Every finding on record at Garden Terrace at Overland Park

Based on observation, record review, and interview, the facility failed to provide adequate supervision and failed to ensure staff responded appropriately to door alarms to prevent the elopement of two cognitively impaired residents. Around 04:30 PM on 05/03/26, Resident (R) 1 and R2 exited the facility without staff knowledge or supervision. Certified Nurse Aide (CNA) M heard a door alarm and reset the alarm without checking to see what triggered the door alarm. At 05:20 PM, the facility learned R1 and R2 were with a community member at a store down the street from the facility. The facility staff did not realize R1 and R2 were out of the facility for approximately 45 minutes. The community member brought R1 and R2 back to the facility in her personal vehicle. This deficient practice placed R1 and R2 in immediate jeopardy. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (a progressive mental disorder characterized by failing memory and confusion). R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented a BIMS score of three, which indicated severe cognitive impairment. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/25/25, documented R1 had a BIMS score of three related to deficits in memory recall, repetition, temporal orientation, and fluctuating behavior. R1's Care Plan, revised on 04/15/24, documented R1 was at risk for elopement related to cognitive decline. The care plan documented the following interventions:03/08/24- Staff completed an Elopement Risk Assessment.03/08/24- Staff encouraged R1 to participate in activities to divert her from exit-seeking behavior.04/15/24- Staff added R1 to the Elopement Book.04/15/24- Staff provided for safe wandering as R1 was an elopement risk. R2's EMR documented diagnoses of Alzheimer's disease and dementia. R2's Quarterly MDS dated 02/18/26, documented a BIMS score of four, which indicated severe cognitive impairment. R2's Cognitive Loss/Dementia CAA dated 06/02/25, documented R2 had a history of dementia with ongoing cognitive impairments that required 24-hour a day care for her safety and well-being. R2's Care Plan, last revised 02/11/26, documented R2 was at risk for elopement. The care plan documented the following interventions:05/10/23- Staff completed an Elopement Risk Assessment.05/10/24- Staff encouraged R2 to participate in activities to divert her from exit-seeking behavior.04/15/24- Staff added R2 to the Elopement Book.04/15/24- Staff provided for safe wandering as R2 was an elopement risk. The facility's Investigation dated 05/08/26, documented on 05/03/26 at approximately 05:20 PM, the facility received a phone call from a community member who stated she believed she had two of the facility's residents with her at a store down the street from the facility. The facility verified the two resident names as R1 and R2 of the facility. The community member stated R1 and R2 were with her at the store since between 04:30 PM to 04:45 PM. The community member brought R1 and R2 back to the facility in her personal vehicle at 05:30 PM. Upon return, the facility assessed R1 and R2 and found no injuries or pain. The investigation revealed R1 and R2 exited the dining room together around 04:30 PM, and Licensed Nurse (LN) G told them she would see them for dinner, to which they agreed and proceeded to walk out of the dining room. CNA M turned off the alarm that sounded when the lobby door opened, without looking through the door. Both R1 and R2 were dressed appropriately for dignity and the weather that day. According to the Kansas State University Historical Weather website, the temperature on 05/03/26 was 83.1 degrees Fahrenheit (F) at 04:00 PM, 82.8 degrees F at 05:00 PM, and 79.4 degrees F at 06:00 PM. Review of Google Maps revealed the distance from the facility to the store R1 and R2 walked to was 0.1 miles. CNA M's notarized Witness Statement, dated 05/03/26, stated she passed drinks and silverware, and at about 05:20 PM, she realized that R1 and R2 were missing from their room. She stated she searched the residents' rooms and realized R1 and R2 were not in the building. CNA M stated the facility located R1 and R2 at 05:30 PM, and they attended dinner. She stated around 04:30 PM, R1 and R2 sat in the dining room, and they left the dining room to go to their room after getting their medications. CNA N's notarized Witness Statement, dated 05/03/26, stated at about 05:20 PM, she answered the phone, and a woman stated she had two women with her that she believed resided at the facility. CNA N stated the woman said they were at the store down the hill from the facility. CNA N stated she took down the residents' names, the community member's information, and vehicle description, and an estimated time the community member planned to bring the residents back. She stated she notified LN H, and together, they notified LN G. LN G's notarized Witness Statement, dated 05/03/26, stated she saw R1 and R2 in the dining room at 04:30 PM, seated and drinking coffee. She stated that both R1 and R2 stood up from where they were seated and started walking out of the dining room. LN G stated she told them she would see them at dinner, and they both agreed with a nod, then walked out. LN G stated at around 05:30 PM, CNA N alerted her about the phone call. She and other staff members waited for R1 and R2 outside as the community member dropped them off. LN G stated she performed a skin assessment on R1 and R2 with no bruising or wounds noted on either resident. LN H's notarized Witness Statement, dated 05/03/26, stated CNA N answered the phone and a community member told her she had two of the facility's residents, R1 and R2. She stated CNA N notified her, and she and CNA N notified LN G. LN H stated she told LN G to do a head count of their residents. The facility completed a head count and accounted for all residents except R1 and R2. LN H stated the community member brought R1 and R2 back in her own car, and LN G performed a pain and skin assessment on them. LN H stated she immediately notified Administrative Nurse D. In an observation on 05/14/26 at 11:01 AM, the facility's front door opened into a driveway with an awning over it, with the driveway curving down slight hills, to two exits onto the road. There was parking available between the two exits and additional parking around the south side of the building. The North driveway exit had uneven ground and depressions in it. The street in front of the facility that led to the store was a busy residential street with no posted speed limit. The East side of the street, which was the closest side to the facility, had no sidewalk, and the street went down a hill and had areas of uneven ground on the side of the street, near the curb. The street that ran in front of the store was a busy [NAME] street with a posted speed limit of 35 miles per hour (mph). In an observation on 05/14/26 at 12:12 PM, R1 and R2 sat in chairs at the same table in the dining room. In an observation on 05/14/26 at 12:15 PM, the double doors between healthcare and the front lobby opened when pushed, and a door alarm sounded immediately upon pushing, and the staff had to enter a code to clear the alarm. On 05/14/26 at 12:17 PM, Administrative Staff B stated if a resident went through the double doors from healthcare, the alarm sounded, and she announced Attention, Dr. Walker three times. She stated she could usually talk to the resident and get them back through the double doors. During an interview on 05/14/26 at 12:40 PM, Administrative Nurse D stated CNA M said she heard the door alarm and reset it, without looking to see who set it off. Administrative Nurse D stated R1 and R2 wore pants and a shirt on 05/03/26. During an interview on 05/14/26 at 01:45 PM, CNA O stated on 05/03/26, around dinner time, she saw R1 and R2 sitting in the dining room. She stated R1 and R2 happened to slip by and get out of the door, and she did not hear the alarm going off because she was down the hall getting residents for dinner. CNA O stated she realized R1 and R2 were missing from their room between 05:00 PM and 05:20 PM before the facility received the phone call, and she looked room-to-room for them. She stated she was in the hall when they received the phone call about R1 and R2 missing from the facility. CNA O stated if she heard the double door alarm go off, she made sure nobody was on either side of the door. She stated she prevented elopements by doing hourly checks and being mindful of where the residents were. CNA O stated R1 and R2 did not have any exit-seeking behaviors on 05/03/26, and they had been drinking coffee at a dining room table the last time she saw them. During an interview on 05/14/26 at 01:51 PM, LN I stated if the door alarm sounded, she checked all around the door to find out if anyone went outside the building. She stated she prevented elopements by knowing which residents were exit-seeking, and she watched them closely. During an interview on 05/14/26 at 02:14 PM, Administrative Nurse D stated on 05/03/26, she received a call between 05:40 PM and 05:45 PM from LN H, who reported R1 and R2 got out of the facility and a community member brought them back. She stated she notified Administrative Staff A, and both of them went to the facility. Administrative Nurse D stated the nurse had completed a skin and pain assessment with no injuries or pain found. She stated she obtained written statements and checked the alarms and doors, which all worked. Administrative Nurse D stated the facility completed elopement assessments on R1 and R2 and placed them on one-on-one when there was no receptionist working until R1 and R2 moved to a secure unit. She stated she asked CNA M if, at any point, an alarm went off, and CNA M stated yes, around 04:30 PM, but she silenced it and assumed it was a visitor, and she did not check around the door for who triggered it. Administrative Nurse D stated if the door alarm went off, she expected staff to check around the door and look all around to see why it went off. She stated staff prevented elopements by being mindful of where residents were and keeping an eye on the exits. During an interview on 05/14/26 at 02:41 PM, Administrative Staff A stated that on 05/03/26, Administrative Nurse D called her about the elopement, and she immediately went to the facility. Together, she and Administrative Nurse D talked to the staff and asked general questions. She stated they talked to R1 and R2, who used foul language and could not tell them everything that had happened. Administrative Staff A stated staff wrote out statements, then they went through a re-enactment of what happened. She stated she walked through an elopement drill with staff on what to do the right way, including putting their head through the doors to check for residents. Administrative Staff A stated the receptionist had left at 04:07 PM that day, and the incident occurred at 04:30 PM. She stated CNA M went to the keypad to turn off the alarm but did not open the door to see who was there because she was not sure when the receptionist left. Administrative Staff A stated the facility thought about moving R1 and R2 to a secure unit that night, but R1 and R2 were not having it, so the facility posted a one-on-one staff member outside their room that night. She stated R1 and R2 moved to a secure unit the next day, and she assigned extra staff to that unit for the day to make sure the transition went okay. On 05/18/26 at 01:20 PM, CNA M stated on 05/03/26, she set up drinks and did rounds for dinner when she noticed R1 and R2 were missing. She stated the nurse and other CNA had also noticed R1 and R2 were missing around that time, and they handled it. CNA M stated she was confused on what the times were. She stated she heard multiple door alarms go off that day and she cleared the alarms but did not look out of the door to check for residents. CNA M stated she received education after the incident to clear the alarm and check behind the door for residents. The facility's Missing Residents/Actual Elopement Event policy, revised 04/05/23, directed the facility to conduct a head count whenever a door alarm sounded but there were no witnesses to the reason for the alarm, when the fire alarm goes into alarm, and any time the alarm system for the doors is not operational. If during the head count a resident is unaccounted for, the facility reviews the sign-out log to determine if the resident or their representative signed out. On 05/14/26 at 02:00 PM, Administrative Staff A was presented with the Immediate Jeopardy [IJ] Template and was notified of the facility's failure to provide adequate supervision to prevent the elopement of R1 and R2 on 05/03/26, which constituted immediate jeopardy at F689. The facility identified, implemented, and completed the following corrective measures:1. The facility assessed all residents for elopement risk accuracy on 05/04/26.2. The facility assessed exit doors and door alarms for functionality on 05/03/26 and 05/04/26.3. The facility reviewed the elopement book for accuracy on 05/03/26 and 05/04/26.4. The facility updated R1 and R2's care plan on 05/04/26.5. The facility completed elopement education with all staff on 05/04/26.6. The facility started daily audits of staff compliance with door alarms on 05/04/26, on-going.7. The facility conducted an AdHoc Quality Assurance and Performance Improvement (QAPI) meeting. Due to the facility's completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a J (isolated, immediate jeopardy).

The facility identified a census of 141 residents. The sample included five residents, with three residents reviewed for dementia care. Based on record review and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment which supported R1's individualized care needs. This deficient practice resulted in ongoing and escalating behaviors, including aggression towards other residents. Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated 01/31/25 documented staff did not conduct a Brief Interview for Mental Status (BIMS) due to R1 being rarely or never understood. R1 wandered daily. R1 required substantial to maximal assistance with oral hygiene, toileting hygiene, showering, upper and lower body dressing, standing, and toilet transfers. R1 required dependence on staff for putting on shoes and personal hygiene. R1 required partial to moderate assistance with bed mobility, and he received antidepressant (a class of medications used to treat mood disorders) medications. The Quarterly MDS dated 10/23/25 documented staff did not conduct a BIMS due to R1 being rarely or never understood. R1 had physical behaviors directed towards others and wandering behaviors one to three days in the lookback period. R1 received antidepressant medications. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/31/25 documented R1 had a history and diagnosis of dementia with ongoing cognitive and physical impairments. R1 retained his ability to make his needs known. The EMR included a Functional Abilities CAA dated 02/03/25 which documented R1 required assistance with activities of daily living (ADL). The EMR included a Behavioral Symptoms CAA dated 02/03/25 which documented R1 exhibited wandering behavior due to advancing dementia R1's 01/25/24 Care Plan revealed R1 had impaired cognitive ability and impaired thought processes due to dementia disease and included the following staff interventions:01/25/24- Staff allowed extra time for R1 to respond to questions and instructions.01/25/24- Staff faced R1 and spoke clearly when they communicated with R1.01/29/25- The facility placed R1 on a secured unit.05/15/25- Staff used R1's preferred name, identified themselves at each interaction, reduced any distractions, provided necessary cues, and stopped then returned if R1 became agitated. The care plan lacked individualized interventions related to R1's behaviors and triggers for behaviors. R1's 02/07/24 Care Plan revealed R1 depended on staff for meeting emotional, intellectual, physical, and social needs due to his disease process and included the following staff interventions:02/07/24- Staff established and recorded R1's prior level of activity involvement and interests by talking to R1, his caregivers, and family on admission and as necessary.02/07/24- Staff invited R1 to scheduled activities.02/07/24- R1 preferred coloring, simple puzzles, and watching his preferred television channels.02/07/24- Staff reviewed R1's activity needs with his family/representative. R1's EMR revealed the following: A Behavior Note dated 07/03/24 at 09:11 PM documented R1 became more aggressive with staff on redirection from common areas. R1 kept self-propelling in his wheelchair through the TV and dining room and rolled over other residents' shoes and toes. When staff redirected R1, he became increasingly violent and tried to strike staff with a closed fist. R1 became increasingly restless and became a higher fall risk. R1 tried to ambulate without assistance and when staff tried to intervene, R1 became angry and tried to kick and punch staff. A Behavior Note dated 07/04/24 at 10:16 PM document R1 transferred himself without assistance and tried to stand up in the hallway. Staff redirected R1 back to his wheelchair several times and R1 sat in the TV room with a Certified Nurse Aide (CNA) for increased supervision for safety. R1 continued to be aggressive with direction and tried to hit and punch staff with a closed fist. A Behavior Note dated 07/09/24 at 09:08 PM documented R1 continued to be very restless and an increased fall risk. R1 needed increased supervision from staff for safety. A Behavior Note dated 10/13/24 at 07:00 AM documented R1 rolled around in his wheelchair that morning and shook both hands in the air, stating he was scared, he wanted to kill himself, and he did not know. Staff provided ineffective verbal redirection. R1 attempted to get out of his wheelchair while he stated he was scared. The nurse applied a gait belt and allowed R1 to ambulate down the hallway with the railings, but he remained anxious. R1's medical record lacked evidence the facility notified R1's provider or R1's representative of his suicidal/death statements on 10/13/24. A Behavior Note dated 10/23/24 at 01:02 PM documented R1 kept trying to stand up and walk. R1 verbalized he did not understand, he wanted to die. Staff redirected and helped R1 take a few steps then sat him back in his wheelchair. The note included the redirection remained ineffective. R1's medical record lacked evidence the facility notified R1's provider or R1's representative of his death statements on 10/23/24. A Behavior Note dated 10/29/24 at 01:06 PM documented R1 refused to eat lunch and refused to allow staff to assist him to the bathroom. R1 yelled loudly the entire time and staff provided ineffective verbal redirection. A Weight Change Note dated 11/11/24 at 11:58 AM documented staff reported R1 expressed feelings of wanting to die and being scared. The note documented a recommendation to refer R1 to the provider for reported issues with his mood. A Physician/PA (Physician Assistant)/NP (Nurse Practitioner) note dated 11/12/24 at 04:26 PM documented the provider reviewed the available medical records and the most recent laboratory results with a plan to continue to monitor and follow R1 closely. The note did not address R1's recent suicidal/death statements. A Behavior Note dated 12/03/24 at 02:32 PM documented R1 refused cares throughout the day and refused to eat lunch. The note included multiple staff reapproached R1 but were ineffective. A Behavior Note dated 12/10/24 at 04:11 AM documented R1 was up all night and resisted staff attempts to redirect him back to his bed. An Order Note dated 12/26/24 at 01:50 PM documented staff notified Consultant GG of R1's ongoing increased anxiety, agitation, and verbalizations of harming himself. Consultant GG gave a new order for Lexapro (antidepressant medication) 10 milligrams (mg) in the morning for mood disorder. A Behavior Note dated 06/30/25 at 01:29 PM documented R1 attempted to exit the unit and set off the alarms. The note included the staff provided ineffective verbal redirection and R1 refused to allow staff to take him to the shower, for his scheduled shower. A Behavior Note dated 07/24/25 at 04:23 PM documented R1 was very active and aggressive early in the shift. The note documented R1 screamed in the hallway, swung his arms around, pushed staff, and tried to bite staff. R1's representative tried to give R1 a snack and R1's mood escalated. R1's representative asked if the facility could give R1 a shot. The facility notified Consultant GG who ordered a one-time order for haloperidol (antipsychotic medication- [a class of medications used to treat major mental conditions that cause a break from reality]) 2 mg intramuscularly (IM- into the muscle). A Physician/PA/NP note dated 07/25/25 at 03:03 PM documented the provider saw R1 that day for increased agitation and anxiety. The note included R1 recently stopped his Lexapro and developed significant agitation the night prior. R1 suffered from dementia with agitation and was doing well up until the night prior. R1 required the administration of Haldol (haloperidol) 2 mg IM one time at the request of his representative. The provider ordered Lexapro 10 mg daily, and a recent urinalysis (UA- lab analysis of urine) for R1 was negative for an infection at that time. A Behavior Note dated 09/08/25 at 06:22 PM documented R1 rolled up to another resident in his wheelchair and grabbed his can of pop. The other resident became upset, staff redirected R1 and gave the other resident the pop back. R1 then grabbed the other resident's water cup and threw it at the window, which just missed another resident. Staff redirected R1 out of the dining room and R1 kicked staff and tried to bite them while he screamed all the way down the hallway. The activities staff took R1 off of the unit for about an hour to try to get R1 to relax. During dinner, R1 threw his tray of food down the hallway and poured his drinks on the wall and floor. The staff redirected R1 and he screamed, kicked, and tried to bite staff during redirection. R1 went down the hall and set off the alarm and when staff redirected R1, he called them names. During the meal, R1 tried to go through the dirty plates in the food warmer and when staff redirected him, he became very agitated and slammed the food warmer into the hallway wall. Staff redirected R1 to his room but R1 came back out quickly and began knocking over furniture in the dining room. After mealtime, R1 calmed down some but did propel his wheelchair into the common areas and ran over other residents toes while saying sorry then did it again. R1's medical record lacked evidence the facility notified R1's provider and representative of his behaviors on 09/08/25. A Behavior Note dated 09/09/25 at 09:01 PM documented R1 almost got through the unit doors while staff tried to redirect him. R1 grabbed both sides of the doors and tried to pull himself forward. R1 screamed, kicked staff, and tried to bite staff. Staff brought R1 back onto the unit and he began wandering. Staff asked R1 if he wanted to take a nap and R1 said yes. R1's representative visited for dinner. R1's medical record lacked evidence the facility notified R1's provider of his behaviors on 09/09/25. A Behavior Note dated 09/19/25 at 09:20 PM documented at 04:00 PM, staff saw R1 standing at the double doors with his pants down, urinating on the floor. Staff went to assist R1 with re-dressing and R1 became loud and violent. R1 pushed staff, kicked staff, and punched both CNAs with a closed fist. R1 propelled into the dining room and rolled up to another resident, who had coffee, and R1 swung at the other resident's head with a closed fist. The other resident managed to move his head enough to not get hit. Staff redirected R1 out of the common area while R1 screamed to kill him, kill him, you cannot kill me [expletive]. R1's screaming and sporadic loud noises escalated. Staff took R1 to his room for a lower stimulated environment, but he started throwing things around his room while screaming. The facility called R1's provider who gave an order for a UA during the weekend. The facility notified R1's representative. A Behavior Note dated 11/01/25 at 12:28 PM documented R1 wandered the unit and ran over a fellow resident's toes in his wheelchair. Staff could not easily redirect R1. Staff attempted to feed R1 breakfast and lunch, but he refused to eat a meal. A Physician/PA/NP note dated 11/21/25 at 03:43 PM documented R1's representative was engaged with the facility regarding the release of R1's medical records and based on an email the provider received, R1's representative withdrew his consent on R1's Lexapro for depression/anxiety and trazodone (antidepressant medication) for insomnia and sleep. The provider attempted to contact R1's representative that day without any success. The provider planned to taper R1's trazodone down then discontinue, and he discontinued the Lexapro entirely with no taper required. A Behavior Note dated 11/30/25 at 07:32 PM documented R1 became very agitated during the shift and repeatedly tried to stand up, which created a fall risk. Staff had to be one-to-one with R1 at all times. Activities did R1's nails, which distracted him during that time. At bedtime, R1 tried to hit staff multiple times. R1's clinical record lacked evidence the facility notified R1's provider or representative of his behaviors on 11/30/25. A Behavior Note dated 12/03/25 at 09:44 PM documented R1 propelled around the unit in his wheelchair and got into other residents' personal space while taking their things. The other residents screamed repeatedly, and staff redirected R1 down the hallway or into his room with short-term results. At dinner, R1 parked his wheelchair in front of the open food cart and tried to grab and touch the food trays. R1 propelled into the dining room and tried to take other residents' drinks and plates. Staff redirected R1 into the closest room and he backed his wheelchair into the bedroom, which blocked him in. Staff managed to get R1 out of the room when his representative arrived. R1's representative assisted R1 to his bedroom with dinner and snacks. R1's clinical record lacked evidence the facility notified R1's provider of his behaviors on 12/03/25. A Behavior Note dated 12/05/25 at 08:00 AM documented R1 attempted to go behind the nurse's desk and when the nurse tried to redirect R1, he kicked the nurse in the leg and proceeded to put his middle finger up. R1 appeared upset but his words made no sense due to being scrambled. A Behavior Note dated 12/09/25 at 08:41 AM documented R1 paced on the hallway, had exit seeking behaviors, and was uncooperative with calming down after reassurance or redirection. Staff left R1 alone to calm down and then R1 accepted a drink and his breakfast fairly well. A Behavior Note dated 12/10/25 at 07:43 AM documented the night shift CNAs reported R1 did not go to bed until 03:00 AM. Staff attempted to help him back to bed, but he stated no. A Behavior Note dated 12/11/25 at 06:43 AM documented the night shift CNAs reported R1 did not go to bed the whole night. Staff attempted to help him back to bed, but he stated no. R1 moved along the hallway without his wheelchair and pushed any item he met on his way. A Behavior Note dated 12/11/25 at 08:04 PM documented R1 repeatedly got out of his wheelchair and walked in the hallway while holding onto the handrail. Staff redirected every time with good short-term results. The facility made a therapy consult for the possible use of a walker. A Behavior Note dated 12/18/25 at 11:40 AM documented R1 refused to use his wheelchair and used a walker on and off. R1 became agitated and walked into other residents' rooms then hit two staff on different occasions. Staff redirected R1 and he later calmed down but still ambulated in the hallway. R1's clinical record lacked evidence the facility notified R1's provider of his behaviors following a gradual dose reduction of trazodone and discontinuation of Lexapro between 11/22/25 and 12/21/25. A Physician/PA/NP note dated 12/22/25 at 02:19 PM documented the facility notified Consultant GG that R1 had increased anxiety and agitation recently. R1 was off his Lexapro and trazodone per R1's representative's wishes despite the Consultant GG's attempt to update R1's representative on R1's condition. The facility staff attempted to speak with R1's representative multiple times but he continued to refuse consent to allow appropriate treatment for R1. Consultant GG's plan included encouraging staff to follow behavior modifications and to continue to monitor and follow R1 closely. The note documented an addendum that stated after Consultant GG left the facility, he received a phone call from the facility that R1 had increased agitation and anxiety and R1 hit staff members. R1 became so agitated that he had become an immediate danger to himself, staff, and other residents. The facility notified Consultant GG that R1's representative was in the building and called 911 to request police at the facility. Consultant GG spoke to R1's representative and explained R1's agitation and aggression placed him as a danger to himself and others. R1's representative became agitated with Consultant GG on the phone. Given the significant limitations for treatment and appropriate management of R1's psychosis (any major mental disorder characterized by a gross impairment in reality perception) at the facility, Consultant GG recommended that R1 be evaluated in an emergency department. An Alert Note on 12/23/25 at 04:13 PM documented the facility spoke with case management at the hospital around 09:00 AM regarding R1's current status in the hospital. The case manager stated she would call the facility back for further conversation and assistance with alternative placement for R1. On 12/29/25 at 01:51 PM, CNA M stated he knew what behaviors a resident had by studying them and reviewing the Kardex (nursing tool that gives a brief overview of the care needs of each resident). He stated the Kardex had behaviors with triggers and interventions. He stated if a resident had increased behaviors, he let the nurse know, tried to calm the resident down, and went back if the resident did not want help at that time. CNA M stated some interventions for behaviors included giving snacks, trying a different approach, and sitting down and talking to the resident. He stated the interventions depended on the resident. CNA M stated R1 liked to go around the unit in his wheelchair, so staff let him go up and down the hall. He stated R1 was sometimes difficult to work with but he liked pineapple juice and snacks which sometimes worked. CNA M stated in the last month, R1 would stand up from his wheelchair to walk on his own, he kicked staff during showers, stepped on other residents' toes with his wheelchair, and tried to hit other residents with his wheelchair. On 12/29/25 at 11:59 AM, Licensed Nurse (LN) G stated R1's had increased behaviors after the provider discontinued his medications. R1 became aggressive, hit people, flipped people off, and tried to bite people. She stated staff immediately separated R1 and he was usually easily redirected. LN G stated she documented any behaviors and if R1 became physical, she notified the provider. She stated she never needed to notify the provider about R1 becoming physically aggressive since he did not have those behaviors on her shift. She stated if she notified the provider, she documented the notification in the EMR. LN G stated she received report that R1 was not sleeping prior to going to the hospital and she notified the provider. LN G confirmed she did not see any provider notification notes in R1's EMR from 11/22/25 to 12/21/25 following his increased behaviors. On 12/29/25 at 01:41 PM, LN H stated if a resident had behaviors, she redirected them with something they enjoyed or needed like reading, a snack, or going the bathroom. She stated she tried to find out why the resident was upset then intervened. LN H stated she documented behaviors in the EMR and the care plans had triggers and what interventions the staff could try. She stated if a resident had increased behaviors, the care plan had interventions and if the interventions were ineffective, she called Administrative Nurse D and the provider. LN H stated she reported what interventions the staff tried and what worked. She stated if the behavior continued and interventions did not work, she called the provider and family. She stated she documented the behavior and notification in progress notes. On 12/30/25 at 12:28 PM, LN G stated if a resident made self-harming statements, she ensured their safety then notified the provider which she then documented in a progress note. She stated she placed the resident on one-to-one depending on the severity of the behaviors. LN G stated R1's behaviors started after he got off of some medications and he started hitting himself and said he wanted to die and kill himself. She confirmed R1's care plan did not have resident-specific interventions for his dementia. On 12/29/25 at 03:34 PM, Administrative Nurse D stated the Kardex had resident behaviors and the care plans had resident specific interventions for dementia. She stated the care plans identified what behaviors a resident had and possible interventions. Administrative Nurse D stated the care plan did not include triggers for behaviors. She stated R1 had minimal behaviors prior to medication changes and redirection worked with him. She stated after medication changes, R1 did not sleep well, he became agitated and anxious, he walked out of his wheelchair, propelled himself unsafely, went after other residents, and hit nursing staff during redirection. Administrative Nurse D stated R1 never physically contacted other residents because staff intervened and got hit instead. She stated residents with a diagnosis of dementia had a dementia care plan which included behaviors and interventions on what staff could do. On 12/29/25 at 12:49 PM, Consultant GG stated he did not receive any notification of R1's increased behaviors from 11/22/25 to 12/21/25. He stated he expected the facility to follow their policies regarding notifications. The facility's Care of the Cognitively Impaired (Dementia Care) policy, revised 08/29/22, directed the facility identified, addressed, and/or obtained necessary services for the dementia care needs of residents. The policy directed the facility developed and implemented person-centered care plans that included and supported the dementia care needs identified in the comprehensive assessment. The policy directed the facility developed individualized interventions related to the resident's symptomology and rate of progression. The policy directed the facility reviewed and revised care plans that were not effective and/or when the resident had a change in condition. The policy directed the facility modified the environment accommodated resident care needs. The policy directed the facility achieved expected improvements or maintained the expected stable rate of decline. This deficient practice was cited at a G (isolated, actual harm), based on reasonable person concept, when the facility did not address R1's escalating behaviors and R1 admitted to the hospital.

The facility identified a census of 141 residents. The sample included five residents, with three residents reviewed for dementia care. Based on record review and interviews, the facility failed to notify Resident (R) 1's provider of new or escalating behaviors. Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated 01/31/25 documented staff did not conduct a Brief Interview for Mental Status (BIMS) due to R1 being rarely or never understood. R1 wandered daily. R1 required substantial to maximal assistance with oral hygiene, toileting hygiene, showering, upper and lower body dressing, standing, and toilet transfers. R1 required dependence on staff for putting on shoes and personal hygiene. R1 required partial to moderate assistance with bed mobility, and he received antidepressant (a class of medications used to treat mood disorders) medications. The Quarterly MDS dated 10/23/25 documented staff did not conduct a BIMS due to R1 being rarely or never understood. R1 had physical behaviors directed towards others and wandering behaviors one to three days in the lookback period. R1 received antidepressant medications. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/31/25 documented R1 had a history and diagnosis of dementia with ongoing cognitive and physical impairments. R1 retained his ability to make his needs known. The EMR included a Functional Abilities CAA dated 02/03/25 which documented R1 required assistance with activities of daily living (ADL). The EMR included a Behavioral Symptoms CAA dated 02/03/25 which documented R1 exhibited wandering behavior due to advancing dementia. R1's 01/25/24 Care Plan revealed R1 had impaired cognitive ability and impaired thought processes due to dementia disease and included the following staff interventions:01/25/24- Staff allowed extra time for R1 to respond to questions and instructions.01/25/24- Staff faced R1 and spoke clearly when they communicated with R1.01/29/25- The facility placed R1 on a secured unit.05/15/25- Staff used R1's preferred name, identified themselves at each interaction, reduced any distractions, provided necessary cues, and stopped then returned if R1 became agitated. The care plan lacked individualized interventions related to R1's behaviors and triggers for behaviors. R1's EMR revealed the following: A Behavior Note dated 07/03/24 at 09:11 PM documented R1 became more aggressive with staff on redirection from common areas. R1 kept self-propelling in his wheelchair through the TV and dining room and rolled over other residents' shoes and toes. When staff redirected R1, he became increasingly violent and tried to strike staff with a closed fist. R1 became increasingly restless and became a higher fall risk. R1 tried to ambulate without assistance and when staff tried to intervene, R1 became angry and tried to kick and punch staff. A Behavior Note dated 07/04/24 at 10:16 PM document R1 transferred himself without assistance and tried to stand up in the hallway. Staff redirected R1 back to his wheelchair several times and R1 sat in the TV room with a Certified Nurse Aide (CNA) for increased supervision for safety. R1 continued to be aggressive with direction and tried to hit and punch staff with a closed fist. A Behavior Note dated 07/09/24 at 09:08 PM documented R1 continued to be very restless and an increased fall risk. R1 needed increased supervision from staff for safety. R1's medical record lacked evidence the facility notified R1's physician about his behaviors from 07/03/24 to 07/09/24. A Behavior Note dated 10/13/24 at 07:00 AM documented R1 rolled around in his wheelchair that morning and shook both hands in the air, stating he was scared, he wanted to kill himself, and he did not know. Staff provided ineffective verbal redirection. R1 attempted to get out of his wheelchair while he stated he was scared. The nurse applied a gait belt and allowed R1 to ambulate down the hallway with the railings, but he remained anxious. R1's medical record lacked evidence the facility notified R1's provider of his suicidal/death statements on 10/13/24. A Behavior Note dated 10/23/24 at 01:02 PM documented R1 kept trying to stand up and walk. R1 verbalized he did not understand, he wanted to die. Staff redirected and helped R1 take a few steps then sat him back in his wheelchair. The note included the redirection remained ineffective. R1's medical record lacked evidence the facility notified R1's provider of his death statements on 10/23/24. A Behavior Note dated 09/08/25 at 06:22 PM documented R1 rolled up to another resident in his wheelchair and grabbed his can of pop. The other resident became upset, staff redirected R1 and gave the other resident the pop back. R1 then grabbed the other resident's water cup and threw it at the window, which just missed another resident. Staff redirected R1 out of the dining room and R1 kicked staff and tried to bite them while he screamed all the way down the hallway. The activities staff took R1 off of the unit for about an hour to try to get R1 to relax. During dinner, R1 threw his tray of food down the hallway and poured his drinks on the wall and floor. The staff redirected R1 and he screamed, kicked, and tried to bite staff during redirection. R1 went down the hall and set off the alarm and when staff redirected R1, he called them names. During the meal, R1 tried to go through the dirty plates in the food warmer and when staff redirected him, he became very agitated and slammed the food warmer into the hallway wall. Staff redirected R1 to his room but R1 came back out quickly and began knocking over furniture in the dining room. After mealtime, R1 calmed down some but did propel his wheelchair into the common areas and ran over other residents' toes while saying sorry then did it again. R1's medical record lacked evidence the facility notified R1's provider of his behaviors on 09/08/25. A Behavior Note dated 09/09/25 at 09:01 PM documented R1 almost got through the unit doors while staff tried to redirect him. R1 grabbed both sides of the doors and tried to pull himself forward. R1 screamed, kicked staff, and tried to bite staff. Staff brought R1 back onto the unit and he began wandering. Staff asked R1 if he wanted to take a nap and R1 said yes. R1's representative visited for dinner. R1's medical record lacked evidence the facility notified R1's provider of his behaviors on 09/09/25. A Physician/PA/NP note dated 11/21/25 at 03:43 PM documented R1's representative was engaged with the facility regarding the release of R1's medical records and based on an email the provider received, R1's representative withdrew his consent on R1's Lexapro for depression/anxiety and trazodone (antidepressant medication) for insomnia and sleep. The provider attempted to contact R1's representative that day without any success. The provider planned to taper R1's trazodone down then discontinue, and he discontinued the Lexapro entirely with no taper required. A Behavior Note dated 11/30/25 at 07:32 PM documented R1 became very agitated during the shift and repeatedly tried to stand up, which created a fall risk. Staff had to be one-to-one with R1 at all times. Activities did R1's nails, which distracted him during that time. At bedtime, R1 tried to hit staff multiple times. A Behavior Note dated 12/03/25 at 09:44 PM documented R1 propelled around the unit in his wheelchair and got into other residents' personal space while taking their things. The other residents screamed repeatedly, and staff redirected R1 down the hallway or into his room with short-term results. At dinner, R1 parked his wheelchair in front of the open food cart and tried to grab and touch the food trays. R1 propelled into the dining room and tried to take other residents' drinks and plates. Staff redirected R1 into the closest room and he backed his wheelchair into the bedroom, which blocked him in. Staff managed to get R1 out of the room when his representative arrived. R1's representative assisted R1 to his bedroom with dinner and snacks. A Behavior Note dated 12/05/25 at 08:00 AM documented R1 attempted to go behind the nurse's desk and when the nurse tried to redirect R1, he kicked the nurse in the leg and proceeded to put his middle finger up. R1 appeared upset but his words made no sense due to being scrambled. A Behavior Note dated 12/09/25 at 08:41 AM documented R1 paced on the hallway, had exit seeking behaviors, and was uncooperative with calming down after reassurance or redirection. Staff left R1 alone to calm down and then R1 accepted a drink and his breakfast fairly well. A Behavior Note dated 12/10/25 at 07:43 AM documented the night shift CNAs reported R1 did not go to bed until 03:00 AM. Staff attempted to help him back to bed, but he stated no. A Behavior Note dated 12/11/25 at 06:43 AM documented the night shift CNAs reported R1 did not go to bed the whole night. Staff attempted to help him back to bed, but he stated no. R1 moved along the hallway without his wheelchair and pushed any item he met on his way. A Behavior Note dated 12/11/25 at 08:04 PM documented R1 repeatedly got out of his wheelchair and walked in the hallway while holding onto the handrail. Staff redirected every time with good short-term results. The facility made a therapy consult for the possible use of a walker. A Behavior Note dated 12/18/25 at 11:40 AM documented R1 refused to use his wheelchair and used a walker on and off. R1 became agitated and walked into other residents' rooms then hit two staff on different occasions. Staff redirected R1 and he later calmed down but still ambulated in the hallway. R1's clinical record lacked evidence the facility notified R1's provider of his behaviors following a gradual dose reduction of trazodone and a discontinuation of Lexapro between 11/22/25 and 12/21/25. A Physician/PA/NP note dated 12/22/25 at 02:19 PM documented the facility notified Consultant GG that R1 had increased anxiety and agitation recently. R1 was off his Lexapro and trazodone per R1's representative's wishes despite the Consultant GG's attempt to update R1's representative on R1's condition. The facility staff attempted to speak with R1's representative multiple times but he continued to refuse consent to allow appropriate treatment for R1. Consultant GG's plan included encouraging staff to follow behavior modifications and to continue to monitor and follow R1 closely. The note documented an addendum that stated after Consultant GG left the facility, he received a phone call from the facility that R1 had increased agitation and anxiety and R1 hit staff members. R1 became so agitated that he had become an immediate danger to himself, staff, and other residents. The facility notified Consultant GG that R1's representative was in the building and called 911 to request police at the facility. Consultant GG spoke to R1's representative and explained R1's agitation and aggression placed him as a danger to himself and others. R1's representative became agitated with Consultant GG on the phone. Given the significant limitations for treatment and appropriate management of R1's psychosis (any major mental disorder characterized by a gross impairment in reality perception) at the facility, Consultant GG recommended that R1 be evaluated in an emergency department. An Alert Note on 12/23/25 at 04:13 PM documented the facility spoke with case management at the hospital around 09:00 AM regarding R1's current status in the hospital. The case manager stated she would call the facility back for further conversation and assistance with alternative placement for R1. On 12/29/25 at 11:59 AM, Licensed Nurse (LN) G stated R1's had increased behaviors after the provider discontinued his medications. R1 became aggressive, hit people, flipped people off, and tried to bite people. She stated staff immediately separated R1 and he was usually easily redirected. LN G stated she documented any behaviors and if R1 became physical, she notified the provider. She stated she never needed to notify the provider about R1 becoming physically aggressive since he did not have those behaviors on her shift. She stated if she notified the provider, she documented the notification in the EMR. LN G stated she received report that R1 was not sleeping prior to going to the hospital and she notified the provider. LN G confirmed she did not see any provider notification notes in R1's EMR from 11/22/25 to 12/21/25, following his increased behaviors. On 12/29/25 at 01:41 PM, LN H stated if a resident had increased behaviors, the care plan had interventions and if the interventions were ineffective, she called Administrative Nurse D and the provider. LN H stated she reported what interventions the staff tried and what worked. She stated if the behavior continued and interventions did not work, she called the provider and family. She stated she documented the behavior and notification in progress notes. On 12/30/25 at 12:28 PM, LN G stated if a resident made self-harming statements, she ensured their safety then notified the provider which she then documented in a progress note. She stated she placed the resident on one-to-one depending on the severity of the behaviors. LN G stated R1's behaviors started after he got off of some medications and he started hitting himself and said he wanted to die and kill himself. On 12/30/25 at 01:25 PM, Administrative Nurse D stated if a resident made suicidal statements or had increased behaviors, staff intervened to make sure they were safe then notified the provider. She stated the staff documented the physician notification. On 12/29/25 at 12:49 PM, Consultant GG stated he did not receive any notification of R1's increased behaviors from 11/22/25 to 12/21/25. He stated he expected the facility to follow their policies regarding notifications. The facility's Changes in Resident's Condition or Status policy, dated 11/26/18, directed the facility immediately informed the resident, resident's physician, and representative when a resident had a significant change in their physical, mental, or psychosocial status; and of the need to alter treatment significantly.

The facility identified a census of 145 residents. The sample included six residents, with six reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to ensure cognitively impaired Resident (R) 2 and R3 remained free from resident-to-resident physical abuse by R1. On 09/30/25 at 07:55 AM, Certified Nurse Aide (CNA) N left the facility dining area unsupervised to assist another staff member. When CNA N returned to the dining area, he observed R2 with blood on his face while R1 (who had a history of wandering into resident rooms and behaviors including wanting to fight) stood nearby with blood on his hands. There was blood splashed on the window and table, and pooling on the floor near R2. CNA N asked R1 if he had hit R2, and R1 stated he had. CNA N asked R1 to walk away and allowed R1 to leave the area unsupervised. R1 walked into R3's room and began punching R3 while R3 laid in his bed. Both R2 and R3 were transported to the hospital for emergency medical treatment. R2 was admitted to the hospital for a subdural hematoma, and R3 was admitted to the hospital for facial lacerations. The facility's failure to prevent physical abuse placed all the residents on R1's unit in immediate jeopardy (IJ).Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (a progressive mental disorder characterized by failing memory and confusion) with unspecified behaviors and other behavioral disturbances. R1's 08/18/25 admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS noted he had no upper or lower extremity impairments and required supervision but could complete his activities of daily living (ADL) independently. The MDS noted R1 displayed physically aggressive behaviors noted one to three days. R1's 08/28/25 Behavioral Care Area Assessment (CAA) noted he had a history of physical aggression and a care plan was implemented to minimize the risk associated with his behaviors. R1's 08/28/25 Functional Abilities CAA noted he was a new admission, required assistance with his ADLs, and a care plan was implemented to minimize the decline of his ADLs. R1's Care Plan initiated 08/19/25 indicated he had a behavioral problem related to his medical diagnoses. The plan instructed staff to assist with his ADLs as needed (08/19/25). The plan instructed staff to administer his medication as ordered (08/19/25), anticipate his needs (08/19/25), and discuss his behaviors (08/19/25). The plan instructed staff to explain and reinforce why his behaviors were inappropriate or unacceptable (08/19/25). The plan indicated he was placed on one-to-one staff supervision to promote safety on 09/30/25. The plan instructed staff to remove R1 from the common area to reduce stimulation and speak to him in a calming manner (09/30/25). A Communication Note completed 09/16/25 indicated R1's resident representative was notified that items were taken out of his room due to the potential they would be used as weapons. A Behavior Note completed 09/19/25 indicated R1 had unpredictable mood changes and extreme behaviors of wanting to fight. The note indicated he walked around smiling and became agitated in seconds. R1 did not take redirections and acted as if he could not hear staff when they spoke to him. The note lacked information on other interventions staff attempted with R1.A Behavior Note completed 09/27/25 revealed R1 spent his free time going into his peers' rooms and taking items. The note revealed R1 did not take redirections and acted as if he could not hear staff when they spoke to him. The note lacked information on other interventions staff attempted with R1.An Alert Note completed 09/30/25 indicated R1 was sent out to an acute medical facility for severe agitation and aggression. The note indicated staff called local law enforcement to stay with R1 until emergency medical services arrived for transport. An Event Note for R2 completed 09/30/25 revealed R2 sustained multiple facial injuries while he was seated in the dining room. The note revealed staff observed a large amount of blood behind his wheelchair, on the table, and the window next to R2's wheelchair. R2 was bleeding from four areas on the left side of his face and was sent out to an acute medical facility for emergency medical assessment and treatment due to his injuries. An Event Note completed 09/30/25 revealed R3 was found in his bed with his head under the covers. The note revealed blood coming from the left side of his mouth. The note revealed he had swelling to the left side of his face and eye, with blood on the walls and his blanket. R3 was sent out to an acute medical facility for emergency medical assessment and treatment due to the severity of his injuries. A Facility Incident Report #0907 completed on 09/30/25 indicated R1 got into a physical altercation with R2 and R3, resulting in facial injuries on both residents. The report noted R2 and R3 were sent out to an acute medical facility for emergency medical evaluation and treatment.A Witness Statement completed by CNA N on 09/30/25 revealed on 09/30/25 at 07:55 AM, CNA N sat in the dining room with the residents and CNA N briefly exited the dining room to assist another staff member in the shower room. CNA N returned to the dining room after about five minutes to find R2 bleeding from his face as he sat in his wheelchair, as R1 stood next to him. The statement indicated CNA N asked R1 if he hit R2 and R1 admitted to hitting R2 and stated, He raped my daughter. The statement noted CNA N asked R1 to leave the immediate area, and then R1 walked into R3's room, where CNA N later observed R1 repeatedly hitting R3 with closed fists as he entered R3's room. The statement revealed CNA N separated the residents, and R1 stated, He raped my daughter. The statement revealed CNA N escorted R1 out of the room and stayed with him until help arrived. A Witness Statement completed by Certified Medication Aide (CMA) N on 09/30/25 revealed on 09/30/25, CMA R entered the dining room to find R2's face bleeding and then went into R3's room. The statement revealed that CMA R had to physically remove R1 from R3's room. A Witness Statement completed by Licensed Nurse (LN) G on 09/30/25 revealed LN G was called to the secured unit due to an emergency on 09/30/25. When LN G entered the dining R2 was bleeding as he sat in his wheelchair. The statement indicated blood was splashed on the window, table, and floor behind his wheelchair. R2 was unresponsive but blinking his eyes at times. LN G also observed R3 in his bed with facial swelling on the left side of his face and eye, with blood on the blanket and wall next to his bed. On 10/02/25 at 12:15 PM, CMA R stated R1 did not display daily behaviors and had no behaviors before his incident on 09/30/25. He stated R1 was usually easily redirectable and kept to himself. He stated R1 kept yelling out, They raped my daughter, during the incident with R2 and R3. He stated that both R2 and R3 had to be sent out due to their injuries. On 10/02/25 at 12:05 PM, Consultant GG stated R3 admitted to the hospital with a subdural hematoma (bleeding around the brain) and a six-millimeter mid-line shift (displacement of the brain structures that can result in increased pressure on the brain). He stated R3's prognosis did not look good. On 10/02/25 at 02:28 PM, R2's Resident Representative indicated he was admitted to an acute medical facility on 09/30/25 for a subdural hematoma and fluid buildup in his lungs. He stated he was told that R2 was not expected to live during the medical facility's first assessment. On 10/02/25 at 02:34 PM, Administrative Nurse D stated R1 exhibited no behaviors on the morning of the incident with R2 and R3, before the incident occurred. She stated R1 was immediately placed on one-to-one supervision until his eventual discharge. She stated all residents in the secured area were screened immediately after the incident occurred for potential abuse and psychosocial concerns. She stated all three residents involved were sent out for emergency medical assessment. She stated that the facility immediately began in-service training for all available staff. The facility's Abuse, Neglect, and Exploitation policy, revised 06/2024, documented that the resident has a right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy indicated it was the responsibility of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse included, but was not limited to, verbal or non-verbal conduct which caused or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment, or threats of punishment or deprivation. The policy indicated that all staff were to be educated to identify, prevent, and intervene when potential abuse was identified. On 10/02/25 at 03:26 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to protect R2 and R3 from R1's physical abuse, which placed all residents in the immediate area in immediate jeopardy. The facility identified, implemented, and completed the following corrective actions related to the incident: 1. The facility immediately assessed R1, R2, and R3 for physical harm. (09/30/25)2. R1 was immediately placed under one-to-one supervision, and his behavioral care plan was updated. (09/30/25)3. The facility immediately notified all three resident representatives and the medical provider. (09/30/25)4. The facility sent R1, R2, and R3 out for immediate acute medical intervention. (09/30/25)5. The facility immediately initiated in-service staff training related to abuse prevention, behavioral health services, dementia care, and unit supervision to be completed by staff before the next available shift on 09/30/25 and completed on 10/01/25. 6. The facility screened all in-house cognitively intact residents for potential abuse or witnessed altercations. (09/30/25)7. The facility screened all residents who resided on the affected secured unit for abuse or psychosocial concerns. (09/30/25)8. Administrative Nurse D completed EMR audits for all residents on the affected unit for potential abuse. (09/30/25)9. The facility's Quality Assurance Committee completed a meeting on 09/30/25. 10. The facility will interview five random staff members about behavioral management five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter. (09/30/25)11. The facility will review all resident-to-resident interactions for the last 30 days to validate root-cause analysis and causative factors. (09/30/25)12. The facility will monitor all residents with known periods of aggression and interventions to reduce the risks of recurring altercations and implement additional measures in the daily clinical meetings and risk meetings. (09/30/25)13. All results will be reported to the Quality Assurance Committee. This deficient practice was deemed past non-compliance due to the corrective actions completed on 10/01/25, prior to the surveyor entering the facility. The citation remains at a J scope and severity to represent R2 and R3's actual harm.

The facility identified a census of 147 residents. The sample included 31 residents, with three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Residents (R) 127, R137, R4, R91, R8, and R11. This deficient practice placed the residents at risk for impaired dignity and quality of life. Findings Included: - On 05/12/25 at 07:23 AM, R127 (a severely cognitively impaired resident) stood in the first room right off the dining room. R127 had her pants and briefs pulled down and was feeling the inside of her briefs. R127 was not in her bedroom. On 05/12/25 at 07:23 AM, R127 stood in the first room right off the dining room. R127 had her pants and briefs pulled down and was feeling the inside of her briefs. R127 was not in her bedroom. On 05/13/25 at 08:04 AM, R137 (a severely cognitively impaired resident) walked down the hallway to the dining room. R137 pushed her left hand down the front of her shirt, causing her whole upper sweater to come down with her upper chest exposed. She then exited the dining room. No staff in the dining room to assist her with her shirt. On 05/14/25 at 12:10 PM, R127 walked holding herself between her legs. R127 walked into the first bedroom right off the dining room, pulled down her pants and briefs, and was feeling in the inside of her briefs. R127 was not in her bedroom. On 05/14/25 at 12:10 PM, R127 walked holding herself between her legs. R127 walked into the first bedroom right off the dining room, pulled down her pants and briefs, and was feeling in the inside of her briefs. R127 was not in her bedroom. On 05/14/25 at 12:35 PM, R4 sat at the dining room table next to the emergency exit. Staff walked up to her, placed a clothing protector on her without asking or speaking to her, and then left her alone. On 05/14/25 at 12:45 PM, R91 (a severely cognitively impaired resident) sat in the dining room at the table next to the wall column. R8 (a severely cognitively impaired resident) at to the left of R91 at the table. Staff placed R8's tray on the table in front of her. R91 began grabbing R8's food off her tray. R8 abruptly stood up and took her tray to her room, stating, I can't stand this. R8 returned to the table with her tray once R91's meal was served. On 05/14/25 at 02:55 PM, R11 (a severely cognitively impaired resident) sat at the dining room table closest to the window. R11 received her ice cream from the facility's Ice Cream Social activity. Upon receiving her ice cream, R11 was immediately pulled away from the table by direct care staff and taken to her bed without staff talking to her or asking if she wanted to take her ice cream. On 05/15/25 at 09:03 AM, Licensed Nurse (LN) G stated that residents should not be in any other resident's room. She stated they should not have their clothing off or pulled down. She stated staff were expected to ensure each resident had a safe and dignified environment. She stated staff were expected to ask the resident's permission before providing care or moving them. On 05/15/25 at 09:17 AM, Certified Nurse's Aide (CNA) M stated the residents were expected to be fully clothed while out on the unit or in others' rooms. She stated staff were to ensure residents were treated with dignity and ask their permission before caring. On 05/15/25 at 02:42 PM, Administrative Nurse D stated that residents should never have themselves exposed in another resident's room or public areas. She stated staff were expected to engage in conversation with each resident and ask their permission before performing care. The facility's Behavioral Health Services dated 03/11/25 documented that the facility would provide behavioral health care and services that create an environment that promotes emotional, psychosocial well-being, resident needs, and includes individualized approaches to care.

The facility identified a census of 148 residents. The sample included 29 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that the Consultant pharmacist (CP) identified and reported Resident (R) 37 and R90's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without an appropriate indication for use. The facility failed to ensure the CP recommended a gradual dose reduction (GDR - tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for R37 and R90's antipsychotic medication. The facility also failed to ensure the physician provided the risk versus benefit for the continued use of R90's antipsychotic medications. These deficient practices placed R37, and R90 at risk of unnecessary medication administration and related complications. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnoses of psychosis (any major mental disorder characterized by a gross impairment in perception), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). R37's Annual Minimum Data Set (MDS) dated 08/08/24 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R37 displayed the behaviors of inattention and disorganized thinking that were present and fluctuated. R37 required supervision for his functional abilities. R37's Delirium Care Area Assessment (CAA) dated 08/13/24 documented he had a history and diagnosis of dementia with ongoing cognitive impairments. R37 can be inattentive and have disorganized thinking related to his dementia disease. R37's Psychotropic Drug Use CAA dated 08/13/24 documented he triggered this CAA due to the use of psychotropic medication use. A care plan directed staff monitored R37 for medication side effects. R37's Care Plan was last revised on 02/13/25 and directed staff to administer antipsychotic medications as ordered by the physician. The plan of care directed staff to consult with the pharmacy and the physician to consider a dosage reduction when clinically appropriate. The plan of care directed staff to discuss with the physician and family the ongoing need for the use of the medication. The plan of care directed staff to educate the resident, family, and caregivers about the risks, benefits, and side effects of psychotropic medication drugs being given. R37's 'Orders tab of the EMR documented a physician's order dated 06/25/24 for Seroquel (an antipsychotic medication) 25 milligram (mg) tablet by mouth one time a date for psychosis. This order was discontinued on 09/27/24. This order lacked an appropriate indication for use for a resident with a diagnosis of dementia. R37's 'Orders tab of the EMR documented a physician's order dated 09/27/24 for Seroquel 25 mg tablet to give 12.5 mg by mouth twice daily for psychosis. This order was discontinued on 09/28/24. This order lacked an appropriate indication for use for a resident with a diagnosis of dementia. R37's 'Orders tab of the EMR documented a physician's order dated 09/28/24 for Seroquel 25 mg tablet by mouth twice daily psychosis. This order was discontinued on 11/21/24. This order lacked an appropriate indication for use for a resident with a diagnosis of dementia. R37's 'Orders tab of the EMR documented a physician's order dated 11/21/24 for Seroquel 25 mg tablet by mouth two times a day for psychosis. This order lacked an appropriate indication for use for a resident with a diagnosis of dementia. A review of the CP's Recommendation to Physician reports from May 2024 to the present for R37 revealed that a GDR had not been attempted or recommended since September 2023. The reports also lacked a CP recommendation for an appropriate indication for the use of Seroquel. A Physician Progress Note in the EMR dated 05/01/25 at 12:51 PM documented R37 continued with episodes of agitation and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R37 continued on Seroquel, 25 mg twice daily. There was a desire to reduce this medication but given the failed attempts in the past, he would continue with the same dose for now. The plan was for R37 to remain on Seroquel at this time for Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) associated agitation. All the available medical records and lab results had been reviewed. On 05/13/25 at 08:34 AM, R37 sat at the dining table of a secured unit. R37 sat at a table with another male resident and took the other resident's ice cream. The certified nurse aide (CNA) intervened and moved R37 to another table. On 05/15/25 at 02:08 PM, Licensed Nurse (LN) H stated she could not say for certain what an appropriate indication for use of an antipsychotic medication was but knew that dementia should not be used. On 05/15/25 at 02:42 PM, Administrative Nurse D stated many of the residents came to the facility already being on antipsychotic medication. Administrative Nurse D stated it has been a team effort with the Interdisciplinary Team (IDT) to try to get the GDRs done and the physician's risk versus benefit done on residents. Administrative Nurse D stated that psychosis in a dementia resident was not a good indication for the use of Seroquel. Administrative Nurse D stated that R37 had many behaviors and the Seroquel seemed to help with his symptoms. The facility policy Area of Focus: Pharmacy recommendations dated 11/19/24 documented the Medication Regimen Review (MRR) was a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. The pharmacist must report any irregularities to the attending physician, the facility's medical record, and the director of nursing. These reports must be acted upon. The attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. The pharmacist's review considered factors such as: Whether the physicians and staff have documented objective findings, diagnoses, symptom(s), and/or resident goals and preferences to support indications for use; whether the medication dose, frequency, route of administration, and duration was consistent with the resident's condition, manufacturer's recommendations, and applicable standards of practice; whether the physician and staff have documented attempts for GDR or added any non-pharmacological approaches, in an effort to reduce or discontinue the medication.- R90's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Pain, hypertension (high blood pressure), insomnia (unable to sleep), cognitive communication deficit ( often stems from problems with attention, memory, executive functions), history of falling, muscle weakness, hyperlipidemia ( an abnormally high concentration of fats and lipid in the blood), aphasia (a condition with disordered or absent language function), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 01/31/25, documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R90 needed substantial to maximal assistance with dressing and toileting and set up for eating. The MDS documented R90 received an antidepressant (a class of medications used to treat mood disorders), antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), hypnotic (a class of medications used to induce sleep), and an antianxiety (a class of medications that calm and relax people during the observation period). R90's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/31/25 documented R90 was receiving antipsychotic, antianxiety, and antidepressant medications. The CAA documented the contributing factors included diagnoses of depression and psychosis. The CAA documented Risk factors include side effects, allergic reactions, and improper dosing. The CAA documented R90's care plan would be reviewed and updated to include interventions to address risk factors. R90's Care Plan revised 10/24/24 documented R90 used psychotropic medications. The plan of care for R90 documented nursing staff were to administer medication as the physician ordered and monitor for side effects and effectiveness. R90's plan of care documented nursing staff were to consult with the pharmacy, and the physician to consider dosage reduction when clinically appropriate at least quarterly. The facility was to review behaviors, interventions, and alternate therapies attempted and their effectiveness as per facility policy. The plan of care for R90 documented staff were to educate the resident, family, and caregivers about the risks, benefits, and side effects of psychotropic medication. R90's EMR under Orders documented the following physician's order: Seroquel (anti-psychotropic) oral tablet (Quetiapine Fumarate) give 75 milligrams (mg) three times a day for psychosis, dated 11/14/24. A review of the CP's Monthly Medication Reviews (MMR) from 04/2024 to 04/2025 revealed no recommendations noting the inappropriate indication of use related to R90's quetiapine fumarate medication. On 05/14/25 at 07:32 AM, R90 laid on his bed, with the head of the bed elevated. On 05/15/25 at 09:25 AM, Licensed Nurse (LN) J stated she did not do anything with the pharmacy reviews. She was unsure who would inform the physician about the correct indication for psychotropic medication. On 05/15/25 at 02:42 PM, Administrative Nurse D stated many of the residents came to the facility already being on antipsychotic medication. Administrative Nurse D stated it has been a team effort with the Interdisciplinary Team (IDT) to try to get the GDRs done and the physician's risk versus benefit done on residents. Administrative Nurse D stated the physician works hard to ensure the correct indication for medication. The facility's Unnecessary Medication policy last revised on 04/22/25 documented the facility would ensure only medications required to treat the resident's assessed condition were being used, reducing the need for, and maximizing the effectiveness of medications was an important consideration for all residents. As a part of medication management, it was important for the IDT to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility would assess the resident's underlying condition, current, symptoms, and expressions, and preferences and goals for treatment. This would assist the facility in determining if there were any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. The resident's medical record should show documentation of adequate indicators for a medication's use and the diagnosed condition for which a medication was described. When there were multiple prescribers, the continuation of a medication needed to be evaluated to determine if the medication was still warranted in the context of the resident's other medications and comorbidities.

The facility identified a census of 148 residents. The sample included 29 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 37, R93, R248, and R90 were free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without an appropriate indication for use or a gradual dose reduction (GDR - tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). The facility failed to ensure the physician provided the risk versus benefit statement for the continued use of antipsychotic medications. These deficient practices placed R37, R93, R248, and R90 at risk of unnecessary medication administration and related complications. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnoses of psychosis (any major mental disorder characterized by gross impairment in perception), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). R37's Annual Minimum Data Set (MDS) dated 08/08/24 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R37 displayed the behaviors of inattention and disorganized thinking that were present and fluctuated. R37 required supervision for his functional abilities. R37's Delirium Care Area Assessment (CAA) dated 08/13/24 documented he had a history and diagnosis of dementia with ongoing cognitive impairments. R37 could be inattentive and had disorganized thinking related to his dementia disease. R37's Psychotropic Drug Use CAA dated 08/13/24 documented he triggered this CAA due to the use of psychotropic medication use. R37's care plan directed staff to monitor R37 for medication side effects. R37's Care Plan was last revised on 02/13/25 and directed staff to administer antipsychotic medications as ordered by the physician. The plan of care directed staff to consult with the pharmacy and the physician to consider a dosage reduction when clinically appropriate. The plan of care directed staff to discuss with the physician and family the ongoing need for the use of the medication. The plan of care directed staff to educate the resident, family, and caregivers about the risks, benefits, and side effects of psychotropic medication drugs being given. R37's Orders tab of the EMR documented a physician's order dated 06/25/24 for Seroquel (an antipsychotic medication) 25 milligram (mg) tablet by mouth one time a date for psychosis. This order was discontinued on 09/27/24. R37's Orders tab of the EMR documented a physician's order dated 09/27/24 for Seroquel 25 mg tablet to give 12.5 mg by mouth twice daily for psychosis. This order was discontinued on 09/28/24. R37's Orders tab of the EMR documented a physician's order dated 09/28/24 for Seroquel 25 mg tablet by mouth twice daily for psychosis. This order was discontinued on 11/21/24. R37's Orders tab of the EMR documented a physician's order dated 11/21/24 for Seroquel 25 mg tablet by mouth two times a day for psychosis. A review of the Consultant Pharmacist's Recommendation to Physician reports from May 2024 to the present for R37 revealed that a GDR had not been attempted or recommended since November 2023. The reports also lacked a consultant pharmacist (CP) recommendation for an appropriate indication for the use of Seroquel or a physician's risk versus benefit for the continued use of the medication. On 05/13/25 at 08:34 AM, R37 sat at the dining table of a secured unit. R37 sat at a table with another male resident and took the other resident's ice cream. The certified nurse aide (CNA) intervened and moved R37 to another table. On 05/15/25 at 02:08 PM, Licensed Nurse (LN) H stated she could not say for certain what an appropriate indication for the use of antipsychotic medication was but knew that dementia should not be used. On 05/15/25 at 02:42 PM, Administrative Nurse D stated many of the residents came to the facility already being on antipsychotic medication. Administrative Nurse D stated it has been a team effort with the Interdisciplinary Team (IDT) to try to get the GDRs done and the physician's risk versus benefit done on residents. Administrative Nurse D stated that dementia was not a good indication for the use of an antipsychotic. Administrative Nurse D stated dementia should not be used as a diagnosis for an antipsychotic without proper physician rationale. Administrative Nurse D stated that R248 was a fairly new resident, and recommendations had not been performed yet by the CP. The facility's Unnecessary Medication policy last revised on 04/22/25 documented the facility would ensure only medications required to treat the resident's assessed condition were being used, reducing the need for, and maximizing the effectiveness of medications were important considerations for all residents. As a part of medication management, it was important for the IDT to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility would assess the resident's underlying condition, current, symptoms, and expressions, and preferences and goals for treatment. This would assist the facility in determining if there were any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. The resident's medical record should show documentation of adequate indicators for a medication's use and the diagnosed condition for which a medication was described, when there were multiple prescribers, the continuation of a medication needed to be evaluated to determine if the medication was still warranted in the context of the resident's other medications and comorbidities. - R93's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychosis (any major mental disorder characterized by gross impairment in reality perception), insomnia (inability to sleep), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time). R93's admission Minimum Data Set (MDS) dated 04/24/25 documented she had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R93 displayed symptoms of delirium (sudden severe confusion, disorientation, and restlessness) that included inattention and disorganized thinking. R93's MDS documented she displayed both physical and verbal behaviors directed toward others. R93's MDS documented she utilized a Broda chair (specialized wheelchair with the ability to tilt and recline). R93's MDS documented she required set-up assistance for eating and substantial to being dependent on staff for her activities of daily living (ADL) and functional abilities. R93's MDS documented she was frequently incontinent of bladder and always incontinent of bowel. The MDS documented R93 received an antipsychotic, an antianxiety (a class of medications that calm and relax people), an anticoagulant (a class of medications used to prevent the blood from clotting), and an antidepressant (a class of medications used to treat mood disorders) medication on a regular basis. R93's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/01/25 documented she used psychotropic medications. The facility administered the medications per physician orders and observed the resident for adverse effects. R93's Care Plan revised on 04/22/25 directed staff to administer her antipsychotic medications as ordered by the physician. The plan of care directed staff to consult with the pharmacy and the physician to consider a dosage reduction when clinically appropriate. The plan of care directed staff to discuss with the physician and family the ongoing need for the use of the medication. The plan of care directed staff to educate the resident, family, and caregivers about the risks, benefits, and side effects of psychotropic medication drugs being given. The plan of care directed staff to observe for and report as needed any adverse reactions to the antipsychotic medications. R93's Orders tab of the EMR documented an order dated 04/18/25 for brexpiprazole (Rexulti - an antipsychotic medication) 3 milligrams (mg) by mouth in the afternoon for psychosis. R93's Orders tab of the EMR documented an order dated 04/18/25 for Seroquel (an antipsychotic medication) 25 mg tablet by mouth twice daily for psychosis. A review of the Consultant Pharmacist's Medication Regimen Review (MRR) for April 2025 lacked a recommendation for an appropriate indication for the use of the antipsychotics Seroquel and brexpiprazole. On 05/13/25 at 08:17 AM, R93 laid in her bed resting. R93's bed was in the low position and the call light was within reach. On 05/15/25 at 02:08 PM, Licensed Nurse (LN) H stated she could not say for certain what an appropriate indication for the use of antipsychotic medication was but knew that dementia should not be used. On 05/15/25 at 02:42 PM, Administrative Nurse D stated many of the residents came to the facility already being on antipsychotic medication. Administrative Nurse D stated it has been a team effort with the Interdisciplinary Team (IDT) to try to get the GDRs done and the physician's risk versus benefit done on residents. Administrative Nurse D stated that dementia was not a good indication for the use of an antipsychotic. Administrative Nurse D stated dementia should not be used as a diagnosis for an antipsychotic without proper physician rationale. Administrative Nurse D stated that R248 was a fairly new resident, and recommendations had not been performed yet by the CP. The facility's Unnecessary Medication policy last revised on 04/22/25 documented the facility would ensure only medications required to treat the resident's assessed condition were being used, reducing the need for, and maximizing the effectiveness of medications were important considerations for all residents. As a part of medication management, it was important for the IDT to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility would assess the resident's underlying condition, current, symptoms, and expressions, and preferences and goals for treatment. This would assist the facility in determining if there were any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. The resident's medical record should show documentation of adequate indicators for a medication's use and the diagnosed condition for which a medication was described, when there were multiple prescribers, the continuation of a medication needed to be evaluated to determine if the medication was still warranted in the context of the resident's other medications and comorbidities. - R248's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (elevated blood pressure), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R248's admission Minimum Data Set (MDS) was still in progress and had not been completed. R248's Care Area Assessment was still in progress and had not been completed. R248's Care Plan dated 05/05/25 directed staff to administer antipsychotic medications as ordered by the physician. R248's plan of care directed staff to observe R248 for side effects and the effectiveness of medications each shift. R248's Orders tab of the EMR documented a physician's order dated 05/05/25 for Aripiprazole (an antipsychotic medication) 5 milligram (mg) tablet by mouth once daily for dementia. This order lacked an approved indication for antipsychotic medication use. A Consultant Pharmacist (CP) review had not been completed yet as R248 was admitted to the facility on [DATE]. On 05/13/25 at 10:19 AM, R248 sat in his wheelchair in his room watching TV. R248's call light was within reach. On 05/15/25 at 02:08 PM, Licensed Nurse (LN) H stated she could not say for certain what an appropriate indication for the use of antipsychotic medication was but knew that dementia should not be used. On 05/15/25 at 02:42 PM, Administrative Nurse D stated many of the residents came to the facility already being on antipsychotic medication. Administrative Nurse D stated it has been a team effort with the Interdisciplinary Team (IDT) to try to get the GDRs done and the physician's risk versus benefit done on residents. Administrative Nurse D stated that dementia was not a good indication for the use of an antipsychotic. Administrative Nurse D stated dementia should not be used as a diagnosis for an antipsychotic without proper physician rationale. Administrative Nurse D stated that R248 was a fairly new resident, and recommendations had not been performed yet by the CP. The facility's Unnecessary Medication policy last revised on 04/22/25 documented the facility would ensure only medications required to treat the resident's assessed condition were being used, reducing the need for, and maximizing the effectiveness of medications were important considerations for all residents. As a part of medication management, it was important for the IDT to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility would assess the resident's underlying condition, current, symptoms, and expressions, and preferences and goals for treatment. This would assist the facility in determining if there were any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. The resident's medical record should show documentation of adequate indicators for a medication's use and the diagnosed condition for which a medication was described, when there were multiple prescribers, the continuation of a medication needed to be evaluated to determine if the medication was still warranted in the context of the resident's other medications and comorbidities.- R90's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Pain, hypertension (high blood pressure), insomnia (unable to sleep), cognitive-communication deficit( often stems from problems with attention, memory, executive functions), deficit, history of falling, muscle weakness, hyperlipidemia ( an abnormally high concentration of fats and lipid in the blood), aphasia (a condition with disordered or absent language function), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 01/31/25, documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R90 needed substantial to maximal assistance with dressing and toileting. The MDS documented R90 required setup for eating. The MDS documented R90 received an antidepressant (a class of medications used to treat mood disorders), antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), hypnotic (a class of medications used to induce sleep), and an antianxiety (a class of medications that calm and relax people during the observation period. R90's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/31/25 triggered secondary to R90 receiving antipsychotic, antianxiety, and antidepressant medications. R90's CAA documented the contributing factors including diagnosis of depression and psychosis. The CAA documented risk factors including side effects, allergic reactions, and improper dosing. The CAA documented R90's care plan would be reviewed and updated to include interventions to address risk factors. R90's Care Plan revised 10/24/24 documented R90 used psychotropic medications. The plan of care for R90 documented nursing staff were to administer medication as the physician ordered and monitor for side effects and effectiveness. R90's plan of care documented nursing staff were to consult with the pharmacy, and the physician to consider dosage reduction when clinically appropriate at least quarterly. The facility was to review behaviors, interventions, and alternate therapies attempted and their effectiveness as per facility policy. The plan of care for R90 documented staff were to educate the resident, family, and caregivers about the risks, benefits, and side effects of psychotropic medication. R90's EMR under Orders documented the following physician's order: Seroquel (anti-psychotropic) oral tablet (Quetiapine Fumarate) give 75 milligrams (mg) three times a day for psychosis dated 11/14/24. Review of R90's EMR lacked evidence of a physician-documented rationale for including the risks versus benefits of R48's antipsychotic medication. On 05/14/25 at 07:32 AM, R90 laid on his bed, with the head of the bed elevated. On 05/15/25 at 02:08 PM, Licensed Nurse (LN) H stated she could not say for certain what an appropriate indication for the use of antipsychotic medication was but knew that dementia should not be used. On 05/15/25 at 02:42 PM, Administrative Nurse D stated many of the residents came to the facility already on antipsychotic medication. Administrative Nurse D stated it has been a team effort with the Interdisciplinary Team (IDT) to try to get the Gradual Dose Reduction (GDRs) done and the physician's risk versus benefit done on residents. Administrative Nurse D stated that psychosis in a dementia resident was not a good indication for the use of Seroquel. Administrative Nurse D stated R90 had many behaviors and the Seroquel seemed to help with his symptoms. On 05/19/25 at 10:40 AM, communication from the facility documented 07/25/23 a pharmacy consult was obtained and approved by the physician for a dose reduction for R90's Seroquel. A GDR was declined on 12/23 for R90's Seroquel. The facility's Unnecessary Medication policy last revised on 04/22/25 documented the facility would ensure only medications required to treat the resident's assessed condition were being used, reducing the need for, and maximizing the effectiveness of medications was an important consideration for all residents. As a part of medication management, it was important for the IDT to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility would assess the resident's underlying condition, current, symptoms, and expressions, and preferences and goals for treatment. This would assist the facility in determining if there were any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. The resident's medical record should show documentation of adequate indicators for a medication's use and the diagnosed condition for which a medication was described, when there were multiple prescribers, the continuation of a medication needed to be evaluated to determine if the medication was still warranted in the context of the resident's other medications and comorbidities.

- R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), history of cervical vertebra fracture (broken bone of the spinal column), history of falls, and unsteadiness on her feet. The Annual Minimum Data Set (MDS) dated 12/06/24 documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview was conducted, which indicated severely impaired cognition. The MDS documented R34 was independent with walking 10 feet and 50 feet. R34 required partial to moderate assistance with walking 150 feet. The Quarterly MDS dated 04/23/25 documented a BIMS score of 99 and a staff interview was conducted, which indicated severely impaired cognition. The MDS documented that R34 was independent to walk 10 feet, required supervision to touch assistance to walk 50 feet, and required partial to moderate assistance to walk 150 feet. R34's Falls Care Area Assessment (CAA) dated 12/16/24 documented she was at risk for fall-related to her psychotropic (alters mood or thought) medication use during the observation period. R34's Care Plan, dated 12/05/22 documented staff would place her call light within reach. R34's EMR under the Assessment tab revealed the following Fall Risk Evaluation dated 05/01/25 that documented a score of 15, which indicated a resident's score above 10 was at risk for falls. On 05/13/25 at 07:27 AM, R34 sat reclined in a Broda chair (specialized wheelchair with the ability to tilt and recline) asleep. She was covered with a blanket. R34's call light was across the room on her bed, out of her reach. On 05/14/25 at 07:20 AM, R34 sat reclined in a Broda chair asleep. She was covered with a blanket. R34's call light was across the room on her bed, out of her reach. On 05/15/25 at 10:15 AM, Certified Nurse Aide (CNA) P stated R34 was not able to recline the Broda chair or cover herself with a blanket. CNA P stated the call light should be within R34's reach. CNA P stated every resident on the unit was a high fall risk. On 05/15/25 at 10:30 AM, Licensed Nurse (LN) I stated every resident on the unit was a high fall risk. LN I stated a call light should always be within reach when a resident was in the room. LN I stated R34 was not able to recline herself in the Broda chair or cover herself up with a blanket. On 05/15/25 at 02:43 PM, Administrative Nurse D stated she would expect the resident's call light to within reach when the resident was in their room. The facility's Fall Management last reviewed on 03/11/25 documented the facility would assess the resident upon admission and readmission, quarterly with change in the condition and with and fall event for any fall risks and would identify appropriate interventions to minimize the risk of injury related to falls.The facility reported a census 147 residents. The sample included 31 residents, with six reviews for accidents. Based on observations, interviews, and record review, the facility failed to promote a safe care environment free from accidents and hazards for Residents (R) 198, R9, and R34. These deficient practices placed the residents at risk for preventable falls and injuries. Findings Included: - The Medical Diagnosis section within R198's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acute femur (upper leg bone) fracture (broken bone), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R198's Significant Change Minimum Data Set (MDS) dated 10/25/24 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted no behaviors observed. The MDS noted one-sided upper extremity impairment and bilateral (both sides) lower extremity impairment. The MDS noted he used a wheelchair for mobility. The MDS noted he was dependent on staff assistance for bed mobility, toileting, bathing, lower body dressing, putting on footwear, and personal hygiene. The MDS noted he was always incontinent of bowel and bladder. The MDS noted he had fractures and other multiple traumas. R198's Cognitive Impairment Care Area Assessment (CAA) completed 07/12/24 noted he had behaviors related to his dementia diagnosis and required 24-hour a day care. The CAA noted he required total care. R198's Communication CAA completed 07/12/24 noted he had severe cognitive impairment that rendered him unclear with garbled speech. The CAA noted he was unable to voice his needs. R198's Care Plan initiated 07/01/24 indicated he was at risk for activities of daily living (ADL) self-care deficit and falls related to his medical diagnoses. R198's plan noted he had verbal and physically aggressive behaviors (07/12/24). The plan instructed staff to speak to him calmly and divert his attention. The plan noted he was dependent on staff assistance for his transfers, toileting, dressing, personal hygiene, bathing, and oral hygiene. The plan noted he required total assistance from two staff for repositioning and turning in bed (10/28/24). The plan noted he required total assistance from two staff for transfers but was changed to a Hoyer lift (full mechanical body lift) on 11/13/24. R198's EMR under Progress Note revealed an Event Note completed on 11/01/24. The note revealed R198 suffered a laceration of his scalp during a staff-assisted transfer from his wheelchair to his bed. The note revealed that he was sent to an acute medical facility for evaluation and treatment for his head injury. A Skin Related Injury report #4946 completed 11/01/24 indicated R198 received a laceration to his scalp (top of head) during a transfer from his wheelchair to his bed. The report indicated he received sutures on his scalp due to a head injury. The report noted R198 was unable to explain how he got injured. The report lacked a root-cause analysis or description of how the injury occurred. The report indicated that witness statements were found. No witness statements were provided with this report. A review of Certified Nurse's Aide (CNA) Q's Corrective Action Form completed on 11/04/24 noted she received a written (final) warning counseling related to R198's accident on 11/04/24. The form indicated R198 became agitated and anxious while being transferred from a Sit-to-stand lift by CNA Q. The form indicated this caused a laceration to R198's head. The form indicated this action put the resident at risk for injuries. The form indicated CNA Q was provided additional training for the utilization of mechanical lifts. The form noted she was expected to complete training in safety and person-centered care related to distracting and reapproaching residents. The form noted she completed the training on 11/13/24. R198's EMR under Progress Notes revealed an Event Note completed 01/02/25 at 07:48 PM by Licensed Nurse (LN) K. The note indicated staff found R198 in his bed with a blood-soaked Band-Aid. The note revealed the oncoming direct care staff then reported the injury to LN K. The note revealed R198 did not have this injury the previous evening. LN K cleaned and assessed the wound to find a three-centimeter (cm) laceration on his forehead. The note revealed LN K believed the wound might need sutures and notified the medical provider. R198 was sent out to an acute care facility for evaluation and treatment. R198's EMR revealed no progress notes or nursing assessments completed at the time of R198's injury prior to LN K's discovery of the wound. The facility was unable to provide this documentation as requested on 05/15/25. A Skin Related Injury report # 5074 completed 01/02/25 indicated staff found R198 around 04:30 PM with a blood-saturated Band-Aid on his forehead. The report noted R198 had a three-centimeter laceration on his forehead and the wound needed to be sutured. The report revealed R198 was unable to explain how he received the injury. The note revealed R198 was sent out to an acute care facility at 05:30 PM for evaluation and treatment. A Witness Statement completed by CNA PP on 01/03/25 indicated she was assisting with R198's Hoyer Lift transfer before his injury occurred. The statement indicated CNA's PP and CNA Q transferred R198 to his bed from his wheelchair. The statement then indicated CNA PP left the room to assist other residents. A Witness Statement completed by CNA Q on 01/03/25 indicated she was assisting with R198's wheelchair-to-bed transfer via a Hoyer lift after lunch. The statement indicated CNA PP left the room to assist another resident and returned to check on R198. The statement revealed upon returning to the room CNA Q found R198's feet were on the floor. The statement revealed R198 placed his feet back on his bed and noticed that R198 was incontinent of bowel. The statement revealed CNA Q raised the bed and turned R198 towards the wall. The statement revealed CNA Q turned R198 back towards her, and R198 punched CNA Q in the mouth. The statement revealed CNA Q saw that R198's head was bleeding as R198 grabbed her shirt. The statement revealed CNA Q placed a Band-Aid on his forehead and told CNA PP that R198 punched her in her mouth. A review of CNA Q's Termination Form completed on 01/07/25 indicated CNA Q was terminated due to her failure to comply with company standards regarding her CNA position. The form noted the risk of poor resident outcomes and a burden to her coworker as the consequences of her actions. R198's EMR under Interdisciplinary Team (IDT) note completed on 01/07/24 indicated R198's injury was caused when he struck his head on a wall outlet next to his bed while he was agitated during care. On 05/15/25 at 09:11 AM, LN NN stated she worked with CNA Q during his accident on 11/01/24. She stated CNA Q brought R198 back to his room after lunch. She stated R198 was agitated and had behaviors with CNA Q. LN NN stated on the 11/01/24 incident, R198 punched CNA Q resulting in the Sit-to-stand to slip and strike him in the head. She stated the Sit-to-stand brakes were not locked. On 05/15/25 at 09:34 AM, CNA Q stated R198 was highly agitated during both accidents. She stated she was attempting to transfer him into his bed via the Sit-to-stand lift. She stated she bent down to look at him, and he punched her in the mouth. She stated the shock of this punch caused her to grab the lift, resulting in the lift arm striking his head (11/01/24). CNA Q stated on 01/02/25 that she moved R198 back to his bed after lunch with another staff. She stated that both staff left the room to assist other residents. She stated she re-entered the room briefly and found R198 hanging off the side of his bed with his feet on the floor. She stated she pulled his feet back up on the bed and noticed he had a bowel movement. She stated she turned him on his side (facing the wall). She stated that upon turning him back, R198 grabbed her and punched her. She stated she noticed his head bleeding. She stated she reported the incident to CNA PP and put a Band-Aid on his head. On 05/15/25 at 09:34 AM, CNA PP stated she assisted CNA Q with R198's bed transfer on 01/02/25 but then left the room to assist other residents. She stated the unit nurse left early that day, so she was not sure who the accident was reported to or if R198 was assessed. She stated the facility completed annual abuse, neglect, and exploitation training. She stated that injuries and accidents a required to be reported to the nurse immediately. On 05/15/25 at 11:43 AM, LN K stated he started his shift with no knowledge or pass-down information related to R198's injury. He stated that the previous shift nurse left early. LN K stated the staff found R198 in his bed, resting, and noticed the head injury. He stated he notified Administrative Nurse D and the medical provider upon assessment of the wound's condition and recommended further evaluation. On 05/15/25 at 02:44 PM, Administrative Nurse D stated she did not feel the accidents were abuse-related due to having witnesses for the accidents. She stated the first accident was related to a slip of the Sit-to-stand lift, and the second was due to his head hitting a wall outlet. She stated that the witness statements corroborated the observations at the time. She stated that staff received annual training related to abuse, neglect, and exploitation. She stated staff were expected to report falls, accidents, and injuries immediately to the on-duty nurse. The Fall Management policy last revised 04/07/22 documented residents would be assessed 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 would be developed and initiated by the admitting nurse for any residents assessed to be a risk for falls. Upon completion of the other interdisciplinary teams (IDT) admission and readmission assessments, the IDT will review any additional fall risk indicators and revise the resident's care plan as indicated.- R9 ' s Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cellulitis (a common bacterial infection of the skin and underlying tissues) of left lower limb, intracapsular fracture (a bone fracture that occurs within the joint capsule, specifically in the hip, the femoral head and femoral neck) of left femur, unsteadiness on feet, muscle weakness, Alzheimer ' s disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), and Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) of right buttock and left buttock. The Modification of Quarterly Minimum Data Set (MDS) for R9 dated 03/04/25 documented a Brief Interview for Mental Status (BIMS) should not be performed, R9 was rarely or never understood. The MDS documented R9 required supervision or touching with eating, dependent on staff for toileting, and substantial to maximal assistance by staff for bathing. The MDS documented R9 had one non-injury fall, one fall with injury, and no falls resulting in a fracture. R9's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/1/25 documented R9 had a history and diagnosis of dementia with ongoing cognitive impairments. R9 was unable to attend his assessment, resulting in a BIMS score of 99. R9's Care Plan dated 01/29/24 documented R9 was a fall risk, and staff were to assist him with his activities of daily living (ADL) as needed and place his call light within his reach. R9 ' s plan of care documented staff were to provide activities that minimize the potential for falls while providing diversion and distraction and utilize activities that interested residents at that time. R9 ' s plan of care documented staff were to toilet R9 upon waking, before, and after meals, and at bedtime. R9 ' s plan of care dated 05/03/24 documented staff were to ensure R9 was in the center of his bed. The plan of care documented a yellow star placed outside of the room on the shadow box along with yellow tape on any ambulation assistive devices to signal to all staff that they are a high fall risk. R9 ' s plan of care dated 01/03/25 documented staff were not to put R9 in his bed until he was fatigued. R9 ' s EMR note Event Note dated 01/02/25 documented at approximal 01:40 PM the nurse was called to R9 ' s room by a CNA. When the nurse entered the room, R9 was observed by the nurse to be on the floor, he was sitting on his buttocks in the middle of his room, with his back against the window. The nurse noted adequate lighting, and there was dried blood on the floor of R9 ' s floor. R9 attempted to clean the blood on the floor with a paper towel. R9 was wearing only his socks and no shoes. R9 ' s bed was in a high position, above the nurse ' s waist. The bed remote was on R9 ' s bed by the head of the bed. The nurse documented R9 was alert and appeared to be alert to himself with confusion per his normal baseline. The nurse documented R9 had bleeding on the right side of his eyebrow. The nurse documented no other injuries during the assessment. R9 was toileted and assisted back to his bed for a nap by the CNA after lunch. The nurse documented CNAs stated R9 ' s bed was placed in the lowest position when he was placed in his bed, but when R9 was found his bed was found to be in the highest position. The nursing staff informed the physician and received orders to send R9 to the emergency room (ER). R9 ' s guardian was called and informed of the transfer. R9 ' s EMR under Physicians Notes documented the resident took Eliquis (blood thinner) and had an open laceration. The physician ordered R9 to be sent to the ER for further evaluation and management with concerns related to fractures or intracranial bleed with the level of fall R9 obtained. The physician documented R9 needed suturing of a laceration. R9 ' s EMR under Event Note dated 01/02/25 at 05:49 PM documented R9 returned from the hospital with no evidence of acute intracranial pathology from the scan, R9 ' s laceration to the left eye was secured with sutures to be removed in seven days. R9 ' s EMR under Event Note dated 01/02/25 at 10:40 PM documented when the nurse was doing neuro checks on R9, R9's left leg had less movement and he grimaced. The nurse noted that the physician was called for an emergent (STAT) X-ray of the left hip order. The X-ray department stated they would not be in the facility until 01/03/25. The physician was notified and ordered to send R9 to the ER for evaluation. R9 ' s EMR under Alert Note dated 01/02/25 nurse noted R9 left the building to go to the ER. R9 ' s EMR under Event Note dated 01/03/25 documented an unwitnessed fall on 01/02/25 with head and hip injuries. R9 attempted to get out of bed after lunch. R9 ' s updated plan of care directed staff to ensure R9 did not lay down until he was ready for a nap. R9 ' s EMR under Admission/Readmission dated 01/10/25 at 02:16 PM documented R9 returned to the facility after his hospital stay. R9 ' s EMR lacked a bed control device assessment to ensure he was safe to operate his bed. On 05/15/25 at 09:25 AM, Licensed Nurse (LN) J stated if a resident had dementia, nursing ensured the resident did not have the bed control. She stated residents with dementia were not safe to operate their own bed. LN J stated that would be a fall risk. On 05/15/25 at 02:27 PM, Certified Nurse ' s Aide (CNA) QQ stated residents with dementia did not have their bed controls, the nursing staff put the bed control at the top of the resident ' s bed to ensure the resident did not raise the bed to a high position. CNA QQ stated residents that had dementia used beds that were put at the lowest position due to the resident being a fall risk. On 05/15/25 at 02:42 PM, Administrative Nurse D stated the Interdisciplinary Team (IDT) reviewed each fall and decided on an appropriate plan of care. Administrative Nurse D stated the team would start with the least restrictive plan, such as ensuring the resident was not laid down in his bed until he was fatigued. Administrative Nurse D stated taking the resident's bed control, which raises his bed up or down would be a restraint. Administrative Nurse D stated she was unsure what an assessment to ensure the resident was safe with a bed device was, she stated the facility does not have an assessment for devices. The facility's Fall Management last reviewed on 03/11/25 documented the facility would assess the resident upon admission and readmission, quarterly with change in the condition and with and fall event for any fall risks and would identify appropriate interventions to minimize the risk of injury related to falls.

- R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), muscle weakness, and cerebrovascular accident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 10/15/24 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R23 had no behavioral symptoms during the observation period. The Quarterly MDS dated 04/10/25 documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented that R23 had no behavioral symptoms during the observation period. The MDS documented R23 had received antidepressant (a class of medications used to treat mood disorders) medication and antianxiety (a class of medications that calm and relax people) during the observation period. R23's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/23/24 documented. She had ongoing cognitive impairment related to her history of strokes. R23's Care Plan dated 10/25/24 directed the staff to reassure her when she was resistive with activities of daily living (ADL), leave and return five to 10 minutes later, and try again as safety allowed. R23's EMR under the Progress Notes tab revealed the following: On 03/28/25 at 08:50 PM, a Behavior Note that documented R23 was verbally and physically aggressive toward the staff during the assistance of ADLs. R23 stated to stop and go away to the staff. R23 continued to hit, pinch, and kick during the ADL assistance. Staff had redirected R23 with minimal effect and R23 continued the verbally and physically aggressive behavior toward the staff during their assistance with ADLs. On 03/29/25 at 01:28 PM a Behavior Note documented R23 was combative during a transfer from her bed into the wheelchair with the assistance of two staff members. On 03/29/25 at 06:46 PM a Behavior Note documented R23 was verbally and physically aggressive toward staff during ADL assistance. R323stated stop and quit it to the staff as they assisted her. R23 kicked, bit, and pinched the staff during their assistance. Staff redirected R23 with minimal effect as they continued to provide care. On 03/29/25 at 05:50 PM an Event Note documented a staff member who had provided assistance to R23 and reported R23 had an open area on her right arm. A skin tear was noted on R23's right arm. On 04/21/25 at 06:40 PM a Behavior Note documented R23 was verbally and physically aggressive toward the staff as they provided her assistance with ADLs. R23 yelled leave me alone and she would get them. R23 continued to hit, pinch and hit at the staff during their assistance. Staff attempted to redirect R23 with minimal effectiveness, and R23 continued to be aggressive toward the staff. On 04/22/25 at 09:01 PM a Behavior Note documented R23 was verbally and physically aggressive toward the staff as they provided her assistance with ADLs. R23 yelled quit it and leave me alone. R23 continued to hit, pinch and hit at the staff during their assistance. Staff attempted to redirect R23 with minimal effectiveness, and R23 continued to be aggressive toward the staff. On 05/2/25 at 01:00 PM a Behavior Note documented R23 was combative toward staff when they attempted to administer her medication. R23 attempted to hit staff and bite down on the spoon which made it difficult for staff to administer R23 her medications. On 05/10/25 at 10:40 AM a Skin/Wound Note documented R23 had received a skin tear on her right forearm during staff assistance with ADLs. Staff reported R23 had been combative during assistance with ADLs, dressing, transfers, and grooming. On 05/11/25 at 01:42 PM a Behavior Note documented R23 was combative with transfers from her bed into the wheelchair. R23 had resisted staff during their assistance with ADLs. R23 would bite staff and grab at staff's arms during their assistance with ADLs. On 05/13/25 at 07:32 AM R23 laid asleep on the right side of the bed. R23's bed was in the lowest position, asleep on her bed, on her left side with the bed in the low position. On 05/15/25 at 10:15 AM, Certified Nurse Aide (CNA) P stated R23 had behaviors at times. CNA P stated she would attempt to reapproach later. CNA P stated it would be helpful to have other person-centered interventions to help with R23's behaviors. On 05/15/25 at 10:30 AM, Licensed Nurse (LN) I stated when R23 became combative with staff during their assistance. LN I stated they were to leave and reapproach her later. LN I was not sure if there were any person-centered interventions on R23 care plan for staff to use when she became combative. On 05/15/25 at 02:43 PM, Administrative Nurse D stated the staff would try to redirect the resident when they became combative during staff assistance with ADLs. Administrative Nurse D stated she would not expect staff to care plan every behavioral intervention. The facility's Residents Rights policy revised on 09/2024 documented the residents have a right to a dignified existence, self-determination, and communication with and access to personnel, and services inside and outside the facility. - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and chronic kidney disease (the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body). R11's admission Minimum Data Set (MDS) dated 02/26/25 documented R11 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R11 displayed signs and symptoms of delirium (sudden severe confusion, disorientation, and restlessness) including inattention and disorganized thinking. The MDS documented R11 was dependent on staff for all activities of daily living (ADL)The MDS documented R11 required the use of an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The MDS documented R11 was on hospice care. R11's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/27/25 documented she had a history and diagnosis of dementia with ongoing cognitive impairments that require 24-hour a day care. R11 needed staff assistance to total dependence on staff with ADL cares. R11's Care Plan revised on 02/19/25 directed staff when she became agitated to intervene before the agitation escalated, guide her away from the source of distress, and engage calmly in conversation. The plan of care directed staff to allow R11 extra time to respond to questions and instructions. The plan of care lacked person-centered staff direction on activities and services to direct staff for her dementia care needs. On 05/14/25 at 02:35 PM, R11 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table awaiting activity staff to pass out ice cream to residents on the unit. Upon receiving the ice cream from the activity staff there was no interaction or further activity with the resident. On 05/15/25 at 02:18 PM, LN H stated the residents were not allowed to enter other residents' rooms or take their property. She stated that staff were expected to redirect and document the behaviors of each resident. She stated staff were expected to intervene when residents exhibited behaviors. On 05/15/25 at 02:27 PM, Certified Nurse's Aide (CNA) QQ stated that residents on the locked unit could walk around the unit under supervision but were not to go into other residents' rooms or take their property. She stated staff were expected to supervise the residents to ensure no behaviors or falls occurred. On 05/15/25 at 02:44 PM, Administrative Nurse D stated that staff were expected to monitor and intervene when resident behaviors occurred. She stated staff were expected to keep residents from entering peers' rooms and taking items from them. The facility's Residents Rights policy revised on 09/2024 documented the residents have a right to a dignified existence, self-determination, and communication with and access to personnel, and services inside and outside the facility. - R37's Electronic Medical Record (EMR) recorded diagnoses of psychosis (any major mental disorder characterized by a gross impairment in perception), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). R37's Annual Minimum Data Set (MDS) dated 08/08/24 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R37 displayed the behaviors of inattention and disorganized thinking that were present and fluctuated. R37 required supervision for his functional abilities. R37's Delirium Care Area Assessment (CAA) dated 08/13/24 documented he had a history and diagnosis of dementia with ongoing cognitive impairments. R37 could be inattentive and have disorganized thinking related to his dementia disease. R37's Psychotropic Drug Use CAA dated 08/13/24 documented he triggered for this CAA due to the use of psychotropic medication use. A care plan directed staff to monitor R37 for medication side effects. R37's Care Plan was last revised on 02/13/25 and directed staff to allow extra time for him to respond to questions and instructions. The plan of care directed staff to face R37 and speak clearly when communicating with him. The plan of care directed staff R37 was on a secured unit. The plan of care directed staff to call R37 by his preferred name. The plan of care lacked person-centered staff direction on activities and services to direct staff for her dementia care needs. On 05/13/25 at 08:32 AM, R37 sat at the dining table at breakfast with another resident on the secured unit. R37 took the other residents' ice cream and started eating it. Certified Nurse Aide (CNA) MM intervened by taking the ice cream from R37 and moved him to another table away from R18. On 05/14/25 at 11:45 AM, CNA MM stated she had been on this secured unit for quite a while. R37 had a lot of behaviors toward other residents and was hard to redirect at times. CNA MM stated the area for dining and watching tv was very small on the secure unit and sometimes staff were not always able to do activities due to resident behaviors and the resident's lack of staying focused. On 05/15/25 at 02:18 PM, LN H stated the residents were not allowed to enter other residents' rooms or take their property. She stated that staff were expected to redirect and document the behaviors of each resident. She stated staff were expected to intervene when residents exhibited behaviors. On 05/15/25 at 02:44 PM, Administrative Nurse D stated that staff were expected to monitor and intervene when resident behaviors occurred. She stated staff were expected to keep residents from entering peers' rooms and taking items from them. The facility's Residents Rights policy revised on 09/2024 documented the residents have a right to a dignified existence, self-determination, and communication with and access to personnel, and services inside and outside the facility.The facility identified a census of 147 residents. The sample included 31 residents, with seven reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related care services for Residents (R) 78, R91, R37, R11, R23, and R25 to promote the resident's highest practicable level of well-being. This deficient practice placed the residents at risk for decreased quality of life, isolation, and impaired dignity. - The Medical Diagnosis section within R78's Electronic Medical Records (EMR) included diagnoses of dementia, dysphagia (difficulty swallowing), major depressive disorder (major mood disorder), aphasia (difficulty speaking), and the need for assistance with personal cares. R78's Significant Change Minimum Data Set (MDS) dated 02/12/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted she exhibited physical, verbal, and self-directed behaviors for one to three days during the assessment. The MDS noted her behaviors would significantly interfere with the care of her and others. The MDS noted her behaviors could put others at risk for privacy intrusion and physical injury. The MDS noted she exhibited wandering behaviors for one to three days during the assessment. The MDS noted she could independently complete her activities of daily living. The MDS noted she could ambulate independently by walking. R78's Dementia Care Area Assessment (CAA) completed 02/24/25 indicated R78 had ongoing cognitive and physical impairments. The CAA noted she required 24-hour care. The MDS noted she was less able to make her needs known and required more assistance with her activities of daily living (ADLs). R78's Behavioral Symptoms CAA completed 02/24/25 indicated she exhibited dementia-related symptoms of physical aggression, verbal aggression, and inappropriate behaviors. The CAA noted she was at risk for falls, ADL decline, incontinence, and impaired cognitive function. The CAA noted that a care plan was implemented to address her risks. R78's Care Plan initiated 02/14/22 indicated she was at risk for an ADL self-care deficit, falls, and a communication deficit related to her dementia diagnosis. The plan noted she had delusions (untrue persistent beliefs or perceptions held by a person, although evidence shows it was untrue), wandering, rummaging through belongings, and sleeping in peers' beds. The plan instructed staff to intervene to protect the rights and safety of others, divert her attention, develop coping methods, and provide redirection from peers. The plan instructed staff to monitor and report episodes of physical and verbal aggression toward others. On 05/14/25 at 11:50 AM, R78 exited her room and into the hallway. R78 was confused and asked which room her daughter was in. R78 headed down the hallway, going into R10's room. R78 exited R10's room and went into R8's room. On 05/14/25 at 12:15 PM, R78 came out of the room and into the hallway holding a green jacket and a white shoe. R78 walked toward the dining area and stopped in the hallway adjacent to the dining room. Licensed Nurse (LN) RR was at the nurse's station looking in the direction of both residents during the argument. R8 yelled out, This is my stuff, and yanked the items out of R78's hands. LN RR left the desk area and walked to the resident's R78 punched R8 in the right upper arm and grabbed her shirt. LN RR separated the residents and returned to the desk. R8 immediately went into her room to put her items up, and R78 followed her in. R78 exited R8's room and returned to the dining area. On 05/14/25 at 02:51 PM, R78 and R91 walked down the hallway holding hands. R78 led R91 into R119's room. R78 opened a drawer, looking through the items in the drawer, and closed it. Both residents exited the room and continued walking around the hallway. On 05/14/25 at 03:16 PM, R78 and R91 walked back into R119's room and took a stuffed bear from the dresser. Both residents returned to the hallway and entered R12's room. R12 attained a plastic trash bag and shoved it down the front of her pants. Both residents exited the room and walked down the hallway to the dining room. On 05/15/25 at 02:18 PM, LN H stated the residents were not allowed to enter other residents' rooms or take their property. She stated that staff were expected to redirect and document the behaviors of each resident. She stated staff were expected to intervene when residents exhibited behaviors and ensure the director of nursing was immediately notified. On 05/15/25 at 02:27 PM, Certified Nurses Aide (CNA) QQ stated that residents on the locked unit could walk around the unit under supervision but were not to go into other residents' rooms or take their property. She stated staff were expected to supervise the residents to ensure no behaviors or falls occurred. On 05/15/25 at 02:44 PM, Administrative Nurse D stated that staff were expected to monitor and intervene when resident behaviors occurred. She stated staff were expected to keep residents from entering peers' rooms and taking items from them. The facility was unable to provide a policy related to dementia care as requested on 05/19/25. The facility's Residents Rights policy, revised on 09/10/24, documented that the residents have a right to a dignified existence, self-determination, and communication with and access to personnel and services inside and outside the facility. - The Medical Diagnosis section within R91's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), cognitive-communication deficit, insomnia (difficulty sleeping), and need for assistance with personal cares. R91's Quarterly Minimum Data Set (MDS) dated 02/05/25 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she exhibited wandering behaviors daily. The MDS noted she required patrial to moderate assistance for bathing, oral hygiene, personal hygiene, dressing, and toileting. The MDS noted she could ambulate independently by walking. R91's Behavioral Symptoms Care Area Assessment (CAA) completed 05/08/24 indicated she exhibited dementia-related behaviors related to wandering the unit and grabbing other residents. The CAA noted a care plan was implemented to address her risks. R91's Care Plan initiated 05/06/24 indicated she had cognitive impairment and exhibited behaviors related to her dementia diagnosis. The plan indicated she wandered the unit and exhibited behaviors of grabbing peers. The plan instructed staff to anticipate her needs and provide a safe environment for wandering. The plan instructed staff to provide diversions and distractions such as food, drink, toileting, or other meaningful activities. The plan instructed staff to reorient her when needed. On 05/14/25 at 12:45 PM, R91 sat in the dining room at the table next to the wall column. R8 sat to the left of R91 at the table. Staff placed R8's tray on the table in front of her. R91 began grabbing R8's food off her tray. R8 abruptly stood up and took her tray to her room stating, I can't stand this. R8 returned to the table with her tray once R91's meal was served. On 05/14/25 at 02:51 PM, R91 and R78 (severely cognitively impaired resident) walked down the hallway holding hands. R78 led R91 into R119's room. R78 opened a drawer, looking through the items in the drawer, and closed it. Both residents exited the room and continued walking around the hallway. On 05/14/25 at 03:16 PM, R91 and R78 walked back into R119's room and took a stuffed bear from the dresser. Both residents returned to the hallway and entered R12's room. R12 attained a plastic trash bag and shoved it down the front of her pants. R91 sat down at the first table in the dining room and pulled the trash bag out of her pants. R91 handed the bag to another resident at the table and stated, This is for you. On 05/15/25 at 02:18 PM, LN H stated the residents were not allowed to enter other residents' rooms or take their property. She stated that staff were expected to redirect and document the behaviors of each resident. She stated staff were expected to intervene when residents exhibited behaviors. On 05/15/25 at 02:27 PM, Certified Nurse's Aide (CNA) QQ stated that residents on the locked unit could walk around the unit under supervision but were not to go into other residents' rooms or take their property. She stated staff were expected to supervise the residents to ensure no behaviors or falls occurred. On 05/15/25 at 02:44 PM, Administrative Nurse D stated that staff were expected to monitor and intervene when resident behaviors occurred. She stated staff were expected to keep residents from entering peers' rooms and taking items from them. The facility was unable to provide a policy related to dementia care as requested on 05/19/25. The facility's Residents Rights policy, revised on 09/10/24, documented that the residents have a right to a dignified existence, self-determination, and communication with and access to personnel and services inside and outside the facility. - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), psychosis (any major mental disorder characterized by a gross impairment in reality perception), hypertension (high blood pressure), hyperlipidemia (condition of elevated blood lipid levels), acquired absence of right great toe, acquired absence of left great toe, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), foot drop (inability or difficulty in moving the ankle and toes upward), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), retention of urine, history of falling, muscle weakness, unsteadiness on feet, encephalopathy (a broad term for any brain disease that alters brain function or structure), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R25 depended on staff for dressing upper and lower body, and bathing. The MDS documented R25 was independent with eating and required partial/moderate assistance with toileting. The MDS documented R25 was a diabetic. The Behavioral Symptoms Care Area Assessment (CAA) dated 08/22/24 documented due to R25's dementia she could be impatient with peers' behaviors and may be verbally aggressive. R25's Care Plan dated 10/05/22 documented R25, had the potential to be verbally aggressive related to dementia. R25 would verbalize understanding of the need to control verbally abusive behavior. R25's plan of care documented when R25 became agitated staff should intervene before agitation escalated and guide her away from the source of distress. On 05/13/25 at 12:28 PM, R25 was served her tray, R69 grabbed for R25's tray, R25 pushed R69's hand away from her plate. R25 ate her lunch with her arm guarding her tray. On 05/15/25 at 09:03 AM, Licensed Nurse (LN) G stated residents should never be able to grab another resident's food. LN G stated the nursing staff monitored to ensure residents did not grab another resident's belongings. On 05/15/25 at 09:17 AM, Certified Nurse's Aide (CNA) N stated nursing staff monitor the dining area to ensure residents do not take food from other residents. She stated residents should not grab at other residents' trays or take from other residents' trays. On 05/15/25 at 02:42 PM, Administrative Nurse D stated residents should not grab food from other residents' trays. She stated residents should not have to guard their trays during mealtime. The facility's Residents Rights policy revised on 09/2024 documented the residents have a right to a dignified existence, self-determination, and communication with and access to personnel, and services inside and outside the facility.

The facility identified a census of 147 residents. The sample included 31 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 37 R93, R90, R248, and R143 This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R37's clinical record revealed PPSV23 was administered on. 04/17/20. R37's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. A review of R93's clinical record revealed a declination was signed for the PPSV23. R93's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R90's clinical record revealed the PPSV23 was administered on 01/12/23. R90's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R248's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R143's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. On 05/15/25 at 10:30 AM, Licensed Nurse (LN) I stated when a resident was due for an immunization it would be listed on the Treatment Administration Record (TAR). LN I stated the infection preventionist (IP) would track the resident's immunizations. LN I stated the Infection Preventionist (IP) would order the vaccines as needed. On 05/15/25 at 11:24 AM, Licensed Nurse (LN) H stated the charge nurses tracked the residents' immunizations. LN H stated the charge nurse would ask the resident at the time of admission for the past immunizations they had received, but sometimes they are unable to ask the questions. LN H stated if the resident was due for an immunization the charge nurse would order the vaccines and administer the vaccine when delivered from the pharmacy. On 05/15/25 at 02:42 PM, Administrative Nurse D stated she was unsure if the PCV20 had been offered. Administrative Nurse D stated the IP would follow up on all vaccines. The facility's Pneumococcal Vaccine policy dated 04/08/25 documented the facility must follow their state rules and regulations regarding physician-approved policies and procedures that incorporate physician orders for the administration of pneumococcal vaccines into physicians' standing orders.

The facility identified a census of 147 residents. The sample included 31 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 25's food preferences were met, due to nursing staff taking dietary items away from the tray. This deficient practice placed R25 at risk for impaired physical, mental, and psychosocial well-being. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), psychosis (any major mental disorder characterized by a gross impairment in reality perception), hypertension (high blood pressure), hyperlipidemia (condition of elevated blood lipid levels), acquired absence of right great toe, acquired absence of left great toe, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), foot drop (inability or difficulty in moving the ankle and toes upward), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), retention of urine, history of falling, muscle weakness, unsteadiness on feet, encephalopathy (a broad term for any brain disease that alters brain function or structure), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R25 depended on staff for dressing upper and lower body, and bathing. The MDS documented R25 was independent with eating and required partial/moderate assistance with toileting. The MDS documented R25 was a diabetic. The Nutritional Status Care Area Assessment (CAA) dated 08/22/24 documented R25 Nutritional CAA triggered secondary a calculation used to estate body fat percentage based on height and weight()R25's CAA documented the risk factors included weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. The care plan would be reviewed and updated to include interventions to address risk factors. R25's Care Plan revised 02/20/25 documented R25 had a nutritional risk related to diabetes and Alzheimer's Disease. R25's plan of care had a history of diabetic foot ulcers. R25's plan of care documented she had her left and right great toe amputation. R25's plan of care documented R25 would maintain her weight without significant weight changes. R25's plan of care directed staff to provide her diet as ordered by the physician and monitor and record her food intake. R25's EMR under Orders revealed the following: Double protein with all meals dated 03/14/25. Regular diet, easy-to-chewy texture, thin consistency with diabetic condiments dated 03/14/25. On 05/12/25 at 08:27 AM, Certified Nurses Aid (CNA) N took toast from R25's breakfast tray after asking Licensed Nurse (LN) G if R25 should get all her bread due to blood glucose readings. LN G stated she should take half the bread from R25's tray. CNA N took two halves of toast from R25's tray. On 05/14/25 at 12:36 PM, LN G took R25's bread stick from her meal tray after stating her blood sugar would be high. R25 grabbed for the bread. LN G put bread on the tray and placed the tray in the food warmer. R25 then grabbed the bread off R124's plate and ate half of R124's breadstick. LN G stated R124 was a good [NAME]. On 05/14/25 at 12:45 PM, LN G stated R25's blood glucose was high, and she got double portions. LN G stated she did not want to call the physician. LN G stated R124 was a good [NAME] and R25 got some bread. On 05/15/25 at 09:17 AM, CNA N stated she always asked the nurse what the residents who are diabetics s would have for each meal. She stated she would tell me if the blood sugars were high or low. She stated during each meal the diabetic's bread or dessert would be pulled from their tray. On 05/15/25 at 02:42 PM, Administrative Nurse D stated residents should get what was served on the resident's tray. She stated staff should never take food away from the resident. The facility's Resident Rights policy revised 09/10/24 documented at the time of admission and periodically throughout their stay, the facility would inform each resident, orally and in writing of their rights.

Citation Text for Tag 0690, Regulation FF16 [NAME], [NAME] The facility identified a census of 147 residents. The sample included 31 residents, with three sampled residents reviewed for bowel and bladder incontinence and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interview, the facility failed to ensure staff provided appropriate treatment and services to prevent potential urinary tract infections (UTI - an infection in any part of the urinary system) for Resident (R) 11 when staff failed to ensure R11's catheter bag (a urine drainage bag that collects urine from a catheter, a tube inserted into the bladder to allow urine to drain) was drained each shift and as needed. This placed R11 at risk of complications, infection, and further urinary problems. Findings included: - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and chronic kidney disease (the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body). R11's admission Minimum Data Set (MDS) dated 02/26/25 documented R11 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R11 displayed signs and symptoms of delirium (sudden severe confusion, disorientation, and restlessness) including inattention and disorganized thinking. The MDS documented R11 required the use of an indwelling catheter. R11's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 02/27/25 documented R11 had an indwelling catheter and was at risk related to psychotropic (altered mood or thought) medication and she needed assistance with toileting. R11's Care Plan was revised on 03/05/25 and directed staff to do catheter care every shift. The plan of care directed staff to position the catheter bag and tubing below the level of the bladder. The plan of care directed staff to observe R11 for pain and discomfort due to the catheter and document. The plan of care directed staff to observe for and report to the physician any signs and symptoms of a UTI. The plan of care lacked staff direction for the frequency of emptying the catheter bag. R11's Order tab of the EMR documented a physician's order dated 02/18/25 for an indwelling catheter to straight drainage. Size 18 French (French gauge is a system of measurement used to size catheters). Change the catheter for infection, obstruction, or when the closed system is compromised every shift and as needed for urinary retention. R11's Order tab of the EMR documented a physician's order dated 02/19/25 for catheter care every shift for urinary retention, keep the catheter bag placed below the level of the bladder. R11's Order tab of the EMR documented a physician's order dated 02/19/25 to change the catheter bag every seven day(s) for urinary retention/infection control. R11's Order tab of the EMR documented a physician's order dated 02/19/25 to record urine output every shift. R11's Order tab of the EMR documented a physician's order dated 02/19/25 to secure a catheter with an anchoring device to prevent tension check every shift and as needed, change the device when clinically indicated and as recommended by the manufacturer. On 05/14/25 at 12:15 PM, R11 sat at the dining table for lunch in her Broda Chair (specialized wheelchair with the ability to tilt and recline). R11's catheter bag hung from the side of her Broda chair and was visibly full of urine. The catheter tubing was also full of urine. On 05/14/25 at 02:35 PM, R11 sat at the dining table in her Broda chair and was verbally complaining of her back hurting and an unidentified Certified Nurse Aide (CNA) was rubbing R11's back. R11's catheter bag hung from the side of the Broda chair, and the catheter tubing and bag were visibly full of urine. On 05/14/25 at 03:16 PM, R11 was propelled back to her room by staff. The unidentified CNA exited R11's room and exited the secure unit to find another staff member to assist with putting R11 back in bed using the Hoyer (total body mechanical lift) lift. After R11 was transferred the staff assisted to empty R11's catheter bag. On 05/14/25 at 03:25 PM, CNA OO stated a resident's catheter bag should be emptied at least each shift and as needed. CNA OO stated the bag, and tubing should not be overfilled with urine that could back up into the bladder and cause pain or infection. On 05/15/25 at 02:08 PM, Licensed (LN) H stated that the catheter bag should be emptied at least every shift and emptied any time the bag appeared full. LN H stated the tubing, and bag should not ever be so full that urine could flow back into the bladder. LN H stated that urine back flowing into the bladder could cause infection or other complications. On 05/15/25 at 02:45 PM, Administrative Nurse D stated the catheter bag should be emptied at least once each shift but could need more depending on the resident's output. Administrative Nurse D stated the tubing, and bag should never be full as that was a big risk for infection and UTI. The facility's Indwelling Urinary Catheter Management policy last revised 06/27/23 documented the facility would ensure residents admitted with a urinary catheter or were determined to need a catheter for a medical indication would have the following addressed; timely and appropriate assessments related to the indication for use of the indwelling catheter; insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; the response of the resident during the use of the catheter; and ongoing monitoring for changes in condition related to potential catheter-associated UTI's, recognizing, reporting, and addressing such changes. Maintain unobstructed urine flow by keeping the catheter and collection tube from kinking. Always keep the collecting bag below the level of the bladder. Do not rest the bag on the floor. Empty the collecting bag regularly using a separate, clean collecting container for each patient, avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container.

The facility identified a census of 147 residents. The sample included 31 residents, with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 89's braces to both knees were applied. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R89's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), pain, insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), history of falling, abnormal weight loss, unsteadiness of fee, and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R89 had a memory problem and was never or rarely understood. The MDS documented R89 had impairment on both sides of her lower body. The MDS documented R89 was dependent on staff for all activities of daily living (ADL). R89's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/27/24 documented R89 had a long history and diagnosis of dementia with ongoing cognitive and physical impairments that continue to require 24-hour day care. R89 was unable to make her needs known in any manner, she was total care for by the nursing staff. R89's Care Plan dated 08/02/22 documented R89 had an ADL self-care performance deficit related to dementia. R89's plan of care documented R89 was dependent on staff for bed mobility. R89's plan of care documented R89 was to walk 75 feet, and R89 was to wear knee extension braces daily for as long as tolerated. A review of R89's clinical record documented no refusals of staff applying knee brace. On 05/12/25 at 07:44 AM, R89 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room waiting for breakfast. R89 did not have braces on her knees. On 05/13/25 at 08:10 AM, R89 sat in her Broda chair in the dining room eating breakfast. R89 did not have braces on her knees. On 05/15/25 at 09:25 AM, Licensed Nurse (LN) J stated all nursing staff have access to the resident's plan of care. She stated that if a resident was to have a brace or any special equipment, it would be the responsibility of all nursing staff to ensure the brace was applied. LN J stated if a resident refused a brace or special equipment, that would be documented in the resident's medical record. On 05/15/25 at 02:27 PM, Certified Nurse's Aide (CNA) QQ stated CNAs have access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident). CNA QQ stated if a resident required special equipment or devices, it was the responsibility of the CNA that the information would be verbally communicated by the nurse. On 05/15/25 at 02:42 PM, Administrative Nurse D stated she could not say it was one specific person's duty to ensure a brace or any other devices were placed on a resident. She stated the facility worked as a team, and anyone could apply the brace. The facility's Restorative Nursing policy dated 09/20/24 documented the facility would promote the residents' optimum function, a restorative program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators. Nursing Assistants must be trained in the techniques that promote residents and involvement in restorative activities.

- R122's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and muscle weakness. The admission Minimum Data Set (MDS) dated 05/08/24 documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R122 was not at risk of the development of pressure-related injuries. The MDS documented R122 had a pressure-reducing device on her bed. The Quarterly MDS dated 02/07/25 documented a staff interview was conducted and R122 had moderately impaired cognition. The MDS documented that R122 was not at risk of development of a pressure-relayed injury. The MDS documented R122 had a pressure-reducing device on her bed. R122's Pressure Ulcer Care Area Assessment (CAA), dated 05/16/24 documented she did not have a pressure injury. R122's Care Plan, dated 04/18/25 documented she had a pressure-reducing mattress on her bed. The plan of care documented staff would encourage her to wear heel protectors while in bed as tolerated. R122's EMR under the Orders tab revealed the following physician orders: Bilateral heels - heel suspension boots at all times when in bed every evening and night shift for skin integrity dated 03/18/25. Right heel - encourage non-weight bearing as much as possible, except for therapy and transfers as needed for wound healing dated 04/18/25. R122's EMR under the Assessment tab revealed a Skin Integrity Update assessment dated [DATE] that documented finding a blister (a bubble that forms on the skin, typically due to friction, burns, or other skin injuries) on R122's right heel. A Wound Observation Tool assessment dated [DATE] of R122's right heel documented was a stage three (full thickness tissue loss, subcutaneous (beneath the skin) fat may be visible, but bone, tendon, or muscle are not exposed), Slough (dead tissue, usually cream or yellow in color) may be present but does not obscure the depth of tissue loss, may include undermining and tunneling. On 05/13/25 at 07:23 AM, R122 laid on her bed asleep on her left side and her heels laid directly on the mattress. R122's suspension boot sat in the chair next to her bed and no extra pillow was noted on R122's bed or in the chair beside her bed. On 05/15/25 at 10:15 AM, Certified Nurse Aide (CNA) P stated she did not always put R122's pressure-reducing boots on her heels, because R122 tried to get up and walk. CNA P stated she was worried R122 would fall. On 05/15/25 at 10:30 AM, Licensed Nurse (LN) I stated she was not sure what pressure-reducing devices were in place for R122 without checking. LN I stated the pressure-reducing devices should be in R122's care plan. LN I stated R122 would stand on her right heel to transfer. On 05/15/25 at 02:43 PM, Administrative Nurse D stated it was everyone's responsibility to ensure a resident had their pressure-reducing device in place. The facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy last revised 07/0924 documented a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and to prevent the development of pressure ulcers unless the individual's clinical condition demonstrated that the pressure ulcers were unavoidable. The facility identified a census of 147 residents. The sample included 31 residents, with five residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure Resident (R) 9 and R122's offloading boots were applied to their heels to prevent pressure ulcers. This placed R9 and R122 at increased risk for pressure ulcer development. Findings Included: - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cellulitis (a common bacterial infection of the skin and underlying tissues) of left lower limb, intracapsular fracture (a bone fracture that occurs within the joint capsule, specifically in the hip, the femoral head and femoral neck) of left femur (thigh bone), unsteadiness on feet, muscle weakness, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), and Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) of right buttock, and left buttock. The Modification of Quarterly Minimum Data Set (MDS) for R9 dated 03/04/25 documented that a mental status interview should not be performed, R9 was rarely or never understood. The MDS documented R9 required supervision or touching with eating, dependent on staff for toileting, and substantial to maximal assistance by staff for bathing. The MDS documented R9 had a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) or greater over a bony prominence. The MDS documented R9 was a t risk of pressure ulcers. The MDS documented R9 had three Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) and had a pressure-reducing device for bed. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 01/16/25 documented R9 had no pressure ulcers. R9's Care Plan dated 01/13/25 documented R9 was at risk for unavoidable pressure injury development or decline of skin integrity. The plan of care for R9 documented staff were to clean and apply a moisture barrier after each incontinent episode. The plan of care for R9 documented staff were to encourage and assist with turning and repositioning. The plan of care documented R9 had a pressure redistribution mattress, and staff were to do wound treatments as the physician ordered. R9's EMR under Orders revealed the following physician orders: Low air loss mattress, check functionality and setting, setting at auto firm mode, and on #3 every shift for wounds dated 02/18/25. Heel protectors were on at all times when in bed every shift for heel protection dated 01/20/25. On 05/12/25 at 07:22 AM, R9 laid in bed on his right side facing the door. R9 had nonskid socks on his feet. R9 did not have heel protectors on. On 05/13/25 at 07:25 AM, R9 laid on his bed. R9's heels laid directly on the mattress. R9 did not have heel protectors on. On 05/15/25 at 09:25 AM, Licensed Nurse (LN) J stated all nursing staff have access to the care plan. LN stated if placing boots on a resident was on the Treatment Administrative Record TAR the nurse would check the resident to ensure the heel protectors were in place. She stated placing heel protectors on residents was the responsibility of the nurses and the Certified Nursing Aide (CNA). On 05/15/25 at 02:27 PM, CNA N stated all CNAs have access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident). CNA N stated nursing would let us know if a resident required any special equipment. On 05/15/25 at 02:42 PM, Administrative Nurse D stated CNAs have access to the Kardex. She stated if a resident was to have heel protectors, the CNA or the nurse could put the heel protectors on the resident. Administrative Nurse D stated the expectation was that a nursing staff member apply heel protectors as ordered by the physician. The facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management dated 07/09/24 documented the facility would provide associates and LN with procedures to manage skin integrity, prevent pressure ulcer/injury, complete would assessment documentation and provide treatment and care of skin and would utilizing professional standards.

The facility identified a census of 147 residents. The sample included 31 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order to apply thrombo-embolic-deterrent hose (TED hose - specialized compression stockings designed to help manage swelling of the feet/legs) in the mornings for edema (swelling resulting from an excessive accumulation of fluid in the body tissues). This deficient practice placed R90 at risk for increased edema, pain, and skin-related difficulties. Findings Included: - R90's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of pain, hypertension (high blood pressure), insomnia (unable to sleep), cognitive-communication deficit( often stems from problems with attention, memory, executive functions), history of falling, muscle weakness, hyperlipidemia ( an abnormally high concentration of fats and lipid in the blood), aphasia (condition with disordered or absent language function), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 01/31/25, documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R90 needed substantial to maximal assistance with dressing, toileting, and set up for eating. The MDS documented R90 received a diuretic (a medication to promote the formation and excretion of urine) during the observation period. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 01/31/25 documented R90 triggered for urinary incontinence CAA triggered secondary to incontinence of bowel and bladder and dependence of staff for incontinent care. The CAA for R90 documented contributing factors included weakness, impaired mobility, and cognitive loss. R90's CAA documented the risk factors included skin breakdown, falls, and recurrent urinary tract infections (UTI). The CAA documented R90's plan of care would be reviewed and updated. R90's Care Plan dated 05/15/25 documented R90 received diuretic therapy medication related to edema. R90's plan of care documented R90 received diuretic medication as ordered by the physician. R90's EMR chart under Orders revealed the following orders: Lasix (diuretic) oral tablet 40 milligrams (mg) give one tablet by mouth two times a day for edema dated 06/01/23. TED stockings off bilateral lower extremities at bedtime for skin integrity dated 07/30/23. TED stockings on bilateral lower extremities on everyday shift for edema dated 03/14/24. On 05/12/25 at 07:45 AM, R90 sat at the dining room table. R90 had nonskid socks on, and R90 did not have TED stockings on his feet. On 05/13/25 at 08:25 AM, R90 sat in front of the nursing station. R90 had nonskid socks on, and R90 did not have TED hose stockings on his feet. On 05/15/25 at 09:25 AM, Licensed Nurse (LN) J stated that if a resident should have TED hose in the AM, it was all the nursing staff's obligation to ensure the TED hose were put on him. On 05/15/25 at 02:27 PM, Certified Nurse's Aide (CNA) QQ stated it was the CNA's duty to apply TED hose when helping get a resident up for the day. CNA QQ stated she had access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident), and any special instructions for a resident would be communicated to her by the charge nurse. On 05/15/25 at 02:42 PM, Administrative Nurse D stated she could not say it was one person's duty to ensure the TED hose were placed as ordered for a resident. She stated all nursing departments could apply the TED hose. The facility's Skin Integrity and Pressure Ulcer /Injury Prevention and Management policy dated 03/31/23 documented skin observations occurred through points of care provided by CNAs and during ADL care, and any changes or open areas were reported to the nurse.

The facility identified a census of 147 residents. The sample included 31 residents, with six residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide the necessary assistance with personal hygiene for Resident (R) 46. This deficient practice placed R46 at risk for poor hygiene, decreased self-esteem, and impaired dignity. Findings included: - R46's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognitive processes), and lack of coordination. The Annual Minimum Data Set (MDS) dated 01/03/25 documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview was conducted which indicated severely impaired cognition. The MDS documented R46 required substantial to maximum assistance with personal hygiene and dressing. The Quarterly MDS dated 04/16/25 documented a BIMS score of 99 and a staff interview was conducted which indicated severely impaired cognition. The MDS documented R46 required substantial to maximum assistance with personal hygiene and dressing. R46's Behavioral Symptoms Care Area Assessment (CAA), dated 01/08/25 documented he had a diagnosis of dementia with ongoing cognitive impairment. R46 could be socially inappropriate due to his dementia. R46's Care Plan, dated 01/26/22, documented staff anticipated and met his needs. The plan of care documented R46 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The plan of care lacked direction to the staff of R46's person-centered choices for personal hygiene. On 05/12/25 at 12:46 PM, R46 sat asleep in his wheelchair in the common area. R46 had several days of facial hair on his face. On 05/13/25 at 08:09 AM, R46 sat asleep at the dining room table in his wheelchair. R46 had several days of facial hair on his face. On 05/14/25 at 03:01 PM, R46 was pushed in his wheelchair by staff into the common area. R46 continued to have several days of facial hair on his face and neck area. 05/15/25 11:14 PM, R46 sat in his wheelchair in the common area. R46 had several days of facial hair on his face and neck area. R46 stated he was not trying to grow a beard and would prefer to be shaved on a daily basis. On 05/15/25 at 11:39 AM, Certified Nurse Aide (CNA) O stated the staff shaved the gentlemen on their shower days. CNA O stated he would not know where to find if a resident had preferred to be shaved on a daily basis. On 05/15/25 at 11:42 AM, Licensed Nurse (LN) H stated that R46's shaving of facial hair would be provided twice weekly on his shower/bath day or if R46 requested to be shaved. LN H stated that R46 was an evening bath, and she was not sure if the evening staff offered R46 on a daily basis to be shaved. LN H stated his choice should be listed on R46's care plan. LN H stated the residents had dementia so they may say yes at one time and then not the next. On 05/15/25 at 02:43 PM, Administrative Nurse D stated she would expect each resident's preference for personal hygiene to be on their care plan. Administrative Nurse D stated the facility tried to get the residents' preferences at the time of admission, but sometimes the residents were unable to answer the questions asked of them due to their dementia or cognitive impairments. The facility's Resident Rights policy last revised on 09/10/24 documented the facility must treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

The facility identified a census of 147 residents. The sample included 31 residents, with 31 residents reviewed for care plan for resident centered revisions. The facility failed to revise the care plan to include resident-centered functional abilities for Resident (R) 23. This placed the resident at risk for unmet care needs. Findings included: - R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), muscle weakness, and cerebrovascular accident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 10/15/24 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R23 had no behavioral symptoms during the observation period. The Quarterly MDS dated 04/10/25 documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented that R23 had no behavioral symptoms during the observation period. The MDS documented R23 had received antidepressant (a class of medications used to treat mood disorders) medication and antianxiety (a class of medications that calm and relax people) medication during the observation period. R23's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/23/24 documented she had ongoing cognitive impairment related to her history of strokes. R23's Care Plan dated 10/25/24 directed the staff to reassure her when she was resistive with activities of daily living (ADL), leave and return in five to 10 minutes later and try again as safety allowed. R23's EMR under the Progress Notes tab revealed the following: On 03/28/25 at 08:50 PM, a Behavior Note that documented R23 was verbally and physically aggressive toward the staff during the assistance of ADLs. R23 stated stop and go away to the staff. R23 continued to hit, pinch, and kick during the ADL assistance. Staff had redirected R23 with minimal effect and R23 continued the verbal and physical aggressive behavior toward the staff during their assistance with ADLs. On 03/29/25 at 01:28 PM a Behavior Note documented R23 was combative during a transfer from her bed into the wheelchair with assistance of two staff members. On 03/29/25 at 06:46 PM a Behavior Note documented R23 was verbally and physically aggressive toward staff during ADL assistance. R23 stated stop and quit it to the staff as they assisted her. R23 kicked, bite and pinched the staff during their assistance. Staff redirected R23 with minimal effect as they continued to provide care. On 03/29/25 at 05:50 PM an Event Note documented a staff member that had provided assistance to R23 and reported R23 had an open area on her right arm. A skin tear was noted on R23's right arm. On 04/21/25 at 06:40 PM a Behavior Note documented R23 was verbally and physically aggressive toward the staff as they provided her assistance with ADLs. R23 yelled leave me alone and she would get them. R23 continued to hit, pinch, and hit at the staff during their assistance. Staff attempted to redirect R23 with minimal effectiveness, and R23 continued to be aggressive toward the staff. On 04/22/25 09:01 PM a Behavior Note documented R23 was verbally and physically aggressive toward the staff as they provided her assistance with ADLs. R23 yelled quit it and leave me alone. R23 continued to hit, pinch, and hit at the staff during their assistance. Staff attempted to redirect R23 with minimal effectiveness, and R23 continued to be aggressive toward the staff. On 05/2/25 at 01:00 PM a Behavior Note documented R23 was combative toward staff when they attempted to administer her medication. R23 attempted to hit staff and bite down on the spoon and made it difficult for staff to administer R23 her medications. On 05/10/25 at 10:40 AM a Skin/Wound Note documented R23 had received a skin tear on her right forearm during staff assistance with ADLs. Staff reported R23 had been combative during assistance with ADLs, dressing, transfers, and grooming. On 05/11/25 at 01:42 PM a Behavior Note documented R23 was combative with transfers from her bed into the wheelchair. R23 had resisted toward staff during their assistance with ADLs. R23 would bite staff and grab at staff's arms during their assistance with ADLs. On 05/13/25 at 07:32 AM, R23 laid asleep on her right side on the bed. R23's bed was in the lowest position, asleep on her bed, on her left side with the bed in the low position. On 05/15/25 at 10:15 AM, Certified Nurse Aide (CNA) P stated R23 had behaviors at times. CNA P stated she would attempt to reapproach later. CNA P stated it would be helpful to have other person-centered interventions to help with R23's behaviors. CNA P stated she had access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident) . On 05/15/25 at 10:30 AM, Licensed Nurse (LN) I stated when R23 became combative with staff during their assistance. LN I stated they were to leave and reapproach her later. LN I was not sure if there were any person-centered interventions on R23 care plan for staff to use when she became combative. LN I stated everyone had access to the resident's care plan and Kardex. On 05/15/25 at 02:43 PM, Administrative Nurse D stated the staff would try to redirect the resident when they became combative during staff assistance with ADLs. Administrative Nurse D stated she would not expect staff to care plan every behavioral intervention. Administrative Nurse D stated everyone had access to the resident's care plan and Kardex. The facility's Comprehensive Care Plans and Revisions policy last reviewed 09/11/24 documented the facility would ensure the timeliness of each resident 's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. The facility would monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occurred, the facility should review and update the plan of care to reflect the changes to care delivery.

The facility identified a census of 147 residents. The sample included 31 residents, with 31 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 46 for person-centered preferences. The facility also failed to develop a comprehensive care plan for R82 for respiratory therapy. These deficient practices placed these residents at risk for impaired care due to uncommunicated care needs. Findings included: - R46's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognitive processes), and lack of coordination. The Annual Minimum Data Set (MDS) dated 01/03/25 documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview was conducted, which indicated severely impaired cognition. The MDS documented R46 required substantial to maximum assistance with personal hygiene and dressing. The Quarterly MDS dated 04/16/25 documented a BIMS score of 99 and a staff interview was conducted, which indicated severely impaired cognition. The MDS documented R46 required substantial to maximum assistance with personal hygiene and dressing. R46's Behavioral Symptoms Care Area Assessment (CAA) dated 01/08/25 documented he had a diagnosis of dementia with ongoing cognitive impairment. R46 could be socially inappropriate due to his dementia. R46's Care Plan, dated 01/26/22, documented staff anticipated and met his needs. The plan of care documented R46 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The plan of care lacked direction to the staff of R46's person-centered choices for personal hygiene. On 05/12/25 at 12:46 PM, R46 sat asleep in his wheelchair in the common area. R46 had several days of facial hair on his face. On 05/13/25 at 08:09 AM, R46 sat asleep at the dining room table in his wheelchair. R46 had several days of facial hair on his face. On 05/14/25 at 03:01 PM, R46 was pushed in his wheelchair by staff into the common area. R46 continued to have several days of facial hair on his face and neck area. On 05/15/25 at 11:14 PM, R46 sat in his wheelchair in the common area. R46 had several days of facial hair on his face and neck area. R46 stated he was not trying to grow a beard and would prefer to be shaved on a daily basis. On 05/15/25 at 11:39 AM, Certified Nurse Aide (CNA) O stated the staff shaved the gentlemen on their shower days. CNA O stated he would not know where to find if a resident had preferred to be shaved on a daily basis. CNA O stated everyone had access to the resident's care plan or Kardex (a nursing tool that gives a brief overview of the care needs of each resident) which should include a resident's preferences. On 05/15/25 at 11:42 AM, Licensed Nurse (LN) H stated that R46's shaving of facial hair would be provided twice weekly on his shower/bath day or if R46 requested to be shaved. LN H stated that R46 was an evening bath, and she was not sure if the evening staff offered R46 on a daily basis to be shaved. LN H stated his choice should be listed on R46's Care Plan. LN H stated the residents had dementia so they may say yes at one time and then not the next. LN H stated everyone had access to the resident's Kardex. On 05/15/25 at 02:43 PM, Administrative Nurse D stated she would expect each resident's preference for personal hygiene to be on their care plan. Administrative Nurse D stated the facility tried to get the residents' preferences at the time of admission, but sometimes the residents were unable to answer the questions asked of them due to their dementia or cognitive impairments. The facility's Comprehensive Care Plans and Revisions policy last reviewed on 09/11/24 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. - R82's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), abnormal findings of lung fields, and hypoxia (inadequate supply of oxygen). The Significant Change Minimum Data Set (MDS) dated 11/13/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS lacked documentation that R82 was on oxygen therapy and had an order for a bi-level positive airway pressure (BIPAP - a device that helps with breathing) during the observation period. The Quarterly MDS dated 04/10/25 documented a BIMS score of eight, which indicated moderately impaired cognition. The MDS lacked documentation that R82 was on oxygen therapy and had an order for a BIPAP during the observation period. R82's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 11/22/24 documented she required staff assistance with some of her activities of daily living. R82's Care Plan, last revised 11/20/24, documented the hospice provider had supplied her with an oxygen concentrator, wheelchair, nebulizer (a device that changed liquid medication into a mist easily inhaled into the lungs), bed frame, and a foam mattress. The care plan lacked direction for her oxygen therapy and the use of a BiPAP machine at bedtime. R82's EMR under the Orders tab revealed the following physician orders: BiPAP upon arrival to the facility while asleep or in bed. Mode: non-invasive ventilation continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep), dated 11/01/24. Check oxygen saturation every shift and titrate oxygen to keep stats above 90% every shift for CHF exacerbation, dated 11/01/24. The order lacked dosing instructions for the oxygen. On 05/13/25 at 08:21 AM, R82 sat at the dining room table with oxygen tubing in her nares. On 05/14/25 at 07:13 AM, R82's oxygen tubing laid directly on the dining room table unbagged. On 05/15/25 at 10:15 AM, Certified Nurse Aide (CNA) P stated she would ask the charge nurse what R82's oxygen flow should be set at. CNA P stated that R82's oxygen tubing should be stored in a bag when not in use. CNA P stated respiratory care should be included in R82's care plan. On 05/15/25 at 10:30 AM, Licensed Nurse (LN) I stated oxygen equipment should be stored in a bag when not in use, and it should not be left unbagged on the dining room table when not in use. LN I stated that R82 should have an order to administer oxygen which included the specific dose to be administered. LN I stated respiratory therapy and her use of a BiPAP should be included in the care plan. On 05/15/25 at 02:43 PM, Administrative Nurse D stated she would expect R82's BiPAP and oxygen equipment to be stored in a bag when not in use. Administrative Nurse D stated she would expect there to be a physician order for the use of oxygen therapy. Administrative Nurse D stated she would expect a resident's care plan to have respiratory therapy. Administrative Nurse D stated everyone had access to the care plans and Kardex. The facility's Comprehensive Care Plans and Revisions policy last reviewed on 09/11/24 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care.

The facility identified a census of 147 residents. The sample included 31 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on interview and record review, the facility failed to issue Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC - the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 199. This failure placed the resident at risk for decreased autonomy and impaired decision-making. Findings included: - A review of R199's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 03/28/25 and ended on 04/16/25. R199 did not remain in the facility for custodial care and was discharged to home. R199's clinical record lacked evidence of a NOMNC issued for this Medicare Part A episode. Review of R199 EMR under the Assessment tab revealed a Discharge Summary Information dated 04/14/25 that documented R199 had met her therapy goals and would be discharged home. On 05/15/25 at 10:10 AM, Social Services Staff X stated the facility did not issue NOMNC notices to residents who had been discharged from the facility with Medicare A days remaining. On 05/15/25 at 11:40 AM, Administrative Nurse F stated the facility was not required to issue a NOMNC notice to a resident who was discharged to home or going to get therapy outside the facility. The facility's Denial or End of Benefits policy last reviewed 05/06/25 documented the denial or end of benefits process was in place to help the resident and family understand their options and needs that they might have regarding their care.

The facility identified a census of 147 residents. The sample included 31 residents, with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 198's physician of changes related to his head injury from staff-assisted cares. This deficient practice resulted in a delay in acute medical treatment. Findings Included: - The Medical Diagnosis section within R198's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acute femur (upper leg bone) fracture (broken bone), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R198's Significant Change Minimum Data Set (MDS) dated 10/25/24 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted no behaviors observed. The MDS noted one-sided upper extremity impairment and bilateral (both sides) lower extremity impairment. The MDS noted he used a wheelchair for mobility. The MDS noted he was dependent on staff assistance for bed mobility, toileting, bathing, lower body dressing, putting on footwear, and personal hygiene. The MDS noted he was always incontinent of bowel and bladder. The MDS noted he had fractures and other multiple traumas. R198's Cognitive Impairment Care Area Assessment (CAA) completed 07/12/24 noted he had behaviors related to his dementia diagnosis and required 24-hour daycare. The CAA noted he required total care. R198's Communication CAA completed 07/12/24 noted he had severe cognitive impairment that rendered him unclear with garbled speech. The CAA noted he was unable to voice his needs. R198's Care Plan initiated 07/01/24 indicated he was at risk for activities of daily living (ADL) self-care deficit and falls related to his medical diagnoses. R198's plan noted he had verbal and physically aggressive behaviors (07/12/24). The plan instructed staff to speak to him calmly and divert his attention. The plan noted he was dependent on staff assistance for his transfers, toileting, dressing, personal hygiene, bathing, and oral hygiene. The plan noted he required total assistance from two staff for repositioning and turning in bed (10/28/24). The plan noted he required total assistance from two staff for transfers but was changed to a Hoyer lift (full mechanical body lift) on 11/13/24. R198's EMR under Progress Notes revealed an Event Note completed 01/02/25 at 07:48 PM by Licensed Nurse (LN) K. The note indicated staff found R198 in his bed with a blood-soaked Band-Aid. The note revealed staff then reported the injury to LN K. The note revealed R198 did not have this injury the previous evening. LN K cleaned and assessed the wound to find a three-centimeter (cm) laceration on his forehead. The note revealed LN K believed the wound might need sutures and notified the medical provider. R198 was sent out to an acute care facility for evaluation and treatment. R198's EMR revealed no progress notes or nursing assessments completed at the time of R198's injury prior to LN K's discovery of the wound. The facility was unable to provide this documentation as requested on 05/15/25. A Skin Related Injury report # 5074 completed 01/02/25 indicated staff found R198 around 04:30 PM with a blood-saturated Band-Aid on his forehead. The report noted R198 had a three-centimeter laceration on his forehead and the wound needed to be sutured. The report revealed R198 was unable to explain how he received the injury. The note revealed R198 was sent out to an acute care facility at 05:30 PM for evaluation and treatment. A Witness Statement completed by CNA PP on 01/03/25 indicated she was assisting with R198's Hoyer Lift transfer before his injury occurred. The statement indicated CNA's PP and CNA Q transferred R198 to his bed from his wheelchair. The statement then indicated CNA PP left the room to assist other residents. A Witness Statement completed by CNA Q on 01/03/25 indicated she assisted with R198's wheelchair-to-bed transfer via a Hoyer lift after lunch. The statement indicated CNA PP left the room to assist another resident and returned to check on R198. The statement revealed upon returning to the room CNA Q found R198's feet were on the floor. The statement revealed R198 placed his feet back on his bed and noticed that R198 was incontinent of bowel. The statement revealed CNA Q raised the bed and turned R198 towards the wall. The statement revealed CNA Q turned R198 back towards her, and R198 punched CNA Q in the mouth. The statement revealed CNA Q saw that R198's head was bleeding as R198 grabbed her shirt. The statement revealed CNA Q placed a Band-Aid on his forehead and told CNA PP that R198 punched her in her mouth. R198's EMR under the Interdisciplinary Team (IDT) note completed on 01/07/24 indicated R198's injury was caused when he struck his head on a wall outlet next to his bed while he was agitated during care. On 05/15/25 at 09:34 AM, CNA Q stated on 01/02/25 that she moved R198 back to his bed after lunch with another staff. She stated that both staff left the room to assist other residents. CNA Q stated she re-entered the room briefly and found R198 hanging off the side of his bed with his feet on the floor. She stated she pulled his feet back up on the bed and noticed he had a bowel movement. She stated she turned him on his side (facing the wall). She stated that upon turning him back, R198 grabbed her and punched her. She stated she noticed his head bleeding. She stated she reported the incident to CNA PP and put a Band-Aid on his head. On 05/15/25 at 09:34 AM, CNA PP stated she assisted CNA Q with R198's bed transfer on 01/02/25 but then left the room to assist other residents. She stated the unit nurse left early that day, so she was not sure who the accident was reported to or if R198 was assessed. She stated the facility completed annual abuse, neglect, and exploitation training. She stated that injuries and accidents a required to be reported to the nurse immediately. On 05/15/25 at 11:43 AM, LN K stated he started his shift with no knowledge or pass-down information related to R198's injury. He stated that the previous shift nurse left early. LN K stated the staff found R198 in his bed, resting, and noticed the head injury. LN K stated he notified Administrative Nurse D and the medical provider upon assessment of the wound's condition and recommended further evaluation. On 05/15/25 at 02:44 PM, Administrative Nurse D stated she did not feel the accidents were abuse-related due to having witnesses for the accidents. She stated the first accident was related to a slip of the Sit-to-stand lift, and the second was due to his head hitting a wall outlet. She stated that the witness statements corroborated the observations at the time. She stated that staff received annual training related to abuse, neglect, and exploitation. She stated staff were expected to report falls, accidents, and injuries immediately to the on-duty nurse. The facility's Changes in Resident Condition or Status revised 11/2018 indicated the facility must immediately inform the resident's physician of accidents that require physician intervention related to physical, mental, or psychosocial changes.

The facility identified a census of 154 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure cognitively impaired Resident (R) 1 remained free from physical abuse. On 10/09/24 at approximately 08:25 AM, Licensed Nurse (LN) G overheard Certified Nurse Aide (CNA) M tell R1 she could not have any sugar because she was diabetic (a condition when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and R1 became upset. LN G turned around and observed R1 hit CNA M in the stomach. LN G observed CNA M react to R1 by making a fist and punching R1 in the left upper arm. LN G immediately notified Administrative Nurse D who removed CNA M from the building and suspended her pending investigation. R1 complained of left upper arm pain. Staff assessed the area and identified R1 had a blue bruise on her left upper arm. R1 continued to complain of left upper arm pain and required as-needed (PRN) pain medication. The facility's failure to ensure R1 remained free from staff-to-resident physical abuse placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, generalized muscle weakness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. R1 had no behaviors in the assessment period. R1's activity preferences documented it was very important to be with groups of people, take care of her personal belongings, choose her own bedtime, and have family involved in discussions with her care. The Quarterly MDS dated [DATE], documented R1 was unable to complete the BIMS interview. R1 had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue); physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, and rejection of care one to three days in the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/16/24, documented R1 had a history and diagnosis of dementia with ongoing cognitive impairments. R1's Care Plan revised 04/17/23, documented R1 had the potential to be physically and verbally aggressive related to dementia and poor impulse control. The care plan directed when R1 became agitated, staff intervened before the agitation escalated, guided R1 away from the source of distress, engaged calmly in conversation, and if R1's became aggressive, staff calmly walked away and approached later. LN G's notarized Witness Statement on 10/09/24, stated at 08:25 AM, LN G was at the medication cart passing morning medications when she heard CNA M yell at R1 that the resident could not have sugar because the resident was diabetic. LN G then heard R1 and CNA M arguing and R1 stated Stop that. LN G stated she turned toward CNA M and R1 and observed R1 hit CNA M in the stomach with a closed fist. LN G observed CNA M hit R1 in her left upper arm with a closed fist. LN G stated she told CNA M that she could not hit R1 and CNA M asked why R1 could hit her but she could not hit R1. CNA M walked away from the area and LN G immediately notified Administrative Nurse D. LN G's notarized Witness Statement on 10/21/24, stated on 10/09/24 at 08:25 AM, she was at the medication cart administering morning medications when she heard CNA M tell R1 the resident could not have sugar because the resident was diabetic. She then heard CNA M and R1 arguing and R1 stated Stop that. LN G stated as she turned around, she observed R1 hit CNA M in the stomach then CNA M hit R1 back with a closed fist in R1's left upper arm. LN G stated she had a clear view of the incident as she was within a few feet of CNA M and R1. The facility's Investigation dated 10/11/24, documented on 10/09/24 around 08:25 AM, R1 sat in the dining room eating breakfast. R1 went to reach for a sugar packet and LN G overheard CNA M yell at R1 that the resident could not have the sugar because the resident was diabetic. LN G heard R1 arguing with CNA M. LN G stood at the medication cart and turned to face the argument in the dining room. At that time, she observed R1 hit CNA M in the stomach with a closed fist then CNA M hit R1 with a closed fist in her left upper arm. LN G immediately moved CNA M away from R1 and notified Administrative Nurse D about the incident. Administrative Nurse D walked CNA M off the unit and out of the facility, suspending CNA M pending investigation. Staff completed a skin assessment on R1 and found what appeared to be the start of a bruise on her left upper arm which had not been there previously. R1 exhibited signs of pain and staff gave her pain medication. Staff notified R1's provider and he ordered an x-ray of her left arm and shoulder. The x-ray did not reveal any acute findings. R1's EMR revealed the following: A Skin Integrity Update on 10/09/24, documented a blue-colored bruise to R1's upper left arm below her left shoulder. An Event Note on 10/09/24 at 10:30 AM, documented on 10/09/24 at approximately 08:25 AM, LN G observed CNA M hit R1 in the left upper arm with a closed fist. LN G immediately removed CNA M and notified Administrative Nurse D who removed CNA M from the facility. Staff completed a skin assessment on R1 and found what appeared to be the start of a bruise on her left upper arm which previously was not there. R1 exhibited signs of pain and received pain medication. Staff notified R1's family, the provider, and law enforcement. A Physician/Physician's Assistant (PA)/Nurse Practitioner (NP) progress note on 10/09/24 at 03:44 PM, documented a staff member struck R1 in the left arm. R1 sat upright in her wheelchair and told Consultant GG her left arm hurt. R1 had a contusion (bruise) to the left arm and received Tylenol (pain medication) for discomfort. An Event Note on 10/10/24 at 08:45 AM, documented alleged abuse occurred between R1 and a nursing staff member. Administrative Nurse D removed the staff member from the unit and escorted her out of the building. Staff completed a skin assessment on R1 which revealed what appeared to be the start of a bruise on her left upper arm and R1 complained of pain to the left upper arm. R1 received pain medication for the pain. The facility notified local law enforcement who came to the facility and interviewed R1 and LN G then received contact information for CNA M. On 10/21/24 at 12:28 PM, R1 lay in bed on her right side, facing the wall. She did not respond to knocking or talking. On 10/21/24 at 12:30 PM, observation of the area where the incident occurred revealed a table in the dining room, right beside the nurse's station. The medication cart was located within 10 feet of the table with a clear view of where R1 sat on 10/09/24. On 10/21/24 at 12:30 PM, LN G stated on 10/09/24, she stood at the medication cart while R1 sat in her wheelchair at the dining room table and CNA M stood beside her. She stated she had a clear view of the table from the medication cart. LN G stated she heard CNA M yelling at R1and CNA M's tone of voice upset R1. LN G stated she turned around and saw R1 hit CNA M in the stomach then CNA M punched R1 in her left upper arm. LN G stated she told CNA M she could not hit the resident and CNA M asked why. LN G stated she notified Administrative Nurse D immediately. She stated immediately after the incident, R1 complained that her arm hurt, and she cried. LN G stated even when they removed R1's shirt to assess her skin, R1 cried and appeared upset and angry. She stated R1 commented that she was hit and her arm hurt. On 10/21/24 at 12:43 PM, CNA M stated on 10/09/24, R1 sat at the dining room table with R2 who was a diabetic. She stated she served R1 and R2 breakfast and R1 tried to put sugar in R2's oatmeal. She stated she told R1 to give her the sugar because R2 could not have sugar as she was diabetic. CNA M stated R1 said to leave her alone and she could do what she wanted then started hitting CNA M. She stated she tried blocking CNA M from hitting her when LN G turned around and told CNA M not to hit R1. CNA M stated she backed away and said she was not hitting R1 and was only blocking R1 from hitting her. She stated when she started her shift that morning, R1 had her shirt off and there was no bruising. CNA M stated she did not touch R1 or her left arm. On 10/21/24 at 12:55 PM, Administrative Nurse D stated LN G notified her on 10/09/24 of what happened between CNA M and R1 and she immediately went to the unit to remove CNA M. She stated she walked CNA M to the timeclock and CNA M stated she did not do it. Administrative Nurse D stated CNA M told her R1 hit her and out of frustration, CNA M brushed her off. She stated she informed CNA M there had been an allegation and it had to be investigated. Administrative Nurse D stated she notified corporate and Administrative Staff A. She stated staff completed a skin assessment which revealed R1 already had bruising started which lined up with what LN G said happened. R1 complained of pain to that arm and the facility completed an x-ray on her left arm. She stated all of the residents on that unit received skin assessments and any residents with a BIMS score of ten or higher were interviewed. Administrative Nurse D stated the facility called law enforcement and an officer came out to take LN G's statement; he talked to R1 even though she was confused, and then he left. She stated the facility terminated CNA M and banned her from returning to the facility. On 10/21/24 at 02:30 PM, Consultant GG stated he saw R1 on 10/09/24 and she appeared visibly shaken. He stated R1 had bruising on her left arm developing already and she made a statement that the place was crazy or there was a ruckus. On 10/21/24 at 02:35 PM, Administrative Staff A stated Administrative Nurse D notified her of the incident on 10/09/24 via phone as she was out of the building. She stated Administrative Nurse D informed her of the interventions and parts of the investigation she had done, and Administrative Staff A guided her on what else she needed to do. Administrative Staff A stated CNA M should have gotten the nurse and removed herself when R1 had behaviors. The facility's Abuse- Identification of Types policy, dated 10/04/22, directed the resident had the right to be free from abuse, neglect, and exploitation of resident property. The policy directed the risk for abuse may increase when a resident exhibits a behavior that may provoke a reaction by staff, residents, or others such as physically aggressive behavior. On 10/21/24 at 02:43 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to ensure R1 remained free from staff-to-resident physical abuse placed R1 in immediate jeopardy. The facility completed the following corrective actions by 10/10/24: The facility suspended CNA M immediately pending investigation on 10/09/24. The facility completed a skin assessment on R1 which revealed a bruise on R1's left upper arm on 10/09/24. The facility notified the State Agency (SA) and law enforcement on 10/09/24. Law enforcement obtained witness statements at the facility on 10/09/24 and provided a case number. The provider saw R1 on 10/09/24 following the incident. The facility completed an x-ray on 10/09/24 on R1's left arm/shoulder with no positive findings. The facility completed skin assessments on all residents on that unit on 10/09/24. The facility interviewed all residents on that unit with a BIMS of 10 or higher for safety and abuse on 10/09/24. Staff received abuse education on 10/09/24. Social Services visited with R1 daily for three days, starting on 10/09/24. The facility terminated CNA M on 10/10/24 and banned her from returning. Because all corrective actions were completed prior to the onsite survey, the deficient practice was cited as past non-compliance, and the scope and severity remained a J.

The facility identified a census of 156 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, a cognitively impaired resident who had a history of making comments about leaving and was at risk for falls, from eloping from the facility. On 07/15/24 at 01:20 PM, Housekeeping Staff U notified Licensed Nurse (LN) G that R1 made a statement to her that he wanted to go home. LN G retrieved a vital sign machine then went to R1's room to obtain his vital signs and noted he was not in his room. LN G asked other staff members if they had seen R1, but they had not. LN G informed Administrative Nurse D that R1 was missing at 01:21 PM. A Dr. [NAME] code was called to inform staff of a missing resident and a resident count began while the facility was searched. Administrative Nurse D and Social Services X exited the second-floor stairwell and exited the facility to the parking lot. R1 was found sitting on the grass, between two parked cars, holding a water glass at approximately 01:30 PM. The temperature outside at 01:00 PM was 92 degrees Fahrenheit (F) and at 02:00 PM was 93 degrees F. R1 wore a T-shirt and long shorts. The door alarm for the stairs where R1 exited did not alarm because the alarm had been turned off for unknown reasons. This placed R1 in immediate jeopardy. Findings included: - R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), chronic respiratory failure, chronic kidney disease (gradual loss of kidney function), and dependence on supplemental oxygen. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 11 which, indicated moderate cognitive impairment. R1 had no behaviors. R1 required supervision or touching assistance with transfers and walking. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA), dated 05/09/24, documented R1 had a BIMS score of 11, retained the ability to make his needs known, and ambulated with a walker. The Functional Abilities CAA, dated 05/16/24, documented R1 needed assistance with activities of daily living (ADLs). The Falls CAA, dated 05/16/24, documented R1 had a history of falls. R1's Care Plan, dated 05/03/24, documented R1 was at risk for falls and directed staff to assist R1 with ADLs as needed, place R1's call light within reach, complete fall risk assessment, and orient R1 to his room. R1's Care Plan, dated 05/23/24, documented R1 had a behavior problem with physical aggression and directed staff to administer medications as ordered, anticipate and meet R1's needs, explain all procedures to R1 before starting, allow him to adjust to changes, and intervene as necessary to protect the rights and safety of others. R1's EMR documented a Nursing (NRSG) Elopement Risk Evaluation, dated 05/03/24, that documented R1 as cognitively impaired with poor decision-making skills, which indicated a yes answer in the evaluation. The summary of findings asked if the resident was at risk for elopement at the time and any yes answer would indicate that the resident had a potential for elopement. The answer to the question was selected as no, R1 was not at risk for elopement at that time. R1's EMR revealed the following: A Behavior Note on 05/14/24 at 01:10 PM documented at around 12:50 PM, the housekeeper reported to the nurse that R1 threw an oxygen cylinder to the window. The nurse went to R1's room and found R1 getting to his couch. R1 stated to the nurse he would go through the window, that was what his intentions were, and all he wanted was to get out of the facility. R1 was agitated and wanted to fight. The Director of Nursing (DON) received an order from the Advanced Practice Registered Nurse (APRN) for Haldol (antipsychotic medication used to treat certain mental/mood disorders) five milligrams (mg) immediately. A quick assessment was done with no injuries noted to R1. A Behavior Note on 05/24/24 at 02:55 PM documented R1 constantly removed his oxygen cannula. He got up multiple times, walked by himself, and stated he wanted to go home. An Orders- Administration Note on 06/19/24 at 01:27 PM, documented that staff administered lorazepam (antianxiety medication used to treat anxiety) 0.5 mg because R1 was anxious and trying to elope. An Orders- Administration Note on 06/21/24 at 01:16 PM, documented that staff administered lorazepam 0.5 mg because R1 kept trying to elope. A Physician/Physician Assistant (PA)/Nurse Practitioner (NP) note on 07/15/24 at 04:52 PM, documented the provider saw R1 after he had been outside for a short time. R1 was anxious and combative, and staff brought him back inside. The provider ordered a Haldol 1 mg injection one time to help calm R1 down. The provider ordered laboratory tests and Ativan (lorazepam) 0.5 mg three times a day scheduled to help with R1's agitation. An Event Note on 07/15/24 at 05:06 PM, documented at approximately 01:20 PM, R1 told a housekeeper that he was going home, and she alerted the nurse. When the nurse checked on R1, he was missing from his room. The nurse asked staff members if they saw R1 enter other rooms and they stated no. Staff began looking for R1 and Administrative Nurse D was notified at 01:21 PM that staff could not locate R1. The facility called a Dr. [NAME] (code name used to indicate a missing resident) and staff searched for R1. Administrative Nurse D went to R1's unit and proceeded to the stairwell with Social Services X. Administrative Nurse D and Social Services X searched the stairwell, exited out of the stairwell door to the parking lot, and found R1 at 01:30 PM. R1 sat on the ground, on the grass, between two parked cars and another resident's family member was with him. R1 stated that he was going home and when he walked outside, he saw a lot of people, so he sat down between the cars to hide. Social Services X obtained a wheelchair from inside and staff assisted R1 back into the facility. R1 was agitated and tried to hit staff. Staff notified the provider at 01:33 PM and received an order for Haldol 1 mg injection. Staff notified R1's family at 01:36 PM and hospice at 01:38 PM. In a Witness Statement, dated 07/15/24, Housekeeping Staff U stated she went into R1's room to clean his room. R1 stated to her that he wanted to go home, and he was leaving. Housekeeping Staff U told Licensed Nurse (LN) G what R1 said, and LN G replied okay. Housekeeping Staff U stated she went into another resident's room and two to three minutes had passed when LN G went into R1's room, came out, and stated R1 was not in his room and asked Housekeeping Staff U if she saw R1 leave to which Housekeeping Staff U responded with no, she was in another resident's room. In a Witness Statement, dated 07/15/24, LN G stated while she was passing noon medications and was on hold for a nurse to give her report on a new admission, Housekeeping Staff U cleaned the floors. LN G stated Housekeeping Staff U told her R1 stated he wanted to go home. LN G stated R1 stated he wanted to go home on a regular basis. She stated she asked Housekeeping Staff U if R1 was agitated, and he was not according to Housekeeping Staff U. LN G stated she hung up the phone and walked down the other end of the hall to get the blood pressure machine for R1 but was interrupted by another resident about a wound on his arm. She stated she would be back to help him with a new bandage after getting vital signs on R1. LN G stated R1 was not in his room and no alarms went off to alert staff that a resident needed help. She stated she asked Housekeeping Staff U and Certified Medication Aide (CMA) R if they saw R1 enter another resident's room and they both said no. LN G stated she and CMA R searched the area and could not find R1. She stated she informed Administrative Nurse D that R1 was missing. LN G stated R1 was found and brought back to the unit after receiving Haldol injection for his combative behavior. In a Witness Statement, dated 0715/24, CMA R stated he came out of his office and saw LN G in the hall. He stated LN G asked him if he had seen R1 and he stated no. CMA R stated he and LN G started looking down the hall and, in every room, bathroom, and closet. He stated when they did not find R1, LN G reported it to Administrative Nurse D. The facility's investigative report, dated 07/18/24, documented on 07/15/24 at approximately 01:20 PM, Housekeeping Staff U alerted LN G that R1 stated he was going to go home. LN G questioned Housekeeping Staff U if R1 seemed agitated or upset at that time and Housekeeping Staff U stated R1 did not appear upset. LN G waited on the phone to receive a report from another facility regarding a new admission. LN G hung up the phone and got the vital sign machine then headed for R1's room. She planned to assess R1 and gather his vital signs for his afternoon medications. By the time LN G got to R1's room, he was not in there. LN G asked two staff members if they observed R1 going into another resident's room, and they stated no. At that time, staff searched the unit for R1. LN G notified Administrative Nurse D at 01:21 PM that staff were unable to locate R1. At that time, Administrative Nurse D notified Administrative Staff A, and the facility called Dr. [NAME] code immediately. All staff searched for R1 while Administrative Nurse D and Social Services X exited the stairwell to the parking lot. Administrative Nurse D found R1 sitting on the grass in a seated position between two parked cars with a water glass in his hand. Another resident's family member was with R1 who had given her his phone and asked them to call 911. The family member gave the phone to Administrative Nurse D while Social Services X obtained a wheelchair from the facility. Staff brought R1 back into the facility. R1 was agitated and tried to hit staff. Staff notified the provider at 01:33 PM and obtained an order for Haldol 1 mg injection one time. Staff notified R1's family at 01:36 PM and hospice at 01:38 PM. Nursing staff completed a skin assessment with no injuries found along with a pain assessment without any complaints of pain. R1 wore a short-sleeve T-shirt and a long pair of shorts. The temperature outside at the time was approximately 97 degrees F. According to the Kansas State University Historical Weather website, the temperature on 07/15/24 at 01:00 PM was 92 degrees F and the temperature on 07/15/24 at 02:00 PM was 93 degrees F. On 07/22/24 at 12:12 PM, R1 sat in a recliner in the day area drinking water. On 07/22/24 at 12:12 PM, R1's room was the third room from the unit door to the stairwell at the end of the hall. Administrative Nurse D and Maintenance V accompanied the surveyor to the stairwell door. Administrative Nurse D pushed on the door which alarmed, and she continued pressing the door for 15 seconds until it opened. There was a keypad beside the top of the door to the left and a slider alarm located on the door in the top left corner. Observation of the area revealed the parking lot with uneven surfaces and the grassy hill sloped up towards another parking lot with uneven surfaces. There was a street that ran in front of the facility with a posted speed limit of 30 miles per hour (mph). On 07/22/24 at 02:02 PM, there was a box located over the keypad beside the unit stairwell door. On 07/22/24 at 02:17 PM, R1 stood up from the recliner and started walking while pushing a tray table. Nursing staff immediately went to him and asked if he needed the restroom, which he replied he did. The nursing staff took R1 to the bathroom down the hallway. On 07/22/24 at 12:12 PM, Administrative Nurse D stated the slider alarm was turned off on 07/15/24 when R1 eloped, and they did not know how or why it was turned off. She stated R1 went down the stairs and exited out the side door. R1 had a cup of water and his phone in his hand. Administrative Nurse D stated she found R1 sitting on a grassy hill directly in front of the door, between two parked cars. On 07/22/24 at 12:15 PM, Administrative Nurse D stated the road in front of the facility was open, not blocked off like it was today. She stated she asked R1 if he had fallen when she found him. Administrative Nurse D stated R1 told her he saw a lot of people, so he hid. She stated there was a band going into the facility, so she assumed that was what R1 saw. Administrative Nurse D stated a box was added over the keypad so the alarm could not be turned off unless they had the key and only limited staff had a key to the box. On 07/22/24 at 12:20 PM, Administrative Nurse D stated on 07/15/24, she just finished a meeting around 01:20 PM and LN G went to her office to report they could not find R1. She stated Housekeeping Staff U reported to LN G that R1 stated he wanted to go home, and staff could not find R1 in his room. Administrative Nurse D stated the facility called a Dr. [NAME] which was a code for a missing resident and prompted all staff to look for the resident. She stated she went upstairs to search the unit with Social Services X. Administrative Nurse D and Social Services X proceeded down the stairwell and went outside. She stated they observed R1 sitting on the ground between the cars, on the grass with a cup of water. Administrative Nurse D stated another resident's family member had R1's phone because R1 asked her to call 911. The family member asked if they were looking for R1 and gave the phone to Administrative Nurse D. She stated Social Services X obtained a wheelchair from inside and they assisted R1 into the wheelchair and then into the facility. Administrative Nurse D stated R1 denied being hurt and staff completed skin and pain assessments. She stated R1 was agitated, stating he wanted to leave and find his girls. Administrative Nurse D stated R1 had two granddaughters that visit. She stated staff obtained an order for Haldol 1 mg injection on time and notified the family and hospice. Administrative Nurse D stated R1 was out of the staff's sight for about 10 minutes. She stated when R1 first admitted to the facility, he broke a window with his oxygen tank and nursing staff told her occasionally R1 stated he wanted to go home but never actually tried to exit. Administrative Nurse D stated she reviewed R1's nurse's notes but did not see any notes that he had exit-seeking behaviors in the past. She stated if a resident exhibited exit-seeking behaviors, she expected staff to provide redirection and if they were near doors then they notified the administration the resident was trying to elope. Administrative Nurse D stated on 07/15/24 when R1 went missing, there were no alarms going off because the slider alarm was turned off and the door opened after being pressed for 15 seconds. On 07/22/24 at 12:38 PM, Housekeeping staff U stated on 07/15/24, she entered R1's room to ask him if she could clean it and he said fine. She stated he said to her that he wanted to go home. Housekeeping Staff U stated she told LN G, and she replied okay. She stated LN G asked her if she saw R1 go into another room because he was not in his room, and she told LN G she had not. Housekeeping Staff U stated everybody started looking for R1 and the facility called a Dr. [NAME] code. She stated when she was in R1's room to clean it, he sat in his wheelchair. She stated the stairwell door at the end of the hallway did not alarm and no other alarms were on. On 07/22/24 at 12:44 PM, LN G stated on 07/15/24 around 01:20 PM, Housekeeping Staff U reported to her R1 said he wanted to go home. She stated R1 says he wants to go home a lot. LN G stated she was on the phone trying to verify orders for a new admission that day and immediately hung up the phone. She stated she went to the end of the other hall to get the vital sign machine and was on her way to R1's room when she was stopped by another resident for a bandage. She told him she would help him later after checking on R1. LN G stated she went down the hall as fast as she could with the vital sign machine to R1's room but he was not in his room. She stated she asked CMA R if he had seen R1, but he had not. She stated they checked every room and bathroom then she notified Administrative Nurse D when they were unable to locate R1. LN G stated she found out the door alarm to the stairwell door was off. She stated R1 took his oxygen off, left his wheelchair in his room, took his water with him, and went down the stairs. LN G stated R1 would say he wanted to go home, and she would talk to him about it but he had not had any exit-seeking behaviors on her shifts. She stated if a resident was actively exit-seeking, she redirected the resident with something they liked such as a snack, music, their family, or an activity. She stated she knew who an elopement risk was by the elopement risk assessments and by word of mouth. LN G stated the care plan addressed residents with elopement risks and the aides had access to the care plans. On 07/22/24 at 01:09 PM, Certified Nurse Aide (CNA) M stated she knew what residents were at risk for elopement by the elopement book at reception and the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). She stated if a resident was exit seeking, she told the nurse and redirected the resident with something they were interested in to shift their mind off of the behavior. On 07/22/24 at 02:10 PM, Maintenance V stated when the unit door was pushed, the magnetic lock alarmed and the slider alarm went off. He stated the slider alarm went off regardless of if the code was put into the keypad or not and the slider alarm was supposed to stay turned on. On 07/22/24 at 02:16 PM, CMA R stated on 07/15/24 when R1 eloped, he did not hear any alarms going off. On 07/22/24 at 02:18 PM, Social Services X stated on 07/15/24, she heard a Dr. [NAME] code called and went upstairs to look for R1. She stated she and Administrative Nurse D went to the end of R1's hall. Social Services X stated there were no alarms going off. On 07/22/24 at 02:31 PM, Administrative Staff A stated on 07/15/24, she was in her office on a call when Administrative Nurse D came in and reported they could not find R1. She stated Social Services X came in for a wheelchair for R1 and staff assisted him into the wheelchair and then brought him inside. She stated R1 was very agitated and said he was hiding from the facility. Administrative Staff A stated the slider alarm was turned off on the unit's stairwell door. She stated her expectations if a resident had exit-seeking behaviors or made a comment about going home the CNA would tell the nurse or if a housekeeper heard it, they were to stay with the resident and use the call light for assistance. The facility's Elopement Policy revised 07/09/14, directs each resident will have an individualized care plan identifying the risk of elopement and appropriate interventions for their safety. Residents who are identified as High Risk for elopement will be determined by a yes to any of the following questions: history of elopement from home prior to admission; history of leaving the unit or facility without staff knowledge; expressing a desire to go home, packing belongings, or staying near or attempting to exit door; new admission; family or responsible party voiced concerns that the resident may try to leave. The facility failed to provide adequate supervision for R1 who eloped from the facility on 07/15/24 at approximately 01:20 PM. R1 was found outside in the parking lot and the temperature outside was 92 to 93 degrees F. The door alarm to the second-floor stairwell door was not turned on and did not alarm to alert staff the resident exited the building. This deficient practice placed R1 in immediate jeopardy. The facility completed the following corrective actions, which were verified by the onsite surveyor:: 1. The facility placed R1 on one-on-one supervision immediately on 07/15/24. 2. The facility updated R1's Care Plan to include the resident's risk for elopement on 07/15/24. 3. An Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 07/15/24. 4. Maintenance audited exit doors and alarms on 07/15/24 with continued audits planned. 5. A key-access-only box was placed over the keypad for the second-floor stairwell door on 07/15/24. 6. Staff education on elopement was completed from 07/15/24 to 07/16/24. 7. An elopement drill was completed on 07/16/24. 8. Residents with a BIMS of 12 or below were audited from 7/15/24 to 7/16/24. 9. Residents at risk for elopement were audited with their care plans updated accordingly from 7/15/24 to 7/16/24. Because all corrective measures were implemented and completed prior to the onsite survey, this deficient practice was cited as past noncompliance. The scope and severity remain a J.

The facility identified a census of 134 residents. The sample included 11 residents reviewed for abuse. The facility failed to ensure Resident (R)1 remained free from sexual and/or physical abuse. On 09/12/22, the facility transferred cognitively impaired female R1, via ambulance, to an acute care facility due to a change in condition listed as shortness of breath, increased confusion, and respiratory infection. The hospital collected a urine sample on 09/12/22 shortly after R1 arrived and the urine contained sperm. R1 had injuries that the facility had no record or documentation of. R1, who was unable to consent and had not participated in marital sex, showed physical evidence of sexual activity, and had injuries of questionable origin incurred while residing in the facility. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of eight which indicated moderately impaired cognition. R1 required extensive assistance of one staff member for activities of daily living (ADL) which included bed mobility, locomotion on and off the unit, dressing, toilet use, and personal hygiene. R1 required extensive assistance of two staff members for transfers. R1 had no behaviors noted. R1 was at risk for pressure ulcers and noted to have skin tears present. The Cognitive Loss Care Area Assessment (CAA) dated 07/05/22 documented R1 had dementia with ongoing cognitive and physical impairment that required 24-hour care. The ADL Care Plan revised on 08/03/22 documented R1 required maximum assistance with toileting, transfers, bed mobility, morning and nighttime cares. The Assessments tab documented a Skin Integrity Data Collection dated 08/10/22 documented R1's skin was not intact with a bruise, skin tear, and blanchable redness. The sites noted with concerns were back of right and left hand discolored likely from an IV, sacral (area located at the base of the lumbar vertebrae and that is connected to the pelvis) redness, right lower leg had an old skin tear, and a small scab on right upper arm. The Assessments documented a Weekly Skin Integrity Data Collection assessment dated [DATE]noted R1's skin was intact with no new findings. The Weekly Skin Integrity Data Collection assessment dated [DATE] documented R1's skin was intact with no new findings. The Progress Notes tab recorded a Health Status Note dated 09/05/22 at 02:42 PM which documented R1 was in her room crying and yelling so much that R1's roommate did not want to go into the room. The Progress Notes tab recorded a Risk Management note dated 09/06/22 at 05:41 AM, which documented R1 was found on the floor with her legs straight out in front near R1's recliner, calling out for help. No new bruising/skin tears or visible injuries were sustained. The Progress Notes tab recorded an Event Note dated 09/06/22 at 06:47 AM, which documented R1 was found on the floor, sitting upright, with her legs straight out on the floor near her recliner, calling for help. R1 had an assessment completed with no visible injuries and no new bruising/skin tears noted. The Weekly Skin Integrity Data Collection assessment dated [DATE] documented R1's skin was intact with no new findings. The Health Status Note dated 09/09/22 at 10:32 PM documented R1 was noted on the floor in her room. R1 was assessed and noted to have a skin tear/abrasion to right wrist and right ear. The Risk Management note dated 09/09/22 documented R1 had a fall and noted a right ear skin tear and right wrist skin tear with no further injuries noted. The eINTERACT Change in Condition Evaluation assessment, under the Assessments tab, dated 09/12/22 documented R1 was not on [MEDICATION(S)] (blood thinner) or any other anticoagulant (blood thinner). R1's skin had no changes observed. The EMR lacked documentation of any other event. Review of the appointments scheduled 09/05/22 through 09/16/22 revealed no appointments scheduled for R1. R1's clinical record and facility documentation lacked evidence R1 was outside of the facility between 09/05/22 until the evening of 09/12/22. Review of the General - Visitor COVID [respiratory infection] Screening forms dated 09/09/22 through 09/12/22 revealed t R1 had a female visitor on 09/10/22, a male visitor on 09/11/22, a female visitor and R1's spouse visited on 09/11/22, and a female visitor on 09/12/22. Review of photographs dated 09/11/22 documented skin tears and bruising to the right hand as noted in facility documentation. Review of the photos revealed R1 had dark purple bruising to her right upper arm. The bruising was circular areas in an arced, linear pattern consistent with fingertips. R1 had multiple bruises to both knees. Review of the Progress Notes dated 09/20/22 in the hospital paperwork documented R1 was unable to discharge back to the same facility memory care unit. R1 had spermatozoa[sperm] in her urinalysis. The care progression team involved the police. A urine drug screen (UDS) was ordered and showed positive for benzodiazepines (class of medication which has a strong calming and/or sedating effect) and tricyclics (TCA, class of medication used to treat [CONDITION(S)] and/or anxiety). The note recorded a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated police had been investigating the situation. The plan further indicated the UDS showed positive for benzodiazepine and tricyclics. The note indicated R1 was on [MEDICATION(S)] (benzodiazepine) but not on a tricyclic. The note further documented R1 had bruising to her bilateral legs and shoulders; it was unclear if the injuries were from falls or abuse. Review of R1's August and September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/22 at 03:19 PM Consultant GG stated that sperm can be in a urine analysis specimen up to 48 hours but was ultimately determined on the storage of the specimen. Consultant GG revealed that did not know how long sperm could remain present in the female genitalia after sexual activity with a male. On 09/20/22 at 10:30 AM Consultant HH stated that once the sperm was noted in the urine analysis specimen, the family was contacted to see if they wanted an investigation. Consultant HH stated R1's spouse was questioned; marital sex was ruled out. R1's spouse was upset and requested an investigation; the police department took a report and a swab was completed. Consultant HH further stated that the results could take a very long time. Consultant HH stated there were bruising on R1's thighs and knees. Consultant HH stated the injuries and bruising were documented in the forensic file related to the R1's case. On 09/20/22 at 04:18 PM R1's representative stated that it was not until the last few weeks before R1 discharged to the hospital on 09/12/22 that she had started screaming and crying a lot. R1's representative further stated that the last couple weeks at the facility, something was wrong with R1 and the facility placed R1 on medication for behavioral changes. R1's representative stated she did not know what was going on with R1. R1's representative stated on 09/12/22 when R1 went to the hospital via the ambulance, R1's representative and R1's spouse left the facility and went to the hospital while the ambulance left the facility with R1. R1's representative reported she arrived roughly five minutes after the ambulance at the hospital. On 09/20/22 at 04:55 PM Certified Nurse Aide (CNA) M stated there were no male residents that had any concerning behaviors on the unit R1 resided on (Unit 7). CNA M said if staff had concerns regarding inappropriate behaviors by the residents, staff contacted Administrative Nurse D and received direction on how to handle the residents. CNA M stated that a male resident had been moved from the unit a few months ago related to his behaviors. CNA M further stated that when residents have visitors, staff make sure that the visitors stay with the resident they are visiting and said staff provide privacy for all visitors. CNA M stated if a resident's roommate had a visitor, staff would ensure the roommate who did not have the visitor was not left in the room. CNA M stated he had not worked on Unit 7 on 09/09/22, 09/10/22, 09/11/22, or 09/12/22. CNA M stated he could not recall how R1 behaved or her demeanor when he last worked up there. CNA M reported he was not able to recall R1 at that time. On 09/21/22 at 10:05 AM CNA N stated she could not recall any residents going into rooms that were not their own room or any residents acting inappropriately. CNA N stated that she worked on 09/12/22 and R1 was not acting like herself that day. CNA N revealed that R1 was more combative that day and did not want assistance that day. She reported R1 was more combative then normal. CNA M stated that R1 was normally very friendly and if R1 had any questions CNA N would explain to R1 and then R1 would wheel around the unit telling staff that R1 loved them. CNA N further revealed that she worked on 09/10/22 and R1 was not combative. CNA N recalled that on 09/12/22 R1 was pushing staff away. CNA N stated on that day she noted bruising on R1's arms and reported it to the nurse on duty; the nurse told CNA N that R1's bruises were known. On 09/21/22 at 11:35 AM CNA O stated she worked with R1 on 09/11/22. CNA O recalled that R1 was yelling and screaming. On 09/21/22 at 11:43 AM Social Services X stated that R1's family had not reported any concerns. Social Services X stated R1 had panic attacks and could not recall why. Social Services X stated that the last couple of weeks R1 was at the facility were no different from when R1 had admitted to the facility. The facility was not alerted to the concerns of sperm in R1's urine culture specimen right away but once it was reported to the facility, Administrative Staff A removed all the male staff off that hallway/unit. On 09/21/22 at 11:55 AM Administrative Nurse D stated that there were no male residents on Unit 7 that could actively walk around without help. Administrative Nurse D further stated there were never any reports of bruising on the resident before she went out to the ER. Administrative Nurse D stated she had reviewed the discharge paperwork from the hospital for R1's current admission and it documented that R1's skin was intact and that there was no bruising. Administrative Nurse D further stated that the sexual contact which led to the sperm in R1's urine could have happened anywhere. Administrative Nurse D revealed she expected staff to report and concerns of behaviors, skin, and all abnormal events. Administrative Nurse D stated there had been no issues with visitors being in rooms or areas they should not be in. Administrative Nurse D stated R1's spouse was usually accompanied by R1's daughter when he visited. Administrative nurse D stated there were no reports of bruising on R1 before she went out to the hospital. Administrative Nurse D said she heard of the bruising when a nurse called her to tell her the police were in the facility looking at R1's room and that nurse said the police mentioned something about bruising. Administrative Nurse D stated she reviewed the hospital paperwork sent to the facility and it did not mention anything about bruising. Administrative Nurse D said the nurse told her that the hospital found sperm in R1's urine. She said she then relooked through the hospital report and it said the urine was contaminated. Administrative Nurse D stated the hospital staff said they could not tell the facility anything more. Administrative Nurse D said if R1 had sexual contact, it could have happened anywhere. Administrative Nurse D went on to say she found it hard to believe that any of the male staff at the facility would do that to the residents. Administrative Nurse D stated that Administrative Staff A suspended any males who worked on Unit 7 and did abuse training again. On 09/21/22 at 12:31 PM Administrative Staff A stated that there were no male residents that wandered on Unit 7, which was R1's unit. Administrative Staff A further stated she could not recall any residents that did not want to work with any staff member. Administrative Staff A stated R1's spouse would come to the facility with his daughters. On 09/21/22 at 01:22 PM R1's representative stated she recalled a voicemail left by R1 the night of 09/11/22 where R1 sounded frantic and like R1 was giving information about herself to the voicemail as if it was a call to a emergency service like 911. R1's representative stated that once R1 was admitted to the hospital on 09/12/22, R1 was constantly stating that she did not feel safe. R1's representative stated that once R1 had calmed down and was no longer displaying behaviors since admitted at the hospital. On 09/21/22 at 02:35 PM Administrative Staff A revealed that R1 had a male visitor on 09/11/22 that the facility was unaware of who the person was. On 09/21/22 at 03:07 PM Administrative Staff A stated facility staff reviewed the sign in logs and noted the visitor listed was not on the sheet of people cleared to visit the resident. On 09/21/22 at 03:36 PM, Administrative Staff A amended her previous statement and said R1's family had not placed any restrictions on visitors. On 09/21/22 at 03:59 PM Social Services X stated anyone could enter the facility and visit any resident at the facility unless the family had placed a restriction; if a restriction was in place, the information was posted at the nurse station in the residents' EMR. On 09/21/22 at 04:06 PM Certified Medication Aide (CMA) R stated R1 was anxious on 09/11/22. CMA R further stated that R1 had family member visit and the family requested information related to the fall that R1 had early that week. CMA R recalled that R1 was very anxious and her words did not make sense. The facility's Protection of Residents: Reducing the Threat of Abuse & Neglect policy revised 08/10/21 documented that all residents would be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation. The policy documented the facility must report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source. The policy further documented the facility is required to protect a resident from non-consensual sexual relations. It is the policy of the facility to identify abuse, neglect, and exploitation of residents that includes but is not limited to identifying and understanding the different types of abuse and possible indicators. Examples that could indicate abuse include, but are not limited to are bruises, including those found in unusual locations such as head, neck, lateral locations on the arms, or posterior torso and truck, or bruises in shapes (e.g. finger imprints); sudden changes in alertness or behavior, including signs of fear, withdrawing from activities previously enjoyed or becoming uncommunicative. Also included are sudden or unexplained changes in behaviors and/or activities such as fear of a person or place to feelings of guilt or shame. The facility failed to ensure R1 remained free from sexual abuse the physical and psychosocial safety of R1 from sexual abusewhich impacted both R1's physical and psychosocial safety and wellbeing. This placed R1 in immediate jeopardy. The facility submitted an acceptable plan to address the immediacy at 10:52 PM on 09/21/22. On 09/22/22 the following corrective actions were verified by the State Agency in removal of the immediacy: All residents with a BIMS of eight or less had a skin assessment to identify any potential unreported abuse. All facility staff were educated on the protection of residents, reducing the threat of abuse and neglect, and identifying signs and symptoms of abuse. A visitor consent procedure was implements and all staff educated to the procedure which included an approved list of visitors set by the resident/and resident's representative with identification of visitors upon entering the facility. The scope and severity remained at the level of a G to reflect the physical and psychosocial harm to R1.

The facility identified a census of 108 residents. The sample included 26 residents, and nine residents sampled for accidents. Based on observations, interviews, and record review, the facility failed to ensure two residents (R) were free from accidents as evidenced by the facility's failure to ensure staff followed R103's care plan for proper transfers which resulted in a 13 centimeter (cm) by 7.5 cm laceration injury while being transferred. The facility also failed to ensure R43 was free from falls and injury when staff failed to use a gait belt for ambulation and R43 fell to her knees resulting in an abrasion. Findings included: - The electronic medical record (EMR) for R103 documented the following under the [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented R103 had Brief Interview for Mental Status (BIMS) score of zero which indicated her cognition was severely impaired. She was totally dependent on one to two staff for all activities of daily living (ADLS). She transferred with use of a Hoyer lift (a total body mechanical lift used to transfer residents) She used a wheelchair for mobility (the ability to move freely and easily). The MDS recorded no falls since admission. The Quarterly MDS dated [DATE] documented R103 had a BIMS score of zero, staff assessment indicated both long-term and short-term memory problems. R103 had severely impaired cognitive skills for daily decision making. She was total dependent on staff assistance of one to two people. She had limited range of motion of both upper and lower extremities. She used a wheelchair for mobility. She transferred with use of a Hoyer lift (a total body mechanical lift used to transfer residents). The MDS recorded no falls since admission. The Care Area Assessment (CAA) dated 12/30/19 documented that R103 admitted with [DIAGNOSES REDACTED]. She was in a wheelchair for ambulation which staff propelled. She had poor trunk control and generalized weakness. The Care Plan last revised on 08/14/20 directed the resident required two staff for transfers. She required a Hoyer only for transfers; she was non-ambulatory and used a wheelchair with positioning devices for safety; R103 required total assistance with wheelchair locomotion, all initiated 12/31/19. The Care Plan recorded on 08/17/20 all staff received re-education on where to find the Kardex and where to find the appropriate way to transfer the resident. Resident was to be a Hoyer lift transfer. The Care Plan directed staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, initiated 10/05/18. A physician's orders [REDACTED]. A Facility Investigation completed by Administrative Nurse D dated 08/20/20documented in summary: R103 was alert, but confused, and sustained a laceration with 39 sutures. It was found that on 08/14/20 agency Certified Nurse Aide (CNA) QQ did not follow the care plan/report sheet instructions when transferring R103. Since the resident did not stand, the CNA attempted to stand the resident and she was slouching when transferring. The CNA quickly turned the resident striking her leg on the post area of the wheelchair where the foot pedals attach. As she scraped across the area it caused a large laceration, 15cm by 7.5 cm, that required 39 sutures by the facility physician. CNA QQ received a report sheet each shift with the instructions for transfer for residents on that hall. A Witness Statement on 08/14/20 from LN LL documented: She worked on 08/13/20 on the 11PM-7AM shift. She was charge nurse on second floor. There were two CNA's assigned to the 2400 hall. CNA QQ agency staff told LN LL that he worked on the back-section of 2400 hall many times. The two CNA's split the report sheet they were given. On the report sheet it gave instructions for each resident that included ADLS, transferring, and mobility. CNA QQ used his report sheet to record vital signs he obtained for residents which he handed to her when he was done. After she completed documenting the vital signs, she handed CNA QQ the report sheet. Around 05:10 AM CNA QQ came to nurse's station wearing blue gloves covered in blood, and said he needed her help. When LN LL entered R103's room, resident was sitting in her wheelchair with blood-soaked towels around her leg. CNA QQ told the LN he used a gait belt to transfer R103 and after he transferred her was when he noticed the blood. LN LL's assessment noted a laceration approximately 15 cm on one side and 7.5 cm on the other. She called the physician determined the wound d sutures. Consultant Physician GG instructed LN LL to cover the wound with an abdominal (ABD) pad and wrap with kerlix (gauze used to wrap wounds). When LN LL returned to the nurse's station, she had noticed CNA QQ's report sheet was still lying on the desk. The report sheet under R103's name stated, Hoyer Lift Only. A Witness Statement on 08/14/20 from CNA QQ documented: He was changing and getting R103 up. After getting her dressed he turned R103 toward him in her bed and put the gait belt on the resident, stood her up, turned her toward the wheelchair, and sat her in the chair. He began to lock in place the leg rests of the wheelchair and put her foot on the foot pad. As he did so he noticed that blood running down the left side of R103's calf. He pulled her pant leg up and there was a long laceration. He immediately went to get the charge nurse. The charge nurse wrapped R103's leg and told him to take R103 to the nurse's station. An Event Note on 08/14/20 at 06:36 AM in the EMR under the Progress Notes tab documented: At approximately 05:10 AM, staff called the nurse to R103's room where upon entry the resident had a laceration to her right leg. The resident sat in her wheelchair and CNA reported that after he transferred her in the wheelchair, he noticed the blood running to the floor. The open area was triangle shaped and approximately 15 cm in length on one side and 7.5 cm on the other. Staff cleaned the open area and applied pressure. Staff notified Physician GG and he verbally stated to wrap the wound with an ABD pad, wrap with kerlix. and secure with tape. He would be in to suture the open area if needed. An Event Note on 08/17/20 at 02:28 PM under the Progress Notes tab documented: The interdisciplinary team (IDT) met to discuss the laceration to R103's leg that happened on 08/14/20. Staff transferred the resident with a gait belt and got her leg caught on the attachment point for the leg rest of the wheelchair. Root cause analysis indicated the resident was totally dependent for mobility and required a Hoyer lift for transfers. Because staff failed to use the lift for transfer, the resident's leg hit the chair. All staff received re-education on where to find the Kardex and where in the Kardex to find the way to transfer a resident. An observation of R103's room door on 08/25/20 at 09:45 AM revealed a sign on resident's door stating, Resident is a Hoyer Lift Only. An observation of R103 on 08/25/20 at 12:41 PM noted the resident was in the dining area, reclined back slightly in a high back wheelchair being fed by one staff member. A Hoyer lift sling was underneath of the resident. An observation of R103 on 08/27/20 at 08:58 AM revealed the resident sat in a high-backed wheelcahir reclined back slightly, with non-skid socks on feet. The nurse pulled up the resident's pant leg so her leg wound could be seen. The area had some redness, sutures clean, dry and intact, and open to air. On 08/27/20 at 11:15 AM CNA OO stated that R103 needed a Hoyer lift for transfers, she had a sign on her door, and we also know how to transfer residents by a report sheet received. at the beginning of our shift. It was also on the Kardex or staff can ask the charge nurse. On 08/27/20 at 01:21 PM Administrative Nurse D stated that agency staff read through a quick orientation packet in the Administrators office. She does not know at the time an agency staff was put on the schedule what competencies they have completed, as the Administrator took care of that. If an agency staff member worked when education was being done with facility staff, they will include agency staff. When a resident had an incident, they do an IDT investigation of what happened, the root cause, implement immediate interventions, and encourage nurses to document their note as soon as possible. She expected staff to add new interventions to the care plan by the next day. If a care/special need was on a resident's care plan, then she expected staff to follow the care plan. Staff received a report sheet at the beginning of every shift that listed each resident on the hall and what special care they needed, such as if a Hoyer lift for transfers. Staff can also look on the Kardex in the EMR. Administrative Nurse D stated the facility is currently working a better system when agency staff come to work so they will get paired with a facility staff CNA to show them how to look in the Kardex that gathers information directly from the resident care plan and MDS of cares each resident need as well as making sure they have the printed report that lists specific cares needed for each resident. On 08/27 /20 at 07:45 AM Physician GG stated that R103's wound was a nasty laceration that he sutured himself. He believed that the staff member that transferred R103 that morning should have used the Hoyer lift. The facility's Fall Management policy dated November 2016 documented the facility ensured residents received treatment and care in accordance with professional standard of practice, their environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. The facility implemented interventions, including supervision, consistent with the residents' needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. The facility failed to ensure that R103 was free from accidents after staff failed to use the proper mechanical device as directed to in the care plan, which caused a laceration requiring sutures to R103's leg . - R43's electronic medical record (EMR) from the [DIAGNOSES REDACTED]. (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R43 required extensive assistance of two staff members for Activities of Daily Living (ADL). The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented R43 required extensive assistance of one staff member for ADL's. R43's Fall Care Area Assessment (CAA) dated 01/14/20 documented R43 had a fall at home that resulted in fractures. She was admitted to the facility for long term care related to the need for more assistance with her ADL's. The Care Plan dated 01/31/20 directed staff to assist R43 with ADL's as needed. An intervention dated 05/04/20 directed staff to use a wheelchair for transportation when R43 was overly anxious. On 08/24/20 documentation of verbal education on gait belt usage given by Licensed Nurse (LN) L directed gait belts were used for every transfer and when ambulating with a resident. Certified Nurses Aide (CNA) N signed the education sheet. In a witnessed fall occuring on 08/27/20 at 08:46 AM in the Geranium Court dining room, CNA N ambulated R43 from her bathroom to the dining room using her walker. CNA N held onto R43's waist band of her slacks during the walk and transfer. R43 walked on her tip toesa nd wore tennies shoes. R43 fell in the dining room and sustained an abrasion to her knee, On 08/27/20 at 09:12 AM CNA N stated he absolutely should have used a gait belt on R43, when he ambulated her. He stated he could not find his gait belt and had assisted R43 for another staff person. On 08/27/20 at 11:45 AM Licensed Nurse (LN) H stated CNA N should have used a gait belt while he had ambulated with R43. On 08/27/20 at 01:40 PM Administrative Nurse D stated gait belt usage for residents depended upon the resident. If a gait belt was used for a resident then it should be care planned. The facility Fall Management policy dated November 2016 documented an avoidable accident means occurred because the facility failed to: Implement interventions, including supervision , consistent with a patient's needs, goals, plan of care and current standard of practice in order to reduce the risk of accidents. The facility failed to provide ensure use of assistive devices, including a gait belt, to prevent a fall with injury for R43.

The facility identified a census of 108 residents. The sample included 26 residents. Based on observations, interviews, and record review, the facility failed to prevent an avoidable reduction of range of motion (ROM) and/or mobility in Resident (R)70 by inappropriate positioning which resulted in his right shoulder dislocation/subluxation (when the humerus- upper arm bone comes out of the shoulder socket). Findings included: - The electronic medical record (EMR) under the [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented R70 had a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. He required total assistance from staff of one to two with all activities of daily living (ADLS). He had limited range of motion (ROM) in both side of the upper and lower extremities. He continued to receive occupational therapy (OT) that began on 03/12/20. The Quarterly MDS dated [DATE], documented R70 had a BIMS of zero. He required total assistance of one to two staff with all ADLs. He had limited ROM in both side of the upper and lower extremities. He received OT beginning on 03/12/20. The ADL Care Area Assessment (CAA) dated 06/14/20 documented R70 admitted from the community for total care due to inability to care for himself. No falls occurred this quarter. He used a wheelchair and was unable to stand or walk. He had contractures of all four limbs. He received OT for his posture. The Care Plan last revised on 07/26/20 documented R70 had contractures to the upper and lower extremities and instructed staff to place pillows between R70's knees and ankles, and to put towels between his arms while in bed as tolerated. The care plan further instructed staff not to place pillows under R70's arms due to [MEDICAL CONDITION]; right shoulder immobilizer (a device that is used to hold your arm against your body) in place due to subluxed shoulder. Staff were educated on proper wedge cushion placement, licensed and certified nurse aide (CNA) educated to use a mechanical lift only for transfers. A physician's orders [REDACTED]. Place an immobilizer for right arm/shoulder dislocation dated 07/25/20. May continue orders for 75 days. A Health Status Note in the EMR under the Progress Notes tab dated 07/24/20 at 10:39 AM documented, reported to this nurse by CNA that resident would not lift right arm. Resident will feed himself finger foods and would not lift his arm to bring a banana to his mouth. There is a visual change in his right shoulder compared to his left shoulder. (Physician) was notified and an order for [REDACTED]. A Health Status Note under the Progress Notes tab dated 07/24/20 at 12:58 PM documented, Xray shows right shoulder not in socket. (Physician) and family notified. Will send resident to hospital, emergency services called. A Health Status Note under the Progress Notes tab in the EMR dated 07/24/20 01:35 PM documented that the ambulance arrived the resident transferred to a local hospital, and notified the emergency department. A Health Status Note under the Progress Notes tab in the EMR dated 07/24/20 at 07:54 PM documented resident returned to facility. Paperwork with right shoulder dislocation, reduced with a right arm/shoulder immobilizer in place. Keep sling in place, ice, and rest. Follow up with orthopedics. Resident assisted to bed by two ambulance attendants. Right shoulder immobilizer to be worn at all times. May remove immobilizer for bathing and dressing only. An Event Note under the Progress Notes tab dated 07/27/20 at 05:44 PM documented the interdisciplinary team (IDT) met to discuss R70's injury of unknown origin. The resident was not using his right arm, x-rayed done, and shoulder found to be dislocated. The facility conducted an Investigation by facility Administrative Nurse E and notarized by Administrative Staff A on 08/21/20. The summary of the incident documented: On 07/24/20 at approximately 09:00 AM CNA Q entered R70's room and discovered that his right arm was propped away from his body with a wedge cushion. Bed pillows separated the resident's extremities from his torso, and he had contractures that pose a pressure risk to skin integrity, however, the wedge cushion was not intended for this use. Resident was unable to move the utensil to his mouth during breakfast. The licensed nurse, family, and physician were notified. An x-ray showed a dislocation and the resident was sent to the ED for joint reduction. CNA MM worked the night shift before the injury was found and she was promptly contacted for a statement. At that time, it was believed that the wedge cushion was responsible for the dislocation. CNA MM stated that she used the wedge cushion instead of a bed pillow. It was reasonable that the leverage needed to insert the wedge cushion could have caused the dislocation. CNA MM was re-educated on the proper use of wedges and cushions, and may not be used for unintended purposes. The staff member did not act appropriately with wedge cushion use and received re-education to prevent future incidents. A notarized Witness Statement signed on 07/24/20 by CNA MM documented: On Friday the 24th (CNA MM) placed a pillow under resident's arm to relieve pressure from his pressure point elbow. The supervisor informed me that it was the wrong pillow. A Witness Statement signed by CNA Q and notarized by Administrative Staff A on 07/24/20 documented: CNA Q walked into R70's room to find him in bed with foot wedge under right arm/shoulder. When CNA Q removed the wedge from under arm to remove his night clothes, CNA Q noticed that his arm appeared to be more limp than normal. R70 did not appear to show any signs of discomfort during ADLS and transfer. We headed to breakfast, at the time of breakfast CNA Q noticed R70 appeared to not be able to feed himself as usual. At that time, CNA Q notified the charge nurse of concerns for R70. The charge nurse looked at R70's arm and called the doctor . An observation on 08/26/20 at 11:44 AM revealed R70 in his high back wheelchair beside the dining table in the dining area, sling noted to right arm/shoulder. Staff assisted R70 to eat . An observation of R70 on 08/26/20 at 03:45 PM revealed the resident lying in bed on his left side, sling in place to right arm/shoulder, and a pillow placed between his knees. In an interview with CNA MM on 08/26/20 at 03:47 PM she stated she used/put the wrong type of pillow under R70's right arm/shoulder. She could not find any regular pillow in his room, so she used the big pillow to put under his arm to elevate it. She was disciplined and re-educated about the proper types of pillows to be used for repositioning. In an interview with CNA LL on 08/27/20 at 11:15 AM, CNA LL stated that at the start of each shift the aides received a report sheet that showed them how a resident transferred, what specific cares they needed, how much assistance each resident required, and if a resident required a lift. An interview with Licensed Nurse (LN) J on 08/27/20 at 12:40 PM stated on the day of the incident she was just coming on to her shift. LN J immediately called the physician. She further stated that staff aides received report of each resident when they began their shift, and also received a printed out report sheet as well as the same information available in the Kardex (tool used to tell staff the specific needs of each individual resident) in the EMR. An interview with Administrative Nurse D on 08/27/20 at 01:21 PM stated that agency staff received a quick orientation packet to go through when they report to work at the facility for the first time. The packet contained a two page check off regarding the packet information. She does not know what competencies agency staff completed when they start working, as that is all taken care of by the Administrator. Currently agency staff get paired with a facility staff CNA to show them how to look in the Kardex that had information directly from the resident care plan and MDS related to cares each resident needed. They also received a printed report that listed specific cares needed for each resident. The agency staff from this incident should not have used the wedge. She was re-educated about the proper use of pillows/wedges and was not allowed to work for a period of time after the incident. In an interview with Consultant Paramedic II on 08/24/20 at 02:38 PM, he stated he felt this incident was odd since the resident had a dislocation to his shoulder and no explanation as to how it happened due to the fact the resident was bed ridden and had contractures. In an interview with Consultant Physician GG on 08/27/20 at 07:45 AM he stated he got the call from the staff nurse about R70's shoulder and ordered an X-ray that confirmed the dislocation. He also stated he thought a staff member tried to lift the resident and his body moved, but his arm didn't. The facility failed to prevent further reduction of R70's ROM and/or mobility when the facility failed to ensure staff followed the care plan as instructed for proper positioning which caused R70's right shoulder dislocation.

The facility reported a census of 116 residents with nine residents on the Covid-19 isolation unit. The sample included seven residents. Based on interviews and record reviews, the facility failed to provide cardiopulmonary resuscitation (CPR-full code, a life-saving medical procedure that consists of chest compressions to allow [MEDICATION NAME] blood to circulate to vital organs, such as the brain and heart and artificial ventilation) to Resident (R)1, whose Advanced Directives (a written document which indicated the medical decisions for health care professionals when the person could not speak) and physician orders [REDACTED]. The facility also failed to ensure staff knew how to confirm a resident's code status. This deficient practice placed R1 and two other residents (R6 and R7) with a full code status on the COVID-19 isolation unit in immediate jeopardy. Findings included: - The [DIAGNOSES REDACTED]. R1's Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severe cognitive impairment. He required extensive staff assistance with his Activities of Daily Living (ADLs). R1's Quarterly MDS dated [DATE] documented a BIMS score of zero. He required extensive staff assistance with his ADLs. The Care Area Assessment (CAA) for cognition dated [DATE] documented R1 had inattention and disorganized thinking due to his [MEDICAL CONDITION] diagnosis. The facility staff received training to care for residents with [MEDICAL CONDITION]. R1's Care Plan revised [DATE] documented R1 had the potential for exposure to Covid-19. The facility staff observed for changes in his level of consciousness, mental status, and lethargy (a lack of energy). The staff notified R1's physician when respiratory conditions developed. The care plan directed staff to monitor oxygen saturation levels (the fraction of oxygen saturated hemoglobin relative to total hemoglobin in the blood) as indicated. The care plan lacked documentation on R1's advanced directives. The physician's orders [REDACTED].>The EMR documented a note under the Progress Notes tab dated [DATE] at 05:32 AM which recorded R1 had a temperature of 101.2 degrees Fahrenheit (F). No new or acute changes were noted, at 01:56 PM R1 voiced no complaints of pain, ate 100 percent (%) of breakfast and 50% of lunch. The Progress Notes tab recorded a note dated [DATE] at 06:38 AM which documented R1's oxygen saturation dropped to 80% at 01:15 AM and staff notified the physician. New orders included a chest x-ray and laboratory blood work. The physician also ordered supplemental oxygen use at two liters per minute. With administration of oxygen R1's oxygen saturation level rose to 93%. At 12:50 PM R1's oxygen saturation level dropped to 80% and his temperature was 99.8 F. He had a productive cough and congestion. Staff notified the physician and received an order for [REDACTED]. He had a [DIAGNOSES REDACTED]. Staff repositioned the resident and secured an air mask (a plastic mask which covers the nose and mouth to deliver oxygen) to deliver five liters of supplemental oxygen per minute. The Progress Notes dated [DATE] documented R1 was under isolation for suspected Covid-19. His oxygen saturation levels were up to the lower limits when on supplemental oxygen at five liters per minute at 09:36 AM. At 01:09 PM his laboratory results were positive for Covid-19. At 08:05 PM his pulse was regular at 90 beats per minute, blood pressure was ,[DATE] mmHg (millimeters of Mercury), and his respirations were 18 breaths per minute. The Vital Signs tab of the EMR dated [DATE] documented an oxygen saturation level of 87% on high flow supplemental oxygen, a temperature of 98.5 F, a blood pressure of ,[DATE] mmHg at 07:15 AM. R1's respirations were 46 breaths per minute at 07:50 AM. The EMR lacked documentation for physician notification of the vital signs listed above. The Progress Notes tab recorded a note dated [DATE] at 09:10 AM which documented Licensed Nurse (LN) J found R1, not breathing and with no heartbeat. Staff attempted to notify facility administrative staff but were unable to. Staff notified Consultant Physician GG at 09:16 AM and the medical examiner at 09:21 AM. The facility released R1's body for cremation at 11:17 AM. A Late Entry Note under the Progress Notes dated [DATE] at 11:16 AM recorded Certified Nurse Aid (CNA) N observed R1 did not look good and reported to LN J. LN J and CNA N entered R1's room and identified R1 had no vital signs. LN J informed LN H. The note recorded LN J did not receive instruction to initiate CPR at that time. An anonymous staff member's notarized Witness Statement dated [DATE] documented R1 was a full code and the staff did not perform CPR. The nurse on the Covid-19 unit was unable to access Point Click Care (PCC- a computer system used for resident records). On [DATE] LN J was unavailable for interview. On [DATE] at 11:49 AM LN G stated she worked in facility a few weeks and received instructions for the access to the residents' records when she started. LN G stated the residents' advanced directive wishes were noted on the EMR and there was a printed list of residents who were full codes at the nurses' station. She first noted this list on a sticky note but, the lists were now on a sheet of paper. On [DATE] at 12:14 PM LN H stated she had not worked with the PCC system (a computer system used for resident records) prior to her shift on [DATE]. She did not know R1's code status. She arrived at the Covid-19 isolation unit around 06:40 AM on [DATE]. She received report and counted narcotics with the night shift nurse. She started a medication pass and another nurse told her R1 had no heartbeat or respirations. She stated she entered R1's room and he had no vital signs, his extremities were cold, his trunk was warm, and his neck appeared stiff. She stated she did not start CPR since she did not know R1's code status. On [DATE] at 12:34 PM CNA M stated she was on the opposite end of the hall when the incident occurred on [DATE]. She reported documentation of the residents' code status was in the PCC records. On [DATE] at 01:41 PM Administrative Nurse D stated residents' code status was found in the PCC records. She expected the staff to initiate CPR when the records indicated the resident was a full code. On [DATE] at 03:51 PM LN H stated she obtained vital signs on R1 between 07:00 AM and 07:30 AM on the morning of [DATE]. At that time, his mouth was open, and his respirations were rapid. He was on five liters of supplemental oxygen. LN H stated she assumed R1 had a Do Not Resuscitate (DNR-an advanced directive to withhold resuscitative measures) order since he was on the Covid-19 unit, so she did not need to call the physician with his change in status or start CPR. On [DATE] at 12:57 PM Physician Consultant GG stated respirations above 24 breaths per minute and a pulse above 85 beats per minute were a sign of [MEDICAL CONDITION] (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead). He expected nurses to notify him of respirations of 46 breaths a minute, a blood pressure of ,[DATE] mmHg, or an oxygen saturation level of 87%. The facility's Advance Directives policy revised [DATE] documented the residents have the right to self-determination regarding their medical care. This includes right of an individual to direct his/or her own medical treatment, including the right to execute or refuse to execute and advance directive. The Admissions Director or designee interviews the resident and/or family upon admission to determine the need and knowledge relative to advance directives. Regardless of whether the resident is in a persistent vegetative state or has a terminal condition, all Life Care Centers of America's residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's Advanced Directive. The facility's Cardiopulmonary Resuscitation (CPR) Guidelines revised [DATE] recorded the facility was able and does provide emergency basic life support immediately when needed. It further documented if a resident experienced a cardiac or respiratory arrest in the resident does not show signs of irreversible death (rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (a purplish red discoloration of the skin following death), decapitation (to cut of the head), transection (creation of a cut or division of a body part) or decomposition (process of breaking down an organic matte) facility staff must provide basic life support including CPR. The facility failed to provide resuscitative measures to R1 whose advance directives and physician's orders [REDACTED]. The facility also failed to ensure the nursing staff knew the process for confirmation of a resident's code status. These failures resulted in the non-adherence to R1's wish for resuscitative measures and R1 was pronounced dead in the facility. This deficient practice had the potential to place all residents on the Covid-19 unit, who desired a full code, in immediate jeopardy. The facility removed the immediate jeopardy when it implemented the following: The Staff Development Coordinator or designee re-educated facility nursing staff, agency nursing staff and therapy staff currently on duty on where to locate code status, and when to initiate CPR, per Cardiopulmonary Resuscitation Guidelines Policy, if a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status, or in accordance with the documented verbal wishes of the resident or the resident's representative while the physician's orders [REDACTED]. The Staff Development Coordinator or designee will reeducate facility nursing staff, agency nursing staff and therapy staff prior to working their next scheduled shift on where to locate code status, and when to initiate CPR, per Cardiopulmonary Resuscitation Guidelines Policy, if a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status, or in accordance with the documented verbal wishes of the resident or the resident's representative while the physician's orders [REDACTED]. ADHOC QAPI Meeting was held on [DATE] with the QAPI Committee and Medical Director via telephone to address the alleged deficient practice incident that occurred on [DATE]. The Director of Nursing or designee audited current in house residents to verify the code status was accurate and Resident's Profile Screen, Care Plan and Kardex were updated accordingly. The agency staff are no longer employed at the facility. This deficient practice remains at the scope and severity of a G.

The facility identified a census of 116 residents. The sample included five residents. Based on record reviews and interviews, the facility failed to ensure Resident (R) 1 received treatment and care in accordance with professional standards of practice when the facility failed to notify the physician with potentially life-threatening vital signs. R1 expired in the facilty before the physician was notified of his vital signs. Findings included: - The [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of zero which indicated severe cognitive impairment. R1 required extensive assistance of one to two staff members for dressing, bed mobility, transfers, toileting, eating, and personal hygiene. The Quarterly MDS dated [DATE] revealed no changes in R1's BIMS score. R1 required extensive assistance of one to two staff members for dressing, bed mobility, transfers, toileting, and personal hygiene. R1 required supervision with set up help with eating. The Cognitive Loss and Dementia Care Area Assessment (CAA) dated [DATE] documented R1 had inattention and disorganized thinking. The Care Plan dated [DATE] revised [DATE] documented R1 was at risk for COVID-19 and directed staff to perform routine respiratory User Defined Assessments (UDA) as scheduled and to obtain routine vital signs not included in the respiratory UDA. The Care Plan directed staff to follow oxygen saturation parameters as indicated and to notify physician and responsible party if respiratory condition developed. The care plan directed staff to clean nebulizers per policy if indicated and weekly replacement of oxygen tubing and nebulizer components if indicated. The Care Plan dated [DATE] documented R1 had potential exposure to COVID-19 and directed staff to observe for changes in level of consciousness, mental status, and lethargy as needed. The Orders tab of R1's EMR documented an order with a start date of [DATE] for full code (resuscitative measures). The Orders tab of R1's EMR documented an order with a start date of [DATE] for oxygen up to five liters per minute to maintain oxygen saturation at or above 90 percent (%). The Progress Notes tab in EMR revealed progress note on [DATE] at 06:38 AM documented R1's oxygen saturation dropped to 80% at 01:15 AM and the physician was notified. New orders were obtained for a chest x-ray, laboratory blood work was ordered. The physician also ordered supplemental oxygen use at two liters per minute. The oxygen was administered and R1's oxygen saturation level rose to 93%. At 12:50 PM R1's oxygen saturation level dropped to 80%, his temperature was 99.8 F. He had a productive cough and congestion. The physician was notified and ordered Tylenol (medication used to lower body temperature) 1000 milligrams orally every four hours as needed for and elevated temperature and to increase the supplemental oxygen to be administered at five liters per minute. At 08:27 PM R1 had crackles in his lungs. He had a [DIAGNOSES REDACTED]. He was repositioned and an air mask (a plastic mask which covers the nose and mouth to deliver oxygen) was secured to deliver five liters of supplemental oxygen per minute. The progress notes on [DATE] at 09:36 documented R1 was under isolation for suspected Covid-19. His oxygen saturation levels were up to the lower limits when on supplemental oxygen at five liters per minute at 09:36 AM. At 01:09 PM his laboratory results were positive for Covid-19. At 08:05 PM his pulse was regular at 90 beats per minute, blood pressure was ,[DATE], and his respirations were 18 per minute. The Weight/Vitals tab in EMR revealed R1's blood pressure on [DATE] at 07:15 AM was ,[DATE] millimeters of mercury (mmHg) and oxygen saturation (the fraction of oxygen saturated hemoglobin relative to total hemoglobin in the blood) was 87% on high flow supplemental oxygen, R1's respirations at 07:50 AM were 46 breaths a minute. The EMR lacked documentation of physician notification for the above vital signs. The progress notes on [DATE] at 09:10 AM documented another nurse made rounds and found resident not breathing with no heartbeat. Licensed Nurse (LN) H entered R1's room and observed R1 was not breathing nor had a heartbeat. LN H notified R1's wife and Director of Nursing at 09:15 AM, the physician at 09:16 AM, and the medical examiner at 09:21 AM. On [DATE] at 03:51 PM, LN H stated she had seen R1 at the beginning of the shift to do vital signs and his mouth was open and his respirations were rapid. She stated did not call the doctor about the vital signs and did not start CPR because she thought since R1 was on the COVID unit, he was a no code (do not resuscitate). LN H stated she notified the doctor after R1 died . On [DATE] at 04:28 PM, Administrative Nurse D stated she would expect the nurse to check code status if a blood pressure is abnormal, look at previous blood pressures to see what they had been, and to call the doctor. She stated she expected the nurse to use her nursing education. On [DATE] at 12:57 PM, Consultant GG stated he had parameters for vital signs but did not know where the facility kept them, but he expected to be called with abnormal vitals such as respirations greater than 24 and heartrate greater than 95. Consultant GG stated those may be signs of [MEDICAL CONDITION] and he should have been notified of R1's abnormal vital signs. The Change in Resident's Condition or Status Policy last reviewed [DATE] documented the facility must immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status which included a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications The facility must immediately consult with the resident's physician when there was a need to alter treatment significantly which included a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment. The facility failed to ensure a cognitively impaired resident received treatment and care in accordance with professional standards of practice when they failed to identify a change in R1's health status as evidenced by abnormal vital signs on [DATE] and failed to notify the physician. R1 was pronounced dead in the facilty on [DATE].

The facility identified a census of 131 residents. Based on record review and interviews, the facility failed to prevent a significant medication error when staff failed to have available and administer Resident (R) 1's physician ordered anti-[MEDICAL CONDITION] medication. The facility further failed to notify the residents physician immediately when the medication error was discovered. R1 did not receive her anti-[MEDICAL CONDITION] medication the evening of 05/26/20, and the morning and evening doses on 05/27/20. On 05/28/20, R1 was documented with [MEDICAL CONDITION] activity and on 05/30/20, R1 was found unresponsive (not reacting) with [MEDICAL CONDITION] signs and symptoms (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). R1 was transferred to the emergency room and admitted to the hospital's intensive care unit (ICU). The deficient practice placed R1 in immediate jeopardy. Findings included: - R1's electronic medical record (EMR) recorded she admitted to the facility on [DATE] for treatment of [REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of nine which indicated her cognition was severely impaired. She required extensive assistance of one to two staff with most of her activities of daily living (ADL's). R1's Care Plan, revised 05/20/20, directed staff to administer her anti-[MEDICAL CONDITION] medication as ordered by the physician. the Care Plan further directed after a [MEDICAL CONDITION] staff were to turn R1 on her side with her head back, hyper-extended to prevent aspiration, keep her airway open, take vital signs, and perform neurological checks. It also instructed staff to document: duration, level of consciousness, any incontinence, [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), sleeping or dazed and postictal stated (period of time following a [MEDICAL CONDITION]). R1's EMR, under the Orders' tab, documented a physician order [REDACTED]. According to the Food and Drug Administration (FDA.gov) lacosamide (also known as [MEDICATION NAME]) is a medication used to prevent and control [MEDICAL CONDITION]. FDA.gov also informs: lacosamide tablets should be withdrawn gradually (over a minimum of 1 week) to minimize the potential of increased [MEDICAL CONDITION] frequency in patients with [MEDICAL CONDITION] disorders. Review of the electronic Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A nurse's Progress Note, located in the EMR under Progress Notes, dated 05/28/2020 at 06:10 AM documented R1 was non-responsive to stimuli. Her body shook, and eyes darted back and forth. The bed was lowered and R1 was placed on her side, in a laying position. R1's blood pressure was recorded as 225/73, her pulse was recorded as 61 beats per minute, her respirations were recorded at 20 breaths a minute and her oxygen saturation (measure of how much oxygen the blood carried as a percentage of the maximum it could carry) was recorded as 98 percent (%). Physician X was notified and at 06:17 AM R1 resumed responsiveness. A nurse's Progress Note, located in the EMR under Progress Notes, dated 05/28/2020 at 04:37 PM documented R1's responsible party was contacted about R1. R1's responsible party was unhappy to hear that R1 was having [MEDICAL CONDITION] and medication had not been administered due to unavailability. R1's responsible party reported to facility staff that past [MEDICAL CONDITION] contributed to the R1's decline. A nurse's Progress Note, located in the EMR under Progress Notes, dated 05/30/2020 at 01:15 PM documented the nurse assessed R1 related to reports of her being non-responsive. The nurse arrived in R1's room,and observed R1 lying in bed, supine (lying on the back) with her head on the pillow facing the wall (turned toward the left). R1's arms were across her chest/stomach. The nurse attempted to speak with R1, asked her questions, but R1 did not attempt to respond. The nurse performed sternal rubs and loudly called R1's name with no response. The note recorded R1 did not open her eyes or turn her head toward the nurse. R1 did not moan or cry in pain or annoyance. The nurse turned R1's head to the right, but R1 did not open her eyes or respond to stimuli. When R1's head was released, R1 moved it towards the left once again. The note further documented the Certified Nurse Aide (CNA) reported she attempted to have R1 drink and eat some mashed potatoes earlier, but R1 was unable to swallow food for a long time and coughed a bit when she did. The CNA stopped feeding the resident due to safety reasons. The nurse called Physician X and updated him on R1's status, and received orders to send R1 to the emergency room . Review of the hospital emergency room report, dated 05/31//20, documented R1 admitted from her skilled nursing facility where she had been having up to eight [MEDICAL CONDITION] daily since 05/27/20. This same report recorded the hospitalist impression/[DIAGNOSES REDACTED]. The hospitalist plan of care included an intravenous (IV) loading dose of lacosamide and restarted the twice daily dose of lacosamide. The facility did not provide an investigation of the medication error and/or a reporting of the error to the state agency. On 06/17/20 at 01:15 PM Administrative Nurse E stated R1 missed a total of three doses of the lacosamide. Administrative Nurse E called the pharmacy and the pharmacy stated they needed a new prescription. Administrative Nurse E called the physician to obtain a new prescription. The pharmacy delivered five pills of lacosamide on 05/28/20. Administrative Nurse E stated R1's physician was not notified of the missed medication doses and stated it was just an oversight that the physician was not made aware of the missed doses at that time. On 06/17/20 at 02:08 PM Administrative Nurse D stated if the medication was not available in the facility, she expected staff to call the pharmacy and find out where the medication was. Administrative Nurse D stated staff did not follow the facility policy for securing medications or reporting a medication error. Administrative Nurse D stated Physician X was notified, at some point, of the medication error. During a telephone interview, on 06/17/20 at 03:22 PM, Physician X stated sudden disruption in anti-[MEDICAL CONDITION] medication did contribute to increased [MEDICAL CONDITION] activity and expressed the medication had a warning which included serious reactions, including [MEDICAL CONDITION], could occur if the medication was withdrawn or abruptly discontinued. The facility's Administration of Medications policy revised 04/24/19 documented all medications were administered safely and appropriately per physician order [REDACTED]. The policy lacked documentation to include any information and/or direction for the unavailability of medications. The facility did not provide a policy related to significant medication errors. The facility failed to prevent a significant medication error for R1, a cognitively impaired and dependent resident, when the facility failed to ensure her [MEDICAL CONDITION] medication was available for administration and failed to administer the medication resulting in R1 being admitted to the ICU for treatment. This failure placed R1 in immediate jeopardy beginning on 05/27/20 when the medication error first occurred. The immediate jeopardy was removed when the facility implemented the following interventions: The Regional Director of Clinical Services reviewed active physician orders, against their [MEDICAL CONDITION] medications, for resident's diagnosed with [REDACTED]. The Assistant Director of Nursing and Staff Development Coordinator educated all facility licensed nursing and certified medication staff including agency staff on the procedure for reordering of [MEDICAL CONDITION] medications to ensure physician orders [REDACTED].>The Staff Development Coordinator or designee will educate all licensed nursing staff including agency staff on the Event Management System Policy (which includes medication discrepancy, notification of physician). A Quality Assurance and Performance Improvement (QAPI) meeting was held with the QAPI Committee and Medical Director via telephone. The deficient practice remained at a scope and severity of a G.

The facility reported a census of 138. The sample included 15 residents. Based on record review, observation, and interviews, the facility failed to provide the needed dementia (progressive mental disorder characterized by failing memory, confusion) care and services to Resident (R) 1. The facility failed to develop and implement personalized care plan interventions for R1, who was severely cognitively impaired and had a history of [REDACTED]. The facility failed to implement care planned interventions for R1 which included 30-minute checks, redirection of R1 to supervised areas, and staff supervision for R1 when he was awake. On [DATE] at 01:30 AM, staff observed R1 on his roommate's side of the room, having an altercation with the roommate (R3). Staff directed back R1 to bed. Staff observed R1 awake and out of bed again at 02:30 AM. Staff again placed R1 into bed. At 04:00 AM, staff found R1 in his room, in a semi standing position with the privacy curtain twisted around his neck. The privacy curtain was cut down, and staff lowered R1 to the floor. Staff assessed the resident and determined he died . The facility's deficient practice created an immediate jeopardy which affected all 16 residents who resided on the 1200 hall, a locked dementia unit. Findings included: - R1's electronic medical record (EMR), under the [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] recorded the Brief Interview for Mental Status (BIMS) did not occur. The staff interview revealed R1 had short and long-term memory problems. He had severely impaired ability to make decision regarding his daily life. The MDS documented R1 had physical behaviors towards others (hitting, kicking, pushing, scratching and /or grabbing) for one to three days of the look back period. The Quarterly MDS dated [DATE] recorded R1 had disorganized thinking and inattention. R1 had a BIMS score of zero which indicated severe cognitive impairment. The MDS documented R1 had no behaviors during the look back period. He required extensive two-person assistance with transfers, bed mobility, dressing, toilet use, and personal hygiene. He also required extensive one-person assistance with eating and ambulated with supervision/set up. The Cognition Care Area assessment dated [DATE] documented d R1 was [AGE] years old and had early onset dementia, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). He had cognitive and memory impairments. He had difficulty making himself understood and understanding others. R1's Care Plan dated [DATE] recorded R1 was at risk for self-care deficit due to impaired cognition, decreased mobility, and behaviors. It documented R1 may have difficulty with pulling up/down pants, providing peri cares, brushing his hair and teeth, and shaving. It directed staff to ensure completion of those tasks daily. It further instructed if R1 became resistive with cares to allow time to self-calm. The Care Plan documented R1 needed supervision to extensive assistance with bed mobility, transfers, eating with tray set up, toileting, ambulation without devices, dressing, personal hygiene, and showers. His level of care depended on mood/behaviors The Care Plan dated [DATE] recorded R1 had a history of [REDACTED]. The interventions dated [DATE] instructed staff to administer medications as ordered and to anticipate and meet R1's needs. It further directed to educate staff, family, and caregivers regarding successful interaction strategies such as (specify). The Care Plan lacked a specified intervention. The Care Plan revised on [DATE] recorded R1 was physically aggressive towards his peers due to dementia. An intervention dated [DATE] directed, when R1 became agitated: staff were to intervene before agitation escalated guide R1 away from source of distress, and engage calmly in conversation. The Care Plan, revised on [DATE] recorded R1 was at risk for falls and had a fall with an actual injury. An intervention dated [DATE] directed staff to provide supervision to extensive assistance with bed mobility, transfers, and ambulation without devices. It directed staff to provide assistance of one to two persons depending on R1's behavior. An intervention dated [DATE] instructed staff to redirect R1 to observable areas for staff supervision and assist with transfers as needed. An intervention dated [DATE] instructed staff to assist R1 out of bed and into observable areas when awake. An intervention dated [DATE] directed staff not to lay the resident in bed until he showed signs of being tired. The Care Plan revised on [DATE] documented R1 was at risk for elopement due to his impaired cognition. An intervention dated [DATE] instructed staff to provide education related to a secure unit and to provide 30-minute checks to R1. Another intervention dated [DATE] directed staff to provide frequent monitoring, every 30 minutes. An Event Note, under the Progress Note tab in R1's EMR dated [DATE] at 06:00 AM documented the Certified Nurse Aids (CNA ) responded to R1's roommate yelling help, help. When the CNAs entered the room, they saw R1's hands wrapped around his roommate's neck while the roommate was lying in bed. The roommate had a scratch above his nose that had not been there before. The CNAs separated the residents by having R1 walk in the hallway and living room with them. An Interdisciplinary Team (IDT) Note under the Progress Note tab in R1's EMR dated [DATE] at 06:08 PM documented the IDT met to discuss the altercation on [DATE]. R1 had his hands wrapped around another resident's neck. The note documented the root cause analysis as the following: It is reasonable that what triggered this resident was a night terror as resident has woke up in an aggressive state before and staff intervened. An IDT Note in R1's EMR under the Progress Note tab dated [DATE] documented the IDT team met to discuss an unwitnessed fall on [DATE]. Staff observed R1 on the floor with bedsheets around his feet. The note documented the following root cause analysis: Resident was not ready/sleepy when put to bed. The note directed the staff were not to put R1 to bed until he became tired. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] at 07:25 AM documented the CNA heard shouting coming from R1's room. Upon checking, the CNA observed R1 on top of his roommate, who was on the floor next to his bed. R1 was held in a headlock position by his roommate. R1 was last seen in his bed resting at about 06:30 AM prior to the incident. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] documented R1 remained on neurochecks (assessment of neurological status) after R1 was found on floor/resident to resident altercation. R1 remained alert with profound confusion when awake. R1 continued to pace the hallways and rooms, yelling and hitting objects for no apparent reason. An IDT Note in R1's EMR under the Progress Note tab dated [DATE] at 01:16 PM documented the IDT team met to discuss an altercation on [DATE] where R1 sat on top of another resident and the resident had R1 in a head lock. The note recorded the root cause analysis as R1 awoke in an agitated state and struck out at the nearest person. The note documented the plan was to move the roommate to another room. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] at 10:38 PM documented when the nurse arrived on the unit R1 paced back and forth aggressively. He went into his room and started hitting his bed and wall. Staff redirected R1 away from his peers for his and his peer's safety. The nurse walked with R1 in his room and he eventually calmed down after 10 minutes. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] at 08:19 PM recorded R1 slapped the CNA while she assisted with his toileting needs. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] 0528 recorded R1 was quiet most of the shift until a peer awakened him in the common area. The residents were separated before a conflict resulted. R1 charged at the nurse two times and staff redirected him back to the common area to calm down. After the resident sat in a recliner, the nurse gave R1 a cookie and juice and his mood shifted. No other problems were noted during the shift. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] at 10:43 PM recorded R1 continued to exhibit intermittent agitation towards peers and staff. Staff had to redirect R1 multiple times throughout the shift. Staff were to monitor for behaviors. A Nurse Note under the Progress Note tab in R1's EMR dated [DATE] at 07:06 AM documented R1 was found with the curtains in his room wrapped around his neck several times. Consultant GG cut the curtains from around R1's neck and CNA O guided R1 to floor. An assessment revealed no pulse, no respirations, and no heart rate. The floor was not wet and no clutter noted in the room. R1 was last seen by CNA O and/or P at 02:30 AM. Staff notified law enforcement and emergency services. Staff also notified R1's physician, family, and Administrative Staff A as well. A Notarized Witness Statement dated [DATE] by CNA P recorded CNA P and CNA O went into R1's room to check his temperature and oxygen at midnight on [DATE]. R1 was in a bad mood and very aggressive. CNA P and CNA O managed to calm R1 down and put him back in his bed. At 01:30 AM CNA P and CNA O heard a loud noise coming from R1's room. They rushed in there and found R1 fighting with his roommate, R3. The CNAs were able to get R1 away from R3's side of the room and back in R1's bed. CNA P and CNA O went back to R1's room around 02:30 AM for rounds. They provided peri cares and put him back in bed, turned off the light and left the door slightly ajar. At 03:55 AM Consultant GG and his assistant called CNA P and CNA O to R1's room. R1 was found in his room hanging in his curtain. CNA P called the nurse . A Notarized Witness Statement dated [DATE] by CNA O documented at approximately 03:55 AM on [DATE] Consultant GG summoned CNA O to R1's room. CNA O documented when he arrived in R1's room he saw R1 hanging from the curtain which was twisted around his neck. CNA O immediately picked up R1 and Consultant GG cut the curtain from the top of the curtain frame. CNA O then placed R1 on the floor to check for a pulse. CNA O recorded CNA P went to get the charge nurse, who called 911. The statement documented CNA O and CNA P checked on R1 several times because of R1's agitation. The statement recorded the last time CNA O checked on R1 was at 02:30 AM when CNA O and CNA P put R1 in bed because R1 was up walking around. A Notarized Witness Statement dated [DATE] by Consultant GG documented at approximately 04:00 AM Consultant GG opened the door to R1's room to find R1 hanging by his neck from his curtain. The curtain had been twisted tightly. Consultant GG yelled for the facility staff to come to R1's room. Consultant GG recorded CNA O came to R1's room and held R1 while Consultant GG used his pocketknife to cut down the curtain. CNA O laid R1 on the floor and checked for vital signs. Consultant GG documented he heard CNA O state CNA O could not detect a pulse. A Notarized Witness Statement dated [DATE] by Licensed Nurse (LN) H documented LN H was called to come immediately to hall to see R1. When LN H entered R1's room, R1 was lying on floor with his legs stretched out towards the door, and his head on a pillow. An assessment revealed no pulse, no respirations, and no heart rate. R1 had a red line visible around the left side of his neck. Consultant GG reported to LN H R1 had several wraps of the privacy curtain around his neck. Consultant GG cut the curtain from around R1's neck with help of CNA O holding R1's body. An observation on [DATE] at 08:47 AM, with CNA Q present, revealed R1's room had a privacy curtain hanging between R1's former bed and R3's bed. The curtain was knotted, with the knot at approximately five feet from the floor. The knot was easily undone by gentle pulling. CNA Q stated the curtains were knotted in order to prevent the residents from messing with the curtains or tugging them. CNA Q stated over the years of being employed at the facility, he witnessed several occasions of the residents pulling on the curtains so hard the curtains would come down, or the entire curtain track would pull loose. The privacy curtain between R1's side of the room and the door was missing. All the hooks, meant to hold the privacy curtain, were intact and slid to end of the track closest to the bed. In an interview on [DATE] at 09:24 AM Social Services Y stated she worked with R1 for over one year. She stated R1 and R3 roomed together because they were both frequently up at night. Prior to this, R1 had been in a room by himself due to multiple resident to resident altercations involving R1 and his roommates. She said R1's behaviors were typical, and his aggressiveness was nothing new. Social Services Y stated R1 was always up moving. He was nonverbal. He would grunt and maybe say yes or no. She said he could walk, and he paced up and down the halls. His coordination was minimal, if handed something even minimally heavy he would drop it. He could not bop a balloon in activities. She stated no one reported anything to her about a change in R1's behaviors or demeanor. She learned of R1's incident when she arrived at work that morning. She was told by Administrative Staff A that a tragedy occurred. She said Administrative Staff A said R1 became wrapped up in the curtains and h suffocated. Social Service Y stated she was also informed during that conversation of the resident to resident altercation which occurred on [DATE] between R1 and R3. In an interview on [DATE] at 04:00 PM, CNA P stated she was familiar with R1 though she was not always assigned specifically to his unit. She stated staff were aware of how to care for the residents, or changes, by verbal report and walking rounds with off going staff. CNA P stated R1 had a history of [REDACTED]. She stated R1 became agitated on the night of ,[DATE] at midnight. Staff calmed him and placed him in bed. At 01:30 AM on [DATE] CNA P stated she heard a noise coming from R1's room. CNA P said that CNA O and she entered R1's room and observed R1 standing on R3's side of room. R3 was in bed and R1 was standing over him, hitting him. R3 was hitting R1 in response. CNA P said the privacy curtain going side to side, dividing the room, was pulled but R1 was able to get through the curtain to R3's side of room. Staff redirected R1 back to his side of the room. CNA P stated she did not think anyone had injuries and they reported the resident to resident altercation to the charge nurse on duty. She stated both CNAs left the room and did not reenter the room until 02:30 AM, when doing routine rounds. CNA P said when they entered the room, the dividing privacy curtain was still pulled and R1's privacy curtain was in place and not in use. CNA P said she saw R1 up, walking around in the room when they entered. R1 became agitated and difficult to redirect back to bed, but they were able to redirect him to bed and change his brief. CNA P stated that during the time they were attending to R1, changing his brief, R1 was agitated, yelling, and hitting his headboard. CNA P said that was normal behavior for R1. CNA P stated R1 seemed more on edge than usual that night although he was always aggressive and agitated and up at night. CNA P said R1 was usually able to be redirected or calmed down after 30 minutes, but on that night he was very agitated and would not calm down. CNA P stated they did not reenter R1's room until around 04:00 AM when the lab people came and alerted them that R1 was hanging from his privacy curtain. CNA P stated when she entered the doorway, she could see R1 hanging. His feet touched the floor, but he was slumped over and had the curtain twisted around him. She stated she could not see if the curtain was twisted or actually knotted because the lab people were blocking her direct line of vision. During an interview on [DATE] at 04:11 PM Consultant GG stated he entered R1's room at around 04:00 AM the morning of the [DATE] in order to draw blood for lab work for R1. Consultant GG said as soon as he entered the doorway, he could see R1 right there, hanging by the neck, facing toward the other side of the room. R1's feet were touching the floor, and he was slumped over. Consultant GG stated R1's shoulders were approximately chest high to Consultant GG. Consultant GG said R1 was about three feet away from the bed and any other furniture. There was a chair in R1's room, but it was not nearby. Consultant GG stated he entered R1's room and told his trainee to get help. Consultant GG stated a male CNA came to R1's room right away and held R1's lower body steady as Consultant GG cut the curtain. He stated he reached up and cut the curtain at the netting part, close to the top. Consultant GG stated the curtain appeared to be twisted, not knotted. On [DATE] CNA O was unable to be reached for interview. On [DATE] LN H was unable to be reached for interview. In an interview on [DATE] at 02:14 PM Administrative Nurse D stated staff completed dementia training during orientation for all new hires. She reported for all other staff, dementia training was ongoing. Administrative Nurse D stated she does not do the training personally, so she was unsure how often it is done, but then stated she was certain it was more than the required amount. She reported the facility used Hand in Hand training on the virtual training site. She stated staff know how to care for each resident by reviewing the care plan and also each residents' Kardex (a tool in the EMR which describes resident care needs). She reported the facility's Abuse, Neglect and Exploitation training included resident to resident altercations. Administrative Nurse D stated for all resident to resident altercations, staff should immediately separate the residents and monitor each resident closely. She also stated resident behaviors should be monitored, and changes or increased behaviors should be reported to the physician. Administrative Nurse D stated she was aware of R1's behaviors. She stated she believed R1's physician prescribed some medication last fall to treat his night terrors, but was uncertain what medication the physician ordered. She said she was notified of R1's death the morning of [DATE]. Administrative Nurse D said she felt staff had not implemented all of R1's care planned interventions on the morning of [DATE]. Administrative Nurse D stated the facility started knotting the privacy curtains on R1's unit in response to R1's death. She stated no other corrective action had been implemented in response to the occurrence. In an interview on [DATE] at 02:55 PM, Administrative Staff A stated she was familiar with R1 but did not know the specifics of his plan of care. She stated she was not aware of any issues or changes in his behavior or mood. She stated R1 did not communicate well and she was uncertain about his specific habits. Administrative Staff A reported R1 had some altercations with roommates in the past. She reported staff moved him from his previous room into a shared room with R3 due to the COVID -19 pandemic. Administrative Staff A stated she was not informed of any altercation between R1 and R3 on the morning of [DATE]. She reported she was aware the staff had heard a noise in the room, but no one mentioned an altercation. Administrative Staff A stated she read CNA P's witness statement since she was the one to notarize it, but because CNA P did not use the word fighting in her verbal statement, Administrative Staff A did not think it required follow up at that time. She said she did not think it involved any type of physical altercation. Administrative Staff A reported the events of the morning placed an emotional toll on her and under normal circumstances, she would certainly follow up on any allegation of residents fighting. Administrative Staff A said she arrived at the facility within 15 minutes of receiving the news regarding the death of R1. She said she spoke with Consultant GG that morning. Administrative Staff A stated, Consultant GG told her R1's privacy curtain was wrapped around R1 up by his neck and R1's feet were still on the ground. Administrative Staff A reported the coroner arrived at the building at around 06:30 AM. She reported as a result of the incident, the facility was looking into break away privacy curtains. Administrative Staff A stated all staff received dementia training as well as training on how to deal with resident behaviors and resident to resident altercations. She stated she was uncertain how the trainings were conducted or how often they were conducted. The undated document Dementia provided by the facility lacked direction on how to care for residents diagnosed with [REDACTED]. The undated facility policy Event Management System Policy recorded a purpose of . provide supervision and assistive devices to each resident to prevent avoidable accidents. The policy listed the following as Events: verbal and physical aggression. The undated facility policy Behavioral Health Management documented the resident who was diagnosed with [REDACTED]. The policy directed the facility to monitor the resident closely for expression or indications of distress. It directed the facility to assess and plan care concerns based on resident assessments. The policy directed the facility must ensure the services for behavioral health were person centered. The facility failed to provide needed dementia care and services and failed to develop and implement personalized care plan interventions for R1. The facility also failed to implement care planned interventions for R1. This deficient practice placed the residents with a [DIAGNOSES REDACTED]. The immediate jeopardy was abated on [DATE] at 10:49 AM when the facility implemented the following actions: The Director of Nursing or Designee will evaluate all residents with dementia for aggressive behavior. Any resident identified as having aggressive behaviors will have their care plan reviewed for person centered interventions to mitigate aggressiveness, and behaviors and their care plan will be updated accordingly. The Staff Development Coordinator or Designee will re-educate all facility staff on the use of the Kardex and care plan to meet the individualized needs of the resident. All facility staff, including agency staff, will be educated prior to working their next scheduled shift. The Staff Development Coordinator or Designee would reeducate all staff including agency staff on protections of the residents and event management system which included implementing immediate interventions following incidents to keep residents safe. The deficient practice remained at a scope and severity of G.

The facility reported a census of 153 residents, with 3 residents selected for review. Based on observation, interview, and record review the facility failed to ensure 2 of 3 residents sampled for loss of personal property remained free from misappropriation of property. (#1, #2) Findings included: - The signed physician order [REDACTED]. The 5-day MDS (Minimum Data Set) dated 5/17/19 revealed he/she had highly impaired hearing and wore a hearing aide. He/she had clear speech and was usually able to make him/herself understood, sometimes understands and had highly impaired vision without visual aids. Resident #1 had a Brief Interview for Mental Status (BIMS) of zero, indicating severe impairment. He/she required extensive assistance of one person for dressing and personal hygiene. The 5/16/19 revised care plan revealed that he/she was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficit and low activity tolerance. Review of the resident's inventory sheet dated 3/9/15 documented the resident had 10 pairs of earrings and 21 necklaces. The inventory sheet lacked documentation that the resident had a wedding ring. Review of the electronic medical record and paper hard chart dated 3/1/2018 - 6/10/2019 lacked documentation of the resident's missing wedding ring. Review of the investigation provided by the facility on 6/10/19 at 1:15 PM revealed the police department report number, a witness statement dated 4/4/18 and untimed from a staff nurse, a replacement price quote for the ring valued at $9476.00, the original bill of sale for the ring dated 8/3/1973 and a picture of the ring. The investigation provided had no further documentation regarding the missing ring. Observation on 6/10/19 at 3:45 PM, resident #1 was lying in bed with his/her eyes open, but did not respond to conversation at this time. Resident #1 was not wearing rings on either hand. An interview on 6/10/19 at 1:09 PM, Administrative staff A stated at the time of the incident (4/4/2018) the resident's family member saw him/her daily and made staff aware the ring was missing. Administrative staff A stated that at this time he/she called the police department. He/she further revealed that at the time of the incident the director of nursing (DON) was new and the state agency was not notified. An interview on 6/10/19 at 2:36 PM, Administrative staff A revealed that families are not to bring valuables into the facility that the facility cannot keep it safe. An interview on 6/10/19 at 5:15 PM, administrative nurse B revealed that missing items are reported to Administrative staff A and he/she does the investigation. Administrative Staff B stated that he/she just started work at the facility when this ring was reported stolen. An interview conducted on 6/10/19 at 5:30 PM with direct care staff D stated that if a resident or family member report an item missing the staff does a thorough search and then tells the charge nurse and the charge nurse reports it to administrative staff. An interview on 6/12/19 at 8:32 AM with resident #1's family member revealed that he/she visited resident #1 daily. He/she further revealed that resident #1 wore a wedding ring since admission on 3/9/2015. This family member stated the resident wore the ring from the admitted until the time of the incident on 4/4/2018 when he/she informed staff that the resident's wedding set was missing. He/she stated that he/she searched the room and then asked staff about the ring. When the floor staff were not aware of what happened to the ring, he/she revealed the concern was taken to administrative staff A, who notified the police department at that time. The family member revealed the police department notified the family the ring could be at a local pawn shop and it was recovered by the family, although he/she could not remember the length of time between the notice of it being absent from the resident's finger and the time it was found at the pawn shop. Resident #1's family stated that due to the incident, family feels unable to allow the resident to continue to wear his/her wedding set. The family member expressed that due to a fear of reoccurence, the resident was only allowed to wear the wedding set on special occasions. Review of the facility's Resident Admission Agreement dated (YEAR) under section 12 Resident Funds, Valuables and Possessions revealed the facility strongly discouraged the keeping of valuable jewelry, large sums of money, or other items considered to be of value in the facility. The facility will make a reasonable effort to safe guard your property/valuables, which you or your representative choose to keep in your possession, but cannot guarantee that items will not be lost or taken. You or your representative agree to inform the facility of all valuable property upon admission, and at any time new items of value are added to your possession. Upon admission, a detailed inventory of your possessions will be done. Review of the Incident Management Manual revised 2/2018 under Investigation and Protection revealed, when an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victims and other resident, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. The facility failed to ensure resident #1 remained free from exploitation when a ring valued at $9476.00 was taken and later recovered at a local pawn shop. - The signed physician order [REDACTED].#2 revealed he/she had [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] revealed resident #2 had a BIMS score of 3 which indicated severe cognitive impairment. The assessment further revealed it was very important to take care of personal belongings and to lock things up and keep them safe. Resident #2 required extensive assistance of one person for dressing, toilet use and personal hygiene. The 6/3/19 revised care plan revealed that he/she was dependent on staff for emotional, intellectual, physical and social needs related to cognitive deficit. Review of the resident's inventory sheet dated 12/6/2018 lacked documentation of jewelry and was not signed by the resident or responsible party. Review of the electronic medical record and the paper hard chart dated 4/1/2019 to 6/10/2019 lacked documentation of the resident missing a wedding ring or chain. Review of the undated investigation provided by the facility on 6/10/19 revealed staff names and the days and shifts worked starting from Saturday afternoon until Wednesday afternoon. Under the area dated Wednesday afternoon there was circle with the words reported missing during his/her shower in the afternoon on the 3pm-11pm. The next page revealed staff called the local police department on 6/7/2019 and 6/10/2019 and given a case number. An observation on 6/10/2019 at 3:58 PM revealed resident #2 was actively participating in an activity of name that tune. Resident #2 was not wearing a ring on either hand and no chain was noted around his/her neck. An interview on 6/10/19 at 2:36 PM, Administrative staff A revealed that families are not to bring valuables into the facility that the facility cannot keep it safe. An interview on 6/10/19 at 5:15 PM, administrative nurse B revealed that missing items are reported to Administrative staff A and he/she does the investigation. An interview conducted on 6/10/19 at 5:30 PM with direct care staff D stated that if a resident or family member report an item missing the staff does a thorough search and then tells the charge nurse and the charge nurse reports it to administrative staff. On 6/12/2019 at 8:30 AM, Resident #2's family declined to comment due to the ongoing police investigation. Review of the facility's Resident Admission Agreement dated (YEAR) under section 12 Resident Funds, Valuables and Possessions revealed the facility strongly discouraged the keeping of valuable jewelry, large sums of money, or other items considered to be of value in the facility. The facility will make a reasonable effort to safe guard your property/valuables, which you or your representative choose to keep in your possession, but cannot guarantee that items will not be lost or taken. You or your representative agree to inform the facility of all valuable property upon admission, and at any time new items of value are added to your possession. Upon admission, a detailed inventory of your possessions will be done. Review of the Incident Management Manual revised 2/2018 under Investigation and Protection revealed, when an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victims and other resident, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator . The facility failed to ensure resident #2 remained free from misappropriation of property when his/her ring and/or necklace valued at approximately $1800.00 was reported missing and later located at two different pawn shops.

The facility's census totaled 151 residents with 3 sampled. Based on observation, interview, and record review, the facility failed to provide effective interventions to prevent elopement for 1 of 3 residents sampled (#1) at risk for elopement with cognitive deficits and this failure placed the resident in immediate jeopardy. The facility identified all 151 residents with cognitive impairment were at risk for elopement and 78 of the residents were independently mobile. Resident #1 was found .9 miles from the facility walking on the edge of the interstate toward oncoming traffic. Findings included: - Resident #1's Physician order [REDACTED]. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident with short and long term memory problems, extensive assistance of 2 staff members with dressing, toilet use, and personal hygiene, and limited assistance of 1 staff member with bed mobility, transfers, walking and locomotion. The MDS documented the resident with wandering behavior for 4-6 days and at a significant risk of getting to a potential dangerous place. The MDS further documented the resident with a fall prior to admission. The behavior Care Area Assessment (CAA) dated 5/23/14 documented the resident would walk in the other direction when staff attempted to help with activities of daily living. The initial care plan dated 5/10/14 documented the resident was an elopement risk due to wandering and/or exit seeking behaviors and history of elopement with the following intervention: educate resident/family on safety, provide for safe wandering, involve in activities, redirect resident, every 15 minute checks, encourage family visits during peak exit seeking times, evaluate exit seeking behaviors to determine causes/patterns, pictures in the Medication Administration Record/Treatment Administration Record/break room, and identification bracelet placed on the resident's left arm. The 5/10/14 care plan for a communication deficit related to the resident's inability to speak English with the following interventions: speak softly, point to objects, staff will demonstrate understanding of what the resident requested, smile and nod approval, maintain eye contact during communication, and provide an interpreter to aide in communication. The facility's Risk of Elopement Review dated 5/10/14 documented the resident was a high risk for elopement related to increased exit seeking behavior. The Fall Risk assessment dated [DATE] scored 18 which a score of 10 or higher revealed the resident was at risk for falls. The resident had a history of [REDACTED]. The nurses' notes documented the following: The resident admitted to facility 5/10/14 at 6:35 P.M. The resident ambulated without assistance and steady gait. On 5/11/14 at 11:32 P.M. the resident was exit seeking, standing by and looking at the exit doors. On 5/12/14 at 3:49 P.M. the resident ambulated around the unit with a gait steady. The resident frequently attempted to get out of the unit and staff placed the resident on 15 minute elopement checks. On 5/13/14 at 12:57 A.M. the staff was aware of the resident high elopement risk earlier in the shift and the resident was continuously by the front exit door standing in front of the door, however the resident did not push the door open. The staff redirected the resident several times away from the exit door related to an elopement risk. The staff was easily able to redirect the resident away from the door and also redirect the resident away from the other residents' rooms. The resident was unable to stay seated in the common area for more than a few minutes at a time, liked to walk around the unit and also liked the activity room. Throughout the shift the resident was in and out of the activity room at times, fell asleep in the activity room, and liked to go into the activity room and sit in the chair which calmed the resident and kept the resident away from the exit door. The resident was resistive with the staff during care. After putting the other residents to bed, one staff sat with this resident in the activity room. The staff who sat with the resident left the floor at 8 P.M. and the other staff helped the resident. The resident refused to go to bed, so the resident was taken back to the activity room and fell asleep in the hammock. Staff assisted the resident to the toilet around 9 P.M. Licensed nursing staff H saw the resident at 9:15 P.M. The licensed nursing staff H asked direct care staff O around 9:40 P.M. where the resident was and direct care staff O replied the resident was sleeping in the activity room. The licensed nursing staff H went to check on the resident in the activity room and the resident was not there. The rest of the rooms on the unit were checked and the resident was not located. Licensed nursing staff H called the management staff and notified them the resident was missing. Licensed nursing staff I stated his/her spouse had called at 10:03 P.M. and saw a resident walking on the side of the road. Licensed nursing staff I left the facility and found the resident with the police. The police brought the resident back to the building at 10:20 P.M. Licensed nursing staff H completed a head to toe assessment of the resident and no injuries noted. Licensed nursing staff H placed a bed alarm on the resident's bed to alert the staff when the resident got up. The 5/16/14 notarized statement of direct care staff P documented the resident was exit seeking all night and successfully got off the locked unit 5 times. The resident was found walking down 1400 hallway 3 times and found in the main dining room 2 times checking out the exit doors. The door alarm did sound when the resident left the locked unit. The resident was lead back to the locked unit by several nursing staff. The 5/12/14 notarized statement of licensed nursing staff H documented staff had to redirect the resident away from the front exit door several times. The resident was unable to sit for more than a few minutes and the staff checked on him/her continuously due to elopement risk. The resident was in the activity room with 1 to 1 staff at 8:30 P.M. Licensed nursing staff H saw direct care staff O assisting the resident to the bathroom around 9:15 P.M. Licensed nursing staff H asked direct care staff O at 9:40 P.M. if the resident was in bed and direct care staff O said the resident was asleep in the activity room. At 9:47 P.M. licensed nursing staff I came into the unit and checked to see if the unit was missing a resident. Staff checked the unit and resident #1 was not located. The 5/15/14 notarized statement of direct care staff Q documented he/she tried to take the resident to his/her room to lay down at 8:00 P.M. on 5/12/14. The resident pulled away from direct care staff Q and ran to the activity room. The resident lay in the white swinging chair (hammock style chair) while direct care staff Q checked the exit door to make sure it was locked and alarmed. Staff positioned the resident with a blanket, and a pillow and went to sleep. Direct care staff Q sat in the rocking chair in the activity room with the resident. The resident appeared to be sound asleep at 8:20 P.M. Direct care staff Q left the activity room at 8:36 P.M. The 5/12/14 notarized statement of direct care staff O documented staff assisted the resident to the bathroom at 9 P.M. and then assisted the resident back into the swinging chair in the activity room at 9:15 P.M., staff covered the resident with a blanket about 9:30 P.M. and direct care staff O left the activity room. Direct care staff O on 7/1/14 at 3:00 P.M. stated he/she was doing 1:1s with the resident. Direct care staff O thought the resident was asleep and he/she left the resident to go to the bathroom without getting another staff to sit with the resident. Prior to returning to the room another staff member asked him/her for help with another resident. The 5/12/14 notarized statement of licensed nursing staff I documented he/she received a call from his/her spouse stating he/she was coming off the interstate and saw someone walking beside the interstate. The licensed nursing staff I's spouse wanted to know if the person belonged at the facility. Licensed nursing staff I went to another unit to check on the newest resident to see if it was him/her. The resident was not on the unit. Licensed nursing staff I left the facility to find the resident and when he/she got to the place where his/her spouse saw the resident; the police were there and assisted the resident into their car. The police drove the resident back to the facility. Review of an outside company inspection report of the entire building's exit doors done on 5/15/14, revealed the lock operation on the 1400 hallway door was intermittent. This was the alleged exit door the resident used. Review of the maintenance log of the operation of the facility's exit doors done on 5/10/14 revealed no problems. The prior log was dated 5/2/14 and revealed no problems with the doors, locks and alarms. The instructions at the top of the sheet documented the doors, locks and alarms should be tested daily. On 6/27/14 at 12:10 P.M. administrative staff A revealed one of the exit door alarms was found to be working only intermittently on 5/12/14 when all doors checked after the incident of the elopement. On 6/27/14 at 12:15 P.M. administrative nursing staff D revealed staff determined the resident was an elopement risk with his/her admission, since she/he had to be returned to his/her home twice by the police prior to admission to the facility. Staff placed the resident on 30 minute checks to ensure his/her safety. Staff observed the resident push on the exit door to try and leave the locked unit, attempted to leave the unit unattended and redirection was unsuccessful. The resident was then placed on 15 minute checks to ensure his/her safety. During the investigation of the resident's elopement, footstep impressions were found outside the 1400 hallway door with the alarm identified as only working intermittently. The resident was last seen on 5/12/14 at 9:30 P.M. on the locked unit by direct care O, who left the unit at this time. A staff's spouse saw the resident on 5/12/14 at 9:47 P.M. who was driving on an exit ramp from the interstate. The resident was wrapped with a white blanket over his/her shoulders and wore a clothing protector over his/her clothes. The resident walked approximately .9 of a mile from the facility. He/she walked from the facility to a busy 4 lane road with speed limit of 35 miles per hour and had to cross the road to get to the interstate off ramp which was .3 of a mile from the facility. The resident then had to walk approximately .6 of a mile on the edge of the interstate into oncoming traffic with the speed limit of 65 miles per hour. The resident was unaccounted for 17 minutes during the night time hours and found along a busy interstate by the police. The approximate temperature on 5/12/14 between 8:53 P.M. and 10:53 P.M. was 53.1 degrees down to 50 degrees per wunderground.com. On 6/27/14 at 1:00 P.M. maintenance staff X revealed prior to the elopement, staff checked the exit doors weekly for functioning. The undated facility policy "Elopement Policy" documented the definition of elopement was an incident in which a resident leaves the facility grounds without staff knowledge; the resident has impaired decision making abilities and is unaware of his/her own safety needs. The resident are assessed at the time of admission for the potential of elopement based on a history of wandering or elopement and resident's decision making ability or impaired cognition with the ability to be mobile. A specific plan and intervention are developed and implemented. A specific system was developed to notify the staff that an exit door has been opened in areas accessible to residents. The facility failed to provide a secure environment for this wandering, cognitively impaired, ambulatory resident who exited the facility and was found walking along the side of the interstate by the police department, which placed this resident in immediate jeopardy. The facility abated the immediate jeopardy on 7/7/14 at 8:00 A.M. when they implemented and provided training for the following: When exit door alarm sounds staff will complete a head count of all residents. All exit door were changed from a 10 second delay to a 5 second delay. Additional alarms were installed on all unit exit doors on 5/14/14. Outside alarm company on 5/15/14 completed an assessment of the facility's alarm system. Safety Committee had a meeting on 5/14/14 and 5/20/14 to review all new safety interventions for effectiveness. Elopement policy and procedure education will be provided to all new hires during orientation. Elopement assessments will continue to be done on admission, with significant change is status and quarterly and reviewed by director of nursing and nursing administration for appropriate interventions. Residents at risk for elopement as determined by the nursing administration team will have pictures placed in elopement book kept at the front desk. On admission all resident's pictures will be placed by the time clock. The Event committee chaired by the Assistant Director of Nursing/designee will monitor weekly for compliance. Developed a Protocol for Placement of residents on 1:1 that were exit seeking. Staff will complete Elopement drills on 6/3/14 and alarm drills in July and August. QA Committee will review at the monthly meeting. This deficient practice remained at the scope and severity of an D.