Every finding on record at Harvest Manor Healthcare and Rehabilitation Center

Based on observation and interviews, the facility failed to prepare and serve food in accordance with professional standards for food safety by failing to ensure staff wore a facial hair restraint while serving residents' food from the steam table. This deficient practice had the potential to affect 164 residents who received food from the facility's kitchen.Findings: An observation was made of the breakfast meal service in the facility's kitchen on 08/11/2025 at 8:45 a.m. S4CK was plating food on the serving line. S4CK had a mustache and beard with no facial hair restraint. An interview was conducted with S3DM on 08/11/2025 at 8:49 a.m. S3DM observed S4CK on the serving line and stated he should have had on a facial hair restraint. An interview was conducted with S1ADM on 08/12/2025 at 12:50 p.m. He stated dietary staff with facial hair should wear a facial hair restraint while preparing and serving food.

Based on observation, interviews, and record review, the facility failed to maintain an effective pest control program so the facility was free of roaches in the facility's kitchen. This deficient practice had the potential to affect 164 residents who received food from the facility's kitchen.Findings: Review of the facility's policy titled, Pest Control and Procedure, and dated 09/01/2019, revealed the following, in part:Policy: Each facility will have an effective pest control plan in place with resident safety as the top priority. Contingency plans will also be in place should active pest activity be identified. Review of the facility's Maintenance Log revealed an entry on 06/25/2025 for roaches in the kitchen on the serving table. An observation was made of the facility's lunch service in the kitchen on 08/11/2025 beginning at 11:27 a.m. There was a hole in the caulk between the cinderblock wall and the steam table. The following was observed coming from the hole onto the steam table and toward the uncovered food on the steam table:11:30 a.m. - a roach the size of a grain of rice. S3DM killed the roach.11:31 a.m. - a roach the size of a grain of rice. S3DM killed the roach.11:32 a.m. - a roach the size of a black bean. S3DM killed the roach.11:33 a.m. - a roach the size of a black bean.11:35 a.m. - a roach the size of a sunflower seed. S3DM killed the roach.11:36 a.m. - a roach the size of a grain of rice. S3DM killed the roach.11:38 a.m. - a roach the size of a grain of rice. S3DM killed the roach.11:39 a.m. - a roach the size of a grain of rice. S3DM killed the roach. An interview was conducted with S3DM on 08/11/2025 at 11:40 a.m. S3DM confirmed the bugs seen were roaches and they were crawling on the steam table with uncovered food. An interview was conducted with S4CK on 08/11/2025 at 11:42 a.m. He stated he had seen roaches on the steam table before. A telephone interview was conducted with a local pest control company representative on 08/12/2025 at 8:13 a.m. He stated he reported to the facility's kitchen on the night of 08/11/2025. He confirmed there was a roach infestation behind the kitchen's steam table. He stated the infestation was in the same area where it was identified in June 2025. He stated the continued roach activity was unacceptable. He stated one roach in a kitchen was too many. An interview was conducted with S1ADM on 08/12/2025 at 9:04 a.m. He confirmed it was not sanitary to have roaches by food.

Based on observations, interviews, and record reviews, the facility failed to ensure the risks and benefits were reviewed with the resident and/or resident representative, and informed consent was obtained prior to bed rail installation for 2 (#3 and #70) of 3 (#3, #70 and #146) residents reviewed with bed rails.Review of the facility's policy dated 11/25/2014 and titled Side Rail Policy and Procedure revealed the following:Purpose: To provide intervention as warranted to assist resident in reaching the highest level of functioning. Policy: We use side rails as appropriate to resident need in creating better bed mobility and positioning, as ordered by the physician. Procedure: 1. Obtain a physician's order and consent for use of side rails. Essential Points:A.) Always explain the purpose to the resident and family before obtaining an order for side rails. Resident #3Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Dementia and Unspecified Mood Disorder. Further review of the Clinical Record revealed no documentation related to the explanation of risks and benefits associated with the use of bed rails and informed consent with resident and/or resident representative. Review of the Physician Orders revealed the following:Order Date: 05/13/2025- May use 1/4 side rails x 2 as needed for bed mobility Resident #70Review of Resident #70's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Dementia, Unspecified Mood Disorder and Hemiplegia with Hemiparesis. Further review of the Clinical Record revealed no documentation related to the explanation of risks and benefits associated with the use of bed rails and informed consent with resident and/or resident representative. Review of the Physician Orders revealed the following:Order Date: 04/25/2023- 1/4 side rails x 2 as needed for bed mobility/positioning On 08/11/2025 thru 08/13/2025 observations were made of Resident #3's and Resident #70's beds with 1/4 side rails in place at the top of the bed in the upright position. On 08/13/2025 at 3:00 p.m., an interview was conducted with S2DON. She reviewed Resident #3's and Resident #70's medical record and confirmed there were no informed consents for bed rail use signed by the resident and/or resident representative. She stated she was unaware the admission, Physician Order for 1/4 side rails required the facility to obtain informed consents prior to use. On 08/13/2025 at 4:20 p.m., an interview was conducted with S1ADM with S11RDO present. S1ADM and S11RDO stated the facility was unaware they needed to obtain informed consents from the resident and/or resident representative prior to the use of 1/4 side rails.

Based on record review and interviews, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure baths were documented as provided for 1 (#149) of 4 (#9, #56, #64, and #149) residents reviewed for activities of daily living.Review of Resident #149's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hereditary and Idiopathic Neuropathy, Muscle Wasting and Atrophy, Chronic Respiratory Failure, Heart Failure, and Chronic Pain Syndrome.Review of Resident #149's Quarterly MDS with an ARD of 06/11/2025 revealed she required substantial/maximal assistance from staff for bathing.Review of the Facility's CNA Schedules dated 08/04/2025, 08/06/2025, 08/08/2025, and 08/11/2025 revealed S9CNA was assigned to Resident #149's hall.Review of Resident #149's ADL-Bathing Documentation dated August 2025 revealed she was scheduled to receive a bath on Mondays, Wednesdays, and Fridays. Further review revealed no documented bath on 08/04/2025, 08/06/2025, 08/08/2025, and 08/11/2025.An interview was conducted with S9CNA on 08/13/2025 at 1:10 p.m. She stated Resident #149 was scheduled to receive baths every Monday, Wednesday, and Friday. She confirmed she was assigned to Resident #149 on 08/04/2025, 08/06/2025, 08/08/2025, and 08/11/2025 and was responsible for providing a bath. She stated she provided baths to Resident #149 on 08/04/2025, 08/06/2025, 08/08/2025, and 08/11/2025. She reviewed Resident #149's ADL-Bathing Documentation dated 08/04/2025, 08/06/2025, 08/08/2025, and 08/11/2025 and confirmed there was no bath documented. She confirmed the baths she provided to Resident #149 should have been documented. An interview was conducted with S2DON on 08/13/2025 at 2:35 p.m. She confirmed if a bath was provided, it should have been documented on the resident's ADL-Bathing Documentation.

Based on observations, interviews, and record review, the facility failed to ensure the resident group had a private space large enough for all residents who wanted to attend resident council meetings. This deficient practice had the potential to affect all residents who wished to attend resident council meetings. The facility had a current census of 165.Findings: Review of the Resident Council Meeting Minutes dated 08/06/2025 revealed the following, in part:Administration: Residents were wondering what's going on with the enclosed area. Review of the Resident Council Meeting Minutes dated May 2025 through August 2025 revealed the following amount of residents were in attendance:05/07/2025 - 15 residents06/04/2025 - 13 residents07/02/2025 - 9 residents08/06/2025 - 14 residents A meeting was held with members of the resident council on 08/11/2025 at 1:10 p.m. in the facility's cafe. Residents #41, #56, #80, #81, and #156 were in attendance. During the resident council meeting, the glass doors leading to the dining room were closed. The walls leading to the main hallways of the facility had 8 feet openings, one each side, therefore, the room was not enclosed or private. There was a staff member who entered the area and opened the glass door to enter the dining room during the meeting. During the resident council meeting, the residents verbalized concerns about the resident council not having a private space large enough for all residents who wanted to attend. The residents verbalized there was an attempt to meet in the facility's conference room, which was not large enough for all residents who wanted to attend. The residents verbalized this had been an ongoing issue discussed in previous resident council meetings. Observations were made of the facility's conference room on 08/11/2025 and 08/12/2025. The conference room contained a large table with chairs surrounding it. The area was not large enough to hold all residents who wished to attend resident council meetings. The area was unable to accommodate wheelchairs around the table. A telephone interview was conducted with S8AD on 08/12/2025 at 10:02 a.m. She stated the Resident Council Meeting Minutes dated 08/06/2025, which revealed residents were wondering what's going on with the enclosed area, was referring to the residents asking about a private space for them to meet that was large enough for everyone who wanted to attend. She stated the concern had been brought up in resident council meetings multiple times. She confirmed there was not a private space large enough for all residents who wanted to attend resident council meetings. She stated the resident council attempted to meet in the facility's conference room one month, but it would not accommodate all of the residents who wanted to attend. She stated the residents wanted a private space with less background noise and no staff walking by the room openings. An interview was conducted with S1ADM on 08/12/2025 at 9:06 a.m. He stated the facility's cafe was where the resident council met. He confirmed the facility's cafe was not a private space. He confirmed there had been concerns from the resident council about not having a private space to meet. He stated the conference room was a private space where the resident council could meet. He stated he was unaware of the resident council attempted to meet in the facility's conference room. He stated the resident council should have a private space to meet.

Based on record review and interviews, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (#5 and #24) of 3 (#5, #24, and #36) residents reviewed for PASARR.Resident #5A review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hereditary and Idiopathic Neuropathy. Further review revealed an additional medical diagnosis of Manic Episode with an onset date of 06/01/2023.Further review revealed no review for a PASARR Level II evaluation and determination had been submitted for Resident #5 following her diagnosis of Manic Episode.Resident #24A review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Depression. Further review revealed an additional medical diagnosis of Bipolar Disorder with an onset date of 03/17/2025.Review of Resident #24's PASARR Level I dated 03/06/2025 revealed no mental health diagnoses were selected. Further review revealed no review for a Level II evaluation and determination had been submitted for Resident #24 following his diagnosis of Bipolar Disorder.An interview was conducted on 08/13/2025 at 1:00 p.m. with S12SSD. She reviewed Resident #5's PASARR Level I dated 12/07/2020 and diagnoses. She stated Resident #5 had a diagnosis of Manic Episode acquired on 06/01/2023 and should have had a new Resident Review conducted at that time. She reviewed Resident #24's PASARR Level I dated 03/06/2025 and diagnoses. She stated Resident #24's PASARR Level I revealed no mental health diagnoses were checked. She stated Resident #24 had a diagnosis of Bipolar Disorder and should have had a new Resident Review conducted in 03/2025.An interview was conducted on 08/13/2025 at 2:35 p.m. with S2DON. She reviewed Resident #5's PASARR Level I dated 12/07/2020 and diagnoses. She stated Resident #5 had a diagnosis of Manic Episode acquired on 06/01/2023 and should have had a new Resident Review conducted at that time. She reviewed Resident #24's PASARR Level I dated 03/06/2025 and diagnoses. She stated Resident #24's PASARR Level I revealed no mental health diagnoses were checked. She stated Resident #24 had a diagnosis of Bipolar Disorder and should have had a new Resident Review conducted in 03/2025.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Diabetes. The facility failed to schedule and complete podiatry appointments for toenail evaluation and care for 1 (#11) of 5 (#9, #11, #56, #64 and #149) residents sampled for Activities of Daily Living (ADLs). Review of the Medical Record for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnosis, which included Type 2 Diabetes Mellitus.Review of the most recent MDS (Minimum Data Set) for Resident #11 with an ARD (Assessment Reference Date) of 07/23/2025 revealed Resident #11 had a BIMS (Brief Interview for Mental Status) of 12, which indicated the resident was moderate cognitively impaired. Further review revealed Resident #11 required supervision for bathing. Further review of Resident #11's medical record revealed no documentation of a Podiatry referral nor nail care provided by a Podiatrist.An observation was conducted of Resident #11 on 08/11/2025 at 9:30 a.m. Abnormally thickened toenails was noted on both big toes. Resident #11 stated she had discomfort when the bedsheets were against her toes and wearing shoes. She stated when her friends visited they brought nail clippers for her to trim her own toenails. She stated she requested to see a podiatrist since January 2025 but still had not seen a Podiatrist. An interview was conducted with S18DSS on 08/13/2025 at 11:40 a.m. She stated they contracted with an outside provider for podiatry and they conducted visits at the facility every 3 months. She stated a resident, nurse, or CNA can make a request for the resident to be evaluated by the podiatrist. She stated once she received the request, she notified the outside provider and the outside provider would reach out to the resident or RP to get the services started. She confirmed Resident #11 and Resident #11's daughter requested to be evaluated by the Podiatrist but could not recall when the request was made. She reviewed Resident #11's chart her emails and confirmed she did not have any documentation of the request. She confirmed she received an email from the daughter on 07/19/2025 but Resident #11 requested an appointment prior to receipt of the email. She confirmed the contracted provider did not have any documentation Resident #11 wanted to begin the services. An interview was conducted with Resident #11's daughter on 08/13/2025 at 3:03 p.m. She stated her mother had been asking since January 2025 to see a podiatrist and after months of Resident #11 requesting to see the podiatrist, she emailed S18DSS on 07/19/2025. She stated S18DSS responded and informed her Resident #11 needed a diagnosis of DM or PVD. Resident #11's daughter stated she informed S18DSS that Resident #11 did have a diagnosis of Diabetes. An interview was conducted with the S2DON on 08/13/2025 at 3:45 p.m. She S18DSS would be notified of a residents request to see the podiatrist and S18DSS should notify the contracted provider to begin services on the next visit.

Based on interviews and record reviews, the facility failed to promote and facilitate residents' self-determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (#11) of 36 residents in the initial pool. The facility failed to ensure Resident #11 had a choice to participate in a sewing activity. Review of the Medical Record for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Depressive Disorder, Mild Cognitive Impairment, and Type 2 Diabetes Mellitus.Review of the most recent MDS (Minimum Data Set) for Resident #11 with an ARD (Assessment Reference Date) of 07/23/2025 revealed Resident #11 had a BIMS (Brief Interview for Mental Status) of 12, which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the following:Section GG- Resident #11 had no impairment to her upper and lower extremities and required supervision for transfers. Section D- Resident #11 felt down and depressed for several days. Review of the most current Care Plan for Resident #11 revealed the following:Problem: Resident #11 had a diagnosis of Depression. 07/23/2025 Resident #11 expressed feeling down, depressed or hopelessInterventions: Encourage Resident #11 to participate in the facilities daily activitiesAn observation was conducted on 08/11/2025 during the initial pool process, Resident #11 was noted to be sitting at the desk in her room painting with watercolor. An interview was conducted with Resident #11 at that time. She stated she loved to paint and sew and had been sewing since she was a young age. She stated she spoke with S1ADM about wanting a sewing machine and was told she could not have a sewing machine because it was not safe. An interview was conducted with S8AD on 08/13/2025 at 2:17 p.m. She stated she assessed Resident #11 for her activity preferences and was aware she wanted to sew. She stated administration would not approve the sewing activity due to a safety hazard. She stated she thought there were a couple of residents who could utilize a sewing machine under supervision. An interview was conducted with S16PT and S17COTA, on 08/13/2025 at 2:45 p.m. They stated Resident #11 painted watercolors in her room and did not have any upper or lower extremity impairments. They stated Resident #11 would be safe to utilize a sewing machine with supervision. An interview was conducted with S15CNA on 08/13/2025 at 2:51 p.m. She stated Resident #11 transferred independently and painted watercolors in her room. An interview was conducted with Resident #11's daughter on 08/13/2025 at 3:03 p.m. She stated when her mother was first admitted to the facility they inquired about a sewing machine and was told it was not allowed. She stated Resident #11's life had always revolved around sewing and painting. She stated she sewed at home until she was admitted to the facility and began sewing at a very young age. She stated she noticed a difference in her mom's mood by complaining all the time and recognized her mom was miserable at the facility without being able to sew. An interview was conducted with S14CRN on 08/13/2025 at 3:45 p.m. He stated a resident would need a special assessment to determine if a sewing machine was safe for them to utilize. He confirmed all residents in the facility should be assessed for activities of their choice and had the right to participate in those activities. An interview was conducted with S2DON on 08/13/2025 at 3:47 p.m. She stated she was not aware of any residents requesting a sewing machine at the facility. She stated she could not determine if Resident #11 would be safe to utilize a sewing machine because she did not know her well enough and had not completed a sewing machine safety assessment. An interview was conducted with S1ADM on 08/13/2025 at 4:10 p.m. He denied Resident #11 or S8AD requested a sewing machine. He stated he was only aware of a resident council meeting discussion on the difference between an unsafe smoker and a sewing machine. He stated it would not be safe for any residents to utilize a sewing machine at the facility independently or supervised. He stated the facility would need to assess the resident's safety of utilizing a sewing machine but this was not normally used for activities in the facility with or without supervision. He confirmed residents had rights to participate in their activity preferences and the facility should do their best to accommodate the resident and keep them safe as well. An interview was conducted with S11RDO on 08/13/2025 at 4:12 p.m. He stated a sewing machine would not be something they wanted in the facility. He confirmed residents had the right to participate in their activity preferences and the facility should do their best to accommodate the resident and keep them safe as well.

Based on interviews and record review, the facility failed to transmit Minimum Data Set (MDS) Assessments in the required timeframe for 1(#166) of 1 (#166) resident reviewed for resident assessment. Findings:Review of Resident #166's Clinical Record revealed an admission date of 02/25/2025. Further review of Resident #166's Clinical Record revealed a discharge date of 03/14/2025. On 08/12/2025 at 8:49 a.m., a review of Resident #166's Discharge MDS with an Assessment Reference Date (ARD) of 03/14/2025 revealed the assessment was completed, but not transmitted, with a status of completed but not accepted. On 08/13/2025 at 2:03 p.m., an interview was conducted with S10LPN. She confirmed she was responsible for entering MDS Assessments and they should be transmitted within 14 days of the assessment completion. She reviewed Resident #166's Discharge MDS Assessment and confirmed it was transmitted on 08/13/2025, and was not transmitted within the required timeframe. On 08/13/2025 at 2:30 p.m., an interview was conducted with S2DON. She reviewed Resident #166's Discharge MDS with ARD of 03/14/2025. She confirmed she was discharged on 03/14/2025 and her Discharge MDS Assessment was not transmitted until 08/13/2024, which was not within the required timeframe.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#20) resident out of a total of 36 sampled residents by failing to ensure Resident #20 was accurately coded for pain medication and opioid use.Review of Resident #20's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Pain in Left Ankle and Joints of Left Foot and Pain Unspecified. Review of Resident #20's Significant Change MDS with an ARD of 05/21/2025 revealed Section J0100.B. Pain Management- Received PRN pain medications or was offered and declined, was coded 0. No, and Section N0415. H. Opioid: is taking, was coded No. Review of Resident #20's current Physician Orders revealed an order for Norco oral tablet 5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain with a start date of 07/01/2024. Review of Resident #20's May 2025 MAR revealed the resident received the ordered pain medication Norco oral tablet 5-325 mg (Hydrocodone-Acetaminophen), as needed for pain on the following dates: 05/01/2025-05/06/2025, 05/08/2025-05/11/2025, 05/13/2025-05/15/2025, 05/20/2025, 05/22/2025-05/25/2025, and 05/29/2025. On 08/13/2025 at 2:08 p.m., an interview was conducted with S10LPN. She reviewed Resident #20's Significant Change MDS assessment with an ARD of 05/21/2025 and reviewed her MAR for May 2025. S10LPN confirmed Resident #20 was taking pain medication Norco as needed at that time. She further confirmed Resident #20's 05/21/2025 MDS was not coded accurately for pain medication as Section J0100.B. was coded no and opioid use as Section N0415. H. was also coded no. She confirmed both sections mentioned above were coded no, and should have been coded as yes since Resident #20 had received PRN pain medication and was taking an opioid during that time. On 08/13/2025 at 2:17 p.m., an interview was conducted with S2DON. She reviewed Resident #20's Significant Change MDS assessment with an ARD of 05/21/2025 and reviewed her MAR for May 2025. S2DON confirmed Resident #20 was taking pain medication Norco as needed at that time. She further confirmed Resident #20's 05/21/2025 MDS was not coded accurately for pain medication as Section J0100.B. was coded no and opioid use as Section N0415.H. was also coded no. She confirmed both sections mentioned above were coded no, and should have been coded as yes since Resident #20 had received PRN pain medication and was taking an opioid during that time.

Based on observations, interviews, and record reviews, the facility failed to ensure the services provided as outlined in the comprehensive care plan met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 2 (#106 and #114) of 3 (#86, #106, and #114) residents reviewed for insulin administration.Findings: Review of the facility's insulin pen needles manufacturer's guidelines revealed the insulin pen needle should always be primed with two units of insulin after applying the needle and prior to drawing up the insulin dose. Resident #106Review of Resident #106's Clinical Record revealed an admission date of 04/30/2024. Further review revealed a Physician's Order for Regular Insulin 100 unit/mL subcutaneously per sliding scale before meals and at bedtime. Resident #106's Regular Insulin sliding scale order was 4 units of insulin for a blood glucose level of 200 to 250 mg/dL. An observation was made of S5LPN administering Regular Insulin 100 unit/mL to Resident #106 on 08/12/2025 at 11:09 a.m. Resident #106's blood glucose level was 219 mg/dL. S5LPN sanitized the insulin pen stopper, applied the insulin pen needle, dialed up 4 units of insulin, and administered the insulin. S5LPN did not prime the insulin pen needle prior to administering the insulin. An interview was conducted with S5LPN on 08/12/2025 at 11:18 a.m. S5LPN confirmed she did not prime the insulin pen needle prior to administering insulin to Resident #106 and should have. Resident #114Review of Resident #114's Clinical Record revealed an admission date of 11/24/2021. Further review revealed a Physician's Order to inject 5 units of Insulin Lispro 100 unit/mL subcutaneously three times daily. An observation was made of S6LPN administering Insulin Lispro 100 unit/mL to Resident #114 on 08/11/2025 at 9:13 a.m. S6LPN applied the insulin pen needle, dialed up 5 units of insulin, and administered the insulin. S6LPN did not prime the insulin pen needle prior to administering the insulin. An interview was conducted with S6LPN on 08/11/2025 at 9:16 a.m. She stated insulin pen needles should always be primed prior to dialing up the ordered dose of insulin. An interview was conducted with S2DON on 08/12/2025 at 12:25 p.m. She stated insulin pen needles should always be primed with two units of insulin prior to dialing up and administering the ordered dose of insulin.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to applying insulin pen needles for 2 (#86 and #114) of 3 (#86, #106, and #114) residents reviewed for insulin administration.Findings: Review of Insulin Lispro Manufacturer's Insert revealed the following, in part:Preparing your Pen:Step 1:Pull the Pen Cap straight off.Wipe the Rubber Seal with an alcohol swab. Resident #86 Review of Resident #86's Clinical Record revealed an active Physician's Order for Insulin Lispro 100 unit/mL subcutaneously before meals and at bedtime per sliding scale. An observation was made of S7LPN administering Insulin Lispro 100 unit/mL to Resident #86 on 08/11/2025 at 10:56 a.m. S7LPN applied the insulin pen needle to the insulin pen without sanitizing the insulin pen stopper. S7LPN administered the insulin. An interview was conducted with S7LPN on 08/12/2025 at 10:58 a.m. She confirmed she did not sanitize the insulin pen stopper prior to applying the insulin pen needle. Resident #114Review of Resident #114's Clinical Record revealed an active Physicians' Order for Insulin Lispro 100 unit/mL subcutaneously three times daily. An observation was made of S6LPN administering Insulin Lispro 100 unit/mL to Resident #114 on 08/11/2025 at 9:13 a.m. S6LPN applied the insulin pen needle to the insulin pen without sanitizing the insulin pen stopper. S6LPN administered the insulin. An interview was conducted with S6LPN on 08/11/2025 at 9:16 a.m. She confirmed she did not sanitize the insulin pen stopper prior to applying the insulin pen needle. An interview was conducted with S2DON on 08/12/2025 at 12:25 p.m. She stated insulin pen stoppers should always be sanitized prior to applying the insulin pen needle.

Based on observations, interviews, and record review, the facility failed to ensure resident's food preferences were honored for 1 (Resident #31) of 19 (#2, #13, #19, #31, #37, #44, #52, #66, #74, #79, #80, #82, #83, #94, #117, #134, #143, #144, and #159) residents observed for dinning. This deficient practice had the ability to affect 166 residents served from the facility's kitchen. Findings: Review of Resident ##31's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #31's current Physician Orders revealed the following, in part: Low Concentrated Sweets Diet with regular texture and regular/ thin consistency liquids, extra large portions. Review of Resident #31's Care Plan revealed the following:Problem: Receives a therapeutic diet with extra large portions.Intervention: Maintain current listing of food likes and dislikes; meals served as ordered by Physician. Problem: At risk for weight loss related to therapeutic dietIntervention: Meals served as ordered by Physician; Maintain current listing of food likes and dislikes. Review of Dietary Profile dated 07/10/2025 per S3DM revealed the following in part: Provide and serve diet as ordered to include food preferences. Review of Resident #31's meal tickets with food preferences revealed the following:Breakfast: No juice or punch, no carrots, no scrambled eggs, no sweet potatoes, no white potatoes, skim milk and water, grits in bowl, 2 boiled eggs. Lunch: No juice or punch, no carrots, no scrambled eggs, no sweet potatoes, no white potatoes, extra vegetables in bowl. Dinner: No juice or punch, no carrots, no rice, no scrambled eggs, no sweet potatoes, no white potatoes, extra vegetables in bowl. On 08/12/2025 at 8:45 a.m., an observation was conducted of Resident #31's breakfast tray, which included two boiled eggs, 2 link sausages, grits, a biscuit, and prepackaged juice (not sugar free). On 08/12/2025 at 12:10 p.m., an observation was conducted of Resident #31's lunch tray, which included fried chicken breast, green peas, one serving of zucchini and tomatoes, a roll, prepacked juice (not sugar free), and glass of water. On 08/13/2025 09:30 a.m., an observation was conduction of Resident #31's breakfast tray, which included two boiled eggs, 2 link sausages, grits, a biscuit, and prepackaged juice (not sugar free). On 08/13/2025 at 9:30 a.m., an interview was conducted with Resident #31. She stated due to her history of Diabetes she attempted to maintain her blood glucose levels with what she ate. She reported the facility often served her rice, white potatoes, non-sugar free juice, even though this was on her preference list, and often forgets to serve her the extra serving of vegetables. On 08/13/2025 at12:15 p.m., an observation was conducted of Resident #31's lunch tray, which included 6 meatballs with gravy over rice in a bowl, one serving of mixed vegetables, pineapple cobbler, a roll, prepackaged juice (not sugar free), and whole milk. On 08/13/2025 at 3:49 p.m., an interview was conducted with S13CNA who stated she worked the 2:00 p.m. to 10:00 p.m. shift. She stated CNA staff were responsible for reading meal tickets when delivering trays and should return the meal to the kitchen if the meal did not match the resident's preferences. She observed Resident #31's lunch meal tray, which was still in her room and confirmed the meal ticket read no rice. S13CNA stated she would not have served this meal to the resident, and would have requested a different tray from the kitchen. On 08/13/2025 at 3:55p.m., an interview was conducted with S3DM. She reviewed Resident #31' food preferences and confirmed Resident #31 did not want juice or rice. She observed Resident #31's meal tray from lunch on 08/13/2025, confirmed there was rice, and only one serving of vegetables, with juice and whole milk. She stated Resident #31 should not have received the juice, milk, or rice on her tray, and should have received an extra serving of vegetables. S3DM confirmed that resident's meal preferences should be honored. On 08/13/2025 at 4:40 p.m., an interview was conducted with S1ADM. He was informed of Resident #31's food preferences not being honored. S1ADM confirmed residents' food preferences should always be honored.

Based on observation, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) sampled residents. The facility failed to:1. Protect Resident's #R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2 from physical and psychosocial abuse by Resident #4;2. Report allegations of physical and psychosocial abuse by Resident #4 to the State Agency in the required timeframe; and3. Ensure Resident #4 received consistent adequate staff supervision to manage the resident's known verbally and physically abusive behaviors.This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when Resident #4, a cognitively impaired resident, hit Resident #R1. Resident #4 exhibited continued aggressive and abusive behaviors, and was transferred to the facility's locked dementia care unit on 03/25/2025. On 03/25/2025, Resident #4 was observed grabbing Unknown Resident #1 by the feet and attempting to pull the resident out of their wheelchair. Unknown Resident #1 was observed by a former employee to be fearful, displaying physical and verbal signs of stress, including crying and repeatedly making a swatting motion with her hands. The IJ continued on 04/17/2025, when Resident #4 interlocked her arms around Resident #3's throat then began pulling back, choking her. The IJ continued on 05/20/2025, when Resident #4 pushed Resident #5, causing Resident #5 to fall to the floor. Resident #4 then hit Resident #5 in her face. Resident #5 complained of hip pain after the incident. Resident #5's family requested Resident #5 be moved out of the locked dementia care unit for safety, which resulted in Resident #5 crying for days. The IJ continued on 05/26/2025, when Resident #4 grabbed Unknown Resident #2's hair, pulled it, and would not let go. On 05/26/2025, Resident #4 was placed on 1:1 supervision until 06/09/2025. However, staff interviews revealed during that time Resident #4 received inconsistent 1:1 supervision. On 06/09/2025 after 1:1 supervision was removed, Resident #4 pushed Resident #6 into the wall, causing Resident #6 to hit her head against the wall. Resident #6 complained of a headache after the incident and required administration of Tylenol for pain management. Resident #4 was placed back on continuous 1:1 supervision on 06/09/2025. On 06/16/2025, Resident #1 was found in a resident's room lying on her left side in a fetal position. Resident #4 was observed standing on the right side of Resident #1's wheelchair with Resident #1's wheelchair pad in her hand, and no staff present with Resident #4. Resident #1 was noted to have swelling to the left side of her face and right knee. Resident #1 was transferred to the hospital where it was determined she had a right femur fracture and a left facial hematoma. Due to Resident #1's age, she was unable to undergo surgery and was ultimately transferred to an inpatient hospice facility where she passed away on 06/25/2025. Staff interviews revealed Resident #4 did not have 1:1 monitoring during the 10:00 p.m. to 6:00 a.m. shifts, and Resident #4 was not provided with consistent 1:1 monitoring during the day until after Resident #1's incident on 06/16/2025. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4. She was lying in her bed with no staff present at bedside. Record review and interview with S1ADM revealed S1ADM was aware of each of the above incidents with Resident #4, but none of the above incidents were reported to State Agency. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Residents #R1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2, it could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #4's abusive behaviors since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 07/11/2025 at 11:10 a.m. This deficient practice continued at a potential for more than minimal harm for the other 167 residents residing in the facility. Findings:Cross reference F600, F609, and F689 Review of the facility's policy dated 03/25/2023 and titled, Abuse-Prevention and ProhibitionPolicy and Procedure, revealed the following, in part:Purpose:Each resident has the right to be free from abuse. 3. Physical Abuse may include hitting, slapping, pinching, biting, shoving, and kicking. 4. Mental Abuse includes, but is not limited to, harassment.There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or impairment, cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. II. Procedures:7. Reporting/Response: The facility employee or covered individual who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator. The Administrator shall immediately initiate a self-reported incident report to the State Agency and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical, sexual, verbal, or mental) or results in serious bodily injury. Resident #R1Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #R1's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 07/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 5, which indicated Resident #R1 had severe cognitive impairment. Resident #4Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's Quarterly MDS with an ARD of 05/14/2025 revealed a BIMS of 2, which indicated Resident #4 had severe cognitive impairment. Further review revealed Resident #4 was ambulatory and required supervision with ADL's. Review of Resident #4's Nurse's Notes revealed the following, in part: 02/22/2025 at 4:42 p.m.-While doing medication pass, Resident #4 was in another resident's room and Resident #R1 (Resident #4's husband) was standing at doorway. I asked Resident #4 to follow me to her room and Resident #4's exited with the other resident's blanket rolled up in her arms. Resident #R1 attempted to take it from her and give it back to the other resident, and when she followed Resident #R1 out she hit Resident #R1 in his back. Signed, S4EMP. On 07/10/2025 at 9:55 a.m., an interview was conducted with S4EMP. She stated she observed the incident between Resident #4 and #R1 on 02/22/2025. She stated prior to the incident, Resident #4 wandered into another resident's room and stole the blanket off the bed. She stated Resident #R1 attempted to take the blanket from Resident #4 and return it to the bed. She stated Resident #4 then became enraged and hit #R1 on the back. She stated she would consider this incident resident to resident physical abuse. She stated she reported the incident but did not recall who she reported it to. She stated the facility's protocol was to notify the direct supervisor immediately after a witnessed incident. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/09/2025 at 3:11 p.m. - Resident #4 went to end of hall and grabbed a wet floor sign. Resident #4 got combative when CNA tried to get her to put the sign down and hit CNA. Signed by S12EMP. On 03/11/2025 at 4:21 p.m.-Resident #4 took an employee's purse/bag, staff attempted to redirect resident and retrieve bag, Resident #4 became combative kicking and hitting the nurse in the chest. Resident #4's husband attempted to talk to the resident and get the bag. The Resident #4 was resistant to him as well but finally let go of the bag. Resident #4 was provided time to calm down. Staff applied non-slip socks for safety as Resident #4 is wondering around the facility without shoes and only one sock on that she is bending over trying to remove. Signed by S6EMP. Review of Resident #4's current Physician Orders revealed the following, in part:03/19/2025-Admit to memory care; secure unit monitoring Review of Resident #4's admission and discharge report revealed Resident #4 was transferred to an inpatient psychiatric facility on 03/12/2025 and returned to the facility on [DATE], when Resident #4 was placed on the locked dementia unit. Review of Resident #4's current Care Plan revealed the following, in part:Problem: Resident#4 went into another resident's room and urinated on the floor, turning on/off others lights. 03/26/25- Resident #4 has been taking other residents food, throwing food at staff, hitting staff members, yelling at other residents, and pushing furniture while other residents are on it. Resident #4 can be difficult to redirect. 03/27/25- Resident #4 has been taking family members belongings and refusing to give them back. Resident #4 attacked a CNA when she could not open window. Unknown Resident #1Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/25/2025 at 7:10 p.m.-Resident #4 noted attempting to take residents from the community area against their will. Unable to redirect, she is becoming verbally aggressive. Resident #4 noted tearing padding off a residents wheelchair, when redirection attempted she grabbed Unknown Resident #1 by both feet and began trying to pull Unknown Resident #1 out of her chair by her feet. Unknown Resident #1 is fearful and showing physical as well as expressing verbal signs of stress. Resident #4 then walked away and took a facility chair making attempts to leave with the chair but while sitting in it. Signed by S30FEMP. On 03/25/2025 at 7:19 p.m. - Resident #4 noted making attempts to snatch the same resident, Unknown Resident #1, out of the top of her chair by the shirt. When redirected, Resident #4 became physically aggressive and pushed the couch in the community living room while another resident was sitting on it. Resident #4 continues to act out verbally and physically against staff and fellow residents. Signed by a former employee. On 07/10/2025 at 9:38 a.m., a telephone interview was conducted with S30FEMP. She stated she was working on 03/25/2025. She stated Resident #4 attempted to pull another resident out of her wheelchair by her feet. She stated she remembered the resident had a seatbelt in place but was unable to recall which resident it was. She stated the incident was unprovoked. She stated she was close by when it occurred and was able to intervene immediately and separated Resident #4 from the resident in the wheelchair before any injuries occurred. She stated after the incident, Unknown Resident #1 was scared, crying, and kept doing a swatting motion with her hands. She stated she informed S1ADM and S2DON frequently of her concerns for the safety of the other residents due to Resident #4's aggressive behavior. She stated she told S1ADM and S2DON, Resident #4 would become violent with no warning, attacked staff and other residents, and could not be redirected. She stated when Resident #4 was transferred to the locked dementia unit, she felt like she was not able to keep the other resident's safe due to Resident #4's aggressive behaviors. She stated after the incident on 03/25/2025, she went to S1ADM's office and told him she could not work under the current conditions of the unit because she could not protect the other residents from Resident #4. She stated S1ADM told her to do what she had to do, so she put in her 2 weeks' notice. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/26/2025 at 12:05 p.m. - During lunch Resident #4 walked over to nurse's desk and removed the top from another resident's food and attempted to pick up the food with her hands. The nurse attempted to redirect Resident #4 and Resident #4 became angry and grabbed a handful of greens and threw them at the nurse and grabbed the bowl of pie and hit the nurse with the pie. Resident #4 swung at nurse multiple times. Resident #4 then lost balance and fell on the floor. Resident #4 did not hit her head. While on the floor, Resident #4 attempted to kick nurse multiple times. Nurse was able to remain holding Resident #4's hand while the CNA went to get assistance. S1ADM and S13NP notified of the Resident #4's aggressive behavior. Signed by S7EMP. On 03/27/2025 at 5:30 p.m.-Late Entry-Resident #4 was attempting to open a window with intent to elope. The CNA sitting directly next to the window turned her head to see what was going on and asked Resident #4 what she was doing and to not do that to the window. Resident #4 immediately turned and began grabbing and hitting the CNA in her head and face. The CNA yelled for assistance I went over to get the resident to stop. Resident #4 then became aggressive towards me. Resident #4 was very difficult to redirect but after some time she walked away but remained agitated until she went to bed. The situation was reported to S1ADM and her responsible party. Signed by S30FEMP. On 04/16/2025 at 12:15 p.m. -Resident #4 took papers from nurse's desk. Nurse attempted to retrieve papers from Resident #4. Resident #4 became aggressive and pulled nurse's hair and kicked nurse in the stomach. Resident #4 then lost balance trying to kick nurse a second time and fell. Resident #4 did not hit head, no apparent injuries noted. Resident #4 assisted off of the floor by staff. Resident #4 refused vital signs. S13NP and RP notified. Signed by S7EMP. Resident #3Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS of 9, which indicated Resident #3 had moderate cognitive impairment. Review of Resident #3's Incident report dated 04/17/2025 at 3:00 p.m.Incident Description: Nursing description-Resident #3 witnessed by hall staff sitting in the community living room area watching television when Resident #4 walked over to Resident #3 and said something indecipherable and then began hitting Resident #3. Resident #3 in no way instigated the interaction. Resident #3 reported she did not do or say anything to Resident #4. No injuries noted. Review of Resident #3's Nurse's Notes revealed the following, in part:04/18/2025 at 1:06 p.m. -Shift Summary: Following report received at shift change, went to visually assess Resident #3 related to incident earlier on previous shift. Assessed Resident #3 for pain and any potential injuries. Resident #3 denied any pain (but specifically to head, neck and back) and no visual markings or bruises noted. Resident #3's speech clear and appropriate. Upon Resident #3 getting up for the day, resident came and sat by this nurse and described earlier incident, Resident #3 continues to deny any pain or discomfort with associated incident. Resident #3 does not appear in any mental anguish, states she is alright but she will not forget what happened to her. Will continue to monitor. Signed by S6EMP. On 04/17/2025 9:49 p.m. -Resident #4 exhibited verbal and physical aggression this shift. Resident #4 was pushing Resident #1 down the hall and Resident #1 was asking Resident #4 to stop. Staff asked Resident #4 not to push Resident #1 as she didn't want to be pushed and Resident #4 became verbally aggressive and threatening toward staff. As I attempted to administer medication to Resident #1, Resident #4 reached out and grabbed the medication which was crushed in pudding. She then laughed and went to the sink to wash her hands. I went off the unit to report the incident to the administrator. Upon returning to the unit, Resident #4 was noted yelling and sitting on top of Resident #1 while aggressively squeezing her hands and pushing them down where they were also crushed between the sides of the resident's legs and the arm rest of her wheelchair. Resident #4 was verbally and physically aggressive with staff as they tried to convince her to get off of Resident #1. I called for the administrator to come assist us. When S1ADM arrived, Resident #4 stood up and continued being verbally aggressive while she walked over to Resident #3. Resident #4 leaned down and spoke aggressively to Resident #3 and when Resident #3 started to speak, Resident #4 began attacking her. Resident #4 was noted standing behind Resident #3 using both hands balled into fists and striking her repeatedly in the head. When staff turned to intervene, Resident #4 leaned over the resident and wrapped both arms around Resident #3's neck squeezing it. As staff attempted to remove Resident #3 from Resident #4's clutch, Resident #4 attempted to stop us from moving Resident #3 and had her hands around the resident's neck. Resident #4 began slapping and grabbing at Resident #3's face. We were finally able to block Resident #4 from Resident #3 and Resident #4 walked away to Resident #1. Resident #4 attempted to push Resident #1 in her wheelchair but staff were able to stand in front of the wheelchair and hold it still. Resident #4 then began pulling on the trunk support contraption and tearing the protective foam padding off of it. Resident #4 continued to try to get Resident #1's wheelchair away from staff but became more frustrated and began pushing tables around the dining area. Resident #4 walked around to the other side of the dining room in order to pull a table out of the way so she would have access to the back of Resident #1's wheelchair. Once behind the wheelchair, she made more attempts to pull the chair from the grasp of staff. When she was unable to, she grabbed the high back wheelchair handles while putting her foot on the rear tippers and pulled aggressively to tip the wheelchair backwards. Two staff members remained in place holding Resident #1's wheelchair so it could not be tipped. Resident #4 finally walked away, remaining quite agitated. Resident #4 continued to speak aggressively to other residents and staff but stopped being physically aggressive at that point. Signed by S30FEMP. On 07/08/2025 at 3:44 p.m. an interview was conducted with S5EMP. She stated she witnessed Resident #4 choke Resident #3 a few months ago. She stated Resident #4's elbows were around the front of Resident #3's neck. She stated she attempted to pull Resident #4's arms away from Resident #3's neck but was told to let her be by S1ADM, who was present at the time of the incident. She stated S30FEMP witnessed the incident as well. S5EMP stated this incident was resident to resident abuse. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. On 07/08/2025 at 10:28 a.m., a telephone interview was conducted with S30FEMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated Resident #3 was sitting in her wheelchair facing the window. She stated Resident #4 wrapped her arms around Resident #3's neck then began pulling Resident #3 backwards. She stated when S5EMP attempted to break up the residents, S1ADM instructed S5EMP to take her hands off of Resident #4. She stated Resident #4 then walked calmly toward Resident #1, stood behind her wheelchair and began trying to tip over her wheelchair from the back and the side. She stated the assistant administrator intervened, sitting on one armrest to prevent the wheelchair from tipping. She stated she continued trying to redirect Resident #4, but it was ineffective as it usually was. She stated Resident #4 eventually walked away, sat on the couch, and cried. Review of Resident #4's Nurse Practitioner Notes revealed the following, in part: On 04/18/2025- Resident #4 had an aggressive episode in which she attacked 3 other residents on the secured Dementia Unit. Resident #4 appears to be a danger to others as she is impulsive and frequently becomes aggressive despite recent change in psychotropic medications. Recent inpatient psychiatric evaluation and treatment noted. Physician Emergency Certificate (PEC) written today as Resident #4 appears to be a danger to others. Signed by S13NP. Resident #5Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS score of 11, which indicated Resident #5 had moderate cognitive impairment. Review of the facility's Incident Log revealed Resident #5 had an unwitnessed fall on 05/20/2025 at 6:00p.m. Review of Resident #5's Incident Report dated 05/20/2025 at 6:00 p.m. revealed the following, in part:Incident Location: Resident's RoomNursing description: The CNA reported that she heard a commotion coming from one of the resident's room. She went into Resident #5's room and noted Resident #5 and Resident #4 were on the floor. Spilled cup of water also noted on the floor near the residents along with their clothes noted wet.Resident Description: Resident #5 stated she fell.Was the incident witnessed: NoImmediate Action Taken: Residents were immediately separated. The CNA removed Resident #4 from Resident #5's room and walked Resident #4 back to her own room. Resident #5 was assessed for injuries, no apparent injuries noted. Resident #5 complained of pain in her right hip. New order obtained for stat x-ray ordered to bilateral hips/pelvis. Review of Incident Witness Statement revealed the following, in part: Witness Name: S5EMPResidents Involved: Resident #4 and Resident #5Date of Incident: 05/20/20251. Provide a brief description of what happened: I was helping another resident and turned around and saw Resident #5 and Resident #4's hands up in the air, middle of doorway, going back and forth. Resident #5 was yelling stop. I called for help and as I entered room, Resident #4 and #5 were on the floor. I grabbed Resident #4 and she swung at Resident #5 on the side of face. 2. Are you aware of an injury? No3. Where did the incident take place? Resident #5's room4. What actions did you take immediately? Running to get Resident #4 out of room [ROOM NUMBER]. Did anyone else other than you witness the incident? No Review of Resident #5's Social Services Note dated 05/23/2025 revealed the following, in part:05/23/2025 at 3:12 p.m.: S17SS went to speak with Resident #5 on the afternoon of 05/23/2025. Upon entering resident room she was visibly distraught and talking with the nurse. Resident #5 said that she was feeling like she was being taken away from her home. When asked about a prior incident that occurred, Resident #5 stated that she didn't know. She said she was very confused because she couldn't remember how the lady hit her or what happened. Resident #5 repeated she was very confused and couldn't remember anything about a woman hitting her and started getting upset more. Resident #5 then changed the subject back to wanting to go back to her room on the memory care unit. Resident #5 said she was happy there and safe there and needs to go back. Signed by S17SS. On 07/08/2025 at 8:48 a.m., an interview was conducted with Resident #3. She stated she recalled when her friend, Resident #5, was attacked by Resident #4. She stated Resident #5 was walking down the hall when Resident #4 pushed Resident #5 to the floor and began hitting Resident #5. She stated Resident #5 told her she was scared to death and did not treat anyone poorly to deserve being treated like that. On 07/08/2025 at 3:27 p.m., an interview was conducted with Resident #5. Resident #5 stated she previously resided on another hall at the facility. She stated she was involved in an altercation with another resident during which she was hit. She stated her family was worried about her safety after the incident and requested a room change. She stated she did not speak to the other resident before being hit. She stated she did not know the name of the resident that hit her. She was unable to recall when the incident took place. She stated she did not remember if she was injured. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was working on 05/20/2025 and witnessed the incident between Resident #4 and Resident #5. She stated she heard Resident #4 yelling at Resident #5 to get out of her room. She stated she saw Resident #4 push Resident #5 from behind. She stated Resident #5 fell down, then Resident #4 fell down as well. She stated while on the floor, Resident #4 was swinging at Resident #5, and Resident #5 had her hands in the air trying to protect herself. She stated she immediately tried removing Resident #4 away from Resident #5, and Resident #4 swung, hitting Resident #5 on the side of her face. She stated she separated the residents and reported the incident to S18EMP. She stated Resident #5 complained of pain after the incident and an x-ray was ordered. She stated she told Administration about Resident #4's aggression and abuse of the other residents but they did not do anything to stop or prevent it. She stated Resident #4 was sent out to a behavioral hospital after the incident, but it did not help. She stated Resident #4's behavior was the same when she returned to the facility. On 07/09/2025 at 12:00 p.m., an interview was conducted with S18EMP. She stated she was not in the locked dementia unit at the time of the incident between Resident #4 and Resident #5. She stated when she arrived on the unit, she was notified of what happened. She stated both residents were already separated and in their rooms. She stated she completed an assessment on Resident #5, and Resident #5 complained of hip pain. She stated she notified the Nurse Practitioner on call and Resident #5's family. She stated an x-ray was ordered. She stated Resident #5 stated, that lady came in my room, why was she in my room? She stated she reported the incident to Administration. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM or S2DON. On 07/09/2025 at 9:55 a.m., an interview was conducted with Resident #5's family member. He stated he was informed Resident #5 had a fall on 05/20/2025 at 7:42 p.m. resulting in hip pain. He stated through his own discussions with staff, he learned the incident was not just a fall, instead it was an altercation with Resident #4. He stated he visited Resident #5 at the facility the following day to check on her. He stated during their visit Resident #5 was paranoid, frequently stating I didn't push her, she pushed me. I don't want to be pushed around again. He stated this prompted him to discuss the incident with S1ADM. He stated when he discussed the incident with S1ADM, S1ADM refused to show him the camera footage, with the reason of him not being Resident #5's Power of Attorney (POA). He stated S1ADM also denied another resident was involved in the incident. He stated he arranged to become Resident #5's POA the same day. He stated when he presented the paperwork to S1ADM, he would not accept it and still would not let him see the camera footage. He stated S1ADM contacted corporate, who agreed to acknowledge the POA and let him see the footage. He stated when he was allowed to watch the camera footage, 2 of the 3 videos had already been deleted. He stated S1ADM did not provide a reason for the deletion. He stated he was initially told the footage was available for 7 days, and it had not yet been that long. He stated when he reviewed the camera footage, it revealed the incident occurred on 05/20/2025 at 7:15 p.m. He stated Resident #5 was followed to her room by Resident #4 at the start of the footage. He stated it appeared Resident #5 was pushed out of the doorway, then the video stopped. He stated Resident #5 never had any altercations with any other residents. He stated after he was made aware the incident involved Resident #4, he requested Resident #5 be moved to another room off the locked dementia unit. He stated if Resident #5 was fully cognitive, she would also classify it as abuse since she had vision impairment causing her to only see 3-4 feet in front of her, and would not be able to defend herself. On 07/10/2025 at 3:35 p.m., an interview was conducted with S17SS. She stated she saw Resident #5 within 72 hours of the incident and room change. She stated Resident #5 cried for days following the incident. Further review of Resident #4's current Care Plan revealed the following, in part:Goal: Resident #4 will have fewer episodes of behavior by review date of 08/12/2025.Intervention: Every 30 minute checks for behavior x 24 hours, initiated 05/20/2025. Redirect as needed. Resident #4 separated on 05/20/2025. Unknown Resident #2Review of Resident #4's Nurse's Notes revealed the following, in part:On 05/26/2025 at 7:47 p.m. - 4:30 p.m.-Resident #4 agitated at another resident continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to another resident yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing Unknown Resident #2 quickly down the hall and then spun Unknown Resident #2 around and started pushing Unknown Resident #2 quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab Unknown Resident #2. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of Unknown Resident #2's head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. Further review of Resident #4's current Care Plan revealed the following, in part:Intervention: 1 on 1 observation 05/26/2025-06/09/2025. Multiple attempts were made throughout the survey to identify the resident in this nurse's note, however, this resident was unable to be identified. On 07/10/2025 at 9:15 a.m., an interview was conducted with S24EMP. She reviewed the staff schedules dated 05/26/2025 through 05/30/2025. She confirmed she worked the 6:00 a.m. to 2:00 p.m. shifts on the locked dementia unit on those dates, and Resident #4 did not have 1:1 monitoring. She stated Resident #4 had been receiving 1:1 monitoring for about 3-4 weeks from today, after a resident to resident incident. She stated she could not recall after which resident to resident incident though. She stated 1:1 monitoring required a staff member to be present with the resident at all times. Resident #6Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #6's admission MDS with an ARD of 04/23/2025 revealed she had a BIMS of 5, which indicated Resident #6 had severe cognitive impairment. Review of Resident #6's Incident Report dated 06/09/2025 at 4:10 p.m. revealed the following, in part: Resident: Resident #6 Incident location: dining roomIncident description: Resident #6 was standing up in the common area with the use of her rolling walker talking to Resident #4 when Resident #4 told Resident #6 to shut up and pushed Resident #6 backwards causing Resident #6 to stumble backwards. Resident #6 hit her head against the wall and fell to the floor.Immediate action taken: Resident #6 assessed for injuries, none noted. Resident #6 complained of pain to her lower back at this time. Tylenol administered for pain. S13NP notified and RP notified. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 06/09/2025 at 11:15 p.m.-Late entry for 4:10 p.m. Resident #4 was talking with Resident #6 in the dining room area when she pushed Resident #6. Signed by S9EMP. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025. She stated Resident #6 was standing up talking and Resident #4 turned around told her to shu

Based on interview and record review, the facility failed to ensure all alleged allegations involving physical and psychological abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency, for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when the facility failed to report allegations of abuse to the State Agency. On 02/22/2025, Resident #4 hit Resident #R1. On 03/25/2025, Resident #4 attempted to pull Unknown Resident #1 out of her wheelchair by her feet. On 04/17/2025, Resident #4 hit Resident #3. On 5/20/2025, Resident #4 pushed Resident #5, causing her to fall then Resident #4 hit Resident #5 in the face. On 05/25/2025, Resident #4 grabbed Unknown Resident #2's hair and pulled it and wouldn't let go. On 06/09/2025, Resident #4 told Resident #6 to shut up and pushed Resident #6 backwards causing her to stumble and hit her head against the wall and fall to the floor. On 06/16/2025, the nurse heard a scream and a wheelchair alarm go off and a second scream and she observed Resident #1 lying on her left side on the floor by the bed in a fetal position, and observed Resident #4 standing at the end of the bed next to Resident #1's wheelchair with the seat pad in her hands. Record review revealed none of the above incidents were reported to the State Agency. Interview with S1ADM revealed he was aware of the incidents above and none were reported to the State Agency. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Residents #R1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2, it could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #4's abusive behaviors since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 07/11/2025 at 11:10 a.m. This deficient practice continued at a potential for more than minimal harm for the other 166 residents residing in the facility. Findings:Cross Reference F600 and F835 Review of the facility's policy dated 03/25/2023 and titled, Abuse- Prevention and Prohibition Policy and Procedure, revealed the following, in part: II. Procedures:7. Reporting/Response: The facility employee or covered individual who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator. The Administrator shall immediately initiate a self-reported incident report to the State Survey Agency and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical, sexual, verbal, or mental) or results in serious bodily injury. On 07/10/2025 at 9:20 a.m., review of the facility's self-reported incidents dated January 2025 through July 2025 revealed no incidents of resident to resident abuse reported to State Agency. Resident #R1Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #4's Nurse's Notes revealed the following, in part:02/22/2025 at 4:42 p.m.-While doing medication pass Resident #4 was in another residents room and Resident #R1 (Resident #4's husband) was standing at doorway. I asked Resident #4 to follow me to her room and she exited with the other residents blanket rolled up in her arms. Resident #R1 attempted to take it from her and give it back to the other resident, and when she followed him out she hit him in his back. Signed, S4EMP. On 07/10/2025 at 9:55 a.m., an interview was conducted with S4EMP. She stated she observed the incident between Resident #4 and #R1 on 02/22/2025. She stated she would consider this incident resident to resident physical abuse. She stated she reported the incident but did not recall who she reported it to. She stated the facility's protocol was to notify the direct supervisor immediately after a witnessed incident. Unknown Resident #1Review of Resident #4's Nurse's Notes revealed the following, in part: On 03/25/2025 at 7:10 p.m.-Resident #4 noted attempting to take residents from the community area against their will. Unable to redirect, she is becoming verbally aggressive. Resident #4 noted tearing padding off a residents wheelchair, when redirection attempted she grabbed Unknown Resident #1 by both feet and began trying to pull her out of her chair by her feet. Unknown Resident #1 is fearful and showing physical as well as expressing verbal signs of stress. Resident #4 then walked away and took a facility chair making attempts to leave with the chair but while sitting in it. Signed by S30FEMP. On 07/10/2025 at 9:38 a.m., a telephone interview was conducted with S30FEMP. She stated she observed the incident above between Resident #4 and Unknown Resident #1 on 03/25/2025. She stated she informed S1ADM of the incident after it happened. Resident #3Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Incident report dated 04/17/2025 at 3:00 p.m.Person Preparing Report: S30FEMPNursing description: Resident #3 witnessed by hall staff sitting in the community living room area watching television when Resident #4 walked over to Resident #3 and said something indecipherable and then began hitting Resident #3. Resident #3 in no way instigated the interaction. Resident #3 reported she did not do or say anything to the other resident. No injuries noted. On 07/08/2025 at 10:28 a.m., a telephone interview was conducted with S30FEMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated Resident #3 was sitting in her wheelchair facing the window. She stated Resident #4 wrapped her arms around Resident #3's neck then began pulling her backwards, choking her. She stated S1ADM was present during the incident. She stated when S5EMP attempted to break up the residents, S1ADM instructed S5EMP to take her hands off of Resident #4. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM, S2DON, or S3ADON. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated she attempted to pull Resident #4's arms away from Resident #3's neck but was told to let her be by S1ADM, who was present at the time of the incident. S5EMP stated this incident was resident to resident abuse. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. Resident #5Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Incident Report dated 05/20/2025 at 6:00p.m., revealed the following, in part:Incident Location: Resident's RoomNursing description: The CNA reported that she heard a commotion coming from one of the resident's room. She went into Resident #5's room and noted Resident #5 and Resident #4 were on the floor. Spilled cup of water also noted on the floor near the residents along with their clothes noted wet.Resident Description: Resident #5 stated she fell.Was the incident witnessed: NoImmediate Action Taken: Resident's #4 and #5 were immediately separated. The CNA removed Resident #4 from this Resident #5's room and walked Resident #4 back to her own room. Resident #5 was assessed for injuries, no apparent injuries noted. Vitals obtained. Neuro checks initiated. ROM performed, Resident #5 complained of pain in her right hip. On call NP notified. New order obtained for stat x-ray ordered to bilateral hips/pelvis. Resident #5's RP notified. Review of Incident Witness Statement revealed the following, in part: Witness Name: S5EMPResidents Involved: Resident #4 and Resident #5Date of Incident: 05/20/20251. Provide a brief description of what happened: I was helping another resident and turned around and saw Resident #5 and Resident #4's hands up in the air, middle of doorway, going back and forth. Resident #5 was yelling stop. I called for help and as I entered room, Resident #4 and #5 were on the floor. I grabbed Resident #4 and she swung at Resident #5 on the side of face. 2. Are you aware of an injury? No3. Where did the incident take place? Resident #5's room4. What actions did you take immediately? Running to get Resident #4 out of room [ROOM NUMBER]. Did anyone else other than you witness the incident? No On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was working on 05/20/2025 and witnessed the incident between Resident #4 and Resident #5. She stated Resident #4 pushed then hit Resident #5. She stated she notified the nurse, S18EMP. She stated Resident #5 complained of pain after the incident and an x-ray was ordered. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. On 07/09/2025 at 12:00 p.m., an interview was conducted with S18EMP. She stated she was not in the locked dementia unit at the time of the incident between Resident #4 and Resident #5. She stated when she arrived on the unit, she was notified of what happened. She stated both residents were already separated and in their rooms. She stated she completed an assessment on Resident #5, and Resident #5 complained of hip pain. She stated she notified the Nurse Practitioner on call and Resident #5's family. She stated an x-ray was ordered. She stated Resident #5 stated, that lady came in my room, why was she in my room? She stated she reported the incident to Administration. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM or S2DON. Unknown Resident #2Review of Resident #4's Nurse's Notes revealed the following, in part:On 05/26/2025 at 7:47 p.m. -Late entry for 4:30 p.m.- Resident #4 agitated at Unknown Resident #2, continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to Unknown Resident #2 yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing Unknown Resident #2 quickly down the hall and then spun Unknown Resident #2 around and started pushing Unknown Resident #2 quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab Unknown Resident #2. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of Unknown Resident #2's head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. Multiple attempts were made throughout the survey to contact S10EMP with no success. Resident #6Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #6's Incident Report dated 06/09/2025 at 4:10 p.m. revealed the following, in part: Resident: Resident #6, incident location was in the dining roomIncident description: Resident #6 was standing up in the common area with the use of her rolling walker talking to Resident #4 when Resident #4 told Resident #6 to shut up and pushed Resident #6 backwards causing Resident #6 to stumble backwards. Resident #6 hit her head against the wall and fell to the floor.Immediate action taken: Resident #6 assessed for injuries, none noted. Resident #6 complained of pain to her lower back at this time. Tylenol administered for pain. Staff assisted Resident #6 up off the floor and into a chair. Range of motion performed and within normal limits. Neuro Checks initiated. Vitals obtained. S13NP notified and RP notified. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025 and witnessed the incident on 06/09/2025 when Resident #4 pushed Resident #6. She stated she would consider it abuse. She stated she reported it to S3ADON as soon as the incident occurred. On 07/10/2025 at 1:00 p.m., an interview was conducted with S3ADON. She stated S9EMP notified her of the incident between Resident #4 and Resident #6 on 06/09/2025. She stated she immediately notified S1ADM. Resident #1 Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #1's Incident Report dated 06/16/2025 at 2:50 p.m., revealed the following, in part: Unwitnessed fall, Date: 06/16/2025 2:50 p.m.Nursing Description: Nurse was on the hall when she heard a scream and then heard a chair alarm sounding off. Upon entering the room Resident #1 noted lying on left side with large hematoma to forehead and swelling and discoloration under left eye. Upon range of motion assessment Resident #1 noted with swelling to right knee.Resident Description: Resident #1 unable to give descriptionWas this incident witnessed: No Review of Resident #1's Nurse's Notes revealed the following, in part:06/16/2025 at 2:50 p.m.- S7EMP heard a scream and then heard a chair alarm sounding off. Upon entering the room, Resident #1 noted lying on left side. Resident #1's wheelchair was next to Resident #1 with seatbelt unbuckled. Resident #1 assessed for injuries. Resident #1 noted with large hematoma to left side of forehead with swelling and redness under Resident #1's left eye. Resident #1 appeared to be very agitated and scared. Nurse attempted to give Resident #1 Tylenol for pain but Resident #1 refused. NP notified, received order to send to ER. Acadian ambulance called for transfer to ER per family request. Nurse sat in room with Resident #1 until ambulance arrived and Resident #1 calmed down. Upon entering the room, nurse noticed two other residents present in close proximity in the room with the resident as well as the upper part of resident's high-back wheelchair was not in the correct position with seatbelt unbuckled. Signed by S7EMP. On 07/08/2025 at 1:15 p.m., an interview was conducted with S7EMP. She stated she was working on 06/16/2025. She confirmed the incident with Resident #1 on 06/16/2025 where Resident #1 was found on the floor out of her wheelchair with Resident #4 standing beside her. She stated she noticed Resident #1 had a large hematoma on the left side of Resident #1's head starting at the hairline and extending to her cheekbone. She stated Resident #1 was crying. She stated she called Administration and informed them she needed assistance immediately due to an unwitnessed incident. She stated she told her supervisors she suspected Resident #4 had pulled Resident #1 out of the wheelchair. She stated she was told since she did not have proof, she did not need to say that. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was familiar with Resident #1 and was assigned to her on 06/16/2025. She confirmed the incident with Resident #1 on 06/16/2025 where Resident #1 was found on the floor out of her wheelchair with Resident #4 standing beside Resident #1. She stated Administration was made aware of this by S7EMP. She stated Resident #4 attempted to push Resident #1 out of her wheelchair three other times that she witnessed. She stated Resident #4 had a known history to target Resident #1. She stated she suspected Resident #4 had pulled Resident #1 out of her wheelchair on 06/16/2025, but was told not to talk about it by administrative staff. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. On 07/10/2025 at 1:28 p.m., an interview was conducted with S1ADM. He stated staff were expected to immediately report any allegations of abuse or witnessed abuse to him. He stated his responsibility for reporting abuse was to report any allegations of abuse or abuse concerns to State Agency within 2 hours. He stated he was aware of the incidents on 02/22/2025, 03/25/2025, 04/17/2025, 05/20/2025, 05/26/2025, 06/09/2025, and 06/16/2025 involving Resident #4. S1ADM stated he was present on 04/17/2025 when the incident occurred between Resident #3 and Resident #4. He stated Resident #4 grabbed Resident #3 around the shoulders, not around the neck, as staff stated. He stated the incident only lasted for 2 seconds. He stated he was notified of the incident on 05/26/2025 of Resident #4 pulling another residents hair. He stated after reviewing camera footage, he could tell Resident #4's hand was by the other resident, but could not confirm she pulled the resident's hair. He stated again, this only lasted 2 seconds. He stated he was aware on 06/16/2025, Resident #1 was found in front of Resident #1's wheelchair lying on her left side. He stated he was aware Resident #4 was observed to be beside Resident #1's wheelchair at that time. He stated there was presently no video camera footage saved to be reviewed for the incidents listed above. He stated based on State guidance in 2024, it was up to the facility to decide if an incident was abuse. He stated abuse was to be reported if the action was willful and caused injury or pain. He stated due to Resident #4's poor cognition, her actions were not willful, therefore none of the incidents listed above would be considered abuse, and he was not required to report them to State Agency. The Immediate Jeopardy was removed on 07/11/2025 at 3:23 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Plan of Removal F609 - The provider allegedly failed to ensure all allegations of physical and psychosocial abuse was reported to the state agency and within the appropriate timeframe.I. Corrective actions were taken for the residents affected by the alleged deficient practice by:a. Administrator in-serviced on facility self-reported incident reporting, reporting timeline and abuse in-service timing requirements by Regional Director of Operations on 07/11/2025.b. Staff in-service initiated per Staff Developer on 07/10/2025 on abuse prevention and reporting to include reporting timeline, appropriate resident supervision and one-to-one supervision procedures. In-service will be done with all staff prior to starting their next scheduled shift and will be ongoing until completed. Any staff member will not be allowed to work until training has been completed.2. All residents who reside in the facilities secure unit have the potential to be affected by the alleged deficient practice.a. Staff in-service Initiated per Staff Developer on 07/10/2025 on abuse prevention and reporting to include reporting timeline, appropriate resident supervision and one-to-one supervision procedures. In-service will be done with all staff prior to starting their next scheduled shift and will be ongoing until completed. No staff member will be allowed to work until training has been completed.3. Measures put in place to ensure the alleged deficient practice will not recur are:a. Administrator in-serviced on facility self-reported incident reporting, reporting timeline and abuse in-service timing requirements by Regional Director of Operations 07/11/2025. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by (monitoring started on 07/11/2025 as observed by Surveyors):a. Regional Director of Operations will conduct audit 3 times per week to ensure all reportable incidents have been reported correctly. Audit will involve review of incident log and behavior notes. Audit will begin on 07/11/2025 and will be ongoing. b. Administrator or designee will interview 3 residents daily to ensure facility is aware of all potential instances of abuse or neglect. Interviews will begin on 07/11/2025 and will be ongoing.c. Ongoing issues to be discussed in daily meeting that occurs Monday through Friday. Discussion started on 07/11/2025.d. Failure to comply will result in progressive disciplinary action.5. The facility will ascertain substantial compliance by 07/11/2025.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident remained free from physical and psychosocial abuse for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when Resident #4, a cognitively impaired resident, hit Resident #R1 on the back. The facility failed to ensure effective interventions were put into place to protect the resident's from abuse after the 02/22/2025 incident. Resident #4 exhibited continued aggressive and abusive behaviors, and was transferred to the facility's locked dementia care unit on 03/25/2025. On 03/25/2025, Resident #4 was observed grabbing Unknown Resident #1 by the feet and attempting to pull the resident out of their wheelchair. The resident was observed by a former employee to be fearful, displaying physical and verbal signs of stress. Unknown Resident #1 was scared, crying, and kept doing a swatting motion with her hands. The IJ continued on 04/17/2025, when Resident #4 interlocked her arms around Resident #3's throat then began pulling back, choking her. The IJ continued on 05/20/2025, when Resident #4 pushed Resident #5, causing Resident #5 to fall to the floor. Resident #4 then hit Resident #5 in her face. Resident #5 complained of hip pain after the incident. Resident #5's family requested Resident #5 be moved out of the locked dementia care unit for safety, which resulted in Resident #5 crying for days. The IJ continued on 05/26/2025, when Resident #4 grabbed Unknown Resident #2's hair, pulled it, and would not let go. On 05/26/2025, Resident #4 was placed on 1:1 supervision then removed from 1:1 supervision on 06/09/2025. On 06/09/2025, Resident #4 pushed Resident #6 into the wall, causing Resident #6 to hit her head against the wall. Resident #6 complained of a headache after the incident and required administration of Tylenol for pain management. Resident #4 was placed back on continuous 1:1 supervision on 06/09/2025. On 06/16/2025, Resident #1 was found in a resident's room lying on her left side in a fetal position. Resident #4 was observed standing on the right side of Resident #1's wheelchair with Resident #1's wheelchair pad in her hand, and no staff present with Resident #4. Resident #1 was noted to have swelling to the left side of her face and right knee. Resident #1 was transferred to the hospital where it was determined she had a right femur fracture and a left facial hematoma. Due to Resident #1's age, she was unable to undergo surgery and was ultimately transferred to an inpatient hospice facility where she passed away on 06/25/2025. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4. She was lying in her bed with no staff present at bedside. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Residents #R1, #3, #6, Unknown Resident #1, and Unknown Resident #2, it could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #4's abusive behaviors since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 07/09/2025 at 4:58 p.m. Findings:Review of the facility's policy dated 03/25/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure, revealed the following, in part:Purpose:Each resident has the right to be free from abuse.3. Physical Abuse may include hitting, slapping, pinching, biting, shoving, and kicking.4. Mental Abuse includes, but is not limited to, harassment.There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or impairment, cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Resident #R1Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #R1's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 07/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 5, which indicated Resident #R1 was severely cognitively impaired. Resident #4Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's Quarterly MDS with an ARD of 05/14/2025 revealed a BIMS of 2, which indicated she had severe cognitive impairment. Further review revealed Resident #4 was ambulatory and required supervision with ADL's. Review of Resident #4's Nurse's Notes revealed the following, in part:02/22/2025 at 4:42 p.m.-While doing medication pass, Resident #4 was in another residents room and Resident #R1 (Resident #4's husband) was standing at doorway. I asked Resident #4 to follow me to her room and she exited with the other residents blanket rolled up in her arms. Resident #R1 attempted to take it from her and give it back to the other resident, and when she followed him out she hit him in his back. Signed, S4EMP. On 07/10/2025 at 9:55 a.m., an interview was conducted with S4EMP. She stated she observed the incident between Resident #4 and #R1 on 02/22/2025. She stated prior to the incident, Resident #4 wandered into another resident's room and stole the blanket off the bed. She stated Resident #R1 attempted to take the blanket from Resident #4 and return it to the bed. She stated Resident #4 then became enraged and hit #R1 on the back. She stated the two were separated immediately by staff and Resident #4 was placed under the direct supervision of staff for the rest of the shift. She further stated Resident #R1 and Resident #4 were not allowed to be alone together and doors were not to be closed to Resident #4's room. She stated #R1 was assessed and no injuries were sustained and he reported no pain. She stated she would consider this incident resident to resident physical abuse. Further review of Resident #4's Nurse's Notes revealed the following, in part: On 03/09/2025 at 3:11 p.m. - Resident went to end of hall and grabbed a wet floor sign. Resident got combative when CNA tried to get her to put the sign down and hit CNA. Signed by S12EMP. On 03/11/2025 at 4:21 p.m.-Resident took an employee's purse/bag, staff attempted to redirect resident and retrieve bag, resident became combative kicking and hitting the nurse in the chest. Resident's husband attempted to talk to the resident and get the bag. The resident was resistant to him as well but finally let go of the bag. Resident was provided time to calm down. Staff applied non-slip socks for safety as resident is wondering around the facility without shoes and only one sock on that she is bending over trying to remove. Signed by S6EMP. Review of Resident #4's admission and discharge report revealed she was transferred to an inpatient psychiatric facility on 03/12/2025 for aggressive behavior and returned to the facility on [DATE], when she was placed on the locked dementia unit. Review of Resident #4's current Physician Orders revealed the following, in part: 03/19/2025-Admit to memory care; secure unit monitoring Review of Resident #4's current Care Plan revealed the following, in part: Problem: Resident went into another resident's room and urinated on the floor, turning on/off others lights. 03/26/25- The resident has been taking other residents food, throwing food at staff, hitting staff members, yelling at other residents, and pushing furniture while other residents are on it. The resident can be difficult to redirect. 03/27/25- The resident has been taking family members belongings and refusing to give them back. The resident attacked a CNA when the resident could not open window.Interventions: Redirect as needed; Administer medications as ordered Unknown Resident #1 Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/25/2025 at 7:10 p.m.-Resident #4 noted attempting to take residents from the community area against their will. Unable to redirect, she is becoming verbally aggressive. Resident #4 noted tearing padding off a residents wheelchair, when redirection attempted she grabbed Unknown Resident #1 by both feet and began trying to pull her out of her chair by her feet. Unknown Resident #1 is fearful and showing physical as well as expressing verbal signs of stress. Resident #4 then walked away and took a facility chair making attempts to leave with the chair but while sitting in it. Signed by S30FEMP. On 3/25/2025 at 7:19 p.m. - Resident #4 noted making attempts to snatch the same resident, Unknown Resident #1, out of the top of her chair by the shirt. When redirected, Resident #4 became physically aggressive and pushed the couch in the community living room while another resident was sitting on it. Resident #4 continues to act out verbally and physically against staff and fellow residents. Signed by S30FEMP. On 07/10/2025 at 9:38 a.m., a telephone interview was conducted with S30FEMP. She stated she was working on 03/25/2025. She stated Resident #4 attempted to pull another resident out of her wheelchair by her feet. She stated she remembered the resident had a seatbelt in place but was unable to recall which resident it was. She stated the incident was unprovoked. She stated she was close by when it occurred and was able to intervene immediately and separated Resident #4 from the resident in the wheelchair before any injuries occurred. She stated after the incident, Unknown Resident #1 was scared, crying, and kept doing a swatting motion with her hands. She stated she informed S1ADM and S2DON frequently of her concerns for the safety of the other resident's due to Resident #4's aggressive behavior. She stated she told them Resident #4 would become violent with no warning, attacked staff and other residents, and could not be redirected. She stated when Resident #4 was transferred to the locked dementia unit, she felt like she was not able to keep the other resident's safe due to Resident #4's aggressive behaviors. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 3/26/2025 at 12:05 p.m. - During lunch Resident #4 walked over to nurse's desk and removed the top from another resident's food and attempted to pick up the food with her hands. The nurse attempted to redirect resident and she became angry and grabbed a handful of greens and threw them at the nurse and grabbed the bowl of pie and hit the nurse with the pie. Resident swung at nurse multiple times. Resident #4 then lost balance and fell on the floor. Resident #4 did not hit her head. While on the floor, resident attempted to kick nurse multiple time. Nurse was able to remain holding Resident #4's hand while the CNA went to get assistance. S1ADM and S13NP notified of the resident's aggressive behavior. Signed by S7EMP. On 3/27/2025 at 5:30 p.m.-Late Entry-The resident was attempting to open a window with intent to elope. The CNA sitting directly next to the window turned her head to see what was going on and asked Resident #4 what she was doing and to not do that to the window. Resident #4 immediately turned and began grabbing and hitting the CNA in her head and face. The CNA yelled for assistance I went over to get the resident to stop. Resident #4 then became aggressive towards me. Resident #4 was very difficult to redirect but after some time Resident #4 walked away but remained agitated until she went to bed. The situation was reported to S1ADM and her responsible party. Signed by a S30FEMP. Resident #3Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS of 9, which indicated Resident #3 was moderately cognitively impaired. Review of Resident #3's Incident report dated 04/17/2025 at 3:00 p.m.Incident Description: Nursing description-Resident #3 witnessed by hall staff sitting in the community living room area watching television when Resident #4 walked over to Resident #3 and said something indecipherable and then began hitting Resident #3. Resident #3 in no way instigated the interaction. Resident #3 reported she did not do or say anything to the Resident #4. No injuries noted. Review of Resident #3's Nurse's Notes revealed the following, in part:04/18/2025 at 1:06 p.m. -Shift Summary: Following report received at shift change, went to visually assess Resident #3 related to incident earlier on previous shift. Assessed Resident #3 for pain and any potential injuries. Resident #3 denied any pain (but specifically to head, neck and back) and no visual markings or bruises noted. Resident #3's speech clear and appropriate. Upon Resident #3 getting up for the day, Resident #3 came and sat by this nurse and described earlier incident, Resident #3 continues to deny any pain or discomfort with associated incident. Resident #3 does not appear in any mental anguish, states she is alright but she will not forget what happened to her. Will continue to monitor. Signed by S6EMP. Further review of Resident #4's Nurses Notes revealed, in part:On 04/16/2025 at 12:15 p.m. -Resident #4 took papers from nurse's desk. Nurse attempted to retrieve papers from resident. Resident #4 became aggressive and pulled nurse's hair and kicked nurse in the stomach. Resident #4 then lost balance trying to kick nurse a second time and fell. Resident #4 did not hit head, no apparent injuries noted. Resident #4 assisted off of the floor by staff. Resident #4 refused vital signs. S13NP and RP notified. Signed by S7EMP. On 04/17/2025 at 9:49 p.m. -Resident #4 exhibited verbal and physical aggression this shift. Resident #4 was pushing Resident #1 down the hall and that resident was asking her to stop. Staff asked Resident #4 not to push her as she didn't want to be pushed and Resident #4 became verbally aggressive and threatening toward staff. As I attempted to administer medication to Resident #1, Resident #4 reached out and grabbed the medication which was crushed in pudding. She then laughed and went to the sink to wash her hands. I went off the unit to report the incident to the administrator. Upon returning to the unit, Resident #4 was noted yelling and sitting on top of Resident #1 while aggressively squeezing her hands and pushing them down where they were also crushed between the sides of the resident's legs and the arm rest of her wheelchair. Resident #4 was verbally and physically aggressive with staff as they tried to convince her to get off of Resident #1. I called for the administrator to come assist us. When he arrived Resident #4 stood up and continued being verbally aggressive while she walked over to Resident #3. Resident #4 leaned down and spoke aggressively to Resident #3 and when that resident started to speak, Resident #4 began attacking her. Resident #4 was noted standing behind Resident #3 using both hands balled into fists and striking her repeatedly in the head. When staff turned to intervene, Resident #4 leaned over the resident and wrapped both arms around Resident #3's neck squeezing it. As staff attempted to remove the resident from Resident #4's clutch, Resident #4 attempted to stop us from moving the resident and had her hands around the resident's neck. Resident #4 began slapping and grabbing at the residents face. We were finally able to block Resident #4 from Resident #3 and she walked away to Resident #1. Resident #4 attempted to push Resident #1 in her wheelchair but staff was able to stand in front of the wheelchair and hold it still. Resident #4 then began pulling on the trunk support contraption and tearing the protective foam padding off of it. Resident #4 continued to try to get the resident's wheelchair away from staff but became more frustrated and began pushing tables around the dining area. Resident #4 walked around to the other side of the dining room in order to pull a table out of the way so she would have access to the back of Resident #1's wheelchair. Once behind the wheelchair, she made more attempts to pull the chair from the grasp of staff. When she was unable to, she grabbed the high back wheelchair handles while putting her foot on the rear tippers and pulled aggressively to tip the wheelchair backwards. Two staff members remained in place holding Resident #1's wheelchair so it could not be tipped. Resident #4 finally walked away, remaining quite agitated. She continued to speak aggressively to other residents and staff but stopped being physically aggressive at that point. After taking evening medication Resident #4 had no more issues and cooperated with her usual bedtime routine. Signed by a S30FEMP. On 07/08/2025 at 8:48 a.m., an interview was conducted with Resident #3. She stated she did not recall being involved in any incidents with another resident On 07/08/2025 at 3:44 p.m. an interview was conducted with S5EMP. She stated she witnessed Resident #4 choke Resident #3 a few months ago. She stated Resident #4's elbows were around the front of Resident #3's neck. She stated she attempted to pull Resident #4's arms away from Resident #3's neck but was told to let her be by S1ADM, who was present at the time of the incident. She stated another nurse S30FEMP witnessed the incident as well. S5EMP stated this incident was resident to resident abuse. She stated Resident #4 was sent to the behavioral hospital after the incident. On 07/08/2025 at 10:28 a.m., a telephone interview was conducted with a S30FEMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated Resident #3 was sitting in her wheelchair facing the window. She stated Resident #4 wrapped her arms around Resident #3's neck then began pulling her backward. She stated when S5EMP attempted to break up the resident's, S1ADM instructed S5EMP to take her hands off of Resident #4. She stated then Resident #4 walked calmly toward Resident #1, stood behind her wheelchair and began trying to tip over her wheelchair from the back and the side. She stated the assistant administrator then intervened, sitting on one armrest to prevent the wheelchair from tipping. She stated she continued trying to redirect Resident #4, but it was ineffective as it usually was. She stated Resident #4 eventually walked away, sat on the couch, and cried. She stated Resident #4 was sent to the behavioral hospital after the incident. Review of Resident #4's Nurse Practitioner Notes revealed the following, in part:On 04/18/2025- Resident #4 had an aggressive episode in which she attacked 3 other residents on the secured Dementia Unit. See Nursing Home Notes. Resident #4 appears to be a danger to others as she is impulsive and frequently become aggressive despite recent change in psychotropic medications. Recent inpatient psychiatric evaluation and treatment noted. Physician Emergency Certificate (PEC) written today as Resident #4 appears to be a danger to others. Signed by S13NP. Resident #5Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS score of 11, which indicated Resident #5 was moderately cognitively impaired. Review of the facility's Incident Log revealed Resident #5 had an unwitnessed fall on 05/20/2025 at 6:00p.m. Review of Resident #5's Incident Report dated 05/20/2025 at 6:00p.m. revealed the following, in part:Incident Location: Resident's RoomNursing description: The CNA reported that she heard a commotion coming from one of the resident's room. She went into Resident #5's room and noted Resident #5 and Resident #4 were on the floor. Spilled cup of water also noted on the floor near the residents along with their clothes noted wet.Resident Description: Resident #5 stated she fell.Was the incident witnessed: NoImmediate Action Taken: Residents were immediately separated. The CNA removed Resident #4 from Resident #5's room and walked her back to her own room. Resident #5 was assessed for injuries, no apparent injuries noted. Vitals obtained. Neuro checks initiated. ROM performed, resident complained of pain in her right hip. On call NP notified. New order obtained for stat x-ray ordered to bilateral hips/pelvis. Resident #5's RP notified. Review of Incident Witness Statement revealed the following, in part:Witness Name: S5EMPResidents Involved: Resident #4 and Resident #5Date of Incident: 05/20/20251. Provide a brief description of what happened: I was helping another resident and turned around and saw Resident #5 and Resident #4's hands up in the air, middle of doorway, going back and forth. Resident #5 was yelling stop. I called for help and as I entered room, Resident #4 and #5 were on the floor. I grabbed Resident #4 and she swung at Resident #5 on the side of face.2. Are you aware of an injury? No3. Where did the incident take place? Resident #5's room4. What actions did you take immediately? Running to get Resident #4 out of room5. Did anyone else other than you witness the incident? No Review of Resident #5's Social Services Note dated 05/23/2025 revealed the following, in part:05/23/2025 at 3:12 p.m.: S17SS went to speak with Resident #5 on the afternoon of 05/23/2025. Upon entering Resident #5's room she was visibly distraught and talking with the nurse. Resident #5 said that she was feeling like she was being taken away from her home. When asked about a prior incident that occurred, Resident #5 stated that she didn't know. She said she was very confused because she couldn't remember how the lady hit her or what happened. She repeated she was very confused and couldn't remember anything about a woman hitting her and started getting upset more. She then changed the subject back to wanting to go back to her room on the memory care unit. She said she was happy there and safe there and needs to go back. S17SS said that she would check in with her more frequently and see how our staff could help her adjust to her new room. SS informed nurse to follow up with NP regarding her mood. S17SS also reached out to NP and to the Psych NP. Psych NP will round on 05/29/2025. Signed by S17SS. On 07/08/2025 at 8:48 a.m., an interview was conducted with Resident #3. She stated she recalled when her friend, Resident #5, was attacked by Resident #4. She stated Resident #5 was walking down the hall when Resident #4 pushed her to the floor and began hitting her. She stated Resident #5 told her she was scared to death and did not treat anyone poorly to deserve being treated like that. On 07/08/2025 at 3:27 p.m., an interview was conducted with Resident #5. Resident #5 stated she previously resided on another hall at the facility. She stated she was involved in an altercation with another resident during which she was hit, unprovoked. She stated her family was worried about her safety after the incident and requested a room change. She stated she did not know the name of the resident that hit her. She was unable to recall when the incident took place. She stated she did not remember if she was injured. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was working on 05/20/2025 and witnessed the incident between Resident #4 and Resident #5. She stated she heard Resident #4 yelling at Resident #5 to get out of her room. She stated she saw Resident #4 push Resident #5 from behind. She stated Resident #5 fell down, then Resident #4 fell down as well. She stated while on the floor, Resident #4 was swinging at Resident #5, and Resident #5 had her hands in the air trying to protect herself. She stated she immediately tried removing Resident #4 from Resident #5, and Resident #4 swung, hitting Resident #5 on the side of her face. She stated she separated the residents and reported the incident to S18EMP. She stated Resident #5 complained of pain after the incident and an x-ray was ordered. She stated she staff told Administration about Resident #4's aggression and abuse of the other residents but they did not do anything to stop or prevent it. She stated Resident #4 was sent out to a behavioral hospital after the incident, but it did not help. On 07/09/2025 at 12:00 p.m., an interview was conducted with S18EMP. She stated she was not in the locked dementia unit at the time of the incident between Resident #4 and Resident #5. She stated when she arrived on the unit, she was notified of what happened and both residents were already separated, and in their rooms. She stated she completed an assessment on Resident #5, and Resident #5 complained of hip pain. She stated she notified the Nurse Practitioner and Resident #5's family. She stated an x-ray was ordered. She stated Resident #5 stated, that lady came in my room, why was she in my room? She stated she reported the incident to Administration. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM or S2DON. On 07/09/2025 at 9:55 a.m., an interview was conducted with Resident #5's family member. He stated he was told Resident #5 had a fall on 05/20/2025 at 7:42 p.m. resulting in hip pain. He stated the nurse said an x-ray was completed and it later revealed no injury, just arthritis. He stated through his own discussions with staff, he learned the incident was not just a fall, instead it was an altercation with Resident #4. He stated he visited Resident #5 at the facility the following day to check on her. He stated during their visit Resident #5 was paranoid, frequently stating I didn't push her, she pushed me. I don't want to be pushed around again. He stated this prompted him to discuss the incident with S1ADM. He stated when he discussed the incident with S1ADM, S1ADM refused to show him the camera footage, with the reason of him not being Resident #5's Power of Attorney (POA). He stated S1ADM also denied another resident was involved in the incident. He stated he arranged to become Resident #5's POA the same day. He stated when he presented the paperwork to S1ADM, he would not accept it and still would not let him see the camera footage. He stated S1ADM contacted corporate, who agreed to acknowledge the POA and let him see the footage. He stated when he was allowed to watch the camera footage, 2 of the 3 videos had already been deleted. He stated S1ADM did not provide a reason for the deletion. He stated he was initially told the footage was available for 7 days, and it had not yet been that long. He stated when he reviewed the camera footage, it revealed the incident occurred on 05/20/2025 at 7:15 p.m. He stated Resident #5 was followed to her room by Resident #4 at the start of the footage. He stated it appeared Resident #5 was pushed out of the doorway, then the video stopped. He stated Resident #5 never had any altercations with any other residents. He stated after he was made aware the incident involved Resident #4, he requested Resident #5 be moved to another room off the locked dementia unit. He stated if Resident #5 was fully cognitive, she would also classify it as abuse since she had vision impairment causing her to only see 3-4 feet in front of her, and would not be able to defend herself. On 07/10/2025 at 3:35 p.m., an interview was conducted with S17SS. She stated she saw Resident #5 within 72 hours of the incident and room change. She stated Resident #5 cried for days following the incident. Further review of Resident #4's current Care Plan revealed the following, in part:Goal: The resident will have fewer episodes of behavior by review date of 08/12/2025.Intervention: Every 30 minute checks for behavior x 24 hours, initiated 05/20/2025. Redirect as needed. Resident separated on 05/20/2025. Unknown Resident #2Review of Resident #4's Nurse's Notes revealed the following, in part:On 5/26/2025 at 7:47 p.m. -Late entry for 4:30 p.m.-Resident #4 agitated at another resident continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to another resident yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing her quickly down the hall and then spun her around and started pushing her quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab her. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of her head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. Further review of Resident #4's current Care Plan dated 05/25/2025 revealed the following, in part:Intervention: 1 on 1 observation 05/26/2025-06/09/2025. Multiple attempts were made throughout the survey to contact S10EMP, which were unsuccessful. Resident #6Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #6's admission MDS with an ARD of 04/23/2025 revealed Resident #6 had a BIMS of 5, which indicated she had severe cognitive impairment. Review of Resident #6's Incident Report dated 06/09/2025 at 4:10 p.m. revealed the following, in part:Resident: Resident #6Incident location: dining roomIncident description: Resident #6 was standing up in the common area with the use of her rolling walker talking to Resident #4 when Resident #4 told Resident #6 to shut up, and pushed Resident #6 backwards causing resident to stumble backwards. Resident #6 hit her head against the wall and fell to the floor.Immediate action taken: Resident #6 assessed for injuries, none noted. Resident #6 complained of pain to her lower back at this time. Tylenol administered for pain. Staff assisted Resident #6 up off the floor and into a chair. Range of motion performed and within normal limits. Neuro Checks initiated. Vitals obtained. S13NP notified and RP notified. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 06/09/2025 at 11:15 p.m.-Late entry for 4:10 p.m. Resident #4 was talking with Resident #6 in the dining room area when she pushed Resident #6. Signed by S9EMP. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025. She stated Resident #6 was standing up talking and Resident #4 turned around told her to shut up and shoved her. She stated there was no forewarning and no triggers noted. She stated Resident #6 fell and hit her head. She stated Resident #6 stated she contacted S13NP. She stated S13NP gave an order for Tylenol for Resident #6's complaint of head pain and stated to monitor Resident #6 with neurological checks. She stated the incident between Resident #4 and #6 would be considered abuse. She stated after this incident, Resident #4 had a staff member assigned to her 1:1 monitoring for 2-3 days. On 07/10/2025 at 3:30 p.m., an interview was conducted with S23EMP. She stated she was working on 06/09/2025. She stated Resident #4 stood up and shoved Resident #6 into the wall. She stated Resident #6 hit her head and then fell to the ground. She stated Resident #6's facial expressions showed fear and Resident #6 kept telling staff to call her husband. She stated it happened so fast she couldn't do anything to prevent Resident #4 from pushing Resident #6. She stated since the nurse witnessed it, she did not report the incident to anyone. She stated she was told by S1ADM not to intervene because they didn't know what triggered Resident #4. She stated S1ADM told staff to avoid trying to stop it, and not to scream or pull at Resident #4 because she might get more aggressive. She stated if a resident shoved another resident it was abuse. Further review of Resident #4's current Care Plan revealed the following, in part:Intervention: Sent to ER for evaluation/treatment dated 06/09/2025. 1:1 close monitoring initiated on 06/09/2025. Resident #1Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE]. Review of Residen

Based on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents for 1 (#4) of 10 (#1, #2, #3, #4, #5, #6, #7, #R1, Unknown Resident #1, and Unknown Resident #2) residents review for incidents. This deficient practice resulted in an Immediate Jeopardy situation on 05/26/2025, when Resident #4, a cognitively impaired resident with a history of aggressive behaviors and was assessed to need 1:1 supervision, was left unattended by staff. Resident #4 was placed on 1:1 supervision from 05/26/2025 through 06/09/2025. On 05/26/2025, Resident #4 was observed grabbing and pulling Unknown Resident #2's hair. On 06/02/2025, Resident #4 grabbed Resident #1's wheelchair, spun her around forcefully and began telling her she was bothering her. Interviews with staff revealed Resident #4 was not receiving 1:1 supervision at that time. On 06/09/2025, 1:1 supervision was removed and later that day, Resident #4 was involved in another incident where she pushed Resident #6 into the wall, causing her to hit her head. Resident #4 was placed back on 1:1 close monitoring following the incident on 06/09/2025. On 06/11/2025, Resident #4 was found in an empty resident's room at 12:21 a.m., attempting to get in bed. Interviews with staff revealed Resident #4 did not have 1:1 supervision during the 10:00 p.m. to 6:00 a.m. shifts. On 06/16/2025, Resident #1 had an incident where she was found lying on the floor in front of her wheelchair, on her left side. Resident #4 was found standing beside Resident #1's wheelchair, with no staff present with Resident #4. Resident #1 acquired a right femur fracture and facial soft tissue hematoma which extended into left frontal scalp. Due to Resident #1's age, she was unable to undergo surgery, and she was transferred to an inpatient hospice facility, where she passed away on 06/25/2025. Staff interviews revealed Resident #4 did not have 1:1 supervision at the time of the incident on 06/16/2025. Staff interviews revealed Resident #4 was not provided with consistent 1:1 supervision during the day until after Resident #1's incident on 06/16/2025. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4. She was lying in her bed with her eyes closed. There was no staff present providing 1:1 supervision. S1ADM was notified of the Immediate Jeopardy situation on 07/11/2025 at 11:10 a.m. This deficient practice continued at a potential for more than minimal harm for the other 24 residents residing in the locked dementia unit and any resident who would require 1:1 supervision. Findings: Cross Reference F600 and F835 Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's Quarterly MDS with an ARD of 05/14/2025 revealed a BIMS of 2, which indicated Resident #4 had severe cognitive impairment. Further review revealed Resident #4 was ambulatory and required supervision with ADL's. Review of Resident #4's current Physician Orders revealed the following, in part:03/19/2025-Admit to memory care; secure unit monitoring Review of Resident #4's current Care Plan revealed the following, in part:Problem: Resident #4 went into another resident's room and urinated on the floor, turning on/off others lights. 03/26/25- Resident #4 has been taking other residents food, throwing food at staff, hitting staff members, yelling at other residents, and pushing furniture while other residents are on it. Resident #4 can be difficult to redirect. 03/27/25- Resident #4 has been taking family members belongings and refusing to give them back. Resident #4 attacked a CNA when the resident could not open window.Intervention: Every 30 minute checks for behavior x 24 hours, initiated 05/20/2025. Redirect as needed. Resident #4 separated on 05/20/2025. 1 on 1 observation 05/26/2025-06/09/2025. Sent to ER for evaluation/treatment dated 06/09/2025. 1:1 close monitoring initiated on 06/09/2025. Review of Resident #4's Nurse's Notes revealed the following, in part:On 05/26/2025 at 7:47 p.m. - 4:30 p.m.-Resident #4 agitated at another resident continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to another resident yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing Unknown Resident #2 quickly down the hall and then spun Unknown Resident #2 around and started pushing Unknown Resident #2 quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab Unknown Resident #2. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of Unknown Resident #2's head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. On 06/02/2025 at 3:23 p.m. -Resident approached Resident #1, who she saw was wheeling herself in her wheelchair down the hallway and grabbed the handles of the wheelchair swinging Resident #1 around with force and trying to push Resident #1 down the hallway. Staff immediately redirected Resident #4 away from Resident #1 and encouraged her to not worry about Resident #1, Resident #4 stated she just makes me so angry. Staff was able to redirect Resident #4 out of situation. Will continue to monitor. Signed by S11EMP. On 06/09/2025 at 11:15 p.m.-Late entry for 4:10 p.m. Resident #4 was talking with Resident #6 in the dining room area when she pushed Resident #6. Signed by S9EMP. On 06/11/2025 at 12:21 a.m. -Resident #4 found up and in another room attempting to get in bed. Brought back to her room and assisted into her room without incident. Will continue to monitor. Signed by S8EMP. On 06/16/2025 at 2:50 p.m. -When nurse entered the room due to an incident of another resident having an unwitnessed fall with injuries, Resident #4 was noted standing next to the injured resident's wheelchair with a pad in her hand folding it in the seat of the wheelchair. No other staff present. Resident #4 was removed from room by staff. Signed by S7EMP. Review of Resident #4's Nurse Practitioner Notes revealed the following, in part: On 04/18/2025- Resident #4 had an aggressive episode in which she attacked 3 other residents on the secured Dementia Unit. Resident #4 appears to be a danger to others as she is impulsive and frequently become aggressive despite recent change in psychotropic medications. Recent inpatient psychiatric evaluation and treatment noted. Physician Emergency Certificate (PEC) written today as Resident #4 appears to be a danger to others. Signed by S13NP. On 06/20/2025- Resident #4 continues to have intermittent agitation and aggressive behavior noted. Resident #4 continues to be aggressive with other residents, especially in the evening time, despite psychotropic medication regimen. Discussed recent behaviors with Psychiatrist.Assessment/Plan: Resident #4 with another altercation with elderly resident and nursing staff overnight. Will have Resident #4 seen at inpatient psychiatric facility. Resident #4 will be transferred to the emergency room today. Signed by S13NP. On 07/10/2025 at 9:00 a.m., an interview was conducted with S22EMP. She stated Resident #4 was on 1:1 supervision. She stated the 1:1 supervision for Resident #4 started 3-4 weeks ago, after a resident-to-resident incident. She stated she was unsure of the exact date. She stated 1:1 supervision required a staff member to be with the resident at all times. On 07/09/2025 at 5:06 a.m., an interview was conducted with S15EMP. She stated she worked the 10:00 p.m. to 6:00 p.m. shifts on the locked dementia unit. She stated Resident #4 had never been on 1:1 supervision during her shifts. She stated she went into Resident #4's room every 15-20 minutes to check on her during her shift but did not provide 1:1 supervision. On 07/09/2025 at 5:13 a.m., an interview was conducted with S16EMP. She stated she picked up a 10:00 p.m. to 6:00 a.m. shift a few times a month. She stated Resident #4 received 1:1 supervision during the day, but not during the 10:00 p.m. to 6:00 a.m. shift. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4 laying in her bed with her eyes closed. No staff was present in the room providing 1:1 monitoring. On 07/10/2025 at 9:15 a.m., an interview was conducted with S24EMP. She reviewed the staff schedules dated 05/26/2025 through 05/30/2025. She confirmed she worked the 6:00 a.m. to 2:00 p.m. shifts on the locked dementia care on those dates, and Resident #4 did not receive 1:1 supervision. She stated Resident #4 had been receiving 1:1 supervision for about 3-4 weeks, after a resident-to-resident incident. She stated 1:1 supervision required a staff member to be with the resident at all times. Throughout survey, multiple attempts were made to contact S10EMP regarding the 05/26/2025 incident with no success. On 07/10/2025 at 12:20 p.m., an interview was conducted with S11EMP. She stated she was working on the locked dementia unit on 06/02/2025. She stated Resident #1 was rolling herself down the hallways back and forth. She stated Resident #4 was sitting in the common area in a chair when she jumped up out of her chair, and quickly went to Resident #1's wheelchair, grabbed the handles, and aggressively turned Resident #1's wheelchair so that Resident #1 was facing her. She stated Resident #4 then sternly told Resident #1 to stop doing that. She stated if Resident #1 would not have had her seatbelt buckled at the time, Resident #1 would have been slung out of her wheelchair. She stated Resident #4 was not on 1:1 supervision at that time. She stated Resident #4's 1:1 supervision started a few weeks ago. She stated Resident #4 had been incredibly aggressive since she was admitted to the facility. She stated the physician had attempted to change Resident #4's medications, sent her to emergency room and Behavior Health Facility to attempt to manage her aggression but none of the interventions had been effective. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025. She stated Resident #6 was standing up talking and Resident #4 turned around told her to shut up and shoved her. She stated there was no forewarning and no triggers noted. She stated Resident #6 fell and hit her head. She stated Resident #6 stated she contacted S13NP. She stated S13NP gave an order for Tylenol for Resident #6's complaint of head pain and stated to monitor Resident #6 with neurological checks. She stated the incident between Resident #4 and #6 would be considered abuse. She stated after this incident, Resident #4 had a staff member assigned to her 1:1 monitoring for 2-3 days. On 07/10/2025 at 4:58 p.m., an interview was conducted with S8EMP. She stated she was working on 06/11/2025 at 12:21 a.m. when she found Resident #4 in an empty resident's room attempting to get in the bed. She stated Resident #4 was redirected back to her room. She stated Resident #4 was not receiving 1:1 supervision at that time. On 07/08/2025 at 1:15 p.m., an interview was conducted with S7EMP. She stated she was working on 06/16/2025. She stated she was in the front part of the hallway by the nurses' station around 2:50 p.m. and heard a scream. She stated when she entered the room, she saw Resident #1 lying on her left side on the floor by the bed, in a fetal position. She stated Resident #4 was standing at the end of the bed next to Resident #1's wheelchair with no staff members present and a seat pad was in Resident #4's hands. She stated she assessed Resident #1 and then noticed Resident #1 had a large hematoma on the left side of Resident #1's head starting at the hairline and extending to her cheekbone and Resident #1's right knee was swollen. She stated Resident #1 was crying. She stated she called Administration and informed them she needed assistance immediately and there had been an unwitnessed incident. She stated Resident #1 was transferred to the hospital and her family was notified of the incident. She stated she called Resident #1's family to check on her while she was in the hospital and was told Resident #1 had a broken Right Femur and multiple other injuries. She stated the family told her she was not a candidate for surgery and was placed on hospice for comfort measures. She stated Resident #4 was supposed to be receiving 1:1 supervision prior to 06/16/2025 but was not. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was familiar with Resident #1 and was assigned to her on 06/16/2025. She stated on 06/16/2025, the nurse called out from a resident's room for assistance, and she went into the room. She stated Resident #1 was lying on the ground, on her left side, in front of Resident #1's wheelchair. She stated Resident #4 was touching Resident #1's wheelchair, and Resident #4 was holding the seat pad of Resident #1's wheelchair. She stated Resident #4 was supposed to have been receiving 1:1 supervision due to her aggressive behavior at the time of Resident #1's incident on 06/16/2025 but was not. On 07/10/2025 at 11:30 a.m., an interview was conducted with S21EMP. She stated Resident #4 had several resident-to-resident incidents. She stated Resident #4's 1:1 supervision had been inconsistent up until 06/17/2025, after Resident #1's incident. She stated she could not keep the residents safe when Resident #4 was not on 1:1 supervision. On 07/11/2025 at 12:20 p.m., an interview was conducted with S29CP. She stated she was responsible for updating care plans for incidents which occurred in the facility. She stated all incidents were discussed in the morning meeting with administrative staff, then S3ADON would tell her what intervention to add to the care plans. She stated the morning meetings consisted of S1ADM, S2DON, S3ADON, S17SS, and the care plan nurses. She stated S3ADON told her to add the 1:1 supervision intervention to Resident #4's care plan on 05/26/2025. She stated she was not responsible to ensure the intervention was implemented. She stated S3ADON was responsible for implementing care plan interventions for incidents. On 07/11/2025 at 12:28 p.m., an interview was conducted with S3ADON. She stated she was responsible for the facility's incidents. She stated incidents were talked about in the morning meeting with administrative staff. She stated when an intervention was added to a care plan, such as 1:1 supervision, one of the administrative staff who were in the morning meeting would relay the information to the floor staff. She stated there was no one staff responsible for this. She stated Resident #4 was placed on 1:1 supervision from 05/26/2025-06/09/2025, then ongoing on 06/09/2025. She stated she was unsure which staff member relayed this information to the Resident #4's direct care staff. She stated she did not know why Resident #4's 1:1 supervision was not implemented at that time, but it should have been. On 07/10/2025 at 2:05 p.m., an interview was conducted with S2DON. She stated S1ADM was responsible for monitoring Resident #4 to ensure she received 1:1 supervision. On 07/10/2025 at 1:28 p.m., an interview was conducted with S1ADM. He stated Resident #4 had a lot of aggressive behaviors. He stated Resident #4 would be calm then in a flip of a switch become aggressive. He stated Resident #4's triggers could not be determined. He stated after an incident on 05/26/2025 with another resident, Resident #4 was placed on 1:1 supervision. He stated Resident #4 did well on 1:1 supervision and it was removed on 06/09/2025. He stated after the 1:1 supervision was removed, Resident #4 had another incident on 06/09/2025, so ongoing 1:1 supervision was initiated. He stated he was aware on 06/16/2025, Resident #1 was found in front of Resident #1's wheelchair lying on her left side, with swelling to the left side of Resident #1's face and right knee. He stated he was aware Resident #4 was found to be beside Resident #1's wheelchair at that time. He confirmed Resident #4 should have been receiving 1:1 supervision and was not at the time of the incident with Resident #1. He confirmed Resident #4 should have been receiving 1:1 supervision beginning on 05/26/2025. He stated when a resident was on 1:1 supervision, he expected staff to be with the resident when the resident was awake and out of their room. The Immediate Jeopardy was removed on 07/11/2025 at 3:23 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Plan of RemovalF689- The facility allegedly failed to ensure staff provided adequate supervision to resident #4. A cognitively impaired resident with known physically and verbally abusive behavior.1. All residents who reside in the facilities secure unit have the potential to be affected by the alleged deficient practice.a. Starting on 07/11/2025, the DON will review behavior notes daily and ensure any resident needing 1:1 supervision is appropriately placed on the monitoring. Review will continue ongoing until completed.b. As of 07/11/2025, there currently is one resident on 1:1 supervision.2. Measures put in place to ensure the alleged deficient practice will not recur are:a. Resident was placed on 24 hour one-to-one staff supervision on 07/09/2025 at 5:00 p.m. and will remain on one-to-one supervision until the facility is able to find placement at another facility.b. Staff in-service initiated per Staff Developer on 07/10/2025 on abuse prevention, appropriate resident supervision and one-to-one supervision procedures. In-service will be done with all staff prior to starting their next scheduled shift and will be ongoing until completed. No staff member will be allowed to work until training has been completed.3. The facility plans to monitor its performance to ensure solutions are achieved and sustained by (monitoring started on 07/11/2025 as observed by Surveyors):a. Starting on 07/11/2025, the NFA or designee will perform facility rounds at random 3 times a week to ensure residents are receiving appropriate supervision. Facility rounds will occur ongoing until completed.b. Starting on 07/11/2025, the NFA or designee will perform facility rounds at random 3 times a week to ensure residents on 1:1 supervision is being monitored appropriately. Facility rounds will occur ongoing until completed.c. Starting on 07/11/2025, DON or designee will review behavior notes daily to ensure residents are assessed and supervised appropriately ongoing until completed.d. Ongoing issues to be discussed in weekly high-risk meeting with IDT. d. Failure to comply will result in progressive disciplinary action. 4. The likeliness of harm to any resident due to supervision no longer existed as of 07/11/2025 when Resident #4 was placed on 24 hour 1:1 supervision. The facility will ascertain substantial compliance by 07/11/2025.

Based on interviews and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring was implemented to ensure corrective actions were put in place after identifying issues with inadequate supervision related to resident-to-resident incidents. This deficient practice had the potential to affect a census of 167 residents. Findings: Review of the facility's policy dated 04/28/2025 and titled, Quality Assurance and Performance Improvement (QAPI) Plan, revealed the following, in part:Our QAPI plan addresses:i. Clinical Care-monitor Quality Measures, internal tracking tools for falls, medication errors, pressure ulcers, incident reports and infection reports. Areas identified will be addressed via Performance Improvement Projects. II. Governance and LeadershipThe Administrator is responsible and accountable for developing, leading and closely monitoring the QAPI program. Review of the facility's Quality Improvement Corrective Action Plan dated 05/20/2025, revealed the following, in part:Identifiable Problem:Facility failed to ensure that each resident received adequate supervision to prevent alleged resident-to-resident incidents. Recommended Plan of Action: Corrective action taken by: e. Facility sent out Resident #4 for evaluation and treatment. f. Facility increased supervision of Resident #4 upon return. 2. All residents have the potential to be affected by the alleged deficient practice. 5. Corrective action will be completed by 07/04/2025.Recurring Problems: Resident had another occurrence on 05/26/2025 therefore placed resident on 1: 1 monitoring. Review of the facility's Follow-up Form dated 05/21/2025-07/04/2025, and completed by S1ADM, revealed the following: 05/21/2025-No behaviors related to wandering. 05/22/2025-No behaviors related to wandering. 05/23/2025-No behaviors related to wandering. 05/26/2025-Resident #4, Resident noted with behavior-resident placed on 1:1. 05/27/2025-Resident #4, 1:1 in place. Currently sitting with staff no issues. 05/28/2025-Resident #4, No new concerns noted. 06/03/2025-Resident #4 noted pushing another resident in chair. 06/06/2025-Resident #4, Minimal concerns noted since 1:1. Consider removing 1:1 effective on 06/09/2025 if no concerns over weekend. 06/09/2025-Resident #4. No concerns noted over weekend. Discontinue 1:1. Will continue to monitor. 06/10/2025-following discontinuance of 1:1, Resident #4 had incident with another resident. Sent out for evaluation. 1:1 reinstated upon return-sent out referral for alternative placement. No other wandering issues noted/observed. QA to be extended to ensure continued compliance. 06/12/2025-No wandering behaviors06/16/2025-Resident #1 had a fall. Resident not previously classified as wandering due to only being ambulatory by wheelchair. 06/17/2025-No issues/concerns noted. 06/18/2025-No concerns. 06/20/2025-Resident #4. Negative behavior noted. Referred physician to review medications. Increase activities in resident room. Additional education provided to staff. Physician increased medication and referred to psychiatric physician for additional thoughts. Spoke with NFA at another local facility about transferring to facility possibly Monday. Attempting to send to behavioral hospital. 06/25/2025-Resident #4 out of facility. NFA virtually observed common areas no concerns noted. 06/26/2025-Resident #4 returning. NFA virtually observed common areas. No concerns noted. Resident #4 noted to be 1:1 upon return. 06/27/2025-Resident #4 Behavior. Resident eating breakfast quietly at table. CNA assigned 1:1 was seated beside her and was attentive. 07/02/2025-No issues. 07/03/2025-No issues. 07/04/2025-No issues. Continue 1:1 until alternative placement achieved. Staff will continue to document 1:1 on designated forms. Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's current Care Plan revealed the following, in part:Intervention: 1:1 observation 05/26/2025-06/09/2025. Sent to ER for evaluation/treatment dated 06/09/2025. 1:1 close monitoring initiated on 06/09/2025. Review of Resident #4's 1:1 monitoring tools revealed documentation of 1:1 monitoring by staff began on 06/20/2025. Review of Resident #4's Nurse's Notes revealed the following, in part:On 06/02/2025 at 3:23 p.m. -Resident approached Resident #1, who she saw was wheeling herself in her wheelchair down the hallway and grabbed the handles of the wheelchair swinging Resident #1 around with force and trying to push her down the hallway. Staff immediately redirected Resident #4 away from Resident #1 and encouraged Resident #4 to not worry about the other resident, Resident #4 stated she just makes me so angry Staff was able to redirect resident out of situation. Will continue to monitor. Signed by S11EMP. On 06/11/2025 at 12:21 a.m. -Resident #4 found up and in another room attempting to get in bed. Brought back to her room and assisted into her room without incident. Will continue to monitor. Signed by S8EMP. On 6/16/2025 at 2:50 p.m. -When nurse entered the room due to an incident of another resident having an unwitnessed fall with injuries, Resident #4 was noted standing next to the injured resident's wheelchair with a pad in her hand folding it in the seat of the wheelchair. No other staff present. Resident was removed from room by staff. Signed by S7EMP. On 07/10/2025 at 9:15 a.m., an interview was conducted with S24EMP. She reviewed the staff schedules dated 05/26/2025 through 05/30/2025. She confirmed she worked the 6:00 a.m. to 2:00 p.m. shifts on the locked dementia care on those dates, and Resident #4 did not have 1:1 monitoring. She stated Resident #4 had been receiving 1:1 monitoring for about 3-4 weeks, after a resident to resident incident. She stated 1:1 monitoring required a staff member to be present with the resident at all times. On 07/10/2025 at 12:20 p.m., an interview was conducted with S11EMP. She stated she was working on the locked dementia unit on 06/02/2025. She stated Resident #1 was rolling herself down the hallways back and forth. She stated Resident #4 was sitting in the common area in a chair when she jumped up out of her chair, and quickly went to Resident #1's wheelchair, grabbed the handles, and aggressively turned Resident #1's wheelchair so that Resident #1 was facing her. She stated Resident #4 was not on 1:1 monitoring at that time. She stated Resident #4's 1:1 monitoring started a few weeks ago. She stated Resident #4 had been incredibly aggressive since she was admitted to the facility. She stated the physician had attempted to change her medications, sent her to emergency room and Behavior Health Facility to attempt to manage her aggression but none of the interventions had been effective. On 07/10/2025 at 4:58 p.m., an interview was conducted with S8EMP. She stated she was working on 06/11/2025 at 12:21 a.m. when she found Resident #4 in an empty resident's room attempting to get in the bed. She stated Resident #4 was redirected back to her room. She stated Resident #4 was not on 1:1 monitoring at that time. On 07/08/2025 at 1:15 p.m., an interview was conducted with S7EMP. She stated she was working on 06/16/2025. She stated she was in the front part of the hallway by the nurses' station around 2:50 p.m. and heard a scream. She stated when she entered the room, she saw Resident #1 lying on her left side on the floor by the bed, in a fetal position. She stated Resident #4 was standing at the end of the bed next to Resident #1's wheelchair with no staff members present and a seat pad was in her hands. She stated Resident #4 was supposed to be 1:1 monitoring prior to 06/16/2025 but was not. On 07/10/2025 at 11:30 a.m., an interview was conducted with S21EMP. She stated Resident #4 had several resident to resident incidents. She stated Resident #4's 1:1 monitoring had been inconsistent up until 06/17/2025, after Resident #1's incident. She stated she felt like she could not keep the residents safe when Resident #4 was not on 1:1 monitoring. On 07/09/2025 at 5:06 a.m., an interview was conducted with S15EMP. She stated she worked the 10:00 p.m. to 6:00 a.m. shifts on the locked dementia unit. She stated Resident #4 had never been on 1:1 monitoring during her shifts. She stated she went into Resident #4's room every 15-20 minutes to check on her during her shift but did not provide 1:1 monitoring. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4 laying in her bed with her eyes closed. No staff was present in the room providing 1:1 monitoring. On 07/11/2025 at 9:00 a.m., an interview was conducted with S1ADM. He confirmed he was responsible for the 1:1 QAPI monitoring for Resident #4 and ensuring she was being monitored. He stated she was placed on 1:1 monitoring from 05/26/2025-06/09/2025, then placed back on 1:1 ongoing monitoring on 06/09/2025. He stated staff documentation of Resident #4's 1:1 monitoring began on 06/20/2025, when the facility received 1:1 monitoring tools. He was made aware of interviews with staff who stated Resident #4 did not receive consistent 1:1 until after 06/16/2025. He stated staff must have been confused because Resident #4 was on 1:1 monitoring beginning 05/26/2025. He further confirmed Resident #4 did not have 1:1 monitoring on 06/16/2025 at the time of Resident #1's incident and should have.

Based on observations, interviews, and record review, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1 (#3) of 2 (#2 and #3) residents reviewed for falls. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed the resident had diagnoses which included Alzheimer's Disease and repeated falls. Review of Resident #3's Quarterly MDS with an ARD of 02/18/2025 revealed a BIMS of 03, which indicated severe cognitive impairment. Review of Resident #3's Physician Orders revealed the following: Fall mat X 2 at bedside for safety, every shift, prescriber written, active, start date 07/01/2024 Review of Resident #3's current Care Plan revealed the following: Problem: The resident is at risk for falls r/t Alzheimer's dementia, history of falls. Intervention: Fall mat x2 at bedside for safety. On 05/06/2025 at 10:18 a.m., an observation was made of Resident #3's room. One fall mat was observed at bedside. On 05/07/2025 at 9:42 a.m., an observation was made of Resident #3's room. One fall mat was observed at bedside. On 05/07/2025 at 9:47 a.m., an interview was conducted with S3LPN. She stated she cared for Resident #3. She confirmed one fall mat was present at bedside and there was not a second fall mat in the room. On 05/07/2025 at 10:00 a.m., an interview was conducted with S4CNA. She stated she cared for Resident #3. She confirmed there was one fall mat at bedside. She stated she was unware of the need for a second fall mat. On 05/07/2025 at 11:50 a.m., an interview was conducted with S2ADON. She stated she was responsible for implementing fall interventions for all residents in the facility. She stated Resident #3 had fall interventions in place due to a history of falls. She stated if the care plan included two fall mats then two fall mats should have been at the bedside. On 05/07/2025 at 12:49 p.m., an interview was conducted with S1DON. She stated if Resident #3 was care planned to have 2 fall mats and had an order for 2 fall mats, there should have been 2 fall mats at the bedside.

Based on observation, interviews, and record review, the facility failed to protect the residents right to be free from verbal abuse for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse by S4CNA and S5CNA. This deficient Practice resulted in an Immediate Jeopardy situation on 01/22/2025 at 4:52 p.m. for Resident #1, a cognitively impaired resident who required staff assistance for care, when S5CNA was observed in video footage verbally abusing Resident #1 while providing care. On 01/29/2025 at 3:51 p.m., S4CNA was observed in video footage verbally abusing Resident #1 while providing care. On 01/30/2025 at 3:46 p.m., S4CNA was again observed in video footage verbally abusing Resident #1 while providing care. S4CNA and S5CNA continued to provide care to Resident #1 and other residents in the facility until S1ADM was notified of an allegation of abuse on 02/04/2025. It could be determined a reasonable person would suffer serious psychosocial harm after being repeatedly verbally abused by staff who the resident was dependent upon to provide care. The facility implemented corrective actions on 02/04/2025, which were completed on 02/21/2025 prior to the State Agency's investigation on 02/24/2025, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's policy titled, Abuse- Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part: Purpose: Each resident has the right to be free from abuse. Policy: To provide a safe, abuse-free environment for all residents. I.) Types of abuse: 1. Verbal Abuse- is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend, or disability. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, Alzheimer's Disease and Dementia. Review of Resident #1's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2024, indicated the resident was unable to conduct a Brief Interview of Mental Status (BIMS) due to the resident rarely or never being understood. Further review of section H0300 and H0400 revealed Resident #1 was frequently incontinent of bowel and bladder. An interview was conducted with Resident #1's Representative (RP) on 02/24/2025 at 3:26 p.m. She stated on 02/04/2025, she observed body language to suggest yelling and chastising from staff through a camera installed in Resident #1's room that was concerning for abuse. She stated she contacted S7SW and reported the abuse. She stated she had a meeting with S1ADM and S7SW on 02/06/2025 to show them the video and audio footage. She reported S1ADM confirmed S4CNA and S5CNA were the accused staff members. Resident #1's RP reported Resident #1 would have felt scared, intimidated or anxious from the verbal abuse if she had not been diagnosed with Dementia. An interview was conducted with S7SW on 02/25/2025 at 1:44 p.m. S7SW stated she received a call from Resident #1's RP on 02/04/2025 around 2:00 p.m. stating staff were verbally abusing Resident #1. S7SW reported Resident #1's RP brought the video footage to the facility on [DATE] for S1ADM and S7SW to observe. S7SW confirmed S4CNA and S5CNA were heard yelling and chastising Resident #1 in the video and it was considered verbal abuse. She stated any reasonable person would feel hurt, scared, or isolated after verbal abuse. She further confirmed a victim of verbal abuse could have psychosocial outcomes such as agitation, restlessness or wandering. S7SW confirmed receiving a verbal in-services on 02/07/2025 on abuse, neglect, abuse reporting, consequences of failing to report abuse and consequences if abuse was substantiated. An observation of video footage of Resident #1's room was conducted on 02/25/2025 at 4:00 p.m. with S1ADM. The video footage with audio was reviewed and revealed the following: 01/22/2025 at 4:52 p.m., S5CNA entering Resident #1's room, turning on the lights and yelling at Resident #1 who was in bed, stating in a demeaning tone, I know you did not take those pants off. Resident #1 responded in a confused tone, Did I take these pants off? S5CNA yelled in an aggressive and chastising tone at Resident #1, Yes, you took those pants off, and oh you're in trouble! S5CNA pulled the covers off Resident #1 aggressively and walked toward the room entrance doorway yelling in the hallway loudly, Y'all, she took her pants off again! Resident #1 remained in bed mumbling incoherently in a sadden tone. 01/29/2025 at 3:51 p.m., S4CNA entered Resident #1's room with gloves on and a brief in her hand. Resident #1 was in bed. She yelled aggressively at Resident #1, Come over here. Get up with all that sh*t on the bed. Look at all that sh*t. S4CNA yelled demandingly several more times at the resident to get up. Resident #1 remained lying in bed and confusingly asked, Who did that? S4CNA yelled, chastising Resident #1, You did that sh*t on the bed! S4CNA assisted Resident #1 into a sitting position, Resident #1 stood from the bed and responded I'm hurting while ambulating to the bathroom. S4CNA yells at Resident #1, Go to the bathroom! 01/30/2025 at 3:46 p.m., S4CNA entered Resident #1's room and turned the light on. She began yelling at Resident #1 who was lying in bed, Why you pulling those clothes off, why you pulling those clothes off? S4CNA yells not uh, indicating no in a scolding tone to Resident #1. Resident #1 was mumbling incoherently and still lying in bed. S4CNA then yells in a disrespectful demanding tone, Let's get up as she attempted to abruptly get Resident #1's pants back on her while she was lying in bed. S4CNA in a rough demanding tone stated Get up, let's go! Once Resident #1's pants were on and Resident #1 stood next to the bed, the CNA yelled in a demeaning tone, I just cleaned up this sh*t. You aint gonna do that on me! Resident #1 stood in front of the entrance to the bathroom and S4CNA yelled in a demanding tone, Sit down, put your shoes on! Resident #1 sat back on her bed and attempted to lay down. S4CNA tells her in an irritated voice, not uh (indicating no), put your shoes on. Got sh*t on all this! An interview was conducted with S1ADM on 02/25/2025 at 4:30 p.m. S1ADM stated he was first aware of the allegations of abuse on 02/04/2025 around 2:00 p.m. He stated he immediately suspended the accused staff until investigation was completed and opened a SIMS report. He confirmed he observed video footage from Resident #1's representative on 02/06/2025. He stated S4CNA and S5CNA were immediately terminated after observation of the video footage with audio revealing the CNAs verbally abused Resident #1. He stated he contacted the ombudsman and law enforcement and a report was filed. He stated 100% of the facility's staff were in-serviced on abuse, neglect, abuse reporting, consequences of failing to report abuse and consequences if abuse was substantiated. S1ADM stated he and S2AADM interviewed all residents which S4CNA and S5CNA care for. He stated no residents had signs of abuse, and no concerns arose from the interviews. He reported S2AADM was interviewing three residents per week for four weeks to inquire if residents had experienced abuse or witnessed abuse in the facility. He confirmed any resident who was a victim of verbal abuse could be frightened or perturbed. Review of the facility's special care form revealed S2ADDM had monitored three residents a week for abuse in the facility beginning 02/10/2025 which would be completed in four weeks. Throughout the survey from 02/24/2025 through 02/26/2025 observations, record reviews, staff interviews revealed they received training on the facility's abuse policies and procedures, reporting of abuse, consequences of not reporting abuse and consequences if abuse was substantiated. Interviews revealed staff were knowledgeable of the types of abuse and how and when, and why to report abuse to administration immediately. The facility had implemented the following actions to correct the deficient practice: 1. Corrective action taken by: a. Removed accused employees from resident care and suspended pending investigation. b. Contacted Ombudsman to provide facility additional in-servicing/training. c. All staff in-serviced regarding abuse, caring for resistant and combative residents and signs and symptoms of staff burnout. The following topics are to be covered: i. Types of abuse: mental, physical, verbal, misappropriation of funds and neglect. ii. Abuse reporting; facility staff's responsibility to report immediately to the administrator. Administrator's responsibility to report to State Agency and the local authority the timeframes for reporting. iii. Consequences for failing to report abuse or suspected abuse. iv. Consequences if allegation is substantiated v. Abuse investigations require the immediate suspension vi. Caring for resistant and combative residents vii. Signs and symptoms of staff burnout **In-servicing began on 02/04/2025 and completed on 02/19/2025** 2. All residents have the potential to be affected by the alleged deficient practice. 3. The measure that will be put in place or a system change that will be made to ensure that the deficient practice not recurred are: a. Accused staff members were terminated. b. All residents on Hall A were interviewed by Assistant Administrator and Social Services Director on 02/07/2025. c. Corrective action plan to be initiated requiring the administrator or designee to interview 3 residents per week starting 02/10/2025. During this interview the administrator or designee is to inquire whether the resident has experienced abuse or witnessed abuse while living at the facility. The interviews are to be recorded on a special care form. Interviews are to be conducted for 4 weeks or until substantial compliance is achieved. The outcomes of the interviews are to be discussed in the daily stand-up meeting with the interdisciplinary team. The interdisciplinary team is to discuss corrective action plan weekly in the Quality Assurance Committee meeting. d. The Director of Nursing or designee will observe staff's provision of peri-care and/or dressing, for signs or symptoms of abuse, of cognitively impaired and/or nonverbal residents, no less than 5 times per week for a minimum of 4 weeks starting week of 02/10/2025. The observations are to be recorded on a special care document. The special care document is to be reviewed in the daily stand up meeting with the interdisciplinary team. The interdisciplinary team is to review the corrective action plan weekly in the quality assurance committee. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: an interdisciplinary team to review the outcomes of audits in the weekly Quality Assurance Committee. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: a. Interdisciplinary team to review the outcomes of audits in the weekly Quality Assurance Committee meeting to ensure continued compliance. b. Quality Assurance Committee will continue to meet weekly to discuss audits until substantial compliance is achieved and quarterly thereafter. 5. Corrective action will be completed by 02/21/2025.

Based on observation, interviews, and record reviews, the facility failed to ensure a resident's right to be free from mental abuse for 1 (#8) of 5 (#8, #76, #101, #102, and #146) residents reviewed for abuse. The facility failed to ensure a resident was free from mental abuse when S18CNA took video of the resident while not fully clothed in the shower room. This resulted in an actual harm on the morning of 09/14/2020 when S18CNA used her cellular phone to video record Resident #8 in the shower room while she was attempting to put on Resident #8's brief and pants. S18CNA told Resident #8 if she did not comply with getting dressed, she was going to show the video to administration. This resulted in Resident #8 being emotionally upset, crying loudly, and taking a long time to calm down. Findings: Review of the Facility's Abuse Prevention and Prohibition Policy and Procedure revealed, in part: Purpose - each resident has the right to be free from abuse. Procedure II. 4. Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Examples - Taking or using photographs or recordings in any manner that would demean or humiliate a resident regardless of whether the resident provided consent and regardless of the resident's cognitive status. This would include, but is not limited to, photographs and recordings of residents that contain nudity, bathing, showering, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part without the resident's face, and showing the resident in a compromised position. Resident #8 was admitted to the facility on [DATE] with diagnoses, which included [CONDITION(S)], [CONDITION(S)], Muscle Wasting and Atrophy, [CONDITION(S)], Depressive Episodes, and Abnormalities of Gait. Review of the quarterly MDS with an ARD of 10/06/2020 revealed Resident #8 had a BIMS of 15, which indicated she was cognitively intact. An observation and an interview was conducted with Resident #8 on 10/13/2020 at 12:58 p.m. She stated S18CNA used her personal cellular phone to take video of her while she was not dressed in the shower room. Resident #8 stated S18CNA was being mean to her and would not adjust the water to a comfortable temperature. She stated she was sitting naked in her wheelchair with no covering over her. She stated S18CNA attempted to get her to stand up, but she could not stand up. She stated S18CNA then told her she was taking video of her. During the interview, Resident #8's voice elevated and quivered as she spoke of the incident with S18CNA. She was observed with tears in her eyes. She stated after the shower was over, she cried. She stated it made her feel bad and embarrassed that S18CNA took video of her when she was naked. She stated she told S6SS what had happened. An interview was conducted with S6SS on 10/14/2020 at 9:24 a.m. She stated Resident #8 was cognitively intact, very smart, and had a great memory. She stated Resident #8 was aphasic, but could make herself understood if she was given time. She stated on 09/14/2020 Resident #8 was found by a staff member sitting in the hall and crying loudly. She stated the staff member brought the resident to her office. She stated Resident #8 was very upset and crying. She stated when Resident #8 gets upset she is extremely loud and hard to understand. She stated by the time Resident #8 made it to her office a lot of staff were coming to check and see what was wrong. She stated it took a long while to calm the resident enough to understand what was upsetting her. She stated Resident #8 explained S18CNA took her to the shower room that morning. She stated S18CNA turned the water on too cold and then turned the water too hot. She stated the CNA did this a few times. She stated Resident #8 said she videoed me. S6SS stated she asked Resident #8 how she knew she was being videoed. Resident #8 said S18CNA told her and she could see herself on the screen of the phone as it was recording. She stated S18CNA told Resident #8 she was going to show the video to S1ADM. She stated Resident #8 reported she was sitting naked in the shower room and S18CNA propped the phone up out of the resident's reach. She stated the phone was facing the resident so she could see her image in the screen. She stated she reported this to S2AADM. She stated Resident #8 reported the exact same thing to him. Review of Resident #8's Grievance Form dated 09/14/2020 revealed, in part: Summary of Complaint - Resident #8 stated during her morning shower on 09/14/2020, the water temperature was too cold. S18CNA raised the water temperature and it was then too hot. Resident #8 also stated S18CNA filmed her without her consent. Steps Taken to Investigate - S2AADM interviewed Resident #8. S1ADM and S2AADM interviewed S18CNA and asked to view her phone. Summary of Pertinent Findings - Resident #8's account of what took place was consistent with the account given to the social worker. S18CNA's phone revealed film was taken of Resident #8. Statement of Final Disposition - The complaint was confirmed. Review of the Employee Disciplinary Action Form dated 09/14/2020 revealed, in part: S18CNA Employee failed to follow policy on refraining from taking photos/[NAME] of a resident. Warranted immediate termination. An interview was conducted with S8LPN on 10/14/2020 at 11:12 a.m. She stated S18CNA had been terminated for taking video of Resident #8. She stated administration informed her S18CNA took video of Resident #8 because the resident was being difficult and the CNA was trying to protect herself. She confirmed taking pictures of a resident in the shower without clothes on was abuse. An interview was conducted with S2AADM on 10/14/2020 at 11:29 a.m. He stated he was made aware of Resident #8's allegation of S18CNA taking pictures of her without clothes on in the shower room on 09/14/2020 by S6SS. He stated Resident #8 was extremely distraught. He stated he and S6SS interviewed Resident #8 and she told the same story to both. He stated Resident #8 told him before the shower began S18CNA said I am going to put my phone right here and record you so I can show my supervisor how you are acting. He stated S18CNA reported Resident #8 was hollering and the she told the resident she was going to record her behavior. He stated he had not seen the video footage of Resident #8. He stated S1ADM told S18CNA to delete the video. He denied putting any increased monitoring into place after the incident occurred. He confirmed staff had not received any abuse education specific to the incident on 09/14/2020 and no monitoring was in place. An interview was conducted with S1ADM on 10/14/2020 at 11:59 a.m. He stated he was made aware of the incident with Resident #8 on 09/14/2020. He stated S18CNA confimred she performed a shower on Resident #8 and the resident was exhibiting behaviors. He stated after S18CNA got the resident dressed she told the resident she was going to video her. He stated he viewed the video and it lasted about 5 seconds. He stated it showed a fully dressed Resident #8 sitting in her wheelchair with no behaviors. He stated he personally deleted the video off S18CNA's phone. He stated an in-service was conducted with staff reminding them that they could not take pictures or videos of residents. He stated after the incident he monitored staff by walking up and down the halls to see if staff were using phones while providing care. He stated he monitored the staff's phone use for several days. He stated there was no monitoring or supervision done in the shower rooms. He stated he had not been made aware Resident #8 alleged she was not dressed in the video from the shower room. An interview was conducted with S18CNA on 10/14/2020 at 12:19 p.m. She stated the morning of 09/14/2020 she brought Resident #8 to the shower room. She stated Resident #8 became combative with her while in the shower room. She stated after the shower Resident #8 was sitting in her wheelchair. She stated she was trying to get the resident dressed. She stated the resident allowed her to put her shirt on. She stated when she tried to stand the resident up to put her brief and pants on the resident started being combative. She stated she propped her phone up facing the resident and told Resident #8 she was recording her and if she did not comply, she was going to show administration the video. She stated later in the day S1ADM called her into his office and asked to look at her phone. She stated it was a short video, but you could see Resident #8's face and also see an image of Resident #8 without a brief or pants on.

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure: 1. Staff did not emotionally abuse a resident by taking pictures of the resident and threatening to show the pictures to others in administration (#8); 2. HR department followed up on Criminal Background checks for new employees (S18CNA); and 3. A resident with inappropriate behaviors was supervised by staff and not be allowed to wander throughout the facility and kiss non-cognitive female residents. This resulted in an actual harm on the morning of 09/14/2020 when S18CNA used her cellular phone to video record Resident #8 in the shower room while she was attempting to put on Resident #8's brief and pants. S18CNA told Resident #8 if she did not comply with getting dressed, she was going to show the video to administration. This resulted in Resident #8 being emotionally upset, crying loudly, and taking a long time to calm down when discussing the incident. Findings: Cross Reference: F 600 F 609 F 610 F F689 Review of S18CNA's Criminal Background check dated 09/02/2020 revealed, in part: 09/12/2019, charge R.S. 14:93.3 Cruelty to the Infirmed Disposition not provided in the report. Review of a handwritten note in S18CNA's employee file revealed, in part: Spoke with Clerk of Court Office this morning regarding the charge on S18CNA. Informed on 08/13/2020 it was changed to [NAME] Prosequi. S1ADM extended the probation period for S18CNA to get the documents since we were able to get the above information. Signed by S28HR An interview was conducted with S28HR on 10/14/2020 at 10:12 a.m. She reviewed S18CNA's criminal background report back with a charge of R.S. 14:93.3 Cruelty to the Infirmed. She stated the facility usually required a written disposition of barring changes, but in this case, the facility accepted a verbal confirmation from the Clerk of Court because they needed to speed the process up. She explained the facility was short staffed and needed CNAs at the time. She stated S1ADM instructed her to hire S18CNA without a written disposition. She stated she instructed S18CNA to provide a written copy of the disposition to her, but she never received one. She stated she would usually follow up within 3 to 4 days to get the written disposition, but in this case forgot and did not think about it again until the employee was terminated. An interview was conducted with S2AADM on 10/14/2020 at 11:29 a.m. S2AADM confirmed Resident #8 made him aware of the allegation that S18CNA took video of her while she was not dressed in the shower room. S2AADM confirmed he assisted with the investigation and conducted and in-service with the CNA staff reminding them they are not allowed to video the residents. He stated S8LPN instructed the CNA staff to get help from other staff if they were dealing with a difficult resident. He denied any further training or monitoring of the staff. He stated, on 09/14/2020, Resident #8 was being difficult and hollering at S18CNA. He explained S18CNA then told Resident #8 she was going to video her and show administration if the resident did not behave. He stated he was not aware S18CNA had a charge of Cruelty to the Infirmed. He stated employees were not supposed to work with the residents before the facility received the written disposition of charges. An interview was conducted with S1ADM on 10/14/2020 at 11:59 a.m. He explained the facility typically gets a written disposition of charges completed prior to allowing staff to work. He stated in the case of S18CNA, HR contacted the clerk of court and received a verbal disposition regarding the Charge of Cruelty to the Infirmed. He confirmed the facility received a verbal disposition and it was acceptable to allow S18CNA to work with the residents. He explained on 09/14/2020 he was informed S18CNA had showered Resident #8, and the resident began having behaviors while still in the shower room. He said S18CNA then told Resident #8 she was going to video her. He stated he was not told Resident #8 alleged she was not dressed in the video. He stated an in-service was conducted with staff making sure they knew it was not acceptable to video residents. He stated he increased monitoring for several days by walking the halls and observing staff for telephone use while providing care to the residents. He confirmed there was no increased monitoring in the shower rooms or interviews conducted with other staff or residents to determine if similar incidents had occurred. He stated he was not concerned emotional or mental abuse had occurred because Resident #8 seemed fine after he told her he terminated S18CNA. On 10/19/2020 at 2:30 p.m., an interview was held with S1ADM. He said he had provided all grievances for September 2019 - present (10/19/2020) for Residents #76, #101, and #146. He confirmed he did not have any additional investigative reports for Residents #76, #101, and #146. He confirmed he did not have any SIMS reports for September 2019 - present (10/19/2020) for Residents #76, #101, and #146. On 10/19/2020 at 3:50 p.m., an interview was conducted with S1ADM. He stated he was not notified by staff of an incident with Residents #76 and #146 on 09/03/2020. He stated he was not notified of any incidents between Residents #76, #101, and #146 on 09/12/2019. S1ADM confirmed he had no written grievance or SIMS related to Resident #76's grandson being upset after witnessing Resident #146 kiss Resident #76 on the lips on 09/03/2020. He stated he was not aware of the incident. S1ADM further stated he did not have any SIMS reports involving Resident #146 kissing Residents #76 and #101 on 09/12/2019 because he was not aware of the incident. He stated he would have reported to SIMS when Resident #146 kissed Resident #101 and stuck his hand under Resident #101's shirt exposing her on 02/26/2020, but both residents' BIMS was not high enough to make a cognitive decision. He stated social services was responsible for conducting the BIMS assessments. He said a BIMS of 13 or higher would make a resident able to consent and make their own decisions. He stated based on the BIMS scores for Residents #76, #101, and #146, they could not make a decision or consent. He stated the facility considers sexual abuse as fondling of the breast/genital area and fondling a resident in the bed. He stated scratching a resident's back was not considered sexual abuse. He stated he would not consider a peck on the lips to be sexual abuse. He stated forced contact between residents was considered abuse. He stated department heads were responsible for monitoring Resident #146's whereabouts during working hours of 8:00 a.m.-4:30 p.m., Monday-Friday. He said hours outside of 8:00-4:30 p.m., Monday-Friday, were the responsibility of the assigned direct care staff to know Resident #146's whereabouts. He stated when staff witness any concerns related to abuse, they should notify administration within 2 hours. He stated Residents #76 and #101 were mobile by wheelchairs and would require staff assistance to move around the facility. S1ADM confirmed neither Resident #76 or Resident #101 would be able to move away from Resident #146 without staff assistance. He verified no staff in-services were completed related to any of the incidents.

Based on observation, interview and record review the facility failed to ensure 1 ( #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to prevent an injury of unknown origin to Resident #6 resulting in: 1. fluid filled blisters and red opened skin with sloughed dermis and epidermis to left anterior thigh measuring 9.0 cm x 7.6 cm x 0.1cm; right anterior lateral thigh measuring 23 cm x 38 cm x 0.1cm, mid-abdominal area, measuring 15.2 cm x 15.4 cm x 0.1cm and peri area measuring 7.6 cm x 10.1 x 0.1 cm. 2. painful wound care/dressing changes 3. pain requiring scheduled pain medication every 4 hours around the clock. 4. insertion of an indwelling foley catheter 5. insertion of a peripheral intravenous catheter 6. inability to use wheel chair secondary to pain Findings: Review of the facility's Incident Log revealed an entry on Resident #6 that documented the following: Date: 01/21/14 Type of Incident: Other Reportable: No Type of Injury: Left Blank Location of Occurrence: Shower Room Disposition: In-House Treatment Status: Open Review of a Louisiana DHH Client Incident Report revealed the following: Incident ID: 6 Events: Discovered 01/21/14 7:00 am Location: Facility Entered: 01/21/14 CEO finding/determination 01/24/14 Contacts: S1ADM Incident Categories: Injury of unknown origin Findings: Facility/CEO unable to verify Accused/Allegation (left blank) Findings (left blank) Victims: Resident #6 Case Notes: Description: After shower was given areas of red and inflamed skin was noted to upper thighs and lower abdomen. Summary: Staff reports that after shower skin on bilateral upper thighs and lower abdomen to be red and inflamed with fluid filled blisters on the left upper thigh. Staff reports water temperatures to be within normal limits. Other residents that received showers that am prior to and after resident did not have any skin irritations. Treatment nurse and DON (Director of Nursing) were immediately notified as well as and the MD/NP (Medical Doctor/Nurse Practitioner). Orders were received to begin treatment on areas of concern. Task care plan was fired to monitor resident hourly. Resident has been left to air dry. Complete body audits were performed on all residents in facility, no areas of concern were noted. NP assessed resident and diagnosed with [REDACTED]. Facility has recently changed the type of brief that is used on residents. Facility wide temperature checks were made. Statements gathered from staff, interview was conducted with staff involved in am care on that date. Staff inserviced on shower protocol. Video footage reviewed and was inconclusive. Family notified of incident. Resident #6 Review of the clinical record revealed the resident was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resides on a locked unit. Review of the most recent Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 12/17/13 revealed the following: Section B: Hearing, Speech, Vision B0700 Speech Clarity - 2. No speech- absence of spoken words Section C: Cognitive Patterns C1000: Cognitive skills for daily decision making - 2. Moderately impaired-decisions poor: cues/supervision required Section G: Functional Status G0110E1: Locomotion on unit - 2. Limited assistance - resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance G0110J2: Personal hygiene: support provided - 2. One person physical assist G0120A: Bathing: self-performance - 3. Physical help in bathing activity G0600C: Mobility Devices: wheelchair (manual/electric) - Checked Review of the Care Plan revealed the following: Problem Onset: 08/11/11 I have the potential for impaired skin integrity secondary to my inc of bowel and bladder 12/20/13: My skin is clear and intact 01/21/14: I have redness and blisters to my abdomen, thighs and peri area Goal & Target Date: Abdomen, thighs and peri area resolved by 04/01/14 Approaches: 01/21/14 - Administer my antibiotic as ordered and notify MD of significant changes; treat areas as ordered; Administer my pain medications as ordered; insert my foley as ordered; check me hourly; 01/22/14 administer my IV antibiotics and IV fluids as ordered; Labs as ordered Problem Onset: 01/21/14 I have a 16 french indwelling foley catheter Goal & Target Date: I will experience no infections from catheter use - 04/01/14 Approaches: Ongoing assessment of color, clarity, and character of my urine; assess me for symptoms of urinary tract infection [MEDICAL CONDITION]; observe me for acute behavioral changes that may indicate UTI; change my catheter tubing bag as appropriate; catheter care for me every shift; evaluate my fluid intake and hydration status Problem Onset: 01/22/14 I am receiving IV medications and IV fluids for redness to my skin Goal & Target Date: I will suffer minimal to no complications from IV medications 04/01/14 Approaches: Monitor my IV site every shift; administer my medication as ordered; monitor my vital signs as ordered by my physician, change my IV tubing per protocol Review of Departmental Notes for Resident #6 revealed the following: 01/21/14: 1:00 p.m Role: Nursing Category: Skin Late Entry for 8:00 am on 01/21/14: called to pt's room on secured unit to assess skin concerns. Peri-area (pelvic/vaginal site) has multiple clear fluid filled blisters noted that are intact with red open skin noted as well, total area measures approximately 7.6 cm x 10.1 cm x 0.1 cm. Assessed (L) anterior thigh site has red/open skin that measures approximately 9 cm x 7.6 cm x 0.1cm with small amount of bleeding as well noted to inner groin. Right anterior lateral thigh assessed, total area measures 23 cm x 38 cm x 0.1cm and is red open skin. Assessed mid-abdominal area, site measures 15.2 cm x 15.4 cm x 0.1cm with red/open skin noted as well. All areas are open red skin (Dermis/Epidermis Sloughed Off). All these affected areas appear moist and pt shows non-verbal signs of pain when areas are touched. I notified the DON as well as NP on-call (S7NP); for which an oral ABX (antibiotic) was initiated as well as pain medication. See E-MAR (electronic medication administration record), Topical Silverdene cream ordered as well to be applied to site, see E-TAR (electronic treatment administration record), will continue to treat/monitor sites as ordered until they are resolved. Pt's family notified as well per DON. Signed By: S6RNT 01/21/14: 7:30 pm Role: Nursing Category: Skin Late Entry for 11:15 am on 01/21/14: 16 french indwelling catheter foley catheter placed with out difficulty; clear yellow urine noted to GU ([MEDICAL CONDITION]) bag: Pt tolerated well, will ctm (continue to monitor). Signed By: S6RNT 01/22/14: 12:09 pm Role: Nursing Category: Skin Late Entry for 8:30 am on 01/22/14: Upon assessment of open, red areas/ruptured blisters to peri-area, R/L thigh, and lower abdomen during tx change; yellow drainage noted to current dressing (saturated), small amount [MEDICATION NAME] tissue continues to slough off edges. Pt is now verbal, continuously tries to touch areas of concern and remove dressing; instructed to not do this, however Pt continues and cognitive status impairs understanding. Tx performed per E-TAR; Pt tolerated fairly well with non-verbal signs of pain noted a (grimacing/pulling away). Pt's pain medication administered. Indwelling foley catheter remains in place, Pt with tea colored urine noted to GU bag. Discussed findings with floor nurse. Floor nurse notified NP on call (S7NP); Pt. not to be sent to the hospital and no new orders given. Instructed to continue current tx in progress. Will continue to monitor. Signed By: S6RNT 01/23/14: 2:50 pm Role: Nursing Category: Skin Late Entry for 11:24 am on 01/23/14: During tx change of open, red areas/ruptured blisters to peri-area, R/L thigh, and lower abdomen; yellow drainage noted to current dressing. Superficial partial thickness loss remains present with epidermis/dermis layers continuing to slough off. Tissue continues to slough off edges as well. Areas remain beefy/red. Pt is non- verbal, she continuously tries to touch areas of concern and remove dressing; instructed to not do this, however Pt continues and cognitive status impairs understanding. Tx performed per E-TAR; Pt tolerated tolerated poorly with non-verbal signs of pain noted a (grimacing/pulling away/grinding teeth/shivering). Pt's pain medication administered prior to tx/change...Discussed with S7NP regarding findings, No new orders given, instructed to continue current tx that is in progress...Signed By: SRNT. 01/22/14 11:03 am Role: Nursing Category: General Note New orders obtained from S7NP to start peripheral IV and hang normal saline at 100 ml/hr x one bag. 22 gauge peripheral IV inserted to (R) hand...... 2 unsuccessful attempts prior to insertion. Signed By: S5ADON. 01/22/14 11:23 am Role: Nursing Category: General Note Late Entry for 01/22/14 @ 8:30. Upon this nurse entering the room, the resident was observed lying in the supine position. Dressing to abdomen intact, and saturated with yellow drainage. T-99.1 axillary. Facial grimacing noted, skin to bilateral thighs red/open.....Signed By: S11LPN 01/22/14 11:33 am Role : Nursing Category: General Note Late Entry for 11/22/14 @ 8:56 am. S7NP notified of increased drainage, pain, and 99.1 axillary temperature. This nurse asked if resident could be sent out to the ER (emergency room ) due to assessment findings. NP stated not to send Pt to the ER at this time and continue current treatment/medication plan...Signed By: S11LPN 01/23/14 11:03 am Role: Nursing Category: General Note .....patient unable to communicate verbally, facial grimacing and shaking noted at this time. Doc (Order given by S7NP) notified of patient pain, new order given for additional [MEDICATION NAME] 5/325 to be given now...Signed by: S19LPN 01/23/14 11:28 am Role: Nursing Category: General Note Late Entry for 01/24/14 @ 8:30 am....Temp = 100.0 axillary, Tylenol 325 mg 2 caplets given.... Review of the physician orders [REDACTED]. 01/21/14 8:00 am Bactrim DS 1 tablet po BID; [MEDICATION NAME] 50 mg 1 tablet po Q 6 prn (as needed) pain 9:50 am Silverdene apply BID to affected areas 12:57 am Order Clarification: Apply Silverdene to bilateral thighs, peri-area, lower abdomen/affected areas/ BID until resolved (No Time) Insert Foley in dwelling catheter; cath care Q shift & prn 4:00 pm [MEDICATION NAME] 5/325 i po Q 6 prn pain 01/22/14 (No Time) Insert peripheral IV; NS (normal saline) @ 100 ml/hr x 1 L (liter) per peripheral IV via dial-a-flow; [MEDICATION NAME] 1 gm IV Q 24 hrs x 7 days (Dx: localized skin infection); flush peripheral IV per SASH protocol (flush with 5 ml NS & 3 u [MEDICATION NAME] after ABT); change IV site & dressing Q 3 days; [MEDICATION NAME] 5/325 mg po Q 6 H; Vanco trough prior to every 3rd dose (01/23/14 & 01/25/14) & (01/27/14) 11:00 am CBC & CMP in am of 01/23/14 5:00 pm Give additional liter of normal saline via IV run at 75 ml/ hour until finished 01/23/14 12:40 am Give one additional [MEDICATION NAME] 5/325 mg now for pain 8:39 am Discontinue [MEDICATION NAME] 5/325 tablet i po Q 6 hours for pain ; Give [MEDICATION NAME] 5/325 mg i po Q4 hours for pain All of the orders were signed by S7NP. Review of the progress notes written by S7NP revealed in part the following: 01/21/14 5:35 pm CC (chief complaint): follow rash/skin break down to thigh Physical examination: Skin: warm, dry, skin breakdown noted blister to abdomen, rt thigh/pubic region Impression/plan: 1. Blister without mention of infection: to abdomen, pubic region, rt and left thigh - now uncovered after bath, no clear etiology - i.e. allergic reaction, [DIAGNOSES REDACTED], burn, will treat with Silverdene and Bactrim DS for now. Spoke with DON, wound care about treatment plan, Will apply Vaseline type gauze daily and monitor closely of signs of infection 01/23/14 5: 22 pm CC: follow up wound to thigh Physical examination: Skin: Ulcer to to abdomen, rt thigh, left thigh Impression/plan: 1. Blister without mention of infection: to abdomen, pubic region, rt and left thigh - plans to clean daily with Silverdene/Vaseline gauze and Bactrim DS with IV vanco. Will monitor labs weekly and hydrate as needed. 01/28/14 3:10 p.m. CC: follow up wound to thigh and abdomen Physical examination: Skin: Open wound rt thigh abdomen - clean no s/s infection see et (E-TAR) note for measurement Impression/plan: Blister without mention infection: to abdomen, pubic region, rt thigh and left thigh - Pt appears comfortable, wound clean spoke with DON at length today about wound care, wound care nurse changing dressings as directed, appears to be healing well per staff, Continue antbx (antibiotics), labs reviewed. No change in treatment plan at this time. On 01/27/14 at 11:25 a.m. an observation was made of the resident lying supine in her bed with the head of the bed elevated 40 degrees. She was awake and alert but did not respond verbally when spoken to. At 11:30 a.m. an interview was conducted with S11LPN at the resident's bedside. She was asked if the resident had any wounds. She stated "yes, she has wounds on her legs and abdomen". She was asked how had the resident sustained [REDACTED]. on that day, but the wound care nurse is doing dressing changes twice a day". On 01/27/14 at 12:00 p.m. an interview was conducted with S6RNT, treatment nurse. She was asked what wounds did the resident have and what was the current treatment being provided. She stated the resident had areas on her (R) and (L) thighs and abdomen. She stated the affected areas are being cleansed with normal saline and then Silverdene cream was applied; the wounds are then covered and with [MEDICATION NAME] gauze and an ABD pad. She reported that recently the dressing changes had been changed from twice a day (BID) to daily (QD). She was asked how the resident sustained [REDACTED]. She observed fluid filled blisters and red open areas on the resident's thighs and abdomen. She stated the wounds were discovered after the resident was showered by the CNA who had bathed her. S6RNT stated she immediately notified the director of nursing (DON), the Nurse Practitioner (NP) on call and the resident's family. S6RNT was asked if the resident had pain as a result of the wounds. She stated "Yes, its painful when I have to clean the areas with normal saline". She was asked if the resident required pain medication prior to dressing changes. She stated "Yes". She was asked who had showered the resident the day of the incident. S6RNT stated "S13CNA". On 01/27/14 at 12:05 p.m. S6RNT and S4DON accompanied the surveyor to the resident's bedside to view the wounds. The surveyor and S4DON observed S6RNT carefully lift one edge of each of the 3 dressing so the wounds could be viewed. The resident showed no verbal or non-verbal signs of pain. The (R) thigh of resident #6 had a large red, rectangle, area with no visible skin covering the wound. The (L) thigh had reddened skin with 2 round areas with no visible skin . On the resident's abdomen was an area across her mid-abdomen that was red and with no visible skin. The skin to her lower abdomen was unaffected. S6RNT was asked if the open areas on the resident's thighs and abdomen had any skin covering the wounds. She stated "No". S6RNT was asked if the resident had any other areas of red, non- intact skin. S6RNT stated "No". S4DON was asked what had caused the wounds. She stated "[MEDICAL CONDITION]". On Monday, 01/27/14 at 12:50 p.m. a telephone interview was conducted with S7NP. He was asked what did he thought caused Resident #6's injury. S7NP stated "She was in the shower room and the CNA told the DON she was soiled and when she took her briefs off she was like that". "I'm not sure if it is a [MEDICAL CONDITION] or a burn, but I'm treating it like a burn". On 01/27/14 at 1:00 p.m. an interview was conducted with both S4DON and S5ADON. They were asked to explain what had happened to Resident #6 to cause the wounds to her legs, abdomen and peri area. S4DON stated on 01/21/14 at 7:30 a.m. they were called to the secured unit by S13CNA. S4DON stated that S13CNA reported that when she went to shower the resident she had loose stool on her thighs and abdomen. The CNA reported the resident's skin began to come off when she started to dry her with a towel. S4DON went on to state they looked for causes including hot water, acidic stool or bathing the resident with the disinfectant used to clean the showers. S4DON stated the disinfectant is a green liquid and the soap used on the residents is pink. S4DON stated S13CNA denied using the disinfectant chemical to bathe the resident. S4DON stated the disinfectant was removed from the showers and now only housekeeping is cleaning the showers. S4DON stated S13CNA reported having tested the temperature of the water on her arm prior to bathing the resident and the water was not hot. On 01/27/14 at 1:15 p.m. an interview was conducted with S13CNA. Both S4DON and S5ADON were present. She was asked to to describe the events of 01/21/14 related to the injuries sustained by Resident #6. S13CNA stated the resident was seated in her wheelchair with loose feces on her thighs and abdomen when she took her to the shower. She stated she checked the water temperature on her own arm prior to bathing the resident and it was not hot. S13CNA stated when she began to dry the resident she noticed the resident's skin was "coming off". She was asked if she noticed the skin coming off while she was bathing the resident and rinsing the resident. S13CNA stated "No, not until I started drying her". She was asked what did she use to bathe the resident. S13CNA stated "The pink soap". On 01/27/14 at 1:25 p.m. an interview was conducted with S6RNT. Both S4DON and S5ADON were present. She was asked to describe the events of 01/21/14 involving resident #6. S6RNT stated she was paged to the unit to view the resident's skin. She stated the resident was in bed and it was noted she had red and blistered areas to her thighs and abdomen. S6RNT stated antibiotics and pain medications were ordered and S7NP saw the resident that day. She was asked if the wounds were being measured. S6RNT stated she is measuring the wounds weekly, and tomorrow will be the second time she measures the wounds. ON 01/27/14 at 2:25 p.m an interview was conducted with S12LPN, S5ADON was present. She verified she was familiar with resident #6. She was asked if she had worked on the morning of 01/21/14. S12LPN stated "Yes, I work from 8 am to 8 pm and when I came on that morning S6RNT was already caring for the resident". She was asked what was the current care the resident was receiving. She stated the resident was on [MEDICATION NAME] daily and was receiving wound care. She reported the resident received pain medication every 4 hours around the clock. She was asked what was the resident's level of activity prior to 01/21/14. S12LPN stated the resident got up daily in her wheel chair. She was asked if the resident could propel herself using her legs. S12LPN stated "Yes, she can roll herself a little bit". She was asked if the resident had been up in her chair since 01/21/14. S12LPN stated "No, its too uncomfortable to move her". S5ADON stated "It's too painful". On 01/31/14 at 9:20 a.m. an interview was conducted with S6RNT at the resident's bedside.The resident was awake in her bed with the head of the bed elevated at 45 degrees. She was asked what the current status of the resident ' s wounds were. She stated the wounds appeared to be healing and were not draining. She stated the wounds to the peri area were healed. S6RNT gently lifted the edges of the dressings to the resident's abdomen and (R) and (L) thighs. The wounds were red in color with no visible skin covering the areas; no drainage noted. She was asked how often the facility performed body audits. S6RNT stated "Weekly body audits are performed on all residents by the nurses caring for them". She was asked if Resident #6 had any areas of non-intact skin prior to 01/21/14, the day the injuries were discovered. S6RNT stated "No". She was asked if body audits had been performed on Resident #6. She stated "Yes". Review of the resident's body audits revealed the following: Resident #6 - Skin Inspection Report 01/03/14 Skin Status: Intact Signed By: S11LPN 01/10/14 Skin Status: Intact Signed By: S12LPN 01/17/14 Skin Status: Intact Signed By: S12LPN 01/24/14 Skin Status: Skin not intact - Existing Signed By: S12LPN On 01/31/14 at 11:00 a.m. a telephone interview was conducted with S21MD, the facility's medical director and Resident #6's physician. He was asked if he had seen the resident's wounds. S21MD stated he had seen pictures of the wounds sent to him by S7NP. He was asked what had caused the injuries. S21MD stated "We don't know whether it was the shower or something else, but I am treating it like a second degree burn". On 01/31/14 at 10:10 a.m. an interview was conducted with S1ADM. He was asked what had caused the injuries to the Resident #6. He stated it was not clear how she had sustained the injuries, but several possibilities were looked at. S1ADM stated the facility looked at the possibility of hot water, use of a disinfectant chemical on the resident, spillage of hot food on the resident and timely peri care. S1ADM stated no clear cause could be determined based on their investigation and staff's statements; however steps had been taken to address all the possibilities. S1ADM stated hot water temperatures were checked, disinfectants were ordered in ready to use bottles and were to be stored in separate cabinets from the soap, video of the resident eating revealed no food spilled on her, and the staff were inserviced on the identified concerns. The resident resided on Hall "f". Review of temperatures taken on 01/22/14 of the Hall "f" shower water temperature was recorded as 108.9 degrees F. On 01/31/14 at 11:30 a.m. a tour of the facility showers was conducted with S1ADM. He stated the facility recently purchased cabinets to store the disinfectant used to clean the showers, in a separate cabinet from the body soap used on the residents. In shower room "4" both a bottle of body soap and disinfectant was stored together in the same cabinet. S1ADM removed the body soap from the disinfectant cabinet. He stated "Whenever you start something new, its takes a while for everyone to get it".

Based on record review, interview and facility policy, the facility failed to ensure that the CertifiedNursingAssistant (CNA) were competent in skills, knowledge and techniques necessary to care for (1) a resident that required extensive assistance with transfers for 1 of 8 sampled residents (#8) and (2) a resident who had a history of [REDACTED].#4). (1) This resulted in an actual harm to 1 of 8 sampled residents (#8) when 2 fractures were sustained to the resident's left tibia and ankle during a 1 person assist transfer when the resident's Minimal Data Set (MDS) assessment stated the resident requirined a 2 person physical assist during transfer. (2) This resulted in an actual harm to 1 of 8 sampled residents (#4) when the resident was left unsupervised and sustained 4 skin tears to her left hand, pain to her bilateral hips, left arm, left wrist, and left shoulder on 10/28/10 and bilateral hematoma's to her left and right orbits, an abrasion to her right lateral aspect of the bridge of her nose, bruise to her right elbow, bruise to her left knee, and a bruise and abrasion to her right knee on 11/13/10. Findings: (1) Resident #8 Resident #8 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set (MDS) dated revealed in section B0600 (0) that resident has clear speech B0700 (0) is understood by the staff and has the ability to express ideas and wants and B0800 (0) understands others and has a clear comprehension. Review of the facility's Transfer Technique From the Bed to Chair Policy revealed in part as follows: Purpose: The most effective means of moving a resident with diminished lower body sensation or weakness, immobility or injury. Equipment: 2. Wheelchair or chair. Procedure: 1. Consult care plan for resident-specific approaches.... Review of the MDS dated [DATE] revealed in Section G0110 (B) that the resident was a (4) totally dependence on full staff performance and (3) required a 2 person physical assist with transfers. Section G0400(A) revealed resident had a 2; impairment on both sides in the upper extremity (shoulder, elbow, wrist, hand) and 2; impairment on both sides in the lower extremities (hip, knee, ankle, foot). Review of the Resident Incident Report dated 11/5/10 at 1:15 p.m. as recorded per S9LPN revealed that Resident #8 was transferred by a CNA from the bed to the wheelchair and the resident's foot went behind the wheelchair. The resident was assessed at that time and did ask for a pain pill with no further complaints. The resident's pain level was a 5 on the pain scale. Further review of the document revealed that an X-ray was ordered due to the resident complaining of pain to the ankle on the night shift. Review of the X-ray results on 11/5/10 revealed that the resident sustained [REDACTED]. Non-displaced fracture through the distal medial tibia metaphysis identified surrounded by soft tissue swelling. Some soft tissue calcification in seen lateral to the lateral malleolus. Cannot exclude a tiny non-displaced [MEDICAL CONDITION] of the lateral malleolus. Vascular calculations noted. On 11/17/10 at 3:30 p.m. an interview was conducted with S9LPN. She stated that the incident recorded on the Resident Accident Report dated 11/5/10 at 1:15 p.m. actually occurred on 11/4/10 between 11:30 a.m. and 12:00 p.m.. She stated that she remembered the time because she gave Resident #8 some pain medication around that time and that was the time S10CNA got her up out of bed. She stated that S10CNA informed them that Resident #8's leg went behind the wheel of the wheelchair on 11/5/10 after she heard staff discussing the X-ray results that revealed the resident had a fracture to her left tibia and ankle. She stated that they recorded the incident happened on 11/5/10 at 1:15 p.m. instead of the actual date of occurrence on 11/4/10 because that's when the resident started to complain about it. On 11/17/10 at 3:47 p.m. an interview was conducted with S1Administrator and S2DON. They said that they did not find out that Resident #8's foot went behind the wheel of her wheelchair until 11/5/10 and that's why the Resident Incident Report was dated for 11/5/10. Asked by this surveyor why it was documented that the actual incident occurred on 11/4/10? They both stated that's when they became aware of the incident. They both verified that S10CNA was written up for the incident for transferring Resident #8 by herself and the resident required a 2 person assist. . On 11/18/10 at 8:26 a.m. an interview was conducted with S10CNA. She stated that she was aware that Resident #8 was a 2 person physical assist. She stated that she had always transferred the resident by herself for 5 years and the staff was aware. She stated that because there was only 1 other CNA on the hall and she have her own residents to attend to. She verified that when she transferred the resident from her bed to the chair on 11/4/10 that the resident's left foot got stuck behind the wheel of her wheelchair. She stated that the resident yelled out when she got her in the chair. She stated that she thought it was the resident's normal behavior when she yelled out because she does that sometimes when she was transferred to the chair. She stated that when she got the resident's leg from behind the wheel on the wheelchair that S9LPN came into the room when she heard the resident yell and assisted her with repositioning her correctly in the wheelchair. She stated that S9LPN was notified of Resident #8's left leg going behind the wheel. She stated that on 11/5/10 S9LPN informed her that Resident #8 had 2 fractures; 1 to her left tibia and the other to her left ankle. On 11/19/10 at 9:33 a.m. an interview was conducted Resident #8. She stated that one of the CNA's transferred her from the bed to the wheelchair and her left foot went under the "shower chair" and she yelled. She stated that S9LPN came to the room when she heard her yell and looked at her left leg. She stated that they tried to move her left foot and it hurt so bad that she could not stand it. She stated that she was in so much pain that they put her back in bed and she could not take a shower that day. She stated that they gave her pain medication and they took an X-ray next day. She stated that she had been getting a bed bath every since the fractures because the CNA's do not like to use the Hoyer Lift. She stated that she brought her own Hoyer Lift upon admit on 12/29/06 from her house that she keep in the bathroom for the CNA's to use, but they do not like to use it. (2) Resident #4 Resident #4 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), Traumatic [MEDICAL CONDITION] Leg (10/5/09), Lack of Coordination, Abnormality of Gait, Failure to Thrive, [MEDICAL CONDITION] Reflux, Senile Dementia, Dementia without Behavior, [MEDICAL CONDITION] and Osteoarthroses. Most recent MDS dated [DATE] revealed the resident's cognitive status to be a 2; Moderately Impaired-decisions poor; cues/supervision required. Review of the MDS dated [DATE] revealed the following: Section G(1) (b) Resident was a 4; Totally dependant on full staff performance of activity during entire 7 days and a 2: 1 person physical assist with transfers. Section J(4) (a) Resident fell in past 30 days (b) Resident fell in past 31 to 180 days (c) [MEDICAL CONDITION] in last 180 days (d) Other fracture in last 180 day Review of the MDS dated [DATE] in Section G(1)(b) revealed that Resident #4 was a 4-Total dependence-full staff performance of activity during entire 7 days;2-1 person physical assist. Review of the MDS Assessment Note dated 8/16/10 revealed in Section B4 that the resident would not call for assistance when she needed to get up to go to the bathroom or when she needed to just get up in the wheelchair. Staff constantly redirects resident to please put on her call light when she wants to get up for any reason. Resident decides she can get up on her own and then falls. Further review of the document revealed that the resident has poor judgement/decision skills. Review of the Assessment of Risk for Falls dated 8/19/10 revealed that Resident #4's score was a 15; High Risk for Falls. Further review of the documentation revealed that the resident remains on the Fall Program. Review of the Resident Incident Report written per S12ADON dated 10/28/10 at 2:50 p.m. revealed that Resident #4 attempted to transfer from the wheelchair to the toilet without assistance and fell to the floor causing 4 skin tears to her left hand. Further review of the documentation revealed that the resident complained of pain to her bilateral hips, left arm, left wrist and left shoulder. An X-ray was ordered. Immediate Post-Incident Action: (1) Resident in low bed with call light in reach (bed in lowest position with fall mat beside bed) (2) Visual aids in room to help resident remember to use the call light. (3) CNA's will be in-serviced on having all supplies in hand when placing someone on the toilet. A review of the facility's Departmental Notes dated 10/28/10 at 3:34 p.m. revealed that S14LPN received report from S15LPN that Resident #4 was found on the floor in the bathroom and had 4 skin tears to her left hand. No documentation of an assessment of the resident's left hand done per S15LPN when the resident was found on the floor or vital signs for 48 hours as per the stated above Accident and Incident Policy on 10/28/10 at 3:34 p.m., 10/28/10 at 3:42 p.m., 10/28/10 at 3:43 p.m., 10/30/10 at 10:24 p.m. or 10/30/10 at 6:31 p.m. Documentation noted that increased supervision was in use. Further review of the facility's Departmental Notes as noted below revealed that the staff were aware that Resident #4 continued to get up unassisted: 11/3/10-10:01 a.m.-Resident #4 would go to her room unassisted and sit on her bed, then proceed to pull her pants off and diaper, and "pee" in the trash can. If she has to defecate she would have a bowel movement on the floor of her room until she makes it to the commode. Assistance provided by staff once they are abreast of the situation. 11/4/10 (unknown time)-Resident had to be reminded that she was not a self-transfer in bathroom. Resident was found sitting at door of the bathroom stating that she could not get through the door. 11/8/10-11:01 a.m.-Self transfer to wheel-chair. 11/11/10-6:05 p.m.-Resident tried to self-transfer from the wheelchair to her bed without assistance. Chair alarm unplugged. Resident was known to unplug the alarm and try to transfer self without help. S2DON notified. 11/12/10-2:48 p.m.-Often does not call for assistance with transfers. Reminded frequently to call for assistance. Review of the facility's Departmental Notes on 11/16/10 at 3:20 p.m. revealed that the Resident refuses to stop transferring independently of staff. Potential for falling which was evident by the bruising on the resident's face. Review of the Comprehensive Care Plan for falls dated 10/28/10 revealed that the staff stepped out of the room to get supplies after placing the resident on the toilet and the resident attempted to get up and fell , causing 4 skin tears to her left hand. Approaches: (1) Resident in low bed with mat and call light in reach (2) Visual aids in room to help resident remember to use call light (3) CNA's in-serviced on having all supplies in hand when placing someone on the toilet. (4) Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. No documentation noted in the Comprehensive Plan of Care for falls that the facility increased supervision/monitoring on Resident #4 nor that the resident continued to be noncompliant with wearing the Velcro self-release belt. A review of the facility's documentation on 10/29/10 revealed that an in-service had been done with the CNA's to have their supplies ready before performing tasks and to not leave the resident in the restroom alone to go back out to get supplies. Review of the Resident Incident Report dated 11/13/10 at 10:45 a.m. revealed that the resident was found in her bathroom on her knees on the floor with her face against the wall in between the wheelchair and the sink. The call light was not engaged. Velcro belt was unfastened by the resident. The resident was noted to have the following injuries: (1) Hematoma to left and right orbits (2) 1 cm x .5 cm abrasion to right lateral aspect of bridge of nose (3) Right elbow with 4 x 4 bruise (4) Left knee with 5 x 5 bruise (5) Right knee with 6 x 6 bruise and 3 x 4 abrasion Further review of the documentation revealed that an ice pack was applied to bilateral orbital hematoma's and an order was received to send the resident to the hospital for evaluation and treatment. Review of the facility's Departmental Notes as documented per S17LPN for 11/13/10 at 1:18 p.m. revealed that Resident #4 was found in her bathroom on her knees on the floor with her face against the wall in between the wheelchair and the sink. Call light system was not engaged. Velcro belt was unfastened by the resident. The following injuries were noted: (1) Hematoma to left and right orbits (2) 1 cm x .5 cm abrasion to right lateral aspect of bridge of nose (3) Right elbow with 4 x 4 bruise (4) Left knee with 5 x 5 bruise (5) Right knee with 6 x 6 bruise and 3 x 4 abrasion Resident stated, "I was standing at the sink brushing my teeth and lost my balance". Resident encouraged to call for assistance when going to the bathroom. Ice pack applied to bilateral orbital hematoma's. MedicalDirector (MD) notified. Order received to send the resident to the hospital for evaluation and treatment. Review of the hospital admit papers dated 11/13/10 noted that Resident #4 presented to the emergency room following a fall while in the bathroom at the facility and her face struck the wall. The resident stated to the hospital staff that she forgot she could no longer stand. Presents with bruising to eyes. Bilateral periorbital swelling with hematoma's and a superficial laceration to the left side of her face. Bilateral knee patella with tenderness, swelling, [DIAGNOSES REDACTED] and ecchymosis. Review of the hospital discharge paperwork dated 11/13/10 noted that the resident had an acute fall and was treated for [REDACTED]. On 11/18/10 at 12:40 p.m. a random observation was noted of a star on the outside of the Resident #4's door indicating that the resident was on the fall program. On 11/18/10 at 1:22 p.m. an interview was conducted with S12ADON. She verified that she typed the Accident and Incident report on 10/28/10 at 2:50 p.m. She stated that after she did an investigation of the incident she found out that S13CNA placed Resident #4 on the toilet and left out of the room to go get supplies. She stated that the resident attempted to transfer from the wheelchair without assistance when the CNA stepped out of the room and end up falling on the floor causing 4 skin tears. She stated that they in-serviced the CNA's on having all supplies on hand when placing someone on the toilet. On 11/18/10 at 2:15 p.m. an interview was conducted with S13CNA. She verified that she placed Resident #4 on the toilet and left out of the room to go get some supplies. She stated that while she was getting the supplies and the resident got up off the toilet without assistance and fell on the floor causing 4 skin tears to her left hand. She verified that she was not suppose to leave the resident in the room by herself. On 11/18/10 at 2:30 p.m. an interview was conducted with S2DON. He verified that Resident #4 was one of the residents that they had to increase monitoring as per the facility's plan of correction for falls that went into effect on 10/25/10. A request was made from S2DON for documentation of how the facility increased the monitoring on Resident #4. No documentation given to this surveyor. On 11/18/10 at 2:35 p.m. a telephone interview was conducted with S17LPN. She stated that S18CNA came and told her that Resident #4 was found on the floor in the bathroom. She stated that it appeared that the resident had unfastened her Velcro seatbelt and got up unassisted. She stated that the CNA's were suppose to monitor the resident but she went into the bathroom on her own. On 11/19/10 at 8:47 a.m. an interview was conducted with S16CNA. She stated that she rolled the resident in her room via wheelchair from taking a shower and told her to sit right there and don't go to the bathroom and that when she finished with the other resident, she would be right back. She verified that the resident has a self-releasing Velcro belt on that she could unfasten at will. She stated that the housekeeper informed her that the resident was yelling, so she told the resident that she was working with that she was coming back. She stated that she ran into Resident #4's room and found her on the floor in the bathroom. She stated that Resident #4 was known to unfasten the Velcro belt and to get up out the chair at least 2 of the 4 days out of the week that she works with her and that she had to watch her more closely. She stated that on the days when she keeps getting up and she had to attend to another resident, she would ask another CNA if they were available to watch her. She verified that she did attend the in-service on 10/29/10. On 11/19/10 at 12:10 p.m. an interview was conducted with S6MedicareCoordinator and S5DataEntry. S5DataEntry stated that the above noted interventions were put in place on 10/28/10. No documentation or explanation of how supervision and monitoring was done on Resident #4 nor that the resident continued to be non-compliant with wearing the Velcro belt as noted in the facility's Departmental Notes given to this surveyor. On 11/19/10 at 1:00 p.m. an interview was conducted with S2DON. A second request was made from S2DON for documentation of how the facility increased the monitoring on Resident #4. No documentation given to this surveyor. On 11/19/10 at 2:30 p.m. an interview was conducted with S19CNASupervisor. She stated that Resident #4 went in her restroom on her own. She verified that the residents were suppose to be monitored by the staff throughout the day and that she did not know how the Resident #4 got into her bathroom by herself.

Based on observation, record review, interview, and the facility's policy and procedure regarding incidents/accidents, the facility failed to ensure that a resident who had a known history of Alzheimer's Disease and was housed on the secure unit was adequately supervised to prevent elopement from the facility for 1 of 8 sampled residents. (#3). Resident #3 was placed in an immediate jeopardy situation 10/29/10 was the resident returned to the facility and the facility failed to thoroughly investigate the incident and put a system in place to prevent further elopement for this cognitively impaired resident after he was found at the store across the street from the facility. The Administrator was notified of the immediate jeopardy on 11/19/10 at 4:00 p.m. The immediate jeopardy was removed on 11/22/10 at 3:10 p.m. when the facility put a system in place to attempt to prevent further elopements for this resident and other residents on the secure unit. The deficient practice continues as a potential for harm for Resident #3 and a potential for more than minimal harm for the other remaining 20 residents on the secure unit. Findings: Resident #3 Resident # 3 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) 8/30/10 revealed the resident's cognitive status for decision making as a 2, Moderately impaired-decisions poor; cues/supervision required. On 11/19/10 at 10:05 a.m. a random observation was made of Resident #3 standing in front of the nursing annex alert and oriented x 1; with confusion noted. The resident was clean and neat in appearance. On 11/19/10 at 10:07 a.m. an interview was conducted with Resident #3. He stated that he did not know how he got off the secure unit to go to the store the night of 10/29/10. Review of the facility's Secure Unit guidelines and admission mission statement revealed in part that the unit was established to provide the least restrictive environment and facilitate meeting the needs of residents diagnosed with [REDACTED]. Review of the admission & discharge criteria for the secure unit revealed in part the following: Purpose: It is in the best interest of the residents that only those individuals deemed appropriate for a secured environment be admitted to the unit. Examples: (1) A resident who's behavior makes them a danger to themselves (wondering in dangerous areas). (3) Those who display socially inappropriate sexual behavior, self-abusive acts, spitting or striking out at others for no apparent reason. (4) A resident who's behavior in the past has demonstrated acts, which require a secure unit at the families' request and the physician's agreement. A review of the facility's Incident and Accident Policy and Procedure revealed in part the following: Nursing Policy and Procedure Manual Purpose: To assure that all persons who are involved in the incident and accident are evaluated, receive treatment as indicated and are monitored for disposition of incident and accident. Policy: 5. Incident and Accident Report: a. All incidents occurring in the building require an incident report regardless of how minor the incident may be... c. Documentation in the nurse's notes must clearly define the incident along with vital signs. 6. Incident involving no injury b. Document incident in the nurse's notes including vital signs for 48 hours. Review of the Staff Assessment for Mental status dated 11/15/10 revealed that Resident #3 has Dementia and requires the secure unit for wandering behaviors. Further review of the document revealed that he had mental confusion with disorganized thoughts, ambulated independently and was at risk for getting to dangerous places. Review of the MDS dated [DATE] revealed in Section E(4)(a) the resident wandered 1 to 3 days in the last 7 days. Review of the Comprehensive Plan of Care dated 8/24/10 revealed the following: Problem Onset: 8/24/10 Special Care Unit Placement: secondary to cognitive impairment related to disease process 8/24/10-Remains on Secure Care Unit due to continued attempts of elopement. Under the problem: Potential for ineffective coping with nursing home placement and disease process, the following is noted: 8/24/10-Still makes statements often that he wishes to go home. Tries to find ways to "get out of here", remains on secure care unit. Review of the Comprehensive Plan of Care for the Special Care Unit Placement dated 10/29/10 revealed the following: Problem Onset: 10/29/10 10/29/10- Resident #3 wandered from the facility to the store across the street and was brought back by the staff. Interventions as noted on the care plan for 10/29/10 were the following: 1. Double doors to the secure care unit checked to ensure that they were properly working 2. CNA's were in-serviced regarding ensuring the doors were shut properly and closed at all times. Review of the Resident Incident Report dated 10/29/10 revealed that Resident #3 wandered from the facility to the store across the street and was brought back to the facility by the Certified Nursing Assistants (CNA). Further review of the document revealed that the resident was unable to state how he got out of the facility. A head to toe assessment was done and no injuries were noted. Immediate Post-Incident Action: (1) Double checked doors for security. (2) Staff in-serviced regarding ensuring that the secure unit doors were closed and secure at all times. Immediate Action Taken: (1) All doors checked for security. Review of the facility's Departmental Notes dated 10/29/10 at 9:19 p.m. revealed that the resident wandered from the facility to the store across the street and was brought back to the facility by the CNA's. Further review of the documentation revealed that the resident was unable to state how he got out of the facility. A head to toe assessment was done and no injuries noted. Vital signs were taken and the resident was assisted to bed by the CNA's. Review of the facility's Departmental Notes dated 10/30/10 at 6:18 a.m., 11:15 a.m., and 3:43 p.m., and 10/31/10 at 12:52 p.m. revealed no vital signs documented as per the above noted policy in 6 (b). On 11/17/10 at 3:47 p.m. an interview was conducted with S1Administrator and S2DON. S1Administrator and S2DON stated that they did not know how Resident #3 got off the unit or what door he exited out of. They said they did not know whether a family member let him out or what. S1Administrator stated that the new interventions that the facility put in place to ensure that the resident did not elope again was to in-service the CNA's to check all the doors to make sure that they were locked. He stated that he gave this surveyor the results of his investigation of Resident #3's elopement on 10/29/10 as noted below: Review of the Social Progress Notes dated 11/1/10 written per S1Administrator with no recorded time revealed that on 10/29/10 he received a call from the ward clerk stating that Resident #3 had eloped from the facility and went to the store across the street. The ward clerk verified that the resident was back at the facility and was in the unit. The ward clerk was instructed by S1Administrator to ensure that all exits were secure and to have the CNA staff to check the door frequently throughout the shift. The ward clerk expressed understanding. S1Administrator documented that he interviewed staff that he did not identify that worked on the unit. The document stated that the staff reported being in another resident room during the time that the resident eloped providing care to another resident. The staff confirmed that the resident had visitors during the shift and reported that they did frequent door checks throughout the shift after the incident. The document further stated that the staff assumed that the resident eloped out of the door after a family member who visited the resident on the unit exited. On 11/17/10 at 4:25 p.m. an interview was conducted with S7LPN. She stated that she did not know how Resident #3 got off the secure unit because she did not see how it happened. She stated that she was covering for another nurse because she went to get something to eat. She stated that there were 2 CNA's on the secure unit on the night of 10/29/10. She stated that one of the CNA's found that the resident was missing when she did her rounds and that she did not know how long the resident was gone before they discovered he was missing. She stated that after they found out that the resident was missing they called the ward clerk and she made an announcement over the loud speaker. She stated that shortly after the announcement, somebody called from the store across the street and asked them if they were missing a resident. She stated that the CNA's went across the street and brought the resident back to the facility. On 11/17/10 at 4:40 p.m. an interview was conducted with S8CNA. She stated that at an unknown time she and another CNA was down in another resident's room changing him and when they came out of the resident's room, Resident #3's family member, who works at the facility, came on the secure unit to tell the resident goodbye. She stated that when the family member went to the resident's room the resident could not be found. She stated that she searched for the resident 3 times on the secure unit before they called the ward clerk in the front of the facility to announce that the resident was missing. She verified that there was no other staff member watching the residents while she and the other CNA were changing the other resident. She stated that she does not know how the resident could have gotten off the unit or what door he could have gotten out of. She stated that the last time she saw the resident, he was sitting at the table on the secure unit. She stated that when she came on to work the doors were locked. She stated that she did not know how long the resident was missing before the store called and asked if we were missing a resident. She stated that his family member was the one who found out that he was at the store and she walked over there and brought the resident back to the facility. She stated that on the secure unit its a "law" that they check the doors when they came on, even before that incident occurred. The facility failed to have a system in place to ensure the residents of the secure unit could not elope. without someone knowing until hours after the escape. There was no documented monitoring of the residents while the CNA's were attending to residents in their rooms and therefore no way to know exactly how long the resident had been missing from the facility. There was no evidence given to ensure that a thorough investigation had been done as to how the resident left the facility and there was no system put in place to prevent further elopements. II. Based on record review, interview and facility policy, the facility failed to keep residents free from accident hazards as evidenced by: (1) Failing to provide a 2 person physical assist during transfer from the resident bed to the wheelchair as per the resident's Minimal Data Set (MDS) assessment for 1 of 8 sampled residents requiring a 2 person physical assist during transfer. (#8) (2) Failed to increase monitoring on a resident who had a known history of trying to get up unassisted for 1 of 8 sampled residents requiring transfer assistance. (#4) An actual harm occurred on 11/04/10 for Resident #8 when the facility failed to ensure that 2 person physical assist was provided to a resident being transferred from the bed to the wheelchair. As a result of the facility's failure to ensure a 2 person physical assist was provided during a transfer from the bed to the wheelchair, the resident's left foot got stuck behind the wheelchair wheel resulting in fractures to her left tibia and ankle during the transfer. An actual harm occurred on 11/13/10 for Resident #4 when the facility failed to ensure that a resident with a history of falls was not left unsupervised allowing the resident to get out of the wheelchair, go into the bathromm when she fell sustaining an acute bilateral periorbital hematomas and an acute head injury. Findings: Resident #8 Resident #8 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set ((MDS) dated [DATE] revealed in section B0600 (0) that resident has clear speech B0700 (0) is understood by the staff and has the ability to express ideas and wants and B0800 (0) understands others and has a clear comprehension. Review of the facility's Incident and Accident Policy and Procedure revealed in part as follows: Purpose: To assure that all persons who are involved in the incident or accident are evaluated, receive treatment as indicated and are monitored for disposition of incident and accident. Policy: Incident and accidents are to be reported, investigated and followed up in a timely manner. Procedure: 1. Reporting of Incidents and Accidents. a. The incident and accident must be reported to the designated departmental supervisor. 2. Assisting Incident and Accident victims: a. Provide immediate assistance. Do not move the victim until they have been assessed for injuries. b. If assistance is needed, call for help. 3. Medical Attention: a. Assess all Incident and Accident victims. b. Notify physician. c. Notify family/responsible party. 4. Investigative Action: a. The nurse will conduct an immediate investigation of any Incident and Accident. b. The nurse will conduct pertinent data for the Incident and Accident report (including vital signs). c. The Director of Nursing or designee will be responsible for making sure all required investigation reports are completed. d. Resident will be assessed for intervention to prevent further incidents. 5. Incident and Accident Report: a. All incidents occurring in the building require an incident report regardless of how minor the incident may be. c. Documentation in the nurse's notes must clearly define the incident along with vital signs. 7. Incident involving injury: a. Complete incident report. b. Document incident in nurses notes including vital signs for 48 hours. c. Notify family/responsible party and MD then document. Review of the facility's Transfer Technique (Bed to Chair) Policy revealed in part as follows: Purpose: The most effective means of moving a resident with diminished lower body sensation or weakness, immobility or injury. Equipment: 1. Gait belt. 2. Wheelchair or chair. Procedure: 1. Consult care plan for resident-specific approaches.... Review of the MDS dated [DATE] revealed in Section G0110 (B) that the resident was a (4) totally dependence on full staff performance and (3) required a 2 person physical assist with transfers. Review of the Resident Incident Report dated 11/5/10 at 1:15 p.m. as recorded per S9LPN revealed that Resident #8 was transferred by a CNA from the bed to the wheelchair and the resident's foot went behind the wheelchair. The resident was assessed at that time and did ask for a pain pill with no further complaints. The resident's pain level was a 5 on the pain scale. Further review of the document revealed that an X-ray was ordered due to the resident complaining of pain to the ankle on the night shift. Review of the Physician order [REDACTED]. Review of the Comprehensive Plan of Care for the [DIAGNOSES REDACTED]. 11/4/10-Resident #8 complained of left leg pain. Further review of the document revealed, give the resident pain medication as ordered and an X-ray was ordered. 11/5/10-X-ray results revealed the following: (1) Non-displaced fracture to distal medial tibia metaphysis. (2) Soft tissue Calcification to lateral Malleolus; can't exclude tiny non-displaced chip fracture. Administrator and DON investigation revealed that on transfer Resident #8's leg went behind the wheel on the wheelchair. Approaches: (1) Orthopedic consult (2) Stirrup splint to left lower extremity. (3) No pain medication adjustment per Nurse Practitioner (NP) (4) Hoyer lift for transfers (5) Counseled CNA on transfers and reporting (6) New order for Oscal and Vitamin D as ordered. Review of the Pain Assessment Roster as recorded per S9LPN for 11/4/10 thru 11/17/10 revealed the following: 11/4/10-10:03 a.m.-Pain-Yes 11/4/10-10:03 a.m.-Can resident give intensity and characteristics of pain? Yes 11/4/10-10:03 a.m.-Intensity of pain: 7 11/4/10-10:03 a.m.-Pain characteristics: Throbbing 11/4/10-10:03 a.m.-Pain Medication Interventions: Repositioning 11/4/10-10:03 a.m.-Was Intervention effective? Yes Review of the 11/10 E-Medication Administration Record (E-MAR) revealed that the resident was given Lortab 10 milligrams (mg) for pain was given per S9LPN on 11/4/10 at 9:30 a.m. and 2:30 p.m. per S9LPN. Pain Monitor every (q) shift: 6 a.m. to 2 p.m. revealed the resident's pain level to be a 3 (moderate pain). Reason for pain medication: 3 (generalized pain) On 11/17/10 at 3:30 p.m. an interview was conducted with S9LPN. She stated that the incident recorded on the Resident Accident Report dated 11/5/10 at 1:15 p.m. actually occurred on 11/4/10 between 11:30 a.m. and 12:00 p.m.. She stated that she remembered the time because she gave Resident #8 some pain medication around that time and that was the time S10CNA got her up out of bed. S9LPN stated that S10CNA informed them that Resident #8's leg went behind the wheel of the wheelchair on 11/5/10 after she heard staff discussing the X-ray results that revealed the resident had a fracture to her left tibia and ankle. She stated that they recorded the incident happened on 11/5/10 at 1:15 p.m. instead of the actual date of occurrence on 11/4/10 because that's when the resident started to complain about her left leg and that was when S9LPN said she assessed it. Review of the Pain Assessment Roster on 11/4/10 revealed that Resident #8 was in pain but did not reveal where the pain was located. Review of the facility's Departmental Notes revealed the following: (1) 11/4/10-No documentation of an assessment was noted for Resident #8. 11/5/10-5:43 a.m.-Resident complains of left lower leg pain when the CNA turns her to change her. Resident stated, "It hurt real bad when you touch it". Further review of the documentation revealed a new order to X-ray the resident's left lower leg. No documentation of an assessment of Resident #8's left leg noted. 11/5/10-12:25 p.m.-Resident still complaining of pain in the leg. X-ray ordered today. Awaiting results. As needed (prn) pain medication given at 9:30 a.m. with some relief noted. the resident stated, "Legs are hurting all over". 11/5/10-2:06 p.m.-Results from the X-ray revealed that Resident #8 has a fracture of the ankle and the tibia. Telephone order obtained for a stirrup splint with an Orthopedic Consult. 11/5/10-9:29 p.m.-Resident continues to complain of pain to lower left leg when moved. Review of the E-MAR for 11/5/10 on the 6 a.m. to 2 p.m. shift as recorded per S9LPN revealed the Pain monitor q shift to be a 0; and that no pain med was given. Review of the Pain Assessment Roster as recorded per S9LPN for 11/4/10 thru 11/17/10 revealed the following: 11/5/10-9:24 a.m.-Pain-Yes 11/5/10-9:24 a.m.-Can resident give intensity and characteristics of pain? Yes 11/5/10-9:24 a.m.-Intensity of pain: 6 11/5/10-9:24 a.m.-Pain characteristics: Aching 11/5/10-9:24 a.m.-Pain Medication Interventions: Repositioning 11/5/10-9:24 a.m.-Was Intervention effective? No On 11/17/10 at 3:47 p.m. an interview was conducted with S1Administrator and S2DON. They said that they did not find out that Resident #8's foot went behind the wheel of her wheelchair until 11/5/10 and that's why the Resident Incident Report was dated for 11/5/10. When asked why it was documented that the actual incident occurred on 11/4/10, no answer was given. They both verified that S10CNA was written up for the incident for transferring Resident #8 by herself and the resident required a 2 person physical assist. During the interview S1Administrator verified that he had written on Resident #8's Comprehensive Plan of Care for the [DIAGNOSES REDACTED]. 11/4/10-Resident complained of pain to left leg. Continue plan of care (poc). Pain medication (med) as ordered. X-ray as ordered. The Administrator was asked, was an order for [REDACTED]. He stated that he did document X-ray as ordered on 11/4/10 and verified that the X-ray was not done. He verified that a verbal order for an X-ray was received on 11/5/10 at 6:00 a.m. per S11LPN. He stated that he writes on Comprehensive Care Plans for residents sometimes. On 11/18/10 at 8:26 a.m. an interview was conducted with S10CNA. She stated that she was aware that Resident #8 was a 2 person physical assist. She stated that she had always transferred the resident by herself for 5 years and the staff was aware. She stated that she does not get the only other CNA on the hall to help because the othe CNA have her own residents to attend to. She verified that when she transferred the resident from her bed to the chair on 11/4/10 that the resident's left foot got stuck behind the wheel of her wheelchair. She stated that the resident yelled out when she got her in the chair. She stated that she thought it was the resident's normal behavior when she yelled out because she does that sometimes when she was transferred to the chair. She stated that when she got the resident's leg from behind the wheel on the wheelchair that S9LPN came into the room when she heard the resident yell and assisted her with repositioning her correctly in the wheelchair. She stated that S9LPN was notified of Resident #8's left leg going behind the wheel. She stated that on 11/5/10 S9LPN informed her that Resident #8 had 2 fractures; 1 to her left tibia and the other to her left ankle. On 11/18/10 at 9:45 a.m. an interview was conducted with S9LPN. She verified that on 11/4/10 she gave Resident #8 Lortab 10 mg at 9:30 a.m. for generalized pain. She stated that it is not the protocol of the facility that nurses go back and document the assessment as to the effectiveness of the pain medication 1 hour after the administration nor or they required to document in the Nurse's Notes. She stated that would be considered double charting. She stated that the EMAR was designed to document per shift and will not let you document hourly. She stated that in the EMAR there was no place to enter the administration of the second prn pain medication that was given at 2:30 p.m. She stated that the EMAR was designed to only document the assessment of 1 prn medication per shift. She stated that she wrote on the paper MAR at 2:30 p.m. that she gave the resident Lortab 10 mg and verified that she did not document the reason for the pain medication, where the pain was located, the resident's pain scale or the effectiveness of the pain medication after she administered it. On 11/19/10 at 9:32 a.m. a random observation was made of Resident #8 lying in bed in a semi-fowler's position with a splint to her left lower leg watching television. On 11/19/10 at 9:33 a.m. an interview was conducted Resident #8. She stated that one of the CNA's transferred her from the bed to the wheelchair and her left foot went under the "shower chair" and she yelled. She stated that S9LPN came to the room when she heard her yelled. She stated that they tried to move her left foot and it hurt so bad that she could not stand it. She stated that she was in so much pain that they put her back in bed and she could not take a shower that day. She stated that they gave me pain medication and they took an X-ray next day. Resident #4 Resident #4 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), Traumatic Fracture of the Upper Leg (10/5/09), Lack of Coordination, Abnormality of Gait, Failure to Thrive, Esophageal Reflux, Senile Dementia, Dementia without Behavior, Depressive Disorder and Osteoarthroses. Most recent MDS dated [DATE] revealed the resident's cognitive status to be a 2; Moderately Impaired-decisions poor; cues/supervision required. Review of the facility's Fall Prevention Program Policy and Procedure in part revealed the following: Purpose: The Fall Prevention Program is an individualized daily plan to promote safety of residents who have been identified as high risk for falls via ID team determination. Policy: All residents will be assessed upon admit, re-admit, quarterly, annually, significant change assessments, and as needed. Procedure: 1. All residents will be placed on the Fall Prevention Program as decided by the Interdisciplinary Team upon admit and evaluated for continuation at quarterly assessment. 2. All residents will be re-evaluated at quarterly assessment and as needed for high risk based on fall assessment, history of falls and overall status. a. If resident triggers with high risk for falls via risk assessment and is not added to the program, documentation must include reason why the resident was not added. 4. All residents on the Fall Prevention Program will be identified by visual cue. Review of the 11/10 physician's orders [REDACTED]. (1) Resident to have a low bed. Review of the MDS dated [DATE] revealed the following: Section G(1) (b) Resident was a 4; Totally dependant on full staff performance of activity during entire 7 days and a 2: 1 person physical assist with transfers. Section J(4) (a) Resident fell in past 30 days (b) Resident fell in past 31 to 180 days (c) Hip fracture in last 180 days (d) Other fracture in last 180 day Section P(4) Resident did not have a restraint. Review of the Comprehensive Care Plan for At Risk for Falls related to a history of falls with an onset date of 10/28/10 revealed that the resident had a self-releasing seatbelt while up in the wheelchair. Review of the MDS Assessment Note dated 8/16/10 revealed in Section B4 that the resident will not call for assistance when she needs to get up to go to the bathroom or to just get up in the wheelchair. Staff constantly redirects her to please put on her call light when she wants to get up for any reason. Resident decides she can get up on her own and then falls (poor judgement/decision skills). Review of the Assessment of Risk for Falls dated 8/19/10 revealed that Resident #4's score to be a 15; High Risk for Falls. Further review of the documentation revealed that the resident remains on the Fall Program. Review of the facility's documentation of record of in-service as per the plan of correction on falls effective 10/25/10 revealed on 10/14/10 that the staff was in-serviced on the following: (1) Falls (2) Reporting and investigating all falls (3) Increase monitoring, assessment of the resident after a fall (4) Interventions in place. (5) Notifying the Medical Director (MD) after every fall (6) Neurochecks with head injury (7) Documenting on all falls witnessed or unwitnessed Review of the Resident Incident Report written per S12ADON dated 10/28/10 at 2:50 p.m. revealed that Resident #4 attempted to transfer from the wheelchair to the toilet without assistance and fell to the floor causing 4 skin tears to her left hand. Further review of the documentation revealed that the resident complained of pain to her bilateral hips, left arm, left wrist and left shoulder. An X-ray was ordered. Immediate Post-Incident Action: Resident in low bed with call light in reach (bed in lowest position with fall mat beside bed) Visual aids in room to help resident remember to use the call light. CNA's will be in-serviced on having all supplies in hand when placing someone on the toilet. A review of the facility's Departmental Notes dated 10/28/10 at 3:34 p.m. revealed that S14LPN received report from S15LPN that Resident #4 was found on the floor in the bathroom and had 4 skin tears to her left hand. Documentation noted that increased supervision was in use. Further review of the facility's Departmental Notes as noted below revealed that the staff were aware that Resident #4 continued to get up unassisted: 11/3/10-10:01 a.m.-Resident #4 would go to her room unassisted and sit on her bed. The resident proceed to pull her pants off and diaper, and "pee" in the trash can. If she has to defecate she would have a bowel movement on the floor of her room until she makes it to the commode. Assistance provided by staff once they are abreast of the situation. 11/4/10 (unknown time)-Resident had to be reminded that she was not a self-transfer in bathroom. Resident was found sitting at door of the bathroom stating that she could not get through the door. 11/8/10-11:01 a.m.-Self transfer to wheel-chair. 11/11/10-6:05 p.m.-Resident tried to self-transfer from the wheelchair to her bed without assistance. Chair alarm unplugged. Resident is known to unplug the alarm and try to transfer self without help. S2DON notified. 11/12/10-2:48 p.m.-Often does not call for assistance with transfers. Reminded frequently to call for assistance. Review of the physician's orders [REDACTED]. Review of the facility's Departmental Notes on 11/16/10 at 3:20 p.m. revealed that the Resident refuses to stop transferring independently of staff. Potential for falling which is evident by the bruising on her face. Review of the MDS dated [DATE] in Section G(1)(b) revealed that Resident #4 was a 4-Total dependence-full staff performance of activity during entire 7 days;2-1 person physical assist. Review of the Comprehensive Care Plan for falls dated 10/28/10 revealed that the staff stepped out of the room to get supplies after placing the resident on the toilet and the resident attempted to get up and fell , causing 4 skin tears to her left hand. Approaches: (1) Resident in low bed with mat and call light in reach. (2) Visual aids in room to help resident remember to use call light. (3) CNA's in-serviced on having all supplies in hand when placing someone on the toilet. (4) Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician. No documentation noted in the Comprehensive Plan of Care for falls that the facility increased supervision/monitoring on Resident #4 nor that the resident continued to be noncompliant with wearing the Velcro self-release belt. A review of the facility's documentation on 10/29/10 revealed that an in-service had been done with the CNA's to have their supplies ready before performing tasks and to not leave the resident in the restroom alone to go back out to get supplies. Review of the Resident Incident Report dated 11/13/10 at 10:45 a.m. revealed that the resident was found in her bathroom on her knees on the floor with her face against the wall in between the wheelchair and the sink. The call light was not engaged. Velcro belt was unfastened by the resident. The resident was noted to have the following injuries: (1) Hematoma to left and right orbits (2) 1 centimeter (cm) x .5 cm abrasion to right lateral aspect of bridge of nose (3) Right elbow with 4 x 4 bruise (4) Left knee with 5 x 5 bruise (5) Rig

Based on observation, record review, and interview the facility failed to assess and use the results of the resident's assessment to develop and revise the resident's comprehensive plan of care that included measureable objectives and timetables to meet the medical, nursing and psychosocial needs identified in the comprehensive assessment for 2 of 6 residents (#4, #5) who had a history of [REDACTED]. The facility's failure to ensure that the comprehensive care plan was updated and revised with new measureable objectives and time tables resulted in a actual harm to a resident (#4) when he sustained a right distal humerus fracture 8/29/10. Findings: Resident #4 Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4's most recent Minimal Data Set ((MDS) dated [DATE] revealed his cognitive status to be a 2; Moderately Impaired-decisions poor; cues/supervision required. Review of the Incident Log for Resident #4 revealed that he sustained falls with injuries on the following dates: (1) 5/1/10 7:00 p. m. Fall with head injury in his room. (2) 6/2/10 9:30 a. m. Head Injury in his room. (3) 8/22/10 10:00 a. m. Fall with head injury in his room-Resident was sent to emergency room . (1) 5/1/10 7:00 p. m. Fall with head injury in his room. Review of the Nurse's Notes for 5/1/10 revealed the following: 5/1/10 4:30 a. m.-Resident pulled on curtain to transfer and the curtain gave out on him. When he tried to keep from falling the wheelchair turned over. Resident was found lying on the floor on his left side with the wheelchair turned over sideways in the hallway. 6:00 p. m.-Resident found on floor on mat with his brief pulled off. Transferred to wheelchair with the assist of two and secured in seat. Unable to manage or orient. 7:00 p. m.-Resident was found in the wheelchair lying on the floor while still in chair. No hematoma found but Resident did hit his head on the floor. Neurological checks initiated. 11:00 p. m.-Neurological checks in place. Review of the Resident #4's record revealed no documentation that Neurological checks had been done on the resident who sustained a head injury. Review of the Comprehensive Care Plan for the Potential for Falls related to use of [MEDICAL CONDITION] drugs dated 5/1/10 revealed the following: Potential for falls related to use of [MEDICAL CONDITION] drugs of [MEDICAL CONDITION], Depression and Anxiety. Falls for 5/1/10, 5/3/10 (2 falls) and 5/5/10 Goals: Resident will have minimal-no side effects of [MEDICAL CONDITION] medication (med) use thru 8/22/10. Approaches: (1) Monitor time and location of falls (2) Report and investigate any and all falls (3) Staff to visit frequently (4) Encourage resident to seek assistance (5) Well lighted room (6) Call light within reach (7) Allow resident time on all procedures (8) Monitor pharmacist's drug regimen for identification of potential drug interaction (9) Reassess on fall risk and restraint reduction every 3 months and as needed (10) Notify family and Medical Director (MD) of abnormal findings (11) Refer to therapy as needed (12) Low bed/mat (13) Geri-chair when out of bed due to poor trunk control. (14) Increase monitoring time (15) Moved resident to room closer to nurse's station (16) Moved resident to B side of room (2) 6/2/10 9:30 a. m. Head Injury in his room. Review of the Nurse's Notes on 6/2/10 revealed the following: 1:00 a. m. Resident on floor mat. No injury noted. No complaints (c/o) pain. Assisted resident back to bed. 5:00 a. m. Resident on floor mat. No injuries noted . No c/o pain. Assisted back to bed. 9:30 a. m. Resident rolled from bed to floor mat, crawled to the door and bumped his head against door facing. Resident checked. No injury noted. Assisted back to bed. Resident moved to another room. Review of the Accident and Incident Report dated 6/2/10 at 9:30 a. m. revealed that the resident bumped his head on the door frame. Further review of the documentation revealed that the incident was un-witnessed. Review of the Comprehensive Plan of Care revealed that the resident rolled out of his low bed and hit his head on the door. Neurological checks initiated times 24 hours. No new interventions noted for 6/2/10. Review of the Comprehensive Care Plan for Potential for falls on 6/2/10 revealed that the resident rolled out of the low bed and hit his head on the door. Neurological checks initiated for 24 hours. (hr) No new intervention noted for 6/2/10. (3) 8/22/10 10:00 a. m. Fall with head injury in his room-Resident was sent to emergency room . Review of the Accident and Incident for 8/22/10 at 7:15 a. m. revealed that the resident was in the Geri-chair and raised his legs and pushed off of the bottom of the chair and landed on the floor. Incident was heard by a CNA. Incident happened five minutes after staff got resident ready for breakfast. Further review of the documentation revealed that the incident was unwitnessed. Review of the Nurse's Notes on 8/22/10 revealed the following: 7:15 a. m. Resident found on floor with a raised area noted above his left eye and a small abrasion. Resident was just dressed, cleaned and placed in a Geri-chair awaiting breakfast when the CNA heard him fall. Ice applied. Neurological checks initiated. 10:00 a. m.-Resident c/o headache. (H/A) 10:15 a. m.-Nurse Practitioner notified that the resident had a H/A. New orders received to send resident to the emergency room (ER) for evaluation and treatment. Review of the hospital discharge documents for 8/22/10 revealed that the resident presented with a contusion (mild traumatic soft tissue swelling over the middle of his forehead) and a concussion (minor head injury). 8:30 p. m- Staff was making rounds and found resident lying on the floor. Resident was assisted back to bed. Review of the Accident and Incident for 8/22/10 at 8:30 p. m. revealed that the resident was found on the floor while making rounds and was assisted back to bed. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed that the resident had one fall with a head injury on 8/22/10 but did not have any new interventions for the fall nor is the second fall at 8:30 p. m. documented. Review of the Nurse's Notes revealed Resident #4 sustained injuries on the following dates: (1) 6/17/10 10:40 a. m. (2) 6/18/10 8:45 a. m. (3) 8/29/10 1:01 p. m. (1) On 6/17/10 10:40 a. m. S5LPN was called to the room per a Certified Nursing Assistant (CNA) and reported to that while positioning Resident #4 a bruise was noted to his left hip. Further review of the documentation noted that an x-ray was obtained at the facility. Review of a verbal Physician order [REDACTED]. Review of the Pelvis with Left Hip View x-ray report dated 6/17/10 revealed that Resident #4 did not have a fracture or dislocation to his left hip. On 9/13/10 at 1:02 p. m. an interview was conducted with S5LPN. She stated that on 6/17/10 at 10:40 a. m. she was called to the room per a CNA and informed that while she was positioning Resident #4 she noted a bruise to his left hip area. She stated that she did not witness the resident falling out of the bed and that she did not do an investigative report as to the occurrence of the injury. She stated that she did notify the physician and obtained an order for [REDACTED]. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no documentation that a bruise was obtained due to the resident falling out of the bed around the date of 6/17/10; as indicated on the statement brought to this surveyor per S1Administrator written per S5LPN which reads as follows: 6/17/10 (unknown time) Bruise found on Resident #4 is due to the result of the resident falling in and out of the bed..... (2) On 6/18/10 8:45 a. m. Review of the Nurse's Notes revealed that the resident was sent out to the hospital to be evaluated and treated due to a deterioration in health. The resident was lying in the bed with eyes open but not focused and hard to arouse. Further review of the documentation revealed that the night nurse reported that the resident had not voided throughout the night and that his bladder was firm. 6/18/10 6:25 p. m. The hospital discharge papers revealed that Resident #4 was diagnosed with [REDACTED]. Review of the hospital documentation for 6/18/10 revealed that the resident had a fracture in the anterior lateral aspect of the right ninth rib. On 9/13/10 at 1:20 p. m. an interview was conducted with S1Administrator. He verified that the rib fracture was found at the hospital when the resident was sent out for a change in status on 6/18/10 and that the facility was unaware as to how the rib fracture occurred. On 8/27/10(documented as 8/29/10) at 10:00 a. m. the resident was found on the mattress next to a low positioned bed. No distress noted. When asked are you hurting, Resident responded, "No, I'm hungry". No injury noted. No redness or swelling noted. On 9/15/10 at 9:21 a. m. an interview was conducted with S5LPN. She stated that she documented the wrong date on 8/27/10. She stated that she put 8/29/10. She verified that she did not do a full assessment including range of motion on the resident when he fell on [DATE] at 10:00 a. m. On 8/28/10 at 10:00 a. m. the resident was found on the mattress next to the bed. Assistance times 2 to bed. No distress noted. Denies any pain. 8/28/10 at 4:00 p. m. Resident continues to come off of bed and Geri-chair throughout the day. Brought out to hallway for observation. (3) On 8/29/10 1:01 p. m. Review of the Nurse's Notes revealed that Resident #4's arm was red, warm and swollen. Ice pack applied. Physician notified. Order obtained for a stat Humerus and Elbow X-ray. Informed wife that the resident was going to be sent to the hospital. Review of the stat X-ray results of the elbow obtained at the facility revealed that Resident #4 had a [MEDICATION NAME] fracture across the supracondylar region of the distal right humerus associated with slight radial displacement of the distal humeral fracture fragment. Soft tissue swelling is seen posterior to the elbow. Right radial head is not well seen on the submitted two view study and therefore is not well evaluated. No definite fracture is seen at the proximal right ulna. Review of the Physician order [REDACTED]. Review of the hospital documents for 8/29/10 revealed that the resident had a right distal humerus fracture. Review of the Comprehensive Plan of Care for Falls dated 5/1/10 revealed the following: 8/29/10 c/o pain. X-ray as ordered. Resident out to emergency room . Review of the Incident Log revealed Resident #4 sustained falls with no injury on the following dates: 5/1/10 4:30 a. m.-Fall/no head injury-Resident room. Review of the Nurse's Notes dated 5/1/10 at 4:30 a. m. revealed that the resident pulled on a curtain to transfer and it gave out on him. When the resident tried to keep from falling the wheelchair turned over on him. Resident denies any pain or injury. Returned back to bed by the staff nurse and CNA's. Review of the Comprehensive Care Plan for falls dated 5/1/10 revealed Goals and Approaches as noted above. 5/3/10 11:45 a. m.-Fall/no head injury-Resident room. Review of the Nurse's Notes for 5/3/10 at 11:45 revealed that the resident attempted to get out of bed unassisted and slipped to his knees on the mat. Low bed down. Assisted back to bed. No injury noted. Review of the Comprehensive Care Plan for falls dated 5/1/10 revealed Goals and Approaches as noted above. 5/3/10 12:20 p. m.-Fall/no head injury-Resident room. 12:20 p. m.-Resident was sitting in chair visiting with family and stretched out his legs and slid to the floor mat from the chair to buttocks. No injury noted. Assisted back to chair. 5/5/10 10:00 a. m.-Fall/no head injury-hallway. Review of the Nurse's Notes dated 5/5/10 at 10:00 a. m. revealed that the resident was noted with arms on the chair with legs on the floor in the hallway. No complaints voiced when asked was he ok? Resident was assisted back in Geri-chair and placed in front of the nurse's station. Review of the Comprehensive Care Plan for falls dated 5/1/10 revealed Goals and Approaches as noted above. 6/28/10 1:30 a. m.-Fall/no head injury-Resident room. Review of the Nurse's Notes on 6/28/10 at 1:30 p. m. revealed that the CNA noted that the resident raised up on his knees while in his bed and climbed out on the floor mat. No apparent injury. Previous bruising was noted to hip still present. Resident was assisted back to bed. Review of the Comprehensive Care Plan for falls dated 5/1/10 revealed that the resident did have a fall on 6/28/10 with no injury noted. No new intervention was noted. 7/16/10 1:00 a. m.-Fall/no head injury-Resident room. Review of the Accident and Incident report dated 7/16/10 at 1:00 p. m. revealed that the resident was found crawling around on the floor at one point. Staff assisted back to bed once assessed and cleared for injuries. Further review of the documentation revealed that after the first incident the resident fell on the fall mat 5 times after the initial fall.. Review of the Nurse's Notes for 7/16/10 at 1:00 a. m. revealed the five other falls as noted: 1:00 a. m.-Resident found on the floor mat and assisted back to bed. No complaints of pain. Vital signs taken. 1:30 a. m.-Resident found on the floor mat. Assisted back to bed. 2:00 a. m.-Resident found on floor mat crawling back in bed. Assisted back to bed, no pain noted. Further review of the Nurse's Notes revealed no documentation of an assessment was noted. 3:00 a. m.-Resident found on the floor mat crawling on the floor. Assisted back to bed. 5:00 a. m.-Resident found on the floor mat. Assisted back to bed. No complaints of pain. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no updated documentation that the resident had a fall on 7/16/10 at 1:00 a. m., 1:30 a. m., 2:00 a. m., 3:00 a. m. or 5:00 a. m. On 9/15/10 at 2:02 p. m. an telephone interview was conducted withS9LPN. She verified that on 7/16/10 that after the first fall at 1:00 a. m. the resident had five other falls after that. She stated that it was a unique situation with him because he use to crawl and get on the floor. She stated that the resident also fought. 7/16/10 2:00 p. m.-Other-Resident room. Resident found on mat again at 11:30 p. m. after the first incident was written. Review of the Accident and Incident (A & I) Report revealed that the incidents were combined as noted below: S5LPN completed an A & I report that at 2:00 p. m. on 7/16/10 the resident was found on the mattress next to the low bed. No injuries noted. No complaints of pain voiced by the resident. Will continue to monitor. Review of the Nurse's Notes on 7/16/10 at 2:00 p. m. revealed that the resident was found on the mattress next to the bedside. No injury noted. Resident asked was he in any pain, resident replied, "No". Resident was transferred back to the bed via assistance of two staff. Will continue to monitor. Vital signs taken. On 9/13/10 at 1:02 p. m. an interview was conducted with S5LPN. She stated that on 7/16/10 at 2:00 p. m. the resident was sitting in a wheelchair. She verified that she did not document where the resident fell from. She stated that at 2:00 p. m. the resident was found on the mattress next to his bed in his room. S5LPN stated that they brought the resident to the nursing station occasionally as recorded in the nurse's notes. S10LPN completed an A & I report on 7/16/10 at 11:30 p. m. stating that the resident was found lying on the mattress next to the low bed. No injuries noted. No complaints of pain. Review of the Nurse's Notes for 7/16/10 at 11:30 p. m. revealed that the resident was found on the mattress on the floor next to the resident's bed. No injuries were noted. Resident refused to get back in the bed so they tucked him in on the mattress on the floor and let the resident sleep there. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no updated documentation that the resident had a fall on 7/16/10 at 2:00 p. m. or 11:30 p. m. 7/17/10-2:00 p. m.-Other-Resident room. Review of the Nurse's Notes for 7/17/10 revealed the following: 4:00 p. m.-Resident found on the mat. No apparent injury. 4:45 p. m. Resident found on the mattress on the floor. All parties notified. No injuries noted. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no new or revised interventions that the resident had a fall on 7/17/10 2:00 p. m., 4:00 p. m., 4:45 p. m. 7/17/10 11:00 p. m.-Other-Resident room. Review of the Nurse's Notes dated 7/17/10 at 11:00 p. m. revealed that the resident was found on the mattress on the floor by the bed. Resident is allowed to sleep on the mattress. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no new or revised interventions that the resident had a fall on 7/17/10 at 11:00 p. m. 7/18/10 10:00 a. m.-Other-Resident room. Review of the Nurse's Notes for 7/18/10 at 11:00 p. m. revealed that the resident was lying in bed. Vital signs taken. Incontinent care per staff. Mattress at bedside. No injury noted from earlier fall. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no updated documentation that the resident had a fall on 7/8/10 at 10:00 a. m. 7/21/10 3:50 a. m.-Other-Resident room. Review of the Nurse's Notes dated 7/21/10 at 3:50 p. m. revealed that the resident was found crawling on the floor on the fall mat. No injury noted. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no updated documentation that the resident had a fall on 7/21/10 3:50 a. m. 8/4/10 5:45 a. m.-Other-Resident room. Skin tear. Review of the Nurse's Notes for 8/4/10 at 5:45 a. m. revealed that the resident was lying on the mattress on the floor. He rolled and hit the chair and received a skin tear above his right eye. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no updated documentation that the resident had a fall on 8/4/10 at 5:45 a. m. 8/8/10 3:05 a. m. Other-Resident room. Review of the Nurse's Notes on 8/8/10 at 3:05 a. m. revealed that the resident was found on the floor off of the bed mattress. NADN. Awake, alert and confused. Vital signs were taken and the resident was placed back on the bed mattress on the floor. A CNA found the resident and reported it to the staff nurse. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no documentation that the resident had a fall on 8/8/10 at 3:05 a. m. 8/14/10 3:00 p. m.-Fall/no head injury-Resident room. Review of the Nurse's Notes for 8/14/10 at 3:00 p. m. revealed that the resident had been repositioned in his Geri-chair numerous times throughout the day. Several times brought out of the room in front of the nursing station where he grabs at people within his reach. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no documentation that the resident had a fall on 8/14/10 at 3:00 p. m. 8/14/10 4:00 p. m. Brought back to his room afterwards and was found sitting on the lower portion of his Geri-chair. Placed back in chair with visitors present feeding him ice cream. Review of the Comprehensive Care Plan for falls dated 5/1/10 revealed that on 8/14/10 at 4:00 p. m. that the resident scooted out of the Geri-chair. Staff found resident on the floor in his room. No injury noted. No new interventions noted. 8/21/10 3:00 p. m.-Other-Resident room. Review of the Nurse's Notes dated 8/21/10 at 3:00 p. m. revealed that the resident was found sprawled out on the floor by the staff nurse laying on his stomach with his brief ripped off and urine around him. Denies any pain. Assisted with CNA to change and put back to bed. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no documentation that the resident had a fall on 8/21/10 at 3:00 p. m. 3:10 p. m. Resident back on mat where he stayed until supper. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed no documentation that the resident had a fall on 7/16/10 at 3:00 p. m. 8/27/10 10:00 a. m.-Fall/no head injury. Resident room. Review of the Nurse's Notes dated 8/29/10 at 10:00 a. m. revealed that the resident was found on mattress next to the low positioned bed. No distress noted. When asked by the staff nurse was he hurting? He responded, "No, I'm hungry". No injury noted. No redness or swelling noted. Review of the Accident and Incident dated 8/27/10 at 10:00 a. m. revealed that the resident continues to roll out of the low bed on the mattress on the floor. Further review of the documentation revealed that that the incident was un-witnessed. On 9/15/10 at 9:21 a. m. an interview was conducted with S5LPN. She verified that when she documented on 8/29/10 at 10:00 a. m. that it was the wrong date that she had written. She stated that she should have written 8/27/10 at 10:00 a. m. She stated that the Nurse's Notes was out of sequence. 8/28/10 10:00 a. m.-Other. Resident room. Review of the Nurse's Notes revealed that the resident was found on the mattress on the floor next to the bed. Resident was assisted times two persons onto the Geri-chair. Denied pain. Review of the A & I Report dated 8/28/10 revealed that Resident #4 constantly rolls out of the low bed to the mattress on the floor. Further review of the documentation revealed that sometimes the resident would roll from the mattress on the floor to the fall mat and then to the tile floor. Incident un-witnessed. Review of the Comprehensive Plan of Care for Falls dated 5/1/10 revealed on 8/27/10 and 8/28/10 that the resident had two incidents. No new interventions were put in place. On 9/13/10 at 12:05 p. m. an interview was conducted with S8LPN. She stated that the resident remained in his room on the mat so much until it was impossible to document every time he was on the floor. She stated that he spent a lot of time on the mat in his room. On 9/13/10 at 1:20 p. m. an interview was conducted with S1Administrator. He stated that the staff was complaining that the resident fell so much that documenting on him was consuming all their time and they would not have time to care for the other residents. He stated that he informed his staff to document the first incident of a fall and how ever many after that put on the incident report times how ever many more falls he had. He verified that it was the facility policy to assess the resident after each fall no matter how minor the incident may be but there was no way that the staff could do this without it consuming their entire day documenting on one resident. He stated that they moved the resident closer to the nurses station, put mattresses all over his floor and a fall mat, moved him to the "b" side of the room and removed all of his furniture. Review of the Comprehensive Care Plan for Falls dated 5/1/10 revealed that these were new interventions for falls on 5/1/10, 5/3/10 and 5/5/10 before the fractures and injuries were noted to occur. He did not provide an answer when asked if the resident's room could be visibly seen from the nurses station and the majority of the incidents that occurred the resident was found on the floor in his room. He replied that the staff would bring the resident to the nurse's station occasionally as noted in the nurse's notes when asked how was monitoring increased. On 9/13/10 at 2:15 p. m. an interview was conducted with S7Clinical Care Coordinator. She verified that on Resident's #4 Comprehensive Care Plan for Falls dated 5/1/10 that on 6/24/10 that she documented that the resident complained of rib pain with noted interventions to assess breath sounds to bilateral lungs every shift times 14 days. ..... She verified that documentation was found in the Nurse's Notes that when Resident #4 was sent out to the hospital that he was diagnosed with [REDACTED]. She verified that the Care Plan is suppose to be updated to reflect the resident's current status as well significant incidents. On 9/15/10 at 9:10 a. m an interview was conducted with S2Medicare Coordinator. She stated that the Comprehensive Care Plan for Falls is suppose to be updated after each fall to reflect the resident's current status. She stated that she updates the care plan after the resident comes back from the hospital using the interventions that the hospital recommends. She stated that another care plan nurse had documented on Resident #4's fall care plan. She verified that the Comprehensive Care Plan for Falls dated 5/1/10 did not contain updated information for falls on the following dates: 6/17/10, 6/18/10, 6/29/10, 7/16/10-8 fall incidents. 7/17/10-2 fall incidents. 7/18/10, 7/21/10, 8/4/10, 8/8/10, 8/21/10, 8/27/10 and 8/28/10. She verified that there were no interventions dated there were put in place for falls noted on 5/5/10, 6/2/10 and 6/10/10 and that all the interventions were put in place prior to the resident sustaining injuries or fractures as per documentation on the Fall Care Plan and that no new intervention was noted after. On 9/15/10 at 9:15 a. m. an interview was conducted with S8LPN. She verified that the facility was aware that Resident #4 had a right distal humerus fracture diagnosed per mobile X-ray two to three hours after the X-ray was taken. She stated that the written copy of the report was in the resident's record. Resident #5 Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Most recent MDS revealed resident's cognitive status to be a 2; Moderately Impaired-decisions poor, cues\supervision required. Review of the Incident Log revealed that Resident #5 had falls on the following dates: 6/15/10 3:45 a. m.-Fall/head injury. Hematoma. Resident room.Sent to ER 7/10/10 9:15 a. m.-Fall/no head injury. Secure Unit Lounge. 7/11/10 10:25 p. m.-Fall/head injury. Hematoma. Resident room. 7/30/10 4:30 p. m.-Fall/no head injury. Secure Unit room. 8/30/10 10:45 p. m.-Fall/no head injury. Resident room. 9/6/10 5:30 a. m.-Fall/head injury. Hematoma. Resident room. emergency room . Review of Resident #5's Comprehensive Plan of Care for Potential for falls dated 4/1/10 revealed no updated information for falls on the following dates: 6/15/10, 7/10/10,7/11/10 and 7/30/10. On 9/15/10 at 9:10 a. m an interview was conducted with S2Medicare Coordinator. She stated that the Comprehensive Care Plan for Falls are suppose to be updated after each fall to reflect the resident's current status. She stated that she updates the care plan after the resident comes back from the hospital using the interventions that the hospital recommends. She verified there were no updates on the resident's Comprehensive Fall Care Plan dated 4/1/10 for falls for 6/15/10, 7/10/10, 7/11/10, and 7/30/10. The facility failed to ensure that after each incident of falls or injury of unknown origin that resident #4 and #5 was reassessed and their comprehensive care plans were revise to meet the residents medical, nursing and psychosocial needs.