Every finding on record at Lenox Care Center

Based on record review, observations, staff interview and policy review the facility failed to utilize enhanced barrier precautions (EBP's) and failed to ensure staff followed infection control practices to protect against cross contamination and potential spread of infection for 2 of 4 residents sampled on EBP's (Resident #1 and #22). The facility staff also failed to use a barrier and utilize appropriate wound care techniques, and failed to handle soiled linens to prevent the potential spread of infection for 1 of 3 residents observed for wound care (Resident #22). The facility also failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility reported a census of 25 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had diagnoses of heart failure, diabetes, and chronic obstructive pulmonary disease (COPD). The MDS documented the resident had a Brief Interview for Mental Status of 14 out of 15 indicating cognition intact. The MDS indicated the resident required partial to moderate assistance for bed mobility, and dependent for transfers and toileting hygiene. The MDS indicated the resident had an indwelling catheter. The Care Plan initiated 1/19/26 revealed the resident required EBP's related to the presence of an indwelling catheter. The Care Plan directed staff to use EBP's during the completion of high contact activities, and ensure hand hygiene completed prior to and after cares. The Care Plan also directed staff to assist with toileting and provide peri-care as needed, and use a mechanical lift and two staff for transfers. Observations revealed the following: a. On 3/21/26 at 2:20 PM, an EBP sign was posted on the door to the resident's room. The resident sat in a wheelchair and had a catheter in a dignity bag. b. On 3/21/26 at 2:28 PM, Staff A, certified nursing assistant (CNA), and Staff B, CNA, were in Resident #1's room. Staff A and Staff B had gloves on and attached a sling under the resident to the mechanical lift, then placed the resident's urinary catheter by his waist and transferred the resident from the wheelchair to the bed. Staff A placed the resident's catheter on the lower bedframe, then removed the resident's pants and brief and placed a bedpan under the resident. Staff removed their gloves and washed their hands and left the room.At 2:44 PM, Staff A and Staff B re-entered the resident's room. Staff A and Staff B donned a pair of gloves. Staff B performed pericare for Resident #1, then took additional wipes and cleansed around the catheter site. Staff assisted the resident to roll onto his right side and removed the bed pan under him. Staff B took disposable wipes and cleansed the buttocks area. Two foam dressings were observed to the bilateral upper buttocks. Staff B removed the gloves on her hands. Staff A placed a clean brief under the resident, rolled the resident onto his back and attached the brief tabs. Staff A removed her gloves. Staff A and Staff B did not wear a gown during high contact care activities such as when the resident was transferred, catheter was handled and when cares were provided for Resident #1. The facility's Enhanced Barrier Precautions (EBP) Policy date 3/25/24 revealed EBP's are utilized to reduce and prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs are indicated for residents with chronic wounds and/or indwelling medical devices. Gloves and gown are applied before performing high-contact resident care activities. High-contact resident care activities requiring the use of a gown and gloves include for transfers, changing briefs or assisting with toileting, and catheter care or use. 2. The annual MDS assessment dated [DATE] revealed Resident #22 had diagnoses of diabetes, peripheral venous insufficiency (veins valves are damaged and cause blood to pool in leg), and lymphedema (swelling caused by buildup of lymph fluid between the skin and muscle). The Care Plan revised 6/24/25 revealed the resident had diabetic ulcers on the toes of his left foot. The Care Plan directed staff to administer treatments as ordered and per facility protocol. The Treatment Administration Record (TAR) for March 2026 revealed an order to cleanse the left toes/foot with Vashe solution, apply betadine to the wounds, cover wounds with absorbent gauze, then secure with a dry gauze daily. The TAR revealed Staff H documented treatment completed on 3/23/26. During observation on 3/23/26 at 9:55 AM, an EBP's hung on the door to Resident #22's room. Staff H, Registered Nurse (RN) placed a bottle of Vashe wound cleanser solution and interdry dressing on top of the dressing supply cart. Staff H pushed the cart down the hall, donned a mask, gown and gloves and then pushed the cart into Resident #5's room. Staff H opened two small bottles of saline, then opened the drawer to the cart to obtain a pile of gauze. Staff H closed the drawer to the cart, then proceeded to pour saline onto a gauze. Staff H took the saline soaked gauze and cleansed under the resident's abdominal folds. Staff H took another gauze and cleansed the groin. Staff H changed her gloves, placed a pad and towel on the floor, then removed the resident's sock and soiled dressings (with green and brownish drainage) from the left foot and between the toes. The toes were swollen and had a grayish appearance to the wound between the big and second toe as well as slough by the base of the toes. Staff H changed gloves, poured Vashe wound cleanser onto the gauze and cleansed the toes on the left foot, scrubbing the skin with the gauze. Staff H took a betadine swab and painted the area between the toes. Staff H changed her gloves, then opened the drawer on the cart, took out gauze and kerlix, closed the drawer on the cart then proceeded to place gauze between the toes and over the top of the toes. Staff H took a kerlix roll and wrapped the dressing over the area. Staff H opened the drawer on the cart again, took out a roll of tape, tore off a piece of tape and stuck the tape on top of the cart. Staff H opened the drawers on the cart, then moved the isolation gown and reached into her uniform pocket to get a pen. Staff H wrote the date on the piece of tape that was stuck to the top of the cart, then placed the tape over the dressing on the resident's foot. Staff H applied the resident's sock, the took a box of gloves on top of the cart and placed the box of gloves in a rack on the side of the cart. Staff H picked up the soiled pad and towel from the floor and placed it on the top of the cart, then removed her gown and placed the gown in the trash receptacle on the side of the supply cart. Staff H put supplies she left on top of the cart into the drawers, then pushed the same cart to room [ROOM NUMBER]. Staff H then donned a pair of gloves, picked up the soiled pad/towel on the cart and took them down the hall. The ADON stood in the room with the surveyor during the observation of Staff H. In an interview on 2/23/26 at 10:30 AM, the ADON reported EBP's are used to prevent the spread of germs and to make sure residents and staff were protected. The ADON confirmed the dressing supply cart should not have been taken into the room when a resident was on EBP's. The ADON also confirmed Staff H touched drawers and items in the cart with contaminated gloves. She expected staff to change gloves and sanitize hands when soiled or whenever went from a dirty to a clean area. A Wound Care policy revised 10/2010 revealed wound care completed to promote healing. Place all items to be used during the procedure on a disposable cloth or paper towel as a barrier. Use one gauze and wash the tissue around the wound. Disposable items should be discarded into a designated container. Disposable supplies cannot be returned to the cart. An Infection Prevention and Control Policy dated 1/1/26 revealed all staff are responsible for following all policies and procedures related to infection control. Equipment shall be cleaned and disinfected according to the facility's policy. Soiled linen shall be collected at the bedside and placed into a linen bag, and placed in a soiled utility room. A Handwashing / Hand Hygiene policy revised 8/2019 revealed the use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing the spread of infections. 3. On 3/23/2026 at 12:00 PM, the Maintenance Director stated he didn't know where the water flow diagram was and didn't know who was responsible for performing Legionella preventative procedures. He also stated he was not sure which part of the building the two (2) water heaters supplied. At 12:20 PM, a facility blueprint review did not identify the service area for each water supply line that entered the facility nor did it provide the location of high-risk stagnant water areas. At 12:30 PM, Staff E, Housekeeping supervisor stated staff flushes the sinks and toilets in the rooms during deep cleaning tasks. She stated it was not on the checklist. An undated facility document titled Deep Clean Checklist did not include toilet or sink flushing. At 12:40 PM, the Administrator stated the whirlpool next to the Director of Nursing's (DON) office was temporarily nonfunctioning and, to her knowledge, it was the last water supplied device in the hall water supply sequence. At 12:44 PM, the Administrator contacted the previous Maintenance Director who confirmed the water heaters' supply destinations. The Administrator confirmed the facility was licensed to house more resident's than their current census. A facility document titled Annual Legionella Environmental Assessment Form dated 1/21/26 revealed the facility had a whirlpool with no filter change or filter backwash documentation. It also revealed the facility had a fish aquarium with water at 77 degrees Fahrenheit ( degrees F) but no maintenance protocol and was last cleaned on 1/15/26. A policy titled Water Management Policy dated 10/2022 indicated the facility will complete an assessment of the water system annually. It also indicated the assessment data will identify where Legionella and other opportunistic waterborne pathogens could grow and spread. It further indicated the assessment will include interventions performed by the facility if risks were identified to prevent the growth of opportunistic waterborne pathogens as well as how the facility will monitor them. On 3/23/26 at 4:11 PM, the Administrator stated the facility could've done better at implementing the water management plan.

Based on observations, staff interviews, kitchen cleaning checklist and policy review the facility failed to maintain clean and sanitary conditions in the kitchen, failed to label and store food items and discard leftovers after 3 days in order to maintain food quality and reduce the risk of food-borne illness in the kitchen for two of two kitchen observations. The facility staff also failed to conceal hair completely in a hairnet for two of two meal service observations. The facility reported a census of 25 residents. Findings include:1.Initial Kitchen observations starting on 3/21/26 at 1:10 PM revealed the following: a. The door inside the Kenmore refrigerator contained one open carton of liquid whole eggs without an open date. The directions on the outside of the contain revealed to use the product within 3 days of the open date. The bottom shelf had a plastic bag that contained what appeared to be uncooked hamburger patties. The bag had no label or date listed on it. b. The Troulsen refrigerator had a container of whipped salad dressing with splatters of the contents on the outside and the lid of the container. The refrigerator also contained a large package of shredded lettuce that was open and lettuce had spilled out and onto the shelf. c. The Frigidaire freezer had a heavy build up of ice on the roof (inside top) of the freezer and shelves inside. d. The Victory refrigerator had a carton of apple juice that had the top corner of the container torn off and juice exposed to air. The carton of apple juice had a use by date 10/20 but no open date listed on the carton. e. A vent/screen on the ceiling above the food prep counter had a dust in-between the appeared dusty.2. On 3/22/26 at 11:49 AM, Staff C, Cook, had a hair restraint on but a moderate portion of beard/facial hair under his chin was uncovered. The hair restraint also had a dime sized hole and several pin sized holes in the front side of the hair restraint. Staff C had no hair restraint over his mustache. Staff C prepared and served food to residents in the dining room for lunch. 3. A follow up tour of the kitchen on 3/22/26 at 1:00 PM revealed: a. The Kenmore refrigerator continued to contain an open plastic bag with what appeared to be hamburger patties on the bottom shelf of the refrigerator, and the item remained unlabeled and not dated. b. The Troulsen refrigerator still had a container of whipped salad dressing with contents splattered on the outside of the container, and an open bag of shredded lettuce spilled on the shelf inside the refrigerator. c. The Frigidaire freezer continued to have a heavy build-up of ice. d. The vent/screen above the food prep counter remained dusty/ dirty. 4. On 3/23/26 at 7:06 AM, Staff D, cook, was observed in the kitchen cooking omelettes on a griddle without a hair net. She stated cooks should absolutely wear a hairnet while in the kitchen. She said she forgot and left hers in her car. In an interview 3/22/26 at 1:15 PM, the Dietary Manager (DM) reported he had worked as the DM at the facility since 2/2/26. The DM reported he expected food and beverage items labeled with the received date when it was taken off the delivery truck. The DM reported food and beverages needed labeled and dated when opened. He stated It's a work in progress. At the time, the Surveyor reported the items found during the initial tour of the kitchen and again during a follow-up visit to the kitchen. The DM then took the bag of hamburger patties and the bag of shredded lettuce and threw it in the trash. The DM reported a cleaning schedule was posted on the refrigerator with tasks for staff to complete daily, weekly, and some deep cleaning tasks. The DM reported they had some issues with the Frigidaire freezer building up with ice and thought maybe it was due to an overstock of food in the freezer. Staff told him the freezer had been defrosted just before he took over as the DM. The DM reported the screen above the food prep counter was a Maintenance duty. He thought Maintenance would clean it soon. The light fixtures in the kitchen also had a fair amount of dust on top, and one light fixture by the refrigerators had several cracks in it. The DM reported he expected facial hair such as a beard and/or mustache needed to be covered while staff in the kitchen and whenever prepared or served food. The DM reported Staff C's beard restraint melted when he got things out of the oven. In an interview 3/23/26 at 9:45 AM, Maintenance reported he did not clean the lights or vent above the food prep cart in the kitchen. Dietary staff were supposed to clean it. He used a TELS system for maintenance tasks that needed done in the in kitchen but cleaning the lights or vent was not a task for maintenance. A Kitchen Cleaning Checklist dated 3/15 through 3/21 revealed the daily, weekly and deep-cleaning tasks. The checklist lacked a task for defrosting freezers, cleaning/dusting light fixtures and cleaning the vent/screen above the food prep counter. The facility's Food Safety Requirement Policy dated 2025 revealed food stored, prepared, distributed and served in accordance with professional standards for food service safety and in a way that prevented foodborne illness. Food safety practices shall be followed including storing food in a manner that helped to prevent deterioration or contamination of the food and growth of microorganisms. Food needed to be labeled and dated including items that had a use-by date. Dietary staff must wear hair restraints (such as a hairnet, hat, and/or beard restraint) to prevent hair from contacting food.

Based on record review, observation, resident and staff interview, policy review and the National Fire Protection Association (NFPA), the facility failed to ensure that oxygen was not in the vicinity of residents that were smoking for 1 of 1 resident observed with oxygen in use (Resident #13). The facility reported a census of 25. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had diagnoses of cerebrovascular accident (CVA) (stroke), anemia, and hypertension (high blood pressure). The MDS indicated the resident did not use tobacco. The resident used oxygen (O2). The MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS recorded the resident was on O2. The Care Plan initiated on 12/2/25 revealed the resident used continuous O2 and at risk for alterations in O2 levels due to a diagnoses of CHF (congestive heart failure). She also had a risk of chest pain and shortness of breath. The Care Plan indicated the resident needed O2 via nasal cannula (NC). The Order Summary dated 3/21/26 revealed continuous O2 via NC at 1.5- 2 liters (L) per minute. During observations on 3/21/26 at 3:02 PM, Staff F, certified nursing assistant (CNA), stood outside as 5 residents were smoking on the patio outside. Resident #13 sat in a wheelchair with a nasal cannula / tubing that was connected to a portable O2 tank on the back of her wheelchair. At the time, the O2 was set at 2 liters and the gauge indicated there was O2 in the bottle. A male resident with a beard sat approximated 2 to 3 feet from Resident #13's portable O2 tank as he held a lighted cigarette and smoked. On 3/21/26 at 3:42 PM, Resident #13 continued to sit in a wheelchair on the patio with portable O2 on at 2 L per NC. At the time, Resident #13 reported she did not know the smokers would be coming out to smoke. The residents that came out to smoke did not bother her but she would just like to give them a lecture about what smoking could do to them.In an interview on 3/23/26 at 2:30 PM, Staff B, CNA, reported any available staff took residents out to smoke at designated smoke times at 10 AM, 3 PM and 8 PM. The front patio is for nonsmoking residents and the other patio (on the North Hall) are where the residents go to smoke. Staff B responded she did not know how far a resident that is smoking would be kept from someone that is on O2. Staff B stated a fire or an explosion could occur if oxygen came in contact with someone that was smoking. In an interview on 3/23/26 at 2:35 PM, Staff G, non-certified nursing assistant, reported he generally took the residents who smoked outside to smoke at 3 PM and 8 PM. The nonsmoking residents were supposed to go to the front patio when they wanted to go outside. The residents who smoked went to the patio on the back patio (North Hall). When the surveyor asked what could happen if someone smoking came in contact with oxygen, Staff G stated it would be bad, it could cause an explosion. Staff G stated he thought a distance of 6 to 8 feet would be best to keep someone that was smoking away from someone that had oxygen in use or in an area with a portable O2 tank. In an interview on 3/23/26 at 2:45 PM, Maintenance reported if someone that was smoking came close to an oxygen apparatus that would not be good. It could cause a fire or an explosion. Maintenance reported the front patio was designated for non-smoking residents and the back patio (by the exit door by the ice machine) was the designated area for residents that smoked. In an interview on 3/23/26 at 3:29 PM, the Administrator reported they generally do a smoking assessment on residents. Nonsmoking residents were allowed to go outside along with smoking residents. The Administrator stated she preferred a resident on O2 to be a little ways away from someone who is smoking so sparks don't fly. When asked how many feet is a little ways away, the Administrator stated probably 20 feet. The Administrator reported staff completed on-line education about oxygen use and safety on Healthcare Academy.An undated Resident Smoking policy revealed the facility provided a safe and healthy environment for residents, visitors and employees, including safety related to smoking. Oxygen use in the smoking area is prohibited. The policy revealed the number of feet from exits and common space utilized by other residents in order to protect non-smoking residents from second-hand smoke was left blank. The National Fire Protection Association (NFPA) website (https://www.nfpa.org/downloadable-resources/safety-tip-sheets/medical-oxygen-safety-tip-sheet) dated 2026 revealed the following medical oxygen safety: a. Smoking materials is the leading heat source resulting in medical oxygen related fires, injuries and deaths.b. There is no safe way to smoke in the home when oxygen is in use. c. Keep oxygen cylinders at least five feet from a heat source or open flame.d. Post No Smoking and No Open Flames signs in and outside to remind people not to smoke (when oxygen in area)e. Oxygen saturates fabric covered furniture, clothing, hair and bedding and made it easier for a fire to start and spread.

Based on clinical record reviews, staff interview, and policy review, the facility failed to identify and consistently document non-pharmacologic behavior interventions for 3 of 3 residents (#3, #6, #7) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 25 residents. Findings include:1) Resident #3's Minimum Data Set (MDS) assessment identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition It included diagnoses of non-Alzheimer's dementia, anxiety, depression, psychotic disorder, and schizophrenia. It indicated the resident required setup assistance with eating, moderate assistance with oral hygiene, maximal assistance with upper body dressing, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It further revealed the resident took antipsychotic and antidepressant medications in the 7-day look-back period.The Care Plan dated 10/14/25 directed staff to attempt nonpharmacological interventions before using PRN (as needed) medications. It did not direct staff what nonpharmacological interventions to use.The Electronic Health Record (EHR) included a Behavior Symptoms Monitoring response history dated 2/21/26 through 3/22/26 that did not include non-pharmacological interventions.Review of the Progress Notes failed to contain non-pharmacological interventions for multiple documented behaviors.On 3/22/26 at 1:44 PM, Staff I, Certified Medication Aide (CMA) stated the non-pharmacological intervention she used was to let the resident sleep.On 3/22/26 at 1:53 PM, Staff J, Registered Nurse (RN) stated she was not aware of non-pharmacological interventions staff were to use for his behaviors.On 3/22/26 at 2:03 PM, Staff K, Licensed Practical Nurse (LPN) stated the non-pharmacological intervention she used was approaching him in a nonconfrontational, calm tone.2) Resident #6's MDS assessment dated [DATE] revealed a BIMS score of 05 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, depression, and psychotic disorder. It indicated the resident required setup assistance with eating, supervision with shower transfers, moderate assistance with toileting and showering, and was independent with all other Activities of Daily Living (ADLs) and all forms of mobility. It further revealed the resident took antianxiety, antidepressant, and antipsychotic medications in the 7-day look-back period.The Care Plan revised 5/29/25 included alterations in mood related to depression, anxiety, and dementia but did not identify nonpharmacological interventions for staff to attempt.The Orders Administration Note Progress Note dated 2/15/26 and 2/16/26 revealed staff observed resident behaviors but no non-pharmacological interventions were identified or documented.The Electronic Health Record (EHR) included a Behavior Symptoms Monitoring response history dated 2/21/26 through 3/22/26 that did not include non-pharmacological interventions.On 3/22/26 at 1:44 PM, Staff I, CMA stated the non-pharmacological intervention she used was to let the resident sleep.On 3/22/26 at 1:53 PM, Staff J, Registered Nurse (RN) stated she was not aware of non-pharmacological interventions staff were to use for his behaviors but assumed it was to encourage the resident to participate in social activities.On 3/22/26 at 2:03 PM, Staff K, Licensed Practical Nurse (LPN) stated the non-pharmacological intervention she used was to talk to the resident about his family and to keep him socializing.3) Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety, depression, and post-traumatic stress disorder (PTSD). It indicated the resident required setup assistance with eating, supervision with shower transfers, and was independent with all other Activities of Daily Living (ADLs) and all forms of mobility. It further revealed the resident took an antidepressant and antipsychotic medications in the 7-day look-back period.The Care Plan revised 8/26/25 included alterations in mood related to depression, anxiety, and PTSD but did not identify nonpharmacological interventions for staff to attempt.The Orders Administration Note Progress Note dated 3/19/26 and 3/20/26 revealed staff observed resident behaviors but no non-pharmacological interventions were identified or documented.The Electronic Health Record (EHR) included a Behavior Symptoms Monitoring response history dated 2/21/26 through 3/22/26 that did not include non-pharmacological interventions.On 3/22/26 at 1:44 PM, Staff I, CMA stated the non-pharmacological intervention she used was offer the resident conversation or snacks.On 3/22/26 at 1:53 PM, Staff J, Registered Nurse (RN) stated the non-pharmacological intervention she used was talking to him.On 3/22/26 at 2:03 PM, Staff K, Licensed Practical Nurse (LPN) stated the non-pharmacological intervention she used was to encourage him to socialize.A policy titled Use of Psychotropic Medication(s) dated 2025 indicated non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications.On 3/23/26 at 3:55 PM, the Director of Nursing (DON) stated staff should have implemented non-pharmacological interventions and documented them.

Based on clinical record review, staff interviews, and policy review, the facility failed to identify an expired medication before it was administered to 1 of 4 residents (#17). The facility reported a census of 25 residents.Findings include:Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of multiple sclerosis, seizure disorder, and respiratory failure. It indicated the resident required setup assistance with eating and oral hygiene, and moderate assistance with all other Activities of Daily Living (ADLs) and all forms of mobility. It revealed the resident received an anticonvulsant medication in the 7-day look-back period.The Medication Administration Record (MAR) included a physician's order dated [DATE] for a 200 milligrams (mg) anticonvulsant medication by mouth twice per day. It further revealed the resident received 42 doses since [DATE].The Care Plan revised [DATE] directed staff to administer the anticonvulsant medication as ordered.On [DATE] at 8:16 AM, a continuous medication observation revealed Staff I, Certified Medication Aide (CMA) commit to administering the anticonvulsant medication to Resident #17. The medication card had five (5) pills remaining and contained two (2) labels. One label indicated the medication was received on [DATE] and directed staff to reorder the medication after [DATE]. The other label had an expiration date of 10/2024. Staff I stated she would remove the medication from the resident's medication stock and pull the replacement from the emergency medication kit (e-kit) and destroy the expired medication. At 8:25 AM, the Assistant Director of Nursing (ADON) stated the medication was just received from the supply pharmacy on [DATE]. She stated the pharmacy needed to be contacted to get the medication replaced.A policy titled Medication Administration dated 2025 directed staff to identify the medication expiration date. If expired, notify the nurse manager.On [DATE] at 3:55 PM, the Director of Nursing (DON) stated staff should have checked the expiration date prior to being administered. If expired, staff should destroy the medication and replace it through the pharmacy. If the medication had been previously administered, then staff should complete an incident report, and notify doctor and the resident's family.

Based on Electronic Health Record (EHR) review, resident interview, staff interview, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed follow physician ordered interventions for a resident with no bowel movement for 3 days and 5 days for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 25 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented no Brief Interview for Mental Status (BIMS) indicating Resident #2 was rarely/never understood. The MDS also documented a diagnosis of constipation. The MDS further documented Resident #2 was always incontinent of bowel. Review of Resident #2's EHR titled, Bowel Elimination from 5/21/25 - 6/24/25 documented no bowel movement from 5/24/25 through 5/29/25. The previous bowel movement was recorded on 5/23/25 at 12:15 PM. The next bowel movement was recorded on 5/30/25 at 1:40 PM. No bowel movements were recorded from 6/18/25 - 6/19/25. The previous bowel movement was recorded on 6/17/25 at 9:20 AM. The next bowel movement was recorded 6/20/25 at 1:01 PM. No bowel movements were recorded from 6/21/25 - 6/22/25. The previous bowel movement was recorded on 6/20/25 at 9:59 PM. The next bowel movement was recorded 6/23/25 at 1:59 PM. Review of Resident #2's EHR titled, Orders documented current physician's orders for milk of magnesia suspension 1200 mg/15 mL give 30 mL by mouth as needed for constipation daily. Review of Resident #2's MAR-TAR for the month of May documented milk of magnesia was given as needed on 5/27/25 and 5/30/25. Review of Resident #2's MAR-TAR for the month of June lacked documentation that milk of magnesia was given as needed at all. Review of Resident #2's EHR titled, Care Plan documented interventions initiated 5/22/25 to document bowel movements every shift, follow facility protocol for administration of stool softeners / laxatives / enemas as indicated and observe for s/s of constipation (abdomen distention, nausea / vomiting, anorexia, decreased bowel sounds etc) and report to physician as indicated. Review of Resident #2's EHR titled, Progress Notes documented PRN milk of magnesia was given on 5/27/25 and was ineffective. Progress Notes also documented PRN milk of magnesia was given on 5/30/25 and was effective. On 6/24/25 at 4:38 PM Staff A, Assistant Director of Nursing (ADON) / Social Services stated she spoke to Staff B on 6/24/25 and she said on 5/27/25 Resident #2 had hypoactive bowel sounds. Staff A stated Staff B said the hospice Certified Nursing Assistant (CNA) reported on the 5/28/25 and 5/29/25 Resident #2 was smearing and that was in an email from the CNA to Staff B. Staff A stated Staff B told her that a nurse that worked at the facility gave milk of magnesia on 5/27/25. On 6/25/25 at 12:00 PM Staff B, Registered Nurse (RN) for hospice provider acknowledged Resident #2 was on her caseload. Staff B stated she had Resident #2 scheduled for 3 times a week for nursing visits. Staff B stated the hospice bowel protocol generally started on the 3rd day of no bowel movement. Staff B stated if milk of magnesia had been given and the results were ineffective on day 3 without a BM she would expect that the milk of magnesia would have been given every day after the 3rd day with no bowel movement. Staff B stated she had documented in her notes that milk of magnesia was given on 5/27/25. Staff B stated her hospice Certified Nursing Aide (CNA) reported Resident #2 was smearing BM during the bath on 5/28/25 and again on 5/29/25 but no bowel movement. Staff B stated there was a time where he was not eating much so it would be less of a concern than no bowel movement at all but still remained a concern. Staff B stated she would expect that an assessment would be expected and possibly the milk of magnesia PRN order given until notable BM depending on the assessment results. 2. The MDS dated [DATE] for Resident #3 documented a BIMS of 12 indicating moderate cognitive impairment. The MDS also documented diagnoses of malnutrition, depression, bipolar, and a history of falling. Review of Resident #3's EHR titled, Bowel Elimination from 5/16/25 - 6/23/25 documented no bowel movement from 5/23/25 through 5/25/25. Previous bowel movement recorded on 5/22/25 at 1:59 PM. Next bowel movement recorded on 5/26/25 at 1:08 PM. Review of Resident #3's EHR titled, Orders documented a current physician's order that started 12/16/24 of milk of magnesia 400 mg/5 mL to give 30 mL by mouth every 24 hours as needed for constipation, Miralax powder started 10/11/24 to give 17 grams by mouth every 24 hours as needed for complaints of constipation, bisacodyl rectal suppository 10 mg insert 1 suppository rectally every 24 hours as need for constipation and milk of magnesia to give 30 mL if no BM for 3 days, give bisacodyl suppository if no bowel movement for 4 days, contact PCC if no BM in 5 days as needed for bowel movement function bowel movement protocol for facility. Review of Resident #3's MAR-TAR for the month of May documentation that both orders for milk of magnesia, the order for Miralax and the order for bisacodyl were given on 5/11/25 and 5/26/25 only for the month of May. Review of Resident #3's EHR titled, Progress Notes documented both orders for milk of magnesia, the order for Miralax and the order for bisacodyl were refused. Progress Notes further lacked documentation of any assessment related to constipation. Review of Resident #3's EHR, Assessments, lacked documentation for abdominal assessment or change in condition. Review of Resident #3's EHR titled, Care Plan documented Resident #3 had potential for episodes of bowel obsessions. On 6/25/25 at 11:30 AM Staff C, Registered Nurse (RN) stated if a resident had gone 24 hours without a BM she would typically follow the bowel protocol that starts at 48 hours for milk of magnesia unless there was s/s of constipation. Staff C stated the protocol that starts at 48 hours was the order and that order superseded any 24 hours order unless the resident requested the medication or had s/s of constipation such as abdominal pain or distention. Staff C stated if an as needed medication was given for constipation and was ineffective she would follow the facility's bowel protocol. Staff C stated if the as needed medication for constipation was ineffective an abdominal assessment would be required. Staff C stated she would chart the results of the abdominal assessment in the Progress Notes. Staff C stated the bowel report was being completed every day shift. Staff C stated the report that she was using prior to the system switching over was accurate but now the bowel report that she utilized was not. Staff C stated the report showed people that had a bowel movement that day and also left residents off that had no bowel movement for 3 or 4 days. Staff C stated the facility found a different report to run that was accurate and that was started 6/24/25. On 6/24/25 at 11:15 AM the Director of Nursing (DON) stated the facility does have a protocol. The DON stated the night nurse was doing the resident bowel movement reports and then the nurses were told to run it on every shift by her. The DON stated the resident bowel movement report lets the nurse know which resident had been 3 or more days without a bowel movement. The DON stated the bowel protocol started on the third day of no bowel movement. The DON acknowledged Resident #3 had orders on the MAR-TAR for PRN constipation. The DON stated she would expect the milk of magnesia would have been given daily to Resident #2 if there was no BM in 24 hours and the order read that way. The DON acknowledged Resident #2 had 5 days without a bowel movement. The DON stated a change in condition assessment should have been completed or a Progress Note with bowel sounds or an abdominal assessment should have been completed. The DON stated a change in condition assessment would not be appropriate but a Progress Note with bowel sounds or an abdominal assessment in the Progress Notes because the as needed medication was utilized especially if the medication was ineffective. The DON stated the assessments should have been completed in the Progress Note when an as needed suppository or milk of magnesia related to constipation was given. On 6/24/25 at 4:23 PM the DON acknowledged the bowel report was not working appropriately. The DON stated there was a concern with the bowel report because the nursing staff had to select the exact right report or the report does not report anybody. The DON explained there were several options for bowel reports to be run. The DON acknowledged the facility noted the report was a problem on 6/24/25. On 6/25/25 at 1:00 PM the Administrator stated Resident #2 was in hospice and intake was very poor some days. The Administrator stated Resident #2 did not eat in the hospital prior to admission for a couple of weeks. The Administrator stated they did not have a bowel protocol policy. The Administrator stated the nurses are to follow the physician orders and that was the residents bowel protocol. The Administrator stated the facility did not have a policy for when an assessment should be completed. The Administrator stated the facility did not have a medication administration policy.

Based on observation, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 25 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented no Brief Interview for Mental Status (BIMS) indicating Resident #2 was rarely/never understood. The MDS also documented utilization of an indwelling catheter. The MDS further documented Resident #2 was always incontinent of bowel. On 6/24/25 at 4:02 PM an observation of personal care and catheter care completed on Resident #2 with the Director of Nursing (DON) present revealed both Staff D, Certified Nursing Assistant (CNA) and Staff E, Certified Nursing Assistant (CNA) completed hand hygiene, applied gloves and donned gowns. Staff D applied lift cloth, full body mechanical lift utilized, Staff D utilized the controls of the mechanical lift, Staff E directed Resident #2 to the bed. The full body mechanical lift was removed from the bedside, Resident #2 assisted with turning to the right by Staff D, lift cloth rolled under, resident assisted to the left by Staff D, lift cloth removed by Staff D, Staff D did not change gloves or perform hand hygiene. Staff D obtained an alcohol wipe from sink area, Staff D cleansed Resident #2's meatus with the alcohol wipe, Staff D then utilized the alcohol wipe to cleanse down the catheter tubing from penis. Staff E removed gloves, completed hand hygiene, and applied gloves. Staff D walked towards the bathroom and opened the curtain, Staff D obtained the graduate and returned to the bedside, Staff D handed Staff E the graduate, Staff D opened an alcohol wipe, Staff E removed the catheter tip from catheter bag, Staff E did not cleanse the catheter tubing tip, Staff E emptied 100 cc of urine from catheter bag, Staff D handed Staff E the alcohol wipe, Staff E cleansed the tip of the catheter tubing, Staff D emptied the graduate into the toilet, Staff D placed a clear garbage bag around the graduate, Staff E removed their gown, removed gloves and completed hand hygiene, Staff D opened Resident #2's bedroom door, Staff D left Resident #2's room with the graduate in a bag with gloves and gown on, Staff D walked down the east hall towards the nurses station toward the utility on the north hall, walked into the residents common area past 4 residents seated near the television, Staff D walked down the north hall to the utility room, Staff D entered the utility room, Staff D removed gloves, and gown and completed hand hygiene. On 6/24/25 at 4:23 PM the DON stated she did have a concern with the personal care and catheter cares provided to Resident #2. The DON stated her expectation was hand hygiene would have been completed when gloves were changed, when moving between tasks, when moving from a dirty area of the body to clean area, after catheter cares, before and after emptying urine from the catheter bag. The DON stated her expectation was that gloves would have been removed and hand hygiene would have been completed before opening the curtain to the bathroom and before leaving the residents room. The DON stated her expectation was that the gown and gloves would have been removed and hand hygiene would have been completed before the staff exited Resident #2's room, before walking down the hall to the dirty utility room. The DON stated her expectation was alcohol would have been utilized to cleanse the catheter tip before opening to drain and after draining urine from the catheter bag. Review of policy dated 3/25/24 titled, Enhanced Barrier Precautions documented EBP's are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied before performing high-contact resident care activities (as opposed to before entering the room). Personal protective equipment (PPE) was changed before caring for another resident. Examples of high-contact resident care activities requiring the use of a gown and gloves include transferring, providing hygiene, changing briefs or assisting with toileting and indwelling device care such as urinary catheters. Review of policy dated 6/19 titled, Handwashing / Hand Hygiene documented hand hygiene should be completed in situations such as before and after handling an invasive device (e.g. urinary catheters), before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling contaminated equipment, after removing gloves and before and after entering isolation precaution settings.

Based on observation, staff interview and policy review the facility failed to provide food at an appetizing temperature when the mechanical soft meatballs temperature was 95 degrees in the steam table. The facility reported a census of 24 residents. Findings include: During continuous observation of lunch service on 2/26/25 at 11:50 AM - 1:00 PM Staff H, AM Cook, completed lunch service with the last plate for a resident on a mechanical soft diet. Staff H obtained a temperature of 95 degrees on the remaining mechanical soft meatballs left in the steam table. On 2/26/25 at 1:00 PM Staff H acknowledged the mechanical meatball temperature of 95 degrees was unacceptable. Staff H stated food in the steam table should have had a holding temperature of 135 degrees or higher. On 2/26/25 at 1:10 PM Staff I, Certified Dietary Manager (CDM) stated the mechanical meatball temperature of 95 degrees was unacceptable. Staff I stated the mechanical soft meatballs in the steam table should have had a holding temperature of 135 degrees or higher. On 2/26/25 at 3:56 PM Staff E, Contract Registered Dietitian stated she would have expected the mechanical meatballs to have a holding temperature of 135 degrees or higher in the steamtable. Review of the undated policy titled, Food Temperatures documented hot food temperatures must read no less than 140 degrees when residents are served.

Based on the clinical record review, resident interview, staff interview and policy review the facility failed to provide access to personal funds managed by the facility for 1 of 1 residents reviewed. The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 2/24/25 at 11:55 AM Resident #11 stated she wanted to have some money on the weekend recently to buy soda but it is not available from personal funds at the facility on the weekends or in the evenings. On 2/25/25 at 2:28 PM Staff C, Business Office Manager stated the facility did have money in a lockbox available for the residents. Staff C stated the facility kept $110.00 in the lockbox. Staff C stated she and the Administrator are the only staff that had access to the petty cash. Staff C stated the residents could not have money if she was not in the building unless it was an emergency. Staff C stated she worked at the facility 8:00 AM to 4:30 PM or 5:00 PM. Staff C stated she worked Monday through Friday. Staff C stated the residents at the facility did not have access to their money in the evening or on the weekend. Staff C acknowledged yesterday a resident wanted to break a $10.00 bill for $10.00's in change but she was not at the facility. Staff C stated the resident did not get the $10.00 bill broken. Staff C stated a CNA told her this morning. On 2/25/25 at 2:55 PM Staff B, CNA stated she works the 2-10 PM shift and every other weekend. Staff B stated a resident asked just the other day if she could have money in the evening. Staff B stated residents did not have access to get money from the resident trust in the evening or on the weekends. Staff B stated the only person that has access to resident funds was Staff C. On 2/25/25 at 3:08 PM the Administrator stated the residents could ask the staff to call the Administrator or Staff C to come in and get money for the residents. The Administrator acknowledged she had not been asked to come in on the weekends or in the evening. The Administrator stated she thought Staff C works sometimes on the weekend. The Administrator acknowledged the residents at the facility did not have access to funds on the weekends or in the evening when the Administrator or Staff C had left. Review of policy revised 3/21 titled, Deposit of Residents' Personal Funds documented that if a resident chose for the facility to hold personal funds, the facility would provide the resident access to funds of 100 dollars (fifty dollars for Medicaid residents) or less within twenty-four hours, and access to funds in excess of 100 dollars (fifty dollars for Medicaid residents) within three banking days.

Based on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents by not serving residents on a mechanical soft diet the appropriate amount of meat according to the menu for 4 of 24 residents reviewed. The facility reported a census of 24 residents. Findings include: On 2/26/25 at 11:50 AM Staff H, AM [NAME] obtained 8 meatballs and placed them in the food processor. Staff H processed the meatballs and removed them from the processor into a plastic container. Staff H then placed the plastic storage container in a pan in the steam table. Lunch was served. Tongs were utilized for serving mechanical soft meatballs. The last plate was for a resident with a mechanical soft diet. Staff H measured 1/3 cup for the remaining mechanical soft meatballs. Review of document titled, Diet Spreadsheets Week 3 Wednesday documented 2 ground meatballs for mechanical soft diets. On 2/26/25 at 1:10 PM Staff I, Certified Dietary Manager (CDM) acknowledged all of the mechanical soft meatballs should have been served. Staff I stated there should not have been 1/3 cup leftover after lunch service. Staff I stated there were 4 servings processed and all of the mechanical soft meatballs should have been served. On 2/26/25 at 3:56 PM Staff E, Contract Registered Dietitian stated all of the mechanical soft meatballs should have been served. Staff E stated there should not have been 1/3 cup leftover after lunch service. Review of the undated policy titled, Portion Control documented food would be served according to standard portion sizes to ensure adequate servings of food and to provide portions that are equal in size for those residents that do not require specialized dietary modifications. Portion control equipment will be used at meal times. Ounce scales will be available to weigh meat portions after they are cooked. Residents on diets that require portion variations will have the required information either stated on their tray card or it could be found on the diet spreadsheet under the diet they are on.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open food items and discarding leftovers. The facility also failed to sanitize a thermometer prior to use. The facility reported a census of 24 residents. Findings include: During a continuous observation on 2/24/25 from 10:00 AM - 10:25 AM revealed a white stand up refrigerator/freezer had containers of cut lettuce dated 2/19, cut tomatoes dated 2/19, cut tomatoes dated 2/18, turkey gravy dated 2/18, bread stuffing (dressing) dated 2/16, cut ham dated 2/19, and cut lettuce dated 2/18. A stand up double door refrigerator had a plastic bag of ham dated 2/4. A double door stand up refrigerator for liquids had a pitcher of lemonade dated 2/14. The same double door stand up refrigerator for liquids also had undated pitchers of grape drink and pitchers of tea. On 2/24/25 at 10:30 AM Staff I, Certified Dietary Manager (CDM) stated the facility's expectation was that open food in containers would be thrown away after 3 days. Staff I acknowledged the containers of tomatoes, lettuce, cut ham, bread stuffing (dressing) and the plastic bag of ham should have been disposed of. Staff I stated the drink pitchers should have been dated and after 3 days should also have been disposed of. A continuous observation on 2/26/25 from 11:50 AM - 1:00 PM revealed Staff I obtained a thermometer and checked the mechanical meatball temperature in the plastic container. A temperature of 109 was revealed for the mechanical soft meatball. The plastic container with mechanical soft meatballs was removed from the table, thermometer placed on the table where the plastic container was, the plastic container with the mechanical meatballs was placed in the microwave, the container was removed from the microwave and taken to the table, the thermometer was picked up, the container was placed where the thermometer was, the mechanical soft meatballs temperature was rechecked. A temperature of 144 was obtained. The process was completed over again until the mechanical soft meatballs in the microwave reached a temperature of 165. On 2/26/25 at 1:10 PM Staff I stated the thermometer should have been cleaned/sanitized prior to rechecking the mechanical meatballs after being microwaved. On 2/26/25 at 3:56 PM Staff E, Contract Registered Dietitian, stated she would expect the food to have been thrown out after 3 days. Staff E stated there should have been dates on items/drinks when they were made. Staff E stated she would have expected the food thermometer would have been sanitized before checking the temperature of foods. Review of policy revised 7/14 titled, Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on Electronic Health Records (EHR) review, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower and reposition 1 of 12 residents reviewed (Resident #5). The facility reported a census of 24 residents. Finding include: The Minimum Data Set (MDS) for Resident #5, dated 12/27/24 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The MDS also documented diagnoses of athetoid cerebral palsy, abnormal posture, contracture of right hand, contracture of left hand, contracture unspecified ankle, contracture unspecified knee, contracture unspecified hip, unspecified quadriplegia, and unspecified dystonia. Review of Resident #5's Care Plan documented Resident #5 had a self-care deficit and required assistance with Activities of Daily Living (ADLs). Resident #5 required 2 people to assist and encourage bathing 2 x weekly. Resident #5 required 2 person assistance with bed mobility. Resident #5 mobility was described as bed bound. The Care Plan documented Resident #5 was at risk for pain/discomfort and increased risk for injury from decreased function related to dx of cerebral palsy. The Care Plan also documented to attempt and document any of non-pharmacological interventions used as appropriate such as repositioning, heat pack, and massage. Encourage Resident #5 to shift weight, if able, every 2 hours to assist with skin integrity. On 2/25/25 at 1:55 PM Staff Q, Certified Nursing Assistant (CNA) stated Resident #5 does not get repositioned. Staff Q stated Resident #5 only had stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 1:55 PM Staff A, CNA stated Resident #5 does not get repositioned. Staff A stated Resident #5 only stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 2:10 PM the Director of Nursing (DON) stated Resident #5 did not get repositioned from side to side. The DON stated Resident #5 only laid on his back while in bed. The DON stated the air flow mattress provided enough change in position that Resident #5 did not need repositioning. On 2/26/25 at 9:40 AM the Administrator stated it was the facility's expectation that staff would reposition Resident #5. On 2/26/25 at 10:06 AM Staff R, Certified Occupational Therapy Assistant (COTA) / Director of Rehab stated he was familiar with Resident #5. Staff R stated the pressure relief mattress would be enough to prevent breakdown. Staff R stated the pressure relief mattress was to offload weight. Staff R stated he did not think repositioning would benefit the resident. Staff R stated there was a current order to evaluate. On 2/26/25 at 5:49 PM the DON stated that Resident #5 was repositioned when care was completed. The DON stated that personal cares were Resident #5's repositioning. Review of documents titled, Bathing Records for the last 90 days revealed 24 opportunities for baths. The clinical record lacked documentation of baths being given on 12/20, 12/13, and 11/29/24. Bathing records revealed Resident #5 received only one bath a week for 3 out of 4 weeks and was not given a bath on Friday 3 out of 4 of the same weeks. The weeks were 11/24/24 - 12/21/24. On 2/27/25 at 9:06 AM the DON stated the facility's expectation for baths was Resident #5 would have received 2 baths a week on Tuesday and Friday and made up if the bath was missed. The DON acknowledged baths were missed on 12/20, 12/13, and 11/29/24. The DON acknowledged Resident #5 did not get a bath 3 out of 4 weeks on Fridays. Review of policy dated 5/13 titled, Repositioning documented the purpose of this procedure was to provide guidelines for the evaluation of the residents repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Residents who are in bed should be on at least an every 2 hour repositioning schedule. Review of policy revised 3/18 titled, Activities of Daily Living (ADL), documented that residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain food nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care including appropriate support and assistance with bathing and mobility. Care and services to prevent and or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. The resident's ability to perform ADL's will be measured using clinical tools, including the MDS. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on observations, record review, staff interview, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 28 opportunities for errors resulting in an error rate of 7.14% (Residents #178). The facility identified a census of 24 residents. Findings include: On 2/25/25 beginning at 7:16 AM, Staff F, Certified Medication Aide (CMA) prepared the following medications to administer to Resident #178: a) One (1) Oxycodone/APAP 5/525 milligrams (mg) tablet b) Miralax 17 grams c) gabapentin 2 milliliters (mL) d) One (1) celecoxib 100 mg capsule e) One (1) citalopram 40 mg tablet f) One (1) azathioprine 50 mg tablet g) One (1) Lisinopril 10 mg tablet h) One (1) Omeprazole 40 mg capsule i) One (1) multivitamin (MVI) tablet j) One (1) vitamin C 500 mg tablet k) One (1) Ocuvite gummy Staff F confirmed there were 11 medications, she then administered them to Resident #178. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not documented. It indicated the resident had memory problems and severely impaired decision-making ability. It included diagnoses of diabetes mellitus, anxiety disorder, immunodeficiency, Alzheimer's Disease, and dementia. The Electronic Health Record (EHR) included a physician's two (2) orders for a) Vitamin C oral tablet 1000 mg; give 1 tablet by mouth one time a day for promote wound healing, and b) Omeprazole oral capsule delayed release 20 mg; give 1 capsule by mouth every morning. The Medication Administration Record (MAR) revealed staff acknowledged administering one (1) Omeprazole oral capsule delayed release 20 mg by mouth one time a day between 2/01/25 through 2/27/25. The pharmacy supplied Omeprazole 40 mg; take 1 capsule by mouth every morning. The Care Plan dated 1/19/25 indicated the resident had an unstageable pressure ulcer on her left heel and included Vitamin C 1000 mg order obtained to promote wound healing. On 2/27/25 at 9:25 AM, Staff F stated the resident received one (1) 500 mg tablet by mouth Tuesday, 2/25/25 during medication pass observation. She confirmed the stock medication bottle was 500 mg tablets. On 2/27/25 at 11:38 AM, the Assistant Director of Nursing (ADON) stated the Omeprazole order was supposed to be 40 mg and was incorrectly entered into the resident's EHR. At 3:46 PM, the Director of Nursing (DON) stated staff should have been looking at the MAR and should have clarified the order with the physician. A policy titled Medication Therapy revised April 2007 indicated all medication orders will be supported by appropriate care processes and practices.

Based on facility document review, family interview, staff interviews, personnel file review and policy review, the facility staff failed to report suspected abuse between a staff member and a resident (#15) within two (2) hours after the observed behavior. The facility reported a census of 24. Findings include: On 2/24/25, a facility-reported incident indicated Staff K, Certified Nurse Aide (CNA) witnessed Staff L, CNA tickle Resident #15's nipple while they helped the resident get dressed. On 2/24/25 at 12:32 PM, Resident #15's relative stated Staff M, Licensed Practical Nurse (LPN) notified him on 2/23/25 at 4:46 PM that Resident #15 was inappropriately touched just before lunch. On 2/25/25 at 1:17 PM, Staff K stated she witnessed the incident at 12:30 PM on 2/23/25 and notified Staff N, CNA around 2:50 PM of the incident. She also stated she waited until after 3:10 PM to notify the Assistant Director of Nursing (ADON). At 2:46 PM, the Director of Nursing (DON) verified the ADON was the on-call leadership staff on 2/23/25. She also stated all staff receive online abuse prevention training upon hire. At 3:21 PM, the ADON verified Staff K notified her of the suspected abuse on 2/23/25 at 3:40 PM. She also stated she notified the Administrator at 3:45 PM. On 2/27/25 at 11:53 AM, staff file reviews revealed Staff K completed a 3-year valid Dependent Adult Abuse training on 3/11/22. On 2/27/25 at 3:18 PM, the Administrator stated the staff should've called the Administrator immediately after the observed behavior. A policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy revised 4/2023 indicated all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Administrator. It also indicated all allegations of resident abuse shall be reported to the appropriate state entity not later than two (2) hours after the allegation is made.

Based on clinical record review, staff interviews, and policy review the facility failed to develop and implement a Comprehensive Care Plan for 2 of 12 residents (Resident #16, and #5) reviewed. The facility reported a census of 24 residents. 1. The Minimum Data Set (MDS) for Resident #16 dated 1/28/25 identified a Brief Interview for Mental Status (BIMS) score of 2/15 indicating a severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia, depression, psychotic disorder, and hypertension. The MDS did not identify a diagnosis for use of oxygen. The MDS indicated Resident #16 did not utilize oxygen during the reporting period. The Electronic Medical Record (EMR) Physician Orders dated 2/25/25 revealed Resident #16 was ordered on 11/20/22 oxygen at 2 liters/minute via nasal cannula as needed to keep saturations above 90%. The Physician Orders failed to identify times for monitoring of oxygen saturations. The EMR vitals oyxgen saturation summary revealed saturations were monitored weekly. The Care Plan revised 1/14/25 revealed lack of documentation related to respiratory compromise. The facility failed to develop a Comprehensive Care Plan with goals and interventions related to oxygen. On 2/25/25 at 12:18 PM Staff A, Certified Nursing Assistant (CNA), stated Resident #16 did use oxygen but not all the time. On 2/25/25 at 2:31 PM Staff B, CNA, stated she had not seen Resident #16 out of breath, and did not know when the resident used oxygen. On 2/25/25 at 2:37 PM Staff P, the Assistant Director of Nursing (ADON)/Social Worker/Licensed Practical Nurse (LPN), stated Resident #16 began using oxygen around Thanksgiving when the resident's oxygen would randomly drop for no apparent reason. Staff P stated saturations should be monitored on each shift which would be twice a day to ensure saturations were stable. Staff P stated the Care Plan should identify the use of oxygen as well as the signs/symptoms for use, what to do, who is responsible, and when to do it. Staff P stated Care Plans should be able to provide instructions for anyone new to working with the resident. On 2/25/25 at 2:55 PM the Director of Nursing (DON) stated she was aware that all of the Care Plans may not be completely up to date and there were likely problems. The DON stated the facility was working to correct this and that Care Plans should reflect the needs of the residents. 47673 2. The MDS for Resident #5, dated 12/27/2024 did not document a BIMS. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The MDS also documented diagnoses of athetoid cerebral palsy, abnormal posture, contracture of right hand, contracture of left hand, contracture unspecified ankle, contracture unspecified knee, contracture unspecified hip, unspecified quadriplegia, and unspecified dystonia. Review of Resident #5's Electronic Heath Record (EHR) titled, Care Plan documented no focus, goal, or intervention in place for restorative, physical therapy, or occupational therapy (OT). The Care Plan also did not document a focus, goal or intervention for repositioning Resident #5. On 2/25/25 at 1:55 PM Staff Q, CNA stated Resident #5 does not get repositioned. Staff Q stated Resident #5 only had stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 1:55 PM Staff A, CNA stated Resident #5 does not get repositioned. Staff A stated Resident #5 only stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 2:10 PM the DON stated Resident #5 did not get repositioned from side to side. The DON stated Resident #5 only laid on his back while in bed. The DON stated the air flow mattress provided enough change in position that Resident #5 did not need repositioning. The DON acknowledged there was no Care Plan focus, goals, or interventions in place related to Resident #5's positioning. The DON acknowledged there should be a Care Plan with focus, goal, or intervention for positioning. On 2/26/25 at 9:37 AM the DON stated a restorative program was on the EHR but fell off in September of 2024. The DON acknowledged there was a system error that led to the restorative program falling off the EHR. The DON stated they would get OT involved to find out if the restorative was appropriate and repositioning was needed. On 2/26/25 at 9:40 AM the Administrator stated it was the facility 's expectation that staff would reposition Resident #5. The Administrator stated Resident #5 was on a restorative program and still should have been. The Administrator acknowledged that the restorative program was on the EHR but fell off in September of 2024. The Administrator acknowledged there was a system error that led to the restorative program falling off the EHR. On 2/26/25 at 5:49 PM the DON stated that Resident #5 was repositioned when care was completed. The DON stated that personal cares were Resident #5's repositioning. On 2/26/25 at 5:51 PM the Administrator stated she would have expected something with therapy would have been completed. The Administrator acknowledged Resident #5 should have a Care Plan in place for positioning and restorative care. The Administrator acknowledged Resident #5 did not have either Care Plan in place. Review of policy revised 7/17 titled, Restorative Nursing Services documented residents will receive restorative nursing care as needed to help promote optimal safety and independence. The document also states the restorative goals and objectives are individualized and resident - centered, and are outlined in the resident's plan of care. Review of policy dated 5/13 titled, Repositioning documented the purpose of this procedure was to provide guidelines for the evaluation of the residents repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Residents who are in bed should be on at least an every 2 hour repositioning schedule. Review of policy dated 3/22/22 titled, Care Plans, Comprehensive Person - Centered documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are derived from a thorough analysis of the information gathered as part of comprehensive assessment. Review of policy revised 3/18 titled, Activities of Daily Living (ADL), supporting documents that residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain food nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care including appropriate support and assistance with bathing and mobility. Care and services to prevent and or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. The resident's ability to perform ADL's will be measured using clinical tools, including the MDS. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on clinical record review, staff interviews, observations and policy reviews the facility failed to review and revise the Care Plan interventions for 3 of 12 residents reviewed (Resident #12, #19, and #2). The facility failed to revise Care Plan Interventions for a resident who smoked, a resident who utilized a power wheelchair (w/c), and failed to include a family representative in the Care Plan Conference. The facility reported a census of 24 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #12 scored 15/15 on the Brief Interview for Mental Status (BIMS) indicating normal cognition. The resident had diagnoses of hypertension, anxiety disorder, depression, and morbid (severe) obesity. The resident required total staff assistance for toilet hygiene, bathing, footwear and substantial/maximal assistance for lower body dressing. Resident #12 completed bed mobility independently, transferred bed to w/c and toilet independently and walked 10 feet. The document revealed ambulation of 50 feet or greater with 2 turns was not attempted due to medical condition or safety concerns. The document revealed the resident utilized a motorized w/c for 150 feet with independence. The Electronic Medical Record (EMR) Progress Notes revealed the resident refused 19/30 opportunities of walk to dine restorative nursing program. The document revealed on 8/9/24 an order was received for discontinuation of the walk to dine restorative nursing program. Resident #12's Care Plan revised 2/3/25 with a focus area of risk of falling revealed an intervention for walking to meals. The facility failed to update the intervention upon discontinuation of the restorative nursing program on 8/9/24. On 2/25/25 at 2:47 PM Staff P, the Assistant Director of Nursing (ADON)/Social Worker/Licensed Practical Nurse (LPN) stated she did not believe Resident #12 walked to the dining room for meals. The staff stated she was not sure if that was on the Care Plan. 2. According to the MDS dated [DATE] Resident #19 scored 11/15 on the BIMS indicating moderate cognitive impairment. The resident had diagnoses of coronary artery disease, hypertension (high blood pressure), Non-Alzheimer's Disease, anxiety, depression, psychotic disorder, and nicotine dependence. The EMR Smoking Data Collection dated 12/2/24 revealed Resident #19 required smoking interventions of a smoker's apron, and supervised smoking. Resident #19's Care Plan revised 10/31/24 revealed a focus area for risk for injury related to smoking. Interventions for staff to follow included that the resident is not required to wear a smoker's apron at this time. The facility failed to update the Care Plan with the interventions from the Smoking Data Collection dated 12/2/24. On 2/25/25 at 2:43 PM Staff P stated she and the Director of Nursing (DON) primarily completed the assessments in the EMR, but sometimes floor nurses may complete an assessment. Staff P stated the smoking assessment was completed upon admission and then quarterly thereafter. Staff P stated the interventions recommended from the smoking assessment should be on the Care Plan. On 2/25/25 at 2:55 PM the DON stated she was aware that the Care Plans may not be completely up to date and there were likely problems. The DON stated the facility was working to correct this and that Care Plans should reflect the needs of the residents. Observed Resident #19 on 2/25/25 at 3:04 PM wearing a smoker's apron while smoking. 47673 3. The MDS for Resident #2 dated 1/7/24 documented a BIMS score of 0 indicating severe cognitive impairment. On 2/24/25 at 3:09 PM Resident #2's Power of Attorney (POA) stated she spoke to Staff P, a couple months ago about when Resident #2's care conferences would be. The POA stated Staff P told her that she was not sure. The POA stated she had not been invited to the care conference held in January 2025. Review of the EHR titled, Progress Notes entry by Staff P on 1/7/2025 at 10:01 AM documented a Care Plan meeting was held with resident, POA, DON, SSD, and charge nurse. No concerns voiced, no request for transfer to another facility, meds reviewed, no change in code status was desired. On 2/25/25 at 10:56 AM Staff P stated Resident #2 usually stated that she did not want to attend the care conferences. Staff P stated she notifies Resident #2 about the care conferences in advance. Staff P stated Resident #2 and Resident #2's POA was not present at the Care Plan meeting that was held 1/7/25. Staff P acknowledged that was inaccurately documented. Staff P stated she did not document when family members were notified of the care conference. Staff P stated she usually calls the resident family or POA. Staff P stated she spoke with Resident #2's POA about the Christmas party being scheduled. Staff P stated she did not remember if she reached out to the POA after that to invite her to the care conference. Staff P acknowledged that care conferences had not been done at all prior to her starting in her position in June of 2024. Staff P acknowledged she did not know what was supposed to be included in the care conference even now. Staff P stated the facility has in-services called lunch and learns and most recently she just found out she was supposed to be documenting who was present at the meetings. On 2/25/25 at 12:16 PM the DON acknowledged Care Plan conferences were not being completed appropriately prior to Staff P starting in her current position in June 2024. The DON stated care conferences should be completed every 3 months with the resident, resident family member, or POA if possible. The DON stated the facility's expectation was that accurate documentation of who was present at the care conferences would be completed. The DON stated the facility's expectation was the resident and/or residents POA would be invited to the care conference. Review of policy dated 3/22 titled, Care Planning - Interdisciplinary Team documented the resident, the resident's family and / or the resident's legal representative / guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

Based on observation, Electronic Health Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing appropriate hand hygiene when personal care was completed for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 24 residents. Finding include: The Minimum Data Set (MDS) for Resident #5, dated 12/27/2024 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. On 2/25/25 at 11:11 AM the Director of Nursing (DON) present during observation of tracheostomy care completed on Resident #5 by Staff M, Licensed Practical Nurse (LPN). Observation revealed Staff M completed hand hygiene, applied gloves, obtained materials for suctioning and tracheostomy cares. Staff M removed Gaze 4x4 around tracheostomy, removed metal trachea appliance. Staff M then removed gloves and applied sterile gloves. Staff M picked up sterile water off the bed, opened the bottle, poured the sterile water into the tracheostomy tray, picked up gauze 4x4, and put gauze in the sterile water in the tray. Staff M removed moistened 4x4, cleansed tracheostomy stoma, applied lube to clean tracheostomy appliance and reinserted. Staff M obtained a gauze 4x4 4 from the night stand and applied it to tracheostomy stoma. Staff M gathered trash and removed it from the bed. Staff M removed gloves, completed hand hygiene, applied gloves, initiated suctioning to clear tracheostomy. Staff M checked oxygen saturation with an oximeter with 94% on 8 L recorded. Staff M removed gloves, completed hand hygiene, applied gloves and completed cleaning of previously inserted tracheostomy appliances. Staff M removed gloves, doffed gown, completed hand hygiene, and exited the room with trash. On 2/25/25 at 11:39 AM the DON acknowledged missed opportunities for hand hygiene during tracheostomy care completed by Staff M. The DON stated the facility's expectation was that hand hygiene would be completed with all glove changes. The DON acknowledged Staff M did not complete hand hygiene with the glove change after initial removal of the tracheal appliance. An observation on 2/26/25 at 4:39 PM revealed Staff O, Certified Nursing Assistant (CNA) and Staff N, CNA knocked on Resident #5 room door, entered the room, completed hand hygiene, applied gloves and donned gowns. Staff O completed peri care to Resident #5's penis with peri wash and wet wipe. Staff O then utilized an alcohol wipe to cleanse catheter tubing and catheter stoma site. Resident #5 was assisted to the right side by Staff N. Staff O then cleansed Resident #5's buttocks and hips. Staff O applied barrier cream to Resident #5's buttocks. Gloves removed by Staff O, hand hygiene completed, gloves applied, assisted Resident #5 to the right side, assisted in helping Staff N apply new brief and completed care. Gloves and gown doffed by both and hand hygiene completed. On 2/26/25 at 5:30 PM the DON acknowledged missed opportunities for hand hygiene when Staff O completed personal cares on Resident #5. The DON stated hand hygiene and glove change should have been completed before moving from peri area to suprapubic catheter stoma, before moving from catheter stoma to buttocks and prior to application of barrier cream. Review of the policy revised 8/19 titled, Handwashing/Hand Hygiene documented hand hygiene should have been completed before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, and after removing gloves.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 1 resident (#1) reviewed for nutrition. This failure resulted in Resident #1 experiencing a weight loss of 11.05% in 6 months. The facility reported a census of 24 residents. Findings include: On 2/24/25 at 11:27 AM, Resident #1 was observed asleep in her bed. At 2:22 PM, Resident #1 got up, walked to the kitchen, knocked on the kitchen door, and got a tray of food the kitchen staff heated up. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, Alzheimer's Disease, non-Alzheimer's dementia, bipolar disorder, psychotic disorder, schizoaffective disorder, and anxiety. It indicated she required moderate assistance with bathing and was independent with all other Activities of Daily Living (ADLs). It also indicated she had a 10% or more weight loss in the previous 6 months and was not on a physician-prescribed weight-loss regimen. The Care Plan dated 8/21/24 indicated Resident #1 had a potential nutritional problem related to her schizoaffective disorder, Alzheimer's Disease, bipolar disorder, anxiety, and diabetes mellitus. It directed staff to monitor/record/report to the medical doctor (MD) as needed (PRN) signs and symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, or >10% in 6 months. It also directed staff to provide, serve diet as ordered: Regular diet with thin liquids. Monitor intake and record every meal. A weight change note authored by the Registered Dietitian (RD) dated 2/05/25 at 12:48 PM revealed Resident #1 experienced a significant weight loss of 7.3% in 30 days, 7.5% in 90 days and 11% in 180 days. It indicated with available information, continue same and monitor as needed. On 2/25/25 at 9:05 AM, the resident was observed asleep in her room. At 11:53 AM, Resident #1 got up, walked to the kitchen, knocked on the kitchen door, and got something to drink. She walked back to her room then returned and sat in the dining room. On 2/26/25 at 7:20 AM and 9:14 AM, Resident #1 was observed asleep in her room. At 9:29 AM, the RD stated she generates a Weights and Vitals Exception Report on Wednesdays when she is at the facility and reviews meal intake amounts, labs, and nurses' notes. She also stated she talks to the Certified Nursing Aides (CNAs) and kitchen staff to see if the resident had been asking for meals, and selecting the regular menu and not a bowl of soup, etc. She confirmed she had not been notified that staff had not been waking the resident for breakfast. She stated had she been told staff hadn't been waking the resident for meals, she would've rechecked the resident's weight and directed staff to attempt to awaken the resident for each meal and document resident refusals or ineffective attempts to awaken the resident. She stated with the available information, she didn't feel a nutrition supplement was necessary because the resident remained above Ideal Body Weight Range (IBWR). On 2/26/25 at 10:05 AM, Staff F, Certified Medication Aide (CMA) stated she had not been instructed to not wake the resident up for meals. She also stated she was not aware of the resident's significant weight loss. At 10:40 AM, Resident #1 walked up to the nurses' station and asked about food. Staff G, Activities Supervisor, told her lunch was not for another hour and 20 minutes. Resident #1 walked to the kitchen entrance, knocked on the kitchen door, and asked Staff H, AM cook, for some lunch. Staff H told Resident #1 lunch was in 1 hour and 20 minutes and offered Resident #1 something to drink. Resident #1 went into the dining room and sat down. At 10:42 AM, Resident #1 stated she was hungry but said staff wasn't getting her any food for another hour. Staff H brought Resident #1 some punch. Resident #1 drank it and went back to her room. On 2/26/25 at 10:54 AM, Staff A, Certified Nurse Aide (CNA) did not identify Resident #1 as not wanting to be awakened for meals. At 10:59 AM, Staff J, CNA stated Resident #1 did not like to be awakened for meals. She also indicated she was not aware of Resident #1's significant weight loss. At 11:08 AM, Resident #1 stated she never asked staff to not awaken her for meals and added she would not get mad if they did. At 1:48 PM, Staff H stated she was told the resident refused breakfast Monday (2/24/25), Tuesday (2/25/25), and Wednesday (2/26/25). She stated she prepared a breakfast plate for Resident #1 on those days but threw it away just before lunch time. She confirmed she does not document resident meal refusals and had not been made aware of the resident's significant weight loss. The Electronic Health Record (EHR) Meal Eaten Response History dated 1/28/25 to 2/25/25 did not include any documented breakfast responses. On 2/27/25 at 3:11 PM, the Administrator stated staff should have given the resident a snack and provided an alternative. She added staff should attempt to wake the resident for breakfast and lunch and document if it's refused. A policy titled Assistance with Meals revised March 2022 indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident.

Based on Electronic Health Records (EHR), staff interview, and policy review the facility failed to provide restorative cares to promote range of motion to 1 out of 1 residents reviewed (Residents #5). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) for Resident #5, dated 12/27/24 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The MDS also documented diagnoses of athetoid cerebral palsy, abnormal posture, contracture of right (R) hand, contracture of left (L) hand, contracture unspecified ankle, contracture unspecified knee, contracture unspecified hip, unspecified quadriplegia, and unspecified dystonia. Review of Resident #5's EHR titled, Care Plan documented no focus, goal, or intervention in place for restorative, physical therapy, or occupational therapy. Review of Resident #5's EHR revealed Resident #5 had no restorative therapy, physical therapy, or occupational therapy. Review of document dated 6/16/24 titled, Occupational Therapy OT Evaluation and Plan of Treatment documented for assessment summary clinical impressions were Resident #5 unable to communicate or actively move upper extremities and lower extremities. Resident #5 dependent for all cares and positioning with good staff support. Review of document dated 6/16/24 titled, Occupational Therapy OT Recert, Progress Report, and Updated Therapy documented continued OT services are necessary in order to assess use of palm protectors for both hands to reduce risk of skin breakdown and ROM to prevent further contracture. The document also documented Resident #5 demonstrated good rehab potential as evidenced by supportive caregivers/staff. Review of document dated, 7/6/24 titled, Occupational Therapy Treatment Encounter Notes documented Resident #5 would benefit from a trial of carrot hand orthosis to improve ROM and reduce contracture. Review of document dated, 7/10/24 titled, Occupational Therapy Treatment Encounter Notes documented Resident #5 would benefit from palm protectors to decrease skin breakdown and prevent contractures from getting worse. Order form given to DON for both R and L. Review of document dated, 7/14/24 titled, Occupational Therapy Treatment Encounter Notes documented palm protectors ordered for both hands to decrease risk of skin breakdown. Recertification completed to continue therapy. Review of Resident #5's EHR titled Treatment Administration Record (TAR) documented no splint orders and no carrot hand orthosis orders. Review of the TAR also revealed no orders for restorative therapy. Review of document titled, Occupational Therapy OT Discharge Summary documented the reason for Resident #5's discharge was because Resident #5 discharged to the hospital. The document also revealed Resident #5 progress was there was no progress to report. Resident #5 was unable to tolerate a gentle range of motion to bilateral upper extremities. Ordered palm protectors as the best options to prevent contractures from worsening and reduce risk of skin breakdown. On 2/26/25 at 9:37 AM the DON stated a restorative program was on the EHR but fell off in September of 2024. The DON acknowledged there was a system error that led to the restorative program falling off the EHR. The DON stated the facility would get occupational therapy (OT) involved to find out if the restorative was appropriate. On 2/26/25 at 9:40 AM the Administrator stated Resident #5 was on a restorative program and still should have been. The Administrator acknowledged that the restorative program was on the EHR but fell off in September of 2024. The Administrator acknowledged there was a system error that led to the restorative program falling off the EHR. On 2/26/25 at 10:06 AM Staff R, Certified Occupational Therapy Assistant (COTA) / Director of Rehab stated he was familiar with Resident #5. Staff R stated Resident #5 was on therapy a couple of times to prevent contractures in the past. Staff R stated Resident #5 was on occupational therapy (OT) from 6/24 to 7/24. Staff R stated Resident #5 was on evaluation only for physical therapy (PT) and was referred for contracture management for PT and then OT picked Resident #5 up. Staff R stated Resident #5's short term goal was trial of orthotic splints for the palms of Resident #5's hands. Staff R stated there was an ordered request given to the DON for purchase of palm protectors. Staff R stated Resident #5 was discharged from OT when he was discharged to the hospital. Review of policy revised 7/17 titled, Restorative Nursing Services documented residents will receive restorative nursing care as needed to help promote optimal safety and independence. The document also states the restorative goals and objectives are individualized and resident - centered, and are outlined in the resident's plan of care.

Based on observations, resident interviews, clinical record review, facility record review and staff interviews the facility failed to provide activities to meet the interests, and the physical, mental, and psychosocial well-being of the residents for 3 of 3 reviewed (Resident #7, #10 and #11). The facility reported a census of 17 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #7, dated 1/2/24, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment for decision-making. Interview on 3/04/24 at 1:54 PM, Resident #7 stated they have activities when someone is here to do them and would attend more activities if they had them. Interview on 3/05/24 at 10:25 AM, Resident #7 in room coloring and stated they did not have or attend an activity this morning unless they didn't tell her. Interview on 3/06/24 at 9:30 AM, Resident #7 stated they did not have scheduled 6PM craft activity last night, as would have attended. 2. The MDS assessment for Resident #10, dated 12/22/23, documented the resident had a BIMS score of 15, indicating no cognitive impairment for decision-making. Interview on 3/04/24 at 1:15 PM, Resident #10 stated she attended bingo this morning, they do have some activities, but would like to have activities such as painting, drawing, or crafts. Observation on 3/05/24 at 10:18 AM, Resident #10 playing checkers with another resident, only 2 residents in the activity area, and no scheduled activity at this time. The facility activity calendar for March 2024, listed activity for 3/5/24 at 10 AM, Coffee and Oldies but Goodies and at 6 PM Crafts. Interview on 3/06/24 at 9:30 AM, Resident #10 stated they did not have a scheduled 6PM craft activity last night, as would have attended as she really likes crafts. 3. Interview on 3/06/24 at 10:35 AM, Resident #11 stated has been at the facility about 2 months and they have started having a few activities in the past couple weeks. Resident #11 stated the activity calendar is not followed. Interview on 3/06/24 at 10:00 AM, Staff C, Licensed Practical Nurse works fulltime 6A - 6P and started at the facility about 2 months ago. Staff C stated the facility has started having activities in the past few weeks, maybe 1 a day. Interview on 3/6/24 at 11:14AM, the Activity Director (AD) stated she tries to do activities 2 times a day, a small one in the AM and larger one in the PM. The AD stated with the scheduled evening activities, the certified nurse aides have to do the activity, and she tries to leave something out for the activity. The AD stated she did not leave out anything for the scheduled craft activity last night. The AD stated she follows the schedule to the best she can and the weekend activities are radio church and sports television (TV) and the staff are to turn on the radio and TV for these activities. Interview on 3/06/24 at 11:59 AM, Staff F, Certified Nurse Aide stated the activities are not happening, can ask any resident, was supposed to be much better with the change in staff but has not, and have only been doing the activities since the surveyors came in this week. Interview on 3/07/24 at 9:30 AM, the Regional Nurse stated she was aware of problems with activities prior to the survey and her expectation for the facility is to provide activities 7 days a week and at scheduled times.

Based on record review, staff and resident interviews, and policy review the facility failed to ensure staff members posses the basic competencies and skill sets to meet the behavioral health needs of residents for whom the facility has assessed with identified behaviors for 2 of 2 residents reviewed (Resident #4 and #6). A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 2, 2022 on March 30, 2023 at 3:15 PM. The Facility Staff removed the Immediate Jeopardy on March 31, 2023 through the following actions: 1. Director of Nursing was suspended on 3/31/23 for alleged abuse pending the investigation. Resident #4 is currently followed by a contracted Psychiatric Services group with an appointment scheduled for 4/4/2023. Resident #4 was interviewed by the Regional Director Clinical services on 3/30/23 and offered to get a call for an earlier appointment. Resident #4 declined the need for an earlier appointment. 2. An audit was completed by the Regional Director of Clinical Services on 03/31/2023 to ensure staff have received training on resident rights and behavioral management with appropriate interventions. Any staff member that has not received the training will receive training prior to the beginning of their next scheduled shift. 3. Facility staff were reeducated by the Regional Director of Clinical Services beginning 3/30/23 on behavioral management with examples of appropriate interventions and resident rights including providing goods/services including food and smoking privileges without disciplinary intent. Employees will complete this training prior to the beginning of their next shift. 4. Interim Director of Nursing and Social Service Director will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure staff continue to receive and follow behavior management training including providing appropriate interventions. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Interim Director of Nursing and Social Services Director are responsible for monitoring and follow-up as needed. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Progress Notes Progress Note dated 5/20/2022 at 2:20 AM written by Staff H, Registered Nurse (RN) for Resident #4 revealed the following: Resident #4 refused her shower yesterday and signed a contract which stated that she would not get cigarettes all day, but kept putting her light on wanting a cigarette. Resident #4 had been reminded about her signed contract to have no cigarettes all day and wanted to talk to the person that had her sign the contract. The writer of this progress note asked her why and Resident #4 stated well they can say I can have a cigarette. Writer of this progress note told her that was not how that worked she can't unsign it. Writer of this progress note told her she was not going outside. The writer of this progress note then informed Resident #4 she has not had a shower since 5/13/22 and it was unacceptable she needed to shower twice a week no matter what. Resident #4 stated she changed her underwear several times a day. Writer of this progress note provided education that does not replace a shower. Progress Note dated 6/3/2022 at 1:51 AM written by Staff H for Resident #4 revealed the following: Resident #4 refused her shower, reminded that she signed a contract that if she doesn't get out of bed to take her shower she agreed to not go out to smoke. Reminder of this given to her at 7:50 PM. Resident #4 also asks for multiple snacks every night, given two (2) oatmeal creme pies and complained it wasn't enough and wanted more and more and continued to ask for a cigarette. Progress Note dated 6/17/2022 3:50 AM written by Staff H for Resident #4 revealed the following: Resident #4 continued with behaviors and not wanting to eat meals and just eat sweets. Resident #4 refused her shower and education given and reminder on contract she signed about getting up for meals and taking her showers. Resident #4 stated I want to talk to the person in charge. Writer of this progress note told her it was her and report given by day shift and unfortunately with the rules Resident #4 was unable to go out to smoke. Progress Note dated 6/17/2022 at 1:18 PM written by the Director of Nursing (DON) for Resident #4 revealed the following: Resident #4 refused a bath yesterday and had refused to come out to meals today. Informed her she would not be allowed to smoke all weekend due to her choices. Progress Note dated 6/18/2022 at 1:30 PM written by the DON for Resident #4 revealed the following: Resident #4 refused to get out of bed for lunch or breakfast. She laid in her bed and wet it until all blankets were soaked. She had been told she was not going out to smoke all weekend due to her refusal of her bath and there was nothing she could do until Monday until she could get a bath. Resident #4 signed a contract she would take a bath or she could not go out to smoke. Progress Note dated 6/18/2022 at 4:25 PM written by the DON for Resident #4 revealed the following: Resident #4 came out of her room at 3:00 PM to smoke and the writer of this progress note told her she was not allowed to smoke all weekend due to a contract she signed with the Director of Nursing (DON) that stated she would take her bath or she doesn't get to smoke. She was angry and yelling. Resident #4 proceeded to go back to her room and had a bowel movement all over the bathroom, and a Certified Nurse Aide (CNA) had to mop up the mess. Resident #4 then said she was not coming out to supper. Progress Note dated 1/2/2023 at 4:19 PM written by Staff A, Licensed Practical Nurse (LPN), for Resident #4 revealed the following: Resident #4 had an agreement with the therapy department that she would go out to smoke then stay in her wheelchair until after supper. Resident #4 called her brother and told him that she was hurting so bad and staff were refusing to put her in the recliner. Staff talked to her brother and explained the situation while Resident #4 yelled I didn't agree to that. Progress Note dated 2/4/23 at 5:12 PM written by Staff A, for Resident #4 revealed the following: Resident #4 was very rude to staff and yelled and screamed at them because they wouldn't push her wheelchair to the dining room. Staff explained that it was part of her therapy and she needed to do it herself. Resident #4 threatened to tell her brother and have this place shut down. Resident #4 yelled at the CNA, when the CNA explained again they would not push her due to her therapy program Resident #4 made a physical gesture of flipping the CNA off. Progress Note dated 2/8/23 at 1:19 PM written by Staff A for Resident #4 revealed the following: CNA's entered Resident #4 room to answer her call light when Resident #4 voiced that she pooped her pants because no one would push her. Progress Note dated 3/3/2023 at 8:00 PM written by Staff I, LPN for Resident #4 revealed the following: Resident #4 at the dining room table tonight asked for second helpings of food. Resident #4 was shown paper on the table and reminded her that she agreed with the dietician that she would not ask for second helpings of food. Resident #4 began to cuss at the staff and stated that she was going to get an attorney to shut the facility down. Resident #4 asked for second (2nd) helpings four (4) more time and each time staff would show her the paper and she would cuss at staff. After the fifth (5th) time staff came to the charge nurse (writer of this progress note) for assistance. The writer of this progress note informed that with this type of behavior there could be consequences and to let Resident #4 know she wasn't going out to smoke. Resident continued sitting at the dining room table and talked to another resident and bad mouthed and cussed about the staff to the other resident, stated she was going to have staff put in jail. At 7:50 PM she asked staff when they would be going out to smoke. The writer of this progress note went and told Resident #4 she would not be going out to smoke, when Resident #4 asked why the writer of this progress note reminded her she had asked five (5) times for more food and each time she was shown the paper and reminded her of her agreement not to ask for second (2nd) helpings of food and each time she began to cuss at staff and was inappropriate and after so many episodes she was advised there would be a consequence to such behavior. Resident #4 began to cuss at the writer of this progress note and asked her for her name. Resident then stopped took a deep breath and then said please let me go out for just a little cigarette. The writer of this progress note stated no, and Resident #4 immediately started to cuss and stated she was going to call her brother and have the facility shut down because she wasn't being treated right. The writer of this progress note asked why she wasn't being treat right and Resident #4 stated the CNA's were not appropriate to her, but could not provide specific details or name or describe which CNA. The writer of this progress note informed her that if someone wasn't appropriate that next time she needed to tell the nurse on duty and they would make sure there are consequences for them instead of her being rude and inappropriate and have consequences. After several moments of Resident #4 cussing at the writer of this progress note Resident #4 again took a deep breath and then began to plead with the writer of this progress note that she wouldn't cuss at staff again if she could just go out for a cigarette the writer of this progress note quietly stated no and then stated she was going back to work unless there was something else Resident #4 wanted to discuss. Record review of a contract provided by the facility titled, Nutrition Therapy Recommendations dated 1/25/23 documented Resident #4 agreed to not ask for seconds at meals and decrease snacks. The contract was not signed by the resident, dietician, or an employee of the facility. During an observation on 3/30/23 at 1:18 PM in Resident #4 room a sign posted stated, you agreed with the dietitian that you will not ask for extra food at meal times and extra snacks as you have had substantial weight gain. The sign was signed by the Director of Nursing. During an interview on 3/30/23 at 1:45 PM with Resident #4 revealed she has had sadness or will get upset with staff not letting her go out to smoke, she revealed she had gotten mad several times when she was not allowed to smoke. Resident #4 also discussed that she was not allowed to have extra food at meals if she was still hungry, she revealed sometimes she might get a snack and sometimes not. Record review of Resident #4 current Care Plan documented an intervention with a date of initiation on 5/13/2022 instructed staff she will attempt to actively fabricate and manipulate staff in regard to her pain medications, smoking privileges, and reasons to stay in her room. The care plan lacked active or resolved interventions of food restrictions for second (2nd) helpings and not being allowed to smoke if she did not shower. During an interview on 3/30/23 at 2:40 PM the DON revealed she does not recall a bathing contract for Resident #4 and doesn't know why Resident #4 wouldn't get to smoke if she refused a shower. She revealed the Dietician talked to Resident #4 and she agreed to not eat seconds at meals. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA stated the DON instructed them if Resident #4 would not get out of bed or refused her bath that she would not be allowed to smoke. Staff D revealed she thought this was a rule and what they were supposed to do, because that was what their DON said. Staff D stated that Resident #4 was usually not allowed to smoke a couple times a week, she added everyone followed that direction because the DON said to. Staff D then informed she was not sure if it was care planned or not. During an interview on 4/5/23 at 10:12 AM Staff F, Certified Medication Aide, (CMA) revealed Resident #4 was on a no seconds at meals and a no snacks contract. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact. The MDS documented needs for extensive assistance (resident involved in activity, staff provide weight-bearing support) of two person physical assist with bed mobility, transfers, dressing and toilet use. The MDS documented diagnoses of cerebral palsy, hypertension, anxiety disorder, depression, and mixed incontinence. Progress Notes Review Progress Note for Resident #6 dated 5/2/22 at 3:21 AM written by Staff H revealed the following: Resident #6 put her light on at 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM and 10:45 PM staff into room all of these times. Resident #6 was incontinent of urine at 4:00 PM, 6:00 PM and 10:45 PM and incontinent of bowel at 8:00 PM. Resident #6 educated that there was no reason for her to be incontinent at all as she was the youngest resident here and has had no children. Her control was amazing and can go from 11:00 PM to 7:00 AM without ever urinating and if doing activities she liked can go up to 6 hours during the day without voiding. Resident #6 only had accidents for attention and when she was mad and she doesn't get her way on something, which she didn't get her way on her coffee, she can only have two (2) cups a day period according to her sister who was very mad at her due to all her behaviors and manipulated CNA's to let her finish a show. The writer of this progress note went to Resident #6 room at 11:10 PM and educated her again to not manipulate staff to let her do things she wasn't supposed to do. Progress Note for Resident #6 dated 6/12/22 at 2:15 AM written by Staff H revealed the following: Resident #6 was very rude and snarky with CNA's, she was incontinent for no apparent reason. Resident #6 had always done this for attention even before she came to this facility. She was like this at home and where she lived before coming to the facility. Resident #6 was very demanding and pouted that she had to wait till 7:00 PM to go to bed. Staff have explained to her numerous times that there are other residents here that need care too and her patience would be greatly appreciated. Resident #6 mumbles under her breathe being mean and nasty to staff then lies about her cares when staff have been in her room two (2) at a time due to her behaviors and lying. The writer of this progress note stood outside her room and listened and intervened to her pouting. Progress Note for Resident #6 dated 6/13/22 at 3:03 AM written by Staff H revealed the following: Resident #6 continued to be rude and demanding to staff. She was on her call light every two (2) hours by the clock. She was incontinent for no reason other than thinks she can get changed and go to bed or her skin will breakdown so she can lay in bed all the time. Resident #6 has the mentality of a teenager related to her diagnosis of cerebral palsy. Her family was aware of her behaviors but not lately, she had the best bladder control of all residents at the facility. Progress Note for Resident #6 dated 6/13/22 at 8:45 AM written by the DON revealed the following: Resident #6 ate her breakfast and had coffee then went back to her room and pooped her pants. Her sister was coming to bring her some stuff and was told what she did. Progress Note for Resident #6 dated 6/17/22 at 1:14 PM written by the DON revealed the following: Resident #6 went back from lunch and soiled her pants. She already asked if she could go to bed early tonight and the writer of this progress note told her it was based on her behaviors. Progress Note for Resident #6 dated 8/6/22 at 8:00 PM written by Staff H revealed the following: Resident #6 was incontinent of urine right before staff put her on the commode and after they put her to bed was incontinent of bowels. The writer of this progress note asked her why she was incontinent when she has best bladder control out of everyone at the facility and definitely has the best bowel control out of everyone here. The writer of this progress note told her there was no excuse other than she wanted to go to bed right away and didn't want to sit on the commode. Resident #6 folded her arms across her chest and said nothing just had a pout on her face. Progress Note for Resident #6 dated 8/10/22 at 3:05 PM written by Staff A revealed the following: Resident #6 very upset and pouted as she had to get weighed after she had already eaten breakfast. Resident #6 wanted to be weighed before she ate and staff didn't have time to weigh her before breakfast. Resident #6 pouted all day and would hardly answer staff when they talked to her, she sat in her room with her arms crossed over her chest and looked at the floor anytime staff entered. Progress Note for Resident #6 dated 8/12/22 at 2:21 AM written by Staff H revealed the following: Resident #6 having an increase in behaviors when she doesn't get her own way, like she didn't last night, and was incontinent of bowel and bladder. She was increasingly incontinent for no reason other than for attention and/or she was mad. Her sister was very upset with her and each time she was incontinent added 15 minutes on her time to lay down early on Sunday which was already unable to lay down at 4:00 PM Sunday due to incontinence, her sister was very upset with her. Progress Note for Resident #6 dated 8/17/22 at 1:52 AM written by Staff H revealed the following: Resident #6 continued to manipulate staff and incontinent for attention. Anxiety when she doesn't get what she wants. Progress Note for Resident #6 dated 1/26/23 1:11 PM written by Staff A revealed the following: Resident #6 up to the dining room for breakfast and started to go back to her room at 7:30 AM, when asked where she was going she replied she was going back to here room. Staff told her it was time for breakfast and she needed to stay. Resident #6 then said she wanted to move to a different table, when asked her why she refused to answer and sat in the middle of the walkway and pouted. Progress Note for Resident #6 dated 2/9/23 at 1:14 PM written by Staff A revealed the following: Resident #6 very needy and manipulative today. Call light on to have staff put her exercise bar away when she knew that she was supposed to wait until staff come to her room then she can ask them to put it away. She has turned on her call light to ask staff to get things for her. She was asking multiple times for multiple things while staff were trying to complete the first request. Repeatedly stated I've been good today I haven't bothered you at all today have I. Staff encouraged her to come out of her room, but prefers to isolate herself in her room. Progress Note for Resident #6 dated 2/18/23 at 12:58 PM written by Staff A revealed the following: Resident #6 very upset and pouted when she got her coffee this morning. The cup wasn't filled to the brim and she didn't think she was getting her full cup. Staff attempted to explain that it was dangerous to carry a cup too full and could get burned Resident #6 dropped her head and wouldn't talk anymore. Progress Note for Resident #6 dated 2/28/23 at 1:08 PM written by Staff A revealed the following: Resident #6 stayed in the dining room too long after breakfast this morning and pooped her pants, resident went to her room and noted to be smiling and grinning and said to CNA's I know you're going to be mad at me. Staff explained to Resident #6 that she needed to start coming to her room sooner, Resident #6 continued to smile and said I know. Progress Note for Resident #6 dated 3/15/23 at 8:58 AM written by the DON revealed the following: Resident #6 was incontinent of bowel two times yesterday. Not allowed to have coffee today. Progress Note dated 3/16/2023 at 8:55 AM written by the DON for Resident #6 revealed the following: Resident #6 had behaviors and lost her coffee privileges today. Resident #6 soiled her pants yesterday and it was not loose. She then got on her tablet until 2:00 AM. Told her it would be at the nurses station. During an interview on 3/30/23 at 9:40 AM with Resident #6 revealed she was on a toileting program and can go once every two hours, she revealed the toileting program doesn't bother her as she has a weak bladder and they are trying to strengthen it. She revealed sometimes she gets sad about it because she might have an accident, and then they let her go. She revealed if she had an accident then she can not have any coffee for the day. She revealed she wouldn't give a name because she didn't want to get the person in trouble. She stated yesterday she lost three (3) cups of coffee since she had an accident on 3/28/23. She revealed her sister put a limit to two (2) cups a day, but she wants three (3) cups of coffee a day. She revealed she would like to have two (2) cups in the morning and one (1) at lunch, she revealed she loves her coffee. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA revealed the DON told her that Resident #6's sister wanted her to get less coffee if she was incontinent. The DON told Staff D this was the resident's sister's rule. Staff D was unsure if this was care planned. During an interview on 4/5/23 at 10:48 AM with Staff D, CNA she revealed Resident #6 goes to the bathroom every two hours, and if she made a mess then we would take her coffee away for that day. We were told it was her sisters rule. Before you came in to do the survey we enforced that. During an interview on 4/5/23 at 10:12 AM with Staff F, CMA revealed Resident #6 was on a toileting program for every two hours and the facility was not giving her extra coffee because that was what the Activities Director and Resident #6 sister decided on to help control some of her behaviors. Record review of Resident #6 current Care Plan on 4/3/23 documented the following active and resolved interventions. a. Resolved, Resident currently have two to three (2-3) caffeinated beverages a day with no caffeine after 3:00 PM. See previous resolved intervention. Subject to change per resident/family/staff agreement. Date Initiated: 04/03/2023. Resolved Date: 04/03/2023. b. Resolved, Per agreement, resident may lay down early 1 day a week, usually chooses Sunday. Date Initiated: 04/03/2023. Resolved Date: 04/03/2023. c. Active, Resident had originally agreed upon in conjunction between herself, her guardian, and interdisciplinary team to limit herself to three (3) caffeinated beverages a day. If she asks for more may educate her regarding possible repercussions but may give her extra. Date Initiated: 04/03/2023. The facility provided a Behavior Management policy dated 5/2014. The policy was directed only to residents with dementia and failed to direct staff on how to care for resident behaviors when they are not due to dementia.

Based on record review, staff and resident interviews, and policy review the facility failed to prevent abuse in the facility when staff documented unreasonable intimidation and punishment which resulted in mental anguish for 2 of 2 residents reviewed, (Resident #4 and #6). A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 2, 2022 on March 30, 2023 at 3:15 PM. The facility staff removed the Immediate Jeopardy on March 31, 2023 through the following actions: 1. Director of Nursing was suspended on 3/31/23 for alleged abuse pending the investigation. Resident #4 was interviewed by the Regional Director Clinical services on 3/30/23 to ensure resident rights are being honored including providing food including second portions, smoking breaks and incontinent care without any intent to discipline the resident. 2. Residents with a BIMS's of 13 or above were interviewed by Regional Director of Clinical Services and Social Service Director on 3/30/2023 related to any concerns of withholding food or smoking privileges with no voiced concerns noted. Residents with a BIMS of 12 or lower had a skin assessment completed by the Registered Nurse on 3/31/23 with no signs or symptoms of abuse noted. 3. The Administrator was educated on 3/31/2023 by the Regional Director of Operations related to requirements of abuse reporting, investigating potential abuse, abuse prevention, and resident's rights including providing goods and services free from disciplinary intent. Facility staff were reeducated by the Regional Director of Clinical Services beginning 3/30/23 on Abuse Prevention and Resident Rights including providing goods/services including food and smoking privileges without disciplinary intent. Employees will complete this training prior to the beginning of their next shift. 4. Regional Director of Operations or Regional Director of Clinical Services will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure the abuse policy continues to be followed including investigating potential withholding of goods and services with disciplinary intent and abuse investigations/reports including fractures continue completed as required. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Administrator is responsible for monitoring and follow-up as needed. The scope was lowered from a J to D after the surveyor verified the facility implemented education and their policy and procedures. The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) score of 12 suggesting moderately impaired cognition. The MDS documented need for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Progress Note Review Progress Note dated 5/20/2022 at 2:20 AM written by Staff H, Registered Nurse (RN) for Resident #4 revealed the following: Resident #4 refused her shower yesterday and signed a contract stating that she would not get cigarettes all day, but kept putting her light on wanting a cigarette. Resident #4 has been reminded about her signing a contract to have no cigarettes all day and wanted to talk to the person that had her sign the contract. The writer of this Progress Note asked her why and Resident #4 stated well they can say I can have a cigarette. Writer of this Progress Note told her that was not how that worked she can't unsign it. Writer of this Progress Note told her she was not going outside. The writer of this Progress Note then informed Resident #4 she had not had a shower since 5/13/22 and it was unacceptable she needs to shower twice a week no matter what. Resident #4 stated she changed her underwear several times a day. Writer of this Progress Note provided education that does not replace a shower. Progress Note dated 6/3/2022 at 1:51 AM written by Staff H for Resident #4 revealed the following: Resident #4 refused her shower, reminders that she signed a contract that if she doesn't get out of bed to take her shower she agrees to not go out to smoke. Reminders of this given to her at 7:50 PM. Resident #4 also asks for multiple snacks every night, gave two (2) oatmeal creme pies and complained it wasn't enough and wanted more and more and kept asking for a cigarette. Progress Note dated 6/17/2022 at 3:50 AM written by Staff H for Resident #4 revealed the following: Resident #4 continues with behaviors and not wanting to eat meals and just eat sweets. Resident #4 refused her shower and education given and reminder on contract she signed about getting up for meals and taking her showers. Resident #4 stated I want to talk to the person in charge. Writer of this Progress Note told her it was her and report given by day shift and unfortunately with rules Resident #4 was unable to go out to smoke. Progress Note dated 6/17/2022 at 1:18 PM written by the Director of Nursing (DON) for Resident #4 revealed the following: Resident #4 refused a bath yesterday and has refused to come out to meals today. Informed her she will not be smoking all weekend due to her choices. Progress Note dated 6/18/2022 at 1:30 PM written by the DON for Resident #4 revealed the following: Resident #4 refused to get out of bed for lunch or breakfast. She laid in her bed and wet it until all blankets were soaked. She has been told she is not going out to smoke all weekend due to her refusing her bath and there is nothing she can do until Monday until she can get a bath. Resident #4 signed a contract she would take a bath or she could not go out to smoke. Progress Note dated 6/18/2022 at 4:25 PM written by the DON for Resident #4 revealed the following: Resident #4 came out of her room at 3:00 PM to smoke and the writer of this Progress Note told her she is not smoking all weekend due to a contract she signed with the Director of Nursing (DON) stating she will take her bath or she doesn't get to smoke. She is angry and yelling. Resident #4 proceeded to go back to her room and had a bowel movement all over the bathroom, and a Certified Nurse Aide (CNA) had to mop up the mess. Resident #4 then said she was not coming out to supper. Progress Note dated 1/2/2023 at 4:19 PM written by Staff A, Licensed Practical Nurse (LPN), for Resident #4 revealed the following: Resident #4 had an agreement with the therapy department that she would go out to smoke then stay in her wheelchair until after supper. Resident #4 called her brother and told him that she was hurting so bad and staff were refusing to put her in the recliner. Staff talked to her brother and explained the situation while Resident #4 was yelling I didn't agree to that. Progress Note dated 2/4/23 at 5:12 PM written by Staff A, for Resident #4 revealed the following: Resident #4 was very rude to staff and yelling and screaming at them because they won't push her wheelchair to the dining room. Staff explained that it was part of her therapy and she needed to do it herself. Resident #4 threatened to tell her brother and have this place shut down. Resident #4 yelling at the CNA, when the CNA explained again they are not pushing her due to her therapy program Resident #4 made a physical gesture of flipping the CNA off. Progress Note dated 2/8/23 at 1:19 PM written by Staff A for Resident #4 revealed the following: CNA's entered Resident #4 room to answer her call light when Resident #4 voiced that she pooped her pants because no one would push her. Progress Note dated 3/3/2023 at 8:00 PM written by Staff I, LPN for Resident #4 revealed the following: Resident #4 at the dining room table tonight asked for second helpings of food. Resident #4 was shown paper on the table reminding her that she agreed with the Dietician that she would not ask for second helpings of food. Resident #4 then cussed at the staff while stating that she was going to get an attorney to shut the facility down. Resident #4 asked for second helpings four more times and each time staff would show her the paper and she would cuss at staff. After the fifth time staff came to the charge nurse (writer of this Progress Note) for assistance. The writer of this Progress Note informed that with this type of behavior there could be consequences and to let Resident #4 know she wasn't going out to smoke. Resident continued sitting at the dining room table and talked to another resident and bad mouthed and cussed about the staff to the other resident, stated she was going to have staff put in jail. At 7:50 PM she asked staff when they would be going out to smoke. The writer of this Progress Note went and told Resident #4 she would not be going out to smoke, when Resident #4 asked why the writer of this Progress Note reminded her she had asked five times for more food and each time she was shown the paper and reminded her of her agreement not to ask for second helpings of food and each time she began to cuss at staff and was inappropriate and after so many episodes she was advised there would be a consequence to such behavior. Resident #4 again cussed at the writer of this Progress Note and asked her for her name. Resident then stopped took a deep breath and then began saying please let me go out for just a little cigarette. The writer of this Progress Note stated no, and Resident #4 immediately started cussing and stated she was going to call her brother and have the facility shut down because she wasn't being treated right. The writer of this Progress Note asked why she wasn't being treated right and Resident #4 stated the CNA's were not appropriate to her, but could not provide specific details or name or describe which CNA. The writer of this Progress Note informed her that if someone wasn't appropriate that next time she needs to tell the nurse on duty and they will make sure there are consequences for them instead of her being rude and inappropriate and having consequences. After several moments of Resident #4 cussing at the writer of this Progress Note Resident #4 again took a deep breath and then began pleading with the writer of this Progress Note that she wouldn't cuss at staff again if she could just go out for a cigarette, the writer of this Progress Note quietly stated no and then stated she was going back to work unless there was something else Resident #4 wanted to discuss. Record review of a contract provided by the facility titled, Nutrition Therapy Recommendations dated 1/25/23 documented Resident #4 agreed to not ask for seconds at meals and decrease snacks. The contract was not signed by the resident, dietician, or an employee of the facility. During an observation on 3/30/23 at 1:18 PM in Resident #4's room a sign posted stated, you agreed with the dietitian that you will not ask for extra food at meal times and extra snacks as you have had substantial weight gain. The sign was signed by the Director of Nursing. During an interview on 3/30/23 at 1:45 PM, Resident #4 revealed she has had sadness or will get upset with staff not letting her go out to smoke, she revealed she has gotten mad several times when she was not allowed to smoke. Resident #4 also discussed that she was not allowed to have extra food at meals if she was still hungry, she revealed sometimes she might get a snack and sometimes not. During an interview on 3/30/23 at 2:40 PM with the DON revealed she does not recall a bathing contract for Resident #4 and doesn't know why Resident #4 wouldn't get to smoke if she refused a shower. She revealed the Dietician talked to Resident #4 and she agreed to not eat seconds at meals. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA stated the DON instructed if Resident #4 would not get out of bed or refused her bath that she would not be allowed to smoke. Staff D revealed she thought this was a rule and what they were supposed to do, because that was what their DON said. Staff D informed Resident #4 was usually not allowed to smoke a couple times a week, she added everyone followed that direction because the DON said to. Staff D then informed she was not sure if it was care planned or not. During an interview on 4/5/23 at 10:12 AM with Staff F, Certified Medication Aide (CMA) revealed Resident #4 was on a no seconds at meals and a no snacks contract. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating she was cognitively intact. The MDS documented needs for extensive assistance (resident involved in activity, staff provide weight-bearing support) of two person physical assist with bed mobility, transfers, dressing, and toilet use. The MDS documented diagnoses of cerebral palsy, hypertension, anxiety disorder, depression, and mixed incontinence. Progress Notes Review Progress Note for Resident #6 dated 5/2/22 at 3:21 AM written by Staff H revealed the following: Resident #6 put her light on at 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM and 10:45 PM staff into room all of these times. Resident #6 was incontinent of urine at 4:00 PM, 6:00 PM and 10:45 PM and incontinent of bowel at 8:00 PM. Resident #6 educated that there was no reason for her to be incontinent at all as she was the youngest resident here and has had no children. Her control was amazing and can go from 11:00 PM to 7:00 AM without ever urinating and if doing activities she likes can go up to 6 hours during the day without voiding. Resident #6 only has accidents for attention and when she was mad and she doesn't get her way on something, which she didn't get her way on her coffee, she can only have two cups a day period according to her sister who was very mad at her due to all her behaviors and manipulating CNA's to allow her finish a show. The writer of this Progress Note went to Resident #6 room at 11:10 PM and educated her again to not manipulate staff to allow her do things she wasn't supposed to do. Progress Note for Resident #6 dated 6/12/22 at 2:15 AM written by Staff H revealed the following: Resident #6 was very rude and snarky with CNA's, she was incontinent for no apparent reason. Resident #6 had always done this for attention even before she came to this facility. She was like this at home and where she lived before coming to the facility. Resident #6 was very demanding and pouting that she had to wait till 7:00 PM to go to bed. Staff have explained to her numerous times that there are other residents here that need care too and her patience would be greatly appreciated. Resident #6 mumbles under her breathe, being mean and nasty to staff then lying about her cares when staff have been in her room two at a time due to her behaviors and lying. The writer of this Progress Note stood outside her room and listened and intervened to her pouting. Progress Note for Resident #6 dated 6/13/22 at 3:03 AM written by Staff H revealed the following: Resident #6 continued to be rude and demanding to staff. She was on her call light every two (2) hours by the clock. She was incontinent for no reason other than thinks she can get changed and go to bed or her skin will breakdown so she can lay in bed all the time. Resident #6 has the mentality of a teenager related to her diagnosis of cerebral palsy. Her family is aware of her behaviors but not lately, she has the best bladder control of all residents at the facility. Progress Note for Resident #6 dated 6/13/22 at 8:45 AM written by the DON revealed the following: Resident #6 ate her breakfast and had coffee then went back to her room and pooped her pants. Her sister was coming to bring her some stuff and was told what she did. Progress Note for Resident #6 dated 6/17/22 at 1:14 PM written by the DON revealed the following: Resident #6 went back from lunch and soiled her pants. She already asked if she could go to bed early tonight and the writer of this progress note told her it was based on her behaviors. Progress Note for Resident #6 dated 8/6/22 at 8:00 PM written by Staff H revealed the following: Resident #6 was incontinent of urine right before staff put her on the commode and after they put her to bed was incontinent of bowels. The writer of this progress note asked her why she was incontinent when she has best bladder control out of everyone at the facility and definitely has the best bowel control out of everyone here. The writer of this progress note told her there was no excuse other than she wanted to go to bed right away and didn't want to sit on the commode. Resident #6 folded her arms across her chest and said nothing just had a pout on her face. Progress Note for Resident #6 dated 8/10/22 at 3:05 PM written by Staff A revealed the following: Resident #6 very upset and pouting as she had to get weighed after she had already eaten breakfast. Resident #6 wanted to be weighed before she ate and staff didn't have time to weigh her before breakfast. Resident #6 pouted all day and would hardly answer staff when they talked to her, she sat in her room with her arms crossed over her chest and looked at the floor anytime staff entered. Progress Note for Resident #6 dated 8/12/22 at 2:21 AM written by Staff H revealed the following: Resident #6 had an increase in behaviors when she doesn't get her own way, like she didn't last night, and was incontinent of bowel and bladder. She was increasingly incontinent for no reason other than for attention and/or she was mad. Her sister was very upset with her and each time she is incontinent added 15 minutes on her time of laying down early on Sunday which she was already unable to lay down at 4:00 PM Sunday due to incontinence, her sister was very upset with her. Progress Note for Resident #6 dated 8/17/22 at 1:52 AM written by Staff H revealed the following: Resident #6 continued to manipulate staff and incontinent for attention. Anxiety when she doesn't get what she wants. Progress Note for Resident #6 dated 1/26/23 1:11 PM written by Staff A revealed the following: Resident #6 up to the dining room for breakfast and started to go back to her room at 7:30 AM, when asked where she was going she replied she was going back to here room. Staff told her it was time for breakfast and she needed to stay. Resident #6 then said she wanted to move to a different table, when asked her why she refused to answer and sat in the middle of the walkway and pouted. Progress Note for Resident #6 dated 2/9/23 at 1:14 PM written by Staff A revealed the following: Resident #6 very needy and manipulative today. Call light on to have staff put her exercise bar away when she knew that she was supposed to wait until staff come to her room then she can ask to put it away. She has turned on her call light to ask staff to get things for her. She had asked multiple times for multiple things while staff were trying to complete the first request. Repeatedly stated I've been good today I haven't bothered you at all today have I. Staff encouraged her to come out of her room, but prefers to isolate herself in her room. Progress Note for Resident #6 dated 2/18/23 at 12:58 PM written by Staff A revealed the following: Resident #6 very upset and pouting when she got her coffee this morning. The cup wasn't filled to the brim and she didn't think she was getting her full cup. Staff attempted to explain that it was dangerous to carry a cup too full and could get burned Resident #6 dropped her head and wouldn't talk anymore. Progress Note for Resident #6 dated 2/28/23 at 1:08 PM written by Staff A revealed the following: Resident #6 stayed in the dining room too long after breakfast this morning and pooped her pants, resident went to her room and noted to be smiling and grinning and said to CNA's I know you're going to be mad at me. Staff explained to Resident #6 that she needed to start coming to her room sooner Resident #6 continued to smile and said I know. Progress Note for Resident #6 dated 3/15/23 at 8:58 AM written by the DON revealed the following: Resident #6 was incontinent of bowel two times yesterday. Not allowed to have coffee today. Progress Note dated 3/16/2023 at 8:55 AM written by the DON for Resident #6 revealed the following: Resident #6 had behaviors and lost her coffee privileges today. Resident #6 soiled her pants yesterday and it was not loose. She then got on her tablet until 2:00 AM. Told her it would be at the nurses station. During an interview on 3/30/23 at 9:40 AM Resident #6 revealed she was on a toileting program and can go once every two hours, she revealed the toileting program doesn't bother her as she has a weak bladder and they are trying to strengthen it. She revealed sometimes she gets sad about it because she might have an accident, and then they let her go. She revealed if she had an accident then she can not have any coffee for the day. She revealed she wouldn't give a name because she didn't want to get the person in trouble. She informed yesterday she lost three (3) cups of coffee since she had an accident on 3/28/23. She revealed her sister put a limit to two (2) cups a day, but she wants three (3) cups of coffee a day. She revealed she would like to have two (2) cups in the morning and one (1) at lunch, she revealed she loves her coffee. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA revealed the DON told her that Resident #6's sister wanted her to get less coffee if she was incontinent. The DON told Staff D this was the resident's sister's rule. Staff D was unsure if this was care planned. During an interview on 4/5/23 at 10:48 AM with Staff D, CNA she revealed Resident #6 goes to the bathroom every two hours, and if she made a mess then we would take her coffee away for that day. We were told it was her sisters rule. Before you came in to do the survey we enforced that. During an interview on 4/5/23 at 10:12 AM Staff F, CMA, revealed Resident #6 was on a toileting program for every two hours and the facility was not giving her extra coffee because that was what the Activities Director and Resident #6 sister decided on to help control some of her behaviors During an interview on 3/31/23 at 11:15 AM Staff G, Maintenance Supervisor, revealed he did not feel like he could tell another staff member if he had witnessed another staff member abuse or mistreat a resident. He indicated he had reported issues before and he would get told they were short staffed, what do you want us to do, he revealed they would tell him they would talk to the staff members in question, but nothing would change. Staff G then revealed he has heard the DON tell a resident if they took their bath staff would bring them out for lunch. He revealed he had also heard her tell residents to stay in their rooms and that she didn't have time for them. When asked if he would at least tell the Administrator, he stated she was only in the building two times a month because she was at the corporations other facility. Review of the facilities policy titled, Abuse Prevention Program and Reporting Policy, last reviewed on 08/2019 instructed staff on the following instructions and definitions: The facility prohibits the mistreatment, neglect, and abuse of residents by anyone including but not limited to: staff, family, or friends. Resident have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse: Includes, but not limited to intimidation with resulting mental anguish. Punishment with resulting mental anguish. Verbal Abuse: Oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental/Emotional Abuse: Include, but is not limited to humiliation, harassment, and threats of punishment or deprivation.

Based on record review, staff interview, and policy review the facility failed to report to the Department of Inspections and Appeals (DIA) an accident with major injury for 1 of 1 residents (Resident #4). The facility also failed to identify and report to DIA abuse for 2 of 2 residents reviewed (Resident #4 and #6). A determination was made that the facility's noncompliance placed the residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 2, 2022 on March 30, 2023 at 3:00 PM. The Facility Staff removed the Immediate Jeopardy on March 31, 2023 through the following actions: 1. Director of Nursing was suspended on 3/31/23 for alleged abuse pending the investigation. Resident #4 was interviewed by the Regional Director Clinical services on 3/30/23 to ensure resident rights are being honored including providing food including second portions, smoking breaks and incontinent care without any intent to discipline the resident. 2. Residents with a BIMS's of 13 or above were interviewed by Regional Director of Clinical Services and Social Service Director on 03/30/2023 related to any concerns of withholding food or smoking privileges with no voiced concerns noted. Residents with a BIMS of 12 or lower had a skin assessment completed by the registered nurse on 03/31/23 with no signs or symptoms of abuse noted. 3. The Administrator was educated on 3/31/2023 by the Regional Director of Operations related to requirements of abuse reporting, investigating potential abuse, abuse prevention, and resident's rights including providing goods and services free from disciplinary intent. Facility staff were reeducated by the Regional Director of Clinical Services beginning 03/30/23 on Abuse prevention and resident rights including providing goods/services including food and smoking privileges without disciplinary intent. Employees will complete this training prior to the beginning of their next shift. 4. Regional Director of Operations or Regional Director of Clinical Services will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure the abuse policy continues to be followed including investigating potential withholding of goods and services with disciplinary intent and abuse investigations/reports including fractures continue completed as required. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Administrator is responsible for monitoring and follow-up as needed. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she has diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Review of untitled document with an admitted [DATE] from the local hospital informed Resident #4 was admitted to the local hospital due to a left hip fracture from an unwitnessed fall at the facility. The document explained the wishes of the resident's Power of Attorney (POA) to proceed with surgery that included pinning of left femoral neck fracture (surgical procedure using wire or pins to hold a broken bone (fracture) together and keeps it still until it heals) Review of the facilities DIA self reports on 3/27/23 revealed the facility failed to report Resident #4 fall with major injury that occurred on 12/16/22. During an interview on 03/30/23 at 8:50 AM the Administrator revealed the physician determined if Resident #4's fall on 12/16/22 met the criteria for a major injury. During the interview the Administrator acknowledged Resident #4 fell at the facility and sustained a hip fracture and was out of the facility multiple days. Review of the facilities policy titled, Fall Risk Reduction and Management last revised on 12/2015 lacked instruction to staff on when and who would report resident falls to DIA. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she has diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Progress Note Review Progress Note dated 5/20/2022 at 2:20 AM written by Staff H, Registered Nurse (RN) for Resident #4 revealed the following: Resident #4 refused her shower yesterday and signed a contract stating that she would not get cigarettes all day, but kept putting her light on wanting a cigarette. Resident #4 had been reminded about her signed contract to have no cigarettes all day and wanted to talk to the person that had her sign the contract. The writer of this progress note asked her why and Resident #4 stated well they can say I can have a cigarette. Writer of this progress note told her that was not how that worked and she can't unsign it. Writer of this progress note told her she was not going outside. The writer of this progress note then informed Resident #4 she has not had a shower since 5/13/22 and it was unacceptable she needed to shower twice a week no matter what. Resident #4 stated she changed her underwear several times a day. Writer of this progress note provided education that does not replace a shower. Progress Note dated 6/3/2022 at 1:51 AM written by Staff H for Resident #4 revealed the following: Resident #4 refused her shower, reminded that she signed a contract that if she doesn't get out of bed to take her shower she agreed to not go out to smoke. Reminders of this given to her at 7:50 PM. Resident #4 also asked for multiple snacks every night, gave two (2) oatmeal creme pies and complained it wasn't enough and wanted more and more and continued to ask for a cigarette. Progress Note dated 6/17/2022 3:50 AM written by Staff H for Resident #4 revealed the following: Resident #4 continued with behaviors and not wanting to eat meals and just eat sweets. Resident #4 refused her shower and education given and reminder on contract she signed to get up for meals and take her showers. Resident #4 stated I want to talk to the person in charge. Writer of this progress note told her it was her and report given by day shift and unfortunately with rules Resident #4 was unable to go out to smoke. Progress Note dated 6/17/2022 at 1:18 PM written by the Director of Nursing (DON) for Resident #4 revealed the following: Resident #4 refused a bath yesterday and has refused to come out to meals today. Informed her she would not be smoking all weekend due to her choices. Progress Note dated 6/18/2022 at 1:30 PM written by the DON for Resident #4 revealed the following: Resident #4 refused to get out of bed for lunch or breakfast. She laid in her bed and wet it until all blankets were soaked. She had been told she was not going out to smoke all weekend due to her refusal to take her bath and there was nothing she could do until Monday until she can get a bath. Resident #4 signed a contract she would take a bath or she could not go out to smoke. Progress Note dated 6/18/2022 at 4:25 PM written by the DON for Resident #4 revealed the following: Resident #4 came out of her room at 3:00 PM to smoke and the writer of this progress note told her she was not allowed to smoke all weekend due to a contract she signed with the Director of Nursing (DON) that stated she would take her bath or she wouldn't get to smoke. She was angry and yelling. Resident #4 proceeded to go back to her room and had a bowel movement all over the bathroom, and a Certified Nurse Aide (CNA) had to mop up the mess. Resident #4 then said she was not coming out to supper. Progress Note dated 1/2/2023 at 4:19 PM written by Staff A, Licensed Practical Nurse (LPN), for Resident #4 revealed the following: Resident #4 had an agreement with the therapy department that she would go out to smoke then stay in her wheelchair until after supper. Resident #4 called her brother and told him that she was hurting so bad and staff were refusing to put her in the recliner. Staff talked to her brother and explained the situation while Resident #4 was yelling I didn't agree to that. Progress Note dated 2/4/23 at 5:12 PM written by Staff A, for Resident #4 revealed the following: Resident #4 was very rude to staff and yelled and screamed at them because they wouldn't push her wheelchair to the dining room. Staff explained that it was part of her therapy and she needed to do it herself. Resident #4 threatened to tell her brother and have this place shut down. Resident #4 yelled at the CNA, when the CNA explained again they would not push her due to her therapy program Resident #4 made a physical gesture of flipping the CNA off. Progress Note dated 2/8/23 at 1:19 PM written by Staff A for Resident #4 revealed the following: CNA's entered Resident #4 room to answer her call light when Resident #4 voiced that she pooped her pants because no one would push her. Progress Note dated 3/3/2023 at 8:00 PM written by Staff I, LPN for Resident #4 revealed the following: Resident #4 at the dining room table tonight asked for second helpings of food. Resident #4 was shown paper on the table and reminded her that she agreed with the dietician that she would not ask for second helpings of food. Resident #4 began to cuss at the staff and stated that she was going to get an attorney to shut the facility down. Resident #4 asked for second (2nd) helpings four (4) more time and each time staff would show her the paper and she would cuss at staff. After the fifth (5th) time staff came to the charge nurse (writer of this progress note) for assistance. The writer of this progress note informed that with this type of behavior there could be consequences and to let Resident #4 know she wasn't going out to smoke. Resident continued sitting at the dining room table and talked to another resident and bad mouthed and cussed about the staff to the other resident, stated she was going to have staff put in jail. At 7:50 PM she asked staff when they would be going out to smoke. The writer of this progress note went and told Resident #4 she would not be going out to smoke, when Resident #4 asked why the writer of this progress note reminded her she had asked five (5) times for more food and each time she was shown the paper and reminded her of her agreement not to ask for second (2nd) helpings of food and each time she began to cuss at staff and was inappropriate and after so many episodes she was advised there would be a consequence to such behavior. Resident #4 began to cuss at the writer of this progress note and asked her for her name. Resident then stopped took a deep breath and then said please let me go out for just a little cigarette. The writer of this progress note stated no, and Resident #4 immediately started to cuss and stated she was going to call her brother and have the facility shut down because she wasn't being treated right. The writer of this progress note asked why she wasn't being treat right and Resident #4 stated the CNA's were not appropriate to her, but could not provide specific details or name or describe which CNA. The writer of this progress note informed her that if someone wasn't appropriate that next time she needed to tell the nurse on duty and they would make sure there are consequences for them instead of her being rude and inappropriate and have consequences. After several moments of Resident #4 cussing at the writer of this progress note Resident #4 again took a deep breath and then began to plead with the writer of this progress note that she wouldn't cuss at staff again if she could just go out for a cigarette the writer of this progress note quietly stated no and then stated she was going back to work unless there was something else Resident #4 wanted to discuss. Record review of a contract provided by the facility titled, Nutrition Therapy Recommendations dated 1/25/23 documented Resident #4 agreed to not ask for seconds at meals and decrease snacks. The contract was not signed by the resident, dietician, or an employee of the facility. During an observation on 3/30/23 at 1:18 PM in Resident #4 room a sign posted stated, you agreed with the dietitian that you will not ask for extra food at meal times and extra snacks as you have had substantial weight gain. The sign was signed by the Director of Nursing. During an interview on 3/30/23 at 1:45 PM with Resident #4 revealed she has had sadness or would get upset with staff who don't allow her go out to smoke, she revealed she had gotten mad several times when she was not allowed to smoke. Resident #4 also discussed that she was not allowed to have extra food at meals if she was still hungry, she revealed sometimes she might get a snack and sometimes not. During an interview on 3/30/23 at 2:40 PM with the DON revealed she does not recall a bathing contract for Resident #4 and doesn't know why Resident #4 wouldn't get to smoke if she refused a shower. She revealed the Dietician talked to Resident #4 and she agreed to not eat seconds at meals. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA informed the DON instructed if Resident #4 would not get out of bed or refused her bath that she would not be allowed to smoke. Staff D revealed she thought this was a rule and what they were supposed to do, because that was what their DON said. Staff D informed Resident #4 was usually not allowed to smoke a couple times a week, she added everyone followed that direction because the DON said to. Staff D then informed she was not sure if it was care planned or not. During an interview on 4/5/23 at 10:12 AM with Staff F, Certified Medication Aide (CMA) revealed Resident #4 was on a no seconds at meals and a no snacks contract. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact. The MDS documented needs for extensive assistance (resident involved in activity, staff provide weight-bearing support) of two person physical assist with bed mobility, transfers, dressing and toilet use. The MDS documented diagnoses of cerebral palsy, hypertension, anxiety disorder, depression, and mixed incontinence. Progress Notes Review Progress Note for Resident #6 dated 5/2/22 at 3:21 AM written by Staff H revealed the following: Resident #6 put her light on at 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM and 10:45 PM staff into room all of these times. Resident #6 was incontinent of urine at 4:00 PM, 6:00 PM and 10:45 PM and incontinent of bowel at 8:00 PM. Resident #6 educated that there was no reason for her to be incontinent at all as she was the youngest resident here and has had no children. Her control was amazing and can go from 11:00 PM to 7:00 AM without ever urinating and if doing activities she liked can go up to 6 hours during the day without voiding. Resident #6 only had accidents for attention and when she was mad and she doesn't get her way on something, which she didn't get her way on her coffee, she could only have two (2) cups a day period according to her sister who was very mad at her due to all her behaviors and manipulating CNA's to allow her finish a show. The writer of this progress note went to Resident #6 room at 11:10 PM and educated her again to not manipulate staff to allow her do things she wasn't supposed to do. Progress Note for Resident #6 dated 6/12/22 at 2:15 AM written by Staff H revealed the following: Resident #6 was very rude and snarky with CNA's she was incontinent for no apparent reason. Resident #6 had always done this for attention even before she came to this facility. She was like this at home and where she lived before coming to the facility. Resident #6 was very demanding and pouted that she had to wait till 7:00 PM to go to bed. Staff have explained to her numerous times that there are other residents here that need care too and her patience would be greatly appreciated. Resident #6 mumbles under her breathe being mean and nasty to staff then lied about her cares when staff have been in her room two (2) at a time due to her behaviors and lying. The writer of this progress note stood outside her room and listened and intervened to her pouting. Progress Note for Resident #6 dated 6/13/22 at 3:03 AM written by Staff H revealed the following: Resident #6 continued to be rude and demanding to staff. She was on her call light every two (2) hours by the clock. She was incontinent for no reason other than she thought she could get changed and go to bed or her skin will breakdown so she can lay in bed all the time. Resident #6 has the mentality of a teenager related to her diagnosis of cerebral palsy. Her family was aware of her behaviors but not lately, she had the best bladder control of all residents at the facility. Progress Note for Resident #6 dated 6/13/22 at 8:45 AM written by the DON revealed the following: Resident #6 ate her breakfast and had coffee then went back to her room and pooped her pants. Her sister was coming to bring her some stuff and was told what she did. Progress Note for Resident #6 dated 6/17/22 at 1:14 PM written by the DON revealed the following: Resident #6 went back from lunch and soiled her pants. She already asked if she could go to bed early tonight and the writer of this progress note told her it was based on her behaviors. Progress Note for Resident #6 dated 8/6/22 at 8:00 PM written by Staff H revealed the following: Resident #6 was incontinent of urine right before staff put her on the commode and after they put her to bed was incontinent of bowels. The writer of this progress note asked her why she was incontinent when she had best bladder control out of everyone at the facility and definitely had the best bowel control out of everyone here. The writer of this progress note told her there was no excuse other than she wanted to go to bed right away and didn't want to sit on the commode. Resident #6 folded her arms across her chest and said nothing just had a pout on her face. Progress Note for Resident #6 dated 8/10/22 at 3:05 PM written by Staff A revealed the following: Resident #6 very upset and pouted as she had to get weighed after she had already eaten breakfast. Resident #6 wanted to be weighed before she ate and staff didn't have time to weigh her before breakfast. Resident #6 pouted all day and would hardly answer staff when they talked to her, she sat in her room with her arms crossed over her chest and looked at the floor anytime staff entered. Progress Note for Resident #6 dated 8/12/22 at 2:21 AM written by Staff H revealed the following: Resident #6 having increased behaviors when she doesn't get her own way, like she didn't last night, and was incontinent of bowel and bladder. She was increasingly incontinent for no reason other than for attention and/or she was mad. Her sister was very upset with her and each time she was incontinent added 15 minutes on her time to lay down early on Sunday which already was unable to lay down at 4:00 PM Sunday due to incontinence, her sister was very upset with her. Progress Note for Resident #6 dated 8/17/22 at 1:52 AM written by Staff H revealed the following: Resident #6 continued to manipulate staff and incontinent for attention. Anxiety when she doesn't get what she wants. Progress Note for Resident #6 dated 1/26/23 1:11 PM written by Staff A revealed the following: Resident #6 up to the dining room for breakfast and started to go back to her room at 7:30 AM, when asked where she was going she replied she was going back to here room. Staff told her it was time for breakfast and she needed to stay. Resident #6 then said she wanted to move to a different table, when asked her why she refused to answer and sat in the middle of the walkway and pouted. Progress Note for Resident #6 dated 2/9/23 at 1:14 PM written by Staff A revealed the following: Resident #6 very needy and manipulative today. Call light on to have staff put her exercise bar away when she knew that she was supposed to wait until staff come to her room then she can ask them to put it away. She had turned on her call light to ask staff to get things for her. She was asking multiple times for multiple things while staff was trying to complete the first request. Repeatedly stated I've been good today I haven't bothered you at all today have I. Staff encouraged her to come out of her room, but prefers to isolate herself in her room. Progress Note for Resident #6 dated 2/18/23 at 12:58 PM written by Staff A revealed the following: Resident #6 very upset and pouted when she got her coffee this morning. The cup wasn't filled to the brim and she didn't think she was getting her full cup. Staff attempted to explain that it was dangerous to carry a cup too full and could get burned Resident #6 dropped her head and wouldn't talk anymore. Progress Note for Resident #6 dated 2/28/23 at 1:08 PM written by Staff A revealed the following: Resident #6 stayed in the dining room too long after breakfast this morning and pooped her pants, resident went to her room and noted to be smiling and grinning and said to CNA's I know you're going to be mad at me. Staff explained to Resident #6 that she needed to start coming to her room sooner Resident #6 continued to smile and said I know. Progress Note for Resident #6 dated 3/15/23 at 8:58 AM written by the DON revealed the following: Resident #6 was incontinent of bowel two times yesterday. Not allowed to have coffee today. Progress Note dated 3/16/2023 at 8:55 AM written by the DON for Resident #6 revealed the following: Resident #6 had behaviors and lost her coffee privileges today. Resident #6 soiled her pants yesterday and it was not loose. She then got on her tablet until 2:00 AM. Told her it would be at the nurses station. During an interview on 3/30/23 at 9:40 AM Resident #6 revealed she was on a toileting program and can go once every two hours, she revealed the toileting program doesn't bother her as she has a weak bladder and they are trying to strengthen it. She revealed sometimes she gets sad about it because she might have an accident, and then they let her go. She revealed if she had an accident then she can not have any coffee for the day. She revealed she wouldn't give a name because she didn't want to get the the person in trouble. She stated yesterday she lost three (3) cups of coffee since she had an accident on 3/28/23. She revealed her sister put a limit to two (2) cups a day, but she wanted three (3) cups of coffee a day. She revealed she would like to have two (2) cups in the morning and one (1) at lunch, she revealed she loved her coffee. During an email correspondence on 4/7/23 at 10:16 AM the facilities Regional Nurse Consultant revealed they have reported to DIA abuse concerns with the Director of Nursing and Staff I, Licensed Practical Nurse (LPN). During an interview on 4/4/23 at 1:04 PM with the facilities corporations Regional [NAME] President informed she would expect the Administrator to report abuse to DIA within two hours of identifying it or sooner. She had provided the facilities Administrator with training for Abuse and her direct care expectations. She revealed she would want it within two hours of the incident so help and support could be given and an investigation could be completed. She revealed she could help the Administrator with notifying DIA regarding falls with major injury as well.

Based on record review, resident and staff interviews, and policy review the facility failed to provide root cause analysis interventions of previous falls to prevent 1 of 1 residents (Resident #4) from sustaining a major injury. The facility also failed to provide adequate supervision for 2 of 2 residents (Resident #2 and #11) after residents sustained falls in the facility. The facility reported a census of 18 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Record review of a Progress Note dated 11/21/22 at 4:24 AM revealed the following, Resident #4 yelling out for help in her room and found sitting on the floor against the side of the cabinet by the door. Resident assessed and had no injuries identified. Record review of the facilities Assessments for Resident #4 lacked documentation that a fall report had been completed for her 11/21/22 at 4:24 AM fall. Record review of a Progress Note dated 11/25/22 at 5:34 AM revealed the following, Resident #4 was yelling out for help and found sitting on the floor with her back against her room door. She was unable to remember what she had tried to do prior to the fall. Resident assessed and had no injuries identified. Record review of the facilities Assessments for Resident #4 lacked documentation that a fall report had been completed for her 11/25/22 at 5:34 AM fall. Record review of a Progress Note dated 12/16/2022 at 7:23 PM documented Resident #4 fell at 6:30 PM in her room and was found on the floor on her left side, Staff used a hoyer lift (mechanical device to lift a resident) with two (2) assist to transfer her from the floor to bed. Resident #4 complained of pain to her hip and screamed with movement to her left lower extremity. Resident left facility at 7:35 PM to go to the local emergency room (ER). Record review of an untitled incident report for Resident #4 dated 12/16/22 regarding the fall at 7:23 PM revealed the following: Staff were at the nurses station when Resident #4 screamed from her room. Upon entering Resident #4 room staff found her on the floor on her left side. The nurse completed vital signs and an assessment was obtained. Resident #4 stated she was trying to go to the bathroom. Staff transferred her from the floor to the bed with a hoyer lift with two (2) people. The resident screamed with minimal movement to her leg. The nurse received an order from the doctor to send her to the ER to get evaluated. Review of untitled document with an admitted [DATE] from local hospital informed Resident #4 was admitted to the local hospital due to a left hip fracture from an unwitnessed fall at the facility. The document explained the wishes of the resident's Power of Attorney (POA) to proceed with surgery that included pinning of left femoral neck fracture (surgical procedure using wire or pins to hold a broken bone (fracture) together and keeps it still until it heals). Record review of Resident #4 Care Plan dated 3/29/2023 lacked implementation of fall interventions regarding the root cause for the reason of the falls on 11/21/22, 11/25/22, and 12/16/22. 2. The MDS dated [DATE] for Resident #2 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Record review of a Progress Note dated 11/5/2022 at 2:13 PM for Resident #2 documented she was found on the floor in her room bleeding above her right eye. The facility provided first aide. Record review of a Progress Note dated 11/8/22 at 2:26 AM by Staff L, LPN documented Resident #2 was found at 1:30 AM sitting on the floor in her room. Record review of a Progress Note dated 11/25/22 at 2:20 PM revealed, Staff A, Licensed Practical Nurse (LPN) entered Resident #2 room and saw her lying on the floor in her room. Staff A documented she identified several raised areas to her face and one in the center of her forehead was bleeding. The facility provided first aid, removed her grab bar from her bed, and placed a fall mat on the floor. Record review of Resident #2 current Care Plan on 4/3/2023 lacked documentation for root cause analysis interventions for repeated falls in Resident #2 room. 3. The MDS dated [DATE] for Resident #11 documented a BIMS of 3 which suggested severe cogitative impairment. The MDS documented need for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with toilet use and personal hygiene. The MDS documented she was independent with transfers and walking in her room. The MDS revealed she had diagnoses of cerebral infarction, hypertension, and chronic pain. Record review of a Progress Note dated 3/7/2023 at 1:15 PM by Staff I, LPN documented Resident #11 was observed stumbling and then fell in the hallway outside of her room. The nurse documented when she lost her balance it caused her to fall into the rail on the wall and then back hitting her head on the wall before landing on the floor. Resident #11 complained of pain to the back center of her head, her left shoulder, and her left hip. Resident #11 was transferred to the emergency room for evaluation. Record review of Resident #11 current Care Plan on 4/13/2023 lacked root cause analysis of why her fall occurred on 3/7/23 or interventions to prevent further falls. Record review of the facilities policy titled Fall Risk Reduction and Management last revised on 12/2015 instructed staff of the following: a. Revise the Care Plan to indicate changes in interventions with each fall and as indicated. b. Modify and document goals and interventions with each fall and as indicated. During an interview on 04/12/23 at 12:44 PM the facilities Regional Nurse Consultant revealed she would expect staff to implement an intervention regarding why she fell to hopefully prevent future falls. She revealed she would also expect staff to update the care plan and communicate to the staff on the changes made.

Based on record review, facility investigative file review, staff interviews and policy review the facility failed to separate Staff D Certified Nursing Assistant (CNA) and Staff E Registered Nurse (RN) after an allegation of abuse was reported to the Director of Nursing (DON) on [DATE]. On [DATE] at approximately 9:50 PM, Staff E allegedly yanked Resident #1 back through an exit door forcefully and she fell . Staff E took away the resident's walker and proceeded to hold her down in a chair against her will. Staff D obtained a flat sheet per Staff E's directive and then Staff D held Resident #1 in the chair while Staff E wrapped the sheet around the resident's right leg. The two 2:00 PM-10:00 PM CNA's saw this and Staff F called the DON (Director of Nursing), who asked that the CNA's provide statements. The DON told the Admin on the morning [DATE]. But Staff E and Staff D continued to work alone in the facility with Resident #1, until 6:00 AM on [DATE] and repeated the same shift on [DATE] until 6:00 AM on [DATE]. This situation constituted an Immediate Jeopardy in resident health and safety. The facility reported a census of 21 residents. Findings include The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview of Mental Status (BIMS) score of 99. A score of 99 suggested the resident was unable to complete the interview. The MDS documented she had modified independent cognitive skills for daily decision making. Resident #1 experiences wandering daily and refused care for ,d+[DATE] days during the 7-day review period. She required supervision of one staff for bed mobility, dressing, eating and used a walker. She also required limited assistance of one staff for toilet use and personal hygiene. The MDS documented the following diagnoses: stroke, cancer, hypertension, and thyroid disease. The Care Plan focus area dated [DATE] indicated Resident #1 had a psychosocial adjustment issue due to recent admission. She felt she was lied to regarding the admission as she thought she was going to a doctor's appointment. Staff are to encourage ongoing family involvement and continue contact with her family via cell phone. The Care Plan also indicated she had impaired cognitive function and impaired thought processes related to disease process including stroke and brain tumor. She had very short-term memory functions and obsesses over issues continually. The care plan encouraged staff to communicate with the family and caregivers regarding resident's capabilities and needs. Staff are to ensure her safety, leave and re-approach later or with a different staff member if the resident gets agitated. Staff are encouraged to keep her routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Staff are also encouraged to re-direct her if she is wandering into an unsafe or unfamiliar area. Staff are to be aware they may have to answer the same questions numerous times before the resident is satisfied or change the topic. The care plan indicated she was deemed a severe elopement risk due to impaired cognition, new admission to the facility, threats to elope, and actual elopement attempts. Staff are encouraged to re-direct her away from exits when she is agitated and offer her to contact family. The Progress Note dated [DATE] at 3:15 PM documented Resident #1 was up and pacing the hallways, became very upset and agitated when staff would not let her go outside to go to her apartment to get some clothes. The Progress Notes dated [DATE] at 10:52 PM documented Resident #1 was going exit to exit door, in and out of other resident's room, grabbed and pinched the nurse, yelling and setting off door alarms. She was very upset and unable to understand she was safe at the facility. Staff provided ,d+[DATE] all day and since the nurse arrived to the facility at 6:00 PM. A call was made to the on-call doctor and received an order to give Haldol 5 milligrams (mg)/milliliter (ml) and to give 2.5 mg intramuscular (IM) right now (STAT) and to call back if not effective. At 11:45 PM she continued to be anxious and hitting, pitching staff and going to exit to exit, yelling and attempting to go in to other resident's rooms. Another call was made to the on-call doctor and gave an order for another 2.5 mg Haldol IM, one time only. At 11:50 PM IM Haldol given in resident's right arm at this time, ,d+[DATE] with resident provided while in the lobby area as she was disturbing other residents; other residents trying to sleep. Several residents afraid to go to sleep as she was going through their rooms and drawers looking for her phone. Family told staff to take the phone at night as the resident makes numerous calls to them daily, up to 50 times per day. This note was documented by Staff E. The Progress Note dated [DATE] at 12:46 AM the nurse walked with Resident #1 down to her room and she laid down for a short time and went to sleep around 12:45 AM. At 2:46 AM staff kept checking on the resident to ensure she was sleeping and in her own bed. Review of the facility's investigative file revealed the following staff statements: - Staff D Certified Nursing Assistant (CNA) wrote as she walked in the Registered Nurse (RN) asked her to get her a sheet and she did. The nurse started to tie down the resident to a chair. Staff D stood at the nurse's desk while this happened. - Staff E RN wrote Resident #1 had set off door alarms and tried to leave the facility. She was assisted back to the commons area and she sat on the loveseat demanding to leave. Explained it was not safe outside at night. Insisted she had an apartment across the street that she could go to, kept saying this over and over. Staff E called the doctor at 10:49 PM and she gave an order to give IM Haldol and call back if ineffective. At 11:45 PM Staff E called back to doctor and received orders to give other Haldol IM. - On [DATE] the Administrator interviewed Resident #1 to see if she remembered anything from the incident on Saturday ([DATE]) night. She reported that she did not have any issues over the weekend, but last night she had a dream she was fighting with someone here. When asked what they were fighting about, she said they were just yelling at each other. The Administrator asked if it was an employee or another resident, she indicated she did not remember, thought it was a staff member. Resident #1 stated it was only a dream and she was tired. She then wanted the Administrator to leave the room. The Administrator signed and dated the typed statement [DATE]. - On Saturday [DATE] at approximately 9:55 PM, Staff G CNA, witnessed Staff E RN abuse a resident. Resident #1 was attempting to leave the facility. She had made her way to the entryway from the common area. Staff E informed the resident that she could not leave the building. When Resident #1 did not respond to her statement, Staff E went in to the entry way and grabbed her by the arm to force their way back to the common area. Resident #1 began to struggle, her walker tipped over and she fell to the floor in the doorway to the common area. Staff E let go of the resident to remove the walker from the area. Resident #1 helped herself up off the floor. Staff E came in the common area with a dining room chair. She then grabbed Resident #1 by the shoulders and forced her to sit in the chair. The resident was screaming that she knew her rights and this was abuse; she was crying in shock because of the situation. Staff E then instructed Staff D CNA to get a flat bed sheet. Staff D complied with the task while Staff E held a hysterical Resident #1 in the chair by holding her shoulders down. Staff D returned a few seconds later with the sheet. Staff E then told Staff D to hold Resident #1 down in the chair as Staff E started to wrap the bedsheet around her leg. Staff D and Staff E did not care that she was screaming, crying and struggling for them to not physically restrain her. As Staff E wrapped the sheet around Resident #1's legs, Staff G exited the facility with Staff F to immediately call and notify the Director of Nursing (DON) of the event they had just witnessed. The hand-written statement was signed and dated on [DATE]. - Around 9:55 PM on [DATE], Staff F witnessed Staff E and Staff D abuse Resident #1. She was attempting to exit the facility due to being upset that Staff E had taken her cell phone for the night. Resident #1 did not want to enter the common area from the entry way. Staff E then grabbed the resident by the arm and pulled her through the door way back in to the main common area. Resident #1 struggled, knocking over her walker then she landed on the floor. Staff E grabbed the resident's walker and removed it from the area. Resident #1 began to cry and yell at Staff E; you are abusing me, I know my rights. Resident #1 was able to get back to her feet and Staff E grabbed her under both arms and physically restrained her to the chair; Resident #1 began to scream. Staff E instructed Staff D to get a flat bed sheet, she complied and brought the nurse a sheet. Resident #1 was still crying and screaming while Staff E continued to physically restrained her in the chair. Staff E then instructed Staff D to hold her down as she began wrapping the sheet around Resident #1's leg. Resident #1 was still struggling against Staff E and Staff D. At that time Staff F exited the facility and immediately called the DON and reported the event. The hand-written statement was signed and dated [DATE]. On [DATE] Staff F made an addendum to her statement. After interviewing with the Administrator, Staff F did not intervene out of fear of Staff E retaliating or linking her to the abuse since she was her superior in the situation. Staff F had never been in that kind of situation before and knew she needed to contact the DON immediately. She personally placed a call to the DON in the presence of Staff G. She also added that when Resident #1 fell to the floor, she was forcefully placed in the chair without an assessment of vitals done. The resident did not seem injured by was immediately restrained with the bed sheet. This addendum was signed and dated by Staff F. - The DON wrote Staff F called and stated her and Staff G were working and the night nurse, Staff E was having trouble with Resident #1 trying to go out the door. It was 10:00 PM on ,d+[DATE] and time for them to leave. Staff G asked Staff D for a sheet and to hold Resident #1 in a chair. When she was getting ready to tie her in the chair, they exited the building and called her at 10:03 PM. Staff F told the DON what she thought was happening. The DON informed her and Staff G that she would need written statements from them both. The DON received a call from Staff E at 10:45 PM asking for help to figure out what do to with Resident #1 since she was trying to leave the building and setting off the alarm. Resident #1 was disrupting other residents. The DON told her to try calling the on call doctor and see if she could get an order to calm her down. She did not admit to tying Resident #1 to a chair. She had never had an abuse report in all her years as a DON. She did not know or think to call the administrator. She asked for written statements from Staff F and Staff G, then sent pictures of their statements to the Administrator on [DATE] and she started the reporting process. Review of the facility's Five Day Investigation Summary revealed the following information: -Date of Incident [DATE] - Reported Event: Allegation of Abuse when Administrator became aware of on [DATE] - Staff were provided re-education regarding the timeliness of communication of unusual events. On [DATE] at 2:09 PM Resident #1 was observed lying in bed with her cell phone on her left hip. When asked if anyone has been mean or unkind to her she stated no. Resident #1 was asked if anyone had ever pushed her to the point of falling, she laughed and stated she had fallen a few times on her own. She then asked if she had eaten lunch yet and remained focused on whether or not she had lunch. On [DATE] at 1:12 PM Staff F reported about 9:50 PM on Saturday [DATE] her and another staff member were waiting for their shift replacement, Staff D to come in to work. Resident #1 had been irritated that her phone had been taken away. Her family had requested her cell phone be taken at night but Staff E took it from her about 7:00 PM, before it should have been taken away. Resident #1 was visibly upset: she was exit seeking and setting off the alarms. When Resident #1 walked to the front door, the door alarm was set off that was when Staff E grabbed Resident #1's right arm; she had one hand at the resident's elbow and the other hand was under the resident's right armpit. Staff E pulled Resident #1 from the entry way, knocked her walker over and she fell to the ground on to her knees. Staff F stated she did not visualize any injuries at that time but the nurse did not look her over. At about 9:,d+[DATE]:55 PM Staff D came up front and Staff E had brought over a chair from the dining room and asked Resident #1 to take a seat and she said no. Staff E then grabbed her shoulders and forced Resident #1 to sit down. Staff E held Resident #1 in the chair with her hands on top of her shoulders and the resident began to yell and pry Staff E's hands off of her shoulders. Staff E asked if someone could get her a bed sheet but Staff F and G told her no so Staff D retrieved it and gave it to Staff E. Staff E then wrapped the sheet around her right leg as Staff D held her shoulders down to keep her in the chair. Staff E had Resident #1's right leg wrapped with the bed sheet but was unsure if it the sheet was wrapped on the chair. Staff F indicated she could not see for sure from the angle she was at. Staff F stated that was when she and Staff G exited the building to call the DON immediately to notify her of what was going on. The DON told her she had already taken her sleeping pills and could not drive to the facility but would call the Administrator to see what needed to be done. When Staff F was asked how Staff E restrained Resident #1 to the chair, she stated she had wrapped the sheet around her right leg while Staff D held her down by pushing her shoulders down from behind. Staff F stated Resident #1 was yelling ow, stop, you are hurting me after she was placed in the chair. She kept saying, I know my rights. She was fighting like hell to get out of the chair. On [DATE] at 11:56 PM the DON stated she received a phone call from Staff F on the evening of [DATE]. Staff F had informed her that Staff E was getting ready to put a sheet around Resident #1. The DON stated she had never worked with Staff E because she worked the overnight shift. The DON acknowledged she should not have waited until [DATE] to report what was reported to her, to the Administrator. When asked why it was not reported sooner, she stated she never had anyone do that before and did not know what to do. She was coached by the Administrator on reporting allegations. She had been a nurse for [AGE] years and never had an abuse allegation before, she was not sure what to do. On [DATE] at 1:55 PM the Administrator stated she had learned of the incident that took place on [DATE] on the morning of [DATE]. She had received a text from the DON with the statements she had received. The text said this happened Saturday ([DATE]) night. Staff E called her asking for advice on what to do because Resident #1 was wandering and suggested she call the doctor. Staff E had received an order to give a PRN IM. The Administrator stated she came in to the facility, got statements and completed her initial report. She talked to the CNAs to demonstrate what was witnessed. Staff indicated the resident got up on her down before a nurse could assess her. The Administrator asked why no one intervened and Staff F did an addendum. Staff G told her Staff E had a way of turning things around, is vindictive and would make him to be the bad guy. When asked what her thought was on what took place, she stated something happened but could not figure it out for certain. Resident #1 told her she had a bad dream, was arguing with someone and she felt bad about that. She told the Administrator there was yelling but does not remember what happened, just told her something happened. She asked Staff F and Staff G why they did not call her about the incident, they told her they called their supervisor. The Administrator let them know she was the Abuse Coordinator, which they did not know. She added she had asked the facility to post this for all staff to see but it had not been done at that time. It is post now with the new Administrator's information. On [DATE] at 2:29 PM Staff G stated about 9:55 PM or so Resident #1 was agitated, in a delusion or some kind of episode. He stated it all started when Staff E took her cell phone. Resident #1 kept trying to open the exterior door and it would alarm because of her wander guard. The door would alarm then the facility alarm would activate. He indicated Staff E had had enough of the alarm going off and grabbed Resident #1, forced her back in to the facility from the foyer area. When asked how she grabbed the resident, he stated Staff E had her left arm under the resident's left arm and her right arm around her back. As they were walking back in to commons area, Resident #1 was putting up a struggle and when Staff E let go of the resident, she fell to the floor. While on the floor Staff E removed her walker from the area and grabbed a chair. Resident #1 was able to get herself up by using the door frame and that was when Staff E grabbed the resident and put her in to the chair. Staff E stood in front of Resident #1, while seated in the chair, and put her hands on top of the resident's shoulders and slammed Resident #1 on to the chair. Staff G was asked if anything was said to the resident at this time, she stated Staff E told the resident she was done and needed to sit inside; she was being demanding and forceful. Staff E then demanded someone to get a bed sheet. Staff D had just got to work, heard her request and got a bed sheet. Staff E continued to hold Resident #1 down in the chair by pressing her shoulders down with her hands. When Staff D returned with the sheet, that was with him and Staff F left the facility to call the DON. As he left the facility Staff E was on her knees in front of Resident #1 and was in the process of wrapping the bed sheet around the leg of the chair. When asked to describe what he saw, he stated she twirled the sheet and had it around the resident's right leg and assumed she was going to tie her leg to the chair. He added Resident #1's leg and foot was already in front of the chair legs; she was crying and screaming out help why are you doing this. Staff D was holding Resident #1's shoulders down to keep her in the chair. Staff G stated when Staff E grabbed Resident #1 from the door, he stood there thinking, she finally snapped, she had enough. He stated Staff E was difficult to work with. When you would arrive for your shift you never knew how she was going to be: happy, demanding, strict, stern, emotional wreck, mean or angry. On [DATE] at 10:15 AM Staff E stated Resident #1 had behavior throughout the day and evening on [DATE]. Resident #1's family did not want her to have her cell phone because she would call them 50 times a night. Family wanted staff to take it at night. That evening Resident #1 gave her cell phone to her husband (who also lives in the facility) and he gave it to Staff E to put in the medication room. Resident #1 was screaming at the top of her lungs wanting it. Resident #1 was going up and down the halls, in and out other resident's rooms and drawers. She was literally going in to resident's room, other residents were running out of their rooms, almost falling, residents were crying. She was exit seeking, setting of the door alarms constantly. When Resident #1 would attempt to get out the front door, Staff E stated she would go with her and talk her in to going back to the common area. Staff E stated she had pulled the hall doors shut to slow her down. Residents were scared to death, it was bad and she added she hadn't had that happen in a long time. They had a resident that needed the help of two staff with incontinent cares and they could not get to her because Resident #1 needed staff with her. Staff E called the DON to get help but she would not come to the facility to assist. She then called the on-call doctor to get an as needed (PRN) order because Resident #1 was screaming and beating on staff. At one time another resident took Resident #1's walker away so she could not walk but Staff E indicated she got it back for her. Staff E was asked if she forcefully put Resident #1 in the chair, she stated when they got the chair, the resident sat down in it. They had to turn it around so it was face her and had to convince her to sit down. When asked if Resident #1 was ever forcefully made to sit down, she stated no. She was at her wits end and needed help, which is why she called the DON. Resident #1 was asked if she pulled her back in the facility as the resident attempted to leave the building, she indicated they linked arms to turn her around, away from the front entrance door. Resident #1 had her walker at that time and was patting Staff E's hand. When asked how they linked arms she put her hand in towards her rib cage making a triangle with her arm and Resident #1 had her arm linked in with hers. As they were walking Resident #1 knelt down on her knees and prayed, telling god she would not call her family if she got her phone back. Staff E stated she did not understand what Resident #1 was doing and it broke her heart to watch it. Staff E was asked if she held Resident #1 down in the dining room chair, she stated no, she knelt in front of her so they were at eye level and not towering over her. They began to talk about her kids because she knew this would calm her down but that lasted about 10 minutes then she was back at it again. Staff E indicated call lights were going off like crazy during all of this. Resident #1 took up so much time that she could not help others or do her tasks such as talking her residents during her medication pass times. There were two residents that she talked to every night because they were lonely. But that night she was not able to do so. Staff E was asked why she asked staff to get a bed sheet that night, she stated she did ask that but changed her mind, she just could not do it. She added history shows that is helps residents to calm down and stay calm. When asked what her thought process was at that time, she stated she just wanted to help calm her down and had thought about putting the bed sheet around her waist. When Resident #1 saw her with the bed sheet, she asked Staff E if she was going to cover her up and she told her no. Staff E was asked if she ever put the sheet around the resident's legs or arm, she said no. Staff E was asked if she was working more than 40 hours a week or 80 hours a pay period (two weeks) she stated oh always, she had overtime every pay period. When asked how much overtime she stated she worked about ,d+[DATE] ever two weeks. When asked if she was burned out at that time, she stated she had a lot going on over the last two years. She acknowledged a lot of immediate family members had died in a matter of 4 months. She was stressed, in counseling and it is helping. On [DATE] at 11:33 AM Staff D stated she had arrived to work about 10:00 PM and Resident #1 was already screaming in the dining room. She was unsure what the reason was for her to be screaming. She did notice Resident #1 kept going to the front door to leave and she kept saying they were holding her hostage, wanting to go across the street to her home. Staff D indicated she talked with the resident about not needing to leave the building. Staff D then sat her belongings down and went to the restroom and heard what sounded like skin hitting skin. She was unsure exactly what happened but knew it sounded like someone was hitting someone. It just sounded like skin slapping skin. When she came out of the bathroom Resident #1 was standing near another resident and Staff E was at the nurse's station. She could tell Staff E was frustrated because she was fidgety, saying there's no reason for this we are not a memory care unit, we are not equipped to do this. Staff D stated call lights were going off, residents that were two assistance needed help but they could not help them because Resident #1 could not be left alone and there were only two staff members working that shift. Staff E called the DON to see what they could but was told to suck it up and call the doctor to get a PRN order. Resident #1 told Staff D they stole her phone so she gave her one the facility's phone to see if that would help. At one point Staff E asked her to get a bed sheet; the first one she brought out was too short, so she got another one. She did not think anything of it because before when there would be water on the floor they would use a sheet to absorb as much as possible before they would get the mop. She just assumed there was a mess that needed cleaned up. Resident #1 was sitting in a chair near the nurse's station and Staff E put the sheet over the chair's arms, folded it in halve and looped it through the spaces of the arm rests, as Resident #1 sat in the chair. Resident #1 stated you are tying me to a chair, Staff D told her they were not. They needed to calm her down because she was hyperventilating and this seemed to help calm her down. Resident #1 then pulled up the sheet from the chair and walked to the couch and continued to calm down and allowed the PRN shot to be given that Staff D had obtained from the doctor. Staff D stated once that sheet was in place as Resident #1 sat in the chair, she was able to sit and catch her breathe. When asked how long she was in the chair the sheet looped in front of her, she stated not more than 5 minutes. When asked if the sheet was tied around her legs to the foot of the chair, she said nothing was at the foot of the chair. Staff D was asked if Resident #1 was ever forcefully put in the dining room chair, she stated not that she recalled. There was a moment when Resident #1 was with her walker and tripped Staff E. Staff E took hold of her walker and grabbed the resident, stated that is enough we are going inside. That was the only thing that was really forceful. Staff D was asked if anyone had held Resident #1 down she indicated no one held her down in the chair. She added Resident #1 was not in any condition to get up because of her breathing and she was rocking back and forth. The facility policy titled Abuse Preventions Program and Reporting Policy revised ,d+[DATE] indicated staff are to immediately separate the resident from the alleged perpetrator. In the care of a direct caregiver being suspected of allegedly abusing a resident, the Administrator (in their absence the DON) must immediately relieve the individual of their duties without pay (suspend) until the investigation is complete. When a nursing facility receives an allegation of abuse, they must report immediately, separate the alleged perpetrator from all potential victims and begin their investigation. The facility was informed of the Immediate Jeopardy on [DATE] at 5:45 PM. The IJ was removed on [DATE] when the facility took the following actions: 1. Residents with a BIMS of 13 or above were interviewed by the Administrator/Designee on [DATE] - [DATE] with no voiced concerns noted. Residents with a BIMS of 12 or lower had a skin assessment completed by the licensed nurse on [DATE]-[DATE] with no signs or symptoms of abuse noted. 2. The DON was educated by the Administrator on [DATE] related to abuse training including immediate separation of alleged perpetrator from residents and immediate reporting of alleged abuse. Facility staff were reeducated by the Administrator/Designee beginning [DATE] on Abuse Training including immediately separating the alleged perpetrator from residents in the event of a reported alleged abuse. Employees will complete this training prior to the beginning of their next shift. 3. Administrator/Designee will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure the abuse policy continues to be followed including immediate separation of the alleged perpetrator from residents for incidents of alleged abuse and abuse investigations/reports continues completed as required. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Administrator is responsible for monitoring and follow up as needed.

Based on clinical record review and staff and resident interviews, the facility failed to provide adequate supervision to prevent an accident causing injury for one of five residents reviewed (Resident #1). The facility reported a census of 28 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated he had [DIAGNOSES REDACTED]. The assessment documented Resident #1 had severe cognitive impairment. The resident needed the assistance of two staff with transfers, had impaired range of motion in both upper extremities and used a wheelchair with staff assistance for locomotion. The resident's Care Plan contained a focus area dated 3/16/18 that identified the resident as at high risk for falls related to confusion, gait/balance due h/her [MEDICAL CONDITION] and lack of awareness of h/her safety. Interventions included placing the resident in a recliner at the nurse's station when restless, placement of a modified lap buddy when in h/her wheelchair for positioning, for staff to monitor h/her every 30 minutes and remove the lab buddy every two hours for toileting and ambulation and place a non-skid tube to wheelchair seat between resident and cushion. Physical therapy recommended to lower the back of the wheelchair seat to prevent the resident from falling forward. The Incident Report dated 8/14/18 at 6:32 a.m. documented an aide reported the resident held onto the dining room table and lowered himself to his knees on the floor and started to crawl. Staff assessed the resident and noted no injuries. Staff reported they were unable to reach the resident when the resident lowered h/herself to the floor. The Incident Report dated 10/2/18 at 7:45 a.m. documented several staff were present when the resident, sitting in his wheelchair in the front lobby with the lap buddy in place, removed the lap buddy and fell forward out of the wheelchair on to the floor. An assessment revealed no injuries. The Incident Report dated 11/9/18 at 11:00 a.m. documented Staff A, a licensed practical nurse (LPN) heard a loud noise and saw the resident had tipped his wheelchair forward with him lying on his right side on the floor in front of the nurse's desk. The nurse documented one side of the lap buddy was on. but one of two sides of the modified lap buddy had moved from normal position. The resident attempted to sit upright and moved all extremities independently. An assessment revealed no injuries. Staff assisted the resident from the floor with the use of a Hoyer back into his wheelchair. The resident appeared restless and was required to be placed next to the nurse until lunch time. A Progress Note dated 11/9/18 at 6:00 p.m. documented staff reported the resident showed signs of pain. Staff A entered the resident's room and found him to be awake and alert to his name. She asked the resident if he hurt and had difficulty understanding the resident. The resident grimaced when she assisted with his incontinent brief and when rolling from side to side, Resident #1 grimaced again, moaned and stated his hip and right groin hurt. The resident reported his back hurt. Staff positioned the resident to a seated position on the edge of the bed and the resident once again grimaced. Upon standing for stand a pivot transfer, Resident #1 placed weight on his left leg and used the toes on the right leg and moaned when he sat down. Staff completed range of motion to both hips and knees and the resident stated it hurt only with right hip movement. Staff contacted the resident's physician who ordered an evaluation/treatment at a local hospital emergency room . The resident transported to the hospital via ambulance and prior to transport staff administered pain medication. An X-ray of both hips on 11/9/18 at the hospital revealed no hip or pelvic fractures. The X-ray showed chronic heterotopic [DIAGNOSES REDACTED] noted with lower lumbar [MEDICAL CONDITION] changes similar to prior images. Progress Notes dated 11/10/18 at 11:31 p.m. recorded Resident #1 displayed pain when repositioning but when asked denied having pain. Progress notes dated 11/11/18 at 7:58 p.m. documented staff administered [MEDICATION NAME] 650 milligram (mg) as the resident showed signs of pain during evening cares. Progress notes dated 11/14/18 at 1:26 a.m. documented pain medication given he displayed non-verbal indications of pain (facial grimacing and grabbing his leg) during repositioning related to the right leg/hip area. Progress Notes dated 11/14/18 at 3:54 p.m. documented he showed signs of discomfort by rubbing the right thigh. While walking from the bathroom to bed with two assist, it appeared his pelvis and left hip or the curvature of the back or hip had greater protrusion. The resident walked differently with his right leg and acted as if it had been painful to bear weight. Progress Notes dated 11/15/18 at 9:49 a.m. documented the resident's speech can be mumbled at times and hard to understand. At times he is able to make his needs known but doesn't always make sense when speaking and at times is confused. The residents usually understands what is being said to him, but has difficulty comprehending and following through with requests or cues at times. Progress Notes dated 11/20/18 at 3:56 p.m. documented MDS charting, noting resident is not physically restrained but had a lap buddy to assist with sitting up due to his [MEDICAL CONDITION]. The resident could not sit up and had increased pain. Progress Notes dated 11/20/18 at 5:45 p.m. documented staff sent a fax to CHI Health center as Resident #1 had increased pain while walking during therapy. The resident raised his leg when attempting to walk. Staff are questioning a pelvic X-ray. An X-ray report dated 1/21/18 documented the reason for the imaging was recent fall, pain and inability to walk. Findings of the X-ray revealed a displaced [MEDICAL CONDITION] femur (hip), likely involving the right femoral neck. Progress Notes dated 11/21/18 at 3:09 p.m. documented Resident #1 denied pain but non-verbal cues are opposite. An entry at 5:48 p.m. documented during a staff transfer from bed to a gurney, he had facial grimacing and kept his knees flexed. Staff administered [MEDICATION NAME] 650 mg for pain. Progress notes dated 11/21/18 at 6:31 p.m. noted the resident's primary physician reported she was getting a second opinion about the resident's fracture. The resident's physicians believed the resident needed a surgical consult. Staff notified the resident's family and they agreed to have him sent to the hospital emergency room and then to another facility for a surgical consult. Medication Administration Records (MARs) for 11/1/18-11/30/18 revealed [MEDICATION NAME] 650 mg every four (4) hours prescribed as needed (prn) for pain. This record documented this medication hadn't been administered 11/1/18 - 11/8/18, but had been administered with increased frequency or a total of 20 times beginning 11/9/18 - 11/30/18 for pain. An Internal Investigation-Injury of unknown origin documented the resident fell from his wheelchair on 11/9/18. X-ray results on 11/9/18 revealed no fracture seen. The resident received physical therapy on 11/13/18. The resident would, at times, show signs of pain with pain medication administered as needed. On 11/20/18 the resident walked with therapy and nurses observed he did not walk very well. Staff requested an order for [REDACTED]. During an interview dated 1/7/19 at 10:58 a.m., Staff A reported the fall the resident sustained [REDACTED]. Resident #1 had been sitting in his wheelchair with a lap buddy placed in front of him and sat in the front lobby approximately 15 feet from the nurse's station. Staff A reported the resident is to be placed adjacent to staff at all times. Resident #1 has had previous falls and is not to be left unattended. The morning of 11/9/18 she had directed staff to lay the resident in bed but had seen him sitting in his wheelchair. When she asked staff why they hadn't laid him down as directed, staff reported another nurse told them to keep the resident up. Staff A recalled that she and Staff D, LPN sat at the nurse's station talking to another resident's family members when she heard a loud noise. She stated she had charted her observation in a progress note on 11/9/18 at 1:22 p.m. The progress note recorded Resident #1 tipped his wheelchair forward and laid on the floor on the right side. It appeared one side of the lap buddy was in place on one side but not the other. She reported the resident has a history of moving the lap buddy when sitting in his wheelchair. Staff are directed to keep eyes on him at all times. During an interview on 1/7/19 at 11:31 a.m., Staff B, LPN reported she didn't work on 11//9/18 and hadn't witnessed the fall. She recalled that Resident #1 fidgeted and leaned forward when sitting in the wheelchair. The resident has a history of falling out of the wheelchair and staff are to keep their eyes on him at all times. Staff are to put the resident to bed mid-morning until lunch time. Staff are directed to get him up last for meals as he becomes restless. The resident could move the lap buddy as he has strong upper body strength. During an interview on 1/719 at 11:45 a.m., Staff C, a certified nursing assistant (CNA) reported there are four CNA's scheduled for days. On 11/9/18 there were only two CNA's working that morning. She and another staff got the resident up from bed and placed him in a wheelchair before lunch and placed him in front of the television. Staff at the nurse's station were to keep their eyes on him as Resident #1 had a history of [REDACTED]. During a phone interview on 1/7/18 at 12:00 p.m., Staff D, LPN (former) reported he worked the day shift 6:00 a.m. - 2:00 p.m. on 11/9/18. He reported Resident #1 has a history of falls, including falling out his wheelchair. A lap buddy had been previously used but was discontinued because it was considered a restraint. The lap buddy was put back into use to reduce the resident's back pain and also because he leaned forward and this reduced his ability to lean to far forward. The resident frequently removes the device and becomes increasingly restless. The morning of 11/9/18 Staff A had directed staff to lay the resident down in bed but another nurse had told staff to keep the resident up, as they were short CNA's. The fall could have been prevented if staff had put the resident down to rest. Staff have been directed to keep eyes on him at all times. Staff C reported when the resident fell , he was sitting at the nurse's station with his back toward the resident. During an interview on 1/7/19 at 1:10 p.m., the Director of Nursing reported the resident fell on [DATE], 9/9/18, 10/8/18 at 11/9/18. The fall of 8/4/18 occurred when the resident self-transferred from the wheelchair during a meal and lowered himself to the floor. The fall of 9/9/18 occurred when the resident self-transferred from bed and staff found him in the bathroom. The last two falls, 10/8/18 and 11/9/18 occurred when he sat in his wheelchair and fell forward on to the floor. These falls could have been avoided if staff had positioned the resident behind the nurse's station where nurses were positioned. The lap buddy kept Resident #1 from leaning forward and it corrected his posture. She confirmed staff hadn't put the resident to bed to rest as they normally did. During an interview on 1/8/18 at 2:30 p.m. the resident's wife stated staff informed her of the resident's fall on 11/9/18. Resident #1 went to the hospital for evaluation and treatment. An X-ray was negative for fracture but she believed the X-ray results were in error. She reported her spouse has a high tolerance for pain and doesn't communicate clearly due to [MEDICAL CONDITION].