questionable. Staff were required to report the suspicions to their supervisor. The DON and the NHA were notified. The DON said an investigation would be immediately started with interviews of staff and residents. The DON said CNA #7 was interviewed after the allegation of abuse was reported. The DON said the CNA was not sure why he threw the chocolate, and used poor judgement at the time. She said CNA #7's actions to throw the chocolate and CNA #8's decision not to report the incident, both lost their jobs.

Based on record review and staff interviews, the facility failed to thoroughly and timely investigate allegations of physical and sexual abuse involving one (#26) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility fail to: -Thoroughly investigate an allegation of abuse with injury by a provider after a substantial sized bruise was discovered on the arm of Resident #26; and, -Initiate a timely investigation of documented potential sexual abuse of Resident #26 occuring on 11/20/21. Cross-reference F742 failure to ensure the resident received appropriate treatment to attain the highest practicable mental and psychosocial well-being. Cross-reference F609 failure to report an allegation of physical abuse with injury. Findings include: I. Facility policy and procedure The Abuse Prohibition-Occurrence Reporting policy, last reviewed 10/5/21, was provided by the facility on 11/30/21. The policy read in part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property and exploitation All residents of the facility are considered vulnerable adults due to their physical or mental disability or dependence on institutional services. (Named corporation) attempts to establish an environment that is as homelike as possible and includes cultures and environment that treat each resident with respect and dignity .All investigations of supported/alleged resident abuse, neglect, exploitation of residents, mistreatment, injury of unknown source and/or misappropriation of resident property shall be properly and thoroughly investigated. According to the policy the facility should Collect data and document investigative findings. The policy identified the investigation may include, but not limited to: -Physical examination of the resident and environment; -Review documentation and the resident's medical record for events leading up to the incident; -Interview the person(s) report of the incident; -Interview the alleged victim; -Interview any potential witnesses to the incident; -Interview other residents to whom the allegation perpetrator provided care or services; and -Review and complete the documentation. The Resident Rights-Abuse Reporting policy, dated June 2016, was provided by the facility on 11/30/21. The policy read in part, It is the policy of this facility that evidence or reports of abuse be thoroughly investigated Charts, reports, observations of residents, and incident reports, are reviewed to identify events, occurrences, patterns and trends that may constitute abuse. II. Resident #26 status Resident #26, age 84, was admitted on [DATE], with an initial admitted [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/18/21 minimum data set (MDS) assessment documented Resident #26 had severe cognitive deficits with a brief interview for mental status (BIMS) score of five out of 15. According the MDS, Resident #26 did not have inattention, or disorganized thinking. The MDS identified under [CONDITION(S)], revealed the resident had both hallucinations and delusions. The MDS did not indicate the resident had verbal, physical behaviors directed at others during the MDS look back period, however, she did exhibit other behavioral symptoms not directed at others. The MDS revealed her behavioral symptoms put her at risk for significant illness or injury and significantly interfered with her care. The MDS indicated rejections of care. Resident #26 required extensive assistance of two or more staff for bed mobility, transfers, dressing, and toileting. She requires extensive assistance from one staff member for personal hygiene and locomotion on and off the unit. III. Resident interview Resident #26 was interviewed on 11/29/21 at 2:46 p.m. Resident #26 said she did not want to have male staff work with her. She said she was not afraid of them but if she had a weapon, she would kill them. She said she did like to talk about it but tells the female staff who were nice to her. IV. Record review The abuse prevention care plan, initiated on 4/27/18, read Resident #26 had potential for abuse/neglect due to her vulnerable status living in the facility. According to the care plan, the resident had physical and cognitive impairment, visual hallucinations, resisted care and hitting staff during care. The skin care plan, initiated on 4/27/18 read Resident #26 was at risk for skin breakdown due to a history of falls with left [CONDITION(S)], decreased mobility, generalized weakness, inpaired cognition, oxygen use and incontinence. 1. Allegation of physical assault a. Progress notes The behavior progress note on 10/19/21 at 5:50 a.m read at 10:00 p.m. (10/18/21), Resident #26 was yelling and swearing at one of the CNAs while the resident was getting changed. During the morning rounds (10/19/21), Resident #26 started to yell and hit the CNA while she was getting changed. The provider was notified via the communication log. The nursing progress note on 10/19/21 read a CNA reported to the nurse at approximately 9:30 p.m. a bruise to the right arm of Resident #26. The nurse assessed and confirmed the bruise. The bruise was identified as reddish in color, warm to touch, and swollen. The bruise measured 8.1 centimeters (cm) by 5.0 cm. A body audit was done with no other skin issue noted. According to the progress note, the resident stated a male doctor caused the bruise. The note indicated the nurse manager (NM) was notified and an email was sent to the director of nursing (DON) and social service director (SSD). The provider was notified via a communication log. The physician assist (PA) rounds note on 10/20/21 read her bruise was evaluated. The bruise was confirmed as 8 cm by 5 cm and healing well. According to the note, the resident was unsure how she obtained it. Nursing staff reported behaviors of swearing at staff while she was being dressed on 10/19/21. The resident reported the area was tender on 10/19/21 but did not report pain on 10/20/21. The 10/21/21 nursing note read Resident #26's bruise to the right forearm had a knot in the center of the large bruise but did not complain of pain. The late entry SSD note on 11/29/21 at 4:52 p.m. (during the survey) for 10/19/21 read staff reported Resident #29 had a bruise on her right arm. According to the late entry note, the resident acquired a bruise to her arm when she was combative during cares. The SSD noted the resident continued to have significant behaviors with cares at times and was verbally and physically aggressive with staff. The nursing home administrator (NHA) provided the 10/19/21 abuse investigation on 11/30/21 at 11:33 a.m. According to the NHA the investigation packet she provided was the complete investigation pertaining the 10/19/21 allegation. The investigation included: -The SSD 11/29/21 late entry progress (see above). -A 10/19/21 interview with Resident #26: Resident #26 was asked how everything was going for her at the facility, the resident responded Okay. She was asked if she was afraid of anyone while at the facility, she responded No. She was asked if anyone came into her room she did not want in her room, she responded No. She was asked if anyone hurt or neglected you in any way while you are a resident at the facility, she responded No. No additional questions were asked of the resident. -An at risk for skin breakdown care plan (see above). -A resident interview audit which was conducted between 7/27/21 and 7/28/21: Six residents were asked if they felt safe at the facility including Resident #26. Five of the six residents replied yes, they felt safe. Resident #26 said yes and no according to the audit. The audit documented Resident #26 said Just as safe as anywhere else. If I tell you I will be moved and I don't want to be moved. -A second resident interview audit was conducted between 8/2/21 and 8/10/21:22 out of 23 residents said they felt safe at the facility. Resident #26 said she did not feel safe. She was asked why she did not feel safe and she responded my thinking. She said moving to California was what would make her feel safe. -A conclusion to the investigation statement: The conclusion read It was concluded that no abuse occurred on 10/19/21 to Resident #26. The resident appeared to have acquired the bruise due to combative outbursts during cares. As an intervention, the facility installed padding on hard surfaces of the bed. Resident #26 displays behavioral expressions such as combative towards staff, hallucinations, and calling staff vulgar names. The facility did not substantiate abuse. The review of the 10/19/21 investigation of a large bruise to with an allegation of abuse by a provider did not include: -Other resident interviews after 10/19/21 allegation. The last resident interviews were conducted in July 2021 and August 2021. -Staff interviews. -Witnesses to the incident the facility reported caused the bruise to determine if the resident hit the hard surface of the bed during her 10/19/21 combative behavior. -A statement or interview from who she hit, where she hit them and did she use her right arm to hit them, potentially causing the bruise. -A skin assessment on 10/19/21 immediately after she hit the hard surface of the bed/and or staff member to determine if there was an injury or redness to her skin. The skin assessment was conducted at 10:46 p.m. on 10/19/21 after a bruise was identified. -A interview or schedule of her providers to determine if she was seen by a male doctor on 10/19/21. 2. Allegation of sexual assault A. Progress notes The 11/20/21 at 2:28 a.m. combative behavior note documented Resident #26 was being changed by aid when she started to yell, this nurse assisted aid in attempts to change resident, but resident was upset at male aid stating that he touched her inappropriately. Resident was screaming, cursing and scratching at male aid. This nurse was able to calm resident down by removing male aid from room and having female aid assist in performing peri-care. Apologized to resident, resident was content by end of conversation and left in bed with call light in reach. The nursing note on 11/20/2021 at 11:51 a.m. read Resident #26 said she was not happy with the care at the facility. No additional follow up was documented regarding her statement. The nursing home administrator (NHA) provided the abuse investigation on 12/1/21. The investigation included: -The initial report from the surveyor -Progress notes -Interview with Resident #26 -Interview with LPN #3 -Interview with CNA#10 -Interview with CNA #11 -Police notification -Resident #26 abuse audits -Resident abuse audits -Education to LPN #3 -Education to CNA #10 -Staff education -Staff schedule on 11/20/21 -A conclusion summary to the investigation. The facility did not substantiate abuse. The conclusion summary read: It was concluded that no abuse occurred on 11/20/21 to Resident #26 by staff at the facility. Police supported this conclusion and did not open a case number on this report. The resident displays behavioral expressions such as combative towards staff, hallucinations, calling staff vulgar names such as racial slurs and making false accusations. The nurse that cared for the resident this night (11/20/21) did not report to her supervisor the documentation on 11/20/21 of the resident was upset at male aide stating that he touched her inappropriately because in her mind she did not interpret it as that. She stated, it was a known behavior that she makes false accusations. The nurse said she heard the resident hollering and was outside the residence door and heard the residents say don't touch me. This statement is what the nurse was referring to when documenting touched her inappropriately. The nurse stated that she did not hear the resident make any comments about sexual touching. Abuse audits were completed of the facility residents residing at the facility on 11/30/21. No additional residents reported abuse and all interviewed felt safe. Education was completed to staff regarding when to report suspicious suspicion of abuse/neglect. B. Staff interviews The nursing home administrator (NHA) was interviewed on 11/29/21 at 3:02 p.m. The NHA said staff reported all allegations of abuse to her. She said anything deemed as reportable that meets the criteria would be reported and investigated. The NHA said the director of nursing (DON) or the nurse on call submitted the reportable allegations to the State Agency. The NHA was asked about the bruise and allegation that was documented on 10/19/21 for Resident #26. According to NHA, she was not familiar with the allegation a male doctor caused a bruise. The 10/19/21 note was reviewed with the NHA. The NHA was asked about the allegation of abuse documented on 11/20/21. The NHA reviewed the note and said the nurse should have contacted her supervisor to see if the allegation was reportable and start an investigation. The NHA said she would follow up the 10/19/21 and 11/20/21 Resident #26 documented incidents. The NHA was interviewed again on 11/30/21 at 1:55 p.m. The 10/19/21 investigation packet materials were reviewed with the NHA. The NHA said they did not have resident interviews pertaining to the 10/19/21 allegation of abuse with a bruise but would start interviews today (11/30/21) for all residents. The NHA confirmed what they provided as their investigation on 10/19/21 was what they had for the investigation. The NHA said they reported and started an investigation for the 11/20/21 allegation of abuse on 11/29/21 after it was reported by the state surveyor. The social service director (SSD) was interviewed on 12/1/21 at 10:27 a.m. She said her role in allegations of abuse was to interview residents related to feeling safe at the facility. She said she would usually do a random sample of residents who needed more staff assistance with ADLs. She said residents with mild to severe cognitive loss could still tell her if they were fearful. She said she submitted the interviews to the DON. She said the DON usually led the investigations. The SSD said she did not conclude the investigations either. The SSD said she was aware of the 10/19/21 allegation with the bruise. She said it was brought up in a team meeting. She recalled the team discussing the bruise was caused when the resident was combative with staff. She said she did not interview other residents because it was clear the bruise to her right forearm was caused during care because of the location of the bruise. She said nursing would have interviewed staff. The SSD said she did not document her follow up with the resident after the allegation. She said she did not document the 10/19/21 allegation until 11/29/21. She said she forgot but usually would put in a note timely. The nurse manager (NM) was interviewed on 12/1/21 at 2:36 p.m. The NM said she was aware of Resident #26's combative behavior. She said she was notified that the 10/19/21 bruise was acquired from combative behavior with care. The DON was interviewed on 12/1/21 at 2:53 p.m. The DON reviewed the facility's abuse protocol. She said staff should report immediately any suspected abuse, even if it was questionable. Staff were required to report the suspicions to their supervisor. The DON and the NHA were notified. The DON said an investigation would be immediately started with interviews of staff and residents. The DON said the allegation on 10/19/21 with the bruise was not reported because she was combative with care. She said the nurse charted the resident was combative. The DON said it was concluded the resident hit the bed rail. The DON said she did not conduct the investigation. She said the investigation was completed by the SSD. The DON reviewed the investigation. She said she could not tell by the investigation what staff member was hit during the combative behavior, what arm the resident used to hit the staff member to conclude that was the cause of the injury or if the resident was observed hitting the bed rail. The DON said she did not conduct staff interviews and confirmed staff interviews were not included in the provided investigation. She said she would have expected staff to have been interviewed. She said the resident should have had a skin check if she hit something during the combative behavior. The DON said there should have been more of a thorough investigation. She said she felt the allegation was checked into so it was decided not to report (cross-reference F609). The DON confirmed the only documented action on 10/19/21 after the allegation of abuse with a bruise included in the investigation packet was Resident #26's interview. The DON said she was not aware of the 11/20/21 investigation because she was out the facility during the time the investigation would have occured. The 11/20/21 incident was reported when the DON became aware of the charted progress note on 11/20/21. She said the regional director of quality (RDQ) interviewed LPN #3. The LPN said she did not know why she charted the resident said she was touched inappropriately, it was not what the resident said. The DON said the abuse was not substantiated. The RDQ, the DON, and the NHA were interviewed on 12/1/21 at 4:27 p.m. regarding the 11/20/21 facility investigation. The RDQ said LPN #3 was interviewed on 11/29/21 and again on 11/30/21 regarding 11/20/21. The RDQ said the LPN said the resident required ADL care three times during the night. The RDQ said during the first round of care, CNA #11 (female) was providing the ADL care. Resident #26 started yelling and using racial slurs against CNA #11. CNA #10 (male) entered the room. The resident allowed CNA #10 to complete the care while LPN listened in from outside the room. On the second round of ADL care needs, Resident #26 did not express concerns. On the third round on care needs on 11/20/21, the LPN sent CNA #10 because the resident seemed more receptive to him. The resident was heard yelling. The LPN entered the room and observed CNA #10 cleaning the resident. LPN #3 had CNA #10 left the room and she completed the ADL care as the resident laughed and joked around with LPN. The RDQ said the direct statement the resident said according to the LPN was dont touch her, not touched her inappropriately as she documented in the resident's medical chart/record. The LPN said she did not report because the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 told the RDQ the resident did not make a comment about sexual touching. The NHA said staff were educated on the requirement of alleged abuse to a resident. She said staff were responsible to ensure the residents felt safe and free from harm. She said they also have to complete competencies on abuse and neglect. LPN#3 did not feel it was something she needed to be reported. The RDQ said touched inappropriately should not have been documented. The RDQ and the NHA were interviewed again on 12/2/21 at 10:05 a.m. The RDQ said if the facility did not have timely investigations, then they would not have timely details. They said systematic changes based on the 11/20/21 investigation would include the daily review of all resident progress notes by the SSD and the DON. The SSD and the DON could identify if concerning words were documented for need to follow up. The NHA pertaining to the 10/19/21 allegation said it was determined the bruise was caused when she hit the CNA. She said she did not know who the CNA was. She said the facility padded bed railing. She said it could have been a combination of circumstances.

Based on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law for one (#26) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility failed to report an allegation on 10/19/21 of potential staff-to-resident sexual abuse and/or physical abuse by Resident #1. Cross-reference F610, failure to timely and thorough investigation of an allegation of abuse. Cross-reference F742 failure to ensure the resident received appropriate treatment to attain the highest practicable mental and psychosocial well-being. Findings include: I. Facility policy The Abuse Prohibition-Occurrence Reporting policy, last reviewed 10/5/21, was provided by the facility on 11/30/21. The policy read in part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property and exploitation All residents of the facility are considered vulnerable adults due to their physical or mental disability or dependence on institutional services Each employee is responsible to report suspected alleged violations of mistreatment, neglect, exploitation of residence, and abuse of residents and/or misappropriation of resident property immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the event that caused the allegation does not involve abuse or does not result in serious bodily injury to the designated facility staff. The administrator/executive director will be notified immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or results in serious bodily injury, or no later than 24 hours if the events that caused the allegation do not involve abuse or do not result in serious bodily injury by one of the above. Staff may go immediately to the administrator/executive director if desired. Report all alleged violations and substantiated incidents immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that causes the allegation does not involve abuse or does not result in serious bodily injury to the state agency and all other agencies required (electronically using the Colorado Health Facilities portal). The Resident Rights-Abuse Reporting policy, dated June 2016, was provided by the facility on 11/30/21. The policy read in part, It is the policy of this facility that evidence or reports of abuse be thoroughly investigated and reported to the appropriate authorities. II. Record review The behavior progress note on 10/19/21 at 5:50 a.m read at 10:00 p.m. (10/18/21), Resident #26 was yelling and swearing at one of the CNAs while the resident was getting changed. During the morning rounds (10/19/21), Resident #26 started to yell and hit the CNA while she was getting changed. The provider was notified via the communication log. The nursing progress note on 10/19/21 read a CNA reported to the nurse at approximately 9:30 p.m. a bruise to the right arm of Resident #26. The nurse assessed and confirmed the bruise. The bruise was identified as reddish in color, warm to touch, and swollen. The bruise measured 8.1 centimeters (cm) by 5.0 cm. A body audit was done with no other skin issues noted. According to the progress note, the resident stated a male doctor caused the bruise. The note indicated the nurse manager (NM) was notified and an email was sent to the director of nursing (DON) and social service director (SSD). The provider was notified via a communication log. The physician assist (PA) round note on 10/20/21 read the resident's bruise was evaluated. The bruise was confirmed as 8 cm by 5 cm and healing well. According to the note, the resident was unsure how she obtained it. Nursing staff reported behaviors of swearing at staff while she was being dressed on 10/19/21. The resident reported the area was tender on 10/19/21 but did not report pain on 10/20/21. The 10/21/2021 nursing note read Resident #26's bruise to the right forearm had a knot in the center of the large bruise but did not complain of pain. The late entry SSD note written on 11/29/2021 at 4:52 p.m.(during the survey) for 10/19/21 read staff reported Resident #29 had a bruise on her right arm. According to the late entry note, the resident acquired a bruise to her arm when she was combative during cares. The SSD noted the resident continued to have significant behaviors with cares at times and was verbally and physically aggressive with staff. The nursing home administrator (NHA) provided the 10/19/21 abuse investigation on 11/30/21 at 11:33 a.m. The facility did report the allegation of physical abuse by a provider/male caregiver. A conclusion to the investigation statement read It was concluded that no abuse occurred on 10/19/21 to Resident #26. The resident appeared to have acquired the bruise due to combative outbursts during cares. As an intervention, the facility installed padding on hard surfaces of the bed. Resident #26 displays behavioral expressions such as combative towards staff, hallucinations, and calling staff vulgar names. III. Staff interviews The nursing home administrator (NHA) was interviewed on 11/29/21 at 3:02 p.m. The NHA said staff reported all allegations of abuse to her. She said anything deemed as reportable that meets the criteria would be reported and investigated. The NHA said the director of nursing (DON) or the nurse on call submitted the reportable allegations to the State Agency. The NHA was asked about the bruise and allegation that was documented on 10/19/21 for Resident #26. According to NHA, she was not familiar with the allegation a male doctor caused a bruise. The 10/19/21 note was reviewed with the NHA. The DON was interviewed on 12/1/21 at 2:53 p.m. The DON reviewed the facility's abuse protocol. She said staff should report immediately any suspected abuse, even if it was questionable. Staff were required to report the suspicions to their supervisor. The DON and the NHA were notified. The DON said an investigation would be immediately started with interviews of staff and residents. The DON said the allegation on 10/19/21 with the bruise was not reported because she was combative with care. She said the nurse charted the resident was combative. The DON said it was concluded the resident hit the bed rail. She said she felt the allegation was checked into, so it was decided not to report it any further.

Based on observations, interviews and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for one (#5) of five residents reviewed for ADLs out of 20 sample residents. Specifically, the facility failed to provide consistent cueing and dining assistance when required for Resident #5, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy and procedures The Feeding of Residents by Staff policy, revised 12/9/19, was provided by the nurse manager (NM) on 12/2/21 at 1:32 p.m. It documented staff should encourage residents to eat and allow plenty of time in a relaxed and unhurried manner. It documented staff should encourage residents to feed themselves self-finger foods, if able. The Dining Room Service policy, revised 1/5/21, was provided by the NM on 12/2/21 at 1:32 p.m. It documented residents would be provided with services to maintain or improve eating skills. It documented the dining experience will enhance the individual's quality of life and be supportive of the individual's needs during dining. It documented assistance at mealtime must be appropriate for individual needs. The policy documented, Appropriate staff will assist as needed to assure adequate intake of food and fluids at the meal. Individuals will be assisted promptly and in a timely manner after the meal arrives. II. Resident #5 A. Resident status Resident #5, age 85, was admitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 resided in the facility's secured memory care unit (MCU). The 9/16/21 minimum data set (MDS) assessment did not document a brief interview for mental status (BIMS) score, but documented the resident was cognitively impaired with both short-term and long-term memory problems. It documented that this resident needed supervision of one for eating. B. Resident observations Resident #5 was initially observed when entering the MCU for the first time on 11/29/21 at 11:40 a.m. At this time, the staff were overheard stating that Resident #5 would be having his lunch in his room. -At 12:13 p.m., Resident #5's lunch was delivered to his room. -At 12:25 p.m., Resident #5's lunch tray had been left uncovered and was on his bedside table, with the food getting cold. No staff was observed assisting the resident with his meal or encouraging him to eat. The resident was lying in bed with his eyes closed. No staff approached the resident to let the resident know his meal had been delivered or offered to warm his food up for him. -At 12:27 p.m., a staff member was observed entering the resident's room to encourage the resident to eat, set up the resident's tray on the bedside table and placed the table over the resident in bed. The staff left the resident's room after this observation. -At 12:34 p.m., Resident #5 remained alone in his room, holding a glass of orange juice, but did not drink it. No staff were observed entering the resident's room and encouraging him to eat or drink anything. -At 12:35 p.m., licensed practical nurse (LPN) #1 stopped in to check on the resident's general status, but did not stay to encourage him to eat or see if he had eaten anything yet. -At 12:48 p.m., Resident #5 was observed to be still holding his orange juice in the same position as he had been at 12:34 p.m. (See above). The resident had not eaten any of his food at this time. No staff were interacting with the resident at this time. -At 1:16 p.m., Resident #5 was still in bed, but the bedside table had been moved to the side of the bed. The resident did not eat or drink anything and staff was not observed assisting this resident with his meal at any time. -At 1:35 p.m., Resident #5 was observed to be independently feeding himself the food on his lunch tray, which had been sitting out uncovered for one hour and twenty-two minutes and would have been cold by then. Resident #5 was observed on 11/30/21 at 12:25 p.m. He was lying in bed and his lunch was on the bedside table, pulled over the resident in bed. The resident was awake, but not eating and no staff were supervising him or encouraging him to eat or drink anything. -At 1:15 p.m., Resident #5 remained in bed, but had not eaten much of his lunch. -At 5:25 p.m., Resident #5 was observed sitting up on the side of his bed with his meal on the bedside table. He was independently eating at this time. Resident #5 was observed on 12/1/21 at 8:45 a.m. His breakfast tray was uncovered and placed on his bedside table, positioned at the side of the bed. Resident #5 was in bed, in a darkened room, with his eyes closed. His food and drinks had not been touched. -At 8:55 a.m., certified nurse aide (CNA) #4 was observed entering Resident #5's room and verbally encouraging the resident to eat. He positioned the bedside table over the bed within the resident's reach and assisted him to sit up straighter to eat. The CNA then began fixing the resident's television. The CNA was not observed cueing or encouraging the resident with his meal again prior to leaving the resident's room. -At 12:14 p.m., the resident was observed at a table by himself, in the MCU dining room. His meal had been delivered approximately 10 minutes earlier and no staff were observed providing assistance or encouragement with his meal. -At 12:37 p.m., Resident #5 was observed eating spinach with his hands. He was not using the weighted utensils provided for him and staff were not encouraging him to use them. -At 12:41 p.m., the resident was observed taking the spinach out of his mouth that he had been chewing on and putting it on his plate. -At 12:44 p.m., CNA #3 was finally observed approaching the resident and asking him if he wanted anything else to drink. This observation occurred shortly after CNA#3, observed this writer, checking on Resident #5. -At 12:50 p.m., Resident #5 had eaten approximately 50% of his meal. Resident #5 was observed on 12/2/21 at 8:15 a.m. He was seated by himself at a table in the MCU dining room. He was eating at this time, as evidenced by his having eaten approximately 50% of his meal and was using his weighted utensils at this time. -At 12:24 p.m., the resident was observed eating at a separate table by the window. Shortly after this observation, staff were observed taking him to the toilet and lying him in bed after using the bathroom. He had eaten approximately 50% of his meal. III. Record review A. Care plans The care plan dated 6/8/18 and revised 9/13/21 documented the resident was at risk for decline in his ability to feed himself due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented the resident was on a mechanical soft diet. Interventions included staff to provide supervision and assist with eating. It documented Resident #5 required set up with his meals. It documented the resident may need occasional mealtime cueing and encouragement. B. Progress notes The progress note dated 9/10/21 documented, Resident seen today to follow up on recent functional decline. He has had a poor appetite, has increasing difficulty ambulating and rarely leaves his room to dine in the dining room. This note was written by the facility's nurse practitioner (NP). The progress note dated 9/14/21 related to a nutrition review change of condition with decreased ADL's (9/10-9/16/21) documented nutrition interventions including cueing and assistance with meals. The nutritional evaluation documented, Resident with significant decline in functional status per clinical presentation and NP notes. Monitor resident at high nutrition risk weekly and continue to support nutritional needs. The progress note dated 11/16/21 documented that the resident occasionally becomes upset when other residents are disruptive in the dining area, but he is easily redirectable. The progress note dated 11/27/21 documented, DIET CONCERN: Resident does not seem to be eating on his own. Recommend resident eat in the common area for each shift or have 1:1 to help him eat. The resident seemed to have difficulty this shift with drinking from a straw. This nurse was able to feed him his lunch and Ensure and noticed a considerable decline in interest in eating. C. Meal intakes The documented meal intake for the observed lunch on 11/29/21 documented Resident #5 only ate 25-50% of his meal. On 11/30/21, Resident #5 consumed 26-50% of his breakfast and 51-75% of his lunch. On 12/1/21, Resident #5 consumed 51-75% of his breakfast and lunch and only 26-50% of his dinner. On 12/2/21, Resident #5 consumed 26-50% of his lunch and 51-75% of his dinner. D. Miscellaneous records The Minimum Effective Dose Committee (MED) Review dated 9/16/21 documented the resident was declining and was eating poorly. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/30/21 at 1:30 p.m. He said Resident #5 was kind of a loner, but could get very frustrated at times with noise. He said the resident's change of condition and recent decline in ADLs, specifically needing increased motivation and cueing to eat, was part of the Alzheimer's disease process. The registered dietician (RD) was interviewed on 11/30/21 at 1:58 p.m. She said she visited the facility weekly and knew Resident #5 well. She said the resident had been steadily declining and was discussed in the weekly nutrition at risk meeting. She said Resident #5 has been requiring a lot more cueing and some adaptive equipment to be more independent with eating. She said his dentures do not fit well and his power of attorney will not approve the expenditure for new ones. She said Resident #5 was ordered a mechanical soft diet even before his dentures became ill-fitting. She said the resident had never choked or struggled with swallowing during meals, but he went through phases of good and bad days due to his level of dementia. She said she had encouraged staff to keep trying to get him to come out for meals, as he ate much better in the dining room. She said the theme of current interventions were to have staff get him out of his room for meals or having staff routinely go into his room and encourage him to eat. She said she would expect all staff to be supervising and encouraging this resident with his meals. CNA #4 was interviewed on 12/1/21 at 9:00 a.m. He said the breakfast trays were delivered a bit earlier that morning and Resident #5 received his breakfast at approximately 8:00 a.m. that morning. He said he did not think the resident was interested in eating this morning because when he usually brought the resident's meal, he began eating right away. He said he had worked in the facility for about two weeks. He said the resident was more interested in having his television working than eating. He was asked if anyone offered to warm up the resident's food, as it had been sitting there without a cover for almost one hour. He said he would warm up the resident's food if they asked, but Resident #5 did not ask for his food to be reheated. CNA #3 was interviewed on 12/1/21 at 12:50 p.m. She said she tried to get Resident #5 to come out of his room for meals whenever she worked in the MCU. She said the resident did not eat much of his lunch yet and she would follow up with him to see if he wanted to have a peanut butter and jelly sandwich because sometimes he would eat both a sandwich and his regular meals. At this time, she said Resident #5 was finally beginning to eat this meal well. At this time, the resident had eaten approximately 50% of his regular meal. CNA #3 was interviewed again on 12/1/21 at 4:20 p.m. She said in relation to Resident #5, He does better out here (in the MCU common area dining room) eating. The NM was interviewed on 12/2/21 at 11:10 a.m. She said Resident #5 did need supervision and cueing for meal intakes at times. She said she did expect staff to check on this resident often for encouragement at meal times. She said the only times staff should not be encouraging the resident to eat was when he did not feel like eating or when their presence was actually distracting him from eating. She said these occasions should be documented, however. The social services director (SSD) was interviewed on 12/2/21 at 11:15 a.m. in relation to meal assistance for this resident who had sustained a significant weight loss. She said she would expect staff to be encouraging him and supervising him during meals, especially when he was eating in his room and not out in the main dining area. She said residents with cognitive deficits who reside in the MCU are unable to ask for their needs, like heating up meals, and the staff need to anticipate their needs. She said she could advocate for the residents and provide additional training to facility staff about consistent meal assistance with confused residents. CNA #1 was interviewed on 12/2/21 at 12:30 p.m. She said Resident #5 should always be supervised, assisted and encouraged with his meals. She said she personally cued the resident by handing him his weighted utensils and after that, he would usually start eating himself. She said he ate approximately 50% of his lunch on this date. She said when this resident ate his meals in his room, one CNA should be in there with him at all times to ensure his dentures were properly fitting and for ongoing encouragement and assistance with eating. LPN #2 was interviewed on 12/2/21 at 12:40 p.m. She said Resident #5 was somewhat of a puzzle. She said bringing him out into the main dining room for meals would sometimes benefit him and sometimes not. She said he did not like loud noises. She said her practice was to go into the room and tell the resident it was meal time. If he refused to come out to the dining area for his meal, she would ensure the resident was seated on the side of his bed with the meal on his bedside table directly in front of him. She said residents usually eat better when they are in a communal group setting. She said the kitchen staff delivered the room trays, not the CNAs working on the MCU. She said she would love for the CNAs to sit with this resident for encouragement during meal times, but sometimes the resident wanted to be alone. She said it was the staff's responsibility to anticipate resident needs and not expect cognitively impaired residents to ask for their food to be warmed up; they would just start eating the cold, unappetizing food. She said she would suggest having new MCU staff take the eight-hour training related to dementia care prior to ever working the floor on the MCU to have the basic skills to assist confused residents appropriately. The nurse practitioner consultant (NPC) was interviewed on 12/2/21 at 1:30 p.m. She said staff should be assisting and encouraging residents with their meals as often as they can. She said additional training for new staff prior to actually working on the MCU would be beneficial for everyone. The director of nursing (DON) was interviewed on 12/2/21 at 2:00 p.m. She said Resident #5 was a very particular gentleman and if he was in bed with his eyes closed, that meant you should not mess with him. She said, if he opened his eyes when staff approached, all was good. She said staff should be anticipating resident's needs and not waiting for them to ask for assistance, especially the residents residing in the MCU. She said staff could always ask the residents what they need and do more for them. She said it would be a good idea to have staff newly assigned to the MCU take the dementia training prior to working the floor rather than taking the course later on.

Based on observations, interviews, and record review, the facility failed to assure that services being provided met professional standards of quality for one (#20) of one resident reviewed for professional standards. Specifically, the facility failed to ensure Resident #20 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: I. Facility policy and procedure A skin integrity policy and procedure last revised 2/4/21, provided by the nurse manager (NM) on 11/30/21 at 4:39 p.m. read: (Facility) seeks to utilize an interdisciplinary approach to promote best practice in areas of skin injury prevention and promotion of healing. Skin care, risk assessment and wound care treatment plans are based on resident focused goals of pressure relief, improved or sustained skin integrity, mobility, comfort, infection prevention, healing and/or palliation. It is the policy of (facility) that a resident entering the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and to provide care and services consistent with professional standards of practice to promote the prevention of pressure injury development, promote the healing of existing pressure injuries and to prevent the development of additional pressure injuries. Wound documentation guidelines: - Implement appropriate treatment from wound care protocol, or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Complete a new comprehensive skin risk assessment if area is pressure, arterial, venous, diabetic, neuropathic or mixed etiology. - Update care plan including nursing assistant assignment sheet or profile with new interventions. - Document in designated area in EMR related to the skin alteration including specific location. of alteration, physical description of alteration and measurements. - Document notifications that were made related to new alteration. Treatment plans: - Appropriate treatment plans will be determined through MD/NP orders and an interdisciplinary team (IDT) approach to wound prevention and healing. The resident and representative will be updated upon discovery and routinely thereafter of any skin integrity issue, what it is, potential causal factors and treatment plan. - Resident lifestyle and preferences, as with all treatment plans will be taken into consideration. - Should the resident and/or representative elect not to follow the treatment plan for any reason, the risks and benefits of making those decisions will be explained and documented in the resident record. - Continued education will be provided on an ongoing basis for risks and benefits of non-compliance and non-compliance will be care planned. - All skin integrity issues, potential and actual will be reviewed at care conferences or more often with changes in condition. Measuring and describing wounds: - Location - Type - Length and width - Depth - Tissue types - Undermining or tunneling - Staging (only for pressure ulcers) - Thickness of injury - Drainage amount and type - Odor - Presence of pain - Describe wound edges and periwound - Progress of healing II. Resident status Resident #20, age 92, was admitted on [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/13/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident was known to have delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #20 required extensive assistance with activities of daily living (ADL) and used a wheelchair for mobility. She required supervision and verbal cues with eating. The resident experienced frequent incontinence of urine and bowels. The resident was at risk for pressure injuries with no wounds documented upon admission. IV. Record review The resident had a baseline care plan initiated 10/8/21and revised 11/2/21 that read in pertinent part: Skin integrity: At risk for alteration of skin integrity related to: Overall Braden score of 18, with individual risks identified: at risk for sensory perception, moisture due to incontinence of bladder and bowel, decreased activity, immobility, nutrition, shear and friction. Staff was to implement the following interventions: Pressure redistribution cushion in wheelchair, turn and reposition every two hours, avoid more than 30 degree side lying elevation or bed elevation, lift resident rather than sliding, complete visual body observation weekly, manage incontinence, moisturize skin, certified nurse aides (CNA) to observe skin daily during cares, pressure redistribution mattress, and position body with pillows/support devices, protect bony prominences. Bed mobility and range of motion (ROM): Resident #20 required assistance with bed mobility. Staff was to assist with repositioning every two hours. A CPO dated 10/13/21- 11/5/21 documented: Resident #20 was to have a comprehensive skin risk with Braden (skin risk assessment) observation weekly for four weeks after admission. A Braden scale performed 10/27/21 documented a score of 17 out of 22 indicating the resident was at risk for skin breakdown. A Braden scale performed 11/3/21 documented a score of 15 out of 22 indicating the resident was at risk for skin breakdown. A visual body inspection dated 11/27/21 documented in pertinent part: Resident #20 had a new pressure injury noted. See wound management for details. Pressure wound to right buttock with foam dressing intact. (There was no documentation of any wounds in the wound management section of EMR). A nursing progress note dated 11/27/21 documented: Resident #20 had a dime sized blanchable red spot to her right gluteal cleft. [MEDICATION(S)] was in place and removed to inspect skin. Staff to encourage turning frequently in bed and not to sit in a chair for long periods of time. Continue to monitor. A nursing progress note dated 11/30/21 documented: Resident #20's coccyx area was reddened and had scabbed/dry areas, no open areas were noted. The nurse practitioner (NP) was notified and would examine the wound. A nursing progress note dated 11/30/21 from the director of nursing (DON) documented: Small dime size area to right upper coccyx was assessed by the NP and was clarified to be chafing of the skin. A new order was written for [MEDICATION(S)] daily for seven days to keep open to air and protect from pressure. Resident #20 was able to move independently in her bed and was able to ambulate with assistance. The resident's daughter was notified of the findings and was agreeable to plan. A nurse practitioner (NP) progress note dated 11/30/21 documented: Resident #20 seen for follow up on skin shear on her right buttock noticed on 11/26/21. The RN who found the wound placed a dressing on it and wrote in a communication book, which the NP read 11/29/21. The NP was unable to see the resident on 11/29/21 as the resident was up in her wheelchair each time she tried to assess her. Plan to dab the wound with [MEDICATION(S)] daily for seven days and keep open to air/protect the wound from pressure. The [MEDICATION(S)] provides antiseptic and helps dry up the wound, it should form a scab and heal within seven days. No dressing needed as there was no drainage. Monitor the wound daily for healing. IV. Observations On 11/30/21 at 9:26 a.m. Resident #20's buttock was observed with CNA #2. The resident had a quarter sized wound on her right inner buttock that was red with scattered open/slightly scabbed areas. There was no dressing present. V. Staff interviews CNA #2 was interviewed during observation on 11/30/21 at 9:26 a.m. She said that there was a dressing on Resident #20's buttock that morning that the resident pulled off with toileting. Registered nurse (RN) #1 was interviewed on 11/30/21 at 9:34 a.m. She said she looked in the EMR and could not find orders for Resident #20 to have wound care. She said that they had to have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she would not be doing wound care for the resident since there were no orders. The NM was interviewed on 11/30/21 at 1:06 p.m. She said that the [MEDICATION(S)] she charted on being present in progress note dated 11/27/21 was present on Resident #20's buttock before she assessed it and she was not the one who placed the bandage. She said that the provider should have been notified of the wound when it was discovered and orders should have been put in place before the bandage was placed on the resident. The NP was interviewed on 11/30/21 at 3:45 p.m. She said that she worked with a wound specialist from the local hospital to determine wound care regimen for residents. She said that she was on vacation when Resident #20's wound was first discovered so she was not aware of it until 11/29/21 and she was not able to assess it until 11/30/21. She said that she examined Resident #20's buttock wound on 11/30/21 and believed the wound to be caused by shearing and not pressure. She said she was going to order [MEDICATION(S)] to treat and leave the wound open to air. The NM was interviewed again on 11/30/21 at 4:00 p.m. She said that there is an on-call physician available when the NP is not available for staff to report changes to. She said the on-call physician should have been called when the new wound was observed. VI. Follow-up A CPO dated 11/30/21 documented: Apply hydrofoam dressing to right buttock, change every three days until healed. Complete pressure relief on the right buttock. A wound management detail report dated 11/30/21 documented Resident #20 had chafing on coccyx with dry scabbed areas.

Based on interviews, observations and record review, the facility failed to provide sufficient nursing staff to ensure resident care needs were met in keeping with their comprehensive plans of care. The failure to provide sufficient nursing staffing contributed to residents experiencing incontinence, inadequate pain management, unsafe transfer assistance, abuse, and inadequate dementia care. Cross-reference F550, dignity and respect. The facility failed to respond in a timely manner to Resident #7's requests for assistance to the bathroom, resulting in incontinence accidents, discomfort and a rude staff response after an incontinence episode. Due to lack of timely assistance, Resident #7 said she sometimes could not hold my urine, had to wait until her bladder hurt and recalled one incident where the nurse gave me a very bad look because I am not supposed to wet myself, and reported feeling uncomfortable sitting in urine. Cross-reference F600, abuse. Resident #10 abused Resident #11 twice within two days. Resident #10 hit Resident #11 with a suitcase on 5/29/21, and punched Resident #11 in the arm on 5/31/21. Resident #11 suffered a laceration and bruising to her hand and arm as a result. Resident #10 also allegedly pushed Resident #13 down to the floor; no injuries were documented. All three residents had dementia and resided in the memory care neighborhood. Cross-reference F689, accident hazards. The facility failed to provide two-person assistance with sit-to-stand lift transfers for Resident #8 resulting in potential for fall. Resident #8 stated the nurses were not comfortable transferring her by themselves, but they often did so. Additionally, the facility failed to provide safe transferring for Resident #7, which resulted in a fall. Cross-reference F697, pain management. The facility failed to respond in a timely manner to Resident #4's requests for pain medication resulting in level 7/10 (seven out of 10) to 8/10 (eight out of 10) pain and the resident having to use the call light for a second request more than two hours later. The resident reported that he was in pain and miserable. Cross-reference F744, dementia care. The facility failed to provide sufficient staffing on the memory care unit, and failed to appropriately respond to Resident #10's behavioral symptoms and aggression, contributing to Resident #10's abuse of Resident #11 on two occasions. Staff responded to Resident #10 with force. Resident #11 suffered a laceration and bruising. Findings include: I. Facility policy and procedures The Nursing Services policy, revised 9/13/19, was provided by the director of nursing (DON) on 6/14/21 at 9:46 a.m. The policy documented in part that the facility provided 24 hour nursing services. The determination of the sufficient numbers of nursing staff was based on the number, acuity and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility would ensure residents' abilities and activities of daily living did not diminish unless unavoidable. Each resident was to receive care to maintain continence unless it was not possible and documented in the care plan. The facility was to ensure implementation of strategies to maintain resident safety and to prevent falls. On 6/15/21 at 11:46 a.m., the DON emailed a Recruitment & Retention Efforts document, updated 6/14/21 (no initiation date provided), which documented in part the following: As the only long term care facility in the county, the value of their services was very high as people were able to stay in their community versus moving two hours away for care as in years past. The community was rural and the cost of living was high, which made recruiting very challenging. Efforts to [MEDICATION(S)] those challenges included: retention, referral and sign-on bonuses; employee housing as a benefit; adding contracted clinical staff; recruitment on social media, hiring websites, direct mail and targeted marketing; positions added including RN staff development and clinical staff scheduler; and certified nurse aide (CNA) training with paid tuition and paid training time. II. Resident census and status The Resident Census and Conditions of Residents, provided by the DON on 6/9/21 at 12:26 p.m., revealed 40 residents lived in the facility, and had the following care and assistance needs: -For transferring, 28 residents needed assistance of one or two staff; -For toilet use, 29 residents needed assistance of one or two; -27 residents were occasionally or frequently incontinent of bladder and 20 were incontinent of bowel; -27 residents were on a urinary toileting program and 20 were on a bowel toileting program; -19 residents received rehabilitative services; -19 residents were on pain management programs. III. Resident interviews Residents who were interviewable per facility assessment made the following comments when asked about facility staffing. Resident #4 was interviewed on 6/9/21 at 1:00 p.m. He said the facility did not have enough staff and as a result he often had to wait for things he needed, especially during shift change. He said recently he asked for pain medication at 5:20 p.m., and the nurse told him it was almost time for shift change and she would report to the oncoming nurse. He recalled having to ring his call bell to request the medication again, and he did not receive his pain medication until two and a half hours after he requested it. By then his pain level of up to a 7 out of 10, and he was miserable. (Cross-reference F697, pain management.) Resident #6 was interviewed on 6/9/21 at 1:40 p.m. She said the facility did not have enough staff and if I ring the buzzer it could be a long time; 10 to 15 minutes. She said she usually just needed ice water, but if she did need something important and had to wait, it could be a problem. Resident #8 was interviewed on 6/9/21 at 2:01 p.m. She said they needed two staff on her neighborhood, but often had only one, and when they transferred her with the sit-to-stand (mechanical) lift with one person it scared the CNA. She said the sit-to-stand was uncomfortable but she wanted to keep her independence. She said she used a power wheelchair once she got assistance out of bed. (According to her care plan, she needed extensive assistance of two for bed mobility and transfers. Cross-reference F689 accident hazards.) Resident #7 was interviewed on 6/9/21 at 2:17 p.m. She said call light response sometimes took a while. She said her longest waits were 10 to 15 minutes, sometimes 20. She said there were not enough CNAs to help with her needs, such as transfers, help to the bathroom, and sometimes I can't hold my urine which made her bladder hurt, and she felt uncomfortable when she was sitting in urine waiting for staff assistance. (Cross-reference F550, dignity.) Resident #5 was interviewed on 6/9/21 at 2:43 p.m. He said, They're short help; call light response isn't good. He said he waited 20 to 30 minutes for call light response, and when he got onto the toilet he told them they can't leave the room because it did not feel safe and he did not want to have to wait for them to return to assist him off the toilet. They need more CNAs. A regular visitor to the facility was interviewed on 6/10/21 at 11:30 a.m., and said she was concerned about staffing. III. Observations Observations of the memory care neighborhood at dinner time, approximately 5:30 p.m., on 6/9/21 revealed the neighborhood was hectic and staff were rushed trying to meet residents' needs. Eleven residens resided in the memory care unit. Three staff were serving and assisting residents to eat. One resident was crying loudly, standing up from the table and trying to leave the dining room. Another resident abruptly stood up from the table several times and was asked by staff to sit down and eat or drink. He eventually got up and walked down the hall to his room; staff followed him to assist him to the bathroom. He was unsteady on his feet. Record review revealed there had been a recent resident-to-resident abuse situation on the memory care unit, resulting in an injury. (Cross-reference F600 abuse, and F744 dementia care.) IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 6/9/21 at 4:50 p.m. She said they had two certified nurse aides (CNAs) on the second floor, and another CNA was coming in soon. For residents who needed two-person transfers, she said she helped the CNAs which was sometimes difficult when she was in the middle of medication pass. CNA #1 was interviewed on 6/9/21 at 5:00 p.m. She said she was very unhappy with how they schedule here. She said she had worked on the memory care neighborhood by herself three days straight for 12-hour shifts without breaks, and they usually needed two CNAs on memory care. She said there were a lot of staff on light duty because they worked by themselves and got hurt. For the residents who needed two-person assistance, they would have to get someone from the other side, or get a nurse to help, and it was not fair to the residents because they have to wait. She said the lack of CNAs definitely causes incontinence and not being prompt. She said with the sit-to-stand and Hoyer lifts at least two staff were needed, but she had transferred residents by herself using the sit-to-stand lift. It happens every shift. I'm the only CNA; sometimes the nurses are not available and the residents need help. You're not going to look in 15-plus rooms to find the nurse before you can get the next person up. She said the residents deserve better. Activity assistant (AA) #1 was interviewed on 6/9/21 at 5:29 p.m. She said there had not been enough CNAs in the facility for about three months, and added that it was too much for all of us who are still here. It's not okay because we here care about (the residents) so much as if they're our family but we're getting burnt out, covering shifts, and if we make a mistake we get in trouble for it, but we're here 24/7. She said the residents were affected. She said it was not good for staff's mental state or the residents' when staff were tired and overworked. She said residents were doing without or waiting too long for assistance with transfers, and had experienced falls as a result. We just need more staff on the memory care unit. We have to transfer three residents (with two staff) and a lot of times there's not enough staff. I can't do CNA duties. The nurse helps when she can. We've had a lot of travelers and they're great. It's a disaster back here with only one CNA. We just need more people up here. CNA #3 was interviewed on 6/9/21 at 5:37 p.m. She said the residents need help so she could not stop and talk. She was helping serve dinner and assisting residents to eat. The nurse manager (NM) was interviewed on 6/9/21 at approximately 5:45 p.m. She said they had enough staff but they need to use their resources. However, she said there was no way for staff to call for help from a resident's room other than the call light. She said all staff should be using two-person assistance for lift transfers. The DON was interviewed in her office on 6/9/21 at 5:55 p.m. She said two persons should always be used with every lift. She said call light response should be five minutes or less. She said they had sufficient staff, and that when staff came in for their shift they were provided an R-Care cell phone for charting and communication if they needed assistance from other staff. During an interview on 6/10/21 at 8:45 a.m., the DON provided policies and documentation, but did not provide follow-up regarding the staffing concerns voiced by residents and staff from the day before. The NM was interviewed a second time on 6/10/21 at 2:10 p.m. Regarding staffing, she said they had had some staffing issues. She said there were times they did not have enough staff to get residents to the toilet on time. She said, I think that's a dignity issue because they're not getting the care they deserve. She said there may have been times when a CNA had to work alone on the memory care unit, and might have had to get assistance from other staff, leaving the residents alone, which was not safe. The NHA and DON were interviewed at 3:20 p.m. on 6/14/21. The NHA said their recruitment and retention process had been extensive. Because of their location in a rural mountain community, recruitment and retention were definitely a challenge. We actually have a whole sheet of everything we've done to try to recruit. The DON said their census as of 6/14/21 was 39 residents; 18 residents on the first floor and 20 residents on the second floor. There were 11 residents in the memory care neighborhood. The facility staffing expectations and current staffing were as follows: -On the first floor rehab hall and LTC hall, one nurse and one CNA each for day shift; night shift one nurse and two CNAs. She said maybe two residents needed two-person assistance. -On the second floor LTC and memory care neighborhoods: for day shift, one nurse (one on LTC and one in memory care) and three CNAs (shared LTC and memory care); for night shift, one nurse and two CNAs from 6 p.m. to 6 a.m., plus an additional CNA 6:00-11:00 p.m. in memory care. She said maybe one resident needed two-person assistance on memory care, depending on the day. On the LTC side, three residents needed two-person assistance. The NHA and DON said in memory care they felt they had really tried to make sure there's care up there. They said they tried to replace call-offs, and to their knowledge residents were never left alone, which was not safe. They said they had put the Zoom app in place on staff cell phones in response to staff's requests, within the past six months, and that staff had not informed them it did not work properly or that had been unable to use the app to summon assistance without leaving residents to do so. V. Record review Review of resident council meeting minutes for the past three months revealed no documentation that residents were asked about nursing staffing levels or nursing care and assistance. Review of staffing daily reports for the past three months revealed nursing staffing, even at the current levels which staff and residents stated were insufficient, was frequently less than planned and expected. Specifically: -On 3/6/21, memory care (MC) was short one CNA on night shift, leaving only one CNA working on MC -On 3/7/21, MC was short a nurse on day shift and a CNA on night shift -On 3/8/21, MC was short a CNA on day shift -On 3/13/21, one CNA worked a short shift on day shift, and was short one CNA on night shift -On 3/14/21, MC was short a CNA on day shift and night shift -On 3/18/21, MC had two CNAs who worked only partial day shifts. There was no CNA documented on duty between 3:00 and 6:00 p.m. -On 3/20/21, MC was short one CNA and the second CNA worked only three hours -On 3/25/21, MC was short a CNA on day shift -On 3/26/21, the second MC CNA worked for only three hours -On 3/27/21, MC was short a CNA on night shift -On 3/28/21, MC was short a CNA on night shift -On 3/29/21, MC was short a CNA on night shift -On 3/30/21, MC was short a CNA on night shift -On 3/31/21, MC was short a CNA on night shift -On 4/1/21, LTC was short a CNA on day shift -On 4/4/21, LTC was short a nurse on day shift -On 4/5/21, MC was short a CNA on night shift -On 4/6/21, LTC was short a nurse on day shift and MC was short a CNA on day shift -On 4/7/21, 2nd floor LTC was short a CNA on day shift -On 4/10/21, the Rehab hall had two CNAs working partial shifts, leaving six hours without CNA coverage on day shift -On 4/11/21, two CNAs worked partial shifts -On 4/14/21, there was no CNA on LTC on day shift -On 4/17/21, two CNAs worked partial shifts on LTC night shift, and MC was short a CNA -On 4/18/21, MC was short a night shift CNA -On 4/20/21, 1st floor LTC was short a nurse -On 4/21/21, MC was short a CNA on day shift -On 4/22/21, MC was short a CNA on day shift and LTC was short a CNA on night shift -On 4/24/21, MC was short a CNA on day shift -On 4/26/21, MC was short a CNA on day shift -On 4/27/21, LTC was short a CNA on day shift and 1st floor LTC was short two CNAs on night shift -On 4/30/21, 1st floor LTC had only one CNA who worked a half shift -On 5/1/21, MC was short a CNA on day shift -On 5/2/21, rehab was short a CNA on night shift -On 5/3/21, LTC was short a CNA and the second CNA worked a half shift on day shift -On 5/4/21, MC was short a CNA on night shift -On 5/5/21, Rehab was short a CNA on day shift -On 5/6/21, Rehab was short a nurse on day shift -On 5/7/21, LTC was short a nurse and a CNA on night shift -On 5/8/21, LTC was short a CNA on day shift and night shift -On 5/9/21, LTC was short a nurse on day shift and the CNA worked a short shift; there was no CNA on night shift -On 5/10/21, LTC had no CNA and MC was short a CNA on day shift -On 5/11/21 and 5/12/21, Rehab had no CNA on night shift -On 5/13/21, LTC had no nurse on day shift; the night LTC CNA worked only four hours and MC was short a CNA -On 5/14/21, LTC had no nurse on day shift and no CNA on night shift; MC was short a CNA on night shift -On 5/15/21, Rehab had no CNA on night shift; LTC had no nurse on day shift and the night shift CNA worked a partial shift -On 5/16/21, Rehab had no CNA on night shift and LTC had no nurse on day shift -On 5/17/21, LTC had no CNA on day shift -On 5/18/21, MC as short a CNA on night shift -On 5/17/21, LTC was short a CNA on day shift -On 5/23/21, LTC had no CNA on night shift -On 5/25/21 and 5/26/21, LTC was short a CNA on night shift -On 5/28/21, MC was short a CNA on day shift -On 5/29/21, MC was short a CNA on day shift. -On night shift 5/29 and 5/30/21, MC had one CNA who was orienting another CNA, and one CNA on LTC; all three staff were instructed to help 1st floor with rounds as no CNAs were on duty there -On 6/1/21, Rehab had no CNA on day shift -On 6/5/21, MC was short a CNA on day shift -On 6/7/21, MC was short a CNA on night shift

Based on record review and interviews, the facility failed to ensure a dignified existence was provided for one (#7) of nine residents reviewed out of 13 sample residents. The facility failed to respond in a timely manner to Resident #7's requests for assistance to the bathroom, resulting in incontinence accidents, discomfort and a rude staff response after an incontinence episode. Due to the facility not providing timely incontinence care, Resident #7 said she sometimes could not hold my urine, had to wait until her bladder hurt and recalled one incident where the nurse gave me a very bad look because I am not supposed to wet myself, and reported feeling uncomfortable sitting in urine. Findings include: I. Facility policy and procedures The Bowel and Bladder Assessment policy, revised 3/22/19, provided by the director of nursing (DON) on 6/10/21 at 2:35 p.m., documented: It is the policy of the (corporate) facilities that residents are assessed upon admission and at other appropriate clinical times for bladder retraining/toileting programs. The standard of care is to provide an individualized, resident-centered toileting program for all appropriate residents, with individualized interventions and goals to enhance the resident's quality of life and functional status. II. Resident #7 status Resident #7, age 70, was admitted on [DATE]. According to the 6/10/21 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/6/21 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score of 15 out of 15 showing the resident was cognitively intact. She required extensive assistance with bed mobility, transfers, locomotion, toilet use, and personal hygiene. Walking was not tested . She had impairment in her bilateral lower extremities and one upper extremity. She was occasionally incontinent of urine and never incontinent of bowel. III. Resident interview Resident #7 was interviewed on 6/9/21 at 2:17 p.m. with a follow up interview on 6/10/21 at 9:33 a.m. She said she felt there were not enough certified nurse aides (CNAs) to help with her needs, such as transfers to the bathroom. (Cross-reference F725, sufficient nursing staffing.) Resident #7 said, Sometimes I can't hold my urine. She said she sometimes had to wait so long that her bladder hurts, and recalled one incident in which the nurse gave me a very bad look because I am not supposed to wet myself. Resident #7 reported feeling uncomfortable sitting in urine. IV. Staff interviews The DON was interviewed 6/10/21 at 8:45 a.m. and again in conjunction with the nursing home administrator during exit on 6/14/21 at 4:00 p.m. The DON stated the resident had increased incontinence due to being on diuretics, and denied any knowledge of an updated treatment plan assessment, such as a revised toileting plan, after diuretics started. She said it was a dignity issue for the resident to experience incontinence due to delayed assistance and call lights should be answered within five minutes. She stated the bad look the resident received from staff was not tolerated and was not reported. The nurse manager (NM) was interviewed on 6/10/21 at 2:10 p.m. The NM stated there were times where they did not have enough staff to get residents to the toilet on time. She said she believed it was a dignity issue because they are not getting the care they deserve. The therapy director (TD) was interviewed on 6/10/21 at 11:00 a.m. She said Resident #7 was on an ongoing skilled maintenance program. To prevent decline the resident received therapy two times a week. CNA #1 interviewed on 6/9/21 at 5:00 p.m. She said it was not fair to residents because they had to wait, which sometimes caused incontinence and not getting prompt care from staff. Activity assistant (AA) #1 was interviewed on 6/9/21 at 5:29 p.m. She said they had not had enough CNAs for approximately three months, which affected the care of residents. She said AAs cannot perform CNA duties, and nurses helped when they could, but the facility) just needed more staff to help. V. Additional interview A frequent visitor to the facility was interviewed on 6/10/21 at 11:30 a.m. She verbalized concerns about lack of staffing and said staff seemed rushed and were not informed of individuals' needs. VI. Record review The resident's care plan, initiated 2/22/21 and revised 4/2/21, identified the resident required assistance with transfers, ambulation, wheelchair mobility, and toileting due to [CONDITION(S)] (CVA) with left sided weakness, generalized weakness, and decreased mobility. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] (diuretic) 20mg started on 5/5/21. -The care plan was not updated after increasing the resident's diuretics. A nursing progress note dated 1/14/21 at 5:54 p.m. documented: Resident refuses to use sit to stand (a mechanical lift). This resident self transferred from wheelchair to toilet this shift. Resident stated, 'I could feel my bone and had to go.' This nurse reminded resident to not self transfer, to wait for staff, it is not safe for her. (Cross-reference F689, accident hazards)

Based on record review and staff interviews, the facility failed to ensure two (#11 and #13) of three residents reviewed for abuse out of 13 sample residents were free from resident-to-resident abuse by Resident #10. Resident #10 abused Resident #11 twice within two days. Resident #10 hit Resident #11 with a suitcase on 5/29/21, and punched Resident #11 in the arm on 5/31/21. Resident #11 suffered a laceration and bruising to her hand and arm as a result. Resident #10 also allegedly pushed Resident #13 down to the floor; no injuries were documented. All three residents had dementia and resided in the memory care neighborhood. Cross-reference F744, dementia care. Findings include: I. Facility policy and procedures The Vulnerable Adult policy, revised 2/4/2020, was provided by the director of nursing (DON) on 6/14/21 at 9:46 a.m. The policy documented that residents had the right to be free from physical abuse, and abuse was prohibited. Procedures in part documented the following: Provide for the immediate safety of the resident upon identification of abuse. Actions include but are not limited to: provide one to one monitoring or special security; initiate behavior crisis management interventions as applicable. II. Residents' status A. Resident #10 Resident #10, age 82, was admitted on [DATE] and discharged to the hospital 5/31/21. According to the resident face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no minimum data set (MDS) assessment available for Resident #10. B. Resident #11 Resident #11, age 86, was admitted on [DATE]. According to the resident face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/2/21 MDS assessment, Resident #11 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had delusions and mood issues related to feeling down/depressed/hopeless and difficulty concentrating. The resident was independent or needed supervision for activities of daily living. C. Resident #13, age 79, was admitted on [DATE]. According to the resident face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] There was no MDS available for Resident #13, who had been discharged . III. Abuse incidents A. 5/29/21 Review of facility investigative documents and interdisciplinary progress notes revealed on 5/29/21 at 6:07 p.m. Resident #10 got into an altercation with another resident taking a suitcase out of the room and then hitting resident (#11) leaving a bruise to the right outer palm and a cut to the outside of the pinky. Resident (#10) has been exit seeking and wandering into others rooms removing things. This resident hit CNA (certified nurse aide) this AM (morning). (Physician) ordered a stat [MEDICATION(S)] 12.5 mg to be given. Call placed to POA (power of attorney), notified and phone consent given. DON (director of nursing), police, POA, MD (medical doctor) notified. Written statements from staff revealed the following, in pertinent part: I was in a room helping a resident when one resident came in the room and told me that there were two residents fighting on the hallway; I immediately came out and separated them. While separating them I saw one of the resident finger was bleeding . I reported the incident to the nurse who took control of the situation. (documented by CNA #4 on 5/29/21) This morning (Resident #10) was in (Resident #11's) room with bags packed (his bags). (Resident #11) was afraid he stole her stuff. I assured her that he didn't and confirmed that the bags were full of his belongings. 30 mins later I found (Resident #10) in (Resident #11's) room again, this time he was taking objects that belonged to (Resident #11). One of them being her suitcase with wheels. (Resident #10) was walking in the hallway with (Resident #11's) suitcase. When I asked for it back and reached for it (Resident #10) swung the suitcase at me. He whacked me with pretty good force. (Resident #10) has been in an aggressive mood all day. Trying to escape and packing his things all day. Later today (CNA #4) went in a room helping a resident and I was charting. (CNA #4) came over to me and asked what happened. I was unaware until (CNA #4) told me what (another staff member) told him, (Resident #10) hit (Resident #11). I then saw (Resident #11) and her hand was dripping blood onto the floor. (documented by CNA #1 on 5/29/21) At approximately (4:30 p.m.), this RN (registered nurse) received a call from the second floor CNA (#1), for assistance. Upon arrival, resident (#11) presented with a cut and bruising to her right hand/pinky finger. Per eyewitnesses, another resident (#10), took a suitcase from her room, and when she attempted to get it back, he swing the suitcase and hit her hand. Per report from CNAs, this was the resident's second attempt to hit someone with a suitcase today. (documented by RN #3 on 5/29/21) B. 5/31/21 Review of investigative documentation revealed abuse by Resident #10 against Resident #11 and allegedly against Resident #13. There were no IDT notes in Resident #10's chart after the 5/29/21 abuse incident, until a second abuse incident, which also involved Resident #11, on 5/31/21 at 5:26 p.m., when licensed practical nurse (LPN) #2 documented: Shortly after breakfast (Resident #10) went to end of hall and started moving clothing to one of the chairs. He became what I would call territorial of this location and when I approached he struck out at me but I was able to handle the moment and he deescalated when I walked away. He refused to leave the area and ate his lunch at the end of the hall on an over bed table. He was witness to another resident (#13) falling at (1:15 p.m.) in the hall. He said he pushed her but the resident that fell did not validate his story nor any other resident witnesses. No staff witnessed. At approximately (2:00 p.m.) another resident approached the end of the hall. Words were exchanged and he punched the resident (#11) in the arm. This was witnessed by staff who intervened, pulling the other resident away to safety. 911 was called and when police arrived he was back up in a chair at the end of the hall, calm but guarded by two CNAs. Police were able to talk him back into his room where he remained until decision was made to transport him to (a local) hospital. When EMS arrived he at first was cooperative, but then started throwing the buckles to the gurney off and calling us names. It required 6 (staff and EMS) to restrain while sedation was administered. He left with EMS at (4:20 p.m.). A call was made to (the hospital) to inform them of his pending arrival. Written statements by staff revealed the following in pertinent part: On (5/31/21 at 10:00 a.m.) I was on duty in memory care by myself to handle 12 residents. (Cross-reference F725 sufficient nursing staffing.) I observed (Resident #10) was agitated since he got up in the morning. While I was busy doing other stuff in the dining room with other residents, I heard that (Resident #10) pushed one of my residents (#13) to the floor. Upon checking at the hallway where (Resident #10) was standing and I saw him very aggressive and I called the attention of my nurse (LPN #2) to help me to calm him down. After lunch on the same day I heard again a commotion on the same hallway wherein (Resident #10) again was agitated and I saw (LPN #2) running towards him to calm him down but instead hit (LPN #2) and helped (LPN #2) to hold (Resident #10) because he was really aggressive and combative at that moment. We were able to take (Resident #10) down to the floor to stop being aggressive, but (Resident #10) was so strong to handle and fortunately (CNA #4) came and helped us to hold (Resident #10) so (LPN #2) could call the cops and the administrator what's going on. And the aggressiveness of (Resident #10) stopped and he calmed down when the two cops came in. (documented by CNA #5) (Resident #10 and Resident #11) were standing at the far end of the memory care hall by the emergency exit door . by the two windows behind the chairs and table. (Resident #11) was in front of the left window when (Resident #10) said, 'I want to break that window open. She needs to move.' (Resident #10) then proceeded to grab (Resident #11) by the right bicep. (Resident #11) then pushed his arms away and said, 'Stop, don't touch me.' (Resident #10) then proceeded to hit and punch (Resident #11) on the right arm (bicep) area. After that happened I then directed (Resident #11) to calm down and walk with me to the dining room for a refreshment. (documented by activity assistant #1) IV. Record review regarding Resident #10 Review of the resident's care plan revealed it was not revised until after the 5/31/21 incidents. The behavior care plan, initiated 5/11/21 and revised 6/2/21, documented: I have a history of expressing myself with aggressive behaviors, wandering/elopement attempts and actions. I have a history of physical altercations with fell ow residents and staff. This is due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Responses from others which help to improve my behavioral expressions are redirecting me from stimulation and other residents, offering me a snack and a drink, visiting with me on the patio, engaging me in an activity, calling my friend/POA. Although Resident #10 was listed on the facility's resident roster/matrix, he had not returned to the facility since he was sent to the hospital after the 911 call on 5/31/21. V. Staff interviews The nursing home administrator (NHA) and DON were interviewed on 6/14/21 at 3:20 p.m. They said there had been two incidents where Resident #10 abused Resident #11. During the first incident on 5/29/21, Resident #10 went into Resident #11's room, got her suitcase and hit her with it. During the second incident on 5/31/21, Resident #10 was having some behaviors, wanted to be left alone, and Resident #11 approached him and they were talking back and forth and he lightly reached out and hit her arm with his hand. Life enrichment staff reported to the nurse, Resident #10 became physically aggressive with the nurse, a CNA came in, 911 was called, he was going after nurses and they were trying to get other residents out of the hallway. He was taken down to the floor by staff because he was attacking them, and then went after police. Police were able to get him into his room. He kind of deescalated and then became aggressive with EMTs and the police; the EMTs gave him intramuscular sedation and took him to the hospital. From there he went to a behavioral facility. They said the hospital staff knew the plan was to send him to a behavioral facility. It was more of a crisis at the time and waiting for resources would only put staff and residents at risk. They said between the first abuse incident on 5/29/21 and the second on 5/31/21, they talked to staff about the suitcase being a trigger for the resident, so they removed suitcases from sight, provided some one-on-one supervision of Resident #10 until the next morning and then he was fine, nothing happened, and he was very redirectable and pleasant. The first incident was a Saturday evening and the next was Monday afternoon. They said they had not heard back from the hospital or the behavioral facility to give an update on Resident #10 and the treatment he received. The NHA and DON did not mention the alleged abuse by Resident #10 against Resident #13 (see 5/31/21 incident documentation above). The facility failed to ensure Residents #11 and #13 were free from abuse by Resident #10.

Based on record review and interviews, the facility failed to ensure adequate pain management was provided for one (#4) of nine residents reviewed out of 13 sample residents. On 6/7/21 the facility failed to respond in a timely manner to Resident #4's requests for pain medication resulting in level 7/10 (seven out of 10) to 8/10 (eight out of 10) pain and the resident having to use the call light for a second request more than two hours later. The resident reported that he was miserable. Findings include: I. Facility policy and procedures The Pain Management policy, revised 1/3/2020, provided by the director of nursing (DON) on 6/10/21 at 3:14 p.m., documented: The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. II. Resident #4 status Resident #4, age 81, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/2/21 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score of 15 out of 15 showing the resident was cognitively intact. No [CONDITION(S)] or behavioral symptoms were documented, including rejection of care. His pain frequency was described as frequent with disruption of sleep, limitation of day to day activities and a numerical level of 10/10. III. Resident interview Resident #4 was interviewed on 6/9/21 at 1:25 p.m. He said he was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He recalled an incident on 6/7/21 stating he had asked for [MEDICATION(S)] for pain relief at 5:20 p.m. before shift change. The resident said his feet were bell-[NAME] (indicators) and let him know when general pain was coming on. He requested medication when his feet started hurting and pain was at 3/10. He preferred to stay at a 2/10 pain level. The resident said he had to use the call button to ask for [MEDICATION(S)] a second time from the evening nurse, and stated there was a shouting match. He reported the nurse did not shout back at him. The resident stated that he believed he received pain medication at about 7:50 p.m., at which time his pain had increased up to 7/10. Resident #4 said, I was miserable. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 6/10/21 at 12:33 p.m. The RN recalled that the resident did request [MEDICATION(S)] at approximately 7:20 p.m. on 6/7/21. She said she told him he had to wait because Tylenol was just given. The RN stated she had received the impression from the nurse practitioner (NP) that day that Tylenol and [MEDICATION(S)] were to be trialed to wean the resident off of [MEDICATION(S)]. The RN said she did report to the night nurse that the resident had requested [MEDICATION(S)], and relayed that they were trying to wean him off. The RN said the night nurse stated the resident had scheduled [MEDICATION(S)] and [MEDICATION(S)] available for pain relief at night. The DON was interviewed in conjunction with the nursing home administrator (NHA) on 6/14/21 at 3:20 p.m. The DON stated they were looking at [MEDICATION(S)] use with the resident due to respiratory distress. She said they (facility) were trying to find a fine line to keep him from being sedated. She said she was unsure of the events of the evening of 6/7/21. VI. Record review The resident's pain care plan, initiated 5/28/21 and not since revised, identified the resident had pain due to chronic pain syndrome, history of [CONDITION(S)], and required medication to help him sleep. The care plan identified the following non-pharmacologic approaches were effective in helping the resident manage his pain: repositioning, warm blanket, ice pack, warm towel, emotional support, activity, music, TV shows, and movies. The undated Observation Detailed List Report (pain assessment) provided by the DON on 6/15/21, documented the following: The resident was able to verbalize and describe pain. He had pain indicators noted three to four days out of the past five days, and stated that pain occurred frequently. He described his pain as aching, tingling, and dull. The resident reported rest, repositioning, medication, and warmth made pain better. Movement, anxiety, and cold made pain worse. Over the past five days the resident had rated his worst pain at a 10/10 level and described it as very severe, horrible. The location of pain was documented as back, stomach, and joint pain (other than hip). The resident reported pain affected sleep and daily activities within the past five days. It was documented that the resident's manner of expressing pain was with agitation/restlessness, change in activities of daily living (ADL) ability, and verbal expressions of pain. The resident's goal for pain relief was to sleep comfortably, have comfort with movement and at rest, have the ability to participate in/or increase participation in ADLs, and have comfort while attending activities. -There was no documentation in the assessment of the resident's preferred numerical pain level. In the resident interview on 6/9/21 he stated his preferred pain level was 2/10. The daily pain assessment log dated 5/26/21-6/10/21 documented that out of 42 entries, 24 were above the resident's preferred level. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)]-[MEDICATION(S)] ([MEDICATION(S)]) 2-0.5mg every six hours as needed for pain level 5/10 or higher (5/28-6/9/21), updated to scheduled medication starting 6/10/21. -[MEDICATION(S)] arthritis pain gel 1% four times a day to bilateral lower extremities (BLE) (ordered 5/26/21) -[MEDICATION(S)] 1,800mg once a day between 7:00 p.m.-10:00 p.m. (ordered 5/26/21) -[MEDICATION(S)] 50 mg as needed at bedtime (discontinued 6/10/21) -Tylenol 650mg every six hours as needed (started 6/7/21) -[MEDICATION(S)] 600mg every eight hours as needed (started 6/7/21) Non-pharmacological treatments included: warm blanket, ice pack, and repositioning. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] given at 10:02 a.m. on 6/7/21, with no other doses given. On all other days that pain level was 5/10 or greater [MEDICATION(S)] was given as ordered. -[MEDICATION(S)] gel given three times (resident refused noon dose) -[MEDICATION(S)] given at 2:22 p.m. and repositioning provided, no other doses given -Tylenol given at 4:44 p.m. and repositioning provided, no other doses given -[MEDICATION(S)] given as scheduled (between 7:00 and 10:00 p.m.), pain level documented 8/10 at 9:47 p.m. -[MEDICATION(S)] was not administered -Pain monitoring performed as ordered A progress note on 6/7/21 from NP #2 documented the resident was still requiring [MEDICATION(S)], but reported pain had significantly improved. Tylenol and [MEDICATION(S)] were ordered as needed for pain. A progress note from the evening nurse on 6/7/21 at 7:51 p.m. documented: Resident was screaming and using vulgar language to the nurse and certified nurse aides (CNAs) about [MEDICATION(S)], entered resident room to assess pain. Resident verbalized complaint of pain 8 out of 10. No signs or symptoms of withdrawals were observed. Resident alert and oriented to person, place, time, and situation. Resident stated he went too long without his [MEDICATION(S)], It took me the whole weekend to catch up on getting it and I've been asking for it since 5:20 p.m. this evening. Nurse told resident he had [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] available to him. (Per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .) At 8:47 p.m. nurse was responding to other call lights and observed resident knocking belongings over off bedside table and began to hang off bed. Two staff members repositioned the resident in bed and lowered bed to floor. At 11:40 p.m. the nurse observed resident in bed with eyes closed resting. -There was no documentation that alternative pain medications were given, such as [MEDICATION(S)], [MEDICATION(S)], or Tylenol. The medication the resident had requested ([MEDICATION(S)]) was not documented to be offered or given to the resident. There was no documentation that the nurse called the resident's physician to report his pain level and that requested pain medication was not given. The care plan was not updated. There was no follow up pain assessment after [MEDICATION(S)] was given.

Based on record review and interviews, the facility failed to provide adequate dementia care to meet the needs of two (#10 and #11) of three residents reviewed, who resided in the facility's memory care neighborhood. The facility was aware upon admission that Resident #10 displayed aggression at a prior facility and aggression toward facility staff shortly after his admission. However, the facility failed to identify and address root causes and unmet needs, and develop person-centered approaches to meet the resident's needs; and appropriately intervene to prevent the resident's behaviors from negatively affecting himself and others, including Resident #11. Instead, the facility staff responded to the resident's aggressive behaviors by using force. These facility failures contributed to Resident #10's abuse of Resident #11 on two occasions. Further, the facility was aware upon admission that Resident #11 was vulnerable due to a history of being abused, and exhibiting invasive behaviors that frustrated other residents. However, the facility failed to identify and adequately address root causes and unmet needs, and develop person-centered approaches to ensure the highest practicable quality of life for Resident #11. These failures contributed to Resident #11 being hit by Resident #10 during two separate incidents, and suffering a laceration and bruising. Findings include: I. Facility policy and procedures The Dementia Care policy, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 9:46 a.m. A systematic process will be used including input from interdisciplinary team members to provide holistic care for residents with dementia, to include in pertinent part: -Review of current/past medications and medical history; -Review plan of care and make changes as necessary based on staff input; -Use of consulting psychologist as needed for assessment/interventions and education to staff; -Review of unresolved behavior issues as needed; -Facility will attempt to obtain life patterns, previous preferences and information on previous psychological and/or behavioral expressions from resident/family to assist in developing a comprehensive, resident centered care plan; -Gather information on the resident's past and current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments; -Gather information on the resident's life experiences, personal preferences, overall health and current medical conditions, including the presence of pain; cognitive status and related abilities; mood and behavior patterns, including how the resident typically expresses physical, emotional and psychosocial needs including distress; -Monitor for safety including wandering; -Create individualized approaches in care plan with measurable goals and specific interventions for management of behavior symptoms/behavioral expressions; -Monitor effectiveness of interventions and modify/change interventions as needed; -Involve resident/family in creating individualized care plan; -Additional training will be given to dedicated staff for the memory care unit regarding dementia care. II. Resident #10 A. Resident status Resident #10, age 82, was admitted on [DATE]. According to the resident face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no minimum data set (MDS) assessment available for Resident #10. B. Record review 1. Care plan The resident's behavior care plan, initiated [DATE], documented: I have a history of expressing myself with aggressive behaviors, wandering/elopement attempts and actions. I have a history of physical altercations w/ fell ow residents and staff. This is due to dx (a diagnosis) of dementia with behaviors. Situations and environmental factors which lead to increased difficulty are other residents becoming agitated and aggressive, excessive stimulation, unfamiliar environment/people. Responses from others which help to improve my behavioral expressions are redirecting me from stimulation and other residents, offering me a snack and drink, visiting w/ me on the patio, engaging me in an activity, calling my friend of POA (power of attorney). Interventions were: -Staff to work with me and my friend/POA to identify situations which trigger behavioral expressions and to identify coping skills which have worked for me in the past. Staff to assist me in using these coping strategies. (start date [DATE]) -Redirect me from stimulation and other residents, offer me a snack and drinks, take me out to the patio and visit with me, attempt to engage me in an activity and assist me with calling my POA friend. (start date [DATE]) 2. Medications Review of [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Interdisciplinary team (IDT) progress notes A nursing admission note documented on [DATE], Resident admitted to facility at 1410 accompanied by facility transportation from (local hospital). Resident is A&O to self only. Vitals on admission WNL. Neuros WNL. Denies pain on admission. Lungs CTA, abdomen soft non-tender. Bruise noted to Right arm. Continent of Bowel & bladder. SBA with all cares and no assistive device use. Oriented resident to room and floor. POA plans to come in [DATE] to complete admission paperwork. Called (name) POA over the phone and received consent to administer all meds including [MEDICATION(S)] 25 mg BID (twice daily). According to a nurse practitioner (NP) #2 note on [DATE], the facility was aware upon his admission that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He had an episode of aggression at (a previous memory care facility in a nearby city). He was hospitalized and work up was negative. He is sitting in dining room painting and is unable to provide ROS (review of systems). He refused physical exam. Nursing and IDT notes further revealed the following behavioral issues and facility response: On [DATE], Medical Management: Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Pleasant and compliant with all nursing cares this shift. No behaviors noted . No use of assistive device, ambulating the unit without assistance and difficulty. Brief episode of wanting to leave this afternoon but was easily redirected. On [DATE] at 6:37 p.m., Unpleasant and non-compliant with VS (vital signs) measurements and medications this shift. Became more friendly this afternoon . Brief episode of wanting to leave this afternoon but was easily redirected. On [DATE] at 4:01 p.m., NP #2 documented, Resident seen today to re-direct from demanding to leave the facility and to 'go home.' He packed his suitcase and was waiting by the exit doors, repeatedly yelling that he wants to go home. He is disoriented at baseline but is more agitated than normal. He has a history of episodes of increased behaviors at his prior facility. Resident was redirectable with popcorn and soda, he is sitting at table eating and 'waiting for his ride.' Spoke with POA. After our discussion I reassured (Resident #10) that his home was safe and he didn't need to worry, and that this is just 'short term'. (Resident #10) enjoys having a job to do such as sweeping and mopping, after eating a snack RN will suggest he sweeps the floor. -Social work was able to redirect with snack, and was able to move his suitcase back to his room. -(POA) mentioned that (Resident #10) recently lost his Iphone 8 and is wondering if it's been found. Staff are checking into this. He isn't aware of any other events that could be triggering him. -He states he will call friends to come and check on (resident name) so he is able to see familiar faces. -Will monitor behaviors and will consider CBC (complete blood count), CMP (complete metabolic panel) and UA (urinalysis) if continues, and increasing [MEDICATION(S)] (antipsychotic). On [DATE] at 9:12 a.m., an activities staff person documented: Res (resident) has been observed as good/active in participating in activities of leisure. Resident enjoys going outside on the patio throughout the day, watching television, art/crafts, projects throughout the day to work on, and enjoys snacks (ice cream and chocolate). Staff will invite, remind, escort res to activities of interest and as resident's mood allows and tolerates staff. Res also enjoys independent activities in his room (reading the newspaper/flipping through magazines) and shows contentment/joy through these activities. Staff will continue to meet with res and ensure that quality of life is maintained and well being needs are met. On [DATE] at 1:52 p.m., Resident pulled white board out of the wall from dining area, yelling and threatening to throw the board at this staff. Attempted to talk to the resident about taking the board out of the area. Attempted to remove away from situation from the common area. Attempted to involve in activity. Interviewed resident for pain. Interventions not effective at time of situation and resident calmed down after and walked to a quiet area with another nursing staff. Notified provider of event. On [DATE], NP #2 documented at 2:05 p.m., Resident seen today to re-direct after taking a picture off of the wall in the dining room, threatening to hit staff with it, and throwing it on the ground. He yelled at an aide calling her an a------ as she retrieved the picture from the floor. He was likely triggered by another resident who was yelling and attacking staff. He does have a history of dementia with aggressive behaviors and became aggressive 3 days ago in dining room. He is Ax0xself, and is redirectable . Dementia with increased behaviors-took one time added dose of 25mg [MEDICATION(S)] today. -Increase [MEDICATION(S)] from 25mg PO (orally) BID (twice daily) to 50mg PO BID for recent increased frequency of agitation. -Will consider CBC, CMP and UA if behaviors continue. On [DATE] at 5:09 p.m., Resident spent most of the day calm but had two outbursts. Mid morning he threw his tylenol across the room. Just prior to dinner he started acting out and angry, saying he wanted to leave. Resident packed a plastic bag and said he wanted to leave; he then used bag to bump (staff person first name) as he passed her. Resident left the dining area and is staying in room. Will continue to monitor. On [DATE] at 5:08 a.m., Around 2:45 am resident came out of his room with a bag of clothes; seeking to go out. Resident walked one loop around the hall and went back to his room. No additional behavior noted this shift. Will continue to monitor. On [DATE] at 9:17 a.m., Unable to administer AM medication d/t res.'s belief that he had already taken his medications. Waited until after breakfast to try to administer medications. Res. became angry stating he had already taken his medications and stated, 'I am better than you are' as he pointed his index finger. Res. Hurriedly walked out of the common area. Will attempt administration after lunch. On [DATE] at 1:59 p.m., This nurse attempted multiple times from start of shift (10:00 a.m. to 2:00 p.m.) to get resident to take medications. Resident is refusing, and continuing to offer it to him is making him more agitated. Will stop attempting to offer it at this time. Will continue to monitor resident as he is displaying some anger, though no outbursts at this time. On [DATE] at 3:33 p.m., Multiple instances this shift of aggressive behavior by resident. He has walked out of his room four times today with two bags of his belongings seeking to leave to 'go to a meeting.' Twice, he made a lap of the unit and went back to his room. The other two times, he became aggressive, once banging the glass on the nurse's station hard with one of bags multiple times, and the other time swinging his bag at staff. After both encounters, he quickly went back to his room for a few hours at a time. On [DATE] at 7:15 a.m., Res. was amenable to taking ordered medications. When CNA (Certified nurse aide) attempted to obtain VS, Res. became agitated and verbally aggressive stating staff would regret touching him. CNA left Res.to inform RN of threats. When RN went to check on Res. he calmly got up from his chair in dining area and walked to his assigned room without answering any questions or making visual contact with staff. Res. has remained in room this AM. On [DATE] at 3:51 p.m., NP #2 documented, Resident seen today to f/u (follow up) on c/o (complaints of) continued aggressive behaviors despite increased [MEDICATION(S)]. Last Friday he had his bags packed and was waiting by the door to leave. Over the weekend he hit the RN with his bag of belongings and was slamming his bag into the glass at the nurses station. Today he is sitting in his bed and doesn't remember either incident. He is alert but not oriented and is unable to answer my questions. -Dementia with increased behaviors-incidents of aggressive behavior continue despite increasing [MEDICATION(S)] from 25mg PO BID to 50mg PO BID. He has a history of aggressive behavior at prior facility. -CBC, CMP and UA for increased behaviors. -If labs normal will consider a change in medication management. On [DATE] at 3:14 p.m., NP #2 documented, Resident seen today to f/u on aggressive behavior this morning. He refused lab draw and refused to provide UA. Both instances made him upset, he attempted to punch and then kick the RN. He was able to be redirected without injuring staff. He is currently walking calmly in the dining room in his bed and doesn't remember either incident. He is alert but not oriented and is unable to answer my questions. -Dementia with increased behaviors-incidents of physically violent behavior continue despite increasing [MEDICATION(S)] from 25mg PO BID to 50mg PO BID. He has a history of aggressive behavior at prior facility. -Refused lab work. -Start [MEDICATION(S)] (an acetylcholinesterase inhibitor that may improve dementia symptoms) transdermal patch, 4.6 mg, change every 24 hours for one month. If behavior improves we will increase dose after one month, if no improvement we will d/c (discontinue) and consider other med management. On [DATE] at 5:25 p.m., Resident was scheduled for blood draw and UA today. He refused both. While I was kneeling at his chair in his room trying to convince him to allow us to do blood draws, he suddenly became upset, throwing a punch at me that I was able to catch and restrain. He then lifted his leg to kick me and I was able to restrain that motion as well. In approximately 10 to 15 seconds he relaxed and I was able to release him. After this he made a comment that I was not able to understand. When I tried to clarify, he angered again and called me a stupid b------. At this point the phlebotomist and I left the room and closed the door. He did come out and eat lunch later but has remained in his room most of the afternoon. He has had most of his belongings gathered up in a trash bag and pillow case all day. Of note, he did take his morning medications for me and is in the dining room eating his evening meal at this time. On [DATE] at 5:58 a.m., Resident refused to take HS (bedtime) medication this shift even after 3 attempts. No other behaviors noted this shift. Resident was awake early around 3:45 (a.m.) this shift and wandering around the hallway; resident took his [MEDICATION(S)] this morning. On [DATE] at 1:51 p.m., NP #2 documented, Resident seen today to f/u on wandering risk behavior this morning. He has his bags packed and is trying to exit via the fire escape. He frequently exhibits this behavior. He isn't violent or aggressive and hasn't been since his last episode, after which we started the [MEDICATION(S)]. He is redirectable. He is alert but not oriented and is unable to answer my questions. -Dementia with increased behaviors-incidents of physically violent behavior, continue despite increasing [MEDICATION(S)] from 25 mg PO BID to 50 mg PO BID. He has a history of aggressive behavior at prior facility. -Refuses lab work. -Started [MEDICATION(S)] transdermal patch, 4.6 mg, change every 24 hours for one month, then increase to 9.5 mg patch Q24 hours for one month, then increase to 13.3 mg patch Q24 hours. Reassess after three months, if no improvement, we will D/C and consider other med management. On [DATE] at 6:17 p.m., Resident continues to exit seek, became upset when going to get a haircut, refused, raised voice, swinging hands. Hard to redirect. On [DATE] at 1:58 a.m., Resident took all his HS (bedtime) PO (oral) medication this shift but refused the [MEDICATION(S)] patch. On [DATE] at 6:07 p.m., Resident got into an altercation with another resident, taking a suit case out of the room and then hitting resident, leaving a bruise to the right outer palm and a cut to the outside of the pinky. Resident has been exit seeking and wandering in others rooms removing things. This resident hit CNA this AM. (Physician) ordered a stat [MEDICATION(S)] 12.5 mg to be given. Call placed to POA. Notified and phone consent given. DON, Police, POA, MD notified. On [DATE] at 5:26 p.m., Resident took meds fine this morning and ate breakfast in the dining room with other residents. Shortly after breakfast he went to end of hall and started moving clothing to one of the chairs. He became what I would call territorial of this location and when I approached he struck out at me but I was able to handle the moment and he deescalated when I walked away. He refused to leave the area and ate his lunch at the end of the hall on an over bed table. He was witness to another resident falling at (1:15 p.m.) in the hall. He said he pushed her but the resident that fell did not validate his story nor any other resident witnesses. No staff witnessed. At approximately (2:00 p.m.) another resident approached the end of the hall. Words were exchanged and he punched the resident in the arm. This was witnessed by staff who intervened pulling the other resident away to safety. After this I went to try and get him back to his room. When I reached out to touch him he swung at me and continued to pursue me. My CNA was close by and we were forced to take him to the ground and restrain him. 911 was called and when police arrived he was back up in a chair at the end of the hall, calm but guarded by two CNAs. Police were able to talk him back into his room where he remained until decision was made to transport him to (local) hospital. When EMS arrived he at first was cooperative, but then started throwing the buckles to the gurney off and calling us names. It required 6 to restrain while sedation was administered. He left with EMS at (4:20 p.m.). A call was made to (the acute care hospital) to inform them of his pending arrival. I was able to call his POA and inform him of the day's events at the end of my shift. He is anticipating a call from administration tomorrow. The facility failed to thoroughly utilize the interdisciplinary team to assess and re-assess the resident's behavioral symptoms, identify triggers, and implement non-pharmaceutical person-centered approaches to improve the resident's quality of life and keep other residents safe from his aggressive behaviors. There was insufficient evidence that the facility used the already-identified approaches, such as going outside, snacks and drinks, and calling the POA to address the resident's unmet needs. III. Resident #11 A. Resident status Resident #11, age 86, was admitted on [DATE]. According to the resident face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the [DATE] MDS assessment, Resident #11 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had delusions and mood issues related to feeling down/depressed/hopeless and difficulty concentrating. The resident was independent or needed supervision for activities of daily living. B. Record review 1. Care plan The resident's behavior care plan, initiated [DATE] and not revised, documented, Upon admission I do not exhibit behavioral symptoms. The resident's abuse prevention care plan, initiated [DATE] and not revised, documented, I have a known history of abuse by a fell ow resident. I am at risk for abuse/neglect due to vulnerable status living in a skilled nursing facility. I am not alert and oriented and may not be able to report abuse/neglect. -The resident's care plan was not revised to document her behavioral symptoms (see below). The abuse prevention care plan was initiated the day before the resident was abused on ,d+[DATE] and [DATE] by Resident #10. However, the care plan was not updated to reflect those incidents or to explain whether the resident was abused at a previous facility. 2. IDT notes On [DATE] at 5:04 p.m., a nurse documented, Resident was pleasant and cooperative for most of the shift with some instances of labile mood. During one instance, she became angry that she and another resident are not allowed to share a room but was able to be redirected after about ten minutes. She also exhibits wandering behavior and will occasionally take a few items from her room and exit seek. On [DATE] at 3:29 p.m., She has a history of wandering and exit seeking behavior at prior facility. On [DATE] at 6:13 p.m., This resident was in an altercation with resident (#10). Resident took suitcase out of this residents room and then hit her with the suitcase leaving a bruise to right outer palm and a cut to the right pinky finger. POA notified of incident. This resident stated, 'I should not have yelled at him to put my stuff back, I didn't mean to make him mad it was my fault I don't want him to get into trouble. DON, Police, POA, MD notified. On [DATE] at 1:50 a.m., Resident has wandered for most of the shift. Resident has entered into other resident's rooms. When told not to enter others resident's rooms, resident becomes angry. Resident has refused to leave others resident's rooms multiple time this shift. Resident is difficult to redirect and does not follow directions. Will continue to monitor resident's behavior. On [DATE] at 9:00 p.m., NP #2 documented, Resident seen today to f/u on reports of wandering onto other resident's rooms. She is difficult to redirect and becomes agitated with staff. She took other resident's belongings and didn't want to return the items, not following commands and becoming upset. -Dementia with behaviors-continue to monitor for increased wandering or behaviors. Consider [MEDICATION(S)] if behaviors increase. Try to intervene before she gets worked up by other residents, and before she takes other residents belongings. On [DATE] at 5:49 p.m., Res was exit seeking most of the shift. Res. continues to need re-direction and guidance as to where she is and where she is not allowed to wander. Res. continues to wander into other Res.'s rooms throughout shift. Res. has 'buddied -up' with another female Res. and encourages her to exit seek, increasing the other Res.'s anxiety. Provided diversional activities (painting, reading, television, patio .) without success. On [DATE] at 2:35 p.m., NP #2 documented, Resident seen today to f/u on reports of exit seeking and packing her belongings throughout the day. She continues to go into other resident's rooms and is difficult to redirect. Her behavior instigates other residents to then become exit seeking. Today she was looking for her son. -Dementia with behaviors-continue to monitor for increased wandering or behaviors. Consider [MEDICATION(S)] if her behaviors become harmful to self or others. -Encourage staff to engage her in more activities and to walk outside. On [DATE] at 4:50 p.m., Patient required frequent re-orientation of situation and surroundings. She was frequently wandering and asked, 'where is all my stuff? I think they took it. I need to get out of here right now and go home.' Patient became increasingly fixated on this throughout this nurses shift. Will continue to monitor. -The [DATE] abuse incident was not documented in Resident #11's progress notes. There was no evidence of IDT involvement to develop non-pharmaceutical, person-centered approaches to ensure quality of life and safety for Resident #11. IV. Staff interviews The director of nursing (DON) and nursing home administrator (NHA) were interviewed on [DATE] at 3:20 p.m. They said there were two incidents involving Resident #10 and Resident #11. During the first incident, Resident #10 went into Resident #11's room, got her suitcase and hit her with it. In the second incident, Resident #10 was having some behaviors, wanted to be left alone, and Resident #11 approached him and they were talking back and forth. He then lightly reached out and hit her arm with his hand. Activity staff reported to nurse, Resident #10 became physically aggressive with the nurse, a CNA came in, and 911 was called because Resident #10 was going after nurses and staff were trying to get other residents out of the hallway. Resident #10 was taken down to the floor by staff, because he was attacking them, and then went after police. The police were able to get him into his room. He kind of de-escalated and became aggressive with EMTs and police. The EMTs gave him IM (intramuscular) sedation and took him to a local acute care hospital. From there he went to a behavioral hospital. It was a crisis at the time and waiting for resources would only put staff and residents at risk. Regarding dementia care training for staff on the memory care neighborhood, the DON and NHA said, We actually just last week did a dementia training, and we have another one scheduled this month. We had some training last fall, for full time staff. Regarding behavioral interventions, they said there was a redirect section, and their upcoming training included more de-escalation training. Regarding individual interventions for Resident #10, they said they talked to staff about the suitcase thing being a trigger, removing suitcases, talking with family members. He did have some one-on-one until the next morning ([DATE]) and then he was fine Sunday, nothing happened, he was very redirectable, pleasant, and the next incident occurred Monday afternoonish. During that incident he was given a one-dose, stat order of [MEDICATION(S)]. They said they had not yet reviewed his status with the behavioral hospital, to see if his behaviors had improved.

Based on observations, record review and interviews, the facility failed to provide an environment as free from accident hazards and risks as possible for one (#20) of two residents reviewed for falls out of 17 sample residents. The facility failed to ensure Resident #20's care plan was followed, continuously monitored the effectiveness of old interventions and updated accurately. The facility failed to implement new effective person centered interventions timely after falls on 7/1/2020, 8/29/2020, 9/6/2020 to include a clear directive of what type of mobility assistance Resident #20 required to decrease risk of future falls. Furthermore, the facility failed to provide adequate supervision for Resident #20 with a history of dementia, difficulty walking and muscle weakness started to walk backwards and attempted to sit down when there was not a chair behind her (see interview section). Resident #20 continued to fall in the facility and subsequently sustained a non-displaced [MEDICATION NAME] S3 [MEDICAL CONDITION] requiring being sent to the hospital. Findings include: I. Facility policy and procedure The Fall Assessment and Managing Fall Risk policy, last revised 11/14/19, was provided by the facility on 9/24/2020. The policy read in pertinent part: -Residents are assessed for fall risk during the pre-admission process, upon admission, quarterly, with significant change in status, and as needed. -Fall risk and appropriate interventions to minimize risk of falls and/or risk of injury from falls is included in the care plan -Based on the review of the fall, interventions in the care plan are updated as indicated -Staff nurses are responsible to make safety rounds throughout their shift to ensure compliance with required safety devices as indicated on the resident's plan of care II. Resident #20 A. Resident status Resident #20, age 87, was admitted [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 8/18/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with short and long-term memory loss. According to the MDS assessment, the resident required extensive assistance of one person physical assistance for bed mobility, transfers, locomotion on and off the unit, toileting, personal hygiene and dressing. She required limited one person physical assistance to walk in her room. The 8/18/2020 MDS indicated Resident #20 walked unsteady with an assistive device (walker and wheelchair) but was able stabilize without human assistance when she transferred from surface to surface (transfer between bed and chair to wheelchair). B. Record review The CPO for therapy, implemented 10/13/18, identified the resident had a current physical and occupational therapy order to evaluate and treat. -Therapy notes were requested and no therapy notes were provided during the survey. The fall care plan, implemented 2018 read, the resident at risk for falls due to NSTEMI with decreased mobility and generalized weakness, dementia, arthritis with chronic low back pain, and poor safety awareness. Approaches included: -Ensure the resident wore gripper socks or shoes when she was up; last updated 10/15/18; -Provide a low bed; last updated 10/15/18; -Observe for changes in gait, steadiness, mobility, judgment and coordination, last updated 10/15/18. -Provide a soft pressure call light; last updated 11/28/18; -Assist to bed or common area after toileting; last updated on 12/19/18; -Offer a baby doll and encourage the resident to rest with her doll; last updated 12/13/18; -Offer a weighted blanket when she was restless; last updated on 12/13/18; The fall care plan was reviewed on 8/27/2020 with no new fall interventions since 2018 after Resident #20 had multiple falls (see below). The 5/27/2020 fall risk assessment identified the resident had one or more falls within the previous six months. Identified risk factors included incontinence, altered awareness of immediate physical environment and received two or more high fall risk drugs. The fall risk assessment determined the resident was nine of 13 possible points, indicating the resident had a moderate fall risk. The assessment summary of the fall risk referred back to the care plan with last updated interventions in 2018. -The 5/27/2020 fall risk assessment indicated the resident did not have mobility issues. A fall risk assessment to indicate a change level of fall risk and factors of risk was not completed after Resident #30 fell on [DATE] (see below). The 7/1/2020 fall assessment identified an unwitnessed fall was discovered at 6:45 a.m. According to the assessment Resident #20 found in her room sitting on a broken dresser drawer. Her feet were bare. The interdisciplinary team (IDT), reviewed the fall and implemented a child lock on the closet and rearrangement. The assessment indicated the resident sat on the furniture. No other interventions were noted. -The fall assessment indicated the residents feet were bare, which would not be in according to her plan of care to wear gripper socks. The 8/18/2020 fall risk assessment identified the resident had one or more falls within the previous six months. Identified risk factors included assistance with mobility and a lack of understanding of cognitive and physical limitations. The fall risk assessment determined the resident was 16 out of 13 or more possible points, indicating the resident had a very high fall risk. -The 8/18/2020 fall risk assessment was completed a month and half after Resident #20 fell on [DATE]. The 8/18/2020 assessment summary of the fall risk referred back to the care plan last updated in 2018, for new interventions. (The interventions were previously documented from 2018, this would not be appropriate to use the previous interventions as new for this resident.) A fall risk assessment was not completed after a fall on 8/29/2020 or 9/6/2020 (see below) to determine if the resident had a change in risk factors that contributed to the falls. A wheelchair care plan was put in place and last reviewed on 8/27/2020. According to the care plan she required assistance with a wheelchair due to decreased mobility, weakness, dementia, and arthritis with chronic back pain. -However, the resident did not utilize the wheelchair for mobility (see staff interviews below). The 8/29/2020 nursing note read Resident #20 was found sitting on the floor between her bathroom door and the nightstand. The resident sat on her buttocks with her back up against the wall. The note indicated that she was not injured. The 8/29/2020 fall assessment identified an unwitnessed fall was discovered at 4:45 p.m. According to the assessment Resident #30 was wearing socks when she was found on her bedroom floor. The assessment indicated the 9/4/2020 IDT review determined the resident was walking alone in her room with only socks contributing to the unwitnessed fall. The new assessment interventions were noted as: -Shoes on when out of bed; -Frequent checks when the resident naps; and, -See care plan for current interventions in place. The shoes and frequent checks were not implemented on the care plan. The 9/6/2020 nursing note read Resident #20 was found with feet flat on the floor and knees bent laying on her back next to the wall at the end of the hallway resident. The note indicated she was not injured. The 9/6/2020 fall assessment identified an unwitnessed fall was discovered at 11:55 a.m. in the hallway. According to the assessment Resident #20 the resident wore tennis shoes and was using a walker at time of fall. The fall occurred two days after she was reviewed for the fall on 8/29/2020. According to the assessment, poor balance and curling of the toes led to the fall. The assessment indicated Resident #20 had a lack of understanding her physical limitations. She had been observed in the past to attempt to sit down when there was nothing behind her. It was noted that her daughter would bring in different shoes. The assessment interventions to reduce and eliminate recurrence of a fall included: -An evaluation of footwear; -Wearing shoes anytime she was out of her bed; -Review with therapy; and, -See care plan for current interventions in place. The 9/23/2020 nursing note read Resident #20 was found on the floor when the CNA went into the resident's room. Resident #20 was sitting on her buttocks with her legs straight out leaning with her back against the bed. Resident assessed and it was noted the resident had tears running down her cheeks, wringing hands, and furrowed brow. The registered nurse determined Resident #20 was not moving the left lower leg and it was turned inward. The physician assistant was notified and she was sent to the hospital for an evaluation. -The note did not document where a wheelchair or walker was present in her room. The second 9/23/2020 nursing note read Resident #20 returned to the facility with pain management. The note indicated she could use a walker when weight bearing. The 9/23/2020 fall assessment identified an unwitnessed fall was discovered at 7:00 a.m. in her room with a major injury (non-displaced [MEDICATION NAME] S3 [MEDICAL CONDITION] via computed tomography scan (CT) scan, see licensed practical nurse (LPN) #2 interview below). The assessment indicated her room was free from slip hazards and her bed was in the low position. According to the assessment, cognitive impairment and poor safety awareness led to the fall. The assessment interventions to reduce and eliminate recurrence of a fall included: -Frequent checks; -Continued physical therapy; -Room arrangement for more sitting area; -Pain control; -Slippers; and, -The emergency department physician recommended a walker in common areas. C. Observations On 9/22/2020 at 10:08 a.m, Resident #20 was observed sleeping in a lounge chair in the common area. -At 10:25 a.m., certified nurse aide (CNA) #7 approached and woke Resident #20. CNA #7 assisted the resident out of the chair. She held the arm of Resident #20 as they walked to the resident's room. Resident #20 did not wear a gait belt or use a walker when she was assisted back to her room. On 9/23/2020 at 6:03 p.m. sat alone in a wheelchair in her room. She clutched a stuffed bunny and a blanket over her legs. -At 6:08 p.m., CNA #8 entered the room and proceed to wipe the hands of Resident #20. According to the CNA, Resident #20 returned to the facility just before dinner and was going to receive a shower before she was laid down. -At 6:10 p.m., CNA #8 exited the room. III. Staff interview Licenced practical nurse (LPN) #2 was interviewed on 9/23/2020 at 12:11 p.m. LPN #2 said CNA #8 found Resident #20 on the floor in her room. She said the resident was tearful. The resident was not able to verbalize pain but her left leg appeared longer than the right and rotated inward. Resident #20 was sent to the hospital for an evaluation and had not returned from the hospital. She said the facility was waiting for the results of a computed tomography scan (CT scan). The LPN #2 said the resident walked independently and it was common for her to fall. Lately she has been walking backwards and would attempt to sit down when there was not a chair behind her. The LPN #2 said resident engagement helped prevent falls and frequent checks but Resident #20 fell sometime before 7:00 a.m. CNA #8 was interviewed on 9/23/2020 at 2:03 p.m. The CNA said her shift began at 6:00 a.m. She said she did not see Resident #20 at 6:00 a.m. CNA #8 said she did not know when the resident was last seen. Resident #20 was supposed to be seen every two hours. She was not sure when the resident was last checked on. She said she started showering residents right away after the 6:00 a.m. shift change. She entered the room of Resident #20 at approximately 7:00 a.m. CNA #8 said found the resident with her back against the bed as if she attempted to stand up but slid to the floor. CNA #8 said the resident was only offered a walker when she attempted to push furniture in front of her. The CNA said she needed some assistance to walk at times so we would hold her hand for balance. LPN #2 was interviewed a second time on 9/23/2020 at 6:16 p.m. She said Resident #20 returned to the facility and 5:15 p.m. The LPN reviewed the evaluation and orders from the hospital. According to evaluation, Resident #20 had a nondisplaced [MEDICATION NAME] s3 [MEDICAL CONDITION]. Resident #20 had a physician order [REDACTED]. The DON was interviewed on 9/24/2020 at 2:16 p.m. The DON said fall prevention was a facility focus. She said falls are reviewed in interdisciplinary team (IDT) stand up meetings and the plan meeting. The details of a fall and staff recounts of the fall were discussed with the team. She said the team incorporates new interventions and reviews why previous inventions to prevent the fall were not successful. The DON said the team tried to have an understanding of the contributing factors that led to the fall to help prevent future falls. She said interventions determined by the team were added to the care plan. Resident #20's four recent falls were reviewed with the DON. According to the DON the unwitnessed fall on 7/1/2020 discovered at 6:45 a.m. was discussed with the IDT. The DON said she did not know why it was documented to rearrange the closet. She said the resident fell into the night stand. The DON said she assumed the night stand was possibly moved further from the resident's bed but she was unsure. She was not aware of other interventions incorporated after the 7/1/2020 and referred back the care plan. The unwitnessed fall 8/29/2020 was discovered at 4:45 a.m. The DON said that was a busy time of day. Staff would have been getting residents ready for the dinner meal. She was not sure the resident was resting in bed prior to her walking in her room resulting in the fall. She said the resident would not have had shoes on if she was in bed but added as an intervention. It was recommended to provide frequent checks on the resident when she was napping to prevent future falls. The 9/6/2020 unwitnessed fall was discovered at 11:55 a.m., shortly before meal service. The resident was found in the hallway with her walker. Resident #20 wore shoes at the time of the fall. The intervention after the fall was to have the daughter provide different shoes. She said the resident had poor balance and tended to curl her toes when she walked. She said she was not working with physical therapy at a fall prevention at the time of the fall. She said she did not know why not. The 9/23/2020 unwitnessed fall was discovered at 7:00 a.m. in her room. She said the fall occurred sometime between 6:30 a.m. and 7:00 a.m. She said Resident #20 had been waking up early for the past couple of weeks prior to the fall. She said Resident #20 required more supervision during the identified times of the falls to ensure she did not try to self transfer out of bed and walk independently in her room. She said staff could anticipate the resident's desire to wake up early and assist her in the common area where she would potentially have more eyes on her. She said staff needed to also watch for discomfort that could prompt the resident to get up. She said a walker had been used off and on in the past as an intervention, however the resident tended to lean back more when she used the walker, creating more of a fall risk. -The newly suggested interventions were not part of the documented interventions of the care plan nor the assessment. The physician order [REDACTED]. A new fall risk assessment had not been in place at time of interview. The DON acknowledged that all four falls occurred unwitnessed when staff could have been occupied with providing activities of daily living (ADLs) with other residents in preparation of the day or an upcoming meal. She said the pattern of falls related to time of day or staff availability was not identified by the IDT. Ongoing supervision and specific interventions would be a key factor in preventing the falls. She said she recently added a 3:00 p.m. to 11:00 p.m. CNA to some afternoon shifts but it did not prevent the fall on 8/29/2020. The DON reviewed the interventions put in place to prevent the falls and acknowledged they provided limited fall prevention. The DON confirmed limited interventions were identified on the care plan as a staff directive. The DON said fall risk assessments should be reviewed and updated after each fall to ensure the risk assessment accurately reflected the resident's current fall status and any changes in the resident or their increased factors.

Based on observation, record review and staff interviews, the facility failed to provide dementia treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for three (#4, #22 and #31) of four residents reviewed for dementia care out of 17 sample residents. The facility failed to prevent a resident to resident physical altercation after a pattern of behavior and aggression was established in the memory care unit, where 10 residents resided. Resident #22, with a [DIAGNOSES REDACTED]. Resident #22 continued to wander into the room of Resident #31 that had a [DIAGNOSES REDACTED]. Resident #31 expressed elevated frustration and aggression over the room entry as documented on 8/27/2020 and 8/31/2020. On 8/31/2020, Resident #31 threatened to physically assault Resident #22. Resident #22 continued to wander into resident rooms with lack of staff intervention to provide ongoing supervision which provided the continued opportunity for him to enter the room of Resident #31. The wandering for Resident #22 without immediate staff intervention created an environment for the physical altercation on 9/1/2020 to occur between Resident #22 and Resident #31. Any person would not want to be slapped in the face by another person. Furthermore, observations and staff interviews revealed Resident #22 continued to wander into resident rooms and the laundry room on the unit without close staff supervision. The observations and activity participation records revealed the facility failed to provide a structured program of meaningful activities for Resident #22 and Resident #31 to decrease resident altercations, restlessness, wandering and exit seeking behaviors. Additionally, the staff in the memory care unit did not appropriately address Resident #4, with a [DIAGNOSES REDACTED]. Due to the facility's failures to develop and implement interventions to address the Resident #22, Resident #31 and Resident #4's dementia care needs, which results in the resident's inability to achieve their highest level of functioning. Findings included: I. Facility policy and procedure The Dementia Care policy and procedure, last revised on 2/25/2020, was provided by the director of nursing (DON) on 9/24/2020 at 4:18 a.m. According to the policy, a systematic interdisciplinary (IDT) team process would be used to provide holistic care for residents with dementia. The policy revealed, in part: -The IDT would Gather information on the resident's past and current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual condition, related to complications, and functional impairments -The facility would attempt to obtain life patterns, previous preferences and information on previous psychological and/or behavioral expressions from resident/family to assist in developing a comprehensive, resident centered care plan -Gather information on the resident's life experience, personal preferences, overall health and current medical conditions, including the presence of pain; cognitive status and related abilities; mood and behavior patterns, including how the resident typically expresses physical, emotional and psychosocial needs including distress -Monitor for safety including wandering and need for electronic monitoring -Create individualized approaches in care plan with measurable goals and specific interventions to be included in the assignment sheet or profile -Monitor effectiveness of interventions and modify/change interventions as needed The policy also identified additional training would be given to dedicated staff working the memory care unit. II. Resident #22 A. Resident status Resident #22, age 77, was admitted on [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 8/21/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. According to the MDS assessment, the resident was independent in the activities of daily living (ADLs) of bed mobility, transferring, walking in the corridor, and locomotion on the unit. The MDS indicated the it was very important for Resident #22 to make choices in his daily routine and do his favorite activities. Resident #22 resided ion the memory care unit, where 10 residents resided. B. Observations Observation of structured or provided activities were limited. Resident #22 was able to engage in some independant leisure but only for moments and a time. The resident continued to seek out stimulation throughout the observation. He was observed to take brief daily outside walks with a staff member. The following observations revealed his activity involvement. All other observations showed the resident pacing through the unit when he was not resting in his room or eating a meal: On 9/21/2020 at 2:20 p.m., Resident #22 was observed to pause for two to three minutes and briefly watched television in the lounge before quickly returning to pacing back and forth in the halls. On 9/22/2020 at 11:22 a.m., Resident #22 stood over the piano and played notes before pacing again and looking out the windows. On 9/23/2020 at 11:20 a.m., Resident #22 walked in and out of an unlocked laundry room unsupervised and unnoticed by staff. -At 11:29 a.m., CNA #6 was informed of the laundry room entry. The CNA said she must have forgotten to lock it. Resident #22 was then encouraged to fold towels. Resident #22 accepted the invitation and finished folding in under four minutes. He quickly returned to wander in and out of resident rooms and exit seek. -At 11:40 a.m., Resident #22 played a scale on piano. -At 11:52 a.m. was observed rapidly walking up and down the hall and in the dining room, pushing on doors to try to open. He turned off lights and proceeded to knock on doors until the lunch meal arrived. Observations demonstrated a potential for future resident to resident altercations related to limited supervision, limited structured activity programming for a high risk resident. Ongoing observations from 9/21/2020 to 9/23/2020 revealed the resident was in constant motion other than when he sat down to eat. The resident was observed to pace the halls and common in areas. He would walk in and out the dining room, kitchenette and walk in out of resident rooms, looking at touching items in the rooms. He was not redirected by staff. He was observed to repeatedly push on doors attempting to open. On 9/23/2020, Resident #22 entered the laundry room located on the unit. A sign above the laundry room door read Staff must lock at all times. Observations revealed the resident was not offered staff assisted or prompted activities other than a daily walk and folding towels after he walked into the laundry room. B. Record review 1. Care plan The abuse care plan, revised 8/17/2020, identified Resident #22 was at risk for abuse due to vulnerable status living in a nursing facility related to his physical impairment/cognitive impairment. According to the care plan goal, the resident would remain safe and free from abuse in my environment. The two care planned interventions indicated an abuse prevention observation would be completed and staff were to observe for signs and symptoms of abuse of abuse such as fear or resistance to allowing a staff person to assist him. The cognition care plan, revised 8/17/2020, read the Resident #22 was not oriented to time, place, or situation. According to the care plan, the resident relied on staff and family to assist in his decision making. The secured placement care plan, revised 9/22/2020, identified Resident #22 resided in the memory care unit due to wandering and dementia. The antidepressant medication care plan, revised 9/22/2020, identified Resident #22 received an antidepressant medication related to anxiety, targeting the behaviors of excessive wandering, restlessness and agitation. The behavior care plan, revised 9/9/2020, identified Resident #22 had a history of [REDACTED]. The care plan read the resident had excess wandering in resident rooms and removing their property. The behavior care plan indicated the wandering in resident rooms triggered other resident agitation and response to remove Resident #22 out of their room. According to the care planned intervention, staff were to provide redirection, assist with an activity or take for a walk when the resident became agitated or restless. The activity care plan, initiated 8/17/2020, read Resident #22 had an activity interest in social events and one to one engagements. The activity care plan offered one intervention: Resident #22 would spend time with the activity staff for one to one and social emotional time. The second 8/17/2020 activity care plan read Resident #22 enjoyed going outside when the weather was nice. According to the care plan, he had no incidents of unsafe behaviors or elopement attempts. A 9/21/2020 activity plan was created at time of survey. The care plan read Resident #22 visited with his wife weekly and expressed his joy by smiling. According to the new care plan, he enjoyed projects such as folding towels and socks. The care plan indicated the resident would also occasionally enjoy copy writing and working on crossword puzzles.The activity care plan offered one intervention: Staff would remind, and escort the resident to activities of choice. - The care plan did not include that the resident had a BIMs of three or how they would modify some of these activities to his abilities. 2. Behavior monitoring The 9/20/2020 behavior monitoring identified Resident #22 had 480 minutes of wandering and exit seeking. According to the behavior monitoring, he was redirected to a meaningful activity. The type of meaningful activity was not identified on the behavior monitoring record. 3. Nursing progress notes The review of the nursing notes confirmed Resident #22 demonstrated a pattern of wandering and exit seeking behaviors, creating verbal and physical aggression between Resident #22 and Resident #31. The notes revealed an increase in escalation that led to the 9/1/2020 resident to resident altercation (cross-reference F600 for freedom from abuse and F610 for investigation of abuse). -The 8/18/2020 nursing note read Resident #22 wandered in and out of rooms in the memory care unit. The note indicated that he was redirected related to his confusion. -The 8/22/2020 nursing note read Resident #22 continued to be exit seeking and became physically aggressive with the nurse after multiple attempts to redirect him when he pushed open the memory care unit front door. -A second nursing note on 8/22/2020 revealed Resident #22 pushed open the fire door and went downstairs before staff could reach him. According to the note, first floor staff had to bring the resident back to the secure memory unit. -The 8/23/2020 nursing note read Resident #22 paced and attempted to leave the unit out the fire exit doors. The resident was reoriented to facility and space. He later attempted to take another resident's dinner meal in the dining room. According to the note, Resident #22 exhibited aggressive behavior, yelling toward staff when asked to not touch other residents or their meals. -The 8/27/2020 nursing note read Resident #22 went into room of Resident #31 multiple times. Resident #22 was redirected by staff without success. According to the note Resident #31 balled his fists at this resident and verbally and physically threatened physically assault towards Resident #22. The note indicated staff intervened and redirected Resident #22 out of the room of Resident #31 without any further incident. -The 8/31/2020 nursing note read Resident #22 continued to pace the hallways and enter other residents' rooms. According to the note, Resident #22 (with a BIMS of three) was reminded to stay out of rooms. Resident #22 entered the room of Resident #31 multiple times. The note indicated Resident #31 was agitated and aggressive and left his room in attempt to confront Resident #22. Staff intervened without any further incident. -The 9/01/2020 nursing note read Resident #22 assaulted another resident (Resident #31), who resided in the room across from Resident #22. Resident #22 acted in response to Resident #31 grabbing his shirt when he wandered into the room of Resident #31. According to the note, staff were aware of hostilities between Resident #22 and Resident #31. The review of resident records, interviews and revealed the physician made medication changes as an intervention but the facility lacked other successful interventions to prevent the 8/27/2020 verbal abuse and the 9/1/2020 resident to resident physical abuse. 4. Providers notes The 9/3/2020 physician assistant (PA) note indicated that a medical evaluation was conducted after the altercation with another resident. Findings revealed no injuries to Resident #22. According to the note, the staff reported changes to his behavior since the incident. The PA documented suggestions to change the room location of Resident #31, creating more distance. The PA also suggested a stop sign on the door to deter Resident #22 from wandering the room. The 9/16/2020 nurse practitioner (NP) note read Resident #22 was seen on 9/16/2020 for increased wandering and restlessness despite behavioral redirection and a medication trail of [MEDICATION NAME] (anti anxiety medication). The NP noted Resident #22 walked independently, was always on the move and walked frequently throughout the unit. The signage on resident doors, relating to the stop sign suggestion, was discontinued after it was determined that the signs were ineffective and confusing to other residents. According to the NP note, Resident #22 was reviewed in a psychopharm meeting with the psychopharmacist. Medications were also discussed with his wife, a retired psychiatrist. She agreed to discontinue the [MEDICATION NAME], which may have an obsessive component to his behavior. The wife also agreed to trial [MEDICATION NAME] (antidepressant medication) and titrate to effect. The NP documented the psychopharmacist recommended decreasing [MEDICATION NAME] (antidepressant medication) dosage as it may contribute to restlessness due to a slightly elevated kidney function as this may contribute to restlessness. The NP indicated [MEDICATION NAME] changed to 150 milligrams (mg) once a day (QD), a dose he took when he was at home. The CPO [MEDICATION NAME] at 150 mg QD was started on 9/16/2020 at [MEDICATION NAME] at 50 mg by mouth QD was started on 9/17/2020. 5. Activity assessment and participation record The admission therapeutic activities assessment, dated 8/17/2020, was reviewed. The assessment identified Resident #22 was able to understand others and had current interest in activity pursuits. According to the assessment, Resident #22 had musical talent, enjoyed animals and time outside. The August 2020 and September 2020 activity participation and attendance record revealed Resident #22 was not provided activity interventions or opportunities on 8/29/2020, 8/30/2020, 9/4/2020, 9/8/2020, 9/10/2020, 9/11/2020, 9/22/2020 and 9/23/2020. The August 2020 and September 2020 activity record showed limited activity involvement. According to the record on average two to three activity interactions a day including brief walks outside, social emotion visits and resources visits. The activity director (AD) identified resource visits as asking if the resident wants anything like a drink. D. Staff interviews The AD was interviewed on 9/24/2020 at 9:00 a.m. The AD said she was new to the facility. She said she started as an activity assistant in June 2020 and was offered the activity director position in July 2020. She was in process of completing her activity director certification and had a consultant through video chat. The AD said her role as the activity director included planning activities, assisting in outdoor visitation, and offering social and emotional visits. She said her life enrichment program on the memory care unit decreased resident agitation, restlessness, wandering, and exit seeking. She said residents should have meaningful activities available to them. She said her program could promote the feeling of residents comfortable and safe in their memory care unit. She said a strong life enrichment or activity program can benefit residents by offering personalized care, including activities customized to the individual needs. The AD said she could reduce anxiety by listening to resident needs. The AD said Resident #22 had a high energy level and was very physically active. She said needed structured activities given to him throughout the day to give him something to do, potentially decreasing his wandering. She said Resident #22 is less restless after he exercised. She said Resident #22 enjoyed magazines, newspapers and projects. The activity participation and attendance record was reviewed with the AD. She said acknowledged Resident #22 had limited activity involvement and there were several days where no activity intervention was offered. The AD received support from management to run some facility activities and the CNAs helped assist residents outside and offer sing along videos and movies. The AD said she had activity staff coverage seven days a week but could use an activity staff member dedicated to the memory care unit. The AD said would be offering small group exercise in the upcoming week and would encourage Resident #22 to participate. She said she would spend more time with Resident #22. She said he needed someone to sit with him to engage in projects that he might enjoy. The SSD was interviewed on 9/24/2020 at 12:36 p.m. The SSD said Resident #22 continued to wander into the room of Resident #31, increasingly agitated and frustrating Resident #31. According to the SSD the continued room wandering of Resident #22 and frustration of Resident #31, led to the 9/1/2020 physical altercation (cross-reference F600 for freedom from abuse). The SSD said Resident #22's providers continued a medication review and requested labs as an intervention to possibly decrease his behaviors. She said Resident #22 continued to exhibit unsafe, anxious and restless behaviors. She said he continued to try to wander in resident rooms and exit seek. The SSD said the IDT was focused on him but successful interventions were not put on board fast enough to prevent the physical altercation on 9/1/2020 between him and another resident. According to the SSD, Resident #22 did not have a behavior aggression before the 9/1/2020 incident. She said staff attempted to close resident doors and place stop signs on the door entrances to encourage Resident #22 not to enter resident rooms. She said the signs but would not always stop him. She said she believed additional interventions were to be put in place including staff following him on the unit, providing ongoing observations and supervision and increased activity to utilize his energy level. The SSD said residents in the memory care unit required a higher level of supervision compared to higher functioning residents on the long term care unit. She said supervision and an ongoing activity programming for Resident #22 could be a key in preventing future resident to resident altercations. She said Resident #22 was at risk for resident to resident altercations if he continued his current wandering behaviors in resident rooms without ongoing supervision and successful redirection. The SSD said she has had over [AGE] years experience and has conducted numerous dementia trainings in the past. The SSD said specific dementia training, including activity involvement, staff interventions and approaches could help prevent incidents of abuse between residents. She said she could be used as a facility resource in dementia training and has offered in the past. She said the former AD used to offer dementia training but has since left the facility. The SSD said the current AD tried to work and train CNAs working on the memory care unit but the SSD did not believe the current AD had as much dementia training experience. She said moving forward, she would help advocate increased activity programming, supervision and dementia training with focus of those staff working on the memory care unit. The DON was interviewed on 9/24/2020 at 3:24 p.m. She said the root cause to the 9/1/2020 physical altercation was the continued wandering in the space of Resident #31. The wandering led to Resident #31 grabbing Resident #22 by the shirt and attempted to walk Resident #22 out of his room, prompting Resident #22 to hit Resident #31. The unsafe wandering behaviors of Resident #22 were reviewed with the DON including incidents of 8/27/2020 and 9/1/2020. The DON discussed the incident where Resident #22 wandered off the unit without supervision by pushing through the fire door exit, walked down the stairs to the first floor. The DON acknowledged the fire door alarm would have been sounding at the time and Resident #22 would have had to push on the door for 15 seconds to open. The DON said there was only one CNA on the unit at the time who was working at the time with another resident. The DON was informed of the observation on 9/23/2020 where the resident wandered into the unit laundry room unnoticed by staff (see above). The DON said the facility was in process of adding a person to the evening shift because a higher level of current acuity needs. The DON stated that she felt there was still a potential safety risk of resident to resident altercations with Resident #22. Resident #31 was no longer in the memory care unit but Resident #22 continued to go to resident rooms. The DON identified another male resident with a history of aggression who resided on the unit. According to the DON, the identified male resident was very protective of his space. The DON said medication adjustments have been made the week prior to the interview, but she has not seen reduction of wandering behaviors.t The DON acknowledged a need to increase supervision and provide more of a program of activities to Resident #22. She said the interventions should be in place until they determine if the medication change was successful and they see a decrease in his behaviors. She said the facility needed to protect him from future altercations because of his wandering. III. Resident #4 status A. Resident #4 Resident #4, age 69, was admitted on [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 7/2/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The MDS indicated the resident frequently and sleep difficulty or feeling of low energy or tiredness. The MDS identified it was very important to make choices of her daily routines and identified the preference for going outside when the weather was good. According to the MDS assessment, Resident #4 was independent in the activities of daily living (ADLs) of bed mobility, transferring, walking in the corridor, and locomotion on the unit. The MDS revealed Resident #4 required supervision with locomotion off the unit. Resident #4 resided on the memory care unit. B. Observations On 9/22/2020 at 9:53 a.m., Resident #4 was observed briskly walking into the dining room. She approached CNA #6. Resident #4 anxiously told CNA #6 that she could not get out. The CNA repeated the resident's statement and then told the resident that she knew she can't get out, in a condescending tone. The CNA told the resident that she could only get out if she walked with someone and said she could have a drink of water or coffee. CNA #6 then walked away from the resident and left the memory care unit. Resident #4 loudly began to cry and rush the patio door and a window. CNA #7 approached Resident #4. The CNA walked down the hall with the resident attempting to calm her down. She provided her a drink and offered to sit in her room and relax with the drink. The resident was assisted back to her room and sat with her for a moment. Resident #4 was no longer crying and appeared to have calmed down. The resident was witnessed to go on a walk earlier that morning. C. Record review The psychosocial well being care plan, initiated 6/26/2020, read staff should provide Resident #4 support and allow her to express feelings, fears and concerns. The activity care plan, initiated 6/29/2020, read the resident enjoyed going on walks outside. According to the care plan, she had unsafe behaviors related to cognitive functioning and required one-on-one staff supervision outside. The cognition care plan, initiated 6/27/2020, read the resident was not alert and oriented to time, place or situation. According to the care plan, required staff to assist her with decision making. The care plan indicated that staff were to report changes of increased confusion and disorientation. The admission therapeutic activities assessment, dated 6/26/2020, was reviewed. The assessment identified Resident #4 had impaired short and long term memory, attention span deficit. She was able to understand others and had strong social skills. According to the assessment, she loved old westerns and going for walks outside. The September 2020 activity participation and attendance record indicated Resident #4 received daily walks between 9/12/2020 and 9/21/2020. D. Staff dementia training The training record for CNA #6 identified she completed a true or false test on 12/1/16. The tested topics included: -Demonstrate skill of activities for residents with dementia; -Demonstrate skill to manage behaviors; -Demonstrate skill of dementia knowledge and communication; and, -Demonstrate skill of care delivery in dementia residents. According to the objectives of the above test on 12/1/16, the participant would: -Understand was [MEDICAL CONDITION] was; -Understand verbal and non-verbal communication skills in dealing with memory-impaired individuals; -Recognize different behaviors a resident with [MEDICAL CONDITION] may exhibit; and, -Report and document changes in resident behavior. In 2018, CNA #6 received one hour of computerized training on dementia and [MEDICAL CONDITION]. In 2019, CNA #6 received 3 hours of computerized training on Dementia, to include: -Dementia actions and reactions; -ADL care for people with dementia; and, -Understanding the person and the disease. E. Staff interview CNA #7 was interviewed on 9/22/2020 at 9:59 a.m. She said Resident #4 could become anxious when she wanted to go outside. The CNA said she can be directed with her stuffed cat or a drink if we can't take her outside at that moment. She said she tried to do what she can to calm Resident #4 down when she became anxious and tearful. CNA #6 was interviewed on 9/23/2020 at 11:42 a.m. The CNA said she has had some dementia training when she was hired. She said she has not had specific dementia training in the last year, or felt she received more than basic dementia training. CNA #6 said if a resident became anxious and attempted to exit seek, she would try to provide reassurance and redirection. She said it was not effective to tell the resident they can't do something, especially when they are upset. The CNA said telling the resident they can't do something could escalate and agitate them more. CNA #6 said she would give the residents something to do or offer to take them to their room. She said if Resident #4 became anxious or was exit seeking, she would try to calm her down, offer her water or coffee and try to talk and comfort her, and assist her to her room to relax. CNA #4 said on 9/22/2020 was the first time she saw Resident #4 try to escape. The AD was interviewed on 9/24/2020 at 9:00 a.m. She said Resident #4 could become anxious but was receptive to staff provided redirection. She said the resident responded well to looking at the bird aviary and watching old westerns. The AD said Resident #4 needed projects to work on and loved having her hair braided when she was stressed. The social service director (SSD) was interviewed on 9/24/2020 at 11:36 a.m. She said she was familiar with Resident #4. The SSD said Resident #4 loved to take walks outside and interact with her stuffed cat. She said Resident #4 could become anxious at times but did not usually have exit seeking behavior that she was aware of. The SSD said if Resident #4 did attempt to leave, staff should be mindful of that behavior. The exit seeking behavior and staff interaction observation was shared with the SSD (see observations above). She said that was a perfect example of what not to do when a resident is anxious and attempting to leave. The SSD said all staff in that situation should speak to the resident in a calm and friendly voice, reassuring the resident. The staff should never use the words can't or don't, it would only upset the resident further as was observed. The staff could offer a snack or a drink or activity to help change the resident's focus and behavior. The SSD said she felt staff on the memory care unit would benefit from increased dementia training so they can respond appropriately to agitated residents. The SSD said a new effective system to train staff on the memory care unit was needed. IV. Resident #31 A. Resident #31 status Resident #31, age 66, was admitted [DATE] and readmitted [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 9/10/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He had no [MEDICAL CONDITIONS], physical, or verbal behavioral symptoms directed toward others. He required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, and had no rejection of care. Resident #31 resided on the memory care unit until 9/1/2020, when he was moved off the unit after altercation with Resident #22. B. Observations On 9/22/2020 at 10:13 a.m., Resident #31 was sitting in a chair in his room. The activities director (AD) entered and showed him some photos. The AD asked him if he wanted to go outside for a walk with her and he agreed. She told him she would be right back and needed to go find a facemask for him to wear. She left the room at 10:15 a.m., and had not returned as of 10:27 a.m. (12 minutes later). At 10:46 a.m., Resident #31 had moved to his bed and was lying down. Continuous observation from 10:46 a.m. to 11:15 a.m. (29 minutes) revealed the AD did not return to his room to take him for a walk. At 11:15 a.m., the AD returned, knocked on his door and was carrying a facemask in her hand. She said his name loudly but he did not respond, and she walked away and did not return to his room that morning. On 9/22/2020 at 3:36 p.m., Resident #31 was sitting in the common area of the second floor alone, watching a game show on television. The AD approached him and asked him if he wanted to go for an outdoor walk with her. He agreed and he used his walker to walk with her. As he was leaving the second floor, his wander guard set off the alarm and the AD disarmed it and they continued toward(TRUNCATED)