Every finding on record at Garden Terrace Alzheimer's Center of Excellence

Based on record review and interviews, the facility failed to ensure one (#2) of five residents were free from physical abuse out of eight sample residents.Specifically, the facility failed to protect Resident #2 from physical abuse by Resident #1.Findings include:I. Professional referenceAccording to the Centers for Disease Control And Prevention's (CDC) Abuse of Older Persons(11/7/24), retrieved on 8/3/26 from https://www.cdc.gov/elder-abuse/about/index.html, Older person abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone aged 60 or older. Physical abuse is illness, injury, functional impairment, or death resulting from the intentional use of physical force. Examples include hitting, kicking, or pushing.II. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, reviewed 4/1/26, was provided by the nursing home administrator (NHA) on 7/30/26 at 11:22 a.m. via email. It read in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as:-Verbally aggressive behavior;-Physically aggressive behavior;-Taking, touching, or rummaging through other's property;-Wandering into other's rooms/space; and,-Residents with communication disorders or who speak a different language.III. Incident of physical abuse between Resident #1 and Resident #2 on 6/19/26A. Facility investigationThe 6/19/26 facility investigation was provided by the NHA on 7/29/26 at 1:00 p.m. The investigation documented Resident #1 and Resident #2 resided on a secured unit.Resident #1 had severe cognitive impairment, impaired communication ability, and unspecified dementia with agitation. Resident #1 was primarily Russian speaking and could become frustrated when others did not understand him. Resident #1 had the potential to become physically aggressive with other residents.Resident #2 had dementia with psychotic features, and per family, he had hallucinations and delusions. Resident #2 was verbally aggressive towards staff, and verbally and physically aggressive to other residents due to his paranoid thoughts and delusions. Resident #2 had a history of climbing out of windows, and his behavior was often unpredictable due to his history of dementia. Resident #2 was often hungry and staff were to offer him snacks to prevent him from taking other residents' food while they were eating.On 6/19/26 after most residents had finished eating breakfast, Resident #1 was in the dining room, seated at a table eating. According to the staff, Resident #2 already had breakfast, but walked back into the dining room and attempted to take food off of Resident #1's plate. Resident #1 stood up and with a closed fist, hit Resident #2 on the left side of his face on the cheek area. After Resident #1 punched Resident #2, staff intervened and separated the two residents.After the incident, Resident #2 said that he knew he had been hit on his face, but he could not recall who hit him or why he was hit. Resident #1 was interviewed in Russian via an interpreter, but his response was illogical and he was unable to be interviewed.Resident #2 was moved to another secured unit in the facility on 6/22/26. After the altercation, both residents were placed on one-to-one supervision by staff for close monitoring. B. Resident #1 (assailant)1. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity with agitation, restlessness and agitation, hypertension (high blood pressure), violent behavior, and difficulty in walking.The 7/1/26 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 needed staff supervision or touch assistance with eating. The resident required substantial/maximum assistance with oral hygiene, toileting, dressing, and personal hygiene. The resident utilized a wheelchair, and could walk approximately 10 ft. (feet) with supervision or staff assistance. The resident's primary language was Russian.The assessment indicated the resident exhibited physical behavioral symptoms directed towards others, which included hitting, kicking, pushing, scratching, and grabbing; and verbal threatening behavioral symptoms directed toward others, which included threatening others, screaming at others, cursing at others on four to six days per week during the assessment look-back period.2. Resident #1's representative's interviewResident #1's representative was interviewed on 7/29/26 at 2:30 p.m. The representative said several months ago, Resident #1 was sent to the hospital for several weeks, and the hospital adjusted the resident's medications. The representative said after Resident #1 returned from the hospital stay, a facility physician adjusted Resident #1's medications by gradual dose reductions (GDRs), and that might be the reason Resident #1 had been more aggressive. The representative said he felt the resident was not as violent with the hospital's medication changes. The representative said the previous week (approximately 7/24/26) he spoke with the NHA and requested a different physician to care for Resident #1 because he wanted the medications changed back to the hospital's recommended dosage. (See primary care physicians interviews below). The representative said he would be open to Resident #1 being transferred to a Russian speaking nursing home if the current facility could find one in the area. The representative said Resident #1 knew some English but had become more reliant on speaking Russian. 3. Record reviewReview of Resident #1's July 2026 CPO revealed a physician's order that staff were to send the resident to the emergency room via 911 for violent behaviors.The progress note, dated 6/19/26, revealed Resident #1 required one-to-one assistance due to a resident-to-resident altercation. Resident #1 came out of his room frequently, peeked around the corner and ambulated up and down the hall with his one-to-one staff person.The progress note, dated 6/20/26, revealed Resident #1 was still on observation for a resident-to-resident altercation. The resident was on one-to-one observation for medication changes.The progress note, dated 6/24/26 revealed Resident #1 was being monitored for increased Depakote (a medication used for mood stabilization). The resident was aggressive before breakfast and later took a long nap. Since napping, the resident had no concerning behaviors observed.The progress note, dated 6/26/26, revealed Resident #1's representative gave permission for changes to be made to Resident #1's medication list. Depakote was now at 375 mg (milligrams) TID (three times daily) and Haldol liquid (an antipsychotic medication) was to be used only for severe agitation, as needed once daily for three days.The progress note, dated 6/28/26, revealed Resident #1 was being monitored for an increase in Depakote and Seroquel dosages. The resident had no sedation, drowsiness, nausea, or vomiting on the shift.The progress note, dated 6/29/26 at 10:13 p.m. revealed Resident #1 was being monitored for an increase in Depakote and an increased Risperdal (an antipsychotic medication) dose. The resident had a one-to-one sitter for increased behaviors.On 7/30/26 at 12:39 p.m. the NHA provided notes via email which documented that Resident #1 was reviewed in the facility's psychopharmacology committee meeting on 7/28/26. The committee included the medical director, the unit manager, social services, the pharmacy consultant and primary care physician #2. The note indicate the following changes were recommended for Resident #1's medications: increase Seroquel and add Zoloft back. The resident's Seroquel was increased from 25 mg to 50 mg three times daily (see director of nursing (DON) interview below). C. Resident #2 (victim)1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included unspecified dementia, severe with psychotic disturbances, syncope and collapse (faint), difficulty in walking, muscle weakness, unspecified dementia, severe with agitation, restlessness and agitation, delirium, hallucinations, and a history of falling.The 7/1/26 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 independent with walking, and eating. The resident required supervision with oral hygiene and toileting.The assessment indicated the resident exhibited physical behavioral symptoms directed towards others which might include hitting, kicking, pushing, scratching, and grabbing; and verbal threatening behavioral symptoms directed toward others which might include threatening others, screaming at others, and cursing at others on one to three days per week during the assessment look-back period. 2. Record reviewThe comprehensive care plan, updated 6/21/26, documented Resident #2 had food insecurities due to past trauma and would reach for other people's food when he was hungry. Resident #2 was often hungry. If other residents were eating and Resident #2 was not, staff were to offer him a second plate of fruit or food of choice, or a snack to prevent him from taking others' food while they were eating. The event progress note, dated 6/19/26, documented after the altercation between Resident #1 and Resident #2, revealed there were no marks or injury noted on Resident #2's face.The 6/19/26 skin assessment, documented after the altercation between Resident #1 and Resident #2, revealed there were no marks or injury noted on Resident #2's face.The progress note, dated 6/22/26, revealed Resident #2 was moved to a different secured unit within the facility.IV. Staff interviewsThe NHA was interviewed on 7/29/26 at 2:00 p.m. The NHA said Resident #1 had been sent to the hospital a few months prior and had his medications adjusted. The NHA said Resident #1 was in the hospital for approximately six weeks before he returned to the facility. The NHA said the resident's representative spoke to her a week ago to request a different physician for Resident #1 because the representative wanted Resident #1's medications to be provided according to the prior hospital's orders. The NHA said four days prior to the survey, the request was completed to change physicians for Resident #1. The NHA said primary care physician #2 met with the facility's management team on 7/28/26 to discuss Resident #1's plan of care.Primary care physician #1 was interviewed on 7/30/26 at 9:05 a.m. Primary care physician #1 said she had been Resident #1's physician for approximately two years. Primary care physician #1 said prior to Resident #1's hospital stay, he was alert, walked around his unit, spoke some English, and even played bingo. Primary care physician #1 said when Resident #1 returned from the hospital, he was in a wheelchair, and primary care physician #1 felt he was sedated at the hospital. Primary care physician #1 said when Resident #1 returned from the hospital, he was not aggressive. Primary care physician #1 said she felt if Resident #1 remained in the post-hospital visit condition, he would be appropriate for hospice. Primary care physician #1 said she did a gradual dose reduction (GDRs) of medications over several months and for a while, Resident #1 had done well with the adjustments, and started to walk again. Primary care physician #1 said recently Resident #1 needed his medications increased again due to ongoing aggressive behaviors when staff provided care for him. Primary care physician #1 said she had increased Resident #1's Depakote after the 6/19/26 incident with Resident #2. Primary care physician #1 said she was concerned that Resident #1 hit a visitor on 7/12/26, because if Resident #1 hit another vulnerable resident, it could be dangerous. Primary care physician #1 said she became aware of the resident's representative's request to transfer Resident #1 to a different physician just a few days ago. Primary care physician #1 said the representative was upset with the GDRs that had happened with the resident's medications. Primary care physician #2 was interviewed on 7/30/26 at 1:25 p.m. Primary care physician #2 said over the past few days he became Resident #1's physician due to a request from the resident's representative. Primary care physician #2 said on 7/28/26 he met with the facility's management team in the psychopharmacology meeting. Primary care physician #2 said Resident #1's medication changes included increased Zoloft, and the resident's Seroquel was increased on 7/30/26. Primary care physician #2 said he was in the facility twice per week and was able to evaluate Resident #1 often. Primary care physician #2 said about every two weeks, Resident #1's medications would be reviewed to determine if the medications were effective. Primary care physician #2 said in the future, there could be other medication changes that that might be effective for Resident #1,if needed. The DON was interviewed on 7/30/26 at 2:00 p.m. The DON said after the 6/19/26 altercation between Resident #1 and Resident #2, Resident #1's Seroquel 25 mg was increased from twice per day to three times per day and his Depakote was changed from 125 mg three times per day to 375 mg three times per day. The DON said in July 2026, Resident #1's Seroquel was increased from 25 mg three times per day to 50 mg three times per day. She said his Depakote was changed from 375 mg three times per day back down to 125 mg three times per day. The DON said the resident's trazodone (medication used for insomnia) had also been increased in July 2026.The NHA was interviewed again on 7/30/26 at 2:30 p.m. The NHA said Resident #2 had no further resident-to-resident incidents after the 6/19/26 incident with Resident #1.The NHA said Resident #1's representative was willing to move Resident #1 to another facility if the facility could find a Russian speaking facility that would meet Resident #1's needs. The NHA said if there was no Russian speaking community, the resident's representative wanted Resident #1 to remain at the current facility. The NHA said this week, on 7/29/26, she requested an outside provider placement company locate a Russian speaking facility.

Based on observations, record review and interviews, the facility failed to ensure two (#9 and #12) of six residents reviewed for abuse out of 12 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #9 and Resident #12 from physical abuse by Resident #8.Findings include:I. Facility policy and procedureThe Abuse-Prevention policy, reviewed on 5/6/25, was provided by the nursing home administrator (NHA) on 3/4/26 at 6:58 p.m. It read in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as verbally aggressive behavior, physically aggressive behavior, and wandering into other's rooms/space.II. Incident of physical abuse by Resident #8 towards Resident #9 on 2/24/26A. Facility investigationThe facility's investigation documented an incident occurred on 2/24/26 at 11:25 a.m. between Resident #8 and Resident #9. Registered nurse (RN) #1 reported Resident #8 was standing at the entrance door of the unit, pushing on the doors in an attempt to open them. Resident #9 walked to the exit doors at the same time and, unprovoked, Resident #8 pushed Resident #9 forcefully against the exit doors. Resident #9 attempted to walk away and Resident #8 followed her to a nearby room. Upon seeing that, RN #1 moved quickly toward both residents to intervene. RN #1 saw Resident #8 continuing to hit Resident #9's back and arms as Resident #8 followed Resident #9 to a room. RN #1 intervened and called for assistance. An unidentified certified nurse aide (CNA) who was in a nearby room arrived to help. Resident #8 attempted to hit the CNA, however the CNA ducked and Resident #8 hit the wall. The social worker also arrived to provide additional support. Staff assured both residents were separated and safe.Resident #8 denied the incident occurred. She was put on one-on-one supervision immediately after the incident and moved to another unit on 2/27/26 where there was more space for her to walk and other residents were less likely to invade her personal space. Resident #8's medications were reviewed and changes were made.Resident #9 had no change in her mood or behavior and did not sustain an injury. She was not fearful and was unable to recall the incident and denied it occurred. Both residents continued their regular daily routines.The facility substantiated the physical abuse.B. Resident #8 (assailant)1. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included dementia (gradual decline in mental abilities), depression, insomnia and other encephalopathy (a condition where the brain is not working normally because of illness or injury in the body).The 2/13/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. She was able to walk independently at least 150 feet. The MDS behavior assessment was not documented. 2. ObservationsDuring a continuous observation on 3/4/26, beginning at 12:30 p.m. and ending at 4:00 p.m., the following was observed:At 12:38 p.m. Resident #8 was eating lunch in her room. She had a visitor at that time.At 1:10 p.m. Resident #8 was sitting in her room with the visitor. No concerning behavior was observed.At 3:30 p.m. Resident #8 was sitting in the activity room alongside other residents watching TV. A staff member was in the room for one-on-one supervision.At 3:45 p.m. Resident #8 walked independently to her room with a staff member at her side.At 4:00 p.m. Resident #8 was sleeping in her room. A staff member was in the room for one-on-one supervision.3. Record reviewResident #8's behavior care plan, initiated 1/20/26 and revised 2/24/26, revealed the resident had diagnoses of depression and insomnia. She would often become agitated when she was upset. Staff reported the resident was often very anxious, mostly related to going home. Resident #8 would refuse care from staff and could be verbally aggressive when she was upset. She could be physically aggressive toward staff by throwing cups, throwing her walker, attempting to hit staff and destroying property. Staff had observed Resident #8 putting her hands on other residents in a non-aggressive manner in an attempt to make them go in certain directions. She could be difficult to redirect and benefited from staff giving her time to calm down in a safe space.Interventions included one-on-one supervision, administering medications as ordered, explaining all procedures to the resident before starting and allowing the resident time to adjust to change, and intervening as necessary to protect the rights and safety of others. Additional interventions included removing the resident from the situation and taking her to alternate locations as needed, observing for behavior episodes and attempting to determine underlying cause and providing a program of activities that was of interest and accommodated the resident's status.-However, the one-on-one supervision was implemented after the incident with Resident #9 occurred on 2/24/26 and discontinued on 2/27/26 (see interviews below), even though Resident #8 had exhibited aggressive behavior multiple times towards staff and other residents before and after the incident occurred on 2/24/26.The nursing progress notes, dated from 2/3/26 to 2/5/26, revealed Resident #8 had moments of restlessness and was impulsive. She wandered around and interfered with other residents'care. She got irritated and agitated when redirected, tried to hit staff and was inappropriate verbally. Staff attempted different approaches, positive redirection and cueing was provided, however the resident was sometimes not easy to redirect, depending on her mood.The behavior note, dated 2/10/26, revealed Resident #8 was pulling another resident in their wheelchair and when asked to stop Resident #8 hit the CNA aggressively on her chest with her arm and lifted her walker and attempted to throw it at a nurse at the nurses' station.The behavior note, dated 2/16/26, revealed Resident #8 got very close to other residents and attempted to prevent them from doing their daily activities. She became verbally and physically aggressive when attempts were made to redirect her.The behavior note, dated 2/23/26, revealed Resident #8 had been exhibiting negative behaviors as she went around the dining room where other residents were sitting in their wheelchairs. She got into arguments with residents and would continue on until others were removed from being near her. The behavior note, dated 2/24/26, revealed Resident #8 was exhibiting physically and verbally aggressive behaviors. Resident #8 was pushing another resident in a wheelchair and yelling at her to Lift your feet so I can push you or I am going to run you into the wall. The floor nurse intervened.The event note, dated 2/24/26, documented Resident #8 was heading to the entrance door. When Resident #8 got to the exit doors, Resident #9 was also heading to the exit doors. Resident #8 proceeded by pushing Resident #9 forcefully against the exit doors. Resident #9 reacted by attempting to get away from Resident #8 and began to walk towards a room. Resident #8 proceeded to follow Resident #9 closely and hit Resident #9 on her back and upper arms aggressively multiple times. Resident #9 started walking faster and went into a room, Resident #8 followed her and pulled the door close, held the door handle and stated If you are going to behave like a baby, you are going to stay there. As soon as RN #1 witnessed that event, she immediately started walking towards those two residents to intervene. A CNA heard the commotion and came to help. The CNA went into the room to check on Resident #9. RN #1 assured that both residents were separated and safe, then called the director of nursing (DON) to come to the unit. RN #1 also called the social services assistant (SSA) to help. The SSA was able to bring Resident #8 to the dining room and sit on a chair. Resident #8 accepted a snack. Both residents were assessed for skin injuries and no injuries were noted. The director of nursing (DON) instructed RN #1 to call the police department's non-urgent line. RN #1 called the police and was provided an incident number by the police. The resident representatives and physicians for both residents were notified.The alert note, dated 2/25/26, documented Resident #8 threw water at another resident that got near her in the common area. Staff intervened and took the resident for a walk.The alert note, dated 2/27/26, revealed Resident #8 remained restless and frequently wandered throughout the unit, going from room to room. Resident #8 was touching another resident and staff.-However, Resident #8 was involved in another incident of physical abuse toward Resident #12 on 2/28/26 (see incident below).C. Resident #9 (victim)1. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dementia, insomnia and anxiety disorder.The 12/24/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. The MDS mobility assessment was not documented.The MDS assessment indicated the resident had physical behaviors directed towards others and wandered in the unit.2. ObservationsDuring a continuous observation on 3/3/26, beginning at 2:30 p.m. and ending at 3:30 p.m., Resident #9 was walking up and down the hallway of the unit.3. Record reviewResident #9's behavior care plan, initiated 7/29/25, revealed the resident had a diagnosis of unspecified dementia with agitation. The resident had been noted grasping others in attempts to self soothe/self comfort. The resident was friendly with other residents and enjoyed dancing even when there was no music. The resident could become agitated at times when she was unable to express herself. The resident could be anxious and restless at times.Interventions included assisting the resident with going to a calm environment and dancing when she appeared agitated, explaining all procedures to the resident before starting and allowing the resident time to adjust to changes, and providing a program of activities that was of interest and accommodating to the resident's status.The event note, dated 2/24/26, documented Resident #8 was heading to the entrance door. When Resident #8 got to the exit doors, Resident #9 was also heading to the exit doors. Resident #8 proceeded by pushing Resident #9 forcefully against the exit doors. Resident #9 reacted by attempting to get away from Resident #8 and began to walk towards a room. Resident #8 proceeded to follow Resident #9 closely and hit Resident #9 on her back and upper arms aggressively multiple times. Resident #9 started walking faster and went into a room, Resident #8 followed her and pulled the door close, held the door handle and stated If you are going to behave like a baby, you are going to stay there. As soon as RN #1 witnessed that event, she immediately started walking towards those two residents to intervene. A CNA heard the commotion and came to help. The CNA went into the room to check on Resident #9. RN #1 assured that both residents were separated and safe, then called the director of nursing (DON) to come to the unit. RN #1 also called the SSA to help. The SSA was able to bring Resident #8 to the dining room and sit on a chair. Resident #8 accepted a snack. Both residents were assessed for skin injuries and no injuries were noted. The DON instructed RN #1 to call the police department's non-urgent line. RN #1 called the police and was provided an incident number by the police. The resident representatives and physicians for both residents were notified.The health status note, dated 2/24/26, documented Resident #9 was the recipient of an aggression event earlier. A head-to-toe skin assessment was done by RN #1 right after the event, specifically focused on her back and arms as those were the areas that the aggressor hit. No injuries were noted, no reddened areas, no open areas, and no bruising was noted.The behavior note, dated 2/26/26, revealed Resident #9 continued on monitoring for a resident-to- resident altercation on 2/24/26 with Resident #8. No interaction was noted between both residents. Resident #9 had no signs of distress noted and did not have any negative reactions when resident Resident #8 was near her.III. Incident of physical abuse by Resident #8 towards Resident #12 on 2/28/26A. Facility investigationThe facility's investigation documented an incident occurred on 2/28/26 at 9:40 p.m. between Resident #8 and Resident #12. An unidentified nurse reported she heard a call for help. As the nurse entered Resident #12's room, she saw Resident #8 standing near Resident #12's bed, holding Resident #12's blanket. The nurse intervened immediately. Resident #12 said Resident #8 walked into her room and tried to take her blanket. Resident #12 said she yelled at Resident #8 asking her what she was doing in her room and Resident #8 slapped her. There was no witness to the incident. The nurse asked Resident #8 about it. Resident #8 said Resident #12 was being a brat so she slapped her.Resident #8 was led out of the room and was put on one-on-one supervision until notable improvement was observed. Medication adjustments were made per physician's orders. Staff were educated about remaining aware and placing themselves strategically throughout the unit in order to provide supervision.Resident #12 had no change in her mood or behavior and sustained a redness with a measurement of 2.5 centimeters (cm) by 1 cm on her left cheek. She was not fearful and maintained her regular routine.The facility substantiated the physical abuse.B. Resident #8 (assailant)1. Record reviewThe event note, dated 3/1/26, documented a nurse heard Resident #12 calling for help in her room. The nurse arrived and observed Resident #8 holding Resident #12's bed sheets and beginning to walk out of the room and not letting go of the sheets. A CNA was called in and walked with Resident #8 down the hallway. Resident #8 was asked what happened and replied, She hit him. When asked who Resident #12 hit, Resident #8 said She hit my husband, she's being a brat and not doing nothing, not even her homework. So, I slapped her. All parties were notified. Staff assessed the resident's skin and no injuries were noted. Resident #8 was put on one-on-one monitoring. Police arrived and took statements from the residents.C. Resident #12 (victim)1. Resident statusResident #12, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included anxiety, dementia and cognitive communication deficit.The 12/24/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident used a wheelchair for ambulation. The MDS assessment indicated the resident had verbal behaviors directed toward others.2. Resident interviewResident #12 was interviewed on 3/4/26 at 3:40 p.m. Resident #12 said Resident #8 slapped her on her left cheek. She said she was coming back into her room and found Resident #8, whom she did not recognize, sitting on her bed. Resident #12 said she told Resident #8 to leave because it was not her room and Resident #8 replied she could be there because it was her room too. Resident #12 said Resident #8 was sitting in her wheelchair. Resident #12 pointed to her name on the wall to show Resident #8 it was her room. Resident #12 said Resident #8 got upset and slapped her cheek. Resident #12 said she called for help and the nurse came in and took Resident #8 out of her room. She said the nurse then checked on her and said her cheek was red. Resident #12 said her cheek hurt for a couple days after being hit by Resident #8. She said she had never seen Resident #8 before that day and had not had any other issues with residents in the past. Resident #12 was not sure if she would recognize Resident #8 if she passed her in the hallway. She said she felt safe at the facility and was not afraid of the other residents. Resident #12 said she stayed in her room a lot even before the incident with Resident #8 happened. Resident #12 said she really did not want anyone in her room that was not supposed to be there.3. Record reviewResident #12's behavior care plan, revised 1/13/26, revealed the resident had diagnoses of adjustment disorder with depressed mood and anxiety disorder. The resident often felt emotional and started crying. The resident would often become upset about concerns with her roommate. The resident had been known to make suicidal statements when she was upset. The resident would often sleep throughout the day and be awake most of the night.Interventions included assisting the resident, family, caregivers to identify strengths, positive coping skills and reinforce those, encouraging the resident to call her daughter/other family members when she was upset and observing and reporting PRN (as needed) any risk for harm to herself.The event note, dated 2/28/26, documented a nurse at the nurses' station heard Resident #12 yelling from her room Help! The nurse hurriedly went to Resident #12's room and halfway down the hall, Resident #12 yelled Help me! Resident #8 was in the middle of the room holding Resident #12's blanket and Resident #12 reported She hit me! She slapped me across the face! The nurse called a CNA to bring Resident #8 outside and stay by her side. The nurse assessed Resident #12 and noted redness measuring 2.5 cm by 1 cm on the left cheek. Resident #12 said I asked her what the hell are you doing in my room and she grabbed my blanket and I told her to get out. All parties were notified. Non-emergency police were called. A police officer arrived and took statements from the two residents.IV. Staff interviewsCNA #3 was interviewed on 3/4/26 at 3:40 p.m. CNA #3 said when she noticed residents having a physical altercation, she would separate them and call the nurse. She said she would talk to residents and see if they needed anything. CNA #3 said she would document residents' behaviors in the residents' electronic medical records (EMR). She said Resident #8 moved rooms the previous week because she was aggressive towards other residents. She said Resident #8 was on one-on-one supervision and she could be uncontrollable sometimes. CNA #3 said on 3/3/26 at approximately 9:00 p.m. when she was providing one-on-one supervision, Resident #8 was in her room and started walking around. She said Resident #8 walked down the hallway and tried to enter another resident's room. CNA #3 said Resident #8 hit her (CNA #3) on her arm when she was trying to redirect the resident. CNA #3 said she called the nurse who was able to calm Resident #8 down. CNA #3 was unable to identify Resident #8's trigger behaviors.The social services director (SSD) was interviewed on 3/4/26 at 4:07 p.m. The SSD said Resident #8 was very impulsive and had unpredictable behavior. She said Resident #8 might have a pleasant conversation with another resident then shift her behavior. The SSD said she was unable to identify the triggers for the resident's behaviors as much as the facility tried. She said Resident #8 could be verbally and physically aggressive and challenging to redirect. She said Resident #8 had destroyed property and could exhibit exit-seeking behaviors. The SSD said there was not much the facility could do from a normal logical approach. She said Resident #8's family provided a busy box with everything in it that Resident #8 had interests in, such as crocheting to keep the resident occupied. The SSD said sometimes the busy box could work and sometimes it did not. The SSD said the physician reviewed Resident #8's medications and added Depakote (a mood stabilizing medication) and Seroquel (an antipsychotic medication) to stabilize the resident's mood.The DON and the NHA were interviewed together on 3/4/26 at 6:10 p.m. The DON said she was notified along with the NHA, who was the facility's abuse coordinator, when there was a physical abuse incident. She said she and the NHA would start the abuse investigation, interview staff, families, and residents who could talk with them. The DON said they tried to keep the same staff on units to help identify changes in residents. The NHA said the facility reported abuse allegations to their regional office, state reporters, and the ombudsman. The DON said the incident between Resident #8 and Resident #9 occurred when Resident #8 wanted to get off the unit and was agitated due to the door not opening. She said Resident #9 wandered into the space where Resident #8 was at the door. The DON said Resident #8 was put on one-on-one supervision immediately and moved to another unit. She said the facility felt the center unit would provide more foot traffic to monitor the resident. The DON said Resident #8's one-on-one supervision remained in place until 2/27/26 at 10:28 p.m. and was discontinued due to no behaviors being noted by staff. The NHA said a nurse assisted Resident #8 to get to bed on 2/28/26. The NHA said the nurse then heard Resident #12 call for help. She said Resident #12 reported that Resident #8 was coming out of her room and she told her it was not her room. She said Resident #12 said she tapped on the wall showing Resident #8 her name (Resident #12's name) on the wall. The NHA said Resident #8 continued into the room touched Resident #12's blanket and Resident #8 yelled at Resident #12 and slapped her. The NHA said Resident #8 was put back on one-on-one supervision after the incident with Resident #12. She said the facility was still trying to identify Resident #8's behavior triggers and the physician had made further medication changes for the resident.

Based on observations, record review and interviews, the facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practical physical, mental, and psychological well-being for one (#4) of four residents reviewed for dementia care out of four sample residents. Specifically, the facility failed to develop and implement effective person-centered dementia management interventions to prevent Resident #4 from wandering into other residents' rooms.Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, revised 9/6/24, was provided by the nursing home administrator (NHA) on 10/28/25 at 12:36 p.m. It read in pertinent part, This facility will provide dementia treatment and services which may include, but is not limited to, ensuring adequate medical care, diagnosis, and supports based on diagnosis, ensuring the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choices, and safety and utilizing individualized, non-pharmacological approaches to care. Residents who display or are diagnosed with dementia will receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.Identify, address, and/or obtain necessary services for the dementia care needs of the residents.Develop and implement person-centered care plans that include and support the dementia care needs identified in the comprehensive assessment.Develop individualized interventions related to the resident's symptomology and rate of progression.Review and revise care plans that have not been effective and/or when the resident has a change in condition.Modify the environment to accommodate resident care needs and achieve expected improvements or maintain the expected stable rate of decline.II. Resident #4A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included wandering in disease classified elsewhere, psoriasis (a chronic autoimmune skin condition), unspecified dementia, unspecified severity with other behavioral disturbances, and need for assistance with personal care.The 5/28/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of three out of 15. He required supervision or touch assistance with toileting and personal hygiene, and was independent with eating.The MDS assessment revealed the resident wandered one to three days during the assessment look-back period and exhibited physical behavioral symptoms, such as hitting, kicking, scratching, grabbing, pushing, and sexually abusive behavior toward others.B. ObservationsDuring a continuous observation on 10/27/25, beginning at 12:00 p.m. and ending at 1:34 p.m., the following observations were made:At 12:15 p.m. Resident #4 was observed leaving his room, heading towards the main nurses' station, which was adjacent to the dining room. He diverted to a room close to the nurses' station, room [ROOM NUMBER], which occupied two residents. The resident laid on bed A and covered himself with the other resident's blanket. Certified nurse aide (CNA) #1 and licensed practical nurse (LPN) #1 were at the nurses' station and were not paying attention to where the resident went. The residents who resided in room [ROOM NUMBER] were in the dining room eating lunch. At 12:50 p.m., LPN #1 said Resident #4 was in his room, asleep. However, upon checking the resident's room, LPN #1 noticed Resident #4 was not in his bed. She started searching room by room and eventually found the resident asleep in room [ROOM NUMBER], bed A. At 12:54 p.m., LPN #1 was able to redirect Resident #4 out of room [ROOM NUMBER] to the dining area.At 12:58 p.m., CNA #1 served Resident #4 his lunch meal. The resident sat at the dining table, dozing off. He then got up and attempted to leave the dining area. CNA #1 encouraged him to stay and eat his food.During a second continuous observation on 10/27/25, beginning at 3:40 p.m. and ending at 4:30 p.m., the following observations were made: At 3:40 p.m., Resident #4 was observed laying on bed B in room [ROOM NUMBER]. The staff were not aware where the resident was at that moment. The residents who resided in the room were in the dining room, engaging in bingo activities.At 3:50 p.m., CNA #2 was in the dining room chatting with an activities staff member. LPN #2 was in and out of the nurses' station.At 4:10 p.m. staff did not attempt to find out where Resident #4 was until prompted. CNA #2 started searching room by room, looking for the resident. CNA #2 found the resident asleep in room [ROOM NUMBER], bed B. She woke the resident up and redirected him to the dining room. The resident continued to fall asleep at the dining table. -Though there were activities going on, the staff failed to encourage the resident to participate.C. Record review Resident #4's wandering and elopement care plan, initiated 5/25/23 and revised 7/5/24, revealed the resident was at risk for wandering and elopement due to his diagnosis of unspecified dementia. Resident #4 was often asked to go home and would usually attempt to follow a staff and visitors off the unit and attempt to open doors on the unit. The resident would wander into other residents' rooms and go to sleep in their beds. The care plan revealed the resident often became aggressive with others when they tried to wake him up, and he was found asleep in another resident's bed. Interventions included documenting the resident's wandering behavior and attempting diversional interventions, encouraging the resident to participate in activities to divert him from exit-seeking behavior, providing structured activities, such as toileting, walking inside and outside, and reorientation strategies, including signs, pictures, and memory boxes.-Facility staff failed to monitor and engage Resident #4 in meaningful activities to minimize his wandering behaviors.The 10/1/25 psychosocial note revealed Resident #4 wandered in and out of other residents' rooms, exhibited physical and verbal aggression towards staff and residents, and destroyed property. The 10/15/25 behavior note, documented at 3:04 p.m., revealed Resident #4 was being monitored for an increase in his Depakote medication dosage. The resident was observed wandering without his pants, with feces noted on his body and hands. The resident became aggressive towards staff when staff attempted to assist him with hygiene and clean clothes. The resident refused staff assistance and physically hit the staff.III. Staff interviewsCNA #1 was interviewed on 10/27/25 at 4:11 p.m. CNA #1 said she knew Resident #4 had wandered based on her observations and the resident's care plan. CNA #1 said that if she saw a resident wandering, she would ensure the resident wandered to a safer area. She said she calmly intervened when Resident #4 wandered into unsafe areas by redirecting him. CNA #1 said Resident #4 often became physically and verbally aggressive towards other residents and sometimes towards staff. CNA #1 said the resident required supervision at all times for his safety and the safety of other residents. CNA #1 said the resident wandered in and out of other residents' rooms and most of the time slept in other residents' beds.LPN #2 was interviewed on 10/27/25 at 4:20 p.m. LPN #2 said she had been provided dementia training and was able to provide dementia care. She said wandering into other residents' rooms and falling asleep in their beds was not safe. She said Resident #4 wandered into all the rooms, urinated on the floor in common areas, and would be in other residents' spaces. LPN #2 said Resident #4 could be physically and verbally aggressive towards residents and staff when redirected. She said wandering into other residents' rooms could result in an altercation with the occupants of the room. LPN #2 said staff only documented the resident's aggressive behaviors, but did not document his wandering.CNA #2 was interviewed on 10/28/25 at 9:30 a.m. CNA #2 said she was familiar with Resident #4 and able to work with him, however, the resident became out of control and exhibited aggression towards staff and other residents when redirected. She said the resident wandered through every room on the unit and attempted to urinate on the floor in common areas. CNA #2 said the staff were unable to stop Resident #4 from entering other residents' rooms. The director of nursing (DON) was interviewed on 10/28/25 at 2:35 p.m. The DON said every staff member had been trained on dementia care and should be able to work with Resident #4. The DON said staff should monitor and be aware of where the resident was at all times. She said the resident entering other residents' rooms and sleeping in their beds with the staff being unaware was unacceptable. The DON said she would immediately offer education to the staff to ensure wandering behaviors were documented appropriately.The social services director (SSD) was interviewed on 10/28/25 at 4:35 p.m. The SSD said she reviewed residents' care plans and behavior notes weekly to identify if there were new behaviors, and she would bring them up to the interdisciplinary team to develop appropriate interventions for the residents. The SSD said she expected all behaviors to be documented, including wandering to other residents' rooms and sleeping in other residents' beds. The SSD said the current behavior tracking was standardized and not person-centered. The SSD said nurses should document all wandering behaviors in the nursing progress notes. The SSD said she did not know why the staff failed to document Resident #4's wandering behavior of entering other residents' and sleeping in another resident's bed. She said such behavior could result in resident-to-resident altercation with possible aggression towards one another.

Based on record review and interviews, the facility failed to ensure that three (#57, #10 and #51) of five residents out of 35 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Residents #57, #10 and #51, the facility failed to: -Adequately identify and monitor target behaviors for psychotropic medications; -Identify resident specific interventions for behaviors; and, -Provide adequate documentation to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications. Findings include: I. Facility policy and procedure The Unnecessary Medication policy, revised 4/22/25, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:14 a.m. It read in pertinent part, The facility will ensure only medications required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications are important considerations for all residents.Therefore, as part of medication management (especially psychotropic medications), it is important for the interdisciplinary team (IDT) to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility will assess the resident's underlying condition, current signs, symptoms, and expressions, and preferences and goals for treatment. This will assist the facility in determining if there are any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. II. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, anxiety, major depressive disorder, and insomnia. The 3/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. The resident required one-person maximum assistance with showering, toileting, dressing, personal hygiene and transfers and required a wheelchair for mobility. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or distruptive sounds). B. Record review Resident #57's elopement care plan, initiated 4/15/25, revealed the resident would often ask her family about taking her home, or would often state that her family was going to come and get her. Interventions, initiated 4/22/25, included providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #57's behavior care plan, revised 12/16/24, revealed the resident used antipsychotic medications for behavior management. Interventions, initiated 12/16/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproaching and assisting to a quiet area. -The care plan did not identify target behaviors to monitor for Resident #57's prescribed antipsychotic medications or resident specific non-pharmacological interventions. Resident #57's April 2025 CPO revealed the following physician's orders: Trazodone (antidepressant medication) 100 milligram (mg) tablet. Give one tablet at bedtime for insomnia, ordered 12/11/24. Sertraline (antidepressant medication) 100 mg tablet,. Give one tablet a day for depression, ordered 12/12/24. Sertraline 50 mg. Give 0.5 (half) tablet a day for major depressive disorder for seven days with 100 mg dosage to equal 125 mg, ordered 4/1/25 and discontinued 4/8/25. Sertraline 50 mg tablet. Give one tablet a day for depression with 100 mg dosage to equal 150 mg, ordered 4/10/25 (an increase in dosage). Document number of hours resident sleeps, ordered 2/4/25. Risperdone (antipsychotic mediation) 1 mg tablet. Give 0.5 mg one time a day for unspecified dementia, ordered 4/1/25. Risperdone 1 mg tablet. Give one tablet at bedtime for dementia with agitation and anxiety, ordered 4/1/25. -Review of Resident #57's April 2025 CPO revealed there were no physician's orders for behavior tracking/monitoring. Review of Resident #57's electronic medical record (EMR) from 3/1/25 to 4/29/25 revealed the following progress notes: A psychotropic medication meeting note, dated 1/31/25, did not identify what behaviors were exhibited by Resident #57 or what resident specific interventions were effective when the resident was exhibiting behaviors. -Additionally, the psychotropic meeting note did not document the justification for continuing Resident #57's antipsychotic and antidepressant medications. A behavior note, dated 3/10/25, revealed Resident #57 displayed obsessive behaviors regarding wanting to call her family to have them take her home. The resident began asking her roommate to help her call and was becoming increasingly anxious. When in her room, the resident attempted to walk and the staff attempted to take her to a common area so the staff could supervise her to prevent falls. This caused the resident to become argumentative with the staff. A behavior note, dated 3/11/25, revealed Resident #57 continued behaviors of obsessing over calling her family and asking her roommate to help her make a call. The resident was encouraged to stay in the common area to prevent falls but the resident became argumentative with staff. Interventions of distraction and snacks were offered but the resident's behavior continued. A behavior note, dated 3/12/25, revealed Resident #57 continued to be restless and requested to call her family. The resident continued to want to go to her room alone. Later in the shift, the resident was found by staff on the floor of her bedroom doorway, with her wheelchair behind her. She told the staff she was trying to go to her room to call her family. -The non-pharmological interventions identified in the care plan for Resident #57's behaviors of obsessing over her family taking her home to prevent agitation (providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes) were not indicated as being used when the resident was wanting to call her family on 3/10/25, 3/11/24 and 3/12/25 (see care plan and progress notes above). A communication note, dated 4/1/25, revealed a call was made to Resident #57's representative to notify her that the physician had increased the resident's risperidone (antipsychotic medication) due to behaviors at night where the resident refused to be changed which caused her to be wet throughout the evening. -Review of Resident #57's EMR revealed there was no physician's progress note or nursing documentation to indicate the resident refused to be changed. Review of the certified nurse aide (CNA) behavior monitoring task for Resident #57, from 3/1/25 to 4/29/25, revealed the following: The resident had eighteen episodes of repetitive motions where the intervention used was marked as not applicable. The resident had four episodes of anxiety, agitation, restlessness and frustration where the intervention used was marked as not applicable. The resident had seven episodes of anxiety, agitation, restlessness and frustration where the interventions used were marked as either redirect or reapproach. -The CNA behavior monitoring task did not identify what the term not applicable indicated or what resident specific redirection or reapproach interventions were attempted. A review of Resident #57's hours of sleep documented from 2/1/25 to 4/30/25 revealed she slept an average of 10 to 12 hours per day. A review of Resident #57's EMR from 1/20/25 to 3/18/25 revealed she had fallen five times. III. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized CPO, diagnoses included unspecified dementia with psychotic disturbance and anxiety. The 2/5/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident used a wheelchair for mobility and required one-person maximum assistance with eating, personal hygiene, showering, toileting, dressing, bed mobility and transfers. The MDS assessment indicated the resident had no behaviors of physical or verbal aggression, rejection of care, disrobing, pacing or wandering. B. Record review Resident #10's elopement care plan, revised 11/18/24, revealed the resident had behaviors of wandering related to a diagnosis of dementia with anxiety. The resident would often forget where her room was and was at risk for exit seeking. Interventions, initiated 11/18/24, included providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #10's behavior care plan, initiated 12/16/24, revealed the resident used antipsychotic medications for behavior management. Interventions, initiated 12/16/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproaching and assisting to a quiet area. -The care plan did not identify target behaviors to monitor for Resident #10's prescribed antipsychotic medications or resident specific non-pharmacological interventions. Resident #10's April 2025 CPO revealed the following physician's orders: Olanzapine (antipsychotic medication) 5 mg. Give one tablet a day for dementia with psychotic features, ordered 2/3/25. Citalopram (antidepressant medication) 10 mg. Give one tablet a day for depression, ordered 2/3/25 and discontinued 3/6/25. Citalopram 20 mg. Give one tablet a day for depression, ordered 3/6/25 (an increase in dosage). Document number of hours resident sleeps, ordered 3/25/25. -Review of Resident #10's April 2025 CPO revealed there were no physician's orders for behavior tracking/monitoring. Review of Resident #10's EMR from 1/1/25 to 4/29/25 revealed the following progress notes: A behavior note, dated 1/4/25, revealed Resident #10 had been restless, pacing the halls and going into other residents' rooms on the evening shift. A progress note, dated 3/4/25, revealed Resident #10 had been crying and requesting to go home so the family picked her up to take her home to spend the night. A physician's note, dated 3/5/25, revealed the physician increased Resident #10's antidepressant medication (citalopram) after nursing staff reported she had an episode of crying uncontrollably and wanting to go home. The physician noted the resident's mental status appeared to be at baseline. -The non-pharmological interventions identified in Resident #10's care plan for her behaviors of wandering (providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes) were not indicated as being used when the resident was wandering on 1/4/25 and crying and wanting to go home on 3/5/25 (see care plan and progress notes above). A psychotropic medication meeting note, dated 3/25/25, did not identify what behaviors Resident #10 exhibited or what resident specific interventions were effective when the resident was exhibiting behaviors. -Additionally, the psychotropic meeting note did not document the justification for continuing Resident #10's antipsychotic and antidepressant medications. Review of the CNA behavior monitoring task for Resident #10, from 1/1/25 to 4/30/25 revealed the following: The resident had five episodes of repetitive motions where the intervention used was marked as not applicable. The resident had four episodes of anxiety, agitation, restlessness and frustration where the intervention used was marked as not applicable. The resident had eight episodes of anxiety, agitation, restlessness and frustration where the interventions used were marked as either redirect or reapproach. The resident had four episodes of pacing and wandering where the interventions were marked as either redirect or reapproach. The resident had five episodes of entering other residents' rooms where the intervention used was marked as not applicable. The resident had four episodes of entering other residents' rooms where the interventions were marked as either redirect or reapproach. The resident had one episode of disrobing, tearfulness, hitting others and screaming at others where the interventions used were marked as either redirect or reapproach. -The CNA behavior monitoring task did not identify what the term not applicable indicated or what resident specific redirection or reapproach interventions were attempted. A review of Resident #10's hours of sleep documented from 3/25/25 to 4/29/25 revealed she slept an average of 10 to 12 hours per day. IV. Resident #51 A. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized CPO, diagnoses included unspecified dementia. The 3/21/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of one out of 15. The resident used a wheelchair for mobility and was dependent on staff for personal hygiene, toileting, showering, dressing, bed mobility and transfers. The MDS assessment indicated the resident had no behaviors of physical or verbal aggression, rejection of care or wandering. B. Resident interview Resident #51 was interviewed on 4/28/25 at 12:15 p.m. Resident #51 inquired about purchasing a plane ticket to [NAME]. When she was advised of the cost of a one-way ticket to [NAME], she asked if there were any sales. When the resident was advised there might be a summer sale on plane tickets, she said she would like to wait for the sale. The resident did not display any agitation and accepted the explanation. C. Record review Resident #51's elopement care plan, initiated 4/28/25 (during the survey), revealed the resident was at risk for elopement due to her diagnosis of dementia with agitation. The resident would often ask the staff about going home and propel herself in her wheelchair to the exit doors. Interventions, initiated 4/28/25 (during the survey), included providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #51's behavior care plan, initiated 3/24/24, revealed the resident used antipsychotic medications related to a diagnosis of dementia with psychosis. Interventions, initiated 3/24/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproaching and assisting to a quiet area. -The care plan did not identify target behaviors to monitor for Resident #51's prescribed antipsychotic medications or resident specific non-pharmacological interventions. Resident #51's April 2025 CPO revealed the following physician's orders: Lorazepam (anti-anxiety medication) 1 mg. Give one tablet every twelve hours as needed for anxiety/restlessness, ordered 4/26/25 and discontinued 5/1/25 (during the survey). Risperdone 0.5 mg. Give one tablet twice a day for dementia with psychotic disturbances, ordered 3/19/25. Document number of hours resident sleeps, ordered 4/1/25. Seroquel (antipsychotic medication) 12.5 mg. Give one tablet at bedtime for dementia with behaviors, ordered 3/19/25 and discontinued 4/1/25. Seroquel 25 mg. Give one half tablet (or 12.5 mg) at bedtime for unspecific dementia, ordered 4/3/25. -Review of Resident #51's April 2025 CPO revealed there were no physician's orders for behavior tracking/monitoring. Review of Resident #51's EMR from 3/19/25 to 4/29/25 revealed the following progress notes: A psychotropic medication meeting note, dated 3/25/25, did not identify any behaviors exhibited by Resident #51 since her admission on 3/19/25. A communication note, dated 4/2/25, revealed Resident #51's representative was unaware the resident's Seroquel (antipsychotic medication) had been discontinued and was upset she had not been contacted. The medication was restarted per the representative's request. A skilled nursing note, dated 4/5/25, revealed Resident #51 had behaviors of anxiety and tried to transfer herself to a chair near the nurses station. The note did not indicate if non-pharmacological interventions were attempted to decrease the resident's anxiety. A behavior note, dated 4/7/25, revealed Resident #51continued to be restless throughout the day, propelling herself around the unit, going into all the rooms, attempting to get up from her chair or transferring herself from her wheelchair unassisted. The resident was obsessed with purchasing a ticket for a train. Positive distraction, snacks, drinks and a fake train ticket were provided, but the interventions were not effective. A behavior note, dated 4/8/25, revealed Resident #51 continued to be restless throughout the day, propelling herself around the unit, going into rooms, attempting to get up from her chair or transferring herself from her wheelchair unassisted. The resident was obsessed with purchasing a ticket for a train. Positive distraction, snacks, drinks and a fake train ticket were provided, but the interventions were not effective. A behavior note, dated 4/13/25, revealed Resident #51 displayed confusion, requesting to go home, attempting to walk independently and exit-seeking. The note documented attempts to redirect the resident were successful for short periods of time, however, the note did not document the interventions that were attempted. A skilled nursing note, dated 4/14/25, revealed Resident #51 had behaviors of wandering, decreased safety awareness, unsafe attempts to self transfer and was obsessed over having a bill, money being taken by staff and needing to catch a bus. The interventions were not always successful, including positive distraction, snacks and drinks. A behavior note, dated 4/20/25, revealed Resident #51 had behaviors of exit-seeking and asking to go home. She required frequent redirection (watching television (TV), reading or attending church services) that were only successful for short periods of time. A behavior note, dated 4/25/25, revealed Resident #51 was observed pacing the unit frequently, restless and anxious and verbalizing concerns intermittently about not being able to find her bag. The note documented that redirection was attempted multiple times with no effectiveness, however, the note did not document the interventions that were attempted. A communication note, dated 4/26/25, revealed the nurse contacted the physician requesting an order for lorazepam as needed for agitation due to Resident #51 not sleeping well the previous two evenings, attempting to get up at night and requiring frequent redirection. A behavior note, dated 4/26/25, revealed Resident #51 was observed pacing the unit frequently, restless and anxious and verbalizing concerns intermittently about not being able to find her bag. The note documented that redirection was attempted multiple times with no effectiveness, however, the note did not document the interventions that were attempted. A behavior note, dated 4/27/25, revealed Resident #51 was observed pacing the unit frequently, restless and anxious and verbalizing concerns intermittently about not being able to find her bag. The note documented that redirection was attempted multiple times with no effectiveness, however, the note did not document the interventions that were attempted. A behavior note, dated 4/29/25, revealed Resident #51 was restless throughout the day, impulsive, continuously getting up and self-transferring without assistance. Redirection (activities, snacks and positive distraction) worked only briefly. -The non-pharmological interventions identified in the care plan for Resident #51's behaviors of wandering (providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes) were not initiated until 4/28/25 (during the survey). A communication note, dated 5/1/25, revealed the nurse and the director of nursing (DON) called Resident #51's representative to confirm she was aware of the lorazepam order obtained on 4/26/25 (see physician's orders above). The nurse documented that the representative said she was aware and had consented. Review of the CNA behavior monitoring task for Resident #51 from 4/28/25 to 4/30/25 revealed the following: On 4/28/25 Resident #51 had behaviors of making disruptive sounds, disrobing in public, agitation, anxiety and exit-seeking. Interventions included redirection, removal from the environment, offering meaningful activity and providing a calm environment without success. On 4/29/25 Resident #51 had behaviors of disrobing in public, agitation, anxiety and restlessness. Interventions included redirection and removal from the environment without success. On 4/30/25 Resident #51 had behaviors of repetitive motions and agitation. The interventions were marked as not applicable. -The CNA behavior monitoring task did not identify what the term not applicable indicated or what redirection or reapproach interventions were attempted. -The CNA behavior monitoring task was not initiated until 4/28/25 (during the survey). V. Staff interviews Registered nurse (RN) #3 was interviewed on 4/30/25 at 1:49 p.m. RN #3 said the nurses documented behaviors and interventions attempted in the residents' progress notes. She said the residents'specific behaviors and residents'specific interventions were documented in the residents' care plans. RN #3 said the nurses had to check every resident's care plan during their shift. She said the nurses did not document behaviors associated with specific psychotropic medications, such as antipsychotics medications. She said the nurses only documented behaviors for 14 days after a medication change and then stopped monitoring. RN #3 said if there were new behaviors or interventions identified in the facility's 24-hour meeting in the mornings, it would be verbally communicated to the nurses, but she said the new behaviors and interventions were not documented. CNA #3 was interviewed on 4/30/25 at 2:05 p.m. CNA #3 said the CNAs documented behaviors in a separate documentation system from the nurses and the CNAs did not have access to the residents' care plans. She said the CNA behavior monitoring tasks displayed a list of behaviors to choose from and a list of interventions to choose from, but the CNA could not personalize the behaviors or interventions. CNA #3 said if the resident had a specific behavior or intervention that was not included in the generic list, the CNAs did their best to select an appropriate choice. She said if the interventions were not included on the list, the CNA would document not applicable and report the interventions to the nurse to document in the progress notes. RN #1 was interviewed on 5/1/25 at 9:45 a.m. RN #1 said Resident #51 had behaviors of agitation and wandering. She said the resident was triggered when others raised their voices and the staff had to remove her from the unit or lay her down. RN #1 said if the resident tried to get up out of bed or her chair repeatedly, the nurses would administer her an as needed lorazepam dose. RN #1 said Resident #57 had behaviors of propelling herself to her doorway and waiting for staff, but she said the resident had no other behaviors. She said the staff would offer her books or magazines. RN #1 said Resident #10 had behaviors due to her language deficits because she spoke only Romanian and the staff had to read her body language. RN #1 said the resident became anxious due to her lack of ability to communicate and there were no specific interventions for her. CNA #4 was interviewed on 5/1/25 at 10:07 a.m. CNA #4 said Resident #51 had behaviors of standing up sometimes and the only intervention that worked was to walk with her. CNA #4 said Resident #57 has behaviors of anxiety and she was not aware of specific behaviors or interventions for her. CNA #4 said Resident #10 did not have any behaviors. The DON and the social services director (SSD) were interviewed together on 5/1/25 at 2:00 p.m. The SSD said the efficacies of the residents' psychotropic medications were reviewed in the psychotropic medication meeting quarterly or as needed. She said the nurses documented behaviors in the progress notes and the CNAs reported behaviors to the nurses as well as documented behaviors in their own behavior monitoring system. She said the nurses notes and the CNA behavior monitoring tasks should match. She said she could not customize the CNA behavior monitoring to be person-centered or individualized. She said the expectation was that the nurses looked for the individualized behaviors and resident specific non-pharmological interventions in the resident care plan. The SSD said the behavior monitoring was used to identify residents' behaviors and effective interventions. She said if the documentation was inconsistent, the information brought to the psychotropic medication meeting was inaccurate and this affected medication decisions. The SSD said the psychotropic medication meeting was intended to be for the interdisciplinary team (IDT) to discuss with the physician and providers the efficacy of psychotropic medications, the effectiveness of the interventions and any changes in residents' behaviors. The DON said if the resident was having behaviors, the nurses would first try generic interventions, such as redirection, offering food or fluids and taking residents to activities. She said if those interventions were unsuccessful, the nurse would look at the resident's care plan for the identified resident specific interventions. The DON said the nurses did not have time to look at every resident's care plan during their shifts unless the generic interventions were unsuccessful. She acknowledged this practice did not demonstrate that individualized, person-centered interventions were being attempted for residents' behaviors. The DON said she was not happy when she discovered Resident #57 had risperidone added to her medication regimen. She said the physician had come into the building and the staff reported the resident was refusing care so the physician prescribed the risperidone. The DON said the physician declined to discontinue the medication when she requested it be discontinued, but she said she had not reached out to the medical director to assist further in getting the medication discontinued. The DON said Resident #51's Seroquel medication was discontinued on 4/1/25 by the physician but consent to discontinue the medication was not obtained from the resident's representative so the medication had to be reinstated on 4/3/25. She said she contacted the representative on 5/1/25 to confirm the lorazepam order had been approved by the representative due to the DON being unable to find documentation that a consent had been obtained. She said the representative informed her that she had never been contacted or asked to start this medication. -However, the nurse who documented the 5/1/25 note regarding the call placed to the resident's representative about the lorazepam indicated the representative was aware of the new physician's order prior to the 5/1/25 call and had given consent for the medication (see 5/1/25 communication progress note above). The SSD said the risperidone for Resident #57 was inappropriate to treat provoked behaviors. She said the behavior monitoring for the resident did not reflect a necessity for the medication. The SSD said Resident #10 went out to the hospital and returned with the olanzapine medication and prior to that, she had been taking Seroquel for hallucinations. She said the hallucinations were not being tracked and when the CNAs documented not applicable on their behavior monitoring task, she thought that indicated no interventions were attempted. The SSD said Resident #51's lorazepam was requested by the overnight nurses because the resident was restless and having trouble sleeping. She said she was not able to say the facility was attempting individualized resident specific nonpharmacological interventions or that the facility was not using psychotropic medications for staff convenience. -An attempt was made to interview the medical director on 5/1/25 at approximately 5:30 p.m. via phone, however, the medical director was unable to be reached.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication storage rooms. Specifically, the facility failed to ensure vaccinations were not stored in dormitory style fridges. Findings include: I. Professional reference According to the Vaccine Storage and Handling Tool-kit, dated 3/29/24, retrieved on 5/5/25 from https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf, it revealed in pertinent part, Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines even when used for temporary storage. II. Facility policy and procedure The Medication Storage in Refrigerator/Freezer policy, reviewed 9/16/24, was received from the nursing home administrator (NHA) on 5/1/25 at 10:46 a.m. It revealed in pertinent part, The facility will ensure that medications which require refrigeration were stored appropriately per manufacturer's instructions. Safe temperatures for refrigeration were between 36 degrees and 46 degrees Fahrenheit (F). The facility should monitor the temperature for vaccine storage twice a day. If there is excessive ice built up in the freezer, the maintenance department should be notified to defrost the unit to ensure proper functioning. III. Observations and staff interviews On 5/1/25 at 9:46 a.m. the west medication room was observed with the infection preventionist (IP). The IP said the facility stored all vaccinations in the west medication refrigerator. The IP said the refrigerator temperature was 34 degrees F. The west medication refrigerator contained 13 doses of 2024/2025 influenza vaccines and eight doses of pneumococcal 21 valent conjugate vaccine. The IP said the refrigerator temperature should be between 36 to 46 degrees F. The temperature at time of observation revealed the temperature was 34 degrees F. The IP said the temperature was too cold for the vaccines. -The IP did not adjust the medication fridge temperature at time of observation. IV. Additional interviews The IP was interviewed on 5/1/25 at approximately 9:55 a.m. She said there was not a concern for the vaccines to be stored in a dormitory style refrigerator as long as there were no temperature fluctuations. The IP said the current refrigerator temperature was just below the refrigerator temperature ranges. The director of nursing (DON) was interviewed on 5/1/25 at 2:00 p.m. She said the temperature for medication refrigerators needed to be between 36 to 40 degrees F. The DON said if a refrigerator was found to not maintain temperature the nurse who identified it should adjust the temperature and check back to see if it was corrected or if further intervention was required. The DON said she has the nurses defrost the freezers to ensure ice does not build up. The DON said she did not know if vaccines should not be stored in dormitory style refrigerators.

Based on record review and interviews, the facility failed to ensure three (#86, #48 and #93) of six residents reviewed for abuse out of 35 sample residents were free from abuse. Specially, the facility failed to: -Protect Resident #48 from physical abuse by Resident #86; -Protect Resident #86 from physical abuse by Resident #48; and, -Protect Resident #93 from physical abuse by Resident #84. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised 6/17/24, was received from the nursing home administrator (NHA) on 5/1/25 at 11:15 a.m. It read in pertinent part, The facility must develop and implement written policies and procedures that identify, assess, and care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect such as verbally aggressive behavior, physically aggressive behavior, sexually aggressive behavior, taking, touching, or rummaging through other's property, or wandering into other rooms/space. II. Incidents of physical abuse between Residents #86 and #48 A. Facility investigation of physical abuse on 2/18/25 The 2/18/25 facility investigation documented a nurse, who was at the nurses' station, heard yelling. The nurse came out of the nurses' station and witnessed Resident #48 sitting in the doorway of Resident #86's room. Resident #86 and Resident #48 had grabbed each other's shirts and were slapping each other on the forearms, open handed. The two residents were separated by staff and assessed for injuries and no injuries were noted. When interviewed by staff, Resident #86 recalled being involved in a negative interaction with another resident but thought that it may have been a male resident. Resident #48 could not recall the event when interviewed. The residents resided on the same secured unit of the facility. Resident #48 was provided a one-on-one caregiver for 72-hours, a medication review was requested and a room move to another unit was completed, per the facility reported incident. The facility unsubstantiated the abuse investigation due to the residents' cognitive impairments. -However, abuse occurred due to Resident #86 and Resident #48 being observed slapping each other. B. Facility investigation of physical abuse on 2/19/25 The 2/19/25 incident investigation documented an altercation occurred between Resident #86 and Resident #48 in the hallway of the secured unit that both of the residents resided on. Resident #48 had been assigned a one-on-one caregiver for supervision after the incident between Resident #86 and Resident #48 on 2/18/25. The one-on-one caregiver took a break and advised the nurse on shift. However, the nurse did not find a replacement to supervise Resident #48, while the one-on-one caregiver took a break. When the nurse looked up from the desk at the nurses' station, she observed Resident #86 pushing Resident #48 in her wheelchair down the hallway. The nurse called for another staff member to come and assist. Before the other staff member or nurse could intervene, Resident #48 swung her arm back and punched Resident #86 in the back causing her to fall. The two residents were separated by staff and assessed for injuries. Resident #86 had redness to her knees and elbows. When interviewed by staff, Resident #86 recalled falling down and hitting her elbow and knee but could not recall further details. Resident #48 could not recall the event when interviewed. The residents resided on the same secured unit of the facility. Resident #48 was to continue with the one-on-one caregiver for 72-hours and to be moved to another unit within the facility. The staff were provided education on intervening promptly to possible altercations between residents. -The investigation did not indicate the staff were provided education regarding not leaving a resident who was required to have a one-on-one unsupervised. The investigation documented abuse was substantiated. C. Resident #86 (victim and assailant) 1. Resident status Resident #86, age 73, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with mood disturbance. The 3/19/25 minimum data set (MDS) assessment documented Resident #86 had severe cognitive impairments with a brief interview of mental status (BIMS) score of four out of 15. She ambulated without a wheelchair or walker. She required one-person moderate assistance with showers, dressing and personal hygiene. The MDS assessment indicated Resident #86 had behaviors of being physically abusive, verbally abusive, and behaviors not directed at others, which included physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming, or distruptive sounds. 2. Record review Resident #86's elopement care plan, revised 9/18/24, revealed she was at risk for elopement related to verbalizations of wanting to leave the facility and would wander into other residents' rooms. Interventions included providing the resident with structured activities such as toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #86's behavior care plan, initiated 9/24/24, revealed she used antipsychotic medications for behavior management. Interventions, initiated 9/24/24, included providing non-pharmacological interventions such as active listening, offering a snack or drink, providing positive distraction, reassurance of safety and reapproaching and assisting to a quiet area. Resident #86's mood care plan, revised 2/21/25, revealed she was at risk for changes in mood. She would often take things from various locations on the unit or from other residents or their rooms. Resident #86 would claim the items were hers and could be verbally and physically aggressive towards staff and other residents. Interventions, initiated 2/21/25, included providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting with encouraging verbalization of the source of her agitation, assisting to set goals for more pleasant behavior, and encouraging her to seek out staff members when agitated. -Review of the resident's comprehensive care plan did not indicate the facility implemented person-centered interventions after the resident was involved in two resident-to-resident altercations. Review of Resident #86's electronic medical record (EMR) from 1/1/25 to 2/19/25 revealed the resident had a history of wandering into other residents' rooms. An event note, dated 2/18/25, revealed Resident #86 had been the victim in an altercation with Resident #48. Resident #86 and Resident #48 were separated by staff and assessed for injuries and no injuries were noted. An event note, dated 2/19/25, revealed Resident #86 had been the victim in an altercation with Resident #48. Resident #48 was to have a one-on-one caregiver and at the time, the caregiver had gone on a break and notified the nurse. The nurse failed to replace the one-on-one caregiver. The nurse looked up from the nurses' station and observed Resident #86 pushing Resident #48's wheelchair down the hallway. Before the nurse could intervene, Resident #48 turned and punched Resident #86 in the back, causing Resident #86 to fall. The residents were separated and assessed for injuries. Resident #86 had redness to her knee and elbow. D. Resident #48 (victim and assailant) 1. Resident status Resident #48, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified dementia and depression. The 1/29/25 MDS assessment revealed Resident #48 had severe cognitive impairments with a BIMS score of five out of 15. She had verbal aggression and behaviors not directed at others such as physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming, or distruptive sounds. Her behaviors impacted her ability to receive care, socialize and participate in activities. Resident #48 required a wheelchair for mobility and required one-person maximum assistance with toileting and bathing. 2. Record review The behavior care plan, revised 12/17/24, revealed Resident #48 used antipsychotic medications for behavior management. Interventions, initiated 12/17/24, included providing non-pharmacological interventions such as active listening, offering the resident a snack or drink, providing positive distraction, providing reassurance of safety, reapproaching and assisting the resident to a quiet area. The mood care plan, revised 2/21/25, revealed Resident #48 had a diagnosis of unspecified dementia with mood disturbance. She struggled at times with excessive tearfulness, increased isolation and changes in mood and appetite. Resident #48 was verbally aggressive and paranoid towards others. She could be territorial of her room and the area around her and would sit in other residents' doorways. Resident #48 presented with delusions and hallucinations and physical aggression towards others such as grabbing and hitting others. Interventions, initiated 2/24/25, included redirecting her to the activities room, offering for the resident to listen to Elvis music and providing coloring or crossword puzzles. -Review of Resident #48's comprehensive care plan did not indicate the resident had been involved in a resident-to-resident altercation. An event note, dated 2/18/25, revealed the director of nursing (DON) was called to the unit by the floor nurse due to an altercation between two residents. The incident occurred in the hallway where Resident #48 and another resident (Resident #86) were observed to be pulling on each other's sleeves and slapping each other on the forearms open handed. The two residents were separated. A behavior note, dated 2/19/25, revealed Resident #48 had been put on one-on-one supervision. A physician note, dated 2/19/25, revealed if behaviors persisted, the physician would increase Resident #48's antipsychotic medication again. A communication note, dated 2/19/25, revealed the DON advised the responsible party that Resident #48 would be moved to another unit again due to the altercation. III. Resident to resident physical altercation by Residents #84 towards and Resident #93 A. Facility investigation of physical abuse by Resident #84 towards Resident #93 The 3/24/25 facility investigation documented the altercation occurred in Resident #84's room. Both Resident #93 and Resident #84 resided in the secured unit. The staff heard yelling coming from Resident #84's room and upon entering the room, the staff observed Resident #84 standing over Resident #93 who was lying on the floor. The two residents were separated and assessed for injuries. Resident #93 sustained a scratch to the right side of his eye, redness to the right side of his face, a cut to his bottom lip and bumps to the forehead and the back of his head. When interviewed by staff, Resident #93 could not recall the event and said something hit his face. When interviewed, Resident #84 initially denied hitting Resident #93, but eventually admitted to hitting him in the face because Resident #93 had wandered into his room and touched Resident #84's belongings. Resident #84 was provided a one-on-one caregiver for 72-hours and moved rooms to another unit. The facility substantiated the abuse investigation. B. Resident #93 (victim) 1. Resident status Resident #93, age 79, was admitted on [DATE]. According to the May2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. The 4/9/25 MDS assessment revealed Resident #93 had severe cognitive impairments with a BIMS score of three out of 15. He ambulated without a wheelchair or walker. He required one-person maximum assistance with shower, dressing and personal hygiene. The MDS assessment indicated Resident #93 had behaviors of being physically abusive, wandering, and behaviors not directed at others such as physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming, or distruptive sounds. 2. Record review The elopement care plan, revised 3/27/25, revealed Resident #93 would often wander into other resident's rooms to use their bathroom, relieve himself on their floor or touch their personal belongings. Resident #93 had made attempts to break windows in order to climb out of them. The care plan documented at times, he could be redirected easily and other times, Resident #93 could become aggressive, both verbally and physically towards staff. Interventions, initiated 3/27/25, included providing Resident #93 with activities or objects to help keep him busy to prevent him from touching others belongings. The behavior care plan, initiated 8/24/24, revealed Resident #93 used antipsychotic medications for behavior management. Interventions, initiated 8/24/24, included providing non-pharmacological interventions such as active listening, offer snack or drink, provide positive distraction, offering reassurance of safety, helping the resident become more comfortable by assessing physical needs, offering validation, assisting with difficult tasks, assisting to a quiet area, providing the resident with a distracting conversation by talking about interest, and reapproaching the resident. -The care plan did not document the resident was a victim of a resident-to-resident altercation on 3/24/25. Review of Resident #93's EMR from 3/1//25 to 4/29/25 revealed the following progress notes: An event note, dated 3/24/25, revealed the staff heard a loud noise and immediately went to the room where staff observed Resident #93 kneeling on the floor with one hand holding the heater on the wall trying to get up. The nurse did a head to toe assessment and observed a scratch to the right side of the resident's eye that was 0.3 centimeters (cm) by 0.1 cm, redness to the right and left side of the resident's cheek bone area, a cut to the left eye that was 1 cm by 0.1 cm, a cut to the resident's bottom lip that was 0.2 cm by 0.2 cm, a bump to the forehead that was 2 cm by 1.5cm and a bump to the back of the resident's head that was 3 cm by 2 cm and blood was coming out from the lip. Both residents were immediately separated. -The note did not document how Resident #93 sustained the injuries. C. Resident #84 (assailant) 1. Resident status Resident #84, age 70, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified dementia with psychotic disturbances, delusional disorder, alcohol abuse and anxiety. The 2/5/25 MDS assessment revealed Resident #84 had severe cognitive impairments with a BIMS score of seven out of 15. He ambulated without a wheelchair or walker and was independent in his activities of daily living. The MDS assessment indicated Resident #84 had behaviors of being verbally abusive, wandering, and behaviors not directed at others such as physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or distruptive sounds. 2. Record review The behavior care plan, revised 11/8/24, revealed Resident #84 used antipsychotic medications for behavior management. Interventions, initiated 12/16/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproach, and assist to a quiet area. The mood care plan, revised 3/27/25, revealed Resident #84 had a diagnosis of dementia with psychotic disturbance and had a history of alcohol abuse. He struggled with paranoid thoughts regarding his brother and former girlfriend stealing from him. Resident #84 could become agitated and frustrated with staff when paranoid, causing him to become aggressive. Resident #84 would perseverate on objects and other residents. He enjoyed doing arts, crafts, and coloring but could become physically aggressive if others touched his art supplies or belongings. Resident #84 would become agitated and aggressive when others entered his room uninvited. Interventions, initiated 11/8/24, included assessing his understanding of the situation and allowing time to express self and feelings towards the situation. -Review of Resident #84's comprehensive care plan did not indicate the resident had been involved in a resident-to-resident altercation on 3/24/25. An event note, dated 3/24/25, revealed the DON was called to Resident #84's unit. Resident #84 was sitting on his bed in his room and told the DON he was not doing alright. He told the DON that he punched another resident (Resident #93) in the mouth because he came into his room and touched his belongings. Resident #84 was moved to a different unit and a one-on-one caregiver for 72-hours was put into place. V. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 4/30/25 at 9:18 a.m. CNA #2 said Resident #86 had behaviors of thinking everyone else had her belongings. She said Resident #86 could be redirected to her room. CNA #2 said Resident #48 did not have behaviors and did not have physical aggression towards staff or other residents. Licensed practical nurse (LPN) #2 was interviewed on 4/30/25 at 9:25 a.m. LPN #2 said Resident #48 had behaviors of becoming tearful and confused but did not have behaviors of aggression towards staff or other residents. She said she did not know why Resident #48 was moved to her current unit. LPN #2 said she was not aware of any behaviors for Resident #86 except wandering. CNA #3 was interviewed on 4/30/25 at 1:49 p.m. She said the CNAs did not have access to the residents' care plans. She said the CNA behavior monitoring task displayed a list of generic, template behaviors to choose from and a list of generic, template interventions to choose from. She said the CNAs were unable to personalize the behaviors or interventions when documenting. CNA #3 said if the resident had a specific behavior or an individualized intervention that was not included in the generic list, the CNAs did their best to select an appropriate choice. CNA #3 said Resident #84 had moved around the building to different units because of behavioral issues or because he did not get along with his roommates. CNA #3 said Resident #84 had behaviors of agitation, paranoia and delusions regarding people stealing from him or items being missing. She said the non-pharmacological interventions that worked were to provide him one-on-one attention in his room to calm down, talk to him about his artwork, or take him outside to color. She said if the CNAs used an intervention like offering coloring, it would be documented as meaningful activity in the behavior monitoring, but there was no way to identify what the meaningful activity was. CNA #3 said she believed Resident #84 had been aggressive toward other residents but she did not know for sure. She said she had observed Resident #84 become agitated if other residents touched his belongings but he was now in a unit where there were less wandering residents going into his room. CNA #3 said Resident #93 had behaviors of wandering and disrobing but he was redirectable by offering him activities of interest to distract him. Registered nurse (RN) #3 was interviewed on 4/30/25 at 2:05 p.m. She said the nurses documented resident behaviors and non-pharmacological interventions attempted in EMR progress notes. RN #3 said the nurses found the resident specific behaviors and interventions in the resident's care plan. She said Resident #84 did not have behaviors of aggression towards staff or other residents. RN #3 said Resident #84 did not like other residents to touch his belongings but he was redirectable. RN #3 said she was not aware of why Resident #84 was moved to his current unit. The DON and the social services director (SSD) were interviewed together on 5/1/25 at 2:00 p.m. The SSD said the residents' individualized behaviors and resident specific non-pharmacological interventions were located in the resident care plan and the nurses were expected to look there for the information. The DON said the process for the nurses to apply interventions for resident behaviors were to first attempt standard, non-specific interventions such as redirecting, offering food or fluids or taking the resident to activities. She said if those interventions were unsuccessful, the nurse would then look at the resident's care plan for the identified resident specific interventions. The SSD said the method described by the DON had the potential to cause residents to escalate if the identified interventions were not tried first. She said the resident specific interventions in the care plan were developed with the assistance of the residents' families and the use of the residents' history in order to mitigate negative behaviors. The DON said the immediate interventions for the altercation between Resident #48 and the Resident #86 on 2/18/25 were to implement a one-on-one caregiver and move Resident #48's room. She said the CNA providing the one-on-one supervision went on her lunch break and advised the nurse she was leaving. The DON said the nurse failed to implement a replacement one-on-one staff member and instead, the nurse was going to keep Resident #48 in her line of sight. The DON said the expectation was to replace the CNA with another dedicated one-on-one caregiver and she did not know why the nurse chose not to follow that process. The DON and the SSD said they did not know why Resident #48 had not been moved on 2/18/25, as it was recommended by the facility after the altercation. The DON and the SSD said Resident #48 remained on the same unit as Resident #86 (the victim), providing an opportunity to attack Resident #86 a second time on 2/19/25. The DON said, other than moving units and 72-hour one-on-one supervision, no additional interventions or training were provided to the staff to ensure the residents were safe from abuse. The SSD said after the incident on 3/24/25 between Resident #93 and Resident #84, Resident #84 was moved to a new unit. She said the staff identified he would do better on a unit with residents who did not wander into each other's rooms as often. The SSD said she could not recall what interventions had been used to prevent Resident #93 from wandering into Resident #84's room and avoiding an altercation. The DON said Resident #93 had behaviors of wandering into other residents' rooms but she was not aware of what interventions had been used to prevent Resident #93 from wandering into Resident #84's room and avoiding an altercation.

Based on record review, observations and interviews, the facility failed to ensure that one (#79) of three residents out of 35 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #79, residing on the secure locked unit, had the required documentation to justify such restrictions including a consent from the resident's responsible party for placement, documentation reflecting secure/locked placement was the least restrictive approach possible. Findings include: I. Facility policy and procedure The Secure Unit policy, revised 1/2/24, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:15 a.m. It read in pertinent part, Upon determination that the resident may benefit from placement on a secure unit, the facility must obtain consent from the resident's representative, as indicated on the Secure Unit Placement, Admission, Evaluation and Authorization form and file that consent in the medical record. The resident's medical record should reflect the following: Documentation of the clinical criteria met for placement in the secure/locked area by the resident's physician, along with information provided by members of the interdisciplinary (IDT) team; Documentation that reflects the resident/representative's involvement in the decision for placement in the secure/locked area; Documentation that reflects whether placement in the secure/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety; Documentation by the IDT team of the impact and/or reaction of the resident, if any, regarding placement on the unit; Ongoing documentation over the review and revision of the resident's care plan as necessary, including whether he/she continues to meet criteria for remaining in the secure/locked area, and if interventions continue to meet the needs of the resident. II. Resident #79 A. Resident status Resident #79, age 80, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia. The 4/7/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She did not have behaviors that affected herself or others and she did not have behaviors of wandering. She required a wheelchair for mobility and was unable to walk. The resident required one-person maximum assistance with showering, toileting, dressing, transfers and bed mobility. B. Resident interview Resident #79 was interviewed on 5/1/25 at 9:15 a.m. She said prior to admitting to the facility she lived with her son. She said she asked her son to take her to the emergency room because she was not feeling well. She said she was discharged from the hospital to the facility. She said she did not know why she was at the facility. She said the facility's doors were locked. Resident #79 said she did not have a history of leaving her home or getting lost. She said it was never explained to her why she needed to be in a locked area. She said no one had spoken to her about her interest in discharging to a lower level of care or back to her home with support. Resident #79 said she hated living in the facility and missed her pets, her friends and her neighbors. She said she did not socialize with the other residents within the facility because the other residents did not seem to know how to socialize. Resident #79 said she would like to start a book club, but did not think the other residents could participate. She said she had tried to attend activities, but the activities were not stimulating for her so she stayed in her room. She expressed feelings of sadness because she enjoyed socializing with her friends prior to admission and now had no one to talk to. C. Record review The cognition care plan, initiated 4/8/25, revealed the resident had an impaired cognitive ability or impaired thought processes related to a diagnosis of dementia with short term memory impairment. Interventions initiated on 4/8/25 included administering medications as ordered, allowing the resident extra time to respond to questions and instructions, and asking the resident yes or no questions. -The care plan did not include a focus for secure unit placement. The April 2025 CPO revealed the following physician orders: Admit to skilled insurance services on 4/6/25. A brief cognitive assessment tool (BCAT) examination for memory and cognitive functioning was conducted at the facility with the resident on 4/7/25. Her score reflected mild stage dementia with no deficits in the areas of verbal recall, visual recognition, abstraction, or language. Progress notes were reviewed from 4/6/25 to 5/1/25 revealed: A physician note, dated 4/7/25, revealed the resident admitted to the facility for a gastrointestinal hemorrhage and was to receive physical and occupational therapy. Her judgment and insight were fair and she had a diagnosis of cognitive impairments but the physician noted, the resident did not have a diagnosis of dementia. A psychosocial note, dated 4/7/25, revealed a baseline care plan meeting had been held with the family but the resident was not included. The decision was made that the resident would transition to long term care after her therapy services ended. A behavior note, dated 4/11/25, revealed the resident was tearful and expressed that she was ready to go home. A psychosocial note, dated 4/16/25, revealed there had been a care conference meeting with the family on 4/16/25. The note documented the resident had not been invited to attend. -Review of Resident #79's electronic medical record (EMR) did not reveal any further documentation that indicated the resident had exit seeking behaviors or least restrictive alternatives were attempted and failed. On 4/30/25 at 11:26 a.m. documentation indicating a consent form was completed by the resident or her responsible party for placement on a secure unit and an initial evaluation for the necessity for secure unit placement was requested from the NHA. An email was received from the unit manager (UM) on 5/1/25 at 6:24 p.m. It revealed the facility did not have a consent or an evaluation for Resident #79's placement in a secure/locked facility. III. Staff interviews Certified nursing assistant (CNA) #4 was interviewed on 5/1/25 at 9:25 a.m. She said Resident #79 did not have any exit-seeking behaviors. CNA #4 said the resident did not show behaviors of elopement attempts, interest in exiting the facility or attempting to enter other residents' rooms. Licensed practical nurse (LPN) #2 was interviewed on 5/1/25 at 9:42 a.m. Resident #79 did not show behaviors of elopement attempts, interest in exiting the facility, or attempting to enter other residents' rooms. She said the resident primarily stayed in her room but appeared sad and tearful. LPN #2 said she did not know why the resident was sad. The director of nursing (DON) and the social services director (SSD) were interviewed together on 5/1/25 at 2:00 p.m. The SSD said the process to evaluate the appropriateness of the residents for admission and continued stay in a locked facility involved the initial review of the referral. The SSD said she looked for a history of behaviors of wandering, elopement, or getting lost in the community. She said the criteria to remain in the facility was to have a diagnosis of dementia and to be at risk for leaving the facility. The SSD said the facility's evaluation process for continued stay did not include record review, staff interviews, or an assessment for the appropriateness of remaining in a secure/locked facility but the process should include these things. She said she was not sure why Resident #79 was admitted and remained in the facility. The DON said she thought if the resident had a diagnosis of dementia and the family wanted the resident placed in the facility, that was enough justification to admit the resident. The DON was unaware once a resident was admitted , if they did not exhibit behaviors of wandering or elopement attempts, the resident should be considered for discharge to a less restrictive environment. She said she could not explain why Resident #79 was admitted and remained in the facility.

Based on observations, record review, and interviews, the facility failed to ensure one (#57) of two residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure staff provided wound care per physician's order for Resident #57. Findings include: I. Facility policy The Physician Orders policy, revised February 2024, was provided by the nursing home administrator (NHA) on 5/1/25 at 10:46 a.m. It read in pertinent part, A physician must personally approve in writing a recommendation that an individual be admitted to the facility. A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Orders must be authenticated, signed and dated, by the provider who gave the order. Signatures may be manual or electronic and may be accepted if faxed. II. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included moderate unspecified dementia (cognitive decline) with mood disturbance, unspecified protein-calorie malnutrition, generalized muscle weakness, Stage 3 pressure ulcer of the sacral region and need for assistance with personal care. The 3/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She required partial assistance with bed mobility and transfers. She required substantial assistance with personal and toileting hygiene and showering. She was frequently incontinent of bowel and bladder, and she was at risk for developing pressure ulcers/injuries. B. Observations During a continuous observation on 4/29/25, beginning at 1:40 p.m. and ending at 1:55 p.m., the following was observed: The facility's wound care nurse (WCN) prepared to do wound care for Resident #57. She verified the resident's wound care orders by checking the physician's orders listed in the resident's electronic medical record (EMR). She went to the unit's medication storage room and removed a zip lock bag from a storage cart. The bag was labeled with Resident #57's name and contained the resident's specific wound care supplies. The WCN said she put the wound care supply bags together for staff to use when needed. The WCN said Resident #57's wound orders included applying Medihoney gel (a moist antibacterial dressing) to the resident's sacral wound daily, and as needed if the dressing was soiled. The WCN revealed that Medihoney gel was in Resident #57's wound care supply bag. The WCN attempted to perform wound care on Resident #57 using the wound care supplies in the zip lock bag, however, the resident was too sleepy and the WCN said she would re-attempt the wound care dressing change later in the afternoon (on 4/29/25). C. Record review A review of Resident #57's April 2025 CPO revealed the following physician's order for wound care: Cleanse wound with wound cleanser, apply Medihoney to wound on coccyx, then cover with bordered gauze, daily in the afternoon, ordered 4/2/25. Review of Resident #57's wound care physician (WCP) visit notes revealed the following: The 4/8/25 WCP visit note, revealed the WCP discontinued Resident #57's daily Medihoney dressings, and changed the wound treatment order to calcium alginate with silver dressing (a highly absorbent antibacterial dressing) once daily for 30 days. The 4/16/25 WCP visit note documented to continue applying calcium alginate with silver dressing to Resident #57's sacral pressure wound. The 4/23/25 WCP visit note documented to continue applying calcium alginate with silver dressing to Resident #57's sacral pressure wound. -However, a review of the April 2025 CPO revealed Resident #57's wound care orders were not updated to reflect the wound care dressing change ordered on 4/8/25 or after the subsequent WCP visits on 4/16/25 and 4/23/25 (see physician's order above) A review of Resident #57's April 2025 medication administration record (MAR) revealed Medihoney gel was applied to the resident's sacral pressure wound on the following dates: 4/9/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 4/26/25, 4/27/25, 4/28/25, 4/29/25, and 4/30/25. -There was no documentation on 4/19/25 to indicate a treatment to the sacral pressure wound was completed. -However, the WCP visit notes indicated the WCP discontinued the Medihoney gel treatment order on 4/8/25 (see WCP visit notes above). III. Staff interviews The WCN was interviewed on 5/1/25 at 8:58 a.m. The WCN said she was primarily responsible for providing wound care to residents and entering/updating wound care orders in the residents' EMRs. The WCN said she would access the WCP's EMR portal, download his wound care visit notes and make any necessary changes to the physician's orders. Registered nurse (RN) #1 was interviewed on 5/1/25 at 10:21 a.m. RN #1 said the WCN was primarily responsible for obtaining wound care orders and putting them into the residents' EMRs. RN #1 said she would verify a resident's wound orders by contacting the WCN and asking if the physician's orders in the EMR were accurate or if any changes were made. The WCN was interviewed a second time on 5/1/25 at 10:56 a.m. The WCN removed Resident #57's wound care supply bag from the medication storage room. The WCN confirmed Medihoney gel was in Resident #57's wound care supply bag. The WCN reviewed the treatment plan from Resident #57's 4/8/25 WCP visit note. She confirmed the wound care orders indicated to add calcium alginate with silver dressings and discontinue the Medihoney gel. The WCN confirmed that facility staff were still applying Medihoney gel to Resident #57's sacral pressure injury, instead of the calcium alginate with silver that was ordered by the WCP on 4/8/25. The director of nursing (DON) was interviewed on 5/1/25 at 2:15 p.m. The DON said the WCP came to the facility on e day per week to round on residents requiring wound care. The DON said the WCP and the WCN did wound rounds together. She said the WCP would either give the WCN verbal treatment orders or he would enter orders into his visit progress notes. The DON said it was the WCN's responsibility to enter the treatment orders into the residents' EMRs. The DON said the facility did not currently have a process to circle back and verify the accuracy of wound orders entered into the EMR. The WCP was interviewed on 5/1/25 at 2:27 p.m. The WCP said when he rounded at the facility, he would give the WCN verbal wound care orders after assessing a resident's wound. The WCP said he sometimes made changes to his treatment plans after he left the facility. The WCP said his official treatment plan and wound care orders were documented in his visit note and it was his expectation that the treatment orders in his visit notes were followed. The WCP said he was unaware Medihoney gel was still being applied to Resident #57's sacral wound until he was notified of it by facility staff on 5/1/25. The WCP said his normal process was to see the resident, remove the old wound dressing, cleanse the wound and then measure it. He said once completed, he would give the WCN verbal treatment orders and then leave the resident's room to finish documenting before moving on to the next resident. The WCP said while he documented, the WCN would stay in the resident's room to apply the ordered wound dressings. The WCP said he would sometimes stay in the room to assist the WCN if she needed help with positioning the resident, however, he said he did not consistently double check the placement of certain dressings if a resident had multiple wounds. The WCP said he did not recall having a specific conversation with the WCN regarding Resident #57's wound care orders when he last rounded on 4/23/25. The WCN was interviewed a third time on 5/1/25 at 2:44 p.m. The WCN said she was given a verbal order by the WCP on 4/8/25 to continue applying Medihoney gel to Resident #57's sacral pressure wound. The WCN said she reviewed the WCP's 4/8/25 wound visit note on 4/9/25 and saw the treatment order to switch wound care dressings from Medihoney gel to calcium alginate with silver, however, she said she did not follow up with the WCP to clarify the order because she had just verified it with him the day before. The WCN said the WCP assisted her with Resident #57's wound care on 4/23/25. The WCN said she believed the WCP could see, and was aware of, the Medihoney gel dressing she applied to Resident #57's sacral pressure wound, however, she acknowledged the WCP did not specifically tell her what wound dressing to use.

Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was not greater than five percent (%). Specifically, the facility had a medication error rate of 8%, which was two errors out of 25 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration?. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure According to the Administration of Medications policy, revised 9/16/24, was received from the nursing home administrator (NHA) on 5/1/25 at 10:46 a.m. It revealed in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Medication error, means the observed or identified preparation or administration of medications or biological which is not in accordance with: the prescriber's order, manufactures specifications regarding the preparation and administration of the medications or biological, and the accepted professional standards and principals which apply to professionals providing services. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response and right education and information. III. Observation and staff interviews On 4/30/25 at 7:42 a.m. registered nurse (RN) #1 was administering medications to Resident #8. The physician's order read sennoside-docusate sodium (anti constipation medications containing two different medications in one tablet) 8.6-50 milligrams (mg), administer one tablet daily for constipation. RN #1 dispensed one tablet of senna 8.6 mg into the medication cup. -RN #1 dispensed a medication which contained sennoside, however, the medication did not contain docusate sodium as the physician's orders instructed. RN #1 then began to dispense polyethylene glycol powder (anti constipation medications). The physician's order read polyethylene glycol powder 17 gram (gm) by mouth one time a day for constipation, hold for loose stool, stir and dissolve 17 grams in four to eight ounces (oz) of water or beverage of choice. RN #1 dispensed the medication from a multidose bottle into a medication cup. RN #1 dispensed the powder to between 15 to 20 milliliters (ml) line on the medication cup. RN #1 said the order was for 17 gm so she dispensed that much into the medication cup. -Review of the medication cup that RN #1 revealed the measurements on the cup were ml and not gm like the order specified. RN #1 was stopped to review orders to the administration of the polyethylene glycol powder to the resident. RN #1 said she did not identify any concerns with the medications she had dispensed. Review of the polyethylene glycol powder bottle with RN #1 it revealed the medication was to be measured with the cap of the container for the 17 gm dose. RN #1 then took the medication cup with the powder she had already dispensed and poured it into the cap of the bottle. The powdered medication was observed to be spilling over the cap and medication was observed falling onto the floor and some powder still remained in the medication cup. -RN #1 had dispensed too much medication than ordered due to using the incorrect measuring device. IV. Additional staff interviews RN #1 was interviewed on 4/30/25 at approximately 8:00 a.m. She said she was taught in nursing school to measure the medication in a medication cup. RN #1 said too much of the polyethylene glycol powder could lead to the resident having loose stools or irregular bowel movements. RN #1 said the Senna 8.6 mg she initially dispensed was incorrect because the physician had ordered a combination medication and had she given the incorrect medication the resident could have become constipated. The director of nursing (DON) was interviewed on 5/1/25 at 2:00 p.m. She said the nurses were expected to follow all the rights of medication administration to ensure no medication errors were made. The DON said nurses were to compare the order to the packaging to ensure the correct medication was dispensed and administered to the residents. The DON said when measuring polyethylene glycol powder, the nurse was to measure using the cap from the bottle as a measuring tool as per manufactures recommendations.

Based on record review and interviews, the facility failed to develop and implement policies and procedures related to COVID-19 immunizations for one (#69) of five residents reviewed for immunizations out of 35 sample residents. Specifically, the facility failed to follow up with a resident and/or the resident's representative to offer and administer COVID-19 vaccination for Resident #69. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), COVID-19 guidelines (revised 1/7/25), retrieved on 45/7/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html. Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization , and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are age 65 and older, are at risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine. II. Facility policy and procedure The COVID-19 (SARS-CoV-2) Vaccination Program policy and procedure, revised 11/27/24, was provided by the nursing home administrator (NHA) on 4/28/25 at 3:39 p.m. It read in pertinent part, The facility will ensure that residents are offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The facility will educate residents or resident representatives regarding the benefits and potential side effects associated with the COVID-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized. Once screening is completed, the facility should offer residents vaccination against COVID-19 when vaccine supplies are available to the facility. III. Resident #69 A. Resident status Resident #69, age 82, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included methicillin resistant staphylococcus aureus infection (MRSA - bacterial infection), pneumonitis (infection of the lungs), esophagitis (infection of the throat), dementia and schizoaffective disorder (mental illness). According to the 3/24/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of one out of 15. He required assistance of one person with bed mobility, transfers, bathing and toileting. The assessment revealed the resident did not reject care. B. Record review A review of Resident #69's electronic medical record (EMR) did not reveal documentation indicating the resident had been offered, declined or had received the COVID-19 vaccination. IV. Staff interviews The director of nursing (DON) and the infection preventionist (IP) were interviewed on 5/1/25 at 2:07 p.m. The IP said the facility conducted COVID-19 vaccine clinics frequently and reviewed the state immunization portal to determine when the residents were due for their next vaccine dose. The IP said when a resident was admitted to the facility, they reviewed the resident' vaccine history. The IP said they did not receive consent from Resident #69's representative after several attempts were made. -However, review of Resident 369's EMR did not reveal documentation that indicated attempts had been made to obtain consent to administer the COVID-19 vaccine to the resident. The IP said Resident #69 was admitted to the facility in January 2024. The IP said the facility staff had not followed up with the resident and/or responsible party to obtain consent for the COVID-19 vaccination after the initial attempt was unsuccessful. The IP said Resident #69 had not received the COVID-19 vaccine. The DON said the facility staff should have followed up with the resident and/or representative regarding the COVID-19 vaccination and obtained consent to administer the vaccination. The DON said there was no documentation indicating the facility had offered the vaccination or evidence that the facility provided education to the residents or their legal representative of the risk and benefit of not receiving the COVID-19 vaccine. She said Resident #69 had not been offered any additional COVID-19 vaccines since the resident was admitted to the facility. The IP said she would reach out to the resident's representative in a formal manner and document her response in the resident's EMR.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of five units in the facility. Specifically, the facility failed to: -Ensure housekeeping staff engaged in hand hygiene and change gloves between resident rooms and between different areas in each resident room (bathroom and bedroom); -Ensure housekeeping staff changed cleaning towels between different areas in a resident rooms (bedroom and bathroom); -Ensure housekeeping staff disinfected high frequency touch areas in resident rooms and shared spaces; -Ensure surface disinfectant times were adhered to for disinfecting products by all staff; -Ensure nursing staff disinfected shared equipment (vitals machines and lifts) between residents; and, -Ensure nursing staff engaged in infection control practices during wound care. Finding include: I. Infection control failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 9/20/23 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 9/20/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas ( patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services Infection Control policy and procedure, undated, was provided by the director of housekeeping (DOH) on 9/14/23 at 2:09 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI); The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness; Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team; Cleaning shall be performed in a manner to minimize the spread of pathogenic organisms;dust high places before dusting lower areas light fixtures, tops of closets, tops of door casings, window coverings, TV's (televisions), pictures and other wall hangings tables, beds, medical apparatus, window sills; straighten displayed resident personal belongings (no gloves on); Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; door knobs, TV remotes, bed controllers, phones, bed-side tables, light switches,closet doors/dresser drawers medical apparatus like oxygen concentrators, clean heavily soiled restroom fixtures and porcelain surfaces using disinfectant and a rag or brush clean restroom walls with disinfectant; clean mirror with glass cleaner; Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; remove trash and re-line the receptacle, clean the receptacle as needed using disinfectant to disinfect sweep entire room including under beds; mop floors with dispensed solution of floor cleaner. C. Manufacturer recommendations The disinfectants in the facility were identified as: Oxivir TB The product label was reviewed which read in pertinent part, Ready-to-use disinfectant cleaner based on proprietary hydrogen peroxide technology to deliver fast, effective cleaning performance. Disinfects in 60 seconds. Virucide, bactericide, tuberculocide, fungicide and non-food contact sanitizer. Kills MRSA (Methicillin-resistant Staphylococcus aureus is a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans) and Norovirus. Meets bloodborne pathogen standards for decontaminating blood and body fluids. Colorless with a characteristic scent. Oxivir Five-16 Concentrate Cleaner The product label was reviewed which read in pertinent part, A one-step disinfectant cleaner based on proprietary Accelerated Hydrogen Peroxide technology to deliver fast, effective cleaning performance. At 1:16 dilution, disinfects in five minutes. Virucide, bactericide, fungicide, mildewcide and non-food contact sanitizer. Kills MRSA, Norovirus and Canine parvovirus. Concentrate delivers economical performance. Meets bloodborne pathogen standards for decontaminating blood and body fluids. Colorless with a characteristic scent. Sani Cloth Bleach Germicidal Wipes The product label was reviewed which read in pertinent part, Effective against 50 microorganisms in 4 minutes. Ideal for disinfecting high risk areas contaminated with Clostridioides difficile (C. difficile or C. diff.) spores and Norovirus. Now effective against SARS-CoV-2, the virus that causes COVID-19. D. Observations LPN #1 was observed on the east hall 9/11/23 at 8:05 a.m. She was taking vital signs of residents while passing medications. LPN #1 took a blood pressure reading then used the same machine on a second resident. She cleansed the machine after the second resident with Sani cloth hand wipes (not a disinfectant) and continued to use the machine on a third resident. -She failed to clean the vitals machine used between each resident and the one time she cleaned the vitals machine she failed to use the proper disinfecting wipe for medical equipment. An unidentified CNA in the 200 hallway was observed on 9/11/23 at 2:40 p.m. She entered a resident room with vital machine equipment and took the resident's vitals. The CNA exited and entered another resident's room and took the second resident's vitals. -There were no disinfecting wipes on the vitals machine carts. -The CNA failed to properly disinfect vitals machine equipment between residents. During continuous observation on 9/12/23 from 8:57 a.m. to 9:28 a.m. housekeeper (HSK) #1 failed to engage in proper hand hygiene and failed to disinfect high frequency touch areas. HSK #1 moved from resident room [ROOM NUMBER] to #306 without changing gloves after spraying the disinfectant cleaner in the bathroom. She changed the trash bags in the second room then moved back to the first room to continue cleaning. HSK #1 changed gloves after cleaning the bathroom, however failed to perform hand hygiene before putting on new gloves. HSK #1 took a clean cloth to dust the dressers and television then wet the same cloth to clean the sink, vanity, soap and towel dispensers. HSK #1 failed to clean the chair and recliner in the room. HSK #1 failed to disinfect any of the horizontal surfaces (bedside tables, vanity and window ledge) in the room. HSK #1 moved to the next room without changing gloves, walked out of the room and down the hall to the nurse station, then back to the room without changing gloves. During continuous observation on 9/13/23 from 9:00 a.m. to 11:00 a.m. HSK #2 failed to adhere to the surface disinfectant time according to the manufacturer's recommendations (see above) and failed to disinfect high frequency touch areas. HSK #2 was observed cleaning room [ROOM NUMBER], # 202 and #203. HSK #2 changed gloves and engaged in hand hygiene after each room but not across different areas in the rooms such as the bathroom and the resident room. HSK #2 did not change gloves and did not change the disinfectant soaked cloths between cleaning two separate sections of a shared room between two residents. HSK #2 touched high frequency touch areas with dirty gloves worn throughout the room and not changed even after cleaning the bathroom. HSK #2 did not disinfect high frequency touch areas in the room that included call lights, light switches and bathroom rails. Horizontal surfaces (bedside tables, vanity and window ledge) in the room were wiped with a disinfectant soaked cloth but the dwell time was not adhered to of five minutes for the disinfectant Oxivir five 16. HSK #2 wiped the surface in a single motion for two seconds per surface. The surface was no longer wet within 30 seconds. During continuous observation on 9/13/23 from 1:00 p.m. to 1:30 p.m. HSK #3 failed to adhere to the surface disinfectant time listed for Oxivir TB and failed to change gloves throughout cleaning room [ROOM NUMBER]. HSK #3 was observed spraying the disinfectant on a horizontal surface (vanity and bedside table) and then wiped it off immediately with a dry cloth. The surface was no longer wet within five seconds of application. HSK #3 was observed cleaning the room shared between two residents using the same pair of gloves throughout the entire cleaning. HSK #3 did not disinfect high frequency touch areas that included call lights, bathroom call light, light switches and bathroom rails. The door handles were wiped with a disinfectant soaked cloth however the surface disinfectant time was not adhered to and therefore the surface was not disinfected. During continuous observation on 9/13/23 from 1:45 p.m. to 2:20 p.m. CNA #4 and CNA #5 failed to disinfect shared medical equipment between two residents. CNA #5 placed back a lift into storage but did not disinfect the machine. CNA #4 brought back a sit to stand machine and cleaned the machine with a bleach cleaner wipe (four minute dwell time). CNA #4 wiped the surfaces for approximately 15 seconds. The surface was no longer wet within 30 seconds. The surface disinfectant time was not adhered to. The sit to stand machine was observed after CNA #4 cleaned it, however the sit to stand still had brown and red streaks of hardened liquid on the handles. The cushions on the leg area had dried brown liquid on them. The surface where a person would stand had approximately one inch of crusted black, yellow and brown pieces of dirt. The shower chair was observed in storage, the shower chair had dried streaks of yellow, brown and black liquid on the chair. E. Interviews HSK #1 was interviewed on 9/12/23 at 9:04 a.m. The HSK said the Clorox cleaner should sit for two to three minutes and high touch items of door handles and call buttons should be cleaned. -However, the HSK failed to spray high touch areas including the door handles, call buttons, and television remote. The HSK said she would come back and clean those items later. HSK #2 was interviewed on 9/13/23 at 11:05 a.m. HSK #2 said surface disinfectant time meant to use a soaked wiping cloth and just wipe the area. HSK #2 was unsure what high frequency touch areas were. She said she did not keep track of time for surface disinfectant times but she just did her cleaning process and enough time should pass for the surface disinfectant time after she completed other housekeeping tasks in the room. HSK #2 said she used the same process to clean every room. HSK #2 said she would change gloves at times if they were dirty but only use hand hygiene at the end of the cleaning and not between glove changes. HSK #3 said she did not consider call lights a high frequency touch area. HSK #2 said she would only use Oxivir disinfectant soaked cloths to clean the room and she only used water to mop the floors because using a cleaning product on the floor would make the floor sticky. HSK #3 was interviewed on 9/13/23 at 1:33 a.m. HSK #3 said she used Oxivir TB, Clorox at times and sometimes Oxivir five depending on how she felt She said the surface disinfectant time was 10 to 15 minutes. She said she would spray the surface first then wipe it with a dry rag but she did not track time to make sure the surface disinfectant time was adhered to. HSK #3 was unable to identify high touch areas. She said she did not keep track of time for the surface disinfectant times to ensure enough time had passed before she wiped the surfaces. CNA #4 was interviewed on 9/13/23 at 1:40 p.m. He said he was uncertain if he was responsible for cleaning the shared medical equipment. CNA #4 said he believed the housekeeping department was responsible for cleaning shared medical equipment. CNA #4 said he did not know what the surface disinfectant time meant and or what product should be used to clean shared medical equipment. CNA #5 was interviewed on 9/13/23 at 1:43 p.m. She said shared medical equipment should be cleaned before the equipment was stored. CNA #5 said the surface disinfectant time for the bleach wipes were one minute and it meant she should clean the surface using a single pass and let it dry for a minute. The housekeeping and laundry manager (HLM) was interviewed on 9/13/23 at 1:48 p.m. The HLM said housekeeping staff should clean all the resident rooms daily. The process to clean the room was to start by emptying the trash and then use four rags per room. First, they start on the right and do light dusting of the window sills, blinds, dresser and desk. Second, they should ring the rag and wipe surfaces, once done they change the rag and then go to the next side and wipe the mirror, counters, sink, paper towel and soap dispenser. Third, they checked if there were paper towels and soap in there. Fourth, they went to the bathroom and wiped all the rails, toilet and inside the bowl with the brush. Lastly, they swept the floors in the room and bathroom then mopped after it and then wiped the window ledge. All high touch areas were to be cleaned such as: call lights, blinds, light switches, door knobs, closet doors and use a duster for the blinds. The HLM said based on the observation of the housekeeping staff hand hygiene was not adhered to, cleaning methods were not correct with the facility's procedure and the surface disinfectant times were not followed. The HLM observed the shared medical equipment in storage and said it was dirty. The HLM said she would train all housekeeping staff again on the process of cleaning rooms, surface disinfectant times, high frequency touch areas, universal cleaning procedures, following manufacturer's recommendations for the cleaning products used and appropriate hand hygiene practices. The infection preventionist (IP) was interviewed on 9/14/23 at approximately 11:00 a.m. The IP said she was not involved yet with the housekeeping department in regards to infection control. The IP was unsure of the cleaning products used at the facility without observing a list of the cleaning products which had to be obtained from the HLM. The IP said she was unaware of the surface disinfectant times of the cleaning products used without asking the HLM. The IP said surface disinfectant times meant the surface must stay wet for the disinfectant time listed on the label of the disinfecting product; if the product did not stay wet for the time listed then the disinfectant would be ineffective. The IP identified high touch areas in the resident room as over the bed table and everything on it, call lights, sink area, faucets, toilet area, everything the resident touched, grab bars, door knobs and light switches. The IP said the shared medical equipment was dirty, however, was cleaned during the survey process and moving forward all staff will be provided with education related to surface disinfectant times, approved cleaning agents and responsibilities of utilizing shared medical equipment. 47064 II. Wound care failures A. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pg. 1265. After applying a solution to sterile gauze, clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice. B. Facility policy and procedure The Treatment of Wounds policy and procedure, revised 9/3/21, received from the NHA on 9/14/23 at revealed in pertinent part, provide comprehensive treatment plan designated to meet the individual resident's goals utilizing a multidisciplinary approach. Intent of this center that a resident having a wound receive necessary medical treatment to prevent infection, deterioration or development of wounds. A resident received care, consistent with professional standards of practice. C. Observations RN #1 was observed on 9/13/23 at 11:27 a.m. providing wound care to a Resident #90. During wound care, RN #1 cleaned the resident's right heel wound with saline and gauze. She wiped over the open wound bed with the same piece of gauze two times. RN #1 continued with wound care for the same resident on the left heel. She obtained a new piece of gauze, added saline to the gauze and wiped the open left heel wound three times with the same piece of gauze. -RN #1 failed to use a new piece of gauze for each wipe over the wound bed during cleaning. D. Staff interviews RN #1 was interviewed on 9/13/23 at 11:45 a.m. She said she should have used a new piece of gauze for each wipe over the wound bed during cleaning. RN #1 said using the same piece over and over again could contaminate the wound. The DON was interviewed on 9/14/23 at 11:00 a.m. She said during wound treatment a new piece of gauze should be used for each wipe over the wound to prevent contamination in the wound bed. The IP was interviewed on 9/14/23 at approximately 11:00 a.m. The IP said when a wound was cleaned a new gauze pad should be used after each pass, or the gauze pad should be folded in between each pass. The same gauze pad should not be used because the infection and or bacteria would be reapplied to the wound and the wound would not be clean. 47024

Based on record review and interviews, the facility failed to ensure residents were free from abuse for two (#3 and #4) out of four residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to prevent an incident of physical abuse by Resident #4 toward Resident #3. Findings include: I. Facility policies and procedures The Abuse - Protection of Residents policy, initiated on 10/4/22, was provided by the nursing home administrator (NHA) on 3/21/23 at 1:42 p.m. The policy revealed the facility would ensure all residents were protected from physical and psychosocial harm during and after an investigation. The following methods were to ensure the protection of residents during an investigation, might include but were not limited to; responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; immediate notification of the alleged victim's practitioner and the family or responsible party; removal of access by the alleged perpetrator to the alleged victim, assurance that ongoing safety and protection was provided for the alleged victim and, was appropriate, for other residents; notification of the alleged violation to other agencies or law enforcement authorities; evaluation of whether the alleged victim felt safe and if he/she did not feel safe, taking immediate steps to alleviate the fear, such as a room relocation, increased supervision; providing emotional support and counseling to the resident during and after the investigation, as needed; protection from retaliation; monitor the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts. II. Incident of resident to resident abuse A. Record review Incident report dated 3/1/23 at 7:20 p.m., revealed a certified nurse aide (CNA) entered Resident #3 and #4's room to find Resident #3 was bleeding on his forehead and Resident #4 holding a belt. The incident was not observed but it was concluded that Resident #3 caused resident #4 emotional distress which led Resident #4 to believe Resident #3 was trying to kill him. Resident #4 said he struck out at Resident #3 to protect himself. Upon discovery the CNA discovering the injured resident reported the incident to the nurse on duty. The nurse on duty and the registered nurse (RN) supervisor on duty responded to assess the resident and determine the cause of the resident to resident altercation. Both residents believed and reported that the other was trying to kill them. Immediate response after the residents were assessed for injury was to separate the residents to a safe space. Resident assessments revealed: Resident #3 had a skin tear that measured 1.5 centimeters (cm) and was cleaned with normal saline. A band aide was applied and an ice pack was also applied to the area. The resident was administered, as needed, Tylenol 650 milligrams for his complaint of pain (3 out of 10, with 10 being the worst pain). It was determined to be caused by being hit by Resident #4 with the resident's belt. Resident #4 had a skin tear on his forearm, the cause of the injury was unknown; but determined to have occurred during the resident to resident altercation. The residents were immediately separated and an investigation was started. The resident's physician and power of attorney (POA), NHA and director of nursing (DON) were notified (read below for more information). Fifteen minute checks were started on 3/1/23 at 8:00 p.m., and continued to 3/5/23 at 5:45 p.m. Event note dated 3/1/23 at 9:45 p.m., by the DON revealed after the incident, Resident #3 was assessed by an RN and Resident #4 was moved (with official room change) to another unit with close monitoring. Neurological assessments were started per facility protocol. Event note dated 3/1/23 at 10:47 p.m., by registered nurse (RN) #2 revealed according to a unit nurse, a physical altercation occurred between two residents (Resident #3 and Resident #4) on 3/1/23 at 7:20 p.m. Resident #3 was found lying in bed on his back holding the right temple of his head. Upon assessment, Resident #3 had a bump on the right temple of his head that measured 3 centimeters (cm) by 2 cm with surrounding emerging bruises that measured 3 cm by 4 cm with a small opening in the skin. RN #2 cleaned the site with wound cleanser and a small ice pack was applied for five to ten minutes to reduce the swelling and discomfort. Neurological assessments were initiated. The resident was unable to explain his pain lever at this time, but no facial grimacing was observed. Resident #3 was resting in his bed without any signs or symptoms of distress. Resident #3 was placed on close monitoring and placed on the 24-hour report for future follow up. Event note 3/1/23 at 11:04 p.m., by RN #2 revealed Resident #4 was found sitting on his bed holding a leather belt in his right hand. RN #2 tried to remove the belt from Resident #4's hand, the resident became aggressive and said the belt was needed for protection. Resident #4 was assessed and observed to have a skin tear on the resident's left dorsal forearm that measured approximately 3 cm by 3 cm. The site was cleaned with a wound cleanser and covered with a bandage. Neurological assessments were initiated. The resident laid down on his left side on the bed and did not exhibit any discomfort or behaviors. The resident rested in bed without any signs or symptoms of distress. The resident was placed on close monitoring and placed on the 24-hour report for future follow up. Event note dated 3/1/23 at 11:25 p.m., by the DON revealed the interdisciplinary team (IDT) post fall huddle note and care plan were reviewed. After the (resident to resident ) incident, Resident #4 was confused, upset, and agitated. The resident tried to self-transfer from his bed to his wheelchair, missed the wheelchair and fell . The resident was assessed by a RN and was moved to the Center Unit. A one-to-one sitter was provided immediately for close monitoring of the resident. Event note dated 3/2/23 at 2:17 a.m., by a licensed practical nurse (LPN) revealed Resident #3 was on follow up for a resident to resident altercation. Resident #3 had a cut and a bump to the right side of his forehead. The resident was on neurological assessments and had no signs of pain or discomfort. The resident did not exhibit any behaviors. A nurse practitioner (NP) note dated 3/2/23 at 4:34 a.m., revealed Resident #3 was seen for involvement in a physical resident or resident altercation. The resident had no acute distress and did not appear to be in any significant discomfort. The staff told the NP that the Resident #3 had gotten into an altercation with his roommate yesterday. Resident #4 hit Resident #3 with a belt on his left forearm (however, it was Resident's #3's forehead that was injured per other documentation). Resident #3 had a small laceration to his left forearm with no active bleeding. Health status note dated 3/3/23 at 3:34 a.m., by a RN revealed Resident #4 continued on monitoring for resident to resident altercation. The resident did not exhibit any aggressive behaviors. A staff sitter was at the resident's bedside during the shift. Health status note dated 3/3/23 at 5:35 p.m., by an LPN revealed Resident #3 was on follow up for a resident to resident altercation. He had a cut on the right side of his forehead and was at baseline for neurological assessments. Health status note dated 3/3/23 at 10:31 p.m., by a LPN revealed Resident 34 was able to make his needs known and continued on 15-minute checks for a recent resident to resident altercation. The resident did not exhibit any aggressive behaviors. B. The social service director (SSD) typed/signed notes The SSD note dated 3/2/23 (not timed) revealed the SSD followed up with Resident #3 regarding his current mood. Resident #3 expressed he did not know English and his daughter was called to translate. The daughter translated that Resident #3 did not remember the altercation and was not afraid of anyone in the facility. The resident had no change in his mood, behavior or affect. The SSD note dated 3/2/23 (not timed) revealed the SSD spoke with Resident #4 regarding the resident to resident altercation. Resident #4 could not recall the altercation but did mention he did not like his roommate. The SSD asked him how he liked his new unit, and he said he was okay. Resident #4 had not officially met his new roommate at this time but sat with him for lunch. The SSD asked him how he felt his mood was today, he said he felt alright. Resident #4 had no change in his mood, behavior or affect at this time. III. Resident #3 A. Resident status Resident #3, age 80, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), pertinent diagnoses included dementia of unspecified severity with other behavioral disturbances, Alzheimer's disease, wandering, and history of transient ischemic attack (stroke). The 2/27/23 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 had disorganized thinking. The resident's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, and/or unpredictable switching from subject to subject). This behavior was present and fluctuated (came and went and changed in severity). The resident required extensive staff assistance for dressing, toileting, and personal hygiene. The resident required staff supervision for bed mobility, transfers, and eating. B. Resident observations On 3/21/23 at 9:51 a.m., the resident laid on the bed in his private room. He answered yes that he was feeling good and yes he liked his private room. He then did not want to talk any more. C. Record review Care plan for change in mood or behavior due to a medical condition was initiated on 3/1/23. The pertinent goals revealed the resident would not harm himself or others through the next review. The resident desired to be consulted with decisions related to his/her care through the next review. The intervention was to consult with the resident on preferences regarding customary routine. Care plan for the resident being at risk for elopement related to a diagnosis of dementia with wandering behavior was initiated on 3/1/23. The pertinent interventions included provide the resident with safe wandering. The resident was an elopement risk and staff were to encourage the resident to participate in activities to divert from exit seeking behavior. Care plan for the potential for decreased life satisfaction and psycho-social well-being subject to dementia and a change in environment was initiated on 3/2/23. The pertinent interventions were when conflicts arose, remove the residents to a calm safe environment and allow them to vent/share their feelings. Encourage participation from the resident, who depended on others to make their own decisions. Allow the resident time to answer questions and to verbalize feelings, perceptions, and/or fears. Kardex for Resident #3 revealed under mood/behavior to encourage the resident to participate in activities to divert him from exit seeking. Offer redirection orientation to the current place and provide for safe wandering; the resident was an elopement risk. Use translator services as needed with care if the resident exhibited confusion resulting in aggression. IV. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE]. According to the March 2023 CPO, pertinent diagnoses included Parkinson's disease, depression, psychosis, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/6/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15 with no behaviors. The resident required extensive staff assistance for dressing and personal hygiene. The resident required staff supervision for bed mobility, transfers, and toileting. B. Resident observations On 3/21/23 at 3:45 p.m., the resident sat in a wheelchair by the nurse cart on the Center Unit. He was interacting with the nurse related to his medications. He did not express any verbal or physical agitation or aggression. C. Record review Care plan for the potential to become physically aggressive with the roommate and also the potential to exhibit changes in orientation related to current level of dementia resulting in changes in behavior (walking down the hall unsafely, and delusions) was initiated on 3/6/23. The pertinent interventions were for staff to analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document. Staff were to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff members when agitated. If the resident communicated or demonstrated issues with the roommate, notify social services to assess and intervene as necessary. When the resident became agitated; staff were to intervene before agitation escalated; guide away from the source of distress; and engage calmly in conversation. If the response was aggressive, staff were to walk calmly away, and approach later. The resident's triggers for physical aggression were changes in the environment, including staff. The resident's behaviors were de-escalated by offering the resident to speak with family and allowing the requested space was initiated on 3/15/23. Kardex for Resident #4 revealed for behavior monitoring and interventions for communication the staff were to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff members when agitated. If the resident communicated or demonstrated issues with the roommate, notify social services to assess and intervene as necessary. The resident's triggers (stimulations/provokes) for physical aggression were changes in the environment, which included staff. The resident's behaviors were de-escalated by offering residents to speak with family, allowing him to have the space requested. When the resident became agitated: staff were to intervene before agitation escalated; guide the resident away from source of distress; engage the resident calmly in conversation; and if the resident's response was aggressive, staff were to walk away and approach later. V. Staff interviews The SSD and the social service assistant (SSA) were interviewed on 3/21/23 at 12:31 p.m. They said Resident #4 hit Resident #3 with a belt. They said Resident #4 had dementia and Alzheimer's disease and Resident #4 had dementia. They said at the time of the altercation, they shared a room on the North Unit. They said Resident #4 was moved to the Center Unit after the altercation. They said neither resident remembered the altercation when interviewed. They said this was the first altercation between these residents. They felt the altercation occurred, because Resident #3 came into the personal space of Resident #4. CNA #1 was interviewed on 3/21/23 at 2:48 p.m. CNA #1 said she was working on the North Unit at the time of the altercation. It was around 7:00 p.m. on 3/1/23, after dinner, the incident occurred , but she did not witness the altercation. CNA #1 said Resident #3 went into another resident's room and was looking for a bathroom. She redirected the resident back to his room and took him to the bathroom. CNA #1 said Resident #3 was taking a long time in the bathroom and she told him to pull the call light and wait for her when he had finished. CNA #1 said when she returned back to the room; both of the residents were bloody. Resident #3 was standing and Resident #4 was seated on his bed. She said Resident #3 had blood on the right side of his head. She said Resident #4 was bleeding from a skin tear from an old bruise on his forearm. Resident #3 said that Resident #4 was trying to kill him. CNA #1 said she asked Resident #4 if he had hit Resident #3 with a belt and Resident #4 said that Resident #3 was trying to kill him; both residents stated that the other one was trying to kill them. CNA #1 said she believed Resident #4 hit Resident #3 with the buckle on the belt. She said Resident #4 was holding a belt and did not want to give it to her because Resident #4 felt he needed the belt for protection from Resident #3. CNA #1 said she reported the incident to the nurse on duty. The residents were separated and Resident #3 was started on 15 minute checks. CNA #1 said Resident #3 said he did not like Resident #4; this was the first time she heard this statement. This was the first altercation between these two residents and the first altercation for either resident. LPN #2 was interviewed on 3/21/23 at 3:19 p.m. LPN #2 said CNA #1 reported that Resident #3 was bleeding from the right temple after a resident to resident altercation between Resident #3 and #4 on 3/1/23 at 7:20 p.m., LPN #2 said when she went into the room, Resident #3 was standing and Resident #4 was seated on his bed; holding a belt. LPN #2 said she reported the incident to the RN on duty and gathered first aid supplies. Pressure and an ice pack was applied to Resident #3's wound. Resident #3's vital signs were assessed and neurological assessments were started. LPN #2 said Resident #4 had a skin tear to his forearm and did not say how he got the skin tear. Neither resident complained of pain. The RN on duty also conducted a full assessment on both residents. LPN #2 said Resident #4 said he hit Resident #3 for personal protection. LPN #2 did not see any blood on the belt or the buckle. Resident #4 was assisted to a neighboring unit for his protection. LPN #2 said to her knowledge, this was the first altercation between these two residents. RN #2 was interviewed on 3/22/23 at 9:00 a.m. RN #2 said on 3/1/23 at approximately 7:30 p.m, she entered resident #3 and #4's room. Resident #4 was seated in the middle of his bed holding a belt and was agitated and yelling. Resident #4 would not give up the belt, saying he needed to keep the belt for protection from Resident #3. Resident #4 had a skin tear to his forearm and would not let RN #2 touch him to assess the injury. RN #2 said she continued to talk with Resident #4 and he finally calmed down and allowed her to clean and bandage the skin tear. Then he allowed staff to take him to a room in the Center Unit. Resident #4 eventually allowed her to complete a head to toe assessment Resident #4's vital signs were found to be within normal range. RN #2 said Resident #3 was very quiet and was found laying in his bed holding on to the right temple area of his head. Resident #3 had a bump on the right temple but showed no signs or agitation or symptoms of being in pain. Pain level was assessed by facial expressions because he was not able to give verbal indication of pain.RN #2 said she completed the initial neurological assessments; all vital signs were in normal range. An ice pack covered with a wash cloth was applied to the resident's temple. The RN had to hold the ice pack in place because the resident kept trying to remove it. RN #4 said she concluded that Resident #4 hit Resident #3 with the buckle of his belt on the right temple area. RN #2 said both residents were separated after discovery of the physical altercation. The NHA and the DON were interviewed on 3/22/23 at 2:24 p.m. They said the residents had been roommates for approximately two weeks. They said they had not exhibited any signs of aggressive behaviors towards each other, prior to this altercation. They said Resident #3 had a tendency to stare at Resident #4. They said Resident #3 was close to Resident's #4 bed and was staring at him. Resident #4 felt he needed to defend himself with the belt and said he did hit Resident #3 with the belt. They said they were unsure if Resident #3 was struck with the buckle of the belt. They said Resident #4 was placed on 15-minute checks with a one-to-one sitter. They said after the altercation, Resident #4 was moved to the Center Unit. VI. Staff in-service for Resident #3 and Resident #4's altercation In-service dated 3/6/23 and 3/7/23 (both not timed) revealed one of the concerns that was discussed pertained to the altercation between Resident #3 and Resident #4. The inservice document that staff intervention when residents were involved in abuse altercations were a priority and all staff that were working on the floor were responsible to intervene and prevent any altercation if possible. Staff were to refer to the resident's Kardex (computerized information system for quick references) or consult with the nurse on duty for appropriate and effective interventions. If an altercation occurred, it needed to be reported to the DON and NHA immediately; timely reporting was crucial.

Based on observations, interviews, record review, and facility policy and document review, the facility failed to: 1. Conduct a thorough visitor screening for COVID-19 for three of four days of the survey; and 2. Prevent possible contamination of one resident's catheter drainage bag by allowing it to rest on the floor for one (Resident #14) of two residents sampled for catheter care. Findings included: A review of a facility policy titled, Visitor - Screening/Communication/Visitation/Education, updated 05/19/2022 revealed, Visitors will be screened for COVID-19 in accordance with current CDC [Centers for Disease Control], CMS [Centers for Medicare and Medicaid Services], and local and state guidelines. This screening will include: -Symptoms of COVID-19, or -Have a positive [CONDITION(S)] test for COVID-19, or -Close contact with someone with [CONDITION(S)]-COV-2 infection . Education should be provided to visitors on the following: -COVID-19 -Visitor restrictions -Actions the facility is taking to protect them, the residents, and associates -Actions they can take to protect themselves while in the facility -The important role of social distancing -How to properly don and doff appropriate PPE [Personal Protective Equipment] -Hand Hygiene, respiratory hygiene, and cough etiquette -Wearing a face covering or mask during presence in the facility as a means of source control -Performing hand hygiene immediately before and after any contact with their facemask or cloth mask. A review of a General - Visitor COVID Screening form, updated 02/08/2022, listed the following signs and symptoms for visitor screening: 1. Fever = Temperature of greater than 100.0. If yes do not allow visit. 2. S/S [signs/symptoms] of COVID-19 = Chills, repeated shaking with chills, New/Change in Cough, Shortness of breath, difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion, Runny nose, Nausea, Vomiting, Diarrhea, New sputum production, Hemoptysis = If Yes do not allow visit. 3. Have you been diagnosed with COVID-19 and have not completed the time/symptom-based requirements to come out of isolation = If Yes, do not allow visit. 4. In the last 10 days have you had close personal contact with a person with a + [positive] COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] = If Yes, do not allow visit. 5. Visitor Acknowledgement: I understand that during my visit, I should wear a face mask and other PPE as directed by the facility, perform hand hygiene before and after my visit, and practice social distancing (6 [feet]) between myself and other residents and staff. The facility had a main entrance, and each hall including the main or Center hall had a keypad lock. In addition to Central, each of the other units, North, South, East, and West, had individual keypad locks to enter and exit the units. 1. An observation of visitor screening on 06/27/2022 at 9:01 AM revealed the Business Office Assistant (BOA) was at the entry desk. She measured and recorded the visitor's temperature and asked the visitor, Do you have any symptoms? The signs and symptoms of COVID were not asked or described nor was a list provided of the symptoms, and the visitor was not educated on infection control practices while they were in the building. The visitor was allowed entrance into the facility. An observation of a visitor on 06/28/2022 at 7:51 AM revealed the Business Office Manager (BOM) was at the entry desk. The BOM measured and recorded the visitor's temperature. No other information was requested, and education was not provided. An observation on 06/29/2022 at 8:09 AM revealed both the BOA and the BOM were at the entry desk. The BOM measured a visitor's temperature and asked the visitor, Do you have any symptoms? When asked what the symptoms were, the BOM used a list to read the symptoms to the visitor. The BOA then clarified the symptom list was on the General - Visitor COVID Screening form and the BOM was reading incorrectly from the staff's screening form. The BOM stated she was supposed to ask the screening questions of new visitors who had not previously entered the building. The BOM acknowledged the visitor had not been asked any questions or provided infection control education during three of three days of entry to the building. During an interview on 06/29/2022 at 8:14 AM, the Infection Control Preventionist (ICP) acknowledged staff did not ask questions about signs and symptoms of COVID for three of three days of building entry. The ICP stated staff should have asked about vaccination status, fever, the signs and symptoms listed on the form, and known exposure to COVID for all visitors every time they enter for a visit. The ICP stated visitors should be educated on personal protective equipment (PPE), handwashing, and social distancing while in the building. The ICP stated staff should use the General - Visitor COVID Screening form and ask the questions listed on the form. The ICP stated, They [staff] have been trained to ask about signs and symptoms; we have gotten away from it a bit. During an interview on 06/30/2022 at 12:01 PM, the Director of Nursing (DON) stated her expectation was for staff to do the screening for visitors and ask the questions for signs and symptoms of COVID. The DON stated visitors may not know what the signs and symptoms were and needed to be informed and given direction on social distancing, PPE, and handwashing. During an interview on 06/30/2022 at 12:09 PM, the Administrator stated it was his expectation the staff reviewed the signs and symptoms of COVID for visitors. 2. A review of a 04/06/2022 quarterly Minimum Data Assessment (MDS) revealed Resident #14 had a Staff Assessment of Mental Status indicating the resident had severe cognitive impairment. Per the MDS, the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS noted Resident #14 did not walk, used a wheelchair for locomotion, and required an indwelling urinary catheter. An observation on 06/27/2022 at 3:58 PM revealed the resident rested in bed. A urinary catheter bag hung from the bed frame and rested on the floor. An observation on 06/30/2022 at 9:37 AM revealed the resident slept in bed with the catheter drainage bag hanging from the bed frame and resting on the floor. During an interview on 06/30/2022 at 10:06 AM, Certified Nursing Assistant (CNA) #1 stated the catheter drainage bag should not touch the floor. CNA #1 stated they usually placed a towel under the bag for infection control purposes. An observation was conducted on 06/30/2022 at 10:10 AM with CNA #1, who confirmed the catheter bag was touching the floor. During an interview on 06/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 stated catheter bags should be covered to be protective. LPN #3 stated the catheter bag should not touch the floor for sanitary reasons and due to possible risk of infection. During an interview on 06/30/2022 at 10:48 AM, the Infection Control Nurse (ICP) stated the catheter bag should not be on the floor, stating, Of course there is a possible risk of infection. During an interview on 06/30/2022 at 12:05 PM, the Director of Nursing (DON) stated the expectation was for staff not to allow catheter bags to touch the floor because it was a potential infection control issue with a risk for possible infection of a resident. During an interview on 06/30/2022 at 12:09 PM, the Administrator stated there may be infection control issues associated with a catheter bag being on the floor and a risk of possible resident infection.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dignity was provided by failing to cover a urinary catheter drainage bag for one (Resident #14) of two residents reviewed for urinary catheters. Findings included: A review of the facility policy titled, Dignity, dated 08/03/2021, revealed, Policy: Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences and choices . Examples of treating residents with dignity and respect include, but are not limited to: 7. Refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered. A review of a 04/06/2022 quarterly Minimum Data Assessment (MDS) revealed Resident #14 had a Staff Assessment of Mental Status indicating the resident had severe cognitive impairment. Per the MDS, the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS noted Resident #14 did not walk, used a wheelchair for locomotion, and required an indwelling urinary catheter. An observation of Resident #14 on 06/27/2022 at 11:37 AM revealed the resident sat in a wheelchair in the dining room with a visible catheter drainage bag containing urine. An observation on 06/27/2022 at 1:40 PM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a visible catheter drainage bag containing urine. An observation on 06/27/2022 at 3:58 PM revealed Resident #14 rested in bed with an uncovered catheter drainage bag visible from the open doorway. The catheter drainage bag contained urine. An observation on 06/28/2022 at 10:22 AM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a visible catheter drainage bag containing urine. An observation on 06/28/2022 at 12:05 PM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a transparent plastic bag covering the catheter drainage bag with urine visible in the bag. An observation on 06/28/2022 at 2:09 PM revealed Resident #14 sat in a wheelchair in the dining room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/28/2022 at 3:02 PM revealed Resident #14 sat in a wheelchair in the resident's room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/28/2022 at 4:07 PM revealed Resident #14 sat in a wheelchair in the dining room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/29/2022 at 9:52 AM revealed Resident #14 sat in a wheelchair in the dining room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/29/2022 at 12:21 PM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. During an interview on 06/30/2022 at 10:06 AM, Certified Nursing Assistant (CNA) #1 stated the catheter drainage bag should be covered while Resident #14 was in the wheelchair and bed, noting an uncovered bag is a dignity issue. During an interview on 06/30/2022 at 10:13 AM, Recreation Staff #2 stated a resident's catheter drainage bag should be covered for respect and dignity. During an interview on 06/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 noted Resident #14's catheter bag should be covered so it did not look offensive. LPN #3 stated, We don't want people to walk by and see the urine. It is a dignity issue. During an interview on 06/30/2022 at 12:05 PM, the Director of Nursing (DON) stated her expectation was for staff to cover a resident's catheter bag because it was a dignity issue. During an interview on 06/30/2022 at 12:09 PM, the Administrator stated a resident's catheter bag should not be visible and should be covered as an aspect of dignity.

Based on record review and interviews the facility failed to ensure a surety bond or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility. Specifically the facility failed to ensure the surety bond had the correct amount to cover the entire balance for the resident's personal needs account at the facility. Findings include: I. The Resident Trust policy and procedure, dated 3/10/16, was provided by the nursing home administrator (NHA) on 5/17/21 at 8:30 a.m. It read, in pertinent part: Through the facility's legal and risk services department, a surety bond is purchased each year. It is the responsibility of the facility ' s business office staff to review the bond each year to ensure it meets state requirements for coverage. It is also the responsibility of the facility business office staff to notify the corporate legal and risk services department when circumstances arise that may necessitate an increase in the bond. II. Record review The personal needs account balance had a total balance of $68,823.00 as of 5/13/21. The 5/13/2020 [MEDICATION(S)] company letter dated signed by the [MEDICATION(S)] company president was read and documented, the surety bond # 94 patient funds were for the amount of $55,000.00. The certificate was effective 5/15/2020 at 12:01 a.m. and shall continue in full force and effect until 5/15/21. III. Interviews The NHA was interviewed on 5/14/21 at 4:10 p.m. The NHA said the facility ' s corporate business office held responsibility to ensure the surety bond was in effect and sufficient to cover the residents funds. He would contact the corporate officer immediately, to gain more information about the surety bond and to request an increase to the surety bond coverage. IV. Follow up The NHA provided an updated surety bond on 5/17/21 at 8:30 a.m. The 5/14/21 change rider and continued certificate [MEDICATION(S)] company letters signed and dated 5/14/21 by the [MEDICATION(S)] company president, read and documented the surety bond # 94 was increased from $55,000.00 to $70,000.00. The certificate was effective 5/15/21 and terminated at midnight 5/15/22. It was acknowledged the previous bond amount was sufficient to cover the personal funds account, until the residents recent installment after receiving an economic stimulus check from the government.

Based on observation record review and interviews, the facility failed to ensure that all resident were free from abuse, neglect, and exploitation, for four residents (#59, #71, #51 and #80) out of eight; for six facility reported incidents of abuse reviewed, out of 40 sample residents. Specifically, the facility failed to identify abusive events, prevent abusive events, and assess and ensure effective interventions to: -Protect Resident #59's right to be free from verbal and physical abuse; -Protect Resident #71's right to be free from verbal and physical abuse; -Protect Resident #51's right to be free from physical abuse; and, -Protect Resident #80's right to be free from physical abuse. Findings include: I. Facility policy and procedure The Protection of Residents: Reducing the Threat of Abuse & Neglect policy, revised 1/21/19, was provided by the nursing home administrator (NHA) on 5/12/21 at 11:30 a.m. It read in pertinent part: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. -It is the policy and practice of this facility that all residents will be protected from all types of abuse .The facility must: -Identify, correct and intervene in situations in which abuse .is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. -Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors, which might lead to conflict or neglect, such as: verbally aggressive behavior; physically aggressive behavior; .taking, touching, or rummaging through other's property; wandering into other's rooms/space; . -Analyze features of the physical environment that may make abuse .more likely to occur, such as secluded areas of the facility. -Identify who is responsible for the supervision of staff on all shifts and how supervision will occur in order to identify inappropriate staff behaviors. The Behavioral Health Management policy, dated 5/18/2020, was provided by the NHA on 5/12/21 at 11:30 a.m. It read in pertinent part: Facility staff must: monitor the resident closely for expressions or indications of distress; assess and plan care for concerns identified in the resident assessment; .ensure appropriate follow-up assessment, if needed; and discuss potential modifications to the care plan. II. 5/14/21 - Allegation abuse - where Resident #59 and Resident #71 engaged in a physically abusive resident to resident altercation. A. Facility reported incident detail The facility investigative report dated 5/14/21 documented: Resident #59 had been wandering the unit hallway throughout the shift. On 5/14/21 at 4:45 p.m. Certified nurse aide (CNA) #6 heard screaming coming from Resident #71's room. Upon entry to the room CNA #6 observed Resident #71 and Resident #59 screaming at each other, then Resident #71 pushed Resident #59. The residents were separated Resident #59 was escorted from the room. Upon exam, Resident #71 had no physical injuries and Resident #59 had a small open area on the knuckle of the right thumb, to which first-aid was provided and a bandage was applied. Neither resident was able to effectively verbalize what had occurred. Facility response: Both residents were monitored closely following the event, to ensure no other aggressive interaction occurred between the two. Conclusions:It is unknown how the incident started. It is unknown how the victim sustained a pinpoint opening, but the injury was discovered after the altercation concluded. -Resident #59 had a superficial skin injury but no apparent change in mood, behavior, or affect. -Resident #71 was not injured physically, but was visibly upset by the Resident #59's intrusion into her room and refusal to leave without staff guidance. Facility response: Resident #59's care plan was updated to add interventions to offer redirection and activity of choice when wandering. -No changes were made to Resident #71's care plan. -The altercation was a willful act upon each resident's actions where each acted in an aggressive intention manner towards each other. Their acts were not inadvertently accidental. B. Observations and resident interviews Neither Resident #59 or Resident #71 were interviewable. Resident #59 had been observed on several occasions wandering and entering other residents ' rooms. On some occasions Resident #59 had been in other residents rooms for several minutes before staff became aware and responded to redirect Resident #59 from the rooms of her peers. On 5/12/21 at 1:45 p.m Resident #59 and Resident #71 were observed. Resident #59 was wandering the unit without purpose going in and out or other resident rooms. Resident #59 was observed going into Resident #71's room, staff had to go in after Resident #59 and redirect her from Resident #71's room. Resident #71 became very upset by Resident #59's actions and yelled at Resident #59. Cross-reference to F744 failure to provide effective dementia care to prevent unsafe wandering. C. Resident #59 and Resident #71 1. Resident #59 a. Resident status Resident #59, under the age of 65, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/13/21 minimum data set (MDS) assessment, the resident cognition was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident had adequate hearing, vision, and speech was unclear. The resident rarely understood others and was unable to make herself understood. The resident had disorganized thinking. She did not reject care and did not display any behavioral symptoms during the assessment period. The resident was steady at times and walked without any assistive device. The resident needed occasional supervision when walking. b. Record review After an incident involving physical aggression between two other residents on 4/25/21 where Resident #59 was a trigger for Resident #10 becoming verbally and physically aggressive Resident #59 was relocated to an all-female unit. (see facility reported incident 4/25/21 below). Resident #59's medical record documented the following pertinent information: -Health status note dated 4/28/21 at 10:15 p.m. Appears to be adjusting to the South unit; wanders and goes in other residents ' rooms. Some residents get upset Resident #59 does not appear affected. -Behavior note dated 4/28/21 at 1:50 a.m. Resident moved to a new unit today, continuously pacing the hall, opening all doors to other residents rooms which upset others, unable to redirect resident effectively. Able to get staff from an old unit where residents resided to help acclimate the resident; this was effective, however resident remained pacing until 2:00 a.m. -Behavior note dated 5/7/21 at 5:40 p.m. Resident was observed this morning after she got up from the bed wander a lot, in hall, agitated, and exit seeking behavior noted. Staff tried to redirect her. -Behavior note dated 5/8/21 at 4:00 a.m. Resident woke up from her sleep around 1:45 a.m. and started to wander the hallway. Resident was opening other residents' doors and going in and out of their rooms. Resident was also exit seeking and tried to open the exit doors and got mad when unable to open it. This nurse offered resident a snack but resident refused. This nurse also offered resident water. Resident accepted the water cup and spilled it on the floor. This nurse cleaned the water from the floor and tried to redirect resident to her room but resident refused. CNA changed resident's brief and let resident to listen to music. Resident enjoyed the music and was able to go back to her be and sleep. Will continue to monitor. -Event note - late entry dated 5/14/21 at 5:14 p.m. Staff heard yelling, A CNA went to Resident #71's room. Resident #71 and #59 were pushing each other and yelling. The CNA stepped in between the two residents and escorted Resident #59 out of room. Resident #59 continued to wander in and out of all the rooms. Will monitor and redirect. -Behavior note dated 5/15/21 at 3:35 a.m. Resident continues on monitoring for resident to resident altercation. Resident was awake all night and was restless. Resident wandered in the hallway, opened other residents ' doors, and entered their rooms. Staffs redirected her to get out of other residents' rooms. Resident was verbally and physically aggressive toward staff at times when redirected. Resident also tried to go to her roommates bed and tried to wake up her roommate, but was redirected by staff Resident also kept turning on the hot water faucet in her room and let the water run. This nurse turned off the water faucet under the sink to avoid skin injury from the hot water. Resident is sitting on her bed in her room at this time. Snack & fluid offered to resident at the beginning of the shift but resident refused. Resident accepted the snack and fluid after a couple of hours. Will continue to monitor. -Health status note dated 5/15/21 at 11:36 a.m. Resident being monitored for altercation that occurred on 5/14/21. No interactions were noted today with Resident #59 and Resident #71. -Health status note dated 5/15/21 9:45 p.m. Resident continues on follow up monitoring for resident to resident altercation. Resident continues to walk up and down hall and continues to enter into other residents rooms. Resident resistant to care and redirection at times. When other residents yell for her to get out of their room, Resident #59 begins to yell. Resident #59 has a pinpoint size open wound to the right thumb knuckle, from the 5/14/21 resident-to-resident altercation. No signs or symptoms of infection noted. -Behavior note dated 5/16/21 at 1:52 p.m. Resident being monitored for resident to resident altercation. No complaints of pain or memory of previous altercation. Has extreme agitation and anxiety, paces the halls going in and out of others resident is rooms collecting items. Resident is very difficult to redirect. Resident #59's comprehensive care plan last revised 5/15/21 revealed a care focus to address the resident's potential to exhibit verbal and physical aggression towards other residents. Interventions included: Administer medications as ordered. Anticipate and meet the resident's needs. Encourage resident to participate in activities of interest when in room alone with residents. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. Minimize potential for the resident's disruptive behaviors by offering tasks, which divert attention. Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Offered to walk with Resident. 2. Resident #71 a. Resident status Resident #71, age 88, was admitted on [DATE]. According to the May 2021 CPO, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/20/21 MDS assessment, the resident cognition was severely impaired with a BIMS score of zero out of 15. The resident had adequate hearing and vision, speech was clear but had limited ability to make concrete requests and usually understood others, misses some part/intent of message but comprehends most conversation. The resident had difficulty focusing attention and was easily distractible; disorganized thinking. The resident displayed physical aggression towards others four to six days during the assessment and rejected care one to three days, during the seven-day assessment period. The resident used a walker to move about. b. Record review Resident #71's medical record documented the following pertinent information: -Event note dated 5/14/21 at 10:13 p.m. Staff heard yelling coming from Resident #71's room upon arrival CNA noted both residents yelling and holding on to others ones arms. The staff stepped in between the resident's and escorted Resident #59 out of the room. Staff will try to keep the residents apart. Will continue monitoring. -Health status note dated 5/15/21 at 3:22 a.m. Resident continues on monitoring for resident to resident altercation. Resident stayed in her room during the shift. Resident slept most of the night. -Health status note dated 5/15/21 at 9:37 p.m. Resident continues on follow up monitoring for resident to resident altercation. Staff has monitored closely to prevent Resident #59 from reentering Resident #71's room. At times Resident #71 came out of her room fussing at different residents and shaking her fist. Staff gently redirects resident back to her room. III. 4/25/21- Allegation abuse - where resident #59 was a trigger for Resident #10 becoming aggressive and Resident #51 was the victim of physical abuse by Resident #10 A. Facility reported incident detail The facility investigative report dated 4/25/21 revealed the following: On 4/25/21 as 1:20 p.m. Resident #10 was observed standing in his doorway, just out of sight from the CNA witness, who was in the hall. Resident #59 was wandering the halls and approached Resident #10 in his doorway. It appeared as if Resident #59 attempt to touch Resident #10. The CNA could not see Resident #10 fully so it was unclear if Resident #59 actually touched Resident #10 or not. Resident #10 became upset with Resident #59's actions and started to yell at her to get away. The CNA on duty approached Resident #10 and Resident #59 and redirected Resident #59 to her room. Resident #10 was still upset and began to follow the CNA and Resident #59 down the hall. The CNA took Resident #59 into her room. When Resident #10 neared Resident #59's room he kept walking. The CNA witness reported that Resident #10 was still upset and was yelling as he walked down the hall. As Resident #10 approached the end of the hall by the nurse's station where other resident were sitting in the hall he rounded the corner and was out of sight of the CNA who was with Resident #59. No staff were with Resident #10 or had a clear view of him. Resident #51 was one of the other residents in the hall around the corner from the nurse's station. Staff heard Resident #59 say something to Resident #10, but staff could not hear or understand what was said and in response to Resident #10's yelling and verbal aggressions. By the time the CNA approached Resident #10 and Resident #51; Resident #10 was observed running his walker into the knees of Resident #51. Neither resident was able to effectively verbalize what had occurred. -The investigative report revealed the assessment for root causes of the event: Based on staff assessment it was written that Resident #59 had been getting too close to male residents on the unit; not in a sexual way but too friendly for Resident #10's liking and this was what triggered his aggressive behaviors. None of the three residents involved had any visible signs of physical injury. It was unknown if Resident #51 had any pain after Resident #10's walker hit her knees because the investigative report did not document if that was considered or explored in the course of the investigation. There was no witness statement to show if any staff observed the resident verbalizing ouch grabbing for or rubbing the knee or making any facial grimace to show pain. It is reasonable to believe that Resident #51 may have at least experienced short term immediate pain upon the impact of the walker to her knees. Facility response: None of the residents' care plans were revised as a result of this event. It is unclear if care plan interventions were assessed for effectiveness. Resident #59 was relocated off the unit to an all female unit, due to her being overly friendly with male residents and potentially putting herself at risk of victimization. B. Resident interview Neither Resident #59 or Resident #51 were able to participate in an interview due to cognitive impairments. Resident #10 was interviewed on 5/12/21 at 11:22 a.m. Resident #10 said he got along with everyone. C. Resident #51 and Resident #10 1. Resident #51 a. Resident status Resident #51, age 85, was admitted on [DATE]. According to the May 2021 CPO, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/20/21 MDS assessment, the resident cognition was severely impaired with a BIMS score of zero out of 15. The resident had adequate hearing and vision; her speech was unclear. The resident had limited ability to make concrete requests but was able to respond if communications were simple and direct. The resident displayed no behaviors during the assessment period. The resident needed supervision to balance herself, once stead the resident needed oversight and cuing to walk on the unit. b. Record review Progress note dated 4/25/21 at 1:54 p.m., read: CNA notified this nurse about Resident #10 running his walker into Resident #51's legs, getting (sic) her by the knees and then started to yell at another resident. Upon arrival to the scene Resident #51 was sitting in her chair, skin assessment done per protocol; no skin issues noted. -Behavior tracking sheet entry dated 4/28/21 from 4:40 p.m. to 5:00 p.m. indicated the resident presented with behavioral expressions including crying. Staff implemented positive distractions, active listening and assisted the resident to a quiet area; the resident was not consoled and there was no change in her behavioral expressions. -Behavior tracking sheet entry dated 4/29/21 from 6:00 a.m. to 2:00 p.m. indicated the resident presented with behavioral expressions including crying. Staff implemented positive distractions, snacks, active listing and the nurse assessed for physical needs; there was no change in the resident's behavioral expressions. -Behavior tracking sheet entry dated 5/1/21 from 6:00 a.m. to 2:00 p.m. indicated the resident presented with behavioral expressions including crying. Staff implemented positive distractions, snacks, active listing and the nurse assessed for physical needs; there was no change in the resident's behavioral expressions. Resident #51's comprehensive care plan revealed a care focus to address communication problems related to resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This care focus was last revised on 9/9/2020. -The care plan did not address the potential for the resident to become a victim of abuse related to responding in a manner of verbal aggression towards another resident's aggression. -The care plan was not revised in response to resident's involvement in the 4/25/21 resident-to-resident altercation with Resident #10. There were no safety or preventive measures in place to protect the resident from becoming a future victim of abuse when confronted and in the presence of any physical or verbally aggressive peer. 2. Resident #10 a. Resident status Resident #10, over the age of 90, was admitted on [DATE]. According to the May 2021 CPO, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/20/21 MDS assessment, the resident cognition was severely impaired with a BIMS score of three out of 15. The resident had adequate hearing and vision, his speech was clear. The resident was able to make himself understood and understood others in conversation. The resident displayed verbal aggression towards others but did not reject care during the assessment period. The resident was able to walk on his own without the use of an assistive device. b. Record review Monthly summary-nurse's note dated 4/2/2021 revealed Resident #10 was wandering, was easily upset and experiencing anxiety. Resident #10's medical record documented the following pertinent information: -The CPO revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was 7/15/2020; the medication was discontinued on 4/7/2021, there was no gradual dose reduction and not further doses of [MEDICATION(S)] were administered until the medication was restarted on 5/3/21. -Behavior note dated 4/14/21 at 10:45 p.m. On charting for discontinued [MEDICATION(S)]. Resident was very confused all afternoon, going to other residents rooms, sitting on beds, following other residents around. Had very confused thoughts and comments; redirection not effective. He was found asleep in a female resident's room. -Behavior note dated 4/15/21 at 7:44 p.m. Resident was wandering all shift, going into other resident's rooms. He was not redirectable. Unable to make his needs known. Not sleeping. Behaviors continue, talking nonstop nonsensical. -Behavior note dated 4/16/2021 at 6:15 a.m. Resident continues on monitoring for discontinued [MEDICATION(S)]. Resident was awake all night. Resident was confused and tried to enter another residents' rooms and had to be redirected by staff. Staff offered snacks and fluid, resident accepted. Will continue to monitor. -Behavior tracking sheet entry dated 4/16/21 at 6:30 a.m., indicated resident present with physical aggressions, verbal aggressions, hallucinations and delusions throughout the common areas of the unit. Interventions were not effective and behaviors worsened throughout the morning. -Health status note dated 4/16/21 at 7:14 p.m.will continue to monitor for any other changes. This was a result of a very belligerent 1.5 hours starting at 6:00 a.m. Additional monitoring was provided and medical causes were explored. -Behavior tracking sheet entry dated 4/17/21 at 1:30 a.m., indicated resident present with physical aggressions, verbal aggressions and was disruptive to others. Despite interventions, the resident's behaviors worsened. -Event note dated 4/21/21 at 12:36 p.m. Nurse was called to female resident's room; upon arrival Resident #10 was found sitting on the female resident's bed. The female resident was a little agitated saying get this son of a b .h out of here. This Nurse was able to guide Resident #10 back to his room and he went straight to bed. -Behavior note dated 4/21/21 at 7:41 p.m. Resident on charting for discontinued [MEDICATION(S)], today was day 14. Resident #10 had instigated a resident-to-resident altercation today with a female resident while she was lying in bed. Resident #10 has had a noticeable cognitive decline over the last couple of weeks, sleep pattern off, anxious and not always redirectable. He starts with wandering, and then unaware of his surroundings. -Health status note dated 4/23/21 at 4:38 a.m. Resident continues on monitoring for resident to resident altercation. Resident slept part of the night. The resident was found wandering the hallway and brought to the common area. Snack and fluid offered, resident accepted. Staff watched resident closely and redirected him not to enter other residents' rooms. No aggressive behavior noted. Will continue to monitor. -Psychosocial note dated 4/23/21 at 3:41 p.m. Mood note: social services spoke with Resident #10 regarding his current mood. Resident #10 stated he believed he was having an all right day. No change in mood, behavior or affect noted. -Behavior tracking sheet entry dated 4/25/21 from 6:00 a.m. to 2:00 p.m. indicated resident present with physical and verbal aggressions. Despite staffs attempts to redirect and implement interventions there was no change in the resident's behaviors and behavior worsened. -Event note dated 4/25/21 at 2:39 p.m. A unit CNA notified this nurse about Resident #10 running his walker into Resident #51's legs, getting her by the knees and then started to yell at another resident. Staff helped the resident back to his room. Resident continues to be restless and gets very upset when the staff tries to redirect him. -Health status note dated 4/25/21 at 10:32 p.m. Resident observed for resident-to-resident altercation .Resident has been doing her daily routine. Resident has been sitting on the chair by the nurse station from 8:00 p.m. until 10:30 p.m. -Behavior tracking sheet entry dated 4/28/21 from 6:00 a.m. to 2:00 p.m. indicated resident present with physical and verbal aggressions. Despite staffs attempts to redirect and implement interventions there was no change in the resident's behaviors. -Behavior note 4/28/21 at 3:54 p.m. Resident being observed for resident-to-resident altercation. Resident slept thru (sic) night, no other incidents noted. -Behavior tracking sheet entry dated 4/26/21 from 2:00 p.m. to 6:00 p.m. indicated resident present with physical aggressions, verbal aggressions, delusions, hallucinations that were disruptive to others. Despite staff's attempts to redirect and implement interventions there was no change in the resident's behaviors. -Behavior tracking sheet entry dated 4/29/21 from 2:00 p.m. to 4:00 p.m. indicated resident present with verbal aggressions, which were disruptive to others. Despite staff's attempts to redirect and implement interventions there was no change in the resident's behaviors. -Behavior tracking sheet entry dated 5/1/21 from 6:00 a.m. to 2:00 p.m. indicated resident present with physical and verbal aggressions that were disruptive to others. Despite staff's attempts to redirect and implement interventions there was no change in the resident's behaviors. -Behavior tracking sheet entry dated 5/1/21 from 2:00 p.m. to 6:00 p.m., indicated resident present with verbal aggressions that were disruptive to others. Despite staff's attempts to redirect and implement interventions there was no change in the resident's behaviors. See the incident dated 5/3/21 below for more detail of Resident #10's aggressive behaviors. Resident #51's comprehensive care plan revealed a care focus to address verbal and other aggressive behavior directed towards others. This care focus was last revised on 4/22/21. Care planned interventions included: -Administer medications as ordered. Anticipate and meet the resident's needs. - Ensure there is a sign on Resident #10's door to assist in reorienting him to the correct room. -Observe for behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. -Praise any indication of the resident's progress/improvement in behavior. -Provide a program of activities that is of interest and accommodates resident's status. -The resident's triggers for physical abuse towards others can be redirected by, de-escalated by offering activities, snacks, to watch television, or just express his frustrations, concerns, or feelings. -There was no documentation to show if the care-planned interventions were assessed for effectiveness; particularly in response to the documented resident-to-resident altercations and the behavior tracking documentation that revealed interventions were not effective despite staff initiating several interventions and in some cases, the resident's behavior got worse. -There were no added interventions placed in the resident's record to address resident's [MEDICATION(S)] being discontinued and potential behavioral effects that staff needed to be aware of and monitor. IV. 5/3/21 - Allegation abuse - where Resident #80 was the victim of physical abuse by Resident #10 A. Facility reported incident detail The facility investigative report dated 5/3/21 revealed the following evidential reporting: On 5/3/21 at 1:45 a.m. the unit licensed practical nurse (LPN) was at the nursing station and heard yelling. The LPN went towards the yelling and into a shared resident room. The LPN observed Resident #10 lying across Resident #80 on resident #80's bed. Resident #80 was sitting with his legs off the side of the bed and Resident #10 was on top of Resident #80 kicking and scratching Resident #80. Staff were able to separate the residents and Resident #80 was relocated to a different room. Resident #80 was unable to say what happened; Resident #10 would not respond to the question about why he physically attacked Resident #80. Resident #80 had a skin tears to his left arm and face with skin discolorations to both arms and to the left eye. The skin tear was treated with first aid and bandaged. Resident #10 was sent to the emergency room for assessment of a swollen left hand at the recommendation of the responding police office. The x-rays were negative for fractures. The unit LPN said Resident #10 had not displayed any unusual behaviors prior to the altercation and that both residents had been sleeping during the last rounds check. The facility was not able to determine the cause of the physical aggression between the two residents; but concluded that it was possible that Resident #10 went to the restroom in the middle of the night and when he left the restroom, accidentally mistook Resident #80's bed for his own. Resident #10 may have lied down in the bed thinking it was his own and became alarmed that someone in his bed. Given this scenario Resident #80 was still subject to physical abusive aggression, as he was woken up by his roommate on top of him kicking and scratching at him; and as a result sustained bruising and several scratches to his person. Facility response: Resident #10 and #80 were no longer sharing a room. Resident #10 will not have a roommate until the facility interdisciplinary team (IDT) can determine it will be safe for another resident to share a room with Resident #10. After consultation with the IDT, the resident's representative and the resident's primary care physician the resident was placed back on antipsychotic medications for dementia with behaviors. Since moving Resident #80 to a different room on a different unit and Resident #10 having his own room they have had no further altercations. Since interventions such as hanging a large pink sign reading Resident #10's room that sticks out into the hall so he can easily find his room, increased monitoring and the reinitiation of Resident #10 resumed taking his evening dose of [MEDICATION(S)] on 5/4/21 the resident had not had any further occurrence of aggression directed towards other residents. B. Resident interview Resident #80 was interviewed on 5/18/21 at 11:28 a.m. Resident #80 did not appear to understand questions; verbal responses were nonsensical. C. Resident #80 and Resident #10 1. Resident #80 a. Resident status Resident #80, age of 83, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/27/21 MDS assessment, the resident cognition was severely impaired with a BIMS score of one out of 15. The resident had adequate hearing, vision, his speech was unclear. The resident had difficulty communicating some words or finishing thoughts and misses some part or intent of message but comprehended most conversation. The resident displayed physical behavioral symptoms directed toward others but did not reject care. The resident used a manual wheelchair to get around and did not walk. The resident needed extensive assistance from staff to complete activities of daily living (ADL) successfully. b. Record review Resident #80's medical record documented the following pertinent information: -Physician note - late entry dated 4/30/21 at 11:25 a.m. Medical necessity of visit: request to be seen. Chief Complaint: dementia with aggressive behavior. Violent behavior associated with dementia: per nursing report, the res[TRUNCATED]

Based on record review and staff interviews, the facility failed to ensure one (#59) of two residents reviewed for dementia care out of 40 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. The facility failed to develop and implement interventions to address the Resident #59's dementia care needs, resulting in the Resident #59's inability to achieve her highest level of functioning. The facility was aware Resident #59 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #59 continued to wander and enter residents room during survey and Resident #59 had been pushed by another resident and sustained a small open area to her right thumb. The care plan for Resident #59 with an identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the review of the care plan indicated that the facility had failed to consistently follow and implement new person-centered interventions to prevent the resident from wandering into other residents' rooms, placing her at risk for potential abuse and other residents in distress. Furthermore, during the survey Resident #59 was observed wandering in and out of residents rooms without staff knowing the whereabouts of Resident #59. Resident #59 put other residents in distress and disturbed private cares being provided by staff as evidenced by residents in room [ROOM NUMBER] and #303 yelling out when Resident #59 went into their rooms and entered room [ROOM NUMBER] while the privacy curtain was pulled. Findings include: I. Facility policy and procedure The Unsafe Wandering and Elopement Policy, revised on 5/15/2020, was provided by the nursing home administrator (NHA) on 5/18/21 at 4:30 p.m. It read in part, A wandering resident can become unsafe. It can lead to an increase for falls and injuries because a resident can become overly tired, enter an area that is hazardous or enters into another resident's room and can lead to an altercation with another resident. At risk residents for wandering or with an identified behavior need interventions in their comprehensive care plan to address the potential for elopement and wandering. II. Census and Conditions demographic The 5/13/21 Census and Condition form documented that 90 total residents resided at the facility, 90 residents (100%) with dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was a designated long term memory care for residents. III. Resident #59 A. Resident status Resident #59, age 63, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/11/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score (BIMS) of one out of 15. She required limited assistance and set up or one person assist with walking in her room, walk in the corridor and bed mobility She also required limited assistance by one person with transfers and locomotion off the unit, as well as extensive assistance with dressing, eating, toilet use and personal hygiene. -Her MDS did not include that she had a behavior for wandering. Resident #59 resided on the secured unit. B. Observations On 5/12/21 at 11:03 a.m. Resident #59 walked into room [ROOM NUMBER] for three minutes while she looked in the mirror. She walked in and out of room [ROOM NUMBER] five times. -At 11:20 a.m. Resident #59 walked into room [ROOM NUMBER] and the resident who resided in that room began to yell and cry. One minute later certified nurse assistant (CNA) #4 entered room [ROOM NUMBER] and walked Resident #59 out of the room to the hallway. Staff did not redirect or distract Resident #59 from entering other resident rooms. On 5/13/21 at 9:17 a.m. Resident #59 walked from the main hallway on the unit into room [ROOM NUMBER]. CNA #5 assisted the resident in room [ROOM NUMBER] with the privacy curtain closed. Resident #59 moved the curtain while CNA #5 was behind it with the other resident. She walked toward Resident #59 quickly and placed her hands on Resident #59 to block and turn her away from behind the curtain and the other resident. CNA #5 called loudly for the nurse to help her and told Resident #59, no, you don't want to fight me. Licensed practical nurse (LPN) #1 entered the room and assisted Resident #59 out of room [ROOM NUMBER]. From 9:30 a.m. until 11:30 a.m. staff did not redirect Resident #59 who went into multiple other resident rooms. -At 1:30 p.m. Resident #59 entered room [ROOM NUMBER] and laid on that resident's bed until 1:45 p.m. On 5/17/21 at 10:30 a.m. Resident #59 began to walk in the hallway. She entered room [ROOM NUMBER] and the resident for that room said, tell her to get away from me. about Resident #59 in her room and left the room at 10:34 a.m.; -At 10:40 a.m. she walked into room [ROOM NUMBER] and walked out at 10:50 a.m.; -At 11:04 a.m. the CNA directed and walked with Resident #59 to her room; -At 11:12 a.m. Resident #59 pulled her pants and garments down to her knees and sat down on the chair next to the window for four minutes and stood up and pulled up her pants and laid down on her bed. -At 11:29 a.m. Resident #59 walked out her room and walked into room [ROOM NUMBER] until 11:40 a.m. On 5/18/21 -At 11:40 a.m. Resident #59 walked into room [ROOM NUMBER] and while she stood in front of the bed closest to the door, she pulled her pants and underwear down to her knees and sat on the bed. While she sat on the bed she took her pants off the left leg and then the right and left her clothing on the floor and laid down on the bed. -At 11:55 a.m., 15 minutes after she entered the room, CNA #4 saw the resident and went into the room and assisted the resident to put on her pants and escorted her out of room [ROOM NUMBER]. C. Record review The care plan revised on 4/25/21, read that Resident #59 needed moderate assistance for leisure engagement with verbal prompts, activity demonstration and set up. She was identified to have episodes of wandering behavior with interventions to offer her a snack from her personal box, provide a drink or a snack. She exhibited verbal and physical aggression towards other people with an intervention planned for when she was observed wandering in rooms, redirect her with an activity of her choice for example, T.V., ice cream, magazines and dancing. She required frequent monitoring. -No further interventions were added to the care plan to encourage and promote Resident #59 existence and dementia needs pertinent to wandering and safety. Resident #59 continued to wander and go into other resident rooms while on frequent monitoring. The facility failed to increase supervision based on the residents' needs. The Risk of Elopement and Wandering review form revealed the following information: The 4/25/21 activities quarterly progress note stated the resident was on a one to one program with activities related to wandering, unable to engage in a leisure activity for more than 10 minutes. She had positive reactions from one on one interaction with staff. However, she was discharged on [DATE] from her one on one activity program because she had met her goal for leisure engagement identified by the activities department. The 5/5/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She had [CONDITION(S)] (has difficulty with speech) and is almost completely mute. Her plan for severe dementia is to continue supportive care and her worsening behaviors at night can be contributed to sundowning. The 5/14/21 event note read staff responded to yelling by a resident from room [ROOM NUMBER] and Resident #59 was found in the room with the resident who resided in that room, in a verbal and physical altercation. Cross-reference F600 The 5/17/21 behavior note read, the resident continued to pace the halls and walked into and collected items from other residents' rooms caused other residents to be upset and yelled at her. IV. Staff interviews CNA #3 was interviewed on 5/17/21 at 4:15 p.m. She stated that she struggled when her unit was short staffed because the residents required staff to assist them with specific needs based on their care plan. The day before she had 21 residents to herself. She was not able to help engage them in their specific dementia care needs and activities. Activities assistant (AA) was interviewed on 5/18/21 at 11:25 a.m. She said she was assigned to the south unit as an activities assistant Monday through Friday from 8 a.m. to 5 p.m. She assisted the residents on that unit with activities for example passed out magazines to the residents and started a movie or show in the dining room to watch. Residents had a care plan to use for specific activities for each resident. Certified nurse aide (CNA) # 4 was interviewed on 5/18/21 at 1:15 p.m. She said she redirected Resident #59 when she wandered however she was very busy and did not focus on the resident's need to be redirected every time. CNA #5 was interviewed on 5/18/21 at 1:30 p.m. her dementia training involved redirecting the residents to offer something for them to eat or drink. It was very hard to do more than her required tasks during her shift. She had a hard time helping redirect residents when other residents needed assistance with their activities of daily living (ADLs) and other needs. Licensed practical nurse (LPN) #1 was interviewed on 5/18/21 at 1:25 p.m. she stated the residents required special supervision and treatments because they have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The director of nursing (DON ) was interviewed at 5:09 p.m. She stated that she expected staff to be with the residents to redirect them when she wandered out of safe areas. A stop sign on the door was used to help Resident #59 from wandering into other resident rooms. There is a person from the activities department on each unit. If the resident had new behaviors or interventions for a current behavior, the staff were to report the information to the DON. She said the staff will be given education on how to report new or worsening resident behaviors and give more information on dementia care.

Based on observations, record review and interviews the facility failed to ensure three out of six carts stored, secured, and labeled medications in accordance with accepted professional principles for drugs and biologicals. Specifically the facility failed to ensure: -Medications were properly labeled; and, -Expired medications were disposed of properly. Findings include: I. Professional reference The [MEDICATION(S)] Company, How to Store [MEDICATION(S)], 2015, last updated November 2020, http://www.[MEDICATION(S)].com/starting/how-to-use/store-[MEDICATION(S)], retrieved on 5/19/21. It read, in part, [MEDICATION(S)] can be either refrigerated or kept at room temperature for 28 days after first use. After 28 days, throw your opened [MEDICATION(S)] away-even if it still has insulin in it. II. Policy The Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles Policy, dated 12/1/07 and last revised on 10/28/19, was provided by the nursing home administrator (NHA) on 5/18/21 at 4:40 p.m. It read in part to, an opened medication is required to have the date on the container when the medication was first opened. -When an injectable medication used from a multi-dose vial and had been opened and accessed with a needle puncture, required a date it was opened and required to be discarded in 28 days after it was opened. -Medications were required to be securely stored in a locked unit or room inaccessible to residents. -A medication was required to be discarded by the manufacturers expiration date on the container to prevent expired medications being administered to residents. A. Observations and interviews 1. Cart #1 On 5/17/21 at 4:25 p.m. medication cart #1 used by registered nurse (RN) #1. In the top right drawer was a [MEDICATION(S)] insulin vial with an opened date of 3/17/21 which was 61 days past when it was first opened. A second [MEDICATION(S)] insulin vial with an opened date of 4/13/21 was 34 days passed when it was first opened. In the same cart, in the top left drawer, a vial for [MEDICATION(S)] 1% 100milligrams/10 milliliter for injection, did not have a date on the container; it was not in a box, it was without a manufacturers seal on the top and needle point punctures were on the top of the vial. RN #1 was interviewed on 5/17/21 at 4:25 p.m. She stated that the dates on both insulin vials were past the required discarded date after opening and needed to be discarded. She also said, the vial for the [MEDICATION(S)] needed to have a date when it was opened. 2. Cart #2 On 5/18/21 at 8:26 a.m. licensed practical nurse (LPN) #2 placed a card of [MEDICATION(S)] medication with pills in the card, was on top of the medication cart. She walked away from the cart and into a different room to administer medications to a resident. -At 8:30 a.m. the medication was left on the cart a second time when she walked away to administer medication to another resident. -At 8:45 a.m. mediation cart # 2 was used by LPN #2. In the top right drawer was an insulin injection pen. It did not have a date it was opened or a designated resident ' s name on the container. LPN #2 was interviewed on 5/18/21 at 8:45 a.m. She said that there was one resident that needed insulin on her unit so the name on the medication was not needed for her to identify who the medication belonged to. She also said, the card of [MEDICATION(S)] medication was placed on top of the cart because it was a discontinued medication and needed to be discarded. -The medication was not kept locked and inaccessible to residents, see policy above. 3. Cart # 3 On 5/18/21 at 9:05 a.m. medication cart #3 was used by LPN #3. She retrieved a bottle of medication, Calcium 250mg with 125 International Units from the top right drawer of the cart. The expiration date printed on the container by the manufacturer was 07/2020. The medication was 10 months past the expiration date. LPN #3 was interviewed on 5/18/21 at 9:06 a.m. She stated that the medication for calcium as described above, was past the expiration date and expired medication should not be given to the resident because it could harm them. III. director of nursing (DON) interview The DON was interviewed on 5/18/21 at 4:45 p.m. She stated it was important that the opened date was on the medication containers in order for nurses who administered the medication knew when to discard it. She said the medication could harm the resident or be ineffective if it was administered. She said it was also important the insulin medication container had the resident ' s name on it to prevent a medication error and or being used on another resident. She said, the unit managers were responsible to monitor the carts for expired medications and discard them as appropriate per professional standards. Education would be provided to nurses about expired medications and how to label them appropriately and to the unit managers about how to monitor the carts to prevent medication errors.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen. Specifically, the facility failed to ensure: Staff removed contaminated gloves, washed hands and put on clean gloves before touching ready to eat food (bread and potatoes), and performed hand hygiene after gloves were removed. Findings include: I. Facility policy and procedures The hand washing/proper use of gloves policy was provided by the nursing home administrator (NHA) on 5/18/21 at 10:00 a.m. It read in pertinent parts, adequate hand washing procedures are the key to infection control. It is not enough to run your hands under the water and rinse them off. Hands are washed before beginning any job requiring food handling, after breaks, after sneezing, after coughing, ect. Proper use of gloves is as important as hand washing since they can become contaminated as easily as the hands. Gloves are suggested when handling ready to eat foods. They are changed between tasks to prevent the contamination of food. II. Observations Observation of meal service was conducted on 5/17/2021 from 11:30 a.m. to 12:25 p.m. Dietary aide (DA) and dietary cook (DC) were observed serving meals. Both servers wore gloves. DA picked up a plate touching the outside of the plate and the meal tray cart with her gloved hands. She held the handle of the utensils to scoop the food into the plate. DC used a tongue to place the bread and potato into the same plate. DA touched the bread and potato with her contaminated gloved hands after touching the meal cart, handle of the oven and the utensils. She did not remove her gloves and wash her hands before touching the ready to eat food. This process was repeated several more times until the meal orders were filled. She did not wash her hands, change gloves, or sanitize her hands during this process. DC left the steam table and opened the refrigerator. She removed her gloves after she was done with the refrigerator and put on clean gloves. She did not wash her hands or perform hand hygiene after removing her contaminated gloves and donning clean gloves. She proceeded to the steam table and resumed the meal service. III. Staff interview The DA was interviewed on 5/17/21 at 12:30 p.m. She said she was trained to use gloves when serving meals. She said after she was done serving the meals then she would change her gloves and wash her hands. She said she was trained to change gloves and wash hands before touching ready to eat food. She said she did not realize she touched the resident ' s food with her contaminated gloves. The DC was interviewed on 5/17/21 at 12:35 p.m. She said education was provided to her on gloves. She said whenever gloves were removed, the staff should wash their hands and put on clean gloves to prevent the spread of infection. She said she changed her gloves but forgot to wash her hands. The food service director (FSD) was interviewed on 5/17/21 at 12:40 p.m. She said her staff were trained to wash their hands before meal service and not to use gloves. She said staff were suppose to use tongs when serving finger food(bread and potatoes) She said if gloves were used, staff should remove gloves, wash their hands and put on clean gloves before touching ready to eat food to prevent infections. She said the DA should have used the tongs to put the bread and potato on the plate. She said if the tong was not available she should have changed her gloves, washed her hands and put on clean gloves before touching the bread and potato. She said staff should be washing their hands every time they changed their gloves. She said she will re-educate the staff on infection control practices. IV. Facility follow-up A class attendance record was provided on 5/17/21 (during survey) by the FSD. It revealed infection control training on gloves use, handling raw meat and ready to eat foods was provided to all kitchen staff. It revealed nine staff signed the attendance form.

Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the spread of infection such as coronavirus (COVID-19) in one of the five neighborhoods observed for infection control practices. Specifically, the facility failed to: -Ensure staff wore full personal protective equipment (PPE) prior to entering isolation rooms; and offered hand hygiene to residents at the time meals were served. Findings include: I. Facility policy and procedure The Hand Washing/Hand Hygiene policy and procedure revised 12/4/2020, was provided by the nursing home administrator (NHA) on 5/17/2021 at 10:00 a.m., It read in pertinent part: the hand washing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infectious. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene. The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to; when to perform proper hand hygiene with alcohol based hand rub (ABHR) and with soap and water; before applying gloves and after removing gloves and prior to eating and drinking. II. Observations and interviews On 5/12/21 at 12:35 p.m., certified nurse aide (CNA) #1 was observed in an isolation room standing approximately two feet from the resident as she was talking to the resident. There was an isolation cart in front of the resident's door with PPE supplies and a signage posted on the door identifying what isolation precautions were in place and what PPE were required to wear before entering the room. CNA #1 wore a face shield and an N95. She did not wear a gown and gloves. She exited the room and performed hand hygiene. She entered the next isolation room without a gown and gloves. On 5/13/21 at 11:50 a.m. There were four residents observed sitting in the common area near the nurse station. CNA #1 was observed to offer hand hygiene to the residents. She used the hand sani-wipes to clean the residents hands. After she had finished cleaning the residents ' hands, she left the area. -At 12:01 p.m., one of the residents wheeled herself into her room touching the tires of her wheelchair. She touched the handle of her room door contaminating her hands after cleaning. -At 12:06 p.m., another resident was observed to touch her walker and removed her glasses from her face and rubbed her eyes. She also touched her hair and rubbed her nose. She stood up and walked down the hall touching the walls and doors contaminating her hands. -At 12:08 p.m., another resident removed her oxygen tubing from her nostrils and rubbed her nose. She was observed to scratch her hair contaminating her hands. The food tray arrived on the unit at 12:25 p.m. (35minutes after hand hygiene was performed for the residents). On 5/13/21 at 12:30 p.m., CNA #1 was observed to enter room108 (isolation room). She wore a face shield and an N95 mask. She did not wear a gown or gloves. She placed the meal tray on the bedside table and moved the table closer to the resident with her bare hands. She picked up the resident's shoes and moved them to the side of the bed. She exited the room and performed hand hygiene. She proceeded to the next isolation room (107) without the appropriate PPE (see observation above). She placed the meal tray on the bedside table. She used the bed controller to raise the head of the bed for the resident. She exited the room and performed hand hygiene. She proceeded to the next isolation room (101) and repeated the same process as above. CNA #1 said she was provided training on what PPE was required before entering an isolation room. She said she was trained to wear the full PPE (face shield, N95, gown and glove) when going to provide care to a resident in an isolation room. She said she was trained to wear a face shield and an N95 when she was going to drop off a meal tray and not provide care. III. Record review Review of the signage on the isolation room doors documented droplet precautions and contact precautions. The droplet precautions documented: everyone must: clean hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry and remove face protection before room exit. The contact precautions documented: everyone must: everyone must: clean hands, including before entering and when leaving the room, put on gloves and gown before room entry and discard before room exit. Do not wear the same gown and gloves for the care of more than one person and use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Even Though the signage on the door identified what PPE should be worn before entering the rooms, CNA #1 did not follow the isolation precautions. Review of staff training done on 4/16/2021, included PPE usage in the green areas (surgical mask). PPE usage in yellow or red areas (N95 mask, face shield or eye protection using foam barrier, gowns for resident care or when entering a room. It documented CNA #1 signed the training form. She said CNA #1 was in the yellow area. IV. Staff interviews CNA #1 was interviewed on 5/13/21 at 12:41 p.m. she said she offered to clean the resident's hands before lunch. She said there was not a specific time to provide hand hygiene to the resident. She said she provided hand hygiene before the meal trays arrived on the unit. She acknowledged that if the resident's hands were cleaned 25 minutes before the meals arrived, the residents could possibly touch dirty surfaces and contaminate their hands again. She said moving forward she would provide hand hygiene at the time the meals are served. Registered nurse (RN) #2 was interviewed on 5/13/21 at 12:50 p.m. she said before a staff member entered the isolation room, the full PPE (face shield, N95 mask, gown and gloves) should be worn to prevent the transmission of infections. She said CNA #1 should have worn the full PPE prior to entering the resident's room to prevent the spread of infection. She said even when a staff dropped off a meal tray, the staff were required to don all appropriate PPE. She said education will be provided to the CNA. She said CNA #1 should have provided hand hygiene to the residents at the time of meal service. She said providing hand hygiene 25 minutes earlier was a long time before meal service. She said the residents could touch dirty surfaces while waiting for their meals and could possibly contaminate their hands again. The infection preventionist (IP) was interviewed on 5/18/21 at 11:14 a.m., She said she provided infection control training to all staff. She said the training included: PPE, hand hygiene, mask wearing and social distancing. She said the training was ongoing as new information became available. She said all staff were trained on the appropriate PPE to wear into the isolations room. She said there was also signage on the isolation room door indicating what PPE to wear before entering the room. She said CNA #1 should have worn the full PPE before entering the rooms. She said even if the staff were not providing care, the staff must don all required PPE before entering to prevent the transmission of infection. She said her expectation was for staff to provide hand hygiene to resident's at the time the meals are served. She said providing hand hygiene to residents 25 minutes before meals were served was a long time to wait. She said the residents could contaminate their hands while waiting for the meals to arrive on the unit. She said she had already provided training to CNA #1 and all other staff on wearing the full PPE before entering an isolation room and hand hygiene to residents at the time the meals are served. The director of nursing (DON) was interviewed on 5/18/21 at 12:23 p.m. she said all staff were trained by the IP on hand hygiene and PPE. She said before a staff member entered an isolation room, full PPE should be worn to prevent the spread of infection. She said CNA #1 should have worn her full PPE before entering the resident's rooms to prevent the spread of infection. She said her expectation was for the staff to offer residents hand hygiene at the time of service to prevent infection. She said offering hand hygiene 25 minutes before the meals arrived on the unit would not be effective because the resident could touch dirty surfaces while waiting and contaminate their hands. She said the IP had already provided education to all staff when the facility was made aware.

Based on observations, record review, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents for six of six residents (#10, #9, #6, #3, #11, and #1) reviewed for falls out of fifteen total sample residents. The facility failed to ensure interventions to prevent falls were implemented and evaluated for effectiveness for Residents #10, #9, #6, #3, and #11. This failure resulted in multiple repeated falls for Resident #10 for which he sustained fractures of the sacrum and hip and a fall for Resident #9 which resulted in a [MEDICAL CONDITION]. Additionally, Residents #6, #3 and #11 have suffered from repeated falls with Residents #6 and #11 suffering minor injuries. Furthermore,the facility failed to ensure fall risks were accurately evaluated for Residents #3 and #1 and ensure residents were properly assessed by a registered nurse following falls. Findings Include: I. Immediate Jeopardy A. Findings triggering Immediate Jeopardy Review of fall events for Residents #10, #9, #6, #3, #11, and #1, observations conducted from 2/16/21 through 2/22/21 and staff interviews revealed the facility failed to ensure an effective system was in place to prevent falls for residents. Observations revealed residents who had experienced multiple falls did not have interventions in place to prevent falls. Staff interviews revealed staff were not aware of resident fall risks, interventions, how to find interventions, or how to report if interventions were ineffective to prevent falls for residents. B. Imposition of Immediate Jeopardy Based on observations, record review, and staff interviews (see below), which revealed multiple residents with repeated falls with interventions not implemented, the nursing home administrator (NHA) was notified on 2/22/21 at 4:01 p.m. the failure to implement effective interventions to prevent further falls, created a situation of immediate jeopardy with the potential of serious harm to residents. C. Facility response and removal of Immediate Jeopardy On 2/23/21 at 3:37 p.m. the NHA submitted the following removal plan (draft number five): Starting 2/22/2021 any resident exhibiting behaviors that might contribute to a fall, such as, repetitive movement, difficulty to redirect, or anxious affect, or found to have fallen the Registered Nurse (RN) completing the assessment will call the Executive Director (ED)/Director of Nursing (DON) to review interventions. This process will continue until all education has been completed with 100% staff and discontinued following review through the Quality Assurance Performance Improvement (QAPI) process. The target date for education completion is 2/25/2021 at which time this will be re-evaluated through the QAPI process to determine if, based on compliance, this should continue or if adjustments should be made to the plan. A full house 100% audit was conducted by members of the nursing and therapy teams. This audit was completed on 2/22/21 for all residents with repeated falls, followed by an audit for all other remaining residents, which will be completed by 02/23/21. This audit included the following: 1. Reviewing physician orders [REDACTED]. 2. Review of all fall interventions recommended by the IDT (interdisciplinary team) or identified on physician orders [REDACTED]. The audit identified some inconsistencies between the care plan interventions and those currently in place. This was determined on 2/22/21 when members from the nursing and therapy departments visualized the current interventions in place and compared to the resident care plans. Order clarifications were obtained and updates to interventions on the care plan and Kardex were made as needed. Referrals to other departments, such as therapy, were made as appropriate. Based on the results of the above audit, the facility developed a plan on 2/22/2021 to have the IDT review residents with falls to determine the factors that led to the fall to ensure that care plan interventions were relevant to the resident's status, consistent with facility policy and procedure and individualized for the resident, in an effort to minimize the risk for further falls. This plan will include interventions being placed on the care plan and kardex, review for accuracy of completed fall assessments, completion of neurological checks and pain assessment, and the completion of initial RN assessments. These IDT reviews were started with the residents who had repeat falls in the last 180 days and then expanded to all other residents. The IDT includes members from Nursing, Social Services, Rehabilitation Services, Registered Dietitian, Activities, and other ancillary departments. The facility fall management policy was reviewed by the Divisional Director of Clinical Services (DDCS) 2/22/2021 and is current. The facility Medical Director was called on 02/22/21 and agreed with the plan for removal of the Immediate Jeopardy. An adhoc Quality Assurance Performance Improvement (QAPI) team meeting was held to review the plan for removal on 02/22/21. The Regional Vice-President (RVP), and DDCS provided re-education to the ED and DON on 2/22/2021 regarding the facility policy 'Fall Management.' The education included definitions of accident, avoidable accident, fall, risk, supervision/adequate supervision, and hazards. Education will be provided to all Nurses by the DON/designee starting on 2/22/2021 and to be completed by 2/25/2021 on the following: Completion of assessment following a fall Fall risk assessment Initial assessment RN Pain assessment Neuro checks if unwitnessed, or if a resident hit their head Putting an intervention in place immediately following a fall and the review process by the IDT Care Plan interventions need to be individualized and relevant to the resident's status, consistent with facility policy and procedure and individualized for the resident, in an effort to minimize the risk for further falls. Education was started with the nurses on premises the evening of 2/22/21 and provided to nurses on subsequent shifts prior to the start of working their assignment. The education will continue until all nurses receive the education. Please reference methods for accomplishing education below. No CNA (certified nurse aide) will be able to work until they have completed this education. Education will be provided to all CNAs by the DON/designee starting on 2/22/21 and to be completed by 02/25/21 on the following: How/where to locate fall interventions via the Kardex in Point Click Care (PCC) Notifying the nurse/nurse manager of any suggested fall interventions that are not currently in place or on the Kardex Notifying the nurse/nurse manager of any fall interventions that are in place and on the Kardex but were not effective Education was started with the CNAs on premises the evening of 2/22/21 and provided to CNAs on subsequent shifts prior to the start of working their assignment. The education will continue until all CNAs receive the education. Please reference methods for accomplishing education below. No CNA will be able to work until they have completed this education. Education will be provided to the IDT by the ED/DON/designee starting on 02/22/21 and to be completed by 02/25/21 on the following: Review of falls during Grand Rounds in an attempt to determine root cause/causative factors to the extent possible and to evaluate the effectiveness of current interventions. Identify relevant fall prevention interventions to ensure that are consistent and individualized for residents. Review of care plans and Kardex information. Resident falls will be reviewed by the IDT daily in Clinical Grand Rounds starting on 02/23/21. Falls, interventions and any recommendation will be reviewed with nurses and CNAs by the IDT during Grand Rounds. The MDS Coordinator (MDSC)/designee will have primary responsibility for updating Care Plans and Kardex information to reflect resident risk and current individualized interventions. The nurses and CNAs will utilize the electronic Kardex to determine fall interventions starting on 2/22/21 and the use of this system will be ongoing. Further education will be conducted by the ED/DON/designee as necessary. Education was started with the IDT on premises the evening of 02/22/21 and provided to other IDT members on subsequent days of work. The education will continue until all members of the IDT receive the education. Please reference methods for accomplishing education below. No CNA will be able to work until they have completed this education. Staff will be educated using all methods of communication to include, but not limited to, in person, phone conversation, COVR (text messaging system), and certified mail. In order to monitor the presence of interventions such as low beds, call lights, floor mats, etc., an RN will conduct rounds each shift and using the Kardex, will check each resident to ensure interventions identified on the Kardex are in place. The nurse will have the Kardex interventions printed and will sign to reflect completion. If discrepancies in interventions are identified, if items are missing or if changes are needed, the RN will take any needed corrective action immediately and provide report to the DON/designee. Further follow-up will be done by the IDT as needed. This will start 02/22/21. On 02/27/21, the IDT will review the process to determine if, based on compliance, it should be continued or revised, or replaced with an alternative method for monitoring. If the process is revised or replaced, the DON/designee will provide training with the nurses and CNAs. Fall Risk Assessments are completed upon admission, quarterly, following a fall and upon a change in status. The DON/designee will review the Fall Risk Assessments for completion and accuracy following admission and following each fall. If discrepancies are noted, the DON/designee will conduct additional education to nurse. This will be done for 30 days and then re-evaluated by the IDT, who will then determine the frequency of ongoing review. This removal plan was accepted and immediate jeopardy was lifted on 2/23/21 at 3:37 p.m. on the basis that the facility had provided education to staff, and reviewed, modified and implemented care plan interventions to prevent further falls for residents. However, deficient practice remained at an H level, with actual harm to residents that is pattern. II. Facility policies and procedures The Fall Management policy, dated 6/4/2020, was provided by the NHA on 2/18/21 at 1:15 p.m. It read, in pertinent part: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. -Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment. -During the admission and readmission process, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be at risk for falls. -Upon completion of other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated. -The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS, upon a fall event and as needed thereafter. -Fall management training will be provided to all associates upon hire, annually and as indicated by fall management performance improvement plans (PIPs). -Resident and/or family members will receive education on the fall management care plan and will be provided opportunity for feedback. All patients have fall indicators. Fall indicators are patient specific information that, when alone or combined with other fall indicators, create a potential to fall. Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls. -Fall indicators may be identified by multiple disciplines, utilizing various assessments, and including but not limited to review of physician orders, progress notes, environmental factors, caregiver conversations. -Patient conditions may vary throughout the day, week, month or other time period and the identification of patient fall indicators is an ongoing, interdisciplinary assessment process. III. Resident #10 Resident #10 fell seven times in three months and sustained two fractures from the facility's failures to implement, monitor and evaluate the effectiveness of fall interventions to prevent repeat falls and injuries. A. Resident status Resident #10, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the February 2021, computerized physician orders [REDACTED]. The 12/7/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He required extensive assistance of two persons with bed mobility, transfers, dressing and toileting. He required extensive one person assistance with personal hygiene. He had fallen prior to admission. He was occasionally incontinet of bladder and frequently incontinent of bowel. He was not on a toileting program. Resident #10 was on oxygen and complained of shortness of breath with exertion. B. Fall 11/19/2020, redness to elbow 1. Record review On 11/19/2020 at 10:15 a.m., the incident note documented, the nurse was told the resident was found sitting on the floor by CNA, by the time the CNA came to get the nurse the resident was already sitting in the chair. The resident stated that he was walking backwards and lost his balance. He had redness to his right elbow. The note documented Resident #10 was oriented to person only and used a front wheeled walker. Additionally, it documented that predisposing factors included his impaired memory. On 11/19/2020 at 5:08 p.m., the nurse notes documented, this writer called by Center nurse to assess resident. Immediately went to resident's room , observed the resident sitting in the chair in his room .Observed redness on right elbow. Resident stated that he got up himself on the floor. On 11/19/2020 at 2:18 p.m., an IDT note documented the resident had a fall on 11/19/2020. The note documented Resident #10 was walking backwards in the bathroom and lost his balance and fell . The only new intervention was to encourage the resident to use the call light despite his noted impaired memory and orientation to person only. The incontinence care plan initiated 11/20/2020 documented to assist with toileting as needed and provide peri care after each incontinent episode. -There was no further documentation for the residents' occasional bladder incontinence and frequent bowel incontinence to indicate if the resident was appropriate for a toileting program or any new interventions to be added to his care plan to help prevent future falls. The fall care plan, initiated 10/5/2020, was reviewed. The care plan documented the resident was at risk for falls related to poor safety awareness and decreased mobility. On 10/5/2020, interventions included assist with activities of daily living as needed, call light in reach, complete fall assessment, orient to room. There were no new interventions added to the care plan for this fall. -Remind residents to use call light was added on 12/29/2020, the only new intervention, over one month later, and after Resident #10 fell three additional times and sustained two fractures. 2. Interview The DON was interviewed on 2/24/2021 at 4:01 p.m. She said the staff were supposed to encourage the resident to use the call light for assistance. She did not mention any additional person centered interventions being added to his care plan. C. Fall 11/25/2020, [MEDICAL CONDITION] 1. Record review On 11/25/2020 at 6:30 a.m., the incident notes documented the resident was lying down on the floor between the bed and the sink on his right side. Right leg bent and left leg was straight. Resident was guarding his right hip and thigh while screaming and sounding wow, and ouch, I asked him how he fell , what he was trying to do before he fell . He said that 'I was trying to walk backward.' Right lower extremity looks shorter than left lower extremity. Resident was guarding and holding his right thigh and right hip. It documented he was confused and had weakness. On 11/25/2020 at 8:52 a.m., the IDT documented, Resident stated that he was walking backwards from sink and fell . IDT Recommends resident be sent to hospital and staff to redirect resident not to walk backwards. Resident #10 was sent to the hospital on [DATE], and readmitted back to the facility on [DATE] with a right [MEDICAL CONDITION]. The fall care plan was updated on 11/25/2020, prior to the resident's return from the hospital on [DATE], and included physical therapy (PT) and occupational therapy (OT). On 12/3/2020, three days after the resident's readmission for a [MEDICAL CONDITION], the care plan documented call light alarm to bed. The incontinence care plan, initiated 11/20/2020, documented to assist with toileting as needed and provide peri care after each incontinent episode. There was no further documentation for the resident's occasional bladder incontinence and frequent bowel incontinence. 2. Observation On 2/22/21 at 10:55 a.m. Resident #10's bed was observed. The regional vice president (RVP) and director of rehabilitation (DOR) were present in the room. There was no call light alarm on the bed. The RVP looked at the bed and confirmed there was no call light alarm. 3.Interviews Licensed practical nurse (LPN) #2 was interviewed on 2/22/21 at 11:09 a.m. She said Resident #10 had no call light bed alarm. She said he did not always remember to use the call light and sometimes he was in a hurry to use the bathroom. CNA #4 was interviewed on 2/22/21 at 11:11 a.m. She said Resident #10 required one person assist to transfer. She said he was at risk for falls and the plan was to try to be attentive to his needs. She said he did not have a bed alarm. The nursing home administrator (NHA) was interviewed on 2/22/21 at 11:13 a.m., standing outside the resident's room. He said he was in the process of getting the alarm put on the bed and he was waiting outside the room until it was put on the bed. At 11:37 a.m., the NHA said the alarm was now on the bed. The DON was interviewed on 2/24/21 at 4:01 p.m. She said the only new interventions put in place after the fall with right [MEDICAL CONDITION] on 11/25/2020 was PT and OT upon his return from the hospital 11/30/2020. She said the call light alarm was never put on his bed. D. Fall 12/27/2020, Sacral fracture 1.Record review On 12/27/2020 at 11:18 a.m., the nurse's notes documented, at 9:05 a.m. the resident was lying on his back on his roommate's side of the room. He told the nurse he had fallen and complained of tail bone pain. He was moaning and about to cry. He was sent to the hospital. The note documented, Per the witness statement: at approximately 09:05 a.m. I heard 'Oh no, Oh no, g .damnit' the bedside table moving and a man yelling out .Resident #10 was lying on the floor on the roommate's side of the room. On 12/27/2020 at 10:47 p.m., the nurse's notes documented the resident came back from the hospital around 12:45 a.m. and had a right [MEDICAL CONDITION] which got worse and a new fracture on S-4 (fourth sacral vertebrae), no surgery or any other procedure done to fix any fractures. On 12/29/2020 at 7:22 a.m., the IDT note documented the recommendation to remind resident to use call light. The care plan was reviewed, it was updated to remind the resident to use the call light, which was added on 12/29/2020. 2.Interview The DON was interviewed regarding this fall on 2/24/21 at 4:01 p.m. She said the only new intervention after this fall was to remind the resident to use the call light. She acknowledged this was the intervention the IDT recommended after the first fall on 11/19/2020 and was not added to the care plan until 12/29/2020. She said, we should have done more. There were no further interventions implemented or care planned at that time. E.Fall 1/25/21, no injury 1.Record review On 1/25/21 at 12:02 p.m., the nurse's notes documented the resident was found on the floor. He said he slid himself out of his wheelchair onto the ground and was crawling. No injuries were noted. On 1/25/21 at 11:15 a.m., the incident note documented the resident was oriented to person and place, but not situation or time. He was confused with impaired memory. On 1/26/21 at 1:00 p.m., the IDT note documented, Resident crawling on the floor in his room. IDT Recommendation: Resident can put himself on the floor and crawl. There were no recommended interventions implemented. The care plan was reviewed. There were no new interventions since 12/29/2020 when remind resident to use call light was added. 2. Interviews The DON was interviewed regarding this fall on 2/24/21 at 4:01 p.m. She said she considered this a fall since he slid out of the wheelchair. The DON said there were no new interventions put in place and there should have been. F. Fall 1/29/21, hit head 1. Record review On 1/29/21 at 7:40 a.m., the nurse notes documented Resident #10 was sitting on the floor with his back against his bed. He said he fell asleep, and fell forward hitting his head on the bedside table. No further injury noted at this time. On 1/29/21 at 7:40 a.m., the incident note documented the resident had a pink spot to the right side of his forehead. He had been sitting on the edge of the bed prior to the fall. On 2/2/2021 at 10:40 a.m., the IDT documented, Staff observed resident sitting on the floor next to his bed and bedside table. IDT Recommendation: Resident to have bedside table only for meals. However, there was no documentation that the bedside table was the cause of the fall. The resident fell asleep while sitting up and fell forward onto the table. The care plan was updated on 2/2/21, to remove bedside table after meals. 2. Interview The DON was interviewed on 2/24/21 at 4:01 p.m. She said the only intervention after this fall was to remove his bedside table. She acknowledged this was four days after the fall. G. Fall 2/15/21, no injury 1. Record review On 2/15/21 at 3:50 p.m., the nurse's notes documented the resident was on his knees. On 2/15/21 at 4:04 p.m the IDT note documented, Resident stated that he was trying to stand up from wheelchair to go to bed and he thought he put the brakes on and fell . IDT fall Recommendation: Resident's wheel chair to have Anti-Roll back. The care plan was updated on 2/17/21 during the survey to include, anticipate and meet resident needs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, provide activities that minimize the potential for falls while providing diversion and distraction, provide adaptive equipment as needed. On 2/18/21 , anti-rollback wheelchair was added. 2. Interview The DON was interviewed on 2/24/21 at 4:01 p.m. She said the anti rollback brakes were added to the wheelchair after the fall. She said this was done three days after the fall. There were no further immediate interventions. H. Fall 2/19/21, abrasion to left leg 1. Record review On 2/20/21 at 9:29 p.m., the nurse's notes documented that the resident was coming out of his room without his walker or wheelchair and fell on his left side. He had an abrasion to his left leg. On 2/21/21 at 4:31 a.m., the IDT note documented, New intervention is resident will use call light before ambulation to provide safety and stand by assist. However, this was not a new intervention. This was the same intervention the IDT recommended for the falls on 11/19/2020 and 12/27/2020. The care plan was reviewed. There were no new interventions after this fall. The fall risk assessment, completed on 2/20/21, documented the resident was not at risk for falls. He scored a 9. The assessment was not accurate, and documented the resident had only one or two falls in the last 90 days. 2. Interview The DON was interviewed on 2/22/21 at 9:07 a.m. She said the fall risk assessment was not accurate and Resident #10 was a fall risk. IV. Resident #9 A. Resident status Resident #9, age 87, was admitted on [DATE] and was discharged to the hospital on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. The 12/12/2020 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15. She required extensive assistance of one to two staff members for mobility and ADLs. B. Record review The resident's fall risk assessment completed upon admission on 8/24/2020 revealed the resident was at risk for falls and scored an 11 on the assessment, with a score of 10 or higher indicating a resident was at risk for falls and the higher the number score, the higher the risk of falling. She had one to two falls in the past 90 days, did not exhibit behaviors, had adequate vision, was independent and continent, ambulated with devices, was unsteady but able to rebalance without physical support, had one to two health conditions that were risk factors for falling and received no medications contributing to risk. A fall care plan was initiated on 8/24/2020 and revised on 9/1/2020 it read, in pertinent part: The resident is at risk for falls related to history of falls with injury. The goal of the care plan read: The resident will not sustain serious injury requiring hospitalization through the review date. Interventions as of 8/24/2020 included: Assist with ADLs as needed; call light within reach; and orient resident to room. A progress note dated 9/17/2020 at 2:58 p.m. revealed the resident reported to her son that she had fallen. The resident was assessed and no skin issues or injuries were identified. The resident did confirm that she had fallen, denied pain or hitting her head. Neurological checks were initiated and baseline. The fall investigation completed 9/17/2020 revealed actions taken were a head to toe assessment, neurological checks and revealed a new intervention of frequent checks on the resident. A fall risk assessment was completed on 9/17/2020 and revealed the resident scored an 11, she had experienced one to two falls in the past 90 days, had moderately impaired vision, was independent and continent, ambulated without problems and with devices, was balanced, had one to two health conditions and received one to two medications considered to contribute to fall risk. An update was made to the resident's care plan on 9/23/2020 and read: Head to toe and neuro (neurological) assessment done on 9/17/2020. Frequent check on resident. -There was no documentation of or quantitative measure to show frequent checks were done for the resident. Review of progress notes from 9/17/2020 to 11/30/2020 revealed the resident frequently suffered from hallucinations, agitation, and confusion. A progress note dated 11/30/2020 read the RN was called to the nurses' station to assess the resident who was found on the floor. The resident was assessed to be fully clothed including socks, and one of her slippers had fallen off. No abnormal rotation of extremities were noted. She was not showing signs of pain. Some discomfort was noted on her right knee which improved after a minute or two and the resident started moving her right leg on her own and scooting backwards on the floor. She was assisted into her chair to continue further assessment and no injuries were noted. Resident was smiling and thankful to be up in a chair. A fall risk assessment was completed on 11/30/2020 and revealed the resident scored 18 and was at risk for falls. The fall risk assessment revealed the resident had one to two falls in the past 90 days, she had not had a change in cognitive status, she had displayed behaviors, she had adequate vision, she was independent and continent, she ambulated with problems and devices, she was not able to balance, she had one to two health conditions and one to two medications contributing to fall risk. A progress note dated 11/30/2020 at 8:34 p.m. read an X-ray was ordered to the resident's right knee to rule out fracture or dislocation. A progress note dated 12/1/2020 read the resident was complaining of pain in her right hip and was sent to the emergency room for a right [MEDICAL CONDITION]. The facility fall investigation dated 11/30/2020 revealed the resident was walking in the hallway, fell on the floor and was hallucinating before the fall. The resident was agitated and was observed pacing the halls. She was independent with using the bathroom, other residents were in the hall, and she was wearing slippers. She was last observed an hour before the fall. The recommendation for prevention read more frequent checks, good fitting shoes, assessment for a wheelchair and more assistance with ambulation. An update was made to the resident's care plan on 11/30/2020 and read: Sent to hospital for right [MEDICAL CONDITION]. Will have PT/OT. An update was made to the resident's care plan on 12/2/2020 and read: Notify MD for changes (swelling/pain) to right knee related to recent fall. A fall risk assessment was completed upon the resident's readmission on 12/5/2020 and the resident scored 15 for risk of falls. The resident had one to two falls in the last 90 days, her cognitive status had not changed, she did exhibit behaviors, she had adequate vision, she was independent and continent, ambulated without problems and with devices, was not able to balance, had one to two health conditions and received one to two medications that contributed to fall risk. Review of the resident's fall care plan revealed there were no person centered interventions on the care plan related to preventing falls for the resident such as proper footwear when ambulating, frequent checks, etc. C. Interviews CNA #8 was interviewed on 2/22/21 at 10:57 a.m. She stated she did not always know which residents were fall risks and did not know where to find which interventions should be in place for each resident. She stated she relied on staff communication in verbal report from the previous CNA at the beginning of each shift. She stated she did not know if Resident #9 was a fall risk and what interventions were to be in place if any. Licensed practical nurse (LPN) #3 was interviewed on 2/23/21 at 10:46 a.m. He stated he worked on all different units throughout the facility and knew the residents well. He stated, W(TRUNCATED)

Based on observations, record review, and interviews, the facility failed to ensure residents who had not used [CONDITION(S)] drugs were not given these drugs unless the medication was medically necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use [CONDITION(S)] drugs received gradual dose reductions and behavioral interventions in an effort to discontinue these drugs for two Residents (#11 and #1) out of five residents reviewed for [CONDITION(S)] medication use out of fifteen sample residents. Specifically, the facility failed to: -Ensure the use of an anti-anxiety medication was justified in the absence of non-pharmacological interventions and was not in excess given Resident #11's age and stature. The excessive use of this medication resulted in an increase in side effects and contributed to a fall. (cross reference F689 Accidents) -Assess the appropriateness of the medication, attempt non-pharmacological behavioral interventions, and obtain consent from the resident representative prior to administering an antipsychotic medication to Resident #1. Findings include: I. Facility policy and procedure The [CONDITION(S)] Medication Use policy, dated 1/28/16, was provided by the nursing home administrator (NHA) on 2/24/21 at 5:00 p.m. It read, in pertinent part: The facility should not use [CONDITION(S)] medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Facility staff should focus on an understanding of behaviors as a form of resident communication or distress. Residents who exhibit new or worsening behavioral or psychological symptoms of dementia will be evaluated by a health care professional and the care team to identify contributing factors: Treatable medical conditions, physical problems, emotional stressors, psychiatric or psychological factors, social issues or environmental factors. Facility should involve the resident or the resident's representative in the discussion of potential non drug and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record. [CONDITION(S)] medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. [CONDITION(S)] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences. Antipsychotic medications used to treat behavioral or psychological symptoms of dementia must be clinically indicated, be supported by an adequate rational for use, and may not be used for a behavior with an unidentified cause. Where physician/prescriber orders a [CONDITION(S)] medication for a resident, facility should ensure that physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of [CONDITION(S)] medication. The [CONDITION(S)] Medication Use policy was received from the director of nursing (DON) on 2/24/21 at 4:50 p.m. It read, in pertinent part: Facility staff should take a holistic approach to behaviour management using a person-centered non-pharmacological approach and interventions before using [CONDITION(S)] medications as an intervention. The facility should involve the resident or resident representative in the discussion of potential non-drug and medication interventions to address the behavior management of their loved one. This should be documented in the resident medical record .All medications used to treat behaviors must have a clinical inclination and be used in the lowest possible dose. All medications used to treat behaviors must be monitored for effectiveness, risks, benefits, and harm or adverse effects. II. Resident #11 A. Resident status Resident #11, age 88, was admitted on [DATE]. According to the February 2021 computerized physician orders (CPO), pertinent diagnoses included dementia with behavioral disturbance, muscle weakness and a history of falling. The 12/29/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for a mental status (BIMS) score of two out of 15. She required supervision for eating and extensive assistance with dressing, toileting and bathing. Behaviors and refusal of care was not noted in the this MDS. B. Observations Resident #11 was observed on 2/22/21 at 11:20 a.m., seated in a recliner chair in her room. The Certified nurse aide (CNA) #8 entered the room to offer assistance when the resident began crying. The CNA assisted the resident from the chair to her bed. CNA #8 handed the resident the call button after the resident was settled in bed and encouraged her to call if she needed help. -At 4:57 p.m. Resident #11 was seated at a table in the dining room. She was crying. Another resident in a wheelchair came up to Resident #11 and asked her what was wrong. The resident did not reply and kept on crying. After approximately five minutes, the resident got up from the table by herself and walked into the hallway outside the dining room without her walker. She was bent over and shuffled her feet. CNA #8 noticed the resident and took her ]hand and walked with her. As she continued to cry out to the CNA. C. Record review 1. Incidents A 2/10/21 interdisciplinary team (IDT) post fall note and care plan review revealed Resident #11 had increasing agitation, yelling and was exit seeking. The resident's anxiety was noted to increase daily. [MEDICATION(S)] was increased on 2/9/21 to 1 mg twice daily following the incident. -No non-medical interventions were used for the resident. An 2/10/21 health status note documented, the resident had increased behaviors and was aggressive towards staff and residents, was agitating residents, screaming, yelling, pacing the halls and awakened resting residents. Redirection was ineffective. The note failed to identify lorazepam was increased on 2/10/21. There were two falls, one witnessed and one unwitnessed. Increase in behaviors as noted above. The resident was alert but very confused, which was noted to be baseline. Abrasion to her mid back were noted. The plan was to continue monitoring. Another health status note written on 2/10/21 documented the resident had increased behaviors including aggression towards staff (hitting) and other residents, agitating other residents, screaming, yelling, pacing the halls and waking resting residents. The note revealed redirection was ineffective. The plan was to start increasing Lorazepam on 2/10/21. The resident had fall incidents on 2/9/21 and 2/10/21 and experienced an abrasion to her mid back. Neurological signs were within normal limits but increasing behaviors (listed above) were noted. A health status note dated 2/21/21 revealed the resident was being monitored for behaviors. The resident had called out at different times when the staff assisted her with her care. An alert note dated 2/21/21 at 5:57 p.m. revealed the resident had a witnessed fall in the hallway outside her room. The resident grabbed the food cart in the hallway and fell to the floor. No injuries were noted. A health follow up note dated 2/21/21 at 11:14 p.m. A bruise was noted on the resident's right forehead. 2. Medications and changes The February 2021 CPO included an order for [MEDICATION(S)] (lorazepam, an antianxiety medication) 0.5mg twice each day (BID for dementia with behaviors. The 1/29/21 order for this medication was discontinued on 2/11/21. The February 2021 CPO also included an order for [MEDICATION(S)] (an antidepressant, start date 8/3/2020) once per day (QD) for dementia with depression. The February 2021 CPO included an order for [MEDICATION(S)] 0.5mg,to give one time only on 2/9/21 for dementia with agitation. The February 2021 CPO included orders for [MEDICATION(S)] 1mg BID for dementia with anxiety. The 2/9/21 order was discontinued on 2/19/21. The February 2021 CPO dated 2/19/21 included an order for [MEDICATION(S)] 1mg three times each day (TID) for dementia with behaviors. This order was placed on hold from 2/22/21 to 2/23/21(during survey). The medication administration record (MAR) for February 2021 revealed lorazepam 1mg TID was administered 2/19/21 to 2/22/21. The medication was then placed on hold beginning with the afternoon dose on 2/22/21. A new medication order was added on 2/24/21 at 2:40 p.m. The order read, [MEDICATION(S)], 1mg BID for dementia with behaviors and agitation. The February 2021 CPO included an order for staff to monitor the resident for side effects of lorazepam if given with other sedatives or alcohol. Side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash (start date 1/23/21). The MAR for January 2021 included side effect tracking on 1/24/21. There was no other side effect tracking completed for the remainder of January 2021 or for February 2021. 3. Care plans The fall care plan, dated 1/9/2021, identified the resident was at risk for falls related to poor safety awareness, incontinence and use of [CONDITION(S)] medications. ] -There was not a care plan for dementia related behaviors and interventions had not been identified. Care plan history note initiated on 2/18/21 indicated the increased dose of [MEDICATION(S)] was secondary to increased agitation, exit seeking, yelling at other residents, and combativeness with cares causing falls ETC. Monitor for side effects:Over sedation, drowsiness, dizziness, headache, nausea, constipation, change in appetite. A care plan for side effects, created 2/23/21, revealed the resident was prescribed Lorazepam 1mg taken two times a day. Side effects included sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. There was a nursing alert for taking the medication with other sedatives, hypnotics or alcohol. Interventions included monitoring the resident for these side effects. The Kardex bedside report dated 2/22/21 indicated increased [MEDICATION(S)] being secondary to increased agitation and combativeness with cares causing falls. One non-medication intervention listed was to move the resident to a quiet area to calm her down when exhibiting behaviors.This intervention did not take the place of the medications prescribed for behaviors. 4. Behavior tracking Behavior tracking for November 2020 to February 2021 was provided by the social services director (SSD) on 2/24/21 at 2:00 p.m. The resident's diagnosis was listed as dementia with depression, anxiety and aggression. Target behaviors such as pulling curtains, crying and physical aggression toward staff were included on the form. Behaviors were recorded for November, December and January. There were no behaviors documented for February 2021 (in the presence of medication increases). Behavior note dated 2/20/21 at 11:14 a.m.The note included the resident was monitored for increase in [MEDICATION(S)]. No behaviors were noted at this time. 5. Progress notes A 2/9/21 nurses' note written at 6:34 p.m., documented the nurse notified the unit manager and the resident's power of attorney about the dose increase in medication. A physician communication dated 2/22/21 indicated the resident had a fall on 2/21/21 and appeared to be weak when she fell . The writer of this note received a call from the director of nursing (DON) to call the physician and request a reduction in the dose of the [MEDICATION(S)] the resident was taking due to possible weakness caused from the [MEDICATION(S)]. This nurse spoke to the nurse practitioner (NP) and he said he was coming to the facility today and would look into this issue. A 2/22/21 Health status note documented a medication review would be sent to the pharmacy due to the resident's recent falls. The medication review was sent to the pharmacy on 2/22/21 at 3:54 p.m. It was noted that the resident was prescribed [MEDICATION(S)] 1mg tab three times a day for dementia with behaviors. A 2/23/21 nurse's note documented the resident had a witnessed fall on 2/21/21. The resident was noted to have dementia with behavioral disturbance. The nurse said the [MEDICATION(S)] dose for the afternoon had been placed on hold (per NP instruction) due the resident's prior fall. The MAR for 2/23/21 indicated that the medication was not given for the afternoon and evening doses. B. Interviews Registered nurse (RN) #3 was interviewed on 2/22/21 at 11:00 a.m. She said she thought the [MEDICATION(S)] made the resident dizzy and contributed to her fall. She said reducing the dose of [MEDICATION(S)] would be a good fall intervention. The nurse practitioner (NP) was interviewed by phone on 2/24/21 at 10:36 a.m. He said he visited the resident on 2/24/21 at 8:00 a.m. The NP said the resident previously took [MEDICATION(S)] and [MEDICATION(S)] for behaviors and dementia before she started taking [MEDICATION(S)]. He said both of those medications were tapered off in November and December 2020 and the resident was no longer taking them. He said the resident was currently taking [MEDICATION(S)] 1mg TID. He said the nurse told him the resident was lethargic and dizzy this morning. He said he decided to hold the afternoon dose of [MEDICATION(S)]. The NP said he was waiting to hear from the physician to discuss the [MEDICATION(S)] dose. The pharmacist was interviewed on 2/24/21 at 11:00 a.m. He said 3 mgs of [MEDICATION(S)] per day was too high for the resident, according to her weight and age. The pharmacist said he would start the resident at 0.5 mg dose and monitor her for two weeks before increasing the dose. He said 3 mg of [MEDICATION(S)] per day would put the resident at a higher risk of falls. He said side effects of the [MEDICATION(S)] were lethargy, dizziness and respiratory distress. He said [MEDICATION(S)] was usually given for behaviors caused by anxiety or anxiety alone. The unit manager (UM) was interviewed on 2/24/21 at 11:12 a.m. She said the dose of [MEDICATION(S)] 1mg 3 times per day was too much medication for Resident #11. She said the DON was communicating with the doctor to try to get the dose reduced. She said the resident had been unsteady on her feet and was lethargic. She said the nurse practitioner gave an order to hold the afternoon dose of [MEDICATION(S)]. The UM said she was concerned the resident would fall again. She said the physician did not respond to the facility timely. The UM said any communications should be documented in the progress notes. The DON was interviewed on 2/24/21 at 12:15 p.m. She said the dose of [MEDICATION(S)] prescribed for Resident #11 was too high. She said she had called the doctor on 2/24/21 and left a message concerning the resident's medication dosage. She said interventions to be used before trying medications should include involving the resident in activities and call the family and ask them what to do for the resident's behaviors. She said, if those interventions don't work, staff should try medications. She said the interventions used depended on the resident. She said the doctor should be called if the interventions were not working. The DON said she was going to wait until 3:30 p.m. to hear from the doctor. If that had not happened, she was going to call the medical director to inform him about Resident #11. The DON said the resident's family had to agree to give the resident the [CONDITION(S)] medication. She said the nurse practitioner was at the facility on 2/24/21 and had seen the resident. She said she had been trying to reach the resident's doctor for three days. She said the communication with the doctor should be documented in the progress notes. III. Resident #1 A. Resident status Resident #1, age 82, was admitted on [DATE] and discharged on [DATE]. According to the December 2020 CPO, pertinent diagnoses included unspecified dementia with behavioral disturbance, urinary tract infection, major depressive disorder, moderate protein calorie malnutrition, difficulty walking, muscle weakness, history of falling and cognitive communication deficit. The 10/6/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. She exhibited continuous inattention but had no other behaviors. She required extensive assistance from one or two staff members for mobility and ADLs. She had one fall since admission, no skin alterations and received an antipsychotic medication daily. B. Record review The 9/24/2020 preadmission screening orders included orders for [MEDICATION(S)] (an antipsychotic medication) 0.5 mg by mouth twice daily as needed (PRN) for hallucinations, delusions, paranoia, and aggressive behavior; and, [MEDICATION(S)] (a cognition enhancing medication) 13.3 mg/24 hour patch for dementia. The length of time the resident had been receiving these medication could not be determined. The 9/29/2020 physician's admission orders included an order for [MEDICATION(S)] but did not include [MEDICATION(S)]. [MEDICATION(S)] was also not included on the MAR at the time of admission. A 9/29/2020 facility event note revealed, upon admission, the resident was seated in her wheelchair at the nurses' station. She was talking to herself constantly and became restless and agitated. The nurse tried to comfort and calm her, turned around for a second and the resident slid from her chair to the floor. A 9/30/2020 physician progress note revealed the nurse practitioner was called to assess the resident to follow up on dementia with behavioral disturbance. The note read, Per staff, patient crying out, will not remain seated in chair for greater than five minutes. Prefers to sit and crawl on the floor. Discussed with DON (the director of nursing). We will discontinue [MEDICATION(S)] patch as it does not appear to be effective with patient's dementia and may even be causing worsening agitation. Patient was ordered [MEDICATION(S)] ([MEDICATION(S)]) at PCPs (primary care physician) office, will discontinue this and place on low dose [MEDICATION(S)] every 12 hours as needed. If patient responds well to this medication, will plan on scheduling, discussed with DON. The progress note continued Attempted to contact POA/daughter (power of attorney) to discuss the change in medication and plan, voice mail box full and unable to leave message. There were no additional facility progress notes describing increase in the resident's behaviors or non-pharmacological interventions attempted by the facility prior to contacting the provider. The physician assessment was also within 24 hours of the resident's admission to the facility. Review of the resident's MAR revealed the resident received [MEDICATION(S)] (an antipsychotic medication) 0.25 MG daily from 10/1/2020 to 10/13/2020. On 10/14/2020 the order for [MEDICATION(S)] was increased to 0.5 MG daily for dementia with behaviors. This order continued until the resident discharged from the facility on 12/9/2020. Review of the resident's progress notes throughout the remainder of her stay in the facility revealed the resident continued to exhibit behaviors of yelling out, yelling at staff, resisting care, and crawling on the floor. A review of admission paperwork, nurses' notes and authorizations failed to reveal the resident's POA was informed of the medication changes or that consent was obtained to administer [MEDICATION(S)]. A risk/benefit consent form was requested from the facility on 2/24/21 but was not provided. C. Interviews The resident's POA was interviewed on 2/17/21 at 4:00 p.m. She stated the resident had been using an [MEDICATION(S)] patch for dementia for a while before admitting to the facility. She stated the resident lived with her for a few weeks before being admitted to the facility. She received home health care and was very confused, though her behaviors were minimal. She stated the resident's home physician did order [MEDICATION(S)] for the resident, though the resident never received it, because she did not agree with the resident receiving an anti-psychotic medication. The POA said she was not informed of the changes to the resident's medications, discontinuing the patch or being stared on [MEDICATION(S)] until the resident was discharged and moved to an assisted living facility. The POA said the resident no longer took [MEDICATION(S)] after being weened off the medication at the assisted living facility. She reported the resident's behaviors were being managed without medication. The facility physician was interviewed on 2/24/21 at 11:29 a.m. She stated she was not the resident's physician at the time of the medication changes. She stated a [CONDITION(S)] medication should not be started for a resident without tracking behaviors, ruling out other causes for the behaviors, and attempting non-pharmacological interventions. She stated the resident's medications should not have been changed so soon after admission as the resident did not have time to adjust to the facility and there was no time to attempt other interventions or to see if other interventions could be effective. The DON was interviewed on 2/24/21 at 12:12 p.m. She said when residents exhibit behaviors the staff should attempt distractions, activities and call the family to inquire about past behaviors or past interventions in order try to change or prevent behaviors for the resident. She stated staff should try these interventions before calling the doctor and asking for a medication. She stated the interventions attempted by the facility should be documented and should be given time to determine if the intervention is effective before a medication is started. She the family or representative should be called to discuss the medication, its risks and benefits, and to obtain consent before administering a [CONDITION(S)] medication. The DON said the NP said she would discuss the medication with Resident #1's family. She stated she was unable to locate a consent from the family to give the medication. She stated the facility should have attempted other interventions and given the resident time to adjust prior to changing her medications.

Based on interviews and record review, the facility failed to manage the pain of one (#1) of three residents reviewed out of nine sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility failed to provide notification to the physician of the resident's continued acute pain following a sustained fall, which resulted in a [MEDICAL CONDITION]. The facility inadequately managed the resident's acute pain with over the counter pain medication. These facility failures contributed to the resident experiencing undue severe pain. The resident continued to experience pain for 27 hours until the resident was transferred to the hospital, where the resident was assessed with [REDACTED]. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy and procedure, effective August 2019, was provided by the director of nursing (DON) on 1/30/2020 at 5:28 p.m. It revealed, in pertinent part, Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. II. Resident #1 status Resident #1, age 73, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 12/25/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting, eating and personal hygiene. -It indicated the resident received a scheduled pain medication regimen and as needed pain medication. It indicated the resident did not receive non-medication intervention for pain. -It indicated the resident sustained [REDACTED]. It indicated the resident had two or more falls since being admitted to the facility. III. Failure to provide adequate notification to the physician of the resident's acute pain following a sustained fall A. Unwitnessed fall sustained on 12/24/19 The fall risk care plan, initiated on 12/28/19, revealed the resident was at risk for falls related to confusion, deconditioning, gait and balance problems, [MEDICAL CONDITION], and unaware of his safety needs. The interventions included: provide non-skid socks at night, a motion activated call light to the room and while awake, and to keep the resident within the view of staff when he was up in the wheelchair. The 12/24/19 nursing progress notes revealed at 9:20 a.m. the nurse heard a loud thud coming from the resident's room. Upon entering the resident's room, the resident was observed on the ground lying on his right side with his head close to the closet facing the sink. It indicated the resident reported pain to the right hip and femur. The resident was assisted off the floor to the wheelchair to a seated position with three staff to assist. The physician ordered an x-ray to the right hip and femur. The 12/24/19 x-ray result indicated an intact arthroplasty (hip replacement) with no abnormal lucency surrounding the hardware to suggest loosening. The resident's medical record did not reveal documentation to indicate the nursing staff had communicated the continued acute pain the resident experienced to the right hip following the unwitnessed fall. IV. Inadequate response to the resident's pain A. Resident and resident representative interviews Resident #1 was interviewed on 2/4/2020 at 4:39 p.m. He said he had sustained a fall on 12/24/19. He said he was in pain following the fall. He said when staff moved him from the floor and into a seated position in the wheelchair, his pain increased. He said at approximately midnight, he told the nurse he was still in pain. He said his pain level was 7 out of 10. He said the nurse gave him Tylenol. He said the nurse told him that was the only pain medication he was allowed to have according to the physician's orders [REDACTED]. He said when his daughter arrived at the facility, his pain level was an 8 out of 10. He said she insisted the resident be sent to the hospital for an evaluation. He said at the hospital, he found out he had a fracture to his right hip prosthetic. The resident's daughter was interviewed on 1/30/2020 at 10:30 a.m. She said her father had sustained a fall at the facility on 12/24/19. She said when she arrived at the facility on the morning of 12/25/19, her father was complaining of severe pain. She said she was an internal medicine physician. She said she spoke with the nurse and insisted the resident be sent to the hospital for an evaluation. She said the resident told her he was in pain since the fall on 12/24/19. She said the facility staff had only administered over the counter Tylenol to manage the resident's pain. She said the facility staff never contacted the physician to determine if the resident required a stronger medication to manage his pain. She said the resident had informed her after he sustained the fall, he had complained of pain to the right hip. She said the facility staff transferred the resident from the ground to a seated position in a wheelchair and then from the wheelchair to the bed. She said the resident said his pain got worse when he was placed in a seated position in the wheelchair. She said the facility staff told her she would have to take the resident out of the facility against medical advice (AMA) if they wanted him to be evaluated at the hospital. She said she insisted the physician be notified of the resident's continued pain and ask for a hospital evaluation. She said the nurse on duty instead, contacted the DON and the DON told her to contact the physician. She said the physician called back with an order to send the resident to the hospital for an evaluation. She said, while at the hospital, an MRI (magnetic resonance imaging) confirmed the resident sustained [REDACTED]. The resident's spouse was interviewed on 2/4/2020 at 4:46 p.m. She said when she arrived at the facility on 12/25/19, the resident was in a significant amount of pain. She said the facility had only provided the resident with over the counter Tylenol medication. She said she and her daughter insisted to the staff the resident be transferred to the hospital for an evaluation. She said the nurse told her and her daughter the only way the resident would go to the hospital was if she took him out of the facility AMA. She said the nurse contacted the DON who told the nurse to call the physician. She said the physician ordered the nurse to send the resident to the hospital to be evaluated. She said the resident was able to tolerate a high amount of pain. She said when she walked into his room on the morning of 12/25/19, he was in so much pain she thought he was dying. She said the resident was found at the hospital with a fracture to the right hip and he was still not walking to this day. She said the experience at the facility was very traumatic for the resident and their family. B. Record review The December 2019 CPOs revealed the following physician order: - Tylenol tablet - give 500 MG (milligram) by mouth every 12 hours as needed for pain - ordered 12/18/19. - Tylenol tablet - give 500 MG by mouth at bedtime for pain - ordered 12/18/19. The 12/18/19 nursing admission collection tool revealed the resident's accepted level of pain was a 5/10. The resident's medical record did not reveal a pain care plan to indicate the resident was at potential risk for experiencing pain due to taking medication for pain, see MDS above. The 12/24/19 pain evaluation tool completed at 7:30 p.m. indicated the resident complained of pain to the right hip and thigh. It indicated the resident's pain level was 4 out of 10. The marking for the resident's accepted pain level, made the pain worse or better, non-pharmacological methods for alleviating pain and the pharmacological methods for alleviating pain, were left blank. The December 2019 Medication Administration Record [REDACTED]. It indicated the resident was administered a Tylenol medication 12/24/19 at 11:46 p.m. The MAR pain assessment revealed the resident had a pain level of 4/10 on 12/24/19 and 0/10 on 12/25/19 (the day the resident's daughter and spouse requested the resident be sent to the hospital because He was in so much pain I thought he was dying. - see spouse's interview above.) The 12/25/19 nursing progress note revealed the resident's daughter requested the resident be taken to the hospital for an evaluation. It indicated the resident still complained of right hip pain. It indicated the resident's daughter, who was a physician, felt the resident sustained [REDACTED]. The nurse indicated she explained to the resident's family, if they took the resident to the hospital it would be AMA. It indicated the nurse called the DON to inform her of the situation. She then called the physician who gave an order to send the resident to the hospital to be evaluated. It indicated the resident left the facility at 12:40 p.m. The 12/25/19 change of condition assessment revealed the resident expressed an 8/10 pain level, prior to his transfer from the facility to the hospital. The 12/25/19 x-ray from the hospital revealed a total right hip arthroplasty with periprosthetic fracture along the greater trochanter which appeared minimally displaced. III. Staff interviews Registered nurse (RN) #2 and licensed practical nurse (LPN) #3 were interviewed on 1/30/2020 at 4:35 p.m. RN #2 said following a fall, the resident should be assessed by the RN. She said if the resident complained of pain, the physician should be notified to get an order for [REDACTED]. She said the facility tried to get x-rays at the facility rather than send the resident to the hospital. She said if a resident complained of hip pain, the resident should not be transferred to a wheelchair in a sitting position. She said it could worsen the resident's injury. LPN #3 said the physician should be notified if the resident was complaining of pain from a fall and obtain an order for [REDACTED]. RN #2 said the as needed Tylenol order and the routine Tylenol order at bedtime was a standard order at the facility. The DON was interviewed on 1/30/2020 at 5:03 p.m. She said following a fall, an assessment of the resident should be performed by the RN. She said the RN should assess for injury and notify the physician and the family. She said the resident should not be moved until it is determined the resident did not sustain an injury. She said for Resident #1, he should not have been moved to a seated position in the wheelchair. She said it would have been appropriate to use the lift to move him off the floor and onto the bed, but not to the wheelchair. She said putting the resident in a seated position after he complained of right hip pain could have worsened the injury and added to the resident's pain. She said she had never provided instruction that action would be okay. She said Resident #1 should never have been transferred from the floor to the wheelchair. She said if the resident only had over the counter Tylenol for pain ordered by the physician, the nurse should have administered the Tylenol and then called the physician and pushed for something stronger to manage the resident's pain. She said the pain levels indicated in the MAR indicated [REDACTED]. She said she did not know how the resident went from a 4/10 pain level, to a 0/0 pain level, and then to 8/10 pain level upon transfer to the hospital. She said over the counter Tylenol would not be able to manage the pain level Resident #1 experienced. She said she was not aware the imaging at the hospital revealed a fracture for Resident #1. She said she was working with the nursing staff and providing education to ensure they are providing the physicians all the information and pushing for the next appropriate step.

Based on observations, interviews and record reviews, the facility failed to accurately assess a pressure ulcer upon admission and provide necessary treatment and services to promote healing and prevent new sores from developing in a timely manner for one of 39 sample residents (#117). Specifically: The resident, who was admitted to the facility with an open area, developed additional pressure areas, including one requiring debridement, after admission. The facility failed to properly assess and timely address known risks. The findings include: 1. Resident #117, age 79, was admitted to the facility from the hospital on [DATE]. A face sheet of the same date documented the following admitting Diagnoses: [REDACTED]. The computerized physician orders [REDACTED]. 2. Status on Admission - Known Risk Factors for Skin Breakdown - Facility Response and Failures in Facility Response a. The first document initiated by the facility, dated 10/29/12 at 6:05 p.m., by a facility registered nurse (RN), and titled "Initial data collection tool/nursing," documented the following: Alert, oriented and able to communicate needs. The body diagram indicating alteration skin integrity documented one open area to left bottom gluteal fold. The measurements of 1cm x 0.7cm. were documented by the nurse using an arrow pointing to a body diagram representing the resident's gluteal fold. No other open areas were documented by the nurse. Under section Bed Mobility, the area titled 'requires assistance to reposition self and 1-2 person assistance' were checked off as pertinent to the resident's condition on admission to the facility. The section Ambulation, documented that the resident was unable to ambulate. The nursing progress note, dated 10/29/12, documented the nurse took report from the hospital and the history included that the resident was confused, had an incision to the left hip and a silver dollar size bruise to the coccyx area. b. The resident's care plan, dated 10/29/12, and updated on 11/15/12, documented the following areas of planned care for the resident: Activities of daily living (ADL); pressure ulcers; and nutrition. (1) The problem area ADLs, initiated on 10/29/12, documented that the resident required assistance to accomplish ADLs on a daily basis. The goal was that the resident would accept the assistance to accomplish daily ADLs by the target date of 1/29/13. Approaches listed included: Extensive assistance of 1-2 staff with bed mobility and staff was to reposition the resident often if the resident was unable to produce major positional changes on his own. The care plan documented that the resident needed extensive assistance of two facility staff for all transfers, toileting, personal hygiene, bathing and dressing. -The plan did not address the resident's continence status or compromised skin condition. (2) The problem area Pressure Ulcer, initiated on 10/29/12, documented the resident had the potential to experience adverse alterations to skin integrity. Approaches documented in the initial care plan included: Performing a skin assessment weekly x 4 weeks; nursing to assess skin twice weekly; observing skin during cares and bathing; and reporting any changes to nursing. Approaches documented in the pressure ulcer care plan for the resident included pressure reducing mattress on bed, appropriate cushion for wheelchair and positioning with pillow to maintain body alignment. A part of the care plan specific for the licensed nursing staff documented that the staff would review weekly the resident's pressure ulcer during wound rounds with documentation of progression. -The plan did not specifically address the open area on the resident's gluteal fold identified in the initial data collection tool. (3) The problem area nutrition in the care plan, initiated on 10/29/12, documented that the resident was at nutritional risk. Approaches included observing and reporting to the physician significant weight loss, providing diet as ordered, allowing adequate time to eat, providing a quiet calm setting, and observing intake of diet and fluids. -The plan did not address the resident's compromised skin condition and nutritional needs to promote healing and to prevent further skin breakdown. c. Record review revealed the facility failed to comprehensively assess the resident's skin condition on admission and failed to identify and promptly address the resident's risk factors for skin breakdown. Specifically: See above "Initial Data Collection Tool/Nursing dated 10/29/12, identifying immobility and skin breakdown on admission, and care plans, initiated 10/29/12, identifying problems of ADL assist, pressure ulcer, and nutrition risks. Notwithstanding knowledge of the resident's skin breakdown and risks: (1) The resident's minimum data set assessments (MDS) documented: -On 10/29/12, (admission), documented in Section 16-Pressure Ulcers, that the resident had no existing pressure ulcers. The section of the assessment of extrinsic risk factors had no areas checked. The areas available to check included requiring staff assistance to move sufficiently to relieve pressure over any one side and confined to a bed or chair all or most of the time. -On 11/5/12, the MDS documented the resident required extensive assistance with all activities of daily living (ADLs) including bed mobility and transfers and was frequently incontinent. Section M-Skin conditions documented the resident was at risk for developing pressure ulcers and had no current pressure ulcers. (2) The resident's Braden scale for predicting pressure ulcer sore risk dated 10/29/12 upon admission documented the resident's score of 14 (moderate risk for developing pressure sores), notwithstanding known risks, including an open area on the resident's gluteal fold. 3. Development of Additional Pressure Ulcers - Facility Response and Failures in Facility Response a. The pressure ulcer care plan was updated beginning on 11/08/12, and reflected the following: -on 11/08/12 had a unstageable left heel pressure ulcer. -on 11/17/12 had a unstageable pressure ulcer to the left ischium. -on 11/20/12 had two actual stage 2 pressure areas to the sacrum. None of the above pressure ulcers was identified on the 10/29/12 and 11/5/12 MDS assessments and only one open area (on the gluteal fold) was identified on the initial nursing assessment 10/29/12. Although there were new areas of skin breakdown at least as of 11/8/12 (see nutrition progress note below, citing breakdown 11/06/12), there was no documentation that planned interventions were reviewed and revised to reduce the resident's risk of further skin breakdown until 11/19/12, when an alternating air mattress and speciality mattress were added. This was the sole intervention update; according to the physical therapist (see interview below), the resident did not have a turning and repositioning schedule. b. The nutrition care plan was not updated following the discovery of two new acquired pressure areas, even though review of nutritional progress notes revealed the registered dietitian documented on 11/06/12, that the resident had one open area to the ischium, and documented on 11/20/12, that the resident had new areas of skin breakdown that were unstageable and a pre-existing pressure areas documented on the nursing admission assessment. c. The Weekly Pressure Ulcer Tracking Report (PUTR) documented on 11/8/12, that the resident had an unstageable area to the left heel and left ischium. The two areas of documentation were new for the resident and not previously addressed in the resident's medical record. There was no documentation on the PUTR of the original open area on the resident's sacrum as documented by the RN on 10/29/12, and there were no further tracking reports or assessments of the resident's pressure ulcers. d. The Braden assessment, re-evaluated 11/12/12, indicated that the resident was now chairfast and had a decreasing level of risk from the previous assessment, although the resident now had two, and possibly three, pressure areas. The score was 16, which changed the risk level from moderate risk to potential for risk of developing a pressure ulcer. e. A physician telephone order date 11/19/12 documented orders to apply a wet to dry gauze, cover with tape and change daily to the left buttock cheek. This order was written 21 days after the resident was admitted and assessed by the facility with one open area to the gluteal fold. f. Record review revealed a physical therapy progress note dated 11/20/12, that documented the resident's skin breakdown as follows: -The ischial wound is full thickness and has damage to the [MEDICATION NAME], dermal and subcutaneous tissues. The area measures 3.8cm in length by 3.8cm. -The wound has 14.44cm in 2 areas with 20% of necrotic (dead) tissue with moderate bloody drainage. -Tunneling measuring 4.2cm depth present with minimal odor. There were no other assessments in the resident's record regarding the ischial ulcer and no documentation, other than the Weekly Pressure Ulcer Tracking Report documentation on 11/8/12, on the resident's left heel ulcer. Finally, there was no documentation, other than the initial nursing assessment, on the open area on the resident's gluteal fold noted 10/29/12. g. A telephone order was received on 11/21/12 for the resident to receive extensive debridement of the open area. However, another telephone order, dated 11/21/12 at an unknown time, documented in bold letters and underlined, that the facility CANNOT do the wound debridement treatment because the resident was on comfort care. A clarification order was received on 11/21/12, to have physical therapy debride the wound. 4. Staff Interviews An interview with the director of nursing (DON) on 12/05/12 at 3:00 p.m., revealed: -She would expect that the nursing staff perform accurate assessments upon admission. This would include completing the body diagram and accurately documenting the resident's skin condition on admission. -If a resident had an open area on admission, the nurse would be expected to put the information on the 24 hour report and forwarded to the appropriate staff; that staff would be wound nurse and therapy. -The unit staff should be documenting in the daily nursing notes any open areas and changes in the areas. -A resident who was dependent on staff for positioning and toileting needs would be at a greater risk for developing pressure ulcer or open areas than a resident who is able to self reposition. -The resident was not admitted with the open areas and pressure sores that were documented in the chart 21 days after admission. -The debridement therapy that the resident was receiving was an aggressive therapy for pressure ulcers staged at a level III or higher. The levels of staging a pressure ulcer are I-IV. An interview with the unit manager, on 12/05/12 at approximately 1:00 p.m., revealed: -The unit nurse manager would expect to have information that a resident has an pressure ulcer on admission communicated to the appropriate staff for follow-up with the appropriate disciplines. -A resident who was dependent on staff for positioning and toileting needs would be at a greater risk for developing pressure ulcers, than a resident who was able to self reposition. -A resident with a pressure ulcer should be followed by the facility wound nurse and therapy. -An increase in a resident's measurements in a wound, open area or pressure area, indicated that the wound was getting larger. -The resident's current pressure sores were not documented or present on the admission assessment. -Repositioning and nutrition are important parts of skin integrity. An interview with the nurse who was regularly assigned to provide care for the resident on 12/05/12 at approximately 2:00 p.m., revealed: -She would expect a care plan for a resident with a pressure ulcer in the resident's medical record. -The initial data collection tool/nursing service assessment form was completed with all new residents admitted to the facility. -The nursing staff is responsible for accurately completing the admission assessment and communicating to the appropriate departments for follow through. -The resident was not admitted with the current pressure sores and open areas that were now documented in his medical record. -The resident was receiving aggressive therapy for pressure ulcers. An interview with the physical therapist performing the treatment for [REDACTED]. 5. Observations On 12/05/12 at approximately 10:15 a.m., an observation of the resident's wound care was conducted while physical therapy (PT) performed the prescribed wound treatment. The observation revealed the following: -The PT performing the therapy had worked at the facility for four years and was very familiar with the resident. -She had been doing the therapy on the resident for approximately 3 weeks. -The purpose of the therapy was meant to keep the wound and the wound bed as free from infection, debris and slough to promote a healing skin bed. -The PT department had placed the resident on service beginning on 11/21/12, after the provider ordered pressure ulcer treatment. -The measurements of the sacral unstageable ulcer were as follows: 3.8 x 3.8 x 4.2 cm and tunneling at 2:00 at .04. The prior measurements were as follows on 11/21/12: 2.5 x 3.5 x 2.5, and on 11/27/12: 3.1 x 4.0 x 3. -The resident was not admitted with the pressure sore to the sacral area.

Based on observation, record review and interview, the facility failed to ensure three of 39 sample residents (#72, #9, #81) with a limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. The facility's failure contributed to decline in the residents' ROM as well as other declines in well-being. (Cross-reference F 309; quality of care). The findings include: A. Facility Policy The facility's undated Contractures policy included the following procedures: "All residents with contractures and residents at risk of contractures will be evaluated and a treatment plan will be included in the individualized care plan. The plan will be implemented and evaluated monthly. Contractures on admission: Nursing will: note the problem on the care plan; request a rehabilitation evaluation; undertake restorative nursing intervention/rehabilitation as recommended by the rehabilitation evaluation." B. Resident Failures 1. Resident #72 Resident #72 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual minimum data set (MDS) assessment, dated 10/3/12, indicated the resident had severe cognitive impairment, and was rarely or never understood. The resident was totally dependent on staff for all activities of daily living (ADLs), except for bed mobility, for which she required extensive assistance. The MDS assessment further indicated the resident had upper extremity impairment on both sides. a. Observations On 12/5/12 at 11:00 a.m., resident #72 was observed sitting in a Broda chair in the 200 hall TV room. The resident had contractures on both hands; her hands were tightly clenched. There was a cloth roll in each hand. b. Record Review - Plan for Contracture Management: Review of the resident's record revealed an Occupational Therapy Plan of treatment for [REDACTED]. The occupational therapist (OT) included the following notes in the Plan of Treatment: -"Reason for referral: Resident is at risk for increased B(oth) wrist and hand contracture and deformity without skilled OT intervention for contracture management ...resident presents to OT with complex B hand and wrist contractures that are currently being managed with orthotic devices. Resident continues to demonstrate greater than 10 degrees PROM (passive range of motion) in each joint, therefore able to progress into greater ROM with skilled therapeutic intervention and orthotic management ... -ROM: UE (upper extremity)- hand- The patient demonstrates PROM of B UE MP (metacarpophalangeal - large joints in the hand at the base of each finger) extension from -90 to -85 degrees ... -Provided extensive training and education to west unit nursing staff (AM/Evening shifts) pertaining to splint/orthotic wearing schedule, proper donning/doffing, OT role, POC (plan of care) and progress with therapy. Provided restorative nursing staff with education pertaining to restorative nursing program ...Resident participated well during OT treatment sessions during this period and demonstrated good progress towards goals. Resident demonstrated increased finger extension and R wrist extension ...will transition to restorative nursing care for PROM to B hands and wrists ... -Plan of Treatment Functional Goals: Education- Caregiver (restorative nursing assistant) - The caregiver will execute functional maintenance program with 100% accuracy to promote carryover in functional environment; ... ROM: UE- hand- The patient will increase B UE MP to -90 to -80 degrees without complaints of discomfort in order to maximize interaction with environment. Long-term outcome: resident to achieve PROM WFL (within functional limits) B wrist and hands within 12 weeks to reduce contracture risk." On 1/31/12, the OT wrote, "Resident presented this PM with both hand rolls in place. Restorative nursing training provided to restorative nurse for B hand and wrists contracture management. Good return demonstration and follow through of techniques for massage and stretching. Program implemented for 3 x/wk x 12 weeks." The resident's record included a Nursing Restorative Care Interventions form, dated 1/31/12, which documented, "BUE hand/wrist contractures - Instructions: prior to PROM stretching, please provide firm massage to (Resident's) wrist and hands; place 2 fingers on each side of wrist and move in circular motion to relax wrist; stretch into extension; place one palm of hand on each side of first knuckle and move in circular motion; stretch fingers into extension; place hand rolls; 3 x/wk - 12 weeks." c. Facility Failure to Implement Contracture Management Plan: There was no documented evidence resident #72 received any restorative nursing services for her hands after February 2012. There was no restorative care plan which addressed the resident's contractures, with documented goals and listed interventions/approaches to increase ROM and/or prevent further decrease in ROM. (Cross-reference F 279; care plans) On 12/5/12 at 1:30 p.m., the restorative nursing assistant (RNA), who was trained by the former OT back in January 2012 to care for resident #72, was interviewed. The RNA explained she worked with the resident three times a week until she went on leave in February 2012. The RNA stated, "I was trained by the OT to massage her hand. This would relax her and she extended her fingers (to where she could hold a broom handle). She was not resistive at all." The RNA further reported that after she went on leave, the facility did not have another RNA until September 2012. On 12/5/12 at 2:00 p.m., the director of nursing (DON) and the regional director of clinical services (DCS), confirmed that after February 2012, the facility did not have a restorative nurse until July 2012 and did not have a RNA until September 2012. The DON indicated that while there was no RNA in the facility, "CNAs were sometimes used for continuing with transferring skills." The DCS acknowledged, "The program had a glitch. There was no tracking ..." d. Record Review and Interviews - Resident Decline: Review of physician orders [REDACTED]." The OT who evaluated and treated resident #72 from 9/4/12 to 9/24/12 was interviewed on 12/5/12 at 1:10 p.m. The OT stated she was new in the facility, and that the first time she assessed the resident's hand contractures was on 9/4/12. The OT stated, "I was called in for odor and skin integrity - not ROM ...She (the resident) wasn't tolerating (having) her hands being opened in September." When asked about the role of restorative nursing for residents experiencing limited ROM, the OT stated, "The restorative nursing program is to make sure there's good carryover to promote the highest quality of life and maintain what the current function is. If there are no interventions, it gets worse." On 9/24/12, the OT wrote the following in the Plan of Treatment: -"Reason for referral: patient with B (both) hands contracture in hands causing skin breakdown ...Patient resistive in PROM during assessment ...R hand MP fixed at 90 ...patient tends to hold R hand in gross grasp; palmer arch fixed in severe opposition with deep divet where 3rd digit contracts into..L hands- patient with contracture in lumbrical grasp with ulnar deviation; MP fixed at 90 ... " -Treatment note- 9/7/12- Patient seen for B hand cleaning and skin integrity check...Patient tolerated hands partially open for cleaning and skin check. Patient stated thank you as therapist finished. Therapist recommends hand carrot at this time as patient tolerating towel rolls ..." Treatment note - 9/11/12-...L hands remains clenched; however able to tolerate cleaning.." 2. Resident #9 Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission History and Physical, dated 8/29/01, indicated the resident's "Left hand is flexed and with some contractures of the fingers." The resident's annual minimum data set (MDS) assessment, dated 11/13/12, indicated the resident was rarely or never understood and had poor decision-making ability. The resident required extensive to total assistance for all activities of daily living (ADLs). a. Observations On 11/27/12 at 11:50 a.m., resident #9 was observed sitting at a table in the South dining room at the start of lunch service. The resident was observed to have contractures of both hands; her hands were tightly clenched. There were no cloth rolls or palm protectors in her hands. At 12:05 p.m., two certified nurse aides (CNAs) took the resident back to her room, and then brought her back into the dining room for lunch. The resident was now observed to have a cloth roll in each hand. b. Record Review and Interview Review of the resident's record revealed an Occupational Therapy Plan of treatment for [REDACTED]. The occupational therapist (OT) wrote the following on 1/18/12 in the Plan of Treatment: -"Reason for referral: Resident at risk for increased pain and deformity of B (both) hands without skilled OT intervention...History: ...L hand contracture with history of L UE (upper extremity) chainsaw accident; R hand contracture ... -Assessment: ...presents with B fisted hand contractures. ROM (range of motion): UE-hand - The patient demonstrates PROM (passive range of motion) of L UE little finger from 90 to 20 degrees MP (metacarpophalangeal) flexion. Splinting: Time - The patient tolerates L UE hand roll and RUE palmer guard for up to 6 hours ...Resident participated well during treatment sessions and has a FMP (functional maintenance program) in place to assist her with maintaining orthotic wearing schedule to increase ROM and decrease further risk of deformity ... -Goals: Education-Caregiver - The caregiver will execute functional maintenance program for orthotic management with 100% accuracy to promote carryover in functional environment; Pain - The patient will demonstrate minimal pain behaviors as evidenced by reduced facial grimacing and reduced tactile avoidance with use of manual therapy in order to complete self care tasks; ROM: UE - Hand- The patient will increase L UE to WFL (within functional limits) in order to decrease pain, reduce deformity, and complete self-feeding tasks; Splinting: Time - The patient will tolerate B UE finger extension for 3 hours, with application of functional position splint in order to increase joint mobility; -Outcome: Resident to increase L hand PROM to WFL with use of orthotic device within 12 weeks. Resident participated in L UE neurostretch to hand and wrist to increase ROM. Total Assist to don hand roll to maximize carryover of finger extension/thumb abduction ROM. -FMP implemented and 1st and 2nd shift nursing staff provided with education for FMP to reduce pain, increase ROM, prevent further deformity, and decrease burden of care ..." Resident #9's record showed the resident received restorative nursing services for her hands three times a week from 12/25/11 through 2/3/12. The resident's record did not contain a restorative care plan which addressed the resident's contractures with goals and listed interventions/approaches to increase ROM and/or prevent further decrease in ROM. Cross-reference F 279. The restorative nursing assistant (RNA) who was trained by the OT in January 2012 was interviewed on 12/6/12 at 11:45 a.m. The RNA stated, "I worked with her hands three times a week for cleaning, and I put a palm protector which she wore all day. She wasn't in pain. It was good because it kept her nails from digging into her skin." The RNA related that when she went on leave in February, there was no other RNA in the facility. A physician's orders [REDACTED]. L hand roll application 4 hours on/ 2 hours off with skin checks every 2 hours and as needed; 2. R palm protector 4 hours on / 2 hours off with skin checks every 2 hours and as needed." c. Failure to implement FMP and orders - resident decline: (1) There was no documentation of restorative nursing services or implementation of the FMP after 2/3/12. (2) A review of the resident's medication administration records (MARs) from January 2012 through June 2012 revealed the following: -January 2012 - resident received the left hand roll application daily and the right palm protector application daily. -February 2012 - resident received the right palm protector application daily, but did not receive the left hand roll application on any day of the month. -March 2012 - resident received the right palm protector application daily, but did not receive the left hand roll application on any day of the month. -April 2012 - resident received the right palm protector application daily, but did not receive the left hand roll application on any day of the month. -May 2012 - resident received the left hand roll application on 28 out of 31 days, but did not receive the right palm protector application on any day of the month. -June 2012 - resident received the left hand roll application on 6/18, 6/17, 6/23, 6/24, 6/30 and 6/31, but did not receive the right palm protector application on any day of the month. The resident's record contained a nurse's note, dated 6/5/12, which read, "Noted fungal infection to left ring finger and scabbing to the tip and indentation to the mid palm. Resident refused any treatment and will not let anybody touch it. Physician notified ..." A physician's orders [REDACTED]. Apply TAO (topical antibiotic ointment) with dry dressing daily and prn (as needed) as tolerated - fungus infection." The resident's record included the following nurses' notes (cross reference F 309): -6/8/12 - "Resident cont(inues) to be monitored for fingers and hand contractures. Resident becomes distressed with staff cleaning and putting wash cloth in place ..." -6/9/12 - "Follow-up charting for left fourth finger; dark coloration of thick fingernail; open pressure wound @ tip of finger, 1 x 1 cm (centimeter), pressure wound @ 0.5 cm of 5th finger, skin intact at this time ...contracted Lt hand was separated with a roll of [MEDICATION NAME] to decrease pressure as needed ..." -6/14/12 - "Remains on follow-up for infection to finger L hand. Evening nurse reported cleansing hand and placing clean roll late in evening, roll remains in place. Resident continues to guard; jerking hand away, with facial grimacing and increased breathing with any attempt to evaluate hand. Will continue to monitor and ask day nurse to update MD of increased pain." On 6/26/12, the physician wrote the following in a progress note: "Patient with advanced dementia and is in bed still having issues with contractures of hands-did have OT eval and attempting to take pressure off open area on fingers using TAO but still some blood with each change -very difficult to change and some seem to cause her distress.." A physician's orders [REDACTED]. The facility's current RNA, who began working as a RNA in September 2012, was interviewed on 12/6/12 at 11:40 a.m. When asked about resident #9's hand contractures, the RNA reported, "She can open her hands just enough to put in a roll. You can tell it's painful for her. She doesn't want you to get close to her. She pulls away because it's painful." In an interview with the regional director of clinical services (DCS) on 12/10/12 at 11:00 a.m., the DCS verbalized that a care plan should be developed for any resident receiving restorative nursing services. The DCS explained that the therapy department and the nursing department will meet monthly to discuss the progress of residents in the restorative nursing program. The DCS indicated that the restorative nurse would keep minutes of monthly meetings and update information in each resident's record under the restorative nursing tab. 3. Resident #81 Resident #81, a [AGE] year old female, was admitted to the facility from hospital on [DATE]. The face sheet of the same date documented the following admitting [DIAGNOSES REDACTED]. The computerized physician orders [REDACTED]. -The ancillary orders included bed against the wall, falling star program, broda chair, derma savers, 1/2 hand roll left upper (lue) extremity for 4 hrs on and 4 hrs off, high low bed, keep lue positioned on folded bath blanket while up in broda chair to prevent pressure to elbow, turn s/s (side to side) while in bed, ted hose, rolled up towel in l hand for contractures. The MDS assessment dated [DATE] documented that the resident had severe cognitive impairment, required total staff dependence for all ADLs and having impairment on both lower extremities. Review of the resident's care plan dated 10/17/12 documented that the resident's husband attended the care conference and was updated regarding the resident's current functioning. . Areas of care that were care planned for the resident included: Cognitive impairment, behavior problems, activities, skin and falls. -The care plan did not not address the ancillary orders for positioning, interventions on the resident's lower extremity impairment, or (see below) the resident's upper body stiffness. (Cross-reference F 279; care plans) a. Therapy documentation A document from the therapy department on 1/8/12, documented that the resident had an order to evaluate the resident for increased upper extremity stiffness. Another documentation dated 1/15/12 documented that the resident was re-evaluated for contractures on 1/15/12 and the family desire was to keep the resident comfortable and implement interventions. However, there was no documentation regarding therapy interventions. The last documentation from the therapy department was made on 5/10/12. The documentation indicted that the resident was resistant to manual therapy to the left hand. The documentation further stated that the resident demonstrated inconsistent participation and resistance to therapy this treatment period. The resident evaluation was for joint contractures in the left hand. b. Observations On 12/5/12 at approximately 11:00 a.m. and 12/6/12 at approximately 9:30 a.m., resident #81 was observed during transfers. A certified nurse aide (CNA) transferred the resident from her wheelchair to the bed using a Hoyer lift on 12/5/12. On 12/6/12, the resident was observed being transferred from the bed into a wheelchair. The resident was observed to be dependent on staff during both transfers. c. Interviews A nurse was interviewed on 12/6/12 at approximately 1:00 p.m. and stated the resident required staff assistance for ADLs. She verified that the resident was not currently on a ROM program. She further stated that there was a period for about six months when the facility did not have a restorative program beginning in January of 2012. The Director of Nursing (DON) and the regional nursing consultant (RNC) reported on 12/9/12 that they had preformed an assessment to determine the severity of the resident's stiffness, limited ROM, and contractures to the lower extremities and the need for further therapy evaluation and restorative cares. d. Further record review On 12/10/12, review of the resident's record revealed the resident had not received any new provider orders for therapy evaluation or interventions. The resident's care plan had not been updated by any disciplines to reflect the need for interventions to prevent further decline in the resident's ROM.

Based on observations, staff interviews and record review, the facility failed to provide adequate care and services for pressure ulcer prevention and management for two (#2 and #5) of six sample residents. Specifically, the facility failed to ensure that resident #2 and #5 received necessary treatment and services to prevent pressure ulcers, to promote healing when ulcers developed and to prevent new ulcers from developing. Resident #2 and #5 entered the facility without pressure ulcers and both developed several pressure ulcers after admission. The findings include: A. Professional Reference The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines, found at the website: http//www. npuap.org. provided the following definitions: Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction . . . Pressure Ulcer Stages -Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . . . -Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister . . . -Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. unstagable. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. B. Resident Failures 1. Resident #2 The resident's medical records were reviewed on 10/12/11, 10/14/11, 10/19/11 through 10/23/11. Record review revealed resident #2, an [AGE] year-old male, was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE], revealed: -He usually understood others and others usually understood the resident. He required one person assistance for bed mobility, dressing, locomotion, eating and was non-ambulatory. The resident required two-person assistance for transfers, toileting and bathing; -He used a wheelchair; was occasionally incontinent of bowel and bladder. -He experienced a 5% weight loss in the last month and was on a mechanically altered diet. -He was coded without pressure ulcers and without pressure ulcer risk. a. Risk for Pressure Sores Although the 9/4/11 MDS indicated that the resident had no risk for developing pressure ulcers, the resident's pressure sore assessment tool dated 8/12/11, indicated that the resident was at moderate risk for pressure sore risk. Braden Risk Assessment Scales On 8/12/11 the skin breakdown assessment tool assessed resident #2 to score 13, indication of moderate risk. -Review of the tool indicated that the resident's nutritional intake was adequate, eating over ? of his meals and taking a supplement when he refused his meal. Care Plans (1) Identification of risk factors for skin breakdown Resident #2's plan of care dated 8/31/11, read in pertinent part, "is incontinent of B&B (bowel and bladder), requires assistance (with) mobility, toileting, hygiene, r/t (related to) decreased cognition ...advanced age. This places him at risk for skin breakdown." -The goal for care plan indicated no signs and symptoms (s/s) of skin breakdown, no unblancable redness, and irritation or open areas for 90 days. -The approaches included, "assist to toilet as needed. Provide peri care after each incontinence episode. Staff to monitor skin with daily cares and report any areas of concern ...Skin assessment as ordered." (2) Identification of risk factors for nutritional concerns The care plan (8/31/11) also indicated a nutritional risk care plan, specifically, a risk for weight loss due to dementia and dysphasia. The care plan read in pertinent part, "Intakes are poor, 25%. Fluid intake is poor. Recent hospitalization for fluid deficient and lethargy." (Recalculation of the resident's Braden score, based on the resident's poor intake indicated the resident's risk for pressure ulcers was high.) (3) Physician Telephone Orders (PTO) and Medication Administration Records (MARs) PTO and MARS dated 8/30/11 indicated skin assessments daily. b. Chronological Development of Pressure Ulcers - Facility response - Facility Failures. (1) Left lateral and medial knee -On 9/10/11, the PTO and MAR indicated [REDACTED]. -On 9/12/11, PTO and MARs indicated TAO with non adherent dressing to open area of left knee. The dressing was to be changed twice a day. -On 9/15/11, the Weekly Pressure Sore Tracking Report - Identified two facility acquired pressure areas , "L (left) lateral knee stage II length 3X1.1(cm) ...(with) 30% eschar. ...Progress ...Lateral knee , granulation ...yellow slough (pressure/shearing) ...Medial L knee stage IV ...4X .1 (cm) peri wound, red, some indurations ...0 (no) drainage." -On 9/20/11, review of the PTO revealed an order to add Magic cup with lunch and dinner for increasing calories related to skin issues. Failures: -Review of the resident's care plan (see above) revealed no indication that the resident had actual skin breakdown or interventions for actual skin breakdown. -Review of the MARs revealed no dressing changes on 9/17/11 and 9/18/11 at 6:00 a.m., as indicated. There was no documentation as to why the dressing changes were not done. There was no documentation that the MD was notified. -In an interview on 9/21/11 at about 10:00 a.m. Unit Manager Registered Nurse, who was also the wound care nurse, said the last tracking for the resident's knee wounds was 9/15/11. (2) Left Scapula On 9/21/11, the resident's wound care by the Registered Nurse (RN) was observed at 3:10 p.m. Resident #2 was observed in bed. A specialized mattress was in place. The resident's (L) shoulder area at the scapula was observed with an open wound. The RN stated, "I first saw it on Sunday (9/18/11) and it was just a little red ...It (has) worsened - it is open now ...It is a stage II and open." Measurements, at the surveyor's request, were: Open area to (L) lower scapular measured 1.9x1.4cm. Surrounding reddened area that did not blanch measured 3x2.8cm. (The resident's knee ulcers were not observed as the resident became restless. The RN stated the resident is restless and rubs his legs together, contributing to the medial and lateral pressure areas on his left knee.) Failures: Review of daily skin assessment documented on a weekly skin integrity data collection tool indicated no skin breakdown on the resident's scapula on 9/17/11, 9/18/11, 9/19/11. The RN said, "I saw the redness on the scapula last Sunday (9/19/11) but I did not document ...I did not measure the area ...I had not looked at it again until now (upon surveyor request) ...Nothing is written on the 24 hour report (from 9/18/11 through 9/21/11)." The RN further stated, "I did not document the redness ...I should have documented the location and size of the area ...It's now open and worse today ...I did not document on the daily skin assessment ...he had a reddened area over the weekend (9/18/11)." On 9/21/11 at 3:30 p.m., the findings above were brought to the attention of the Unit Manager RN (UMRN). The UMRN confirmed that the findings of 9/18/11 (redness) were not documented and were not passed on to staff. The UMRN stated that yesterday, the Licensed Practical Nurse (LPN) had reported "concern" to the UMRN; however, the UMRN did not assess the resident's (L) shoulder area. The UMRM stated that the wound with measurements should have been documented in the resident's medical record. Action Taken During Survey: - On 9/21/11, after the surveyor brought to the facility's attention the resident's stage II area on his scapula, the care plan was updated to include the resident's actual skin breakdown. On 9/21/11 the care plan was updated to include in pertinent part, "Has skin breakdown to knee + area to scapula." --The goal for the care plan indicated a restricted diet as indicated, and no s/s (signs or symptoms) of weight loss. --The approaches indicated cueing of resident to eat, supplements as ordered, regular mechanical soft diet. The care plan indicated no specific interventions like treatments, specialized mattress, or repositioning to promote healing of the resident's skin breakdown. -After the surveyor brought the resident's scapula wound to the facility's attention, physician orders were obtained for treatment of [REDACTED]. 2. Resident #5 Closed record review revealed resident #5, a [AGE] year-old female, was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] revealed: -She usually understood others and others usually understood the resident. -She required one-person assistance for bed mobility, transfer, dressing , toilet use, hygiene, bathing, locomotion and was non-ambulatory. She used a wheelchair. -She was occasionally incontinent of bowel and bladder. -She experienced a 5% weight loss in the last month and was on a mechanically altered diet. -She was coded without pressure ulcers but at risk for the development of pressure ulcers. a. Risk for Pressure Ulcers MDS: See above; the 9/8/11 MDS indicated that the resident was at risk for developing pressure ulcers. Braden Risk Assessment Scales: On 9/1/11 the skin breakdown risk assessment for resident #5 indicated a score of 14, indicating moderate risk for skin breakdown. Care Plan: A care plan, dated 9/1/11, read in pertinent part, "frequently incontinent of B&B, requires assistance with mobility ...weakness. She has a potential to develop skin irritation." -The goal read in pertinent part, "monitor her skin frequently when giving daily care, and report any areas of concern ...skin assessment weekly ...Staff to assist her to reposition frequently." The care plan indicated no skin breakdown (but see below; breakdown identified stage I on 9/1/11, and stage II to heels and coccyx 9/23/11). Although the 9/8/11 MDS triggered a care plan for pressure ulcers, no care specific to this problem was developed. b. Development of pressure ulcers: Bowel and Bladder (B&B) Assessment The B&B assessment, dated 9/1/11, revealed the resident was assessed with [REDACTED]. Skin Assessments: Weekly skin integrity data collection sheet (WSIDCS) (original WSIDCS) presented to the surveyor on 10/12/11, indicated circles to the resident's coccyx with redness on 9/18/11, 9/19/11, 9/20/11, 9/21/11, 9/22/11 9/23/11 and 9/24/11, without any measurements. Failures: (1) See care plan failures above; no identification of actual skin breakdown to heels and coccyx. (2) See original WSIDCS above; redness noted to coccyx, beginning 9/18/11, but no measurements documented. Nurses' notes dated 9/23/11 indicated "open areas" to heels and coccyx. On 10/14/11 at about 10:00 a.m., the UMRN stated that after the surveyor brought the above findings to the facility's attention, the facility looked at all the resident's records on skin issues. Although the original WSIDCS and nurses notes dated 9/23/11 (provided on 10/12/11) revealed no measurements or documentation of size regarding the redness that was documented on the original WSIDCS, new WSIDCS records and new nurses notes, also dated 9/23/11, were provided that were different from the original documentation provided. New documentation which was not in sequence with the original WSIDCS or nurses notes dated 9/23/11 (in the chart) which were provided by the facility on 10/14/11, read in pertinent part, "(R) heel wound mushy unblanchable area 0.7x1 mid (R) heal ...(L) heel with intact blister [MEDICAL CONDITION]. Coccyx (R) buttock with unblanchable red area 3.2x3.5 ...small intact blister within red area ...heels cleansed with NS (normal saline), skin prep applied ...transparent dressing applied ...Coccyx wound cleansed ...polymen applied and secured with transparent dressing. Has adequate pressure reduction cushion to w/c ...reduction boots to feet." The original nurses notes dated 9/23/11 (provided to the surveyor on 10/12/11), which were in sequence of all other nurses notes, revealed no assessment of pressure areas on 9/23/11; those documents indicated "open area," without staging, for both the heels and coccyx. The differences in the documentation were not explained by the UMRN. (3) Delay in Physician Notification The nurses' notes originally provided on 10/12/11 and dated 9/25/11, read in pertinent part, "11:00 (a.m.) Call placed & message left to notify Dr (physician) of bilateral heel wounds, coccyx & scratch under ? breast ...Called ...POA (medical power of attorney) to notify of pressure wounds left message for her to return my call." This was two days after the "open areas" on heels and coccyx were documented. Review of physician orders revealed no physician orders for pressure sore treatment until 9/25/11, two days later after the pressure areas were identified as "open." (4) Failure to Implement Orders Consistently Review of Physician Telephone Orders (PTO) and Medication Administration Record/ Treatment Administration Record (MARs/TARs) dated 9/25/11, read in pertinent parts, Podus boots on @ all times check every shift. -Review off the resident's TARs dated 10/11, revealed no application of the resident's pressure reducing boot from 6:00 a.m. to 6:00 p.m. on 10/1/11, 10/3/11 and 10/4/11. There was no documentation as to why those pressure reduction boots were not applied. PTO dated 9/27/11, read in pertinent part, "Lenard walking boots ...Bil (bilateral) heels ...pressure. " That order was transcribed to begin on 9/29/11. Review of 9/11 MARs/TARs indicated one application of the boots on 9/28/11 on the evening/night shift. There was no documentation that showed the boots were applied after 9/28/11. Review off the resident's TARs for 10/11 revealed no application of the L'Nard boots on the day shift (6:00 a.m. through 6:00 p.m.), 10/1/11, 10/3/11 and 10/4/11. There was no documentation as to why those boots were not applied. The resident was discharged from the facility to an assisted living facility on 10/4/11, with PTO for a wound care nurse. (5) Failure to Document Wound Progression There was no indication or documentation in the nurses' notes with regard to improvement or deterioration of the resident's coccyx and heel wounds for over ten days (9/23/11 until 10/3/11). No assessment was documented until 10/3/11, a period of 10 days from the time the wounds were discovered. Original nurses' notes, dated 10/3/11 at 12:30 p.m., read in pertinent part, "Skin assessment completed. Skin warm to touch. Skin turgor good ...Unstagable deep tissue, necrotic area that measures 4.8x2cm to (R) heel; [MEDICAL CONDITION] unstagable deep tissue to (L) heel ...(L) buttocks area noted 2cmx1cm stage II ...(with) necrotic [MEDICAL CONDITION] ...Resident was visited (name of MD) today." c. Interviews On 10/27/11 at 5:50 p.m., the findings were brought to the Director of Nurses' (DON) attention. -The DON acknowledged that a care plan for pressure prevention was not initiated. The DON agreed that the intervention to use loading boots was not initiated timely or consistently applied after the resident experienced skin breakdown to her heels. The DON agreed that the resident's pressure ulcers were not consistently documented. -The DON stated, "My expectation is that preventative measures are in place to include turning her, making sure proper interventions are in place, consistent and appropriate monitoring ...assessment of pressure areas, appropriate treatment is in place." The DON clarified that she initiated a daily skin assessment although she expected a minimum of weekly skin assessments to be completed for every resident in the facility. In summary, resident #5, who entered the facility without pressure ulcers, was discharged to another facility with multiple pressure ulcers which were not assessed consistently, at least weekly, as indicated by physician orders.