Every finding on record at Mercer Manor Rehabilitation

Based on observation, interview, and record review the facility failed to ensure nursing aides completed a training and competency evaluation program prior to working. This affects all 58 residents residing in the facility. The findings include:On 4/25/26 the facility provided a resident roster showing 58 residents residing in the building.The facility's Nursing and CNA (Certified Nursing Assistant) schedules were reviewed for the previous 2 weeks and showed either V9 (CNA Student) or V11 (CNA Student) assigned their own halls on 4/11/26, 4/12/26, 4/13/26, 4/17/26, 4/18/26, 4/19/26, 4/20/26, 4/21/26, 4/22/26, 4/23/26, 4/24/26, and 4/25/26. On 4/25/26 at 9:50 AM, V4 (CNA) said, There is supposed to be 4 CNAs scheduled on the south end. I've actually put in my notice here because of the staffing issues. We are short staffed today. Students are being given hall assignments, and they haven't finished the class or tested. On 4/25/26 at 10:00 AM, V6 (CNA) said, It's me, [V9] (a CNA student), and [V5] (CNA) today. We are frequently working with students. They say the students are able to do everything. I struggle. I struggle to get showers done, struggle to get call lights answered. I just do the best I can.On 4/25/26 at 1:37 PM, V7 (CNA) said, . Having the students working makes it take extra time because they are new, they need help, they have questions, and they have their own assignment. I've not had a student put with me for training. V2 (Director of Nursing/DON) did some kind of clinical training here with them and then they were on their own assignments after that.On 4/25/26 at 11:22 AM, V9 (CNA Student) said, I am taking the CNA course through the facility. I have been here 1-2 months. Today I am assigned the 100 hall and two rooms on the 200 hall. At 12:18 PM, V9 said, In the program I take online classes and do Tuesday and Thursday as clinical hours. I get scheduled 6a-2p for clinical hours and then pick up other days to help. There is nothing different for my clinical hours verses the other days I pick up, but I've been a caregiver before. I should be certified by the end of May. I will have to take the state certification test.On 4/25/26 at 1:47PM V3 (Assistant Director of Nursing) said, . For students, in my understanding, once they do the classroom work, they can take a hall and when they have been signed off that they know how to do certain things. It is okay for them to work their own assignment prior to their certification. On 4/25/26 at 2:03 PM, V2 (DON) said, I have been told that when they are signed off on their skills, they can perform them on the floor independently. Most of the girls end up working together with the mechanical lifts and two people assist anyway. I believe they are counting them and reporting the CNA students as our CNA staff. When I do the schedule, I count them as an independent staff member in the building once signed off on their skills. I try not have the students scheduled in the memory care unit because there is only one CNA back there.The facility's policy and procedure revised 2/20/26 showed, Staffing. Policy Statement Purpose: the purpose of this procedure is to provide guidelines for staffing the facility for resident care. Procedure: the facility will provide sufficient staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Facility Staffing includes but is not limited to Nurse Managers, Nurses, Certified Nurses Aides, Social Services, Activities.

Based on observation, interview, and record review the facility failed to ensure adequate staffing to meet the needs of dependent residents and failed to ensure nursing aides are certified for 3 of 3 residents (R1, R2, R3) reviewed for staffing in the sample of 6. This has the potential to affect all residents residing in the facility. The findings include:R1's face sheet documents R1 was admitted to the facility 3/17/26 with diagnoses to include spinal stenosis, localized edema, asthma, low back pain, idiopathic progressive neuropathy, hypertension, atrial fibrillation, osteoarthritis, and congestive heart failure. R1's facility assessment dated [DATE] documented R1 has no cognitive impairment and requires substantial to maximal assistance of staff for toileting needs. On 4/25/26 at 10:47 AM, R1 said, Staff have to help me get ready for bed, shower, go to the bathroom, there isn't much I can do myself. There are issues with staffing. Just this morning it took an hour for them to answer my call light. I had to go to the bathroom. I kept waiting and waiting. I was hoping someone could at least come in and put me on the toilet and I could just wait there then for them to come back. I couldn't wait any longer. I had a bowel movement in my pants. It just makes me upset when that happens. I can tell when I have the urge coming but I can't stop it. I'm mad at myself.R2's face sheet documents R2 was admitted to the facility 4/15/26 with diagnoses to include multiple myeloma, convulsions, anemia, hypothyroidism, hypotension, and atrial fibrillation. R2's 4/16/26 Nursing admission Screening assessment documents R2 is alert and oriented, has an unsteady gait, poor balance, and is dependent for all cares except eating.On 4/25/26 at 10:42 AM, R2 was sitting up in bed. R2 said, They come and get me up and help me at night and in the morning. Last night my call light was hooked on the privacy curtain, and I couldn't reach it. My roommate got it for me this morning. When I use my call light, it frequently takes an hour or more for them to get to me on the 2nd and 3rd shift. R3's face sheet documents R3 was admitted to the facility 10/19/24 with diagnoses to include flaccid hemiplegia affecting left nondominant side, insomnia, spinal stenosis, transient cerebral ischemic attacks, pemphigus, and acute kidney failure. R3's facility assessment dated [DATE] documents R3 has no cognitive impairment and is dependent on staff for most cares. On 4/25/26 at 12:10 PM, R3 said, We don't have very many CNAs (Certified Nursing Assistants) a lot of times, even today they are short. There are usually 4 CNAs to be fully staffed, but they have a lot of turn over here. A week ago, they wouldn't do my shower because they didn't have enough staff. They only had 2 CNAs that night on second shift. The next day the CNA told me she would do my shower that night, if I went right to bed after it to save time.On 4/25/26 at 9:40 AM, R4 approached this surveyor and said, Staffing here is a joke. There was only one CNA two Saturdays ago. Many, many, times there are just 3 CNAs working and it is not fair to the girls to have to work this way. I use my call light, but I try not to, so I don't take their time. Sometimes it is answered quickly and other times it takes an hour and a half. They can't help it. There is only so many of them.On 4/25/26 at 10:54 AM, R6 was being assisted into her room by V6 (CNA). V6 used the sit to stand lift to assist R6 into the bathroom. When R6 was lifted off the wheelchair, there was a strong urine odor present and R6's pants appeared wet. V10 (R6's daughter) was in the room. V10 said she is in the facility many times throughout the week and on the weekend to visit her mom. V10 said she often finds that R6 is in need of being changed and smells of urine when she arrives. V10 said she thinks they are usually short staffed on the weekends for sure. V10 said today [R6] was wet when she came in and they had a 20- minute wait for someone to come and help them just now. V10 said [R6's] wheelchair cushion is wet and smells like urine. V10 used some wipes and wiped down the wheelchair cushion. V6 exited R6's bathroom and began getting a fresh set of clothes and stated, we need to do a full wardrobe change. On 4/25/26 at 11:04 AM, R5 said she is pretty independent but does use her call light to request ice water and when she needs her bedding changed. R5 said it does often take over an hour at times for them to respond about 2-3 days out of the week. R5 said the length of time it takes depends on how many people didn't show up for work. R5 said on 3rd shift there is usually only one CNA the majority of the time. R5 said her roommate's bedding is supposed to be changed on first shift due to her incontinence overnight but it is often not done until just before she is going back to bed. The facility's Nursing and CNA schedules were reviewed for the previous 2 weeks and showed either V9 (CNA Student) or V11 (CNA Student) assigned their own halls on 4/11/26, 4/12/26, 4/13/26, 4/17/26, 4/18/26, 4/19/26, 4/20/26, 4/21/26, 4/22/26, 4/23/26, 4/24/26, and 4/25/26. The facility's 4/11/26 schedule showed 2 CNAs and 1 student scheduled from 6a-2p. The facility's 4/13/26 schedule showed 2 CNAs and 1 student scheduled from 2p-10p. The facility's 4/17/26 schedule showed 2 CNAs and 1 student scheduled from 6a-2p. The facility's 4/23/26 schedule showed 2 CNAs and 1 student scheduled from 2p-10p. The facility's 4/25/26 schedule showed 2 CNAs and 1 student scheduled from 6a-2p and again from 2p-10p. The nursing and CNA schedules showed frequently there were only 2-3 CNAs present on first and second shift. On 4/25/26 at 9:50 AM, V4 (CNA) said, There is supposed to be 4 CNAs scheduled on the south end. I've actually put in my notice here because of the staffing issues. We are short staffed today. Students are being given hall assignments and they haven't finished the class or tested. On 4/25/26 at 10:00 AM, V6 (CNA) said, It's me, [V9] (a CNA student), and [V5] (CNA) today. We are frequently working with students. Then the 2p-10p shift will be 2 CNAs and a student. We should have 4 CNAs. They try to still schedule 4 . and 2nd shift would usually staff 4 as well but we usually work with 3. 2 weekends ago the ADON (Assistant Director of Nursing) came in and worked as a CNA because they couldn't find anyone to help. It ended up being the ADON, a CNA and a student working that shift. They say the students are able to do everything. I struggle. I struggle to get showers done, struggle to get call lights answered. I just do the best I can.On 4/25/26 at 1:37 PM, V7 (CNA) said, This is definitely a struggle to be able to answer call lights. Having the students working makes it take extra time because they are new, they need help, they have questions, and they have their own assignment. I've not had a student put with me for training. V2 (Director of Nursing/DON) did some kind of clinical training here with them and then they were on their own assignments after that. Typical staffing would be 3 and that is with or without students working. There have been times we would have run the floor with 2 but usually we have 3 but 3 is running short because we should have 4. with only 3 CNAs we can only get a couple showers done and the rest we have to put off to another day. Residents have been complaining to me about having to wait so long.On 4/25/26 at 11:22 AM, V9 (CNA Student) said, I am taking the CNA course through the facility. I have been here 1-2 months. Today I am assigned the 100 hall and two rooms on the 200 hall. At 12:18 PM, V9 said, In the program I take online classes and do Tuesday and Thursday as clinical hours. I get scheduled 6a-2p for clinical hours and then pick up other days to help. There is nothing different for my clinical hours verses the other days I pick up, but I've been a caregiver before. I should be certified by the end of May. I will have to take the state certification test.On 4/25/26 at 1:47PM V3 ADON (Assistant Director of Nursing) said, . On a typical day shift we always run one aide in the memory care and 4 on south. We can run with 3 on south but it is tough. Second shift staffing runs about the same, 3 out here, 1 in the memory care. On third shift, we run 2 nurses and 3 aides in the building. If someone calls off on third shift, they will run with 2 aides in the building. For students, in my understanding that once they do the classroom work, they can take a hall and when they have been signed off that they know how to do certain things. It is okay for them to work their own assignment prior to their certification. On 4/25/26 at 2:03 PM, V2 (DON) said, Weekends are more difficult than weekdays with call ins. I have been told that when they are signed off on their skills, they can perform them on the floor independently. Most of the girls end up working together with the mechanical lifts and two people assist anyway. I believe they are counting them and reporting the CNA students as our CNA staff. When I do the schedule, I count them as an independent staff member in the building once signed off on their skills. I try not have the students scheduled in the memory care unit because there is only one CNA back there.The facility's Resident Council meeting minutes dated 4/16/26 showed, . Council members had complained of bathrooms not being cleaned in between resident use, call light wait times, soiled depends being left on floor, not getting fresh water daily, staff saying they will come back but to not return.The facility's policy and procedure revised 2/20/26 showed, Staffing. Policy Statement Purpose: the purpose of this procedure is to provide guidelines for staffing the facility for resident care. Procedure: the facility will provide sufficient staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Facility Staffing includes but is not limited to Nurse Managers, Nurses, Certified Nurses Aides, Social Services, Activities.

Based on interview and record review, the facility failed to ensure each resident was reviewed no less than every three months using the standardized assessment tool for 7 of 56 residents (R2, R6, R9, R16, R27, R45, R53) in a sample of 46. Findings include:The Minimum Data Set (MDS) 3.0 Process Interdisciplinary Team (IDT) policy, dated 11/1/15, documents quarterly assessments will be completed no less than every three months. 1. R2's standardized quarterly assessment was due to be completed by 11/13/25. The assessment was completed on 1/14/26, 46 days overdue.2. R6's standardized quarterly assessment was due to be completed by 1/5/26. The assessment is currently not completed,16 days overdue.3. R9's standardized quarterly assessment was due to be completed by 12/28/25. The assessment is currently not completed, 24 days overdue.4. R16's standardized quarterly assessment was due to be completed by 12/30/25. The assessment is currently not completed, 22 days overdue.5. R27's standardized quarterly assessment was due to be completed by 12/28/25. The assessment is currently not completed, 24 days overdue.6. R45's standardized quarterly assessment was due to be completed by 1/1/26. The assessment is currently not completed, 20 days overdue.7. R53's standardized quarterly assessment was due to be completed on11/14/25. The assessment was completed on 1/14/26, 47 days overdue.On 1/21/26 at 11:00 AM, V3 (Minimum Data Set (MDS) Coordinator) demonstrated the Clinical- MDS Scheduler report and explained the form identified resident MDS's which were not completed and the length of time the MDS's were overdue. V3 stated she and corporate work on trying to get the overdue MDS's completed but agreed there are many which are overdue.On 1/21/26 at 12:30 PM, V1 (Administrator) stated corporate oversees the MDS's. At 1:45 PM, V1 stated during a phone call with V8 (Corporate MDS Nurse), V8 stated the corporation is aware they are behind on completing the MDS assessments. There was no specific reason given.

Based on observation, interview, and record review the facility failed to keep medical records private for six (R1, R5, R12, R37, R51, R58) of six residents reviewed for medication administration in a sample of 46. Findings include:The facility policy titled, Medication Administration-General Guidelines, dated November 2021, documents not in its entirety, Medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy maintained always for all resident information (e.g., MAR/Medication Administration Record) at all times when not in use. On 1/20/2026 at 11:26 AM V6 (Licensed Practical Nurse) observed doing medication pass in the dining room. V6 left resident information up on the screen each time she left the cart to give R5, R12, and R58 their medication making their personal medical records visible to all visitors, staff, and residents that went by the medication cart. When V6 was asked if the screen should be hidden or closed, she stated, Well yeah, typically it should be hidden. I should have pressed this (points to icon to hide screen) before leaving the cart and giving the residents their medication. On 1/21/2026 at 11:15 AM V7 (Registered Nurse) observed passing medications to R1, R37, and R51. V7 left resident information up on the screen each time she left the cart to give them (R1, R37, R53) their medication making their personal medical records visible to all visitors, staff, and residents that went by the medication cart in the hallway outside of the dining room. When asked if the screen should be hidden or closed, V7 stated, Yeah, I realized too late I left the screen up when I left the cart to give them their medication. Yes, I should have closed the screen so nobody could see it. On 1/21/2026 11:31 AM V2 (Director of Nursing) stated that when passing medications the nurses should either close their computer screen or press the hide screen icon before leaving their carts to protect patient information.

Based on observation, interview, and record review the facility failed to administer medications in a safe manner for one resident (R9) of thirty-two residents observed during mealtime in a total sample of 46. This failure has the potential to affect all thirty-two residents (R1, R4, R5, R9, R11, R13, R15, R18, R19, R26, R27, R29, R30, R31, R32, R33, R34, R36, R37, R39, R40, R41, R42, R43, R44, R45, R47, R48, R51, R58, R63, R65) who dined in the main dining room. Findings include: The facility policy titled, Medication Administration-General Guidelines, dated November 2021, documents not in its entirety, Medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR (Medication Administration Record), and action is taken as appropriate. Monitoring of side effects or medication-related problems occurs continually, but particularly after medication administration and especially after the first few doses of a new medication. On 1/20/2026 at 12:33 PM 200 Hall Medication cart noted to have a pill cup with three (3) pills in it; cup is not labeled with a name. V6 (Licensed Practical Nurse/LPN) stated, That's (R9)'s medication. Dietary handed me the cup because it was left sitting on the dining room table. She's (R9) not my patient so I am going to take them to (V2 Director of Nursing/DON). On 1/20/2026 at 12:40 PM (DON) observed taking medication cup from V6 (LPN) and taking the medication to V5 (Registered Nurse/RN). V2 stated to V5 that the medication cup was found on a dining room table and then given to her (V2 DON). V5 stated she knew whose medication was in the cup, That's (R9)'s. V5 also stated the medication in the cup were two Tylenol 325mg (milligram) (non-narcotic pain reliever) pills and one Tramadol 50mg (Narcotic Pain Reliever) pill. V5 stated, I thought she (R9) had taken the pills. When asked if she saw R9 place the pills in her mouth V5 stated, I didn't see her (R9) put them in her mouth, that's obvious. I should have made sure she took them before walking away. R9's admission Record documents R9's admission date to the facility was 9/11/25 and R9's admitting diagnoses include but not limited to Delusional Disorder, Disorientation Unspecified, Pain Unspecified, and Unspecified Dementia, Unspecified Severity. R9's physician orders dated 8/5/24 documents that R9 has an order for Tramadol (narcotic pain reliever) 50mg (milligram) give 1 tablet three times a day for pain and orders dated 2/21/24 for Tylenol (non-narcotic pain reliever) 325mg give 2 tablets three times a day for pain. On 1/20/2026 at 12:47 PM V2 (DON) stated the nurses should remain with the resident and watch them take their medication before leaving and they should never be left on a table.

Based on observation, interview, and record review the facility failed to correctly don personal protective equipment/PPE for one resident (R6) of 2 residents reviewed for infection prevention practices in a sample of 46. Findings include:The Center for Disease Control Sequence for Putting on Personal Protective Equipment (PPE) documents to fasten the back of the gown when putting the gown on. The facility's Policy and Procedure for Enhanced Barrier Precautions dated 10/28/2024 documents, It is this Facilities policy that Enhanced Barrier Precautions (EBP) are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. This facility's EBP policy covers indwelling medical devices to include but are not limited to, central lines, urinary catheters, feeding tubes, and tracheostomies. This facility's EBP policy documents that staff will wear a clean, non-sterile gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood or body fluids, secretions, or excretions and during specific high-contact resident care activities. R6's admission record documents that R6 was admitted to the facility on [DATE] with a principal diagnosis of cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery. Other pertinent diagnoses documented include but are not limited to, feeding difficulties, dysphagia, and severe protein-calorie malnutrition. R6 has an active physician order dated 12/17/2024 for enteral feeding every shift via a gastrostomy tube, order dated 8/19/2024 for gastrostomy site dressing care, and an order dated 5/1/2025 for Enhanced Barrier Precautions documenting that staff wear gown/gloves when in direct patient contact and includes device care/use and or Wound care. On 1/22/2026 at 10:45am V2 (Director of Nursing) and V4 (Assistant Director of Nursing) performed gastrostomy dressing change per doctor's order. V4's gown was not tied around her neck or back therefore kept opening and coming forward toward the resident. When asked what proper procedure is for donning a gown, V2 responded that one should put on the gown and tie it. When V4 was asked what the proper procedure for donning a gown would be V4 stated that her gown would not stay tied but admitted that the gown should have been tied securely. V2 stated I should have tied your gown for you.

Based on observation, interview, and record review the facility failed to ensure an appropriate indication for use to administer antipsychotic medications and failed to identify and document target behaviors for six residents (R25, R26, R36, R48, R50, R51) of seven residents reviewed for unnecessary psychotropic medications in the sample of 33. Findings include: Facility Policy/Psychotropic Medication Management dated 12/4/24 documents: The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: Wandering; Poor self-care; Restlessness; Impaired Memory; Anxiety; Depression (without psychotic features); Insomnia; Unsociability; Indifference to surrounding; Fidgeting; Nervousness; Uncooperativeness; Agitated behaviors which do not represent danger to resident or others. 1.) Current Physician Orders Summary Report indicates R25 is [AGE] years old with diagnoses that include Frontotemporal Neurocognitive Disorder, Frontotemporal Dementia, Unspecified Dementia, Bipolar Disorder, Schizophrenia, Schizoaffective. Summary Report also indicates R25 has orders to receive Haloperidol (antipsychotic) 0.5mg (milligram) two time per day related to bipolar disorder and Schizophrenia (date initiated 2/2/23) and Quetiapine (antipsychotic) 150mg at bedtime related to bipolar disorder (date initiated 12/24/24). Pharmacy Recommendations dated 9/29/24 indicates (Psych) recently increased Seroquel (Quetiapine) due to hallucinations. Psychiatric Evaluation and Consultation dated 12/17/24 indicates R25 continues to appear confused, is crying and calls her family a lot of times. Evaluation indicates R25 Still sometimes makes up false stories about her family based off the television show however her family can help redirect her through those thoughts. Evaluation indicates R25 is showing signs of increased anxiety and depression; no symptoms of psychosis or mania; no evidence of auditory or visual hallucinations. Evaluation indicates R25 has some exit seeking behaviors, follows the nurses around and has been crying a lot. On 1/9/25 at 10:13am V8 (Certified Nurse Assistant/CNA) stated she only works in the Memory Care Unit and stated that 25's behaviors are confusion, sometimes tries to elope, cries to leave and go home and is unsteady on her feet. Behavior Monitoring 12/13/24 to 1/8/25 indicates R25 exhibited: Frequent crying 6 times Wandering 8 times Repeats Movement 3 times Rejection of care 2 times Pacing 3 times Disrobe in Public 2 times Current Care Plan indicates R25 is on anti-psychotic therapy related to Schizophrenia. R25's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 2) Current Physician Orders Summary Report indicates R26 is [AGE] years old with diagnoses that include Moderate Severity Dementia and Mood (Affective) Disorder. Summary Report indicates R26 receives Risperidone (antipsychotic) 0.5mg two times per day (date initiated 11/18/24) related to Mood (Affective Disorder). On 1/9/25 at 2:45pm V2 (Director of Nursing/DON) stated R26 has not yet been seen by any psychiatric services. On 1/9/25 at 10:10am V8 (CNA) stated R26's behaviors are wandering and not sleeping at night. Behavior Monitoring 12/13/24 to 1/8/25 indicates R26 exhibited: Wandering 10 times Pacing 2 times Rejection of care once Yelling/screaming/disruptive sounds 2 times Repeats Movement 2 times Current Care Plan indicates R26 is on anti-psychotic therapy related to Affective Disorder. R26's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 3) Current Physician Orders Summary Report indicates R36 is [AGE] years old with diagnoses that include Depression, Anxiety, Dementia without Behavioral Disturbance. Summary Report indicates R36 receives Risperidone 0.5mg twice daily related to aggressiveness and irritability (date initiated 10/23/24). Psychiatric Evaluation and Consultation dated 12/24/24 indicates R36 has had no aggressive behaviors, and she is doing well; no anxiety out of the ordinary; no symptoms of psychosis or mania were observed or reported; no evidence of auditory or visual hallucinations. Eval indicates to continue Risperdal for irritability and aggressiveness. On 1/9/24 at 10:12am V8 (CNA) stated R36's behaviors are poor sleep, sometimes not sleeping for two days. Behavior Monitoring 12/1/24 to 1/8/25 indicates R36 exhibited: Kicking/Hitting/Pushing/Grabbing 2 times Yelling/Screaming/Disruptive Sounds/Rejection of Care 6 times Frequent Crying 8 times Wandering 9 times Disrobing in public twice Current Care Plan indicates R36 is on anti-psychotic therapy related to Major Depressive Disorder, recurrent and Generalized Anxiety Disorder. Disorder. R36's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 4) Current Physician Order Summary Report indicates R48 is [AGE] years old and has the following diagnoses: Unspecified Dementia with Agitation and Behavioral Disturbance. Order Summary indicates R48 receives Risperdal 1mg twice daily related to Unspecified Dementia with Agitation (date initiated 8/23/24). Psychiatric Evaluation and Consultation dated 12/24/24 indicates R48 had no symptoms of psychosis or mania reported or observed; no evidence of auditory or visual hallucinations; no reports of mood instability. On 1/9/24 at 10:10am V8 (CNA) stated R48 has no behaviors other than refuses toileting and/or incontinent care at times. Behavior Monitoring 12/1/24 to 1/9/25 indicates R48 exhibited: Rejection of Care twice. Current Care Plan indicates R48 is on anti-psychotic therapy related to Aggression. Care Plan indicates R48's Target behaviors are: Thinking he is in the military at war, telling staff people are going to shoot through the window, wanting to speak with his sergeant, believing his fire alarm is a camera and he is being watched. These target behaviors were not added to R48's care plan until 1/7/24 (Survey Day 1). 5) Current Physician Orders Summary Report indicates R50 is [AGE] years old with diagnoses that include Dementia without Behavioral Disturbance (3/23/24), Anxiety, Insomnia; Schizoaffective Disorder (12/27/24). Summary Report also indicates R50 has orders to receive Risperidone - 1mg twice daily related to Hallucinations/Aggressive Behavior (date initiated 12/26/24). Psychiatric Evaluation and Consultation dated 12/2424 indicates R50 is hitting people in the face, still hallucinating, and speaking to people who aren't there; believes she is running a business and has to run to meet people. Evaluation indicates R50 is having some auditory and visual hallucinations. Evaluation indicates R50's Risperdal was increased on 12/26/24 from 0.5 mg twice daily to 1mg twice daily. On 1/9/24 at 10:15am V8 (CNA) stated R50's behaviors are that R50 screams at self in mirror, disrobes, is mean to other residents/verbal and physical, paranoid/suspicious. On 1/9/24 at 9:50am R50 was seen coming out of her room naked holding a pillow in front of her. R50 accepted redirection from staff to go back to her room to get dressed. A short time later, R50 was assisted to a table in the dining area and given a snack. R50 also took her scheduled medications when offered by the nurse. Behavior Monitoring 12/1/24 to 1/8/25 indicates R50 exhibited: Rejection of Care once Wandering 3 times Frequent Crying once Current Care Plan indicates R50 is currently on Antipsychotic therapy related to schizoaffective disorder. R50's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 6) Current Physician Orders Summary Report indicates R51 is [AGE] years old with diagnoses that include Moderate Unspecified Dementia without Behavioral Disturbance, Alzheimer's Disease, Metabolic Encephalopathy. Summary Report also indicates R50 has orders to receive Quetiapine 50mg twice daily related to Dementia. Psychiatric Evaluation and Consultation dated 11/26/24 indicates (R51) has no current significant behavioral issues that needs medication changes. Evaluation indicates R51 has no auditory or visual hallucinations. Progress Note dated 6/11/24 indicates R51 moved from South unit to Memory Care room, has displayed no untoward behaviors this far, continues to wander about in her wheelchair as is her habit. On 1/9/24 at 10:16am V8 (CNA) stated R51's behaviors are She just wants to be left alone. Behavior Monitoring 12/1/24 to 1/8/25 indicates R51 exhibited no behavioral symptoms. Current Care Plan indicates R51 is currently on antipsychotic therapy related to Unspecified Dementia without Behavioral Disturbance. R51's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. On 1/9/24 at 10:30am V2 (Director of Nursing) stated that she is responsible for the residents who are on psychotropic medications. V2 stated the residents in the Memory Care Unit have Tele-Health Psychiatric services that started about 2 months ago. V2 stated that the Psychiatric services get the information about the residents from the staff And some of the staff think the answer to behaviors is more medications, so they are part of the problem. V2 stated I think it's gotten out of hand back there - as far as the number of residents receiving antipsychotic medications. V2 stated I knew this was going to happen. I haven't been able to get back there to clean this up. V2 stated the care plans should have target behaviors as part of the reason the psychotropic medications are needed.

Based on observation, interview, and record review the facility failed to provide an ongoing program of activities for 15 residents (R13, R14, R19, R20, R25, R26, R28, R36, R41, R44, R47, R48, R49, R50, R51) that reside on the Memory Care Unit of 33 residents reviewed for activities in the sample of 33. Findings include: Facility Policy/Programming for Resident with Cognitive Impairments dated/revised 11/5/24 documents: It is the Policy of this facility to: Offer meaningful activity programs to residents who display disorientation to time, place and/or person. Promote activity programs to reflect each resident's physical and mental status, and to promote cognitive health. Facility Policy/Activities Programs dated/revised 11/5/25 documents: An ongoing program of activities is designed to meet the needs of each resident. Our activities program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident. Facility assessment dated [DATE] documents: The facility serves long and short-term residents. It also has a Dementia Unit that is locked. Assessment indicates Services Provided Based on Resident Needs: Provide person-centered/directed care: Psycho/social/spiritual support: Provide opportunities for social activities/life enrichment (individual, small group). Facility Resources Needed to provide Competent Resident Support and Care Daily and During Emergencies: Activities - One Activity Director and 2.5 Activity Assistants. Resident Room Roster dated 1/7/24 indicates there are 15 residents who reside in the locked Memory Care Unit. January 2025 Memory Care Activity Calendar indicates: Tuesday (1/7/25) 7am Breakfast 9am Good Morning 9:30am Greetings 10am Balloon Swat 10:30am Light Tunes 11am Lunch 1pm Spa treatment 2pm Horseshoes 2:30pm Snack cart 3pm Walk with Me 4pm Sensory Dough 5pm Supper 6pm All hands-on deck 6:30pm Sounds of Nature 7pm Snack cart On 1/7/25 at 10:40am V6 (Licensed Practical Nurse/LPN) stated that activity staff come back on the unit when they can. V6 stated they had not been on the unit that morning and the unit was staffed with one CNA (Certified Nursing Assistant) and one nurse. On 1/7/25 at 10:45am V6 was monitoring several residents in the dining/common area while the assigned CNA was giving a shower to R14. V6 was attempting to redirect R36 who was dragging a table across the room. R50 and R51 were sitting at a table and staring into space. There was no music or television on at the time. No magazines or other type of table activities were on the tables or nearby. R25, R28 and R48 were in their rooms. R47 was sleeping in a chair by the nurse's station. Wednesday (1/8/25) Memory Unit Activity Calendar 7am Breakfast 9am Good Morning 9:30am Greetings 10am Wednesday Workouts 10:30am Songs of the past 11:30am Lunch 1pm Spa treatment 2pm Crafter's Club 2:30pm Snack cart 3pm Walking Club 4pm Button Sorting 5pm Supper 6pm What's in the bag. 6:30pm Soothing Sounds 7pm Snack cart On 1/8/25 at 2:25pm V7 (Nurse) and V11 (CNA) stated that earlier today, activity staff dropped off a package of craft pieces for the residents to make snowmen. At that time V7 displayed a clear plastic bag full of stick-on eyes, small fabric and paper pieces and multiple other small piece craft supplies. V7 stated We can't do this activity with them. We don't have enough staff to help them with this activity and monitor the other residents too. V7 stated some of the residents would put the pieces in their mouth as that is what happened when activities dropped off some beads for residents to string. V7 stated activities staff expect the nursing staff to do the activities with the residents. V7 stated Otherwise, activity staff doesn't come back here anymore. V11 (CNA) stated my shift started at 2pm and V11 works until 10pm. V11 stated she will be the only CNA assigned to the unit and there is only one nurse for the Memory Care Unit. Thursday (1/9/25) 7am Breakfast 9am Good Morning 9:30am Greetings 10am Parachute Fun 10:30am Morning Melodies 11:30am Lunch 1pm Spa treatment 2pm Kickball 2:30pm Snack cart 3pm Making tracks. 4pm Adult coloring 5pm Supper 6pm Puzzles 6:30pm Mindful melodies 7pm Snack cart On 1/9/25 at 9:25am R50 was noted to be walking down the hallway without any clothes and holding a pillow in front of her naked body. V14 (Nurse) was near the nurse's station passing medications and V8 (CNA) was assisting residents in the dining area. V8 responded and provided assistance to R50 when notified by this surveyor that R50 needed immediate assistance. On 1/9/25 at 9:40am eight residents were sitting in the day area, four of those residents were sleeping. R13 was being redirected from behind the nurse's station by V8 after V8 returned with R50 and assisted her to a table with R51. R50 was noted to be sitting at the table looking down and staring at a blank table. Five residents were in their rooms. On 1/9/25 at 9:50am V8 turned on music in the dining area. Shortly after the music started playing, R51 began tapping her foot to the music. R51's care plan dated 4/4/24 indicates It is very important to me to listen to music. I enjoy reminiscing with others. I enjoy watching comedies, westerns and shows that involve animals. Please turn this on the television. Three days of random observations on the Memory Care Unit - 1/7,1/8, and 1/9/25 found no music playing in the dining area except on 1/9/25 at 9:50am. The television in the same area where the residents sit for most of the day, was not on during any of the observations. No magazines, books or any type of activity materials were accessible to residents in the common/dining area where the majority of the residents spent most of their time. No activity staff arrived on the Memory Care Unit on 1/8/25 at 10am to provide Parachute Fun as listed on the activity calendar for that day. On 1/9/25 at 1:05pm V13 (Activity Aide) was observed painting fingernails for three of the residents R13, R14 and R20. R13 had a busy board in her lap and was intently engaged in working the various objects on the board. V13 stated Yes, (R13) really likes that. I keep it on my cart. I don't leave it back here. I keep my supplies on my cart which I take with me when I leave the unit. On 1/9/25 at 3:30pm V9 (Activity Director) stated V13 only works eight hours per week and V10 (Activity Aide) works full time So, I really only have one other activity employee besides myself. V9 stated Last year there were five of us. V9 stated the expectation is that the CNAs on the unit lead the activities But I know that's not always possible. V9 stated there are totes behind the nurse's station with activity supplies. V9 acknowledged the snowman crafts project was not suitable for most of the residents on the unit and acknowledged some of residents do put the supplies in their mouth. V9 stated that V10 works every other weekend but does not work on the Memory Care Unit at all on the weekends so there are no activities on the weekends for that unit. V9 also stated there are no activities in the Memory Care Unit on alternating Mondays and Fridays because V10 does not work on those days and I am the only one here and can't get back there on those days. V9 acknowledged the Activity Calendar programming often does not get done due to lack of activity staff.

Based on observation, interview, and record review the facility failed to develop a comprehensive assessment for the use of oxygen for one of 17 residents (R33) reviewed for care plans in a sample of 17. Findings include: A policy revised on June 25, 2024, and titled Comprehensive Care Plan documents, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. This policy further states that each resident's comprehensive care plan has been designed to incorporate identified problem areas. R33's Physician Order Sheet dated December 19, 2024, has an order for Oxygen at 2 liters per minute via nasal cannula for as needed for dyspnea or chest pain. On 01/07/25 at 10:15 AM and 01/08/25 at 9:22 AM R33 was lying in bed with oxygen on via nasal cannula. R33's current comprehensive care plan was reviewed and did not contain information or goals regarding oxygen usage. On 01/08/25 at 2:24 PM V4 (Care Plan Coordinator) confirmed R33's current care plan does not address R33's oxygen need.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was changed as ordered for one (R33) of two residents reviewed for respiratory care in a total sample of 33. The findings include: An Oxygen Administration and Storage policy and procedure revised on March 8, 2024 documents a nasal cannula or mask should be changed weekly or when soiled and the humidifier bottle is to be labeled with the date of application and changed weekly if refillable. R33's POS/Physician Order Sheet dated 12/19/24 has orders to change oxygen water bottle on night shift every Sunday night and as needed, date and initial bottle and to change oxygen tubing on Sunday and as needed for infection control. R33's December 2024 TAR/Treatment Administration Record documents Sunday, December 15th 2024 night shift was the last date in December R33's humidification bottle was changed. The two other Sundays (December 22 and December 29, 2024) have no documentation. On 01/07/25 at 10:15 AM, R33 was lying in bed asleep. R33 was receiving oxygen via nasal cannula from a concentrator. R33's nasal cannula tubing was dated 12/16/24 and the date on the refillable humidifier bottle was 12/16/24. On 01/08/25 at 9:22 AM, R33's nasal cannula tubing and refillable humidifier bottles were still dated 12/16/24. On 01/08/25 at 1:39 PM V2 (Director of Nursing) confirmed R33's nasal cannula was dated 12 something (day not legible) 24 (2024) and R33's refillable humidity bottle was dated, 12/16/24. V2 confirmed both should be changed weekly.

Based on observation, interview, and record review the facility failed to prepare medications without cross contaminating the pills for one resident (R23) of four residents observed during a routine medication pass. Findings Include: The Facility's Standard Precautions policy dated 11/1/2015 documents It is this Facility's policy that Standard Precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. On 01/08/24 at 10:30 AM V5 (Registered Nurse) had all R23's 9:00 AM medication in a medicine cup that she sat on R23's bed on a clean field while she unclamped and flushed R23's gastric tube. The medicine cup tipped over and spilled two pills directly onto R23's fitted sheet. V5 picked the pills up with her gloved hand and put them back in the cup with the rest of R23s medication. V5 then administered all the medications in the cup via R23's gastric tube. On 01/08/25 at 1:30 PM V5 confirmed that the two pills did roll out of the medicine cup when it tipped over in R23's room. V5 stated I should have thrown those two pills away and got new ones because (R23's) bedsheet would not be considered clean. 30722

Based on observation, interview, and record review the facility failed to thoroughly assess and measure a pressure ulcer for one resident (R23) of two residents reviewed for wounds in a total sample of 33. Findings Include: The Facility's Skin Prevention, Assessment and Treatment policy dated 11/1/2015 documents that the purpose of the policy is to identify factors that place the residents at risk for the development of pressure ulcers, to implement appropriate interventions to prevent the development of clinically avoidable wounds, to promote a systematic approach and monitoring process for the care of the residents with existing wounds and for those who are at risk for skin breakdown and to promote healing of existing pressure ulcers. The Facility's Skin Prevention, Assessment and Treatment policy dated 11/1/2015 documents Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the Medical Record. a) Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surround tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining. R23's current Physician Order Sheet documents Cleanse area on buttocks with normal saline, pat dry, apply calcium alginate and cover every day and as needed. On 01/08/25 at 1:00 PM R23's coccyx area was noted to be red with areas noted that were approximately 2 centimeters long and less than a half a centimeter wide open area noted directly across her coccyx. There were 4 of these small slit looking areas. R23's Wound Care assessments on 11/22/24,11/27/24,12/6/24,12/11/24, 12/18/24 and 12/26/24 refer to R23's wound as irritant contact dermatitis. The Wound Care assessments document Wound Measurements: not applicable. None of the Wound Care assessments document that there is more than one open area on R23's coccyx. On 01/08/25 at 9:00 AM V2 (Director of Nursing/DON) stated that the facility uses Telehealth wound care doctors that do not come on site or do any hands-on assessments of the wound. V2 reports that she takes a computer tablet and uses the camera function to show the provider the area and then the provider will document an assessment. On 01/09/25 at 11:15 AM V2 (DON) stated that the facility does not measure non pressure ulcers that is why there were no wound measurements done weekly. V2 stated that the wound doctor stated that wound is Moisture Associated Skin Dermatitis therefore not pressure. V2 confirmed that R23's wound is from inability to move and incontinence V2 also confirmed that R23s wound is directly over the pressure point of her coccyx. V2 also confirmed that there is no documentation of how many of the little open areas on R23's coccyx there have been or currently are on R23. CMS website: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Based on interview and record review the facility failed to weigh a resident daily and report weights to the doctor as ordered for one resident (R23) of 17 residents reviewed for weight loss or gain in a total sample of 33. Findings Include: R23's hospital discharge instructions dated 08/20/24 documents weigh daily with same scale and at the same time of the day if possible. Report weight gain of 3 pounds in one day or 5 pounds in one week to the cardiologist/CHF (Congestive Heart Failure Clinic) (phone number listed) every day shift for cardiac health. R23's MAR (Medication Administration Record) dated 08/20/24-8/31/24 does not document any weight for R23 on 8/22/24,8/23/24,8/24/24.8/25/24,8/27/24, 8/28/24 and 8/30/24. R23's MAR for August 2024 documents her weight on 8/20/24 as 158.2 and her weight on 8/21/24 as 163.5 which would indicate a weight gain of 5.3 pounds in one day. R23's documented weight on 8/26/24 was 160 pounds and her weight on 9/29/24 was 165 pounds which indicates a weight gain of 4 pounds in one week. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified of those weight fluctuations as ordered. R23's MAR (Medication Administration Record) dated 09/01/-24-09/30/24 does not document any weight for R23 on 09/07/24,09/08/24, 09/24/24,09/26/24, and 09/27/24. R23's MAR for September 2024 documents her weight on 09/05/24 as 165.5 pounds and her weight on 09/06/24 as 168.5 which indicates a 3-pound weight gain in one day. R23's Medical Record did not contain any documentation of Cardiology/CHF (Congestive Heart Failure Clinic) being notified of those weight fluctuations as ordered. R23's MAR dated 09/01/24-09/30/24 documents her weight on 9/23/24 as 146.5 pounds and her weight on 9/29/24 as 160.5 which indicates a 14-pound weight gain in one week. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified. R23's MAR dated 10/01/24-10/31/24 does not document any weight for R23 on 10/8/24,10/9/24,10/10/24,10/14/24,10/15/24,10/18/24,10/22/24,10/27/24 and 10/30/24. R23's MAR for October 2024 documents her weight on 10/21/24 as 163 pounds and her weight on 10/26/24 as 169.5 which indicates a weight gain of 6.5 pounds in one week. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified. R23's MAR for 11/1/24-11/30/24 does not document any weight for R23 on 11/1/24,11/5/24,11/6/24,11/9/24,11/12/24,11/14/24,11/15/24,11/17/24 and 11/25/24. R23's MAR for November 2024 documents her weight on 11/10/24 as 163.5 pounds and her weight on 11/16/24 as 169.5 pounds, indicating a 6-pound weight gain in one week. R23's November MAR documents her weight on 11/19/24 as165 pounds and on 11/20/24 as 168.5 pounds, indicating a 3.5-pound weight gain in one day. R23's November 2024 MAR documents R23's weight on 11/26/24 as 168.5 pounds and on 11/27/24 173 pounds, indicating a 5-pound gain in one day. R23's Medical Record did not contain any documentation of Cardiology/CHF clinic being notified. R23's MAR for 12/1/24-12/31/24 does document any weight for R23 on 12/6/24,12/8/24,12/15/24,12/19/24,12/20/24,12/22/24 and 12/26/24. R23's MAR for December 2024 documents that on 12/2/24 R23's weight was 167.5 pounds and on 12/3/24 her weight was 170.5 pounds, indicating a 3-pound weight gain in one day. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified. On 01/09/24 at 1:00 PM V2 (Registered Nurse/Director of Nursing) confirmed the missing weight documentation on the August, September, October, November, and December Medication Administration Records. V2 acknowledged the order from Cardiology/CHF (Congestive Heart Failure) Clinic. V2 stated They (Cardiology/CHF Clinic) should have been notified per the parameters that the gave on 08/20/24 and they have not been notified of any of these weight changes.

Based on observation, interview, and record review the facility failed to ensure the memory care unit exit doors and bracelet alarms were loud and widespread enough to alert staff when activated. The facility failed to identify and investigate incidents of elopement, revise a care plan, and implement interventions for a resident who eloped from the facility. The facility failed to follow facility elopement policies and failed to provide adequate supervision for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in a cognitively impaired resident (R1) who resides in the facility's locked memory care unit, exiting the facility without staff knowledge and being found soaking wet, laying on the parking lot pavement with facial and head trauma accompanied with excessive bleeding, approximately 50 to 70 feet from the exit doors. R1 was found at approximately 5:45pm and the weather was pouring down rain and cool. R1 was transferred to the local emergency room and later transferred to a tertiary (higher level) hospital where he was admitted to an intensive care unit for treatment of facial and cervical spine fractures. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy began on 5/10/24 when R1 left the building unsupervised. V1 (Administrator) was notified of the Immediate Jeopardy on 6/4/24 at 9:20 AM. On 6/5/24 the state surveying agency accepted a plan of correction submitted in regard to Elopement management. While the immediacy was removed on 6/5/24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance program. The facility's Wandering and Elopement policy, dated 8/24/20, documents All residents in this facility shall be assessed for risk of elopement/unsafe wandering, utilizing the Elopement Risk Assessment tool. Procedure: Elopement is defined as a wandering resident who is assessed as being cognitively impaired, who is not capable of protecting him/herself from harm who has left the building unsupervised. If the resident is considered to have eloped, the incident must be reported to (the State Agency). This facility will complete assessment upon admission, readmission, quarterly, significant change and upon an attempt of elopement, each resident will be assessed for their risk assessment utilizing the Elopement Risk Assessment tool. This policy also documents An accident/incident report must be done by the charge nurse. All incidents of elopement must be investigated by nursing administration and reported to the facility administrator. The administrator of his designee must report every incident of elopement to the (State Agency). All incidents of elopement must result in comprehensive care plan review/revision. The facility's Fall Reduction policy, dated 11/5/19, documents Purpose: To provide an environment that remains as free of accident hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. To promotes a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk. R1's current electronic Care Plan, printed on 5/29/24, documents R1 has diagnoses of Unspecified Dementia, Psychotic Disturbance, Mood Disorder, Anxiety, Epilepsy and recurrent Seizures, Repeated Falls, Muscle Weakness, Abnormalities of Gait and Mobility, Lack of Coordination, Muscle Wasting and Atrophy. This care plan documents My current risk for Wandering /Elopement is high risk and my safety will be monitored every shift by all staff. This care plan was implemented on 5/25/23 and has no updated intervention since 2023. This same Care Plan documents I currently have an alteration in my behavior status related to exit seeking, insomnia, aggression towards staff, yelling/screaming, rejection of care. This care plan was last updated/revised on 4/30/24. This same Care Plan documents I am currently a High Risk for falls. Cognitive Deficit, Vision Impairment, Poor balance. This care plan was last updated on 1/25/24. R1's Minimum Data Set assessment, dated 4/12/24, documents R1's mental cognition is severely impaired. R1's Behavior Note, dated 5/10/24 at 1:55 PM, documents Resident reached door to 400 hall, alarm (ankle bracelet) sounded. Staff followed behind and was able to redirect (R1) back inside. (V2 Director of Nursing) aware. R1's Behavior Note, dated 5/14/24 at 8:57 PM, documents (R1 is) antsy, wandering this shift. Becoming slightly aggressive when staff tries to redirect him. Aide was able to get him to the restroom and changed and ready for bed. Currently resting in bed with eyes closed and breathing even and unlabored. R1's Nursing Progress Note, dated 5/24/24 at 6:00 PM, and completed by V2 (Director of Nursing) documents Late Entry: Note Text: Nurse observed resident (R1) on the ground around 5:45 PM, resident noted to have injuries to face, knees, and arms. 911 (Emergency Services) called. Nurse then requested supplies to help stop bleeding. Ambulance arrived and transported resident (R1) to hospital. R1's Wandering/Elopement Risk Assessment, dated 4/4/24, documents R1 was assessed to be at a high risk of elopement. R1's Wandering/Elopement Risk Assessment, dated 5/27/24, documents R1 has No history of escape or elopement. The facility's incident report to the State Agency, dated 5/25/24, documents 5/24/24: (R1) is [AGE] years old with diagnoses of Unspecified Dementia, Severe without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Muscle wasting and Atrophy, was observed on the ground by nurse. Resident ambulating self without walker. EMS (Emergency Medical Services) called and transferred to the emergency room . On 5/29/24 at 10:24 AM, V6 (Local emergency room Registered Nurse) stated I was (R1's) nurse in the emergency room . From my understanding staff saw the resident outside (the facility) and called 911. Emergency Medical Services reported they got the call that (R1) was found outside on the ground with facial trauma. (R1) had an ankle bracelet on and there was a facility staff member (V15 Certified Nursing Assistant/CNA) who came with the resident. (V15) told me who he was and that he was a resident in the facility's memory care unit. (R1) had facial injuries but also had further testing and his injuries were pretty significant. (R1) arrived in the emergency room at 6:06 PM and was discharged to (tertiary hospital) at 8:48 PM, due to his injuries. On 5/29/24 at 12:00 PM, V11 (Certified Nursing Assistant/CNA) stated (R1) typically is an exit seeker. Especially lately, he didn't want to take his Ativan (anti-anxiety medication) and he would become more anxious. (R1) was aggressive that morning (5/24). We (staff) would sit with him and that would help him stay calm. (R1) required a lot of one-on-one attention. When (R1) would exit seek, he would always go to the end of the hall exit door. That is the exit I believe he used that day (5/24). I am not sure if it alarmed or not. You may not hear it if you were further up the hall because it's not a loud alarm noise. (R1) has gotten outside before this incident. Maybe about a month ago (R1) got out into the facility parking lot. On 5/29/24 at 2:20 PM, V8 (CNA) stated I was working that day (5/24) in (R1's) unit. I had taken him to the bathroom probably 10-15 minutes prior to when he was found. I went to the linen closet and took (R3) into their room. Once I got done in (R3's) room I was going out and the other CNA (V14) was coming back from break, and she notified me of (R1) being outside. I went down to see if they (staff) needed help. Sometimes (R1) does just tend to get up and walk. He uses a walker to get around. When I was in (R3's) room I didn't hear any alarms with the door closed but once I opened the door, I could hear an alarm sounding down the hall. The (ankle bracelet) and the door alarm were all going off. (V7 Licensed Practical Nurse/LPN) was the nurse for the memory care unit that day, she was also in another room with a resident. On 5/29/24 at 2:40 PM, V13 (CNA) stated I was taking my linen out just before 6:00 PM (on 5/24). I noticed there was an oncoming nurse (V9 LPN) banging on the door outside of the 300 hall exit door. She was hollering for help. (V15 CNA) and I both went to (R1) and then I called (V2 Director of Nursing), (V15) called 911, we both saw (V9) at the same time. Employees enter that way which is how (V9) saw him. (R1) was laying partially on his butt also trying to push himself up. Once he saw help, we had control of him. The weather was pouring down rain that day, not super cold, maybe high 60's (degree Fahrenheit) temperature. To me it looked like (R1) fell face first in the parking lot. That's where he was when we got to him. It would have taken him a good ten minutes at least to get from where he exited the locked unit door to where we found him. There is some grass out there and also pavement. I entered back into the locked unit. I could hear the locked unit alarm going off from outside the doors. I couldn't hear any alarms inside the building from the 300 hall. I do know that (R1) has gotten out before. I am actually the one who found him that time. (R1) was holding onto one of the signs out there. A male was outside mowing and banged on the door (of the 300 hall) from the outside. He was alerting us that we had a resident outside. I can't remember if the alarm was going off that day. I just remember the adrenaline of it all and getting him back inside the building. That time he was maybe 10 feet away from the building, closer than he was this last time (5/24). On 5/30/24 at 11:05 AM, V15 (CNA) walked down the 300 hall and outside to the employee parking lot. V15 pointed to a lined area of parking lot pavement and stated (R1) was lying here in a rain puddle, and you could see his blood mixed in the water. Who knows how long he was laying there or how long before he had fallen once he got out. (V9) was coming into work this way, and she is the one who found him. V9's (LPN) written statement, dated 5/24/24, documents I arrived at (the facility) on May 24th for my 12 hour shift (around 5:45 PM). Upon entering the facility's back parking lot, I saw an individual lying on the ground, in a puddle, unable to get up. I ran to the 300 hall door and knocked for assistance. I requested gauze to apply to the resident's face to stop the bleeding. (R1) was taken by ambulance for injuries. On 6/3/24 at 10:00 AM, V7 (LPN) confirmed she was working in the memory care unit on 5/24/24 when R1 got outside of the building unattended. V7 stated (V14 CNA) was on break. (V8 CNA) was in a resident's room (R3) by the nurse's station with the door closed. I was in another resident's room (R2), trying to get him calmed down. I came out the get (V8) to help me with (R2) and that is when I heard the alarm. At that time there was already several staff outside with the resident and so I started getting paperwork ready to be sent to the hospital. (V8) and I couldn't hear the alarms when in resident rooms. (R1) is a known wanderer and has gotten out from time to time. He is usually re-directable when he is walking. During the time that (R1) was outside it was pouring down rain. On 5/29/24 at 2:19 PM, V1 confirmed the facility did not report R1's elopement on 5/24/24 to the State Agency. V1 stated We reported the fall with injury to (the State Agency). We did not report the elopement because (R1) was still on the property. (R1) was outside but not off property and that is what I was told to do. On 5/30/24 at 10:15 AM, V1 activated the locked memory care unit's ankle bracelet alarm and confirmed that when you are up the hall or if inside a resident's room it may not be audible. V1 then activated the exit door alarm that R1 exited on 5/24/24. The alarm was much louder but only alarmed at the exit doorway. V1 confirmed there is no speaker for this alarm up the hallway, at the nurse's station or anywhere else in the facility outside of the locked memory care unit. V1 confirmed that R1 has had another incident of getting out prior to this one and believes the date was 5/10/24. On 5/30/24 at 11:24 AM, V18 (Social Services Director) stated I do a wandering/elopement assessment in the computer quarterly, annually and with significant change. If there is an incident, we make sure alarms are working, care plan updated and see if assessment needs updated. On May 10th, (R1) breeched the door on 400 hall (in the memory care unit). What was reported to me is that he breeched the door and was brought back in by a CNA. After the 5/10/24 incident of getting out of the building, I reviewed the care plan, and we checked that alarms were sounding. I also checked to make sure they were doing 15-minute checks on (R1) and they were. So, I didn't have any new form or any care plan update to complete. On 6/3/24 at 10:30 AM, V1 (Administrator) stated Upon further investigating the incident where (R1) was found in the parking lot before the 5/24/24 incident was on 5/10/24. I think the reason it didn't get reported as an elopement is because our maintenance man (V20) was outside mowing, and he saw (R1) and they got him back into the building. So (R1) didn't go far. I didn't know he got outside at all during that incident until last week when you asked. It was never relayed to me. On 6/3/24 at 12:55 PM, V2 (Director of Nursing) stated I was not here that day (5/24), but I went in and made the notes in the resident's record once I read (employee) statements. On 5/10/24 I saw an CNA (V19) walking by quickly and so I followed her into the memory unit and then we went down by the (exit) doors. The alarm was going off, but the aids (V10 and V11 CNAs) were in the 500 hall (past the memory care nurse's station) and they thought it was the other door to go into the facility, due to it not being super loud. So, I went down to the end of the hall and when we went to open the door (V13 CNA) was coming in with (R1). I didn't do an investigation or an incident report. They (V13 and V20) had seen him right around the corner and so I didn't see it as an elopement. (V16 LPN) was the nurse that day and when I went back up the hall, she was behind the nurse's station. (V16) said she was in the medication room and didn't hear the alarm sounding. R1's Emergency Physician Note, dated 5/24/24, documents (R1) was found on the ground bleeding from the mouth. According to staff member at (facility) I spoke to, the Certified Nursing Assistant said she saw (R1) ten minutes prior to him being discovered down. Unknown loss of consciousness. Patient with history of Dementia, unable to contribute to history. Noted facial/mouth bleeding and deformity. Abrasions to bilateral knees. These Physician Notes also document Impression and Plan: Fall, Fracture of Thoracic Spine, Cervical Spine Fracture, Bilateral Mandibular (lower jaw) Fracture, Closed Maxillary (upper jaw) fracture. Transfer to (tertiary hospital) on 5/24/24 at 8:40 PM. R1's (tertiary hospital) emergency room to Admission notes, dated 5/25/24, documents R1 was admitted to the Cardiac Intensive Care unit on 5/25/24. This note documents R1 underwent a T10-T11 (thoracic spine) Open Reduction Internal Fixation with Percutaneous screws on 5/26/24 and was transferred to the hospital's Neuroscience Critical Care unit on 5/27/24. On 6/3/24 at 2:30 PM, V1 confirmed R1 remains hospitalized . On 6/6/24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy. 1. An audit of the memory care unit's alarms was conducted and determined that all exit alarms are functioning and audible, including behind closed doors. All 17 rooms (100%) were audited on the unit, including the room furthest from the exit. 5/5/24 & 6/4/24 2. All nursing staff present were in-serviced on: May 25, 2024 -Proper monitoring and supervision of residents at risk for elopement -The definition of elopement -Review of the facility's elopement detection and prevention systems -The need to reassess and review a resident's plan of care after an elopement. 5/25/24 3. All residents at high risk for elopement have been reviewed and no instances of exiting the building unattended have been identified. 5/28/24

Based on observation, interview, and record review, facility dietary staff failed to have their hair restrained while handling and preparing food. This failure has the potential to affect all 60 residents currently residing in the facility. Findings Include: The facility policy, Personnel Adherence to Sanitary Procedures, dated November 5, 2019 directs staff, Food services personnel shall follow appropriate sanitary procedures. In addition to employee personnel policies, food services and dietary personnel will be required to adhere to the following sanitary standards: Hair nets or approved hats, covering all of the hair, will be worn while handling or preparing food. On 4/6/24 from 8:30 A.M. until 8:55 A.M., V11 (Dietary Assistant) was in the facility Main Dining Room serving the morning meal from the facility steam table. V11 had no hair net or approved hat on. V11's hair was unrestrained while V11 leaned over the steam table, plating food for the facility residents. V11 was observed pouring drinks from the facility drink cart; going into the facility kitchen to retrieve a canister of brown sugar and removing a scoop of sugar, placing it in a small glass dish and placing it in front of R3; filling the facility heated, wheeled food cart with filled plates; and delivering filled plates of food to R3, R5, and R6. At that time, V11 stated she had been at work since 6:00 A.M. During this same timeframe, V12 (Dietary Assistant) was in the facility dish room, washing dishes. V12 had a black cap covering the top of her head with loose hair hanging from the front, sides and back. V13 (Dietary Cook) was observed going into and out of the facility kitchen, making peanut butter and jelly sandwiches, with a hairnet in place. Loose hair was unrestrained in the front, sides and back of V13's hair net. On 4/6/24 at 10:35 A.M., V10 (Dietary Manager) verified that facility dietary staff were to have all hair restrained while handling and preparing food. The facility Room Roster, verified and provided by V1 (Director of Nurses) dated 4/6/24 documents that 60 residents currently reside in the facility.

Based on interview and record review, the facility failed to provide twice weekly showers for one of four residents (R3), reviewed for showers, in a sample of 7. Findings Include: The facility policy, Shower Care, dated November 24, 2020 directs staff, It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin conditions. R3's Physician Order Sheet, dated April 2024 documents that R3 was admitted to the facility on [DATE] with the following diagnoses: Dementia and Parkinson's Disease. The (undated) facility Shower List documents that R3 is to receive morning showers on Wednesday and Saturday. R3's Care Plan, dated 12/12/2023 documents that R3 requires staff assistance for all Activities of Daily Living (ADLs). A review of R3's Certified Nursing Assistant Shower Sheet documents that R3 only received showers 20 out of 34 times, for the period of 12/9/23 through 4/3/24. On 4/6/24 at 11:00 AM, V3 (Certified Nursing Assistant) stated, There's no reason why (R3) missed so many showers. (R3) likes his showers. On 4/6/24 at 11:10 A.M., V4 (Certified Nursing Assistant) verified the missing showers for (R3) and also stated that (R3) enjoyed his showers and didn't fight the staff when it was time for a shower. On 4/6/24 at 12:05 P.M., V1 (Director of Nurses) confirmed that R3 was admitted to the facility on [DATE], had not been discharged from the facility during the timeframe of 12/9/23 through 4/3/24 and was missing shower sheets to verify that R3 received his twice weekly showers.

Based on interview and record review the facility failed to follow its policy for the Antibiotic Stewardship Program. This failure has the potential to affect all 57 residents who currently reside in the facility. Findings Include: Facility Room Resident Room Roster dated 3/5/24 documents 57 residents in the facility. The Facility's Infection Control with Antibiotic Stewardship Policy dated 11/01/2015 documents this policy establishes directives for antibiotic stewardship at this facility in order to develop antibiotic use protocols and a system to monitor antibiotic use. The Facility's Infection Control with Antibiotic Stewardship Policy dated 11/01/2015 documents The Antibiotic Stewardship Committee will: support and promote antibiotic use protocols which include Assessment of residents for infection using standardized tools and criteria. The criteria used by this facility are Mc [NAME] Criteria-see policy. The McGeer Criteria for Long Term Care is defined by the CDC (Center for Disease Control) website as an assessment of infections that considers fever, leukocytosis (high white blood cell count), acute change in mental status or acute functional decline. The Facility's Infection Control Monitoring Logs for December 2023, January and February 2024 did not include any documentation of the use of the standardized tool (McGreer Criteria) for any of the infections listed. On 03/06/2024 V2 (Director of Nursing/Infection Preventionist) confirmed there was no documentation of any standardized assessment for any of the facility's known infections. V2 stated I keep telling the nurses they need to fill out the McGreer Data Tool for all of the infections because it gives a bigger picture, I guess I will be telling them again.

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication for two residents (R13, R53) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 25. Findings include: Facility Policy/Psychotropic Medication Management dated 12/4/19 documents: An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing identified behaviors. The physician should evaluate the use of antipsychotic medication use if one or more of the following are the only indication: Wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which do not represent danger to the resident or others. The resident or (resident representative)/responsible party will be advised on the non-pharmacological interventions attempted and the response. The need for psychotropic medication, indication for use and any potential side effects will be presented to assist them in making an informed decision. 1. On 3/5/24 at 10:15am R13 was sitting in her room with the lights off and did not want the light turned on. R13 appeared confused and was unable to answer simple questions appropriately. On 3/8/25 at 10:20am V9 (Certified Nurse Assistant/CNA) stated that R13 Sometimes talks to people who aren't there and/or sometimes wants to cover her baby up, but there is no baby. V9 stated that R13 did not appear to be distressed when talking to people who aren't there or when she wanted to cover up her baby. V9 stated R13 can be resistive to care at times Last night she slapped away the night CNA's hands. Psychiatric Evaluation and Consultation (obtained via tele-medicine) Note dated 2/6/24 indicates R13 is [AGE] years old is alert, cooperative and of broad affect. R13's mood is okay but looks confused. Note recommends obtaining a urinalysis to rule out a UTI (Urinary Tract Infection). Behavior Monitoring dated 2/1/24 to 3/5/24 indicates R13 is monitored for agitation/restlessness, delusions, exit-seeking, and refusal of care. Monitoring indicates there were five occurrences of refusal of care - all other behaviors did not occur. Current Physician Order Summary Report indicates R13 has orders for Risperidone (antipsychotic) 0.25mg (milligrams) twice daily for Delusional Disorder (date initiated 10/26/23). Psychotropic Medication Consent indicates consent was signed by R13's representative on 8/2/23 for R13 to receive Risperdal 0.25mg for Depressive Disorder. Consent does not include how often Risperdal should be given or specific behaviors exhibited by R13 requiring the use of an antipsychotic medication. R13's Care Plan dated 3/5/24 indicates R13 is currently on Anti-psychotic therapy for Delusional Disorder. Care Plan does not include specific target behaviors. On 3/8/24 at 11:45am V2 (Director of Nursing/DON) stated that R13 has less behaviors than in the past, but still can be resistive to care. 2. On 3/5/24 at various times of the day, R53 was seen in his room and complained of not feeling well. Later during the day R53 asked for some cookies. R53 did present guarded, confused with disorganized thinking. On 3/8/24 at 10:20am V9 (CNA) stated that R53 used to be always trying to go through the exit doors and verbally aggressive toward staff. On 3/8/24 at 11:45am V2 (DON) stated that R53 used to be delusional about being in the war but was never in a war. V2 stated R53 has been aggressive toward staff but not toward residents. Psychiatric Evaluation and Consultation (obtained via tele-medicine) Note dated 2/20/24 indicates R53 is [AGE] years old who was alert and cooperative. Note indicates per nurse R13 yells and tries to throw stuff at the staff before now. Note recommends to Increase Seroquel to 25mg twice daily. Note indicates R53 denies Suicidal Ideation, Homicidal Ideation and Audio-Visual Hallucinations. Behavior Monitoring dated 21/24 to 3/5/24 indicates R53 exhibited yelling, screaming, wandering (8 occurrences), and was also monitored for agitation/restlessness (10 occurrences), delusions (7 occurrences), exit-seeking (12 occurrences), hallucinations (2 occurrences) and physical/verbal aggression (10 occurrences). Monitoring does not include nature/content of delusions or hallucinations. Current Physician's Order Summary Report indicates R53 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia with Behavioral Disturbance. Order Summary includes an order for Seroquel (antipsychotic) 25mg twice daily for Anxiety related to Dementia (date initiated 2/22/24). Psychotropic Medication Consent indicates R53's representative signed a consent for R53 to receive Seroquel 25mg by mouth twice daily for Agitation. Consent does not indicate specific behaviors R53 was exhibiting requiring the use on an antipsychotic medication. Current Care Plan indicates R53 is on Anti-psychotic therapy. Care plan does not identify target behaviors for use of an antipsychotic medication. On 3/8/24 at 2:30pm V1 (Administrator) and V2 (Director of Nursing) stated they have been auditing the psychotropics during care plan meetings, but were unaware of the consent discrepancies.

Based on observation, interview and record review the facility failed to revise the care plans for three residents (R13, R16, R53) of 14 residents reviewed for care plans in the sample of 25. Findings include: Facility Policy/Comprehensive Care Plan dated 6/25/20 documents: Care plans are revised as changes in the resident's condition dictate. Facility Policy/Psychotropic Medication Management dated 12/4/19 documents: A plan of care will be developed to include precipitating factors, non-pharmacologic interventions, and potential side effects. Residents will receive ongoing evaluation to identify possible causes that may be reduced or eliminated through care plan modification. 1.) On 3/5/24 at 10:15am R13 was sitting in her room with the lights off and did not want the light turned on. R13 appeared confused and was unable to answer simple questions appropriately. Fall Incident Report dated 1/16/24 at 7:45pm indicates R13 was found sitting on the floor next to her recliner chair which was occupied by another resident. Report indicates R13 was not interviewable and unable to give any details regarding the incident. Report indicates intervention implemented was to increase activities for (R13) while still awake. Current Fall Care Plan was not updated with R13's fall on 1/16/24 or with interventions. Current Physician Order Summary Report indicates R13 has orders for Risperidone (antipsychotic) 0.25mg (milligrams) twice daily for Delusional Disorder (date initiated 10/26/23). Current Care Plan dated 3/5/24 indicates R13 is currently on Anti-psychotic therapy for Delusional Disorder. Care Plan does not indicate target behaviors requiring the use of an antipsychotic medication. 2.) Incident Report dated 2/15/24 at 4:50pm indicates R16 was found sitting on the floor in front of a chair in the common area of the Memory Care unit. Incident Report indicates intervention was to place non-skid material in chair of R16's choice when in the common area. Current Care Plan was not updated with R16's fall on 2/15/24 or with interventions. 3.) Current Physician's Order Summary Report indicates R53 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia with Behavioral Disturbance. Order Summary includes an order for Seroquel (antipsychotic) 25mg twice daily for Anxiety related to Dementia (date initiated 2/22/24). Current Care Plan indicates R53 is on Anti-psychotic therapy. Care plan does not identify target behaviors for use of an antipsychotic medication. On 3/8/24 at 11:20am V1 (Administrator) stated A fall should automatically get pulled over into the care plan from the incident report. On 3/8/24 at 2:30pm V1 and V2 (Director of Nursing) stated it's been difficult to keep up with the care plans, so the plan is to have the MDS (Minimum Data Set)/Care Plan Coordinator take over the care plans.

Based on observation, interview and record review the facility failed to identify an appropriate indication for use of an antipsychotic medication. The facility also failed to identify specific target behaviors for administration of an antipsychotic medication for three residents with a diagnosis of dementia (R19, R46, R100) of seven residents reviewed for unnecessary medications in the sample of 25. Findings include: Facility [CONDITION(S)] Medication Policy dated 12/4/19 documents: 1. An assessment must be made to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing identified behaviors. 2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. 4. The physician should evaluate the use of antipsychotic medications if one or more of the following are the only indication: Wandering Poor self-care Restlessness Impaired Memory Anxiety/ Depression [CONDITION(S)], Unsociability Indifference to surroundings Fidgeting/nervousness Uncooperativeness Agitated behaviors which do not represent danger to resident or others. 12. A plan of care will be developed including precipitating factors, non-pharmacologic interventions, and potential side effects. 1.) Facility diagnosis Sheet indicates R19 was admitted to the facility 2/23/17 with diagnosis of Dementia with Lewy Bodies and Delusional Disorder. In 2019 R19 was diagnosed with [CONDITION(S)] and in 2021 diagnosed with Unspecified Dementia with Behavioral Disturbance and General Anxiety Disorder. Physician Order Sheets indicate [MEDICATION(S)] (antipsychotic) was initiated on admission at 25mg (milligram) at bedtime for Dementia with Lewy Bodies and increased as follows: 10/9/21 [MEDICATION(S)] increased to 25mg twice daily and diagnosis changed to Long Term Usage related to Delusional Disorder. 11/22/21 [MEDICATION(S)] increased to 50mg at bedtime, 25 mg daily and diagnosis changed to [CONDITION(S)]. 12/21/21 [MEDICATION(S)] increased to 50mg twice daily 2/15/22 [MEDICATION(S)] increased to 75mg twice daily 8/5/22 [MEDICATION(S)] increased to 100mg twice daily 10/7/22 [MEDICATION(S)] Increased to 125mg twice daily 11/11/22 [MEDICATION(S)] increased to 150mg twice daily Current [MEDICATION(S)] order (11/11/22) indicates [CONDITION(S)], Unspecified as diagnosis for [MEDICATION(S)]. Progress Notes dated 10/2022 thru 11/16/22 do not include justifications or documentation of an increase in behaviors other than (R19) continues to hear voices. On 11/17/22 at 1:30pm V8 (Licensed Practical Nurse/LPN) stated (R19) has multiple versions of herself and talks to (an alternate R19). V8 stated that they used to argue sometimes, now they just talk. V8 stated R19 also has OCD (obsessive compulsive disorder) and has very ritualistic behaviors at times. V8 stated that R19 has never been violent or aggressive. V8 stated that the residents are seen by a Nurse Practitioner for psychiatry needs thru a Telehealth company. Telehealth Note dated 10/3/22 at 1:30pm indicates (R19) has reported significant symptoms related to dementia and [CONDITION(S)]. (R19) reports talking to voices she refers to as her friends. Note indicates R19 continues to talk under her breath with a voice and states everyone talks to her as they are her friends. Note indicates R19 denies the voices are commanding stating They just talk to me. Note indicates R19 reports difficulty hearing, reports hallucinations, memory loss and dementia; denies depression, no sleep disturbances, no suicidal thoughts, and normal appetite. R19 was observed in the community areas of the memory care unit as well as in her room at various times on 11/15/22 and 11/16/22. R19 was accepting of care, mostly stayed to herself, and ambulated between the dining area and her room with a walker. R19 did seem preoccupied, however was not distressed. Current Care Plan indicates on 2/15/22 R19's [MEDICATION(S)] was increased to 75mg twice daily. No target behaviors, diagnosis or indication for use are identified in the care plan. Care Plan was not updated to reflect the continued increases of [MEDICATION(S)] after 2/15/22. Behavior Tracking Sheets dated 10/1/22 thru 11/16/22 indicate R19 is being monitored for refusing care, [CONDITION(S)], restlessness, yelling out when anxious related to hallucinations and delusions and talking in third person to her friends. [CONDITION(S)] Medication Consent dated 11/11/22 indicates consent was received on that date to increase R19's [MEDICATION(S)] to 150mg BID with Indication for Use: [CONDITION(S)]. Consent dated 10/7/22 indicates [MEDICATION(S)] was increased to 125mg with Indication for Use: Antipsychotic. Consents indicates Antipsychotics are used to treat behavior problems such as combativeness, explosiveness, manic behaviors, and treatment of psychotic disorders. Consent does not indicate specific target behaviors or conditions to justify the use of an antipsychotic medication. Consent also include Black Box Warning: Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotics are at increased risk of death compared to placebo. No consents were found or presented for the increase in [MEDICATION(S)] on 2/15/22 or 8/5/22. 2.) Physician's Order Summary Report (POS) indicates R46 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia without Behavioral Disturbance, Psychotic and Mood Disturbance and Anxiety. Physician Order Sheet indicates [MEDICATION(S)] (antipsychotic) 25mg (milligram) every night at bedtime for Unspecified Dementia without behavioral disturbance; Restlessness/Agitation was ordered on 9/11/22. Physician Order Sheet indicates [MEDICATION(S)] 25mg every night at bedtime was revised on 10/27/22 with diagnosis changed to Delusional Disorder. Current Physician Order Sheet indicates [MEDICATION(S)] 25mg was increased to be given twice daily on 11/9/22 for Delusional Disorder. Telehealth Note dated 11/7/22 indicates R46 had increased exit-seeking, wandering into other resident's rooms, yells and refuses care and had been verbally/physically aggressive with staff. Note indicates R46 wanted a gun to kill herself and was sent to the hospital, diagnosed with [MEDICATION(S)], and started on antibiotics. Note indicates R46 reported feeling better. Telehealth recommendations on 11/7/22 were to increase R46's [MEDICATION(S)] to 25mg twice daily with diagnoses of Conduct Disorder, Restlessness/Agitation, Depressive and Delusional Disorder and Anxiety. Current Care Plan indicates R46 is currently on antipsychotic therapy related to dementia without behavioral disturbance. Care Plan does not include target behaviors, specific indications for use or specify [MEDICATION(S)] as the antipsychotic medication. [CONDITION(S)] Medication Consent indicates consent was received on 9/12/22 for [MEDICATION(S)] 25mg at bedtime with Indication for Use: Dementia with Aggression. [CONDITION(S)] Medication Consent indicates consent was received on 11/9/22 for [MEDICATION(S)] 25mg twice daily with Indication for Use: Delusional Disorder. Behavior Tracking 10/1/22 to 11/16/22 indicates incomplete monitoring of behaviors identified as exit-seeking and agitation. 3.) Physician's Order Sheet (POS) indicates R100 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia without Behavioral Disturbance, Anxiety and Alzheimer's Disease. POS indicates [MEDICATION(S)] (antipsychotic) 0.5mg once daily was ordered on 11/10/22 with diagnosis of Dementia with other behavioral disturbance. [CONDITION(S)] Medication Consent indicates consent for [MEDICATION(S)] 0.5mg was received on 11/10/22 with Indication for Use: Dementia with Behavioral Disturbance. Progress Notes dated 10/1/22 thru 11/16/22 indicate R100 was having a difficult time adjusting to the locked unit, was exit-seeking and attempting to take screens off windows in empty rooms. Telehealth Note dated 11/8/22 at 2:34pm indicates Recommend starting [MEDICATION(S)]; Diagnosis Dementia with Behavioral Disturbance. Current Care Plan indicates R100 is on an antipsychotic therapy related to Dementia. Care Plan does not identify target behaviors. On 11/15/22 at 10:15am R100 was working on a puzzle with a staff member. R100 was pleasant, smiling and engaged. Several minutes later a hairdresser asked R100 if she wanted a haircut and R100 thanked the hairdresser and allowed her to cut her hair. R100 seemed very happy to be getting her hair cut. On 11/16/22 at 1:15pm R100 was smiling and interacting with staff. At that time V8 (LPN) stated that both R46 and R100 are fairly new and can become very intent on going back home. On 11/17/22 at 1:30pm V1 (Administrator) stated that they are aware the Telehealth practitioners are ordering more antipsychotic medications for residents with dementia than they should and are looking to get a psychiatrist who will come to the facility and be part of the team.

Based on observation, interview, and record review, the facility failed to immediately notify the physician of a resident's fall with injury for one of three residents (R1) reviewed for falls in the sample of four. This failure resulted in R1 not being immediately sent to the emergency room for evaluation after a fall with noted injury to the head and a left arm radial fracture that was not diagnosed or immobilized for approximately 19 hours with increased pain and decreased range of motion to left hand and wrist. Findings include: The facility's Change in Condition Procedure policy, dated 9/21/20, documents This facility will provide guidelines for the appropriate handling of a resident's change in condition. We recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change in condition. The following guidelines will be utilized as appropriate to each situation and change in condition: Notify MD (Medical Doctor) of change and give assessment information. Receive orders, if any. If not during normal business hours for provider, place call to provider to update on resident's condition if there is a significant change. R1's nursing progress note, dated 1/17/22 at 5:15 PM, and signed by V3 (Assistant Director of Nursing) documents This nurse heard loud noise from hallway, upon entering (R1's) room noted resident bed in highest position, (R1) laying on floor face down between bed and window. This same note further documents Upon assessment noted to have hit head with large hematoma to left side of head above eye at brow line. Hand grasps good. Left hand weaker due to complaints of hand and wrist pain. Noted to have small abrasion on hematoma with noted active bleeding, pressure dressing applied with ice. R1's nursing progress note, dated 1/17/22 at 8:32 PM, and signed by V3 documents (V12 R1's Physician) notified of fall with injury via fax, awaiting reply. R1's nursing progress note, dated 1/18/22 at 12:30 AM, and signed by V3 documents (R1) up to bathroom with staff assistance utilizing call light like educated to do so with complaints of headache and left wrist pain rated 6/10. PRN (as needed) Tylenol (pain medication) given at this time. (R1) continues to be able to move hand and wrist freely with complaints of pain, noted to have bruising to palm of hand and left side of hand. R1's nursing progress note, dated 1/18/22 at 5:06 AM, and signed by V3 documents (R1) awake, alert and pleasant this am with continued neurological checks, and mental status checks all within normal limits. Hematoma to head no longer actively bleeding, around left eye is swollen and discolored. Resident has been using call light for assistance to ambulate to bathroom throughout the night. Resident has complaints of increased left hand/wrist pain, slightly swollen and noted bruising to palm of hand. (V12) notified via fax, awaiting reply. R1's nursing progress note, dated 1/18/22 at 12:16 PM (19 hours after the fall with injury), and signed by V5 (Licensed Practical Nurse) documents Resident is currently at (local emergency room ). On 1/31/22 at 1:50 PM, R1 was sitting in R1's bed upright. R1 had faded gray/purple facial bruising to R1's left and right cheekbones, below her eyes and a dark purple line on the left side of R1's forehead. R1's left arm and hand was immobilized and wrapped in a soft bandaged cast. R1 confirmed falling out of bed on 1/17/22. R1 stated R1 doesn't know how R1's bed got so high in the air but R1 hit the floor when trying to get out of bed. R1 stated That floor is hard, and my face was hurting. On 1/31/22 at 1:00 PM, V3 (Assistant Director of Nursing) stated When I notified (V12 R1's Physician) at 8 PM he wouldn't have got it, unless at the office, because it was just via fax. I am assuming (R1) would've hit her head on the floor or the window. Her neurological checks were normal and so I didn't see the urgency to notify the doctor. She didn't start out with a lot of pain or any deformities, as the night went on, she started to develop more bruising and increased pain. They would've not gotten any faxes until (V12) was at the office, likely not at 5:00 AM. At some point between that time (5:00 AM) and noon, the next nurse must've called (V12) and they sent (R1) out to emergency room . V3 confirmed that R1 was found to have a left radial fracture upon emergency room visit. On 1/31/22 at 1:17 PM, V5 (Licensed Practical Nurse) confirmed she worked the day R1 was sent to the emergency room . V5 stated When a resident has a fall, if you can see an obvious injury, I would call the doctor. If there is a hematoma or swelling or bleeding to the head, they need to go to the emergency room . I was also working the day she (R1) fell but wasn't (R1's) nurse. So, then the next day I called the office (of V12) and then I called (V12's) cell phone. If you just fax (V12) it goes to the office and they (staff) don't see it until they're in the office. On 2/1/22 at 1:35 PM, V12 (R1's Physician) stated If a fax is sent after office hours, I wouldn't see it until the next day I am in the office. They need to be calling me. If a resident falls and has bleeding and a hematoma to the head I would need to be notified right away to have them sent out for evaluation.

Based on record review and interview the facility failed to notify the Physician of a change in condition for one resident (R3) of three residents reviewed for change of condition in a sample of 8. This failure resulted in R3 experiencing a continued decline in normal functioning and eventually being hospitalized for [REDACTED]. Findings Include: The Facility's Change in Condition Policy and Procedure dated 11/5/2019 documents This facility will provide guidelines for the appropriate handling of a resident's change in condition. The following guideline will be utilized as appropriate to each situation and change in condition: and continues Notify MD (Medical Doctor) of change and give assessment information. Receive orders if any. The policy also shows 5. Initiate vital signs every shift for a minimum of 72 hours or until condition stabilizes or improves. and 6. Document in chart a minimum of every shift for 72 hours or until condition stabilizes or improves. R3's Nurse's Notes dated 2/12/2020 show (V3 Advance Practice Nurse) office closed, sent a fax describing resident's need for being in feeders (requiring assistance to eat). Resident has taken a serious decline in the past two weeks. Resident food barely makes it to his mouth, most food ends up in lap. Resident's grip to hold his own cup has even become difficult. R3's Medical Record was reviewed and does not document any additional assessments, vital signs or Physician notifications related to R3's decline in function. On 8/31/2020 at 3:30 P.M. V2 (Director of Nursing) confirmed this is the only documentation of R3's decline other than the day he was sent to the hospital (3/7/2020). V2 confirmed no vital signs or assessments were done between 2/12/2020 until 3/7/2020. On 8/31/2020 at 9:45 AM V3 (Nurse Practitioner) stated To notify me or anyone else via fax to my closed office is acceptable for baseline findings. It is dangerous to do it the way they did. I had no idea this man was declining the way he was until 2/27/20 and then I ordered some labs to see what was going on and then the facility didn't even draw the labs. I discontinued seeing residents at this facility because the nursing staff is dangerous, (R3) should have been sent to the hospital in an ambulance when he declined so far that he wasn't talking or responding. On 8/31/2020, V5 (Medical Director) stated that R3 should have been assessed per the facility's protocol and that V5 felt that if R3's decline would have been addressed in a timely manner he would have been treated sooner and he wouldn't have became as sick as he did. R3's emergency room Admission Record dated 6/7/2020 shows Acute [MEDICAL CONDITION] and [MEDICAL CONDITION] (Low Sodium) as admitting [DIAGNOSES REDACTED].

Based on interview, observation and record review, the facility failed to ensure a resident (R15) was offered the right to refuse an intramuscular [MEDICAL CONDITION] medication or provided the least restrictive means of medication intervention for one of two allegations of abuse reviewed. This failure resulted in the following: On 05/29/18, V11 (Licensed Practical Nurse) and V12 (Certified Nursig Assistant) refused to allow R15 to use her own bathroom, causing R15 to become upset. R15 was then chemically restrained with an intramuscular injection of [MEDICATION NAME], causing extreme emotional distress to R15 that still continues. Findings include: The facility's Resident's Bill of Rights policy (dated 12/01/17) documents the following: Resident's Bill of Rights contains: Be free from physical or mental abuse, sexual abuse, corporal punishment, involuntary seclusion, degradation related to unauthorized photograph/social media exposure and any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms unless pursuant to written physician's orders for a specific limited period of time to ensure the physical safety of the resident or other residents or as a result of certain emergency circumstances established under federal law. R15's Abuse Investigation (dated 05/30/18) that R15 complained the morning of 05/30/18 about staff working the afternoon of 05/29/18. R15 had been having loose stools for a few days and had been instructed to pull the emergency cord in her bathroom every time she had a bowel movement by one of the charge nurses, which R15 had been doing. On 05/29/18, R15 continued to pull the call light, and was instructed by V11 (Licensed Practical Nurse) that the call light was only to be pulled in an emergency. V11 then instructed V12 (Certified Nursing Assistant) to lock R15's private bathroom door, and instructed R15 that she had to use the unit's central restroom when needed. R15 was then incontinent of stool with and again pushed the call light. R15 was instructed to walk down to the unit's central shower area in order to get cleaned up. Since R15 had been incontinent, stool was visually soiled through R15's pants and running down R15's leg. R15 became upset, began yelling and shaking her finger at V11 and V12. V12 assisted R15 to clean up, while V11 phoned V17 (R15's physician) and obtained the following orders: [MEDICATION NAME] 2 milligrams inject intramuscularly one time only for severe agitation/aggression; [MEDICATION NAME] inject 5 milligrams intramuscularly for severe agitation/aggression. Give one time only if no relief from the [MEDICATION NAME]. R15's most recent Brief Interview of Mental Status documents a score of 15, indicating R15 is cognitively intact. V18's (Care Transition Supervisor) first undated written statement documents the following: Referral to talk with (R15) about formally reporting a concern about (V11, Licensed Practical Nurse). (R15) stated she wanted to voice her concern. She stated that all day (V11) was acting 'high and mighty.' (R15) was told she couldn't use her bathroom and had to use central bathroom. (R15) voiced concern of not being able to make it in time. (V12, Certified Nursing Assistant) who locked (R15's bathroom door) said she was just doing what she's supposed to. (R15) was still unsure why she couldn't use her bathroom. (R15) felt she didn't do anything wrong. (R15) kept saying 'I am doing what I am supposed to do' by pulling the call light in the bathroom. (R15) voiced 'Never having anyone act like that to me before.' (R15) said she didn't understand what (V11) was telling her to go to the central bathroom. 'I just didn't understand what (V11) wanted me to do. I thought I was doing everything right.' (R15) went back to her room and since she was confused and didn't know what to do, she stayed seated concerned she would do the wrong thing. R15 stated, '(V11) was just so high and mighty,' and kept repeating this. After her incontinence issue, she had to take a shower. (R15) stated, 'I took a shower and was told to sit on the toilet. I don't know when I got up.' (R15) was told to sit in a chair in the sitting room and didn't want to. While this was happening, (R15) was told she was going to get a shot to be calm and 'be the way I should be.' (V11) then stated (to R15) 'You (R15) need to be in a mental institute.' I (V18) asked (R15) how that made her feel. She said 'Stunned. She (V11) was just so high and mighty.' This written statement also documents, (R15) stated 'I thought all night about her telling me I needed to be in a mental institute. I couldn't stop thinking about it. I just thought what's the matter women? You need to be in a mental institute.' Overall, (R15) feels this happened because she did something wrong, but doesn't know what. Just states, 'I try to do what I am supposed to do.' V18's second written statement (dated 05/31/18) documents the following: I spoke with (R15) regarding yesterday's incident. I asked (R15) how she felt today, she stated the exact same as yesterday. I said, so you are upset and (R15) stated 'I told you already. I feel the same way as yesterday and I will feel that way everyday.' I (V18) told her that I was sorry this happened and she stated, 'I don't know what else you want me to say.' I told her I just wanted to make sure she felt better. (R15) stated, 'I feel the same. No one has ever treated me like that here.' I said we are making sure that doesn't happen again or to anyone else. (R15) again stated that she is just stunned. I told (R15) that staff would be talking to her to follow up. (R15) didn't care for the idea because she said she has nothing to change it and will feel the same way day after day. (R15's) concern is that she never wants anyone to lock the bathroom door on her again, she doesn't want to feel that way again. As I left, (R15) said, 'I don't know what you want me to say. I will always feel this way. This same written statement documents the following note written by V18 to V1 (Administrator): When I (V18) spoke with (R15) you could tell her day was interrupted and it made her uncomfortable. Her story was unchanged from yesterday. She just didn't understand what is going on with asking her how she feels. I (V18) am concerned continuing to talk to with her daily only brings it up and makes her feel uncomfortable. (R15) stated multiple times her feelings won't change. Her major concern of the bathroom being locked and I assured her we wouldn't do it again. I am concerned there would be no benefit to her for continued conversation. V1's (Administrator) written statement (dated 05/31/18) documents the following: Spoke with (V17, R15's physician), he states (V11) called and said (R15) extremely agitated, complete change from normal behavior, out of control. (V11) requested [MEDICATION NAME] injection. (V17) advised to redirect, (V11) stated they had tried and unable to do at this time. (V17) asked about oral medication, (V11) stated (R15) is refusing oral and would not be possible. (V17) stated he trusts our nurses' judgement and if at this point, [MEDICATION NAME] order given times one and [MEDICATION NAME] times one if [MEDICATION NAME] ineffective. V3's (Licensed Practical Nurse) written statement (dated 05/30/18) documents the following: V3 was working another unit in the facility on 05/29/18 and received a call from V11(Licensed Practical Nurse) asking what injectable medications were available in the medication back up. V11 then asked if the back up had [MEDICATION NAME] and V3 replied yes. V11 called V3 back and asked if V3 could bring over the [MEDICATION NAME]. This statement also documents, (V11) told me (V3) that (R15) had been combative, yelling, argumentative with staff and out of control. (V11) stated that she wanted to know what we had in back up so she could relay it to the doctor if/when asked. I saw an order for [REDACTED].' (V11) drew up the [MEDICATION NAME]. (R15) was in the central shower room sitting on a shower chair with (V12). All three staff members (V11, V12 and V3) and (R15) were in the shower room. (R15) was sitting on shower chair calmly. (V11) told (R15) we were going to give her a shot. I can't recall what (R15) said. But I think something was said about (R15) needed to (something). (V11 and V12) were still in front of (R15) and I gave the shot in her left gluteus. (V11) signed the narcotic sheet and stated that we had 0 vials left. I corrected (V11) stating we had half a vial left. (V11) stated about me taking the vial with me and I said 'No you might need it again' (V11) said 'No. It was a one time order.' (V11) stated to me that she would have to stay late and do the charting. V19's (Registered Nurse) written statement (dated 05/30/18) documents the following: When I came in (05/29/18) at 06:00 PM, (V11) and (V12) told me that (R15) was being belligerent, severely agitated and paranoid. That (R15) was always pulling the call light even if it was unnecessary. That she messed up her couch with feces and that's why they had to remove it from her room. According to (V11 and V12) they locked her bathroom because she kept pulling the call light and from now on, she had to go to the central bathroom. I (V19) talked to (R15) and she said that they gave her a shot. I explained to her what the [MEDICATION NAME] was for. Per (R15) 'I need to know what they are giving me, it is my basic right to know why they gave me a shot. (R15) slept through the night with no episode of loose stools.' On 10/31/18 at 09:30 AM, R15 was sitting at the table in the dining room. R15 was able to recall the incident that occurred on 05/29/18 with V11 and V12. When asked about the incident, R15's facial expression became visibly upset, and R15 stated, They were high and mighty. I didn't feel safe. I was very upset. They locked me out of my bathroom, and then they gave me a shot. That made me mad, really mad. It hurt. I didn't think I needed something like that. I didn't want it. She (V11) told me that I needed to be in a mental institute. I still don't understand why they did all of this to me. They didn't ask me if I wanted a shot, they just told me they were giving me a shot. It upset me a lot, it really bothered me, and it still does. R15's (MONTH) (YEAR) Physician's Orders did not have any type of PRN (as needed) [MEDICAL CONDITION] medication ordered for R15, except the one-time intramuscular injections of [MEDICATION NAME] and [MEDICATION NAME] ordered on [DATE]. R15's Medication Administration Record [REDACTED]. R15's Progress Notes dated 05/29/18 - 05/30/18 did not document that R15 was offered or refused any type of PRN (as needed) oral medication for behavior management after V11 and V12 locked and secluded R15 from her personal bathroom. On 10/31/18 at 10:35 AM, V1 (Administrator) verified that R15 was given an intramuscular injection for displaying behaviors after V11 and V12 locked and secluded R15 from her personal restroom. V1 would not confirm or deny whether he considered R15's intramuscular injection a chemical restraint, but then stated, If they would have had to give the [MEDICATION NAME] after the [MEDICATION NAME], that would have been a chemical restraint. On 11/01/18 at 10:05 AM, V2 (Director of Nursing) confirmed that the 05/29/18 incident involving V11, V12 and R15 caused R15 mental anguish.

Based on observation, interview and record review, the facility failed to protect a resident (R15) from involuntary seclusion and verbal abuse for one of two allegations of abuse reviewed. V11 (Licensed Practical Nurse) instructed V12 (Certified Nursing Assistant) to lock R15's bathroom door after R15 pressed the bathroom call light multiple times, leaving R15 without access to her personal restroom. These failures resulted in, R15's restroom door remained locked for the remainder of V11 and V12's shift, causing R15 to be incontinent of stool, and was then verbally abused by V11. These failures also resulted in R15 suffering extreme emotional distress, that still continues today. Findings include: The facility's Abuse Prevention policy (revised 02/15/17) documents the definition of Involuntary Seclusion as follows: The separation of a resident from other residents or from his/her room, or confinement to his/her room against the resident's will or the will of the resident's legal representative. R15's Abuse Investigation (dated 05/30/18) documents that V1 was notified by V4 (Licensed Practical Nurse) at 08:55 AM that R15 complained the morning of 05/30/18 about staff working afternoon of 05/29/18. R15 had been having loose stools for a few days and had been instructed to pull the emergency cord in her bathroom every time she had a bowel movement by one of the charge nurses, which R15 had been doing. On 05/29/18, R15 continued to pull the call light, and was instructed by V11 (Licensed Practical Nurse) that the call light was only to be pulled in an emergency. V11 then instructed V12 (Certified Nursing Assistant) to lock R15's private bathroom door, and instructed R15 that she had to use the unit's central restroom when needed. R15 was then incontinent of stool and again pushed the call light. R15 was instructed to walk down to the unit's central shower area in order to get cleaned up. Since R15 had been incontinent, stool was visually soiled through R15's pants and running down R15's leg. R15 became upset, began yelling and shaking her finger at V11 and V12. V18's (Care Transition Supervisor) first undated written statement documents the following: Referral to talk with (R15) about formally reporting a concern about (V11, Licensed Practical Nurse). (R15) stated she wanted to voice her concern. She stated that all day (V11) was acting 'high and mighty.' (R15) was told she couldn't use her bathroom and had to use central bathroom. (R15) voiced concern of not being able to make it in time. (V12, Certified Nursing Assistant) who locked (R15's bathroom door) said she was just doing what she's supposed to. (R15) was still unsure why she couldn't use her bathroom. (R15) felt she didn't do anything wrong. (R15) kept saying 'I am doing what I am supposed to do' by pulling the call light in the bathroom. (R15) voiced 'Never having anyone act like that to me before.' (R15) said she didn't understand what (V11) was telling her to go to the central bathroom. 'I just didn't understand what (V11) wanted me to do. I thought I was doing everything right.' (R15) went back to her room and since she was confused and didn't know what to do, she stayed seated concerned she would do the wrong thing. R15 stated, '(V11) was just so high and mighty,' and kept repeating this. After her incontinence issue, she had to take a shower. This same written statement documents, (R15) stated, 'I took a shower and was told to sit on the toilet. I don't know when I got up.' (R15) was told to sit in a chair in the sitting room and didn't want to. While this was happening, (R15) was told she was going to get a shot to be calm and 'be the way I should be.' (V11) then stated 'You (R15) need to be in a mental institute.' I (V18) asked (R15) how that made her feel. She said 'Stunned. She (V11) was just so high and mighty.' This written statement also documents, (R15) stated 'I thought all night about her telling me I needed to be in a mental institute. I couldn't stop thinking about it. I just thought what's the matter women? You need to be in a mental institute.' Overall, (R15) feels this happened because she did something wrong, but doesn't know what. Just states, 'I try to do what I am supposed to do.' V18's second written statement (dated 05/31/18) documents the following: I spoke with (R15) regarding yesterday's incident. I asked (R15) how she felt today, she stated the exact same as yesterday. I said, so you are upset and (R15) stated 'I told you already. I feel the same way as yesterday and I will feel that way everyday.' I (V18) told her that I was sorry this happened and she stated, 'I don't know what else you want me to say.' I told her I just wanted to make sure she felt better. (R15) stated, 'I feel the same. No one has ever treated me like that here.' I said we are making sure that doesn't happen again or to anyone else. (R15) again stated that she is just stunned. I told (R15) that staff would be talking to her to follow up. (R15) didn't care for the idea because she said she has nothing to change it and will feel the same way day after day. (R15's) concern is that she never wants anyone to lock the bathroom door on her again, she doesn't want to feel that way again. As I left, (R15) said, 'I don't know what you want me to say. I will always feel this way. This same written statement documents the following note written by V18 to V1 (Administrator): When I (V18) spoke with (R15) you could tell her day was interrupted and it made her uncomfortable. Her story was unchanged from yesterday. She just didn't understand what is going on with asking her how she feels. I (V18) am concerned continuing to talk to with her daily only brings it up and makes her feel uncomfortable. (R15) stated multiple times her feelings won't change. Her major concern of the bathroom being locked and I assured her we wouldn't do it again. I am concerned there would be no benefit to her for continued conversation. V4's (Licensed Practical Nurse) written statement (dated 05/30/18) documents the following: When I went to (R15's) room this morning, she was still upset about the incident last night. She voiced to me that (V11) told her that she needed to quit pulling the bath light, and she was told to pull the light so the nurse could look at her bowel movement. I agreed with her that I did tell her to pull the light when she had a bowel movement because I wanted to monitor her. I had told her this last week when she was having all the loose stools. She also told me that the other girl who was working (V12) came and locked her out of the bathroom. V19's (Registered Nurse) written statement (dated 05/30/18) documents the following: When I came in (05/29/18) at 06:00 PM, (V11) and (V12) told me that (R15) was being belligerent, severely agitated and paranoid. That (R15) was always pulling the call light even if it was unnecessary. That she messed up her couch with feces and that's why they had to remove it from her room. According to (V11 and V12) they locked her bathroom because she kept pulling the call light and from now on, she had to go to the central bathroom. V12's written statement (dated 05/30/18) verified that V12 locked R15's bathroom door on 05/29/18 after being instructed to, as a redirection for pulling the emergency cord every time (R15) went to the bathroom. On 10/31/18 at 09:30 AM, R15 was sitting at the table in the dining room. R15 was able to recall the incident on 05/29/18 with V11 and V12. R15's facial expression became visibly upset, and R15 stated, They were high and mighty. I didn't feel safe. I was very upset. They locked me out of my bathroom. It upset me a lot, just really bothered me, and it still does. On 10/31/18 at 09:40 AM, V4 (Licensed Practical Nurse) stated that R15, Has a strict routine. Is very [NAME]D ([MEDICAL CONDITION]). If you do anything to her room- like change the arrangement, or if anyone unfamiliar enters her room, she would freak out. On 11/01/18 at 10:00 AM, V1 (Administrator) verified that V11 and V12 locked R15 out of her personal bathroom on 05/29/18, which cause emotional distress to R15. V1 would neither confirm nor deny if he considered the 05/29/18 incident of locking R15 out of her personal bathroom involuntary seclusion. On 11/01/18 at 10:05 AM, V2 (Director of Nursing) confirmed that the 05/29/18 incident caused R15 mental anguish.

Facility non-compliance resulted in three deficient practices: A. Based on observation, record review and interview, the facility failed to investigate, monitor, and implement interventions to prevent further injuries (skin tears/skin impairments) for one of eight residents ( R9) reviewed for falls in the sample of 13. This failure resulted in R9 subsequently sustaining multiple skin tears/skin impairments and cellulitis of the left lower extremity. B. Based on interview, observation and record review, the facility failed to maintain a functioning bed alarm to prevent further falls for one of eight residents (R7) reviewed for falls in the sample of 13. C. Based on interview, observation and record review, the facility failed to provide supervision while using a mechanical lift for one of eight residents (R4) reviewed for falls in the sample of 13. Findings Include: A. The facility's Skin Impairment policy, dated 8/20/2014, documents, Practice/Procedure: B.) All skin tears, bruises, hematomas, lacerations, blisters, and abrasions will be assessed using the skin injury form with input from the direct care nurse responsible for that resident. Immediate interventions will be put into place Follow up will be documented at least weekly in the resident's record. On 2/17/16 at 9:00 a.m., R9 had two open areas to the anterior portion of the left lower leg measuring: 1 CM x 0.5 CM (Centimeters) with a small amount of bloody drainage and red tissue surrounding the area; and a 0.5 CM x 0.5 CM scabbed area with surrounding red tissue. R9 also had an open area to the posterior calf of the left leg measuring 5 CM x 3 CM, with a moderate amount of bloody drainage. Its wound bed being very red with a small amount of yellow tissue present, with a reddened surrounding area. E14 (Registered Nurse) verified the surrounding skin for all of these open areas was warm to the touch. R9's Skin Injury Report Form, dated 12/28/2015, documents that R9 sustained a bruise and blood blister to the posterior left lower extremity. The bruise around the blood blister measures 5.8 CM x 7 CM and the blister measures 5 CM x 4 CM. The Skin injury report also documents it is unknown if the injury was sustained during transfer, dressing, fall, bath,mechanical lift lift or ambulation, other contributing factors, and R9 stated, Must be that d--- wheelchair. R9's Progress Notes, dated 12/3/2015, documents that R9 sustained a skin tear to R9's right lower extremity. R9's Progress Notes, dated 12/14/2015, documents that R9 has a 1 CM x 1 CM skin tear on the left lower extremity, superior to the wound on the left lower extremity. R9's Progress Notes, dated 12/21/2015, documents that R9 sustained a new open area on an old wound (not identified in the record), and steri strips were applied. R9's Progress Notes, dated 12/28/2015, documents that R9 sustained a discoloration on the left lower extremity measuring 5.8 CM x 7 CM , with a blood blister in the center that measures 5 CM x 4 CM. On 2/17/2016 at approximately 1:00 p.m., R9 stated, These open areas started out as skin tears caused by hitting the back of my wheelchair pedals. I have asked repeated times for the wheelchair pedals and frame to be padded for protection. The (facility) still has not padded pedals or frame. R9's Minimum Data Set, dated dated [DATE], documents that R9's BIMS score, (Brief Interview for Mental Status) is 15/15, indicating that R9 is not cognitively impaired. On 2/17/16 at 1:00 p.m., there were no padded areas present on R9's wheelchair frame or foot pedals. R9's Care plan, dated 5/15/2015, documents, R9 has an actual skin impairment to skin integrity related to fragile skin LLE (left lower extremity) with open areas anterior and posterior. Intervention: 1.) Follow facility protocols for treatment of [REDACTED].) Monitor/document location, size and treatment of [REDACTED]. R9's Physician order [REDACTED]. areas to R9's left lower extremity and wrap with gauze twice a day. R9 also had an order to start Keflex (antibiotic) 250 MG (Milligrams) by mouth every eight hours for seven days, for [DIAGNOSES REDACTED]. On 2/17/2016 at 11:00 a.m., E14 (Wound Nurse) stated, There are no interventions put into place for the bruise/blister to the posterior left lower leg. that was sustained on 12/28/2015. I do think that (R9) hit left leg on wheelchair pedals and sustained the injuries. On 2/18/2016 at 8:50 a.m., E14 verified, there is no Skin Injury reports for R9's open areas to the anterior portion of the left lower leg, and interventions were not put in place for each skin tear/ impairment. E14 also verified there is no weekly monitoring of each open area sustained to the left lower leg. On 2/18/2016 at 8:45 a.m., E2/DON (Director of Nurses) stated, I have no idea how (R9) sustained the open areas to the anterior and posterior left lower leg. There is no documentation to support that the skin tears/ skin impairments on left lower legs were investigated. On 2/18/2016 at 10:10 a.m., Z1 (R9's Advance Practice Nurse) stated, I examined resident (R9) on 2/12/2016 , because she came to me about her wounds on the left lower extremity. I noticed (R9) had an increase in redness and edema, so I started (R9) on an oral antibiotic and a medicated ointment to be applied to the wounds on the left lower extremity due to cellulitis .The areas could be caused by (R9) bumping (R9's) legs on (R9's) wheelchair pedals. B. The facility's Fall Prevention policy (Revised 4/1/14) documents the following: Interventions will be implemented to minimize the risk of resident falls .a 'blue falling star' will be placed on the doorframe alerting staff of a recent fall. R7's fall care plan, dated 12/16/15, documents that R7 is at risk for falls and includes the following fall intervention: Replace bed alarm if indicated. The facility's undated fall log documents R7 fell at the facility on the following dates: 5/26/15, 12/7/15 and 2/16/16. R7's Post Fall Assessment Form dated 12/7/15 documents that R7 was found on the floor on a safety mat in R7's room. This same form documents that R7 had a bed alarm in place, and the alarm was not sounding at the time of R7's fall. R7's Post Fall Assessment Form dated 2/16/16 documents that R7 had an unwitnessed fall and was found on the floor in R7's room. This same form documents that R7's bed alarm was not sounding at the time of R7's fall. On 2/17/16 at 9:00 a.m., a picture of a blue star was posted on R7's doorframe, indicating R7 had recently fallen. On 2/17/16 at 10:40 a.m., E2, Director of Nursing, stated, (R7's) bed alarm wasn't sounding when (R7) fell on [DATE] and 2/16/16. E2 then stated, They (bed alarm wires) become loose sometimes and can be very touchy. On this same date at 12:30 p.m., E2 stated that the facility does not have a policy in place regarding the use of bed alarms. E2 stated that facility staff checks residents' bed alarms weekly, but cannot provide any documentation, We (facility staff) don't log the checks. It just seemed like another piece of paper. C. The facility's sit-to-stand mechanical lift's Operating and Product Care Instructions manual (undated) documents the following: (Sit-to-stand mechanical lift) shall always be handled by a trained caregiver, continuously attending to the resident . R4's Minimum (MDS) data set [DATE] documents that R4 has severely impaired cognitive skills for daily decision making. This same form also documents that R4 is not steady, and can only stabilize with staff assistance while moving on and off the toilet. R4's Fall Risk assessment dated [DATE] documents a score of 8, indicating R4 is at moderate risk for falls. On 2/17/16 at 12:30 p.m., R4 was sitting on the toilet in the facility's 400 hall common bathroom and was yelling out incomprehensible sounds. A sit-to-stand mechanical lift was positioned in front of R4, and the sling apparatus remained in place around R4's waist and hooked securely to the mechanical lift bar. R4's feet remained in position on the mechanical lift stand platform. R4 was sitting alone with no facility staff present. On 2/17/16 at 12:33 p.m., E12 verified that R4 was sitting alone secured in a sit-to-stand mechanical lift in the facility's 400 hall common bathroom. On 2/18/16 at 9:40 a.m., E10, Certified Nursing Assistant, was standing in the facility's north nurse's station and stated, (R4) is on the toilet and (R4) is going to be transferred in just a minute when (R4) is finished. Approximately two minutes later, E10 and E6, Licensed Practical Nurse, approached the facility's 400 hall common bathroom, and pulled back the privacy curtain. R4 was sitting alone on the toilet with a sit-to-stand mechanical lift positioned in front of R4, and the sling apparatus remained in place around R4's waist and hooked securely to the mechanical lift bar. R4's feet remained in position on the mechanical lift stand platform. On 2/17/16 at 12:30 p.m., E2, Director of Nursing, stated the facility does not have a policy in place regarding the use of mechanical lifts. E2 then stated that two staff members must be present when a resident is being transferred with a sit-to-stand mechanical lift. E2 also stated if a resident is transferred onto a commode with a sit-to-stand mechanical lift and remains secured in mechanical lift while sitting on the commode, then one staff member should remain with the resident to supervise while the resident uses the restroom.

Based on observation, record review and interview, the facility failed to obtain medical treatment, continued to have the resident bear weight with transfers, and failed to provide pain control after a fall with injury for one of ten residents (R4) reviewed for falls on the sample of eighteen. R4 sustained a fracture to the left pubic and ischial bone resulting in pain untreated for [REDACTED]. Findings include: According to the nurse's notes dated 12-7-12 at 2:45p.m., R4 was found on the floor with her wheelchair tipped over. Review of the nurse's notes and the post fall assessment form dated 12-7-12 to 12-9-12, the Physician was not notified until 12-9-12 at 11:05 a.m. regarding the fall. The nurse's notes dated 12-7-12 at 11:30 p.m, document R4 complained of left hip pain. The nurse's notes dated 12-8-12 at 6:45a.m. document that R4 had difficulty weight bearing, during a transfer, due to pain, appeared to be in more pain on the left side, and grabbed at her left leg when it was moved. The nurse's notes on 12-8-12 at 10:45 a.m. document that R4 continued to have pain during transfers. The nurse's notes on 12-9-12 at 4:30 a.m. document R4 was grimacing, moaning, and yelling out with flexion of the bilateral hips and knees and with repositioning. The nurse's notes dated 12-9-12 at 5:30 a.m. document that R4 was calling out with pain and guarding the bilateral lower extremities during cares and transfers. The nurse's notes dated 12-9-12 at 7a.m. document R4 was having increased pain and moans and grimaces with movement of the legs. According to the nurse's notes dated 12-7-12 through 12-9-12, the Physician was not notified of R4's multiple complaints of pain until 12-9-12 at 11:05a.m when the Physician gave an order for [REDACTED]. On 12-10-12 at 11:25 a.m., during a family interview, Z1 verified R4 was in a lot of pain and screaming out on 12-8-12. On 12-10-12 at 2p.m., E5 (Licensed Practical Nurse) verified that E5 did not notify the Physician about R4's fall and complaints of pain on 12-7-12. On 12-10-12 at 1:40p.m., E6 (Licensed Practical Nurse) verified that a Physician was not notified about R4's fall and complaints of pain on 12-7-12, until E6 called the on call Physician on 12-9-12 at 11:05 a.m. On 12-10-12 at 2:15p.m., E4 (Nurse Manager) verified that R4's primary Physician was not notified about R4's fall and complaints of pain on 12-7-12, until 12-9-12 at 1:45p.m. by fax. On 12-13-12 at 11a.m. E2 (Director of Nursing) verified that the facility nurses should have notified the Physician immediately following R4's fall on 12-7-12 and after R4's complaints of pain. On 12-13-12 at 11a.m. E2 also verified that the facility staff should not have had R4 bear weight with transfers. According to the facility's undated pain policy an procedure, residents will either be pain free or their pain will be controlled to a level that is acceptable to the resident and allows the residents to maintain the highest level of functioning possible.