Every finding on record at Monument Healthcare Cottonwood Creek

Based on observation, interview, and record review, the facility did not treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, for 4 out of 33 sampled residents, residents who required dining assistance experienced delays while others at the same table received feeding assistance. Resident identifiers: 20, 26, 32, and 33.Findings included:On 7/13/26 at 7:33 AM, an observation of the East dining room was conducted. The breakfast meal cart had been delivered to the dining room. On 7/13/26 at 7:40 AM, resident 33 was served their breakfast tray. At 7:42 AM, resident 32 was served their breakfast tray, at 7:45 AM, resident 20 was served their breakfast tray, and at 7:48 AM, resident 26 was served their breakfast tray. It should be noted that the residents were sitting at the same table. On 7/13/26 at 7:50 AM, feeding assistance was provided to resident 26. At 7:54 AM, feeding assistance was provided to resident 33. Resident 20 and resident 32 were placed at the same table and were observed watching resident 26 and resident 33 eat their breakfast. Resident 32 was mumbling and stated .and there is not a goddamn thing you can do about it. On 7/13/26 at 8:18 AM, resident 32 was provided feeding assistance with eating. [It should be noted that resident 32 waited 36 minutes for feeding assistance from the time her breakfast tray was served.]On 7/13/26 at 8:18 AM, resident 20 was provided feeding assistance with eating. [It should be noted that resident 20 waited 33 minutes for feeding assistance from the time her breakfast tray was served.]1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, anxiety disorder, cognitive communication deficit, need for assistance with personal care, and vascular dementia.A care plan focus revised on 6/22/26, documented that resident 32 had an activity of daily living self-care performance deficit related to dementia. The interventions included Eating: [resident 32] requires total assistance of staff for eating. Clothing protector to be worn as needed and as requested Date Initiated: 09/01/2018.2. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included aphasia, cognitive communication deficit, need for assistance with personal care, Alzheimer's Disease, and dementia.A care plan focus revised on 7/3/25, documented that resident 20 had or was at risk for Functional Self Care Deficits and/or Functional Mobility limitations related to dementia and impaired mobility. The interventions included, EATING: I require total assist to bring food and/or liquid to my mouth and swallow food and/or liquid once the meal is placed before me. Date Initiated: 07/03/2025. On 7/15/26 at 1:44 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that generally the facility policy would be to serve the food to the independent residents first and do the assisted residents last. ADON 1 stated unexpected interruptions during meal service could cause delays between serving meal trays. ADON 1 stated she was not sure what happened on Monday. ADON 1 stated that new staff were learning the policy to serve an entire table after delivering the first meal tray. ADON 1 stated if an assisted table was served the staff would need to help the residents and not leave. ADON 1 stated that certain residents were served first, but the residents' levels of agitation varied day to day.

Based on record review and interview, the facility did not maintain medical records on each resident that were accurately documented. Specifically, for 1 out of 33 sampled residents, documents for a different resident were uploaded in another resident's electronic medical record. Resident Identifier: 47Findings Included:Resident 47 was admitted on [DATE] with diagnoses including, but not limited to polyneuropathy, dementia, neurocognitive disorder with lewy bodies, and carpal tunnel syndrome.Resident 47's medical record was reviewed from 7/13/26 through 7/15/26.A document labelled, Behavioral Complex Submitted 12.23.25 had been uploaded into resident 47's medical record. The document contained a different resident's medical record. On 7/15/26 at 9:34 AM, an interview was conducted with the Medical Records (MR) staff member. The MR stated that she did not upload the document to the resident's medical record, but that the document was uploaded by the facility's finance department. The MR stated that the document from another resident's medical record should not have been uploaded into resident 47's medical record and stated she would correct the error.

Based on observation, interview, and record review the facility did not, for 2 of 26 sampled residents, ensure that the environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistance device to prevent accident. Resident identifiers: 35 and 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction due to thrombosis, type 2 diabetes mellitus, squamous cell carcinoma, protein-calorie malnutrition, atrial fibrillation, need for assistance with personal care, history of falling, mood disorder, pressure ulcer of sacral region, dementia, generalized edema, anemia, hypertension, hyperlipidemia, and renal osteodystrophy. On 4/1/24 at 9:18 AM an observation of resident 56 was made. Resident 56 was sitting in a wheelchair close to the nurses' station. Resident 56 was observed to have a bandage on her head dated 4/1. Resident 56 was unable to explain why she had a bandage on her head. Resident 56's electronic medical record was reviewed. Resident 56's Minimum Data Set (MDS) from 12/20/23 documented that resident 56 required a two-person extensive assist with bed mobility, transfers, and toilet use. The MDS documented that the resident scored a 5 on the Brief Interview for Mental Status (BIMS). In accordance with the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Manual (RAI) Version 3.0 Manual, a score of 5 represents severe cognitive impairment. Resident 56's care plan was reviewed. Resident 56 had a care plan initiated on 9/20/23 with a focus that stated, [resident 56] is at risk for falls related to dementia with Confusion and decreased safety awareness, deconditioning, weakness. The goal stated, [resident 56] will be free of minor injury through the review date. The interventions stated, Allow resident to sleep in upright position as she prefers. , initiated 12/1/23. Anticipate and meet the resident's needs., initiated 9/20/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance., initiated 9/20/23. Bolster mattress to bed., initiated 2/16/24. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room., initiated 9/20/23. Ensure resident bed remote is clipped near resident on bedsheet., initiated 10/13/23. Ensure that the resident is wearing appropriate footwear (non-skid shoes, non-skid socks, etc.) prior to any transfers or ambulating., initiated 9/20/23. An incident report from 10/12/23 documented, resident found sitting on the floor, by bathroom door, with lower extremities under the bed. Resident wearing non skid socks when found. Bed found not in low position. Bed was in low position before fall. CNA [Certified Nursing Assistant] states resident plays with a bed remote. The resident's description on the incident report documented, Resident stated, I don't think I fell resident denies hitting head. The immediate action taken on the incident report stated, head to toe assessment done. Redness to R [right] hip noted. Skin intact. No deformities noted. ROM [range of motion] at baseline. Resident assisted back into bed. The care plan was reviewed, and it revealed that an intervention was added to the residents fall care plan. The intervention was added on 10/13/23 and stated, Ensure resident bed remote is clipped near resident on bedsheet. An incident report from 11/26/23 documented, During rounds @ 0120 [at 1:20 AM], CNA observed resident on the floor in her room next to the bed, resident bleeding from the forehead, . resident assessed for injury and assisted onto the bed, resident stated her head hurt when assessed for pain, no other pain noted. The resident states she doesn't know what happened but states that it has not been a great day for her. The incident report did not document any new interventions. An Emergency Department (ER) documented dated 11/26/23 documented that resident 56 was seen at theER on [DATE] at 5:25 AM and was given 6 sutures on her forehead. On 4/4/24 at 11:45 AM an interview with the Director of Nursing (DON) was conducted. The DON stated that that the intervention after the fall on 11/26/23 was to send her out to the hospital, and on 12/1/23 the care place was updated that stated, Allow resident to sleep in upright position as she prefers. An incident report from 1/20/24 documented, When giving res [resident] her morning meds this RN [registered nurse] observed a bruise to resident's L [left] forehead and swelling down to L eye. When asked res stated she fell , but is unable to give any details regarding what happened. The incident report did not document any new interventions. The care plan was reviewed and there were no updated interventions for the residents fall care plan. On 4/4/24 at 11:46 AM an interview with the DON was conducted. The DON stated that the intervention for the call on 1/20/24 was to ensure that pillows were placed between her bed and her dresser. The DON stated that she could not find the intervention in her fall care plan and that the fall care plan should have been longer than what it currently was. The DON stated that she found the intervention regarding the pillow placement in the resident's skin care plan and that it was added on 1/22/23. On 2/15/24 an incident report from 2/15/24 documented, Nurse heard noise coming from the residents room approx [approximately] at 3:20 [AM]. Responded to noise. Observed resident laying face down between beds with head towards wall. Bed in low position and call light within reach. Assessed resident noted large laceration to forehead. Called the west nurse over for assistance. Pressure applied to laceration. Head to toe assessment completed. Swelling to R [right] ring finger. Laceration to bridge of nose. Bilateral knee discoloration . Resident c/o [complained of] pain to right ring finger, bilateral knees and head. Neuro checks initiated resident A&O [alert and oriented] x 1 . Received orders to send resident out to hospital. 911 called. EMS arrived. Resident sent out to [name redacted] hospital. Resident unable to give a description. An ER documented dated 2/15/24 documented that resident 56 was seen at theER on [DATE] at 4:12 AM for a 10 centimeter (cm) head laceration and was give 20 sutures and 2 staples. An x-ray was preformed on the residents finger and the ER document reported, no acute abnormality of the right hand. A Nurses Note from 2/15/24 at 9:31 AM documented, Resident returned from [name redacted] hospital at approx. 0730 [7:30 AM] with a dx [diagnosis] of laceration without foreign body of scalp. Resident returned with 2 staples and 20 sutures to laceration on forehead. Splint noted to R ring finger . No neurological deficits noted. H-T [head to toe] completed by this nurse. New discoloration/swelling noted to L eye, resident unable to open eye due to swelling. Small laceration also noted above left eyebrow. Site cleansed and steri strip applied. During assessment resident observed picking at both lacerations. Slight bleeding noted to both sites, site cleansed . Staff attempted to ice residents face, but resident refused. NP [Nurse Practitioner] notified . The care plan was reviewed, and it revealed that an intervention to resident 56's care plan on 2/16/24 and it stated, Bolster Mattress to bed. On 4/3/24 at 4:53 PM an interview with RN 3 was conducted. RN 3 stated that she was the nurse for resident 56 when resident 56 fell on [DATE]. RN 3 stated, I was at the nurses' station when I heard a loud noise. I began checking rooms, I opened her door and saw that she wasn't on her bed. I walked in and saw her laying face down and she [resident 56] was saying, oh god it's dripping. [resident 56] wasn't able to tell me what happened. [Resident 56] does often try to get up. I called the doctor right away, and reported it to the family and the on call manager. I believe resident 56 got a bolster mattress after that fall. RN 3 stated that the fall happened during the night shift and there were three CNA's and 2 nurses working at the time. 2. Resident 35 was admitted to the facility on [DATE] with diagnoses which included dementia, abnormalities of gait and mobility, type 2 Diabetes Mellitus, mild protein-calorie malnutrition, cognitive communication deficit, dysphagia, nondisplaced fracture of lateral malleolus of right fibula, mood disorder, major depressive disorder, and hypothyroidism. On 4/4/24 at 1:29 PM an observation of resident 35's room was made. Resident 35 was observed in her bed. A bolster mattress was on resident 35's bed, the bed was in the low position, the room was free of clutter, the call light was within reach, and there was not a fall mat observed next to the bed. Resident 35 was unable to be interviewed due to low cognition. Resident 35's electronic medical record was reviewed. A quarterly MDS from 3/19/24 documented that a BIMS questionnaire could not be conducted do the resident being rarely or never understood. Resident 35's care plan was reviewed. A care plan initiated on 10/13/23 stated, [Resident 35] is at risk for falls related to dementia with decreased safety awareness and poor impulse control, gait imbalance, weakness, psychotropic medication use. The goal stated, [Resident 35] will be free of minor injury through the review date. The interventions stated, Anticipate and meet the resident's needs., initiated 10/13/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance., initiated 10/13/23. Bolstered mattress in place while resident is in bed., initiated 10/23/23. Educate staff to allow resident to stay up after meals as she seems to prefer to stay out of bed., initiated 1/12/24. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility., initiated 10/13/23. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room., initiated 10/13/23. Ensure that the resident is wearing appropriate footwear (non-skid shoes, non-skid socks, etc.) prior to any transfers or ambulating., initiated 10/13/23. [Resident 35] has a custom wheelchair. Ensure that resident is positioned correctly while up in wheelchair., initiated 3/1/24. Offer resident her strips of fabric she enjoys fiddling with., initiated 2/9/24. Offer sensory blanket when awake., initiated 2/19/24. Resident moved to a room closer to the nurses' station., initiated 10/20/23. The resident needs a night light., initiated 12/4/23. The resident needs activities that minimize the potential for restlessness/falls while providing diversion and distraction., initiated 12/4/23. The resident uses fall prevention device: Floor ma. Ensure the device is in place as ordered., initiated 2/2/24. An Alert Note from 8/11/23 at 10:26 AM documented, CNA witnessed the patient fall on her buttocks with no head injury. She reported that she saw the patient get up from the chair, stumbled back and fell on her buttocks. It should be noted that the resident's fall care plan was initiated on 10/13/23. On 4/4/24 at 11:52 AM an interview with the DON was conducted. The DON stated, With her fall on 8/11/23, we were concerned that she wasn't getting enough sleep. The fall happened right after lunch. A staff member saw her stand up and fall down on her bum. I think that's when we put in charting of hours of sleep for her as an intervention. A Nurses Note from 9/23/23 at 7:28 AM documented, Resident was found on the floor in front of the bathroom door by the CNA. The floor was clear of clutter and debris. Residents right ankle was perpendicular to her leg. Notified provider and sent to [hospital name redacted]. Notified on-call . notified family [name redacted] who requested [name redacted] hospital. EMS administered Morphine, sent facesheet, POLST, medication list with EMS. A Nurses Note from 9/23/23 at 11:50 PM documented, .Res [resident] received morphine just before leaving hospital. Res with medial/lateral Malleolor fracture. Reduction was performed in the ER. NWB [non-weight bearing] and will need surgery. 1150 [11:50PM] resident returned from hospital. Resident has splint on right foot . Resident responds when the foot is touched by being startled . Resident with facial grimace and frowning, tense musclesand [sic] moaning . Resident is restless, crying, attempting to get out of bed. Stayed with resident until a 1 to 1 staff arrived. Neuro checks in place. Will continue to monitor. A Progress Note from 9/28/23 at 5:37 PM documented, Resident arrived from orthopedic surgery appointment at approx. 1600 [4:00 PM] . Orders from [Doctors name redacted] X-ray show non-displaced fibula Malleolus fx [fracture]; surgery not needed. No weight bearing for 2-3 weeks. Keep splint for now, [Doctors name redacted] will change in two weeks. Return to clinic 10/12 or 10/16 to get x rays . Resident currently resting in bed eating dinner. A Nursing Note from 10/19/23 at 10:48 AM documented, Resident observed sitting on the floor next to her bed. Residents [sic] was leaning towards her left side and was using her left hand to support herself. The bed was at the lowest position. Head to toe completed-assessed for injury prior to getting her back in bed. No new skin injury noted . The care plan was updated on 10/20/23 and stated, Resident moved to a room closer to the nurses' station. A Nurses Note from 10/22/23 at 5:47 AM documented, Resident found lying face down on the floor next to the bed. Head to toe assessment completed. No lacerations, skin tears, bruising, or deformities noted. No new injuries noted . The care plan was updated on 10/23/23 and stated, Bolstered mattress in place while resident is in bed. An Alert Note from 12/1/23 at 3:58 AM documented, Resident was found sitting on the floor in front of her w/c [wheelchair] with her feet forward towards her bed in her bedroom doorway. The UWF [unwitnessed fall] happened on 12/1/23 at 1815 [6:15 PM]. Resident unable to tell nurse what happened. Looks like she slipped out of her w/c . Resident has black boot to her R foot for fracture from a previous fall on 9/23. Circulation on R foot is good and boot is in place. She had a sock and shoe on the other foot. She was helped up into w/c and taken to her bed and placed in her bed where she has spent the rest of the evening relaxing . The care plan was updated on 12/4/23 after the residents next fall on 12/3/23. A Nurses Note from 12/3/23 at 5:47 AM documented, Resident was found sitting on floor next to bed. Assessed by nurse. No new injuries or areas of redness or bruising found. Started on neuros . The care plan was updated on 12/4/23 and stated, The resident needs a night light. And The resident needs activities that minimize the potential for restlessness/falls while providing diversion and distraction. An Alert Note from 12/10/23 at 4:00 AM documented, Resident was found by nurse sitting on floor next to bed on opposite side of her bedside mat. Bed in lowest position. Resident had removed boot from RLE [right lower extremity]. Head to toe assessment complete. No new injuries noted. The care plan was not updated. An Alert Note from 1/11/24 at 6:45 PM documented, At approximately 1845 [6:45 PM] nurse was notified that resident had slid of [sic] her bed. Nurse went into room and observed resident sitting on the floor next to her bed. Her back was against the bed and she was sitting upright on her bottom. Bed was at lowest position. Resident had been put into bed 10 min prior. Resident did not hit her head. H-T [head-to-toe] assessment completed. No new injuries upon assessment . The care plan was updated on 1/12/24 and documented, Educate staff to allow resident to stay up after meals as she seems to prefer to stay out of bed. An Alert Note from 2/1/24 at 8:30 PM documented, Resident found on floor beside bed. Bed at lowest setting. Brief was undone, but still on. Head to toe assessment done. No injuries seen, but she did have some fresh BM [bowel movement] on finger tips and a few scratches on bottom. Brief did have BM. Helped back intobed [sic] at lowest setting . The care plan was updated on 2/2/24 and stated, the resident uses fall prevention device: Floor mat. Ensure the device is in place as ordered. An Alert Note from 2/5/24 at 2:35 AM documented, [Resident 35] had a new unwitnessed fall this evening. She was found on the floor next to her bed. Small abrasion to L knee found. Wound cleaned with wound spray and covered with bandaid. No further injuries . She was unable to tell nurse how the fall occurred . The fall care plan was updated on 2/9/24 and documented, Offer resident her strips of fabric she enjoys fiddling with. A Nursing Note from 2/17/24 at 2:32 PM documented, Resident slid herself off the bed onto her buttocks. The bed is on the lowest setting. This nurse was watching from the nursing station. No injuries/deformities noted . The fall care plan was updated on 2/19/24 and documented, Offer sensory blanket when awake. An Alert Note from 2/23/24 at 4:25 PM documented, Resident slipped out of her wheelchair onto the floor in the main dining room during the activity at 1620 [4:20 PM]. Fall was witnessed by CNA. Resident did not hit her head or appear to have any pain. Nurse assessed. No injuries noted. Resident has been very anxious today attempting to stand up several times throughout the shift. Staff redirecting her with sensory activities . The fall care plan was not updated. A Nurses Note from 3/3/24 at 9:45 AM documented, The resident got up from her wheelchair and sat down on the floor. This nurse got up and walked out of the nursing station and around to the left of the hall. The resident fell back while sitting on her buttocks and hit the back of her head. A small bump on her posterior head noted. Resident has full range of motion in all extremities .Will continue to monitor. The fall care plan was not updated. On 4/4/24 at 9:05 AM an interview with CNA 4 was conducted. CNA 4 stated that if a resident had an unwitnessed fall, CNA's were instructed to make sure the resident was safe, and immediately tell a nurse. CNA 4 stated that vitals were started and staff were supposed to try and find out if anyone saw the fall or try to identify the cause of the fall. CNA 4 stated that neuros were filled out and once the neuros were completed the sheet was given to the nurses station. CNA 4 stated that there were general fall preventions for all of the residents. CNA 4 that staff were typically educated on new fall prevention interventions during rounds. On 4/4/24 at 9:47 AM an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that if a resident had an unwitnessed fall, the nurses are expected to initiate neurological checks, assess for injuries, check range of motion, ask the resident about pain, assess the residents baseline, complete a skin check, and identify any immediate injuries. LPN 1 stated that staff are expected to inform the DON, complete an incident report, and try to identify the cause of the fall. On 4/4/24 at 11:40 AM an interview with the DON was conducted. The DON stated that the facility conducts a fall committee meeting weekly. The DON stated that the fall committee members included herself, the unit managers, sometimes social services, and the activities members. The DON stated that recent falls, trends and new interventions were discussed in the fall committee meetings. The DON stated that all new interventions were placed in the care plan. The DON stated that new interventions were implemented after each fall. The DON stated that after a resident fell , an incident report was completed, and the fall was discussed in the interdisciplinary team meeting.

Based on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, soiled ceiling tiles and dusty air vents were observed throughout the facility, the west hall was found to have a urine-like odor, and the facility environment was in disrepair. Findings include: 1. On 4/1/24 at 9:49 AM and 4/2/24 at 10:56 AM, a strong smell of urine was observed throughout the west hall. The odor could not be pinpointed to a specific room or resident. On 4/2/24 at 12:03 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated she did notice a smell in the west hall and that the whole west hall had a smell. 2. On 4/3/24 at 12:35 PM, a strong smell of urine was observed throughout the west hall. The odor could not be pinpointed to a specific room or resident. 3. On 4/4/24 at 10:39 AM, a strong smell of urine was observed in the west hall, starting near room [ROOM NUMBER] down to the end of the hall near the nursing manager's office and exit corridor. 47432 4. On 4/2/24 at 12:22 PM, an observation was made of the west hallway of the building. There was noted to be a foul odor near room [ROOM NUMBER]. 5. On 4/3/24 at 9:17 AM, an observation was made of the hallway outside of the east nursing station. The drop ceiling tiles were noted to be covered in a black, dusty substance. The ceiling vent was also covered in black dust. 6. On 4/3/24 at 9:23 AM an observation was made of a cobweb hanging from the ceiling outside of room [ROOM NUMBER]. An observation was made of stains on the drop ceiling tiles outside of room [ROOM NUMBER]. 7. On 4/3/24 at 9:24 AM, an observation was made of multiple dirty fingerprints above the doors leading from the east hallway to the main lobby. The bottoms of the doors were covered in scuff marks and were dirty. 8. On 4/3/24 at 9:33 AM, an observation was made of the west hallway. There were two ceiling vents covered in black dust and the surrounding drop ceiling tiles were also covered in black dust. 9. On 4/3/24 at 9:34 AM, an observation was made of multiple dirty drop ceiling tiles in the main lobby. 10. On 4/3/24 at 10:53 AM, an observation was made of the west hallway of the building. There was again noted to be a foul odor near room [ROOM NUMBER]. 11. On 4/3/24 at 10:53 AM, an observation was made of an orange, sticky substance on the wall between rooms [ROOM NUMBERS]. 12. On 4/3/24 at 10:54 AM, an observation was made of writing written in permanent marker on the wall between room [ROOM NUMBER] and the soiled linens closet. On 4/3/24 at 11:06 AM an interview was conducted with the Housekeeper (HK). The HK stated that she was responsible for cleaning resident rooms, showers, the nurses' stations, and the dining room. The HK stated that she was not responsible for cleaning the hallway. The HK stated that she did not know if the facility had any maintenance staff. 45470 On 4/4/24 at 1:37 PM an interview with the Administrator (ADMIN) was conducted. The ADMIN stated that he was currently filling in for maintenance staff. The ADMIN stated that the vents should have been cleaned about once a month. The ADMIN stated that the vents looked like they had not been cleaned in a while. The ADMIN stated that typically the facility was free of any offensive odors.

Based on observation, interview, and record review, it was determined that for 6 of 26 sampled residents, that the facility did not ensure that all allegations of abuse or neglect were reported to the State Survey Agency (SSA). In addition, the facility did not ensure the results of all investigations of alleged abuse and neglect were reported to the necessary officials, including the SSA, within 5 working days. Due to the facility's identification of missed reporting of reportable allegations and their subsequent implementation of corrective measures, as well as the facility's current compliance in this regulatory area, this deficiency was determined to be past noncompliance. The facility achieved compliance on 3/15/2024. Resident identifiers: 23, 28, 35, 49, 51, 56 Corrective Action On 3/15/2024, the Administrator and DON (Director of Nursing) received training and education on company wide risk management processes to ensure Trigger Events are reported to the Administrator and/or DON. Per the education, a Trigger Event is an unusual situation or adverse event that meets criteria for reporting to State Agencies or Law Enforcement and/or results in: harm; has the potential for serious harm; and/or has the potential for civil, criminal or regulatory action. The education provided instruction that each Trigger Event is to be reported to the Administrator and/or DON, who will review the event with the Regional Nurse Consultant (RNC), who will facilitate a Trigger Call, if applicable, to ensure the event is addressed according to federal regulations, as well as facility and company policy. Action Taken: Facility staff were educated by Administrator and DON on abuse/neglect policy and procedures. In-Service dates for Abuse, Neglect, Reporting requirements, and Close Monitoring Assisgnments were completed on 3/20/24 and 3/26/24. The RNC will audit all abuse allegations to ensure they were immediately reported to the facility Administrator and reported to the appropriate State Agencies. These audits will occur monthly for three months to ensure compliance has been maintained. Audits were completed on 3/22/24 and 3/28/24. Two allegations were found to be reported to the State Survey Agency within 2 hours of the allegation. System Changes: Administrator and DON reviewed and approved Abuse and Neglect policies. Findings of audits will be presented to the Quality Assessment and Assurance (QA&A)committee for review and consideration. Trigger Events Trigger Events are unusual incidents/situations or adverse events which require thorough investigation and follow up by facility leadership. These events can be challenging to manage and often require additional guidance in the handling, documenting and/or resolution of such situations or events. In order to provide a forum for supportive team discussions and decision making in managing incidents, Sandstone Healthcare has implemented a Risk Management Process, including the use of trigger event calls. 1. Trigger events should be reported immediately to the Administrator or the Director of Nursing (DON) by facility department managers and staff. 2. The Administrator and/or DON should then notify the Regional Nurse Consultant (RNC) via phone for the purpose of discussing the trigger event. 3. The RNC may proceed to set up a trigger event call, (if deemed necessary), with the Administrator, DON, Regional Director of Operations (RDO). (The Chief Operating Officer and [NAME] President of Clinical Services may also be added to the call as optional attendees). This notification process should be completed as quickly as possible in order to comply with regulatory standards for reporting, should the event be deemed reportable by the team. Following the Call: 4. The Administrator, DON or RNC will send a confirmation email to the Management Group named above, with a short summary including: type of event, facility, date, time, and residents/staff involved. Trigger events are tracked, trended for QA&A Process Improvement Plans, and handled in a confidential manner. The Management Team will assist and support the facility to handle the issues in an appropriate manner to achieve the best possible outcome related to the situation or event. 5. The Administrator or Director of Nursing/Nursing Manager will complete the Risk Management Report in Point Click Care. Subsequent to the education provided on 3/15/24, the facility has met the requirements of this regulation. Findings Include: 1. Resident 51 was admitted [DATE] with diagnoses including unspecified dementia moderate with other behavioral disturbance, Alzheimer's disease unspecified, mood disorder due to known physiological condition unspecified, personal history of other diseases of the circulatory system, and other symptoms and signs involving cognitive functions and awareness. Resident 23 was originally admitted [DATE], readmitted [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration sequela, unspecified dementia mild with agitation, unspecified dementia mild with mood disturbance, type 2 diabetes mellitus without complications, bipolar disorder unspecified, obsessive-compulsive behavior, personal history of traumatic brain injury, wernicke's encephalopathy, anxiety disorder due to known physiological condition, long qt syndrome, and pseudobulbar affect. Resident 51's medical record was reviewed from 4/1/24 through 4/4/24. Resident 51's most recent annual Minimum Data Set (MDS) assessment did not have a Brief Interview for Mental Status (BIMS) Score. Resident 51 was marked as rarely/never understood and the assessment was not completed. Resident 23's medical record was reviewed from 4/1/24 through 4/4/24 Resident 23's most recent annual MDS assessment dated [DATE] gave Resident 23 a BIMS score of 9. In accordance with the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Manual (RAI) Version 3.0 Manual, a score of 9 represents moderate cognitive impairment. An incident report for Resident 51 dated 2/22/24 at 11:45 AM revealed, pt [patient] was in in dining room past [sic] by another female resident, and slapped at female resident. Other female reciprocated slap, residents separated by staff. Nurse assessed for any injury. No injuries noted, no S/S [signs and sypmtoms] of distress noted. emotional and cognitive status at baseline. MD [doctor of medicine] and DON [director of nursing] and Admin notified. Family notified. A progress note for resident 23 dated 2/22/24 at 11:54 AM revealed, This Resident was in dining room. Another female resident approached this resident and slapped at her. This Resident reciprocated and slapped at other female resident. Staff responded and separated and redirected residents. Resident assessed. No injuryfound [sic]. Resident denies injury or distress. She is laughing and shows no s/s of distress or agitation. Family, MD and DON notified. Administrator notified and aware. Currently resident does not recall occurrence. Resident 51's care plan was reviewed. The following focus, goals, and interventions were revealed: [Resident 51] needs supervision during activities in regard to personal boundaries. This focus was initiated on 2/23/24. [Resident 51] will have no inappropriate contact with others. This goal was initiated on 2/23/24. Meet and anticipate residents [sic] needs. This intervention was initiated on 2/23/24 and was revised on 2/23/24. Redirect resident away from others in crowded situations. This intervention was initiated on 2/23/24 Speak in a positive/upbeat tone. This intervention was initiated on 2/23/24. Resident 23's care plan was reviewed. The following focus, goals, and interventions were revealed: [Resident 23] has potential to be physically aggressive r/t Dementia, Poor impulse control. This focus was initiated 8/2/22 and was revised 3/1/24. [Resident 23] will seek out staff/caregiver when agitation occurs through the review date. This goal was initiated on 8/2/22, revised on 3/4/24, and had a target date of 5/11/24. [Resident 23] will demonstrate effective coping skills through the review date. This goal was initiated on 8/2/22, was revised on 3/4/24, and had a target date of 5/11/24. [Resident 23] will not harm self or others through the review date. This goal was initiated on 8/2/22, was revised on 3/4/24, and had a target date of 5/11/24. The resident's triggers for physical aggression are by residents going into her room. The resident's behaviors [sic] is de-escalated by distraction and staff redirection. This intervention was initiated on 8/2/22 and was revised on 8/2/22. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. This intervention was initiated on 8/2/22. Coach [Resident 23] about physically reacting to others. This intervention was initiated on 2/23/24. Redirect other residents out of [Resident 23's] room and personal space. This intervention was initiated on 9/20.22. When the resident becomes agitated: Intervene before agitation escalates; Guide away from/remove source of distress; Engage calmly in conversation. This intervention was initiated on12/18/23 and was revised on 12/28/23. On 4/3/24, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that she had heard about the incident between resident 52 and resident 23, but that she was not present for the incident. The CNAC stated that the incident happened in the main dining room, and she had been in the smaller dining room. (Note: the incident report for Resident 51 listed the CNAC as a witness.) On 4/3/24, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that he was not present when the incident happened. RN 2 stated that the incident occurred in the dining room. RN 2 stated that he only knew what he was told by other staff members and that he was only responsible for filing the incident report. RN 2 stated that anybody on shift that day would remember what happened because it was talked about amongst staff members. (Note: the incident report for Resident 52 was submitted by RN 2.) On 4/4/24 at 2:47 PM, an interview was conducted with the DON. The DON stated that Resident 23 was very impulsive. The DON stated that she did not know why Resident 51 would have started the altercation. The DON stated that Resident 51 is usually mild mannered. The DON stated that Resident 51 does not speak to staff, so they were unable to determine what had upset Resident 51. The DON stated that if Resident 23 is asked, she does not remember the incident. The DON stated that the incident occurred during an activity, and that the activities director had her back turned to both residents and did not see what had happened. The DON stated that there were no injuries and that it was a gentle fight. 48709 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease, dementia, hypertension, chronic kidney disease, polyosteoarthritis, major depressive disorder, and anxiety disorder. Resident 28's medical record was reviewed from 4/1/24 through 4/4/24. The MDS for Cognitive Patterns dated 1/18/24 indicated that resident 28 had a memory problem and his, Cognitive Skills for Daily Decision Making Made decisions regarding tasks of daily life .[was] Severely Impaired. An Alert Note progress note dated 2/14/24 at 4:32 PM indicated, Resident came out of room and stood at nurses station. Nurse observed open abrasion to L [left] cheek just below eye. Blood in eye, Nasal bridge swelling and bleeding from nose. Resident could not recall what happened. UM notified and responded. Administrator responded. Resident has s/s [signs/symptoms] of pain to cheek bone and nose. No other injury noted. Able to move all extremities. Grasps equal, PERRLA. NP [nurse practitioner] notified and requests resident transported to ER [emergency room ] for evaluation. Son notified. EMS [emergency medical services] contacted and initiated for transport. Ice applied to bridge of nose, pressure to abrasion to control bleeding. Upon investigation, blood found in room next to bed and on sheets. Blood drops in front of night stand. Drawers to night stand all open. Injury and blood consistentwith [sic] fall in room due to environmental factors, poor balance, and impulse control. Resident attempting to transfer and ambulate with no foot wear. EMS arrived and report given to EMTP. Copy of POLST [Physician Orders for Life-Sustaining Treatment], Face sheet and meds given to EMS. Resident transferred to St. [NAME] ER for eval. A Physician/Practitioner Note dated 2/16/24 at 5:28 PM indicated, [Resident 28] is an 82 yo [year old] male who resides at [facility name redacted]. The evening of 2/14 he came to the nurse's desk with blood on his face. Facility staff report that he had a small laceration just below the left eye, bleeding from lac and nose, and swelling of the nose and area around left eye. He was unable to say what happened, but staff found blood on his sheets and on the floor next to his bed. He c/o [complained of] pain to the nose and left cheek. LOC [level of consciousness] at baseline of alert, oriented to self only. VS [vital signs] WNL [within normal limits]. He was sent to the ER for eval of facial injuries. He RTF [returned to facility] about 3 hours later. No facial fractures found. ER staff had closed the laceration with medical skin glue. Today he continues to be at cognitive baseline. He has some swelling to left cheek but not enough to impair vision. He is sitting in the hall near the desk and seems irritable when spoken to. Facility staff will continue neuro checks. The Care Plan indicated a focus of, [Resident 28] has been recipient of mild physical aggression due to wandering secondary to dementia Date Initiated: 01/05/2024 Revision on: 01/05/2024; which included the goal of, [Resident 28] will remain safe around others through next review date Date Initiated: 01/05/2024 Revision on: 03/06/2024 Target Date: 06/24/2024; and the interventions included, Administer meds as ordered Date Initiated: 01/05/2024 Monitor resident while wandering to avoid going into private spaces. Date Initiated: 01/05/2024 Redirect resident away from other residents while wandering Date Initiated: 01/05/2024. A focus of, [Resident 28] has potential to be physically aggressive (shoving staff with cares and hitting) r/t [related to] Dementia, Poor impulse control. Date Initiated: 07/20/2023 Revision on: 07/20/2023; which included the goal of, [Resident 28] will not harm self or others through the review date. Date Initiated: 07/20/2023 Revision on: 03/26/2024 Target Date: 06/24/2024. A focus of, [Resident 28] is at risk for falls related to deconditioning, gait/balance problems, dementia with confusion and decreased safety awareness. Date Initiated: 05/23/2023 Revision on: 05/23/2023; which included the goal of, [Resident 28] will be free of falls through the review date. Date Initiated: 05/23/2023 Revision on: 03/26/2024 Target Date: 06/24/2024. On 4/3/24 at 10:19 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated resident 28 had a steady gait and walked all over the facility. CNA 4 further stated that resident 28 would not know if he had a fall. On 4/3/24 at 12:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she saw resident 28 standing in the hallway near his room with a bloody face and was unable to tell her what happened. LPN 1 stated the facility was not sure if he fell because she did not see resident 28 come out of his room, but it was ascertained that he fell because of the blood pattern found in his room. LPN 1 stated resident 28 had poor impulse control, safety awareness, and judgement and that he would become aggressive out of the blue. On 4/4/24 at 11:59 AM, an interview was conducted with the DON. The DON stated the nurse facility did not know what happened, but the nurse found resident 28 with injuries. The DON stated that the facility did not conclude that he had a fall. On 4/4/24 at 2:42 PM, an interview was conducted with the Unit Manager (UM). The UM stated she saw resident 28 slobbering and noticed he had blood coming out of his nose. The UM stated that the resident could not articulate what happened. The UM stated she called the Administrator and that he came to the resident's room and investigated the incident. 45470 3. Resident 49 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's Disease, neurocognitive disorder with Lewy bodies, dementia, cognitive communication, mild protein-calorie malnutrition, psychotic disorder with delusions, depression, hyperlipidemia, arthritis, hallucinations, and insomnia. Resident 35 was admitted to the facility on [DATE] with diagnoses which included dementia, abnormalities of gait and mobility, type 2 Diabetes Mellitus, mild protein-calorie malnutrition, cognitive communication deficit, dysphagia, nondisplaced fracture of lateral malleolus of right fibula, mood disorder, major depressive disorder, and hypothyroidism. Resident 35's medical records were reviewed. A Nursing Note from 8/12/23 at 4:32 AM documented, Resident [49] sleeping in chair when waking up walked over to other resident sitting in chair ([resident 35]) and slapped her on the shoulder. Resident ([35]) pushed her back and resident ([49]) fell down on her buttocksThis (sic) nurse and cna's intervened, and separated residents, resident assessed([resident 49]) no injurys (sic) noted, denies pain. ROM [range of motion] wnl [within normal limits] for patient, walked patient to her room and help her transfer to her chair, other patient ([resident 35]) assessed, no injurys (sic) noted, ROM wnl for patient help patient ambulate to her room and transferred to bed, On call nurse manager notified . MD [medical director] notified. On 4/4/24 at 1:56 PM an interview was conducted with the Administrator. The Administrator stated when an instance of a resident-to-resident altercation occured, he evaluated the willfulness of the act and the resulting harm as factors when determining whether to report or not the incident to the State Survey Agency (SSA) 4. Resident 56 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction due to thrombosis, type 2 diabetes mellitus, squamous cell carcinoma, protein-calorie malnutrition, atrial fibrillation, need for assistance with personal care, history of falling, mood disorder, pressure ulcer of sacral region, dementia, generalized edema, anemia, hypertension, hyperlipidemia, and renal osteodystrophy. An incident report from 11/26/23 documented, During rounds @ 0120 [at 1:20 AM], CNA observed resident on the floor in her room next to the bed, resident bleeding from the forehead, . resident assessed for injury and assisted onto the bed, resident stated her head hurt when assessed for pain, no other pain noted. The resident states she doesn't know what happened but states that it has not been a great day for her. An Emergency Department (ER) documented dated 11/26/23 documented that resident 56 was seen at theER on [DATE] at 5:25 AM and was given 6 sutures on her forehead. On 2/15/24 an incident report from 2/15/24 documented, Nurse heard noise coming from the residents room approx [approximately] at 3:20 [AM]. Responded to noise. Observed resident laying face down between beds with head towards wall. Bed in low position and call light within reach. Assessed resident noted large laceration to forehead. Called the west nurse over for assistance. Pressure applied to laceration. Head to toe assessment completed. Swelling to R [right] ring finger. Laceration to bridge of nose. Bilateral knee discoloration . Resident c/o [complained of] pain to right ring finger, bilateral knees and head. Neuro checks initiated resident A&O [alert and oriented] x1 . Received orders to send resident out to hospital. 911 called. EMS arrived. Resident sent out to [name redacted] hospital. Resident unable to give a description. An ER documented dated 2/15/24 documented that resident 56 was seen at theER on [DATE] at 4:12 AM for a 10 centimeter (cm) head laceration and was give 20 sutures and 2 staples. An x-ray was preformed on the residents finger and the ER document reported, no acute abnormality of the right hand. The falls on 11/26/23 and 2/15/24 were not reported to the State Survey Agency or investigated by the facility. 5. Resident 35 was admitted to the facility on [DATE] with diagnoses which included dementia, abnormalities of gait and mobility, type 2 Diabetes Mellitus, mild protein-calorie malnutrition, cognitive communication deficit, dysphagia, nondisplaced fracture of lateral malleolus of right fibula, mood disorder, major depressive disorder, and hypothyroidism. A Nurses Note from 9/23/23 at 7:28 AM documented, Resident was found on the floor in front of the bathroom door by the CNA. The floor was clear of clutter and debris. Residents right ankle was perpendicular to her leg. Notified provider and sent to [hospital name redacted]. Notified on-call . notified family [name redacted] who requested [name redacted] hospital. EMS administered Morphine, sent facesheet, POLST, medication list with EMS. A Nurses Note from 9/23/23 at 11:50 PM documented, .Res [resident] received morphine just before leaving hospital. Res with medial/lateral Malleolor fracture. Reduction was performed in the ER. NWB [non-weight bearing] and will need surgery. 1150 [11:50PM] resident returned from hospital. Resident has splint on right foot . Resident responds when the foot is touched by being startled . Resident with facial grimace and frowning, tense musclesand [sic] moaning . Resident is restless, crying, attempting to get out of bed. Stayed with resident until a 1 to 1 staff arrived. Neuro checks in place. Will continue to monitor. A Progress Note from 9/28/23 at 5:37 PM documented, Resident arrived from orthopedic surgery appointment at approx. 1600 [4:00 PM] . Orders from [Doctors name redacted] X-ray show non-displaced fibula Malleolus fx [fracture]; surgery not needed. No weight bearing for 2-3 weeks. Keep splint for now, [Doctors name redacted] will change in two weeks. Return to clinic 10/12 or 10/16 to get x rays . Resident currently resting in bed eating dinner. The fall on 9/23/23 and 2/15/24 was not reported to the State Survey Agency or investigated by the facility. On 4/4/24 at 2:21 an interview with the Corporate Resource Nurse (CRN) was conducted. The CRN stated that the facility had recently adapted a new process for investigating and reporting. The CRN stated that the new process what put in place approximately five weeks ago. The CRN stated that the new process involved a conversation with the Administrator, the Regional Nurse Consultant, the DON, and other members of the team immediately after an incident of possible abuse or neglect to determine if the incident required a full investigation and reporting to the State Agency. On 4/4/24 at 4:02 PM an interview with the DON was conducted. The DON stated that to determine the cause of unwitnessed falls, staff interviews were conducted. The DON stated that she did not have staff interviews written down for resident 56's falls or resident 35's falls. The DON stated that interviews were conducted to determine how often staff checked on the resident, if the residents' briefs were wet, among other things to determine if the resident was neglected. The DON stated that if the falls happened at night, then the interviews were conducted the following day. The DON stated that it was her understanding that the facility was to report abuse, and that she didn't think that the falls were due to neglect by the staff because she knew how hard it was to take care of resident 56. 47431

Based on interview and record review, it was determined, for 1 of 26 sampled residents, that the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, a PRN order for Ativan was ordered for more than 21 days. Resident identifier: 16. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care, dysphagia, major depressive disorder, Alzheimer's disease, chronic kidney disease, anxiety disorder, dementia, hypertension, and type 2 diabetes mellitus. Resident 16's medical record was reviewed from 4/1/24 through 4/4/24. A BIMS (Brief Interview for Mental Status) V3 dated 10/19/23 at 7:08 PM indicated that Cognitive Skills for Daily Decision Making was, Severely Impaired: never/rarely made decisions. A [Company Name Redacted] Hospice Physician Order dated 3/14/24 at 10:33 AM indicated, Start Lorazepam 2 MG/ML [milligram/milliliter] solution. Give 0.25 ML PO/SL [by mouth/sublingual] every 2 hrs [hours] as needed for restlessness or anxiety. No end date was included in the medication order. A physician's order dated 3/14/24 at 6:00 PM indicated, LORazepam Oral Concentrate 2MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Anxiety. No end date was included in the medication order. A Psychotropic Medication Review dated 3/17/24 at 8:44 PM indicated that Lorazepam Oral Concentrate 2 MG/ML with a dosage of 0.25 ml every 2 hours as needed was reviewed. It further indicated the Committee Recommendation was to maintain current medication dosages. The Medication Administration Record dated 3/1/24-3/31/24 indicated Lorazepam Oral Concentrate 2MG/ML [milligram/milliliter] (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Anxiety, was administered on 3/15/24 at 1:07 AM, 8:41 AM, and 1:34 PM; and on 3/21/24 at 12:10 PM. On 4/4/24 at 12:20 PM, a concurrent interview was conducted with the Director of Nursing (DON) and the Corporate Resource Nurse (CRN). The DON stated the hospice company did not want to follow the 14-day rule. The CRN stated that the Ativan medication should have been limited to 14 days for PRN medications and that the medication should have probably been discontinued because the resident was not using it.

Based on observation, interview, and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming. Specifically, a resident with severely impaired cognitive skills had long fingernails with brown substance under the fingernails. Resident identifier: 28. Findings include: 1. Resident 28 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease, dementia, hypertension, chronic kidney disease, polyosteoarthritis, major depressive disorder, and anxiety disorder. On 4/1/24 at 9:51 AM, an observation of resident 28 was made of him standing at the nurse's station in the west hall, his nails were long with a brown substance observed under all of his nails. Resident 28's medical record was reviewed from 4/1/24 through 4/4/24. The MDS (Minimum Data Set) for Cognitive Patterns dated 1/18/24 indicated that resident 28 had a memory problem and his, Cognitive Skills for Daily Decision Making Made decisions regarding tasks of daily life .[was] Severely Impaired. The LN-Functional Abilities-GG document dated 1/18/24 at 5:13 AM indicated resident was dependent for Self-Care Personal Hygiene. On 4/3/24 at 12:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 28 refused cares but that they would give him time, space, and approach him later to provide cares. LPN 1 stated he had poor impulse control, safety awareness, and judgement. On 4/4/24 at 10:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated staff cut his fingernails when they are noticeably long. CNA 1 stated that resident 28 would allow her to cut his fingernails sometimes. On 4/4/24 at 10:39 AM, an interview was conducted with CNA 2. CNA 2 stated she had to initiate asking resident 28 to provide showers and hygiene because he would not ask for it. CNA 2 stated she did notice that his nails were long and soiled and that sometimes residents had poop under their nails. CNA 2 stated when a resident has long nails they could scratch staff or themselves. CNA 2 stated she did not cut them this morning because he would not answer her and that she planned on returning to ask again later. On 4/4/24 at 11:20 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that a resident who continuously refused cares would eventually come around if you kept trying. In a follow-up interview at 11:20 AM, RN 1 stated she was able to cut resident 28's nails today with no problems. On 4/4/24 at 12:19 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNA's were trained to try again later if a resident refused hygiene that was offered. The DON stated that the CNA should report to the nurse when they were unable to provide hygiene to a resident. The DON stated that staff should look at a resident's fingernails anytime they go and do anything with the resident and were to be cut as needed or as allowed. The DON stated that the CNAs needed to get the nurse involved if a resident had continuously refused getting his fingernails clipped. The DON further stated that resident 28 could not cut his own nails.

Based on interviews and record review, it was determined for 2 out of 26 sampled residents, the facility did not ensure that each resident was free from abuse. Specifically, a staff located a female resident standing in front of a male resident, in the male resident's room. The male resident was seated in a wheelchair and had a hand up the shirt of the female resident, touching the female resident's breast. Both residents have significant cognitive impairment. Due to the facility's identification of abuse, subsequent corrective measures, and the facility's current compliance in this regulatory area, the deficiency was determined to be past noncompliance and the facility achieved compliance on 3/25/2024. Resident identifiers: 21 and 51 Corrective Action Action taken to ensure residents are free from abuse following incident involving sexual contact between two residents with significant cognitive impairment on 3/18/24; resident 51 and resident 21: Residents were immediately separated and redirected. Resident [21] on close observation status; 2:1 oversight, labs ordered-UTI diagnosed . Antibiotics ordered to treat UTI Skin assessed for resident [51] - skin intact, no sign of trauma noted Notifications to physicians, legal guardians and appropriate State Agencies were completed timely The resident [21] was referred to BHS [behavior health services] for potential medication adjustments as appropriate to manage aggression and sexual behaviors Admin and SS [social services] addressed with resident [21]'s legal guardian alternative placement Resident transferred 3/20/24, per resident family Psychosocial monitoring initiated for resident [51] IDT updated both resident care plans as applicable Provider to assess/evaluate residents including medication review SW [Social Work]/IDT wellness visits completed to ensure resident [51] remained at baseline Identification of Like Residents & Action Taken: An audit was completed by DON [Director of Nursing]/designee to ensure there were no other residents who exhibit sexually inappropriate behaviors towards other residents. The audit was performed 3/18/24, and no other residents were identified as having inappropriate sexual behaviors towards other residents. Progress notes from [DATE]-March 2024 were reviewed for reach resident residing in the facility Facility staff were educated by Administrator and DON on abuse/neglect, (including sexual abuse), reporting requirements, close observation monitoring assignments. IDT was educated on the same, including focus on roll of IDT in care of residents with dementia, residents with sexual behaviors, and interventions and care planning. The education was initiated on 3/20/24. To ensure all staff received training, additional training sessions were provided on 3/25/24 and 3/26/2. The DON/designee will complete random audits of at least 5 resident charts weekly x4 weeks then monthly x2 months to ensure when incidents of sexually inappropriate behavior occurs, appropriate interventions are implemented and no trends are noted, and all allegations of abuse are reported to administrator and state agency timely. After the initial audit on 3/18/2-24, a follow-up audit was conducted 3/25/24 and no inappropriate behaviors were identified. System Changes: Administrator and DON reviewed Abuse & Neglect policies and deemed appropriate. Admin, DON, and RNC [Regional Nurse Consultant] reviewed the event to ensure thorough and timely investigation completed. Any resident exhibiting sexual behavior towards other residents will be evaluated by the IDT. Findings of all audits will be presented to the QAA committee for review and consideration of further corrective actions. Findings include: 1. On 3/18/24 at 4:28 PM, the facility Administrator submitted a form DLBC - 358 Facility Reported Incidents (Form 358) for an allegation of sexual abuse involving resident resident 21 and resident 51 that was alleged to have occurred on 3/18/24 at 1:05 PM. The Form 358 is used by Medicare and/or Medicaid certified nursing homes, in the State of Utah, to make an initial report of allegations abuse, neglect, misappropriation of resident property, and injuries of unknown origin to the State Survey Agency (SSA). On the Form 358, the Administrator documented on 03/18/2024 at 1:05 pm, a nurse reported finding Memory Care resident 21 sitting in his wheelchair, in his room, with his hand up Memory Care resident 51' shirt. The Administrator also documented the nurse reported that resident 51 had been standing in front of resident 21 and was not moving. The Administrator documented resident 21 and resident 51 were separated, with resident 51 being assisted back to her room. The Administrator documented neither resident 21 or resident 51 showed any sign of distress and that the residents were placed on opposite sides of the facility and were being monitored. On 4/2/24 at 1:59 PM, an interview with Licensed Practical Nurse (LPN) 1. LPN 1 stated she had been working at the facility since November 2023, and resident 21 had been her patient since she started. LPN 1 stated resident 21 had always been so pleasant, but he was placed on close observation at the end of February. LPN 1 stated resident 21 had started to exhibit some behaviors and nursing staff were tracking them. LPN 1 stated resident 21's behaviors included verbal aggression and that he touched a staff member inappropriatly. LPN 1 stated resident 21 tried to touch other residents. LPN 1 stated staff were able to stop resident 21 and redirect him when he tried touching other residents. LPN 1 resident 21 had been evaluated medically to determine if there were medical reasons to explainhis increased behaviors. LPN 1 stated resident 1 did have a urinary tract infection (UTI) and was started on an antibiotic. LPN 1 stated resident 21 was placed on medication to address his behaviors and when the incident where resident 21 had his hand up resident 51's shirt occurred, resident 21 was discharged to another facility. On 4/2/24 at 2:45 PM, a follow-up interview was conducted with LPN 1. LPN 1 was asked to clarify what she meant when she stated in her previous interview that resident 21 was placed on close observation. LPN 1 stated close observation was implemented when a resident began to exhibit increased behaviors, or had past behaviors. LPN 1 stated when the close observations were necessary, the implementation was a specific assignment for a certified nurse aide (CNA). LPN 1 stated the assigned CNA performed the close observations as well as redirecting the involved residents and ensuring additional observations of the residents were made. LPN 1 stated close observations were not specifically prescribed or ordered, but behavior monitoring was ordered and nurses charted behaviors each shift. LPN 1 stated nursing staff charted close observations in progress notes when implemented. On 4/4/24 at 2:38 PM an interview was conducted with the DON. The DON stated resident 21 and resident 51 were observed going into resident 21's room together. The DON stated that a nurse had found resident 51 in resident 21's room and resident 21 had his right hand under resident 51's shirt. The DON stated that the residents were separated immediately. The DON stated at the time resident 51 was entering resident 21's room, another resident was experiencing a medical emergency. The DON stated since resident 21 had not exhibited any sexual behaviors before this incident, staff were more focused on attending to the resident experiencing a medical emergency than redirecting resident 51. The DON stated resident 21 was placed on close observations immediately, and resident 21 was transferred the next day, per his family's request. Resident 51 was admitted to the facility on [DATE]. Resident 51's diagnoses included: aphasia following nontraumatic subarachnoid hemorrhage; Alzheimer's Disease; unspecified dementia, which was identified to be moderate and included behavioral disturbance; mood disorder, due to known physiological condition; and other signs and symptoms involving cognitive functions and awareness. A review of Resident 51's medical records was completed between 4/1/24 and 4/4/24. Facility staff completed an annual Minimum Data Set (MDS) assessment for resident 51. The assessment reference date (ARD) was 1/28/24. Facility staff assessed that a Brief Interview for Mental Status (BIMS) questionnaire was unable to be performed for resident 51 as the resident was rarely or never understood. On 1/27/23, facility staff initiated a care plan for the focus area of elopement and wander risk, related to Alzheimer's dementia for resident 51. The care plan included documentation that resident 51 may be disoriented to place, had impaired safety awareness, and that she wandered throughout the facility. The goal for this care plan, as initiated on 1/27/23 and last revised on 3/4/24, was that resident 51's safety would be maintained. To achieve the identified goal, the facility developed the following interventions on 1/27/23: distract resident from wandering by offering pleasant diversions; provide structured activities; offer food; engage in conversation; television; and books. In addition to the structured activities, interventions included, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. On 3/18/2024 at 3:40 PM, a facility nurse documented in a nursing note that the nurse called resident 51's daughter to inform her staff had found her mother in the room of a male resident and that the male resident was touching her mother. The nurse documented the daughter asked if her mother was all right. The nurse documented that she informed the daughter staff were not able to determine if her mother was able to even remember the incident and that her mother appeared to be acting normally. The nurse documented the daughter responded by stating, As long as she is ok. The nurse further documented the daughter requested to be updated if her mother's condition changed. On 3/18/2024 at 5:27 PM, a facility nurse documented an alert nursing note for resident 51. The nurse documented, Skin check per DON [Director of Nursing] orders. Nothing notable found. Resident at baseline from a res to res [resident to resident] interaction. No psychosocial distress noted. On 3/18/2024 at 11:26 PM, a facility nurse documented an alert nursing note for resident 51. The nurse documented, Resident observed wandering hallways during the evening per usual behavior. No signs of psychosocial distress noted. Resident calm, pleasant and compliant with cares and medications. Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE]. with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery, vascular dementia, moderate, with agitation, urinary tract infection, site not specified, anxiety disorder, unspecified. Resident 21's medical records were reviewed between 4/1/24 and 4/4/24. Facility staff completed a Quarterly MDS assessment for resident 21, with an ARD of 12/20/23. Facility staff assessed that resident 21's cognitive status was moderately impaired. On 9/8/23 facility staff initiated a care plan for a potential for resident 21 to be verbally aggressive related to dementia and poor impulse control. The goal for this care plan, as initiated on 9/8/23 and revised on 12/12/23, was that the resident will not be harmed and will remain safe. To achieve the identified goal, the facility developed the following interventions on 9/8/23: analyze key times, places, circumstances, triggers, and what de-escalated behavior and document. On 2/28/2024 at 12:44 PM, a facility nurse documented the following nursing note entry for resident 21: Behaviors: Resident was in hall and asked female resident to 'go to bed and take a nap with him'. Staff present and redirected resident. Shortly after, a female resident was wandering and this resident attempted to touch her buttocks. Staff intervenedand [sic] prevented contact, again redirecting this resident. This resident then positioned himself next to another female resident in a w/c (wheelchair) and attempted to touch her upper legs. Staff again intervened prior to contact being made and redirected. Female resident removed from area. NP (Nurse Practitioner) in house and notified. DON notified. On 2/29/2024 at 5:43 PM, a facility nurse documented the following alert nursing note for resident 21: Upon entering to give room mate medication, Resident was observed in bathroom doorway with no pants, pleasuring self. Resident redirected that he needs to conduct this behavior in privacy. During afternoon shift, staff observed resident trying to touch a female resident. Staff redirected prior to contact being made. UM (Unit Manager) and Administrator aware, NP notified, new orders obtained. On 3/3/2024 a 5:22 PM, a facility nurse documented the following alert nursing note for resident 21: Female CNA [Certified Nursing Assistant] stated to this nurse, while she was helping to transfer resident from toilet to chair resident had his hand under her chest. She informed the resident that, 'that action was not welcome and he needed to be appropriate.' He asked, 'why?' and theCNA [sic] stated, 'it is because we are here to take care of you and I am not okay with you touching my body.' The resident agreed and stopped his attempt to pursue that action. Male staff is assigned to this resident for the rest of the shift. On 3/6/2024 at 12:55 PM, a Social Services note was documented for resident 21. The note included the following: SS (social services) : Follow up with [resident 21] regarding boundary issues with other residents. [Resident 21] was in better mood this date. He is being treated for a UTI (urinary tract infection) and appears less agitated. He was able to communicate appropriately. No yelling or cursing as he was doing over the past 2 weeks. SS to continue to monitor [Resident 21] for behaviors and boundary issues with other residents. On 3/7/2024 at 11:17 AM, a Social Services note was documented for resident 21. The note included the following: SS follow up with [Resident 21] regarding mood and behaviors. Prior boundary issues with peers. [Resident 21] was calm and foucsed (sic) on working with a Rubics (sic) Cube puzzle. His mood was stable and interactions were without incident this morning. On 3/11/2024 at 4:54 PM, a Physician/Practitioner note was documented for resident 21. The note included the following: Facility staff report that [Resident 21] has had some inappropriate behaviors towards female staff and residents over the past couple of weeks. He has not been aggressive but has attempted to grope females. UA [urinalysis] was ordered and he did have a UTI, which was treated with antibiotics. His inappropriate behavior has improved somewhat, but still continues. On 3/12/2024 at 6:31 PM, a facility nurse documented the following nursing note for resident 21: Resident had one episode of verbal aggression towards a female resident during activity this shift. Redirected per staff and seating rearranged to separate female resident from this resident. On 3/18/2024 at 4:18 PM, a facility nurse documented the following nursing note for resident 21: Phone conversation with resident's daughter concerning an incident today where her father was observed touching a female resident. She was also informed that the facility was exploring new placement for the resident. She replied that she understood but did not understand where the behavior was coming from. On 4/4/24 at 1:56 PM an interview was conducted with the Administrator. The Administrator stated when an instance of a resident-to-resident altercation occurs, he evaluates the willfulness of the act and the resulting harm as factors when determining whether to report or not the incident to the SSA and Adult Protective Services. The Administrator stated if two residents were to hit each other, he would look for physical injury and/or any difference in either residents' behavior to determine whether abuse had occurred. The Administrator stated if two residents swatted at each other, it may or may not need to be reported to the SSA and investigated as abuse. The Administrator stated that a resident punching another resident may be more serious than a resident striking another resident with an open hand slap or a pat.

Based on observation, interview, and record review, it was determined, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 26 sampled residents, residents that had multiple falls with injuries were not provided interventions or adequate supervision to prevent falls from occurring. A resident had a fall that resulted in a left [CONDITION(S)] and the resident was hospitalized . In addition, a resident had a fall resulting in a hematoma to the forehead. Resident identifiers: 32, 48, and 53. Findings included: 1. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, [CONDITION(S)] not due to a substance or known physiological condition, dementia, need for assistance with personal care, muscle weakness, unsteadiness on feet, dysphagia, major depressive disorder, presence of left artificial hip joint, presence of left artificial ankle joint, [CONDITION(S)], persistent affective mood disorder, essential hypertension, and convulsions. On 5/2/22 at 8:35 AM, an interview was conducted with resident 48. Resident 48 stated that he had been hospitalized on ce since his admission to the facility. Resident 48 stated that he was unable to recall the details of the hospitalization or when it happened. During the interview Resident 48's call light was observed on the floor near the head of the bed. On 5/2/22 at 12:39 PM, an observation was conducted of resident 48's room. A fall mat was not present in resident 48's room. Resident 48 stated that he did not have a fall mat. Resident 48's medical record was reviewed on 5/3/22. A care plan Focus initiated on 11/17/19, documented [Name of resident 48 removed] is at risk for falls [CONDITION(S)], intracranial injury, convulsions, repeated falls, abnormal posture, need for assistance with personal care, abnormality of gait and mobility, lack of coordination, dementia. A care plan Goal initiated on 11/17/19, documented [Name of resident 48 removed] will not sustain serious injury through the review date. The interventions included, but not limited to: a. Be sure resident 48's call light is within reach and encourage him to use it for assistance as needed, resident 48 needs prompt response to all requests for assistance. Initiated on 11/18/19. b. Ensure commonly used items were within reach prior to leaving the room. Initiated on 11/18/19. A Fall Risk Evaluation dated 6/15/20, documented resident 48 Not at Risk for falls. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 48 had a Brief Interview for Mental Status (BIMS) score of 6. A BIMS score of 0 to 7 indicates severely impaired cognition. In addition, resident 48 was documented as requiring extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident 48 required supervision of one person for walk in room and corridor. Resident 48 was not steady moving from a seated to standing position and surface to surface transfers between bed and chair or wheelchair. Resident 48 was only able to stabilize with human assistance. On 8/2/20 at 4:27 AM, an Alert Note documented Around 0400 (4:00 AM), pt (patient) was seen getting up from the floor of his room. Pt had his nasal cannula wrapped around his R (right) shoe. Pt appeared to have tripped and fallen because of that. Pt stated, 'I fell but I am okay.' Pt was assessed for any injuries. No apparent injuries. V/s (vital signs) WNLs (within normal limits). Neuro (neurological) checks started. Pt denies any pain. MD (Medical Director) notified. [Note: No new interventions were implemented to prevent falls.] On 8/4/20 at 8:15 AM, a Nursing Note documented At approximately 0815 (8:15 AM) [name of resident 48 removed] was standing at the nurses station just hanging out. Night nurse [name of nurse removed] and I were in the process of counting narcotics when we heard [name of resident 48 removed] saying 'whoa' 'whoa' so we both quickly turned around to find [name of resident 48 removed] on the floor. I asked [name of resident 48 removed] what happened when he said 'I slipped on my socks' 'I am fine honey' Upon assessment I did NOT find as (sic) injuries, bruises, or markings. A care plan Focus initiated on 8/4/20, documented The resident has had an actual fall with injury A care plan Goal initiated on 8/4/20, documented The resident broke his left hip and had surgery. Will resume usual activities without further incident through the review date. The interventions included: a. Ensure that resident 48 was wearing shoes while ambulating. Initiated on 8/4/20. b. Physical Therapy (PT) consultation for strength and mobility. Initiated on 8/4/20. c. A second pair of shoes was ordered for resident 48. Initiated on 8/4/20. d. Pharmacy consultation to evaluate medications. Initiated on 8/4/20. [Note: A pharmacy consultation to evaluate resident 48's medications related to the fall on 8/4/20, was unable to be located.] e. Neuro checks per facility protocol. Initiated on 8/4/20. [Note: Intervention was a medical intervention and not an intervention to prevent falls.] On 8/7/20 at 7:47 AM, an Alert Note documented CNA (Certified Nursing Assistant) witnessed fall. Resident fell and hit his head on back of chair. Assessed for any injuries. Resident denies any pain, says 'I feel fine.' CNA and Nurse helped him up on either side and helped him back to his room and bed. Neuro checks started. Resident denied any weakness or pain. Both CNA and Nurse helped him up and ambulating to room with one on each side. His gait felt weak to nurse as we were helping him. When spoke with sister she was concerned, and asked about awareness of numerous brain surgeries he has had in past. A care plan intervention initiated on 8/7/20, documented Nurse Practitioner to asses resident [Note: No new interventions to prevent falls were identified within the Nurse Practitioner (NP) assessment.] A care plan intervention initiated on 8/10/20. documented CBC (complete blood count) and CMP (comprehensive metabolic panel) for increase in falls. [Note: No new interventions to prevent falls were identified from the laboratory blood draw.] On 8/11/20 at 4:10 AM, an Alert Note documented Heard groaning sounds coming from residents room. Nurse and CNA went to check on resident and was found on the floor laying on his right side by they (sic) door. Resident stated 'I just fell hard' when asked if he could describe what happened.Immediate (sic) head to toe assessment. No bruising, skin tears or red spots noted, pupils PERRlA (pupil, equal, round, reactive to light and accommodation) no bumps or bruising on head. Resident stated 'I hurt everywhere'. No visual signs of pain when moving Lower extremities, Resident was able to stand with assist and transfer into wheelchair and then transfer back to bed. Non-skid socks place on resident. Care plan interventions initiated on 8/11/20, documented Non-skid socks when in bed. and COVID-19 (Coronavirus disease) testing as needed. [Note: The COVID-19 testing intervention was a medical intervention and not an intervention to prevent falls.] A Fall Risk assessment dated [DATE], documented resident 48 At Risk for falls. A quarterly MDS assessment dated [DATE], documented that resident 48 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 48 required limited assistance of one person for walk in room and corridor and locomotion on and off the unit. Resident 48 was not steady moving from a seated to standing position and surface to surface transfers between bed and chair or wheelchair. Resident 48 was only able to stabilize with human assistance. On 10/16/20 at 6:48 PM, a Nursing Note documented On assessment Resident noted to be guarding his left leg and grimacing & saying 'ouch ouch' post fall incident, unwitnessed dated 10/16/20, 1814pm (6:14 PM). No skin breakdown noted, no redness. Limited ROM (range of motion) to left leg noted. Assisted Resident to bed, Oxygen on, bed in low position. Call light in reach. NP ordered xray of hip, called in for STAT (immediately) tonight, . [Note: No new interventions were implemented to prevent falls.] On 10/16/20 at 7:32 PM, a Nursing Note documented Sent patient to [name of hospital removed] ED (emergency department) for further evaluation of left hip post unwitnessed fall incident tonight. Resident is verbalizing intense pain even on light palpation and unable to perform any ROM over left leg. Requested STAT-Xray earlier but has not been performed at this time prior to transfer. The Hospital History and Physical dated 10/16/20, documented a chief complaint of left hip pain. presents to the emergency room after a ground level fall from his wheelchair. He landed on his left hip. Workup in the emergency room showed a left [CONDITION(S)]. I was consulted. Orthopedics was called by the emergency room physician. On 10/17/20 at 9:12 AM, a Nursing Note documented Spoke with [name of Power of Attorney (POA) removed] in regard to [name of resident 48 removed] fall and transfer to hospital last night. Surgery is scheduled for sometime today, [name of POA removed] calling for update and will call back to give information. A reentry Fall Risk assessment dated [DATE], documented resident 48 At Risk for falls. On 10/21/20 at 3:45 AM, an Alert Note documented . Resident doing well with readmission. Resident denies pain at the moment, but will say 'ouch' during brief changes. Resident is following hip precautions and is compliant with medications. A significant change MDS assessment dated [DATE], documented that resident 48 had a BIMS score of 4. A BIMS score of 0 to 7 indicates severely impaired cognition. In addition, resident 48 was documented as requiring extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident 48 was not steady with surface to surface transfers between bed and chair or wheelchair and was only able to stabilize with human assistance. A quarterly MDS assessment dated [DATE], documented that resident 48 required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident 48 required limited assistance of one person for walk in room and corridor. An admission Fall Risk assessment dated [DATE], documented resident 48 Not at Risk for falls. On 2/15/22 at 10:49 PM, a Nursing Note documented Resident was heard calling out from room at 2155 (9:55 PM). When staff entered to check on him he was found lying on his back on the floor. Resident stated, 'I fell on my back.' Resident was assessed. No injuries noted to head. Denied hitting his head. Redness and some minor scratches were found to the right side of his back. Area cleaned. Also has redness to the front of left thigh. Originally stated his back hurt but quickly said it was feeling better while nurse was assessing. Denies pain at this time. Neuro checks initiated and WNL. A Fall Risk assessment dated [DATE], documented resident 48 Not at Risk for falls. A care plan Focus initiated on 3/5/19, documented [Name of resident 48 removed] has limited physical mobility r/t (related to) r/t (sic) dementia, lack of coordination, abnormalities of gait and mobility, need for assistance with personal care, intracranial injury, convulsions. He is at risk for falls. [Name of resident 48 removed] had an actual fall 2/15/2022. The interventions included, but not limited to: a. Fall mat placed at bedside. Initiated on 1/18/22. b. Non-skid socks to prevent further incident of fall (2/15/22). Initiated on 2/16/22. [Note: A care plan intervention Non-skid socks when in bed. Was initiated on 8/11/20.] c. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Initiated on 2/16/22. On 5/3/22 at 12:49 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that falls were discussed in the morning meeting with the team and the team would try to find the cause of the fall. UM 1 stated that interventions were implemented to prevent another fall from happening and interventions were based on the previous fall. UM 1 stated that fall interventions were on the resident care plan. UM 1 stated that each resident had a Kardex in the Kardex book that staff were expected to review and sign. UM 1 stated the Kardex were updated weekly and as needed. [Note: The resident Kardex book was reviewed and five staff had signed the book.] On 5/3/22 at 1:04 PM, an interview was conducted with CNA 9. CNA 9 stated that she would check the Kardex book for resident fall interventions or she would check with the nurse in the morning. CNA 9 stated that she would check with the nurse in the morning to make sure no one fell the day before. CNA 9 stated the fall interventions in place for resident 48 were to check on him and offer a drink, check to see if he was wet, and ensure resident 48's bed was in a low position. CNA 9 stated that resident 48 did not eat much but resident 48 would eat ice cream. CNA 9 stated that resident 48 did not have a fall mat. [Note: CNA 9 had not signed the Kardex book.] On 5/3/22 at 1:23 PM, an interview was conducted with CNA 10. CNA 10 stated that she would have to ask the charge nurse and check the resident's care plan for fall interventions. CNA 10 stated that resident 48 was an extensive one person assistance. CNA 10 stated that she would have to ask someone regarding fall interventions for resident 48. CNA 10 stated that she did not know off the top her head if resident 48 had a low bed or a fall mat in place. [Note: CNA 10 had not signed the Kardex book.] On 5/3/22 at 1:43 PM, an interview was conducted with CNA 2. CNA 2 stated if a resident had a fall she would report to the nurse immediately, she would check the resident, and take the resident's vital signs. CNA 2 stated that resident 48 had never fallen in the bed but he would get unsteady on his feet when he walked. CNA 2 stated that resident 48 did not have a fall mat. [Note: CNA 2 had not signed the Kardex book.] On 5/4/22 at 9:03 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 48 was noncompliant at every aspect. LPN 1 stated that resident 48 was on hospice and required assistance with everything and resident 48 refused to get out of bed and walk. LPN 1 stated that several interventions for falls have been implemented at different times. LPN 1 stated that resident 48 had been more compliant and very verbal lately. LPN 1 stated resident 48 did have a fall mat at one time. LPN 1 stated that interventions in place to keep resident 48 safe from falls were supervision while in the wheelchair and a one to two person assistance with transferring. LPN 1 stated that resident 48 was able to reposition himself and preferred to do that on his own but LPN 1 would check resident 48 every hour and a half to check on his positioning. LPN 1 stated that resident 48 had not fallen recently but in the past resident 48 would fall because he did not want help. LPN 1 stated staff had tried many interventions prior to get resident 48 where he was at. LPN 1 stated if the fall intervention was something she could put into place immediately she would. LPN 1 stated if the falls were a trend they would be discussed in the morning meeting every day with the team. LPN 1 stated that fall interventions were on the resident Kardex and the staff must check the Kardex book daily. LPN 1 stated that interventions were also discussed through report with the nurses every morning. LPN 1 stated the Kardex book was updated weekly and the UM's would tell the staff if the book was updated prior to the weekly update. LPN 1 stated if a resident had a fall the nurse would assess the resident and the immediate concerns would be addressed by the MD. On 5/4/22 at 10:01 AM, an observation was conducted of resident 48's room. A floor mat was not present in resident 48's room. 2. Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, Alzheimer's disease, muscle weakness, cognitive communication deficit, difficulty in walking, mood disorder due to known physiological condition, major depressive disorder, spondylosis, and chronic pain. Resident 53's medical record was reviewed on 5/5/22. A care plan Focus initiated on 8/31/21, documented [Name of resident 53 removed] has limited physical mobility. [Name of resident 53 removed] has an actual fall without injury 3/18/22. [Name of resident 53 removed] had an actual fall without injury 4/11/22. [Name of resident 53 removed] had an actual fall with injury, (R forehead hematoma) 5/4/2022. A care plan Goal initiated on 8/31/21, documented [Name of resident 53 removed] will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. The interventions included, but not limited to: a. Ambulation: Resident 53 requires up to extensive assistance of one staff to walk. Initiated on 8/31/21. b. PT and Occupational Therapy (OT) referrals as ordered, and as needed. Initiated on 8/31/21. A reentry Fall Risk Evaluation dated 1/28/22, documented resident 53 Not at Risk for falls. A quarterly MDS assessment dated [DATE], documented that resident 53 had a BIMS score of 3. A BIMS score of 0 to 7 indicates severely impaired cognition. In addition, resident 53 was documented as requiring extensive assistance of two persons for bed mobility, transfers, walk in room, locomotion on the unit, and dressing. Resident 53 required extensive assistance of one person for walk in corridor, locomotion off unit, toileting, and personal hygiene. Resident 53 was not steady moving from a seated to standing position, walking, turning around and facing the other direction while walking, moving on and off the toilet, and surface to surface transfers between bed and chair or wheelchair. Resident 53 was only able to stabilize with human assistance. On 3/18/22 at 5:58 PM, a Nursing Note documented resident was found on the floor beside the window, she states that she hit her head, CNA to take vitals, lung sounds clear with dim (diminished) to bases, no pain with movement reported, no skin tears noted. Neuro checks to start. A care plan intervention initiated on 3/18/22, documented Provide supportive care, assistance with mobility as needed. Document assistance as needed. [Note: The care plan intervention was initiated on 8/31/21. No new interventions were implemented to prevent falls.] A care plan intervention initiated on 3/22/22, documented PT referral and medication changes (3/18/22) [Note: A review of the March 2022 Medication Administration Record (MAR) revealed that [MEDICATION(S)] was decreased from 2 milligrams (mg) three times a day to 1 mg two times a day. Resident 53 was not referred to PT until 4/11/22.] A Fall Risk Evaluation dated 4/1/22, documented resident 53 At Risk for falls. On 4/11/22 at 3:07 AM, an Incident Report documented Resident was found by CNA at 0240 (2:40 AM) on her floor. Resident was previously sleeping. Nurse assisted resident back to bed and checked for injuries. No injuries noted. Resident requires a 1 to 1 for safety due to resident's constant pacing and instability on her feet. Soft C (cervical)-Collar ordered. A care plan intervention initiated on 4/11/22, documented Staff will attempt to place soft C-Collar when [name of resident 53 removed] is out of bed (4/11/22). [Note: Intervention was a medical intervention and not an intervention to prevent falls.] On 4/22/22 at 11:00 PM, an Alert Note documented 2045 (8:45 PM) Resident was on neuro checks for an unwitnessed fall in her room from previous shift. Resident was found on the floor in her room. Head to toe assessment [NAME] (sic), did not find any injury. helped into bed. She continually is moving her legs back and forth. CNA stayed with her until she went to sleep. Meds (medications) also given including scheduled [MEDICATION(S)], tolerated well. Daughter was understanding and even saying she would give her permission for her mother to sleep on the floor if it would help. I assured her we didn't want to do that. We want her to be safe and comfortable. [Note: No new interventions were implemented to prevent falls.] On 5/3/22, an observation was conducted of resident 53 ambulating in the hall with staff. Resident 53 was observed without the C-Collar each time resident 53 was in the hall ambulating with staff. On 5/4/22 at 11:35 PM, a Nursing Note documented 2135 (9:35 PM) CNA called out that resident was on floor. Resident was lying on back when assessed, but CNA reported when she first saw her on floor her feet were under her bed. Resident seems in constant motion most of the time. However the fall occurred she must have hit her head as there was a large hematoma on the R side of her forehead with swelling and bruising, a little larger than a fifty cent piece. On full head to toe assessment no other injuries were found. helped back to bed, she is resistant as she continues to move and makes effort to get up out of bed. Taking 2 people to hold her still to obtain VS (vital signs) . Hand grasp strong and equal on both hands. When asked resident what had happened she did not respond. When she was placed in bed nurse emphasized to her it was important that she stay in bed to not get hurt. Resident responded, 'okay' while moving to bring self out of bed. CNA at bedside. daughter [name of resident 53's daughter removed] asked if she would be ok if we were to get a protective helmet for her to wear on her head. She was ok with that. A helmet was found, but was unable to get on her head with the current swelling. No new orders. OK to use ice on forehead. On 5/5/22 at 12:21 PM, an interview was conducted with CNA 9. CNA 9 stated that a staff member was with resident 53 all the time. CNA 9 stated that resident 53 was sleeping right now and CNA 9 tired to watch her. CNA 9 stated that resident 53 would go to the bathroom every two to three hours. CNA 9 stated that she would walk with resident 53, offer her water, and be with her to prevent falls. CNA 9 stated that resident 53 was not on a toileting program for every one to two hours. A care plan intervention initiated on 5/5/22, documented AMBULATION:The resident requires (SPECIFY: assistance) by (X) staff to walk (SPECIFY FREQ (frequency)) and as necessary. [Note: The care plan interventions was initiated on 8/31/21. No new interventions were implemented to prevent falls.] On 5/5/22 at 12:29 PM, an interview was conducted with LPN 1. LPN 1 stated that resident 53 was a one to one when out of bed. LPN 1 stated that resident 53's feet were always moving even when resident 53 was sleeping. LPN 1 stated that resident 53 was started on a scheduled dose of [MEDICATION(S)]. LPN 1 stated that resident 53 would sleep for two hours versus 20 minutes prior to the [MEDICATION(S)]. LPN 1 stated if resident 53 had someone with her she did not fall. LPN 1 stated that resident 53 was extremely active that morning and it took two people to take her vital signs. On 5/5/22 at 1:23 PM, an interview was conducted with UM 1. UM 1 stated that resident 53 had a change in January 2022. UM 1 stated that resident 53 was ambulatory and very aggressive. UM 1 stated that resident 53 had broken a window and would push people. UM 1 stated that resident 53 had been transferred at that time to a Behavioral Health Hospital and the hospital put resident 53 on high doses of [MEDICATION(S)]. UM 1 stated that resident 53's decline was before the taper of the [MEDICATION(S)] because resident 53 was snowed. UM 1 stated that when the [MEDICATION(S)] was decreased she did not have behaviors but she was extremely weak. UM 1 stated resident 53's [MEDICATION(S)] was discontinued on 3/18/22. UM 1 stated that resident 53 was now active again since the [MEDICATION(S)] was discontinued. UM 1 stated that resident 53 was eating when she was readmitted but resident 53 was not moving at all and would barley wake up. 3. Resident 32 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, dementia without behavioral disturbance, muscle weakness, need for assistance with personal care, malignant neoplasm of breast, anxiety disorder, chronic pain, restless legs syndrome, history of falling, and depression. Resident 32's medical record was reviewed on 5/4/22. An admission Fall Risk Evaluation dated 12/8/21, documented resident 32 At Risk for falls. An admission MDS assessment dated [DATE], documented that resident 32 had a BIMS score of 11. A BIMS score of 8 to 12 indicates moderately impaired cognition. In addition, resident 32 was documented as requiring extensive assistance of one person for bed mobility, transfers, walk in room and corridor, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident 48 required supervision of one person for locomotion off unit. The Care Area Assessment Summary documented that Falls triggered for a new care plan. A care plan for falls was unable to be located. On 1/9/22 at 6:45 AM, an Incident Report documented Patient fell next to her bed. fell forward from the foot of her bed, toward the head of her bed. Overbed table moved slightly aside as she fell on bedside mat. Patient stated that she bumped her head on the overbed table as she fell . Attempts made through the rest of the night to keep her from walking without assist. Very forgetful and continuously getting up and walking around, with and without walker, gait very unsteady. On 1/24/22 at 7:21 PM, a Nursing Note documented Resident was walking near the nurses station and slipped and fell and was in a sitting position with her legs out and walker beside her resident was then assessed and no c/o (complains of) pain . [Note: No new interventions were implemented to prevent falls.] A Fall Risk Evaluation dated 1/24/22, documented resident 32 At Risk for falls. A care plan Focus initiated on 1/25/22, documented [Name of resident 32 removed] had had an actual fall on 1/9/2022, and 1/24/22 with (no injury) Poor Balance, Unsteady gait. A care plan Goal initiated on 1/25/22, documented [Name of resident 32 removed] will resume usual activities without further incident through the review date. The interventions included, but not limited to: a. Provide activities that promote exercise and strength building when resident 32 is getting up from bed to walk. Initiated on 2/10/22, for fall on 1/9/22. [Intervention was implemented a month after resident 32 fell .] b. Monitor, document, and report as needed for 72 hours to MD for signs and symptoms of pain, bruises, change in mental status, and new onset of confusion, sleepiness, inability to maintain posture, and agitation. Initiated on 1/25/22. [Note: Intervention was a medical intervention and not an intervention to prevent falls.] c. Neurological checks. Initiated on 1/25/22. [Note: Intervention was a medical intervention and not an intervention to prevent falls.] d. Reorient resident 32 and provide frequent education regarding use of wheelchair and walker. Initiated on 2/10/22, for fall on 1/24/22. [Intervention was implemented 17 days after resident 32 fell .] On 3/23/22 at 5:57 PM, an Alert Note documented Fall day 1. During shift at 5:30pm staff heard resident crying from her room. This nurse and staff went immediately into her room and observed resident sitting on her buttocks by the bathroom and next to bed A. As per resident, 'I was going back to bedand (sic) I fell .' 'My head hurts' As per assessment, resident able to follow commands. Able to move her upper and lower extremity well. Able to stand up with 1 assist. No skin tear. No bumps or bruise. Resident complained of pain on her head, but no rednessor (sic) bumps noted at this time. Received order to closely monitor neuro check and notify on call for any furtherchange (sic) of conditions. Endorse oncoming nurse to continue monitor. Educated resident to use of call light. Bed at thelowest (sic) position and call light in reach. Frequent check done to continue monitor neuro and resident's safety. Resident is up for dinner in dining room at this time. Care plan interventions initiated on 3/24/22, included Non-skid socks (3/23/22) and Toileting schedule in place (3/23/22). A Fall Risk Evaluation dated 3/23/22, documented resident 32 Not at Risk for falls. On 3/24/22 at 12:15 AM, an Incident Report documented 0015 (12:15 AM) Resident found on floor beside bed. Helped back into bed. Total body assessment done, no injuries found. no new orders. 0050 (12:50 AM) Resident c/o pain in R hip, can move it freely, Acetaminophen given. Resident seen from nursing desk sitting on side of bed, when nurse at bedside assisting her to lay back down asked her first what she was trying to do. she responded, 'She was going to see her father'. Staff to keep more frequent checks on her. Consider 1:1 (one to one) staffing for her. [Note: No new interventions were implemented to prevent falls.] A Fall Risk Evaluation dated 3/24/22, documented resident 32 At Risk for falls. On 4/2/22 at 4:18 PM, a Nursing Note documented patient was found in her room on the floor. She reported a fall and reported that she did fall. From the aids (CNAs) she is not a person who is normally oriented and she was only oriented to self and situation. She reported that she did not hit her head, it is unknown if she is a reliable historian at this time due to her diagnosis and being on hospice. Patient was then moved off of floor and put back into bed. She reported no pain except for her right arm . Patients is able to bear weight on both bilateral extremities and has adequate grip strength at this time. No other acute problems noted at this time. Patient will be monitored on the Neuro check protocol for any worsening signs of intracranial bleeding. A care plan intervention initiated on 4/2/22, documented PT / OT Referral (4/2/22). [Note: Resident 32 was discharged from PT services on 9/17/21. A PT and OT referral was unable to be located.] On 4/30/22 at 12:18 AM, a Nursing Note documented At 2300 (11:00 PM) on 4/29/2022 heard resident call out for help. She was found sitting on floor near the bathroom. When asked what happened she said she had to go to the bathroom, but then was too weak and she fell . Head to toe assessment done, no injuries seen.Resident (sic) moves all extremities. Was helped up and helped to toilet and completed having BM (bowel movement). Cleaned up, helped back to bed using walker. Gave orders for CBC with diff (differential), CMP and Urine for UA (urinalysis) and C/S (culture and sensitivity) Stat. [Note: No new interventions were implemented to prevent falls.] A Fall Risk Evaluation dated 4/30/22, documented resident 32 At Risk for falls. On 5/4/22 at 1:38 PM, an interview was conducted with LPN 1. LPN 1 stated that resident 32 would use her call light and resident 32 liked to spend most of her day in bed. LPN 1 stated that resident 32 was one on one with ambulation and transfers. LPN 1 stated that last week resident 32 preferred her wheelchair over the walker. LPN 1 stated that resident 32 would wear the nonskid socks and LPN 1 would try and remind resident 32 when she walked by the nurses station to use the toilet and would ask resident 32 if she needed anything. LPN 1 stated if a resident were on a toileting schedule the staff would check on the resident every two hours and encourage toilet use. LPN 1 stated that resident 32 would usually go to the toilet if encouraged. LPN [TRUNCATED]

Based on interview and record review, it was determined, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 26 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 53's medical record was reviewed on 5/5/22. A care plan focus initiated on 5/2/22, documented [Name of resident 53 removed] has nutritional problem or potential nutritional problem r/t (related to) dx (diagnosis) depression, Hx (history) Covid 19 (Coronavirus disease) w/ (with) BMI (body mass index) 17.5 w/recent sign (significant), weight losses and need for supplements to meet needs. The care plan goals initiated on 12/1/21, documented No significant weight loss of 5% (percent) in 30 days or 10% in 180 days. and [Name of resident 53 removed] will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs or symptoms) of malnutrition through review date. The care plan goal was revised on 4/24/22. The following care plan interventions included: a. Provide and serve diet as ordered. Initiated on 8/31/21. b. Provide, serve diet as ordered. Monitor intake and record every meal. Initiated on 9/7/21. c. Weigh per facility policy. Initiated on 9/7/21. d. Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. Initiated on 9/7/21. Resolved on 9/14/21. e. Provide and serve supplements as ordered. Initiated on 5/2/22. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 53 had a Brief Interview for Mental Status (BIMS) score of 3. A BIMS score of 0 to 7 indicates severely impaired cognition. A Skin and Nutrition Review dated 2/22/22, documented that resident 53 had a recent significant weight loss of 3.2% since 2/15/22. Will recommend Med Pass 60 milliliters (ml) three times a day (TID) for recent significant weight loss. [Note: The Med Pass TID recommendation was not implemented until 4/13/22. This indicated a 50 day delay for the implementation of the Med Pass TID supplementation.] On 2/22/22, resident 53 had a documented weight of 152 pounds (lbs). On 4/13/22, resident 53 had a documented weight of 126.8 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 16.58 % during a two month interval. The Amount Eaten was reviewed for February 2022. Out of 84 opportunities resident 41 ate 76 to 100 % of the meal on 39 occasions, 51 to 75 % of the meal on 43 occasions, and 26 to 50 % of the meal on 3 occasions. On 3/4/22, resident 53 had a documented weight of 153.6 lbs. On 4/5/22, resident 53 had a documented weight of 134.4 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 12.50 % during a one month interval. The Amount Eaten was reviewed for March 2022. Out of 93 opportunities resident 53 ate 76 to 100 % of the meal on 16 occasions, 51 to 75 % of the meal on 31 occasions, 26 to 50 % of the meal on 27 occasions, and 0 to 25 % of the meal on 10 occasions. A Skin and Nutrition Review dated 4/13/22, documented that resident 53 had a recent significant weight loss on 4/13/22, of 17.4% since 3/4/22. A 19.9% weight loss since 1/28/22, and a 18.5% weight loss since 10/19/21. Will recommend Med Pass 90 ml four times a day (QID), fortified diet, and Magic cup every day. Resident 53 has had a slow decline since January 2022. Resident 53 had been eating less and has had a cognitive decline. Resident 53 had a gradual weight loss with her change of condition. [Note: The Med Pass QID recommendation was not implemented.] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: This was the recommendation that was placed from documentation of the Skin and Nutrition Review on 2/22/22.] A Skin and Nutrition Review dated 4/20/22, documented that resident 53 had a recent significant weight loss of 3.5% since 4/13/22. A 22.7% weight loss since 1/28/22, and a 21% weight loss since 10/26/21. Resident 53 averages 25 to 50% of meal intake of a regular fortified diet. Resident 53's Magic cup intake was 50% 2 out of 6 days and refuses the other days. Resident 53's Med Pass intake was 25% TID. Recommend stopping the Magic cup due to poor acceptance, will recommend Med Pass 60 ml QID, and a Healthshake every day. May also consider an appetite stimulate related to recent weight losses. [Note: Recommendations were not implemented.] The Amount Eaten was reviewed for April 2022. Out of 90 opportunities resident 53 ate 76 to 100 % of the meal on 4 occasions, 51 to 75 % of the meal on 16 occasions, 26 to 50 % of the meal on 19 occasions, and 0 to 25 % of the meal on 36 occasions. On 10/26/21, resident 53 had a documented weight of 155.6 lbs. On 4/30/22, resident 53 experienced a documented weight of 118.8 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 23.65 % during a six month interval. On 4/5/22, resident 53 had a documented weight of 134.4 lbs. On 5/3/22, resident 53 had a documented weight of 115.4 lbs. With these reference weights, resident 53 experienced a documented significant weight loss of 14.14 % during a one month interval. A Skin and Nutrition Review dated 5/4/22, documented that resident 53 had a weight loss of 14.1% since 4/5/22, and a weight loss of 27.1% since 11/2/21. Resident 53 continues to decline and was on comfort cares per the unit manager (UM). Recommended the Med Pass 60 ml QID, and evaluate for appetite stimulant. [Note: These recommendations were recommended during the Skin and Nutrition Review dated 4/20/22. The recommendations were not implemented on 4/20/22. This indicated a 14 day delay in implementation of nutritional interventions, and during the time frame from 4/19/22 to 5/4/22, resident 53 had experience a 5.7 % further decline in weight.] The Amount Eaten was reviewed for May 2022. Out of 14 opportunities resident 53 ate 51 to 75 % of the meal on 1 occasion, 26 to 50 % of the meal on 2 occasions, and 0 to 25 % of the meal on 9 occasions. On 5/5/22 at 12:36 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 53 did not like to eat. LPN 1 stated that resident 53 would eat the softer foods but resident 53 had zero appetite. LPN 1 stated that it was hard to get resident 53 to drink the Med Pass. LPN 1 stated that she would try frequently to get resident 53 to drink the Med Pass. LPN 1 stated that resident 53 would drink water. LPN 1 stated that resident 53 was not able to feed herself. LPN 1 stated that resident 53 had a head droop and resident 53 would move her head away when she was finished eating. LPN 1 stated that resident 53's daughter would come to the facility and feed resident 53 either during breakfast or lunch. LPN 1 stated that a health shake was separate from the Med pass and they were not the same thing. LPN 1 stated a Magic cup or a high protein supplement would come on the snack tray from the kitchen. LPN 1 stated a health shake would come from the kitchen. LPN 1 stated items like Breeze, Boost, Med Pass, or Ensure came from the nurse and were documented on the Medication Administration Record or the Treatment Administration Record. LPN 1 stated that resident 53 did not like the Magic cup. LPN 1 stated that the RD recommendations went to the UM and the UM would communicate the recommendations to the floor nurse. LPN 1 stated that the Skin and Nutrition meetings were every Wednesday and the UM would let the nurses know about recommendations on Thursday mornings. On 5/5/22 at 1:23 PM, an interview was conducted with UM 1. UM 1 stated that resident 53 had a change in January 2022. UM 1 stated that resident 53 was ambulatory and very aggressive. UM 1 stated that resident 53 had broken a window and would push people. UM 1 stated that resident 53 had been transferred at that time to a Behavioral Health Hospital and the hospital put resident 53 on high doses of [MEDICATION(S)]. UM 1 stated that resident 53's decline was before the taper of the [MEDICATION(S)] because resident 53 was snowed. UM 1 stated that when the [MEDICATION(S)] was decreased she did not have behaviors but she was extremely week. UM 1 stated that resident 53 would eat 100% of her meals but because she was snowed she was not eating much. UM 1 stated that resident 53 was on weekly weight for a month when she was readmitted from January 2022 to 2/23/22. UM 1 stated that resident 53 was eating during that time. UM 1 stated resident 53's [MEDICATION(S)] was discontinued on 3/18/22. UM 1 stated that resident 53 was now active again since the [MEDICATION(S)] was discontinued. UM 1 stated that resident 53 was eating when she was readmitted but resident 53 was not moving at all and would barley wake up. UM 1 stated that in April 2022 was when she noticed that resident 53 was not eating well. UM 1 stated that when a recommendation was received the UM would put in the orders. UM 1 stated if an appetite stimulant was recommended the UM would ask the doctor. UM 1 stated that Med Pass QID may have been an error. UM 1 stated the Med Pass was entered TID and the paper notes documented TID. UM 1 stated the physician and Doctor of Nursing Practice do not attend the Skin and Nutrition meetings. On 5/5/22 at 1:50 PM, an interview was conducted with UM 2. UM 2 stated that she had missed putting in the orders from the Skin and Nutrition meeting on 4/20/22. UM 2 stated that all of the notes from the Skin and Nutrition meeting were input into the evaluation, the recommendations were followed up on with the physician and orders would be documented.

Based on observation and interview, it was determined, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, staff members were observed standing over residents while the residents were provided with meal consumption assistance. In addition, on one occasion a resident was observed to be seated with other residents who were consuming their meal, while the resident was not provided with eating assistance timely. Findings included: On 5/2/22 at 12:06 PM, a resident, who required total assistance with meal consumption, was observed seated in the communal main dining room at a table next to their covered meal. Two other residents were also seated at the table with this resident. The other two residents were provided with their meal and began to consume their lunch while the resident who required total assistance with meals remained unable to consume their lunch. The resident waited from 12:06 PM until 12:28 PM, when the Social Services Director came to assist the resident with lunch meal consumption. [Note: This resident sat in front of her meal, while other residents were consuming their lunch meals for 22 minutes.] The Social Services Director then provided the resident with meal consumption assistance while standing over the resident to provide assistance. On 5/3/22 at 8:12 AM, Unit Manager (UM) 1 was observed to provide a resident with total assistance with consumption of their breakfast meal. UM 1 was observed to be standing over the resident while they provided the resident with assistance. On 5/3/22 at 12:12 PM, UM 1 was observed to provide a resident with total assistance with consumption of their lunch meal. UM 1 was observed to be standing over the resident while they provided the resident with assistance. On 5/5/22 at 8:13 AM, Licensed Practical Nurse (LPN) 1 was observed to provide a resident with total assistance with consumption of their breakfast meal. LPN 1 was observed to be standing over the resident while they provided the resident with assistance. On 5/5/22 at 8:14 AM, Certified Nursing Assistant (CNA) 2 was observed to provide a resident with total assistance with consumption of their breakfast meal. CNA 2 was observed to be standing over the resident while they provided the resident with assistance. On 5/5/22 at 8:25 AM, CNA 1 was observed to provide a resident with total assistance with consumption of their breakfast meal. CNA 1 was observed to be standing over the resident while they provided the resident with assistance. On 5/5/22 at 8:26 AM, CNA 3 was interviewed. CNA 3 stated a person that was providing a resident with assistance at a meal service should always be seated. CNA 3 stated the staff member should be seated while providing assistance because it made the resident feel comfortable and it was respectful. On 5/5/22 at 12:52 PM, CNA 4 was interviewed. CNA 4 stated staff who were providing a resident with assistance at a meal should be seated. CNA 4 stated the staff member should sit down before helping a resident with meal consumption because it would make the resident comfortable. CNA 4 stated the staff member should sit down, take their time and explain to the resident what they were eating.

Based on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 7 out of 26 sampled residents, the facility did not ensure implementation of a resident's care plan interventions regarding limited range of motion and contractures; for three residents, the facility did not update and implement interventions for fall prevention; and, for three residents, the facility was unable to demonstrate development and implementation of dementia related care plans. Resident identifiers: 3, 15, 16, 32, 45, 48, and 53. Findings included: 1. A resident with a care plan for contractures to their bilateral upper extremities and hands did not have care plan interventions implemented. Resident 15 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 8:45 AM, resident 15 was observed seated in the dining room, in a reclining wheel chair with their legs bent to the side, and a pillow was placed behind resident 15's legs. Resident 15 did not have any towels placed in their hands during this observation. At the time of this observation resident 15 was being provided with total assistance with breakfast meal consumption. On 5/4/22 at 9:05 AM, resident 15 was observed seated in their wheelchair in their bedroom. Resident 15 was looking out the window, and at the time of this observation resident 15 did not have a pillow behind her legs and did not have towels or cloths in her hands. On 5/4/22 at 11:09 AM, resident 15 was observed in their wheelchair and seated in the hallway. Resident 15 was making a whining noise and was wincing. Registered Nurse (RN) 1 did acknowledge resident 15 and stated that resident 15 had just received their [MEDICATION(S)] medication, and RN 1 stated resident 15 should feel less pain soon. At the time of this observation resident 15 did not have towels or cloths in her hands and did not have a pillow behind her legs. On 5/5/22, a review of resident 15's medical record was completed. The following were noted; Resident 15's Treatment Administration Record had an order which read, Hand towels to be placed in bilateral hands every shift for contractures -Start Date- 03/10/2022 1800 (6:00 PM). Resident 15 had a Care Plan Focus which read, [Name of resident 15 removed] has contractures in bilateral upper extremities and hands. Date Initiated: 03/10/2022. Interventions in place regarding this Care Plan Focus included; a. Hand towel encouraged to be placed in bilateral hands. Date Initiated: 03/10/2022; Revision on: 04/22/2022. b. Provide gentle ROM (range of motion) to upper and lower extremities. Date Initiated: 03/10/2022. c. PT (physical therapy), OT (occupational therapy), ST (speech therapy) to eval (evaluate) and treat as needed. On 5/4/22 at 9:05 AM, Certified Nursing Assistant (CNA) 6 was interviewed. CNA 6 stated they had worked with resident 15, for a long time. CNA 6 stated staff placed pillows behind resident 15's legs when resident 15 was in her wheelchair because of contractures. CNA 6 stated resident 15's contractures in her legs were getting worse. CNA 6 stated they did not know if resident 15 was having worsening ROM to her upper extremities or hands and CNA 6 stated they did not know of any interventions resident 15 had in place to prevent contractures or worsening ROM to their upper extremities. CNA 6 stated, You would have to ask the nurse. On 5/4/22 at 9:15 AM, CNA 3 was interviewed. CNA 3 stated staff placed pillows behind resident 15's legs while resident 15 was in their wheelchair to provide resident 15 with comfort and to prevent her legs from hitting the back of the chair. CNA 3 stated resident 15 did not have any issues with limited ROM in their upper extremities and there were no interventions in place for preventing decreased ROM to resident 15's upper extremities. CNA 3 stated resident 15 only had contractures to their knees. On 5/4/22 at approximately 9:20 AM, RN 1 was interviewed. RN 1 stated resident 15 did have contractures to her upper extremities and staff were to place cloths in resident 15's hands. RN 1 stated the CNA staff were to place the cloths in resident 15's hands daily to help prevent her hands from closing more and RN 1 stated CNA staff were also to provide resident 15 with exercises for her hands to prevent worsening ROM. RN 1 stated resident 15's contractures were in her hands as well as her legs, and resident 15 was on comfort care measures so the staff were trying to keep resident 15 comfortable. RN 1 stated the contractures do appear to cause resident 15 pain. RN 1 stated the presence of contractures was within resident 15's Care Plan and this would then relate with the CNA's Brain, which was a sheet that described the cares each resident on the unit required. Resident 15's section of the CNA Brain read, Dressing/splint care: Dressing [name of resident 15 removed] requires up to extensive to total assist of one to two staff to dress upper body and is dependent on dressing lower body and donning her shoes. [Note: Within resident 15's section of the CNA Brain there was no mention of contractures or limited ROM with applicable interventions.] On 5/4/22 at 9:41 AM, CNA 7, who worked for the facility as an agency CNA, was interviewed. CNA 7 stated resident 15 had issues with ROM. CNA 7 stated resident 15 would demonstrate that they were in pain and complained unless the resident was left in a specific position. CNA 7 stated resident 15 did not have any contractures. CNA 7 stated once resident 15 was placed in her wheelchair she wanted to be left in one position. CNA 7 stated if resident 15 did have contractures or had any interventions in place for limited ROM the CNAs would be prompted of this on their Activities of Daily Living (ADL) task reporting, or the CNA could learn of a resident's contractures or limited ROM interventions through report from the night shift CNA. On 5/4/22 at 11:49 AM, Unit Manager (UM) 2 was interviewed. UM 2 stated resident 15 was observed to have contractures to her lower extremities around the end of January 2022. UM 2 stated when a CNA observed resident 15's legs were contracted the facility did x-rays to ensure there were no issues, and UM 2 stated the x-rays indicated osteoporotic changes. UM 2 stated resident 15 did not have any limited ROM or contractures to their upper extremities. Upon review of resident 15's care plan, UM 2 stated, resident 15 did have a care plan initiated in March of 2022, which indicated resident 15 had bilateral upper extremity contractures. UM 2 stated either herself or UM 1 would have developed the Care Plan, and ensured the implementation of the care plan interventions. UM 2 stated staff should place towels in resident 15's hands and provide resident 15 with ROM exercises. UM 2 stated CNA staff would implement both of these interventions, and the CNAs should be aware of the interventions through review of the CNA Brain. UM 2 then reviewed the CNA Brain, and stated the interventions to prevent further decreased ROM in resident 15's upper extremities were not present on the CNA Brain. [Note: CNAs were not aware of the care plan interventions related to the contractures to resident 15's bilateral upper extremities and hands.] 2. The facility was unable to demonstrate the implementation of a Care Plan for a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 3 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations were made of resident 3, while on the East wing unit. The following observations were noted; On 5/2/22 at 9:40 AM, resident 3 yelled shut the door. Resident 3 then slammed her bedroom door closed. On 5/2/22 at 10:53 AM, resident 3 was observed to accept a Tylenol pill from the nurse. Resident 3 then asked the nurse when they could be provided with the next Tylenol. Resident 3 then stated I want to sleep. On 5/2/22 at 12:58 PM, resident 3, using her wheelchair went to the nurses' station. Resident 3 stated they wanted a Tylenol. Resident 3 then stated they wanted candy. No staff acknowledged resident 3. On 5/2/22 at 1:25 PM, resident 3 returned to the nurses' station. Resident 3 asked staff for candy. CNA 9 stated resident 3 would have to wait for candy. At 1:28 PM, while still at the nurses' station resident 3 then asked the surveyor for candy. On 5/3/22 at 10:25 AM, resident 3, using her wheelchair, went to the nurses' station. Resident 3 asked Licensed Practical Nurse (LPN) 1 for candy. LPN 1 stated there was no candy, and resident 3 then stated they were going to bed. Resident 3 returned to her room, and LPN 1 then entered resident 3's room. Resident 3 stated they wanted a candy bar. LPN 1 noted to have no response to resident 3. Resident 3 then asked for Tylenol, and LPN 1 asked resident 3 if they were in pain. Resident 3 responded, yes. LPN 1 did not have resident 3 elaborate on pain and did not offer a pharmacological or non-pharmacological pain intervention. After several seconds, resident 3 then asked LPN 1 for candy, and LPN 1 stated they did not have any candy. On 5/3/22 at 11:15 AM, resident 3, using their wheelchair, went to the nurses' station. Resident 3 asked for candy. No staff were at the nurses' station as resident 3 asked for candy. Resident 3 then stated loudly, Tylenol. A staff member walked by and informed resident 3 it was not time for Tylenol, and the staff member stated they did not have any candy. On 5/3/22 at 11:23 AM, resident 3 was observed to yell from their room, Shut the door. Resident 3 then got up from her bed, and slammed her bedroom door shut. On 5/3/22 at 12:05 PM, resident 3 was observed, in the dining room, to eat 2 bites of her mashed potatoes. Resident 3 then stated to staff, I'm going to bed. Resident 3 left dining room by themselves and went to their bedroom. On 5/3/22 at 12:21 PM, resident 3 left her bed, and while using her wheelchair, went to the nurses' station. Resident 3 asked LPN 1 for Tylenol, and resident 3 was informed it was not time for Tylenol. Resident 3 then asked LPN 1 for candy, and LPN 1 responded there was no candy available. On 5/3/22 at 12:37 PM, resident 3, using their wheelchair, returned to the nurse's station. Resident 3 then stood from their wheelchair, and held onto the counter, and then asked LPN 1 for Tylenol. Resident 3 was told they would have to wait until 2:00 PM for Tylenol. Resident 3 then asked LPN 1 for candy, and LPN 1 responded they did not have any candy. On 5/3/22 at 2:30 PM, resident 3 was observed at the nurses' station. Resident 3 asked staff for Tylenol, and staff did not respond. On 5/3/22 at 2:36 PM, resident 3 was observed at the nurses' station. Resident 3 asked staff for Tylenol, and staff did not respond. Resident 3 then asked for candy, and staff did not respond. On 5/3/22 at 2:54 PM, resident 3 was observed at the nurses' station. Resident 3 asked staff for Tylenol, and staff did not respond. Resident 3 then asked for candy, and staff did not respond. On 5/4/22 at 10:08 AM, resident 3 was at the nurses' station. Resident 3 was accepting a Tylenol from LPN 1. LPN 1 asked resident 3 if they were in pain, and resident 3 responded yes and gave the pain a 10 out of 10 level. Resident 3 stated the pain was everywhere in her head. As of 10:29 AM, LPN 1 did not follow-up with resident 3 to identify if the Tylenol medication was effective. On 5/4/22 at 10:29 AM, resident 3 returned to the nurses' station. Resident 3 asked LPN 1 for Tylenol, and resident 3 was told it was not time for Tylenol. Resident 3 then asked LPN 1 for candy, and LPN 1 responded there was no candy. LPN asked resident if they would go to the activity, and resident 3 said they were going to bed. On 5/4/22 at 12:31 PM, resident 3 returned to the nurses' station. Resident 3 asked for Tylenol, and CNA 9 informed resident 3 it was not time for Tylenol. CNA 9 stated resident 3 would have to wait until 2:0 PM. On 5/4/22 at 12:34 PM, resident 3, while standing from their wheelchair, began to yell Tylenol. Resident 3 then stated they wanted to eat, and said, Feed me. On 5/5/22 at 10:35 AM, resident 3 was at the entrance to the dining room. Recreational Therapist (RT) 1 was attempting to entertain resident 3. After 1 minute, resident 3 stated they were going to bed. As resident 3 left the dining room to go to their room, resident 3 stopped at the nurses' station and asked LPN 1 for Tylenol. LPN 1 informed resident 3 it was not time for Tylenol. LPN 1 asked resident 3 if they enjoyed the activity and resident 3 responded, No, and then stated they were going to bed. On 5/5/22 at 10:38 AM, resident 3 returned to the nurses' station and said, Please Tylenol. LPN 1 responded to resident 3 that it was not time for Tylenol and that resident 3 could have Tylenol at 2:00 PM. On 5/5/22 at 11:01 AM, resident 3 left their room and returned to the nurses' station, Resident 3 stood from their wheelchair, and while holding onto the counter of the nurses' station, resident 3 asked for Tylenol. LPN 1 stated it was not time for Tylenol, and resident 3 then asked for an ibuprofen. LPN 1 did not ask resident 3 if they were in pain, but told resident 3 it was not time for any medications. Resident 3 then stated they had a headache, and LPN responded, Try not to scream. That may help your headache. On 5/5/22 at 11:20 AM, other residents were gathered to have coffee prior to lunch and were watching a movie. Resident 3 was not offered or encouraged to join in the dining room. At this time resident 3 remained in their bed. On 5/5/22 at 11:32 AM, resident 3 returned to the nurses' station. Resident 3 asked staff for Tylenol. LPN 1 stated resident 3 would have to wait until 2 PM for Tylenol. Resident 3 was offered a drink, and resident 3 responded, Yes and Tylenol. On 5/5/22 a review of resident 3's medical record was completed. The following were noted, Resident 3 had a Care Plan focus which read, RECREATION: [Name of resident 3 removed] exhibits alteration in thought process manifested by moderate cognitive impairment r/t (related to) dementia; needs reminders/ prompts/cues to choose activities; mood problem: anxiety; has little interest/pleasure in doing things. Date Initiated: 02/18/2022- Revision on: 02/18/2022. Interventions related to this care plan included; a. Check for satisfaction with leisure choices & supply with leisure materials PRN (as needed). Post calendar in room. b. Provide with opportunities to recall long/short term memories during activities. c. Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. Encourage involvement in activities & provide positive praise to increase interest/pleasure during activities. d. Invite, encourage and involve in activities of importance/interest including:family/friend phone calls/visits, TV/movies, music, socials, cards, bingo, games, arts/crafts, painting/drawing, outdoors, reminisce, &/or special events. e. Engage in social/reminisce/discussion activities in accordance to past occupation/life role at a sewing company. Resident 3 had a Care Plan focus which read, [Name of resident 3 removed] has impaired cognitive function/dementia or impaired thought processes r/t Dementia. Date Initiated: 03/06/2022- Revision on: 03/06/2022. Interventions related to this Care Plan focus included; a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Ask yes/no questions in order to determine the [name of resident 3 removed] needs. c. Communicate with the resident/family/caregivers regarding residents capabilities and needs. d. COMMUNICATION: Use [name of resident 3 removed] preferred name, [name of resident 3 removed]. Identify yourself at each interaction. Face [name of resident 3 removed] when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. [Name of resident 3 removed] understands consistent, simple, directive sentences. Provide [name of resident 3 removed] with necessary cues- stop and return if agitated. e. Cue, reorient and supervise as needed. f. Present just one thought, idea, question or command at a time. [Note: The Care Plan did not indicate resident 3's Tylenol and candy seeking behaviors, and did not provide staff with possible interventions for this behavior.] On 5/3/22 at 12:56 PM, LPN 1 was interviewed. LPN 1 stated resident 3 did have a behavior of constantly asking for Tylenol and candy. When asked about interventions for resident 3's Tylenol and candy seeking behavior, LPN 1 stated, I don't know what has been tried. LPN 1 stated staff now tried to redirect resident 3 or just provided resident 3 with a reminder that it was not time for medication or candy. On 5/3/22 at 1:23 PM, CNA 9 was interviewed. CNA 9 stated resident 3 required extensive assistance with cares like using the bathroom, getting dressed, and eating, When she wants to eat. CNA 9 stated resident 3 did need consistent supervision, and CNA 9 stated, We have to watch her more now. CNA 9 stated resident 3 could get, worked up, from her behaviors like when resident 3 wanted a pain pill, wanted candy, wanted a drink, or wanted to sleep. CNA 9 stated if staff had time they tried to go down to resident 3's room and talk with her, but that did not happen regularly. CNA 9 then stated, staff had to remind resident 3 consistently about what was already provided like her pain medication. At this time UM 2 provided input, and stated, She is a normal dementia patient. She just can't remember. On 5/5/22 at 12:05 PM, RT 1 was interviewed. RT 1 stated all dementia residents' Care Plans were, based on the healing heart program. RT 1 stated the healing heart program was a part of the facility staff's dementia training, and RT 1 stated the different colors of the healing heart program correlated with a different level of functioning. RT 1 stated the goals and interventions of a resident's recreation Care Plan were based on the resident's level of functioning. The categories within the healing heart program could be a green healing heart which meant the resident was independent, a yellow healing heart which indicated the resident was higher functioning and need a little more stimulation, a red healing heart indicated moderate dementia, or a lavender healing heart indicated the resident had advanced dementia and would need more sensory based recreation. RT 1 was asked what level of the healing heart program resident 3 would fall within, and RT 1 stated they did not know. RT 1 stated the RT staff had forgotten to review resident 3's healing heart recreation level at her recent assessment. 3. The facility was unable to demonstrate the development and implementation of a Care Plan for a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 45 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/2/22 at 8:25 AM, resident 45 was observed to pace in their wheelchair through halls, and entered other residents' rooms. On 5/2/22 at 10:21 AM, resident 45 continued to pace through the hall in her wheelchair, and sat in front of other residents' room doors. At this time, other residents on the East wing unit were gathered, and brought to the dining room for an activity. On 5/2/22 at 11:36 AM, resident 45 was assisted to the shower room, and was heard to yell, You are hurting me. Following resident 45's time in the shower room, resident 45 was observed to mumble more angrily and loudly at staff and residents. Resident 45 continued to pace into and out of other residents' rooms. At 11:45 AM, resident 45 was attempted to be directed toward the dining room, and resident 45 began to yell. Resident 45 was then allowed to continue to pace the hallways. Other residents were brought to the dining room to be seated for lunch service. On 5/2/22 at 12:59 PM, resident 45 was observed in her room. Resident 45 hollered at her roommate, resident 3. Resident 3 told resident 45, Stop. A resident from a nearby room then came out to the hallway and yelled, Can you make them stop screaming? At this time CNA 9 then entered the room of resident 45 and resident 3. Resident 45 continued to holler, and resident 3 began to ask for candy. CNA 9 left resident 45 and resident 3's room. Resident 45 continued to holler. CNA 9 stated, She can be very agitated, and we just try to calm her down. CNA 9 stated no, CNA 9 was not able to calm down resident 45 right now. On 5/2/22 at 1:34 PM, resident 45 was within their room and began to holler. A CNA entered resident 45's room and resident 45 continued to holler, with a howling type scream, until 1:42 PM. On 5/3/22 at 10:52 AM, resident 45 was observed in the sunroom area of the East wing unit. Resident 45 had another resident yell at her, Get out of here. This is my area. Not yours. Resident 45 then stated with a stutter, I guess I've been left here to die. On 5/3/22 at 10:55 AM, resident 45 paced into a resident room that was not her own. Staff attempted to redirect resident 45, and resident 45 began to holler, with a howling type scream. Resident 45 continued to holler until the staff member walked away from resident 45. Resident 45 then continued to pace through the hall. On 5/3/22 at 11:13 AM, resident 45 paced through the hallway. Staff attempted to redirect resident 45 from bumping into another resident, and resident 45 hollered. Resident 45 then stated to the staff member in stuttered voice, Shut up. That is not funny. On 5/3/22 at 11:22 AM, staff attempted to help resident 45 to change her shirt in resident 45's room. Resident 45 hollered, in a howling tone, No. A resident who walked down the hall then yelled at the room, Shut up. On 5/3/22 at 12:08 PM, resident 45 was assisted to her room to be provided assistance with lunch. Resident 45 began to scream while the CNA attempted to feed resident 45. Resident 45's roommate, resident 3, who was laid in their bed yelled, I want to sleep. The CNA who assisted resident 45 sat on the resident's bed while resident 45 continued to yell for 2 minutes. On 5/3/22 at 1:18 PM, resident 45 was observed in her bed. Resident 45 was alone in their room and had tried to take off their pants. Resident 45 was observed to be yelling, You are hurting me. A CNA who walked by, looked into the room and then continued to walk toward the other end of the East wing unit. On 5/4/22 at 10:03 AM, residents on the East wing unit were gathered in the dining room for snacks and hydration. Resident 45 remained in the hallway and mumbled to herself no staff attempted to redirect or invite resident 45 to the dining room. On 5/4/22 at 12:45 PM, resident 45 was observed in her room. Resident 45 pointed at her roommate, resident 3, and screamed, with a stuttered voice, You are a [OBSCENITY] . CNA 9 was within resident 45 and resident 3's room. CNA 9 was assisting resident 3 to consume ice cream, and resident 45 continued to scream, You're a [OBSCENITY] , and, I'm gonna kick your ass. On 5/4/22 at 12:59 PM, resident 45 was observed within her room, hollering, with a howling type scream. A resident from a different room came to the hall and yelled, Is someone going to do something about that screaming? I want to sleep. On 5/5/22 at 8:17 AM, resident 45 was observed to be in her wheelchair and seated in her room. Resident 45 was pointing at her roommate, and resident 45 called her roommate a [OBSCENITY] several times. Resident 45 then left her room and paced in the hall while, in a stutter voice, she stated, I'm sick of the baby. On 5/5/22 at 10:20 AM, residents were gathered in the East wing dining room for an activity. Resident 45 remained in the hallway and mumbled to herself. Other residents were gathered in the dining room, in a circle, while they conversed and had a snack. At 10:38 AM, resident 45 remained in the same position in the hallway, and mumbled to herself. No staff interacted with resident 45 during this time. On 5/5/22 at 10:41 AM, CNA 11 was observed to attempt to redirect resident 45 toward her room. Resident 45 then began to holler. CNA 11 stated that resident 45 seemed, agitated all the time. From 10:41 AM until 10:49 AM, CNA 11 remained in resident 45's room, and attempted to calm the resident. Resident 45 continued to holler from 10: 41 AM until 10:49 AM. At this time, CNA 11 placed the call light on and LPN 1 went to resident 45's room to assist. As the door was open, resident 45 was observed to repeatedly yell, You are hurting me, and, Stop. On 5/5/22 at 10:51 AM, CNA 11 left resident 45's room. CNA 11 was interviewed about the incident. CNA 11 stated this was her first shift on the east wing unit, and CNA 11 stated they had not previously worked with resident 45. CNA 11 stated they did not know any of resident 45's behaviors at the beginning of their shift, and CNA 11 was unaware of interventions that could be tried if resident 45 began to experience behaviors. CNA 11 stated they learn from this interaction with resident 45 that if resident 45 experienced behaviors it was best to step away. On 5/5/22 at 10:54 AM, LPN 1 was interviewed. LPN 1 stated there were no guides that described to the CNA's all the resident's different behaviors and interventions. LPN 1 stated, we generally have the same CNAs. LPN 1 stated, for CNA 11, since it was her first day LPN 1 would have liked the CNA to come early to their shift. At that time LPN 1 would have provided pointers or information on how certain residents responded to interactions, but CNA 11 had ran late for the start of her shift. LPN 1 stated they were unable to provide CNA 11 with any information prior to the start of CNA 11's shift. On 5/5/22, a review of resident 45's medical record was completed. The following were noted; Resident 45 had a Care Plan focus, related to the activities' department, which read, RECREATION: [Name of resident 45 removed] exhibits alteration in thought process manifested by cognitive impairment r/t dementia; needs reminders/prompts/cues to choose activities; communication difficulties: fragmented thought process; mood problem: psychotic disorder/depression; has physical/verbal behaviors at times. Date Initiated: 04/11/2022. Interventions related to this Care Plan focus included; a. Check for satisfaction with leisure choices & supply with leisure materials PRN. b. Post calendar in room. c. Provide with opportunities to recall long term memories during activities. d. Encourage positive statements/feelings/gestures to increase mood during activities. e. Use validation to help re-direct behaviors and be calm in approach. f. Provide 1:1 (one on one) visit 1 x weekly. g. Engage in red healing heart activities PRN. Engage in my ways preference including: dancing, chicken in a biscuit, bottled Dr. Pepper, listening to music and balloon ball. Deep breathing and taking the time to acknowledge her helps to reduce agitation. h. Invite, encourage and involve in activities of importance/interest including: family/friend phone calls/visits, TV/movies, music, pets, socializing, outdoors, bingo, painting/drawing, adapted games/sports (balloon volleyball), reminisce, &/or special events. i. Support and engage in social/reminisce/discussion activities in accordance to past occupation/life role as a volunteer. [Note: Within resident 45's Care Plan, there was no Care Plan focus related to cognitive function/dementia or impaired thought processes as of 5/3/22.] On 5/4/22 at 12:49 PM, CNA 9 was interviewed. CNA 9 stated resident 45 did best when she could avoid large, loud interactions. CNA 9 stated if resident 45 was experiencing a behavior like yelling, crying, or appeared agitated, CNA 9 would redirect resident 45 to a quiet area. CNA 9 stated at times this could be difficult because the CNA staff were working with other residents, or leading other activities with a group of the east wing residents. On 5/5/22 at 12:05 PM, RT 1 was interviewed about resident 45's recreation related care Plan. RT 1 stated resident 45 was still a newer admit to the facility, and the Activities Department had not completed their quarterly assessment on resident 45. RT 1 stated it could be difficult to include resident 45 in any group activities, but resident 45 enjoyed the time she spent with her son. RT 1 stated the indication that resident 45 was a, red healing heart, actually came from resident 45's stay at a sister facility. RT 1 stated resident 45 had not yet had a formal evaluation completed by this facility. RT 1 stated resident 45's care plan would have to be updated to match her current level of functioning. 4. The facility was unable to demonstrate the implementation of a Care Plan for a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 6:42 AM, the survey team was completing Coronavirus disease screening at the desk in the main lobby. A banging on the door inside the East unit was heard. The Medical Records staff member stated that she thought the sound was from resident 16. On 5/3/22, the following observations were conducted of resident 16 banging on the locked door from the East unit to the main lobby. During these times resident 16 was not provided redirection from staff. At 8:57 AM, 9:03 AM, 9:11 AM, 9:43 AM, 9:58 AM, 10:21 AM, 10:35 AM, 10:42 AM, 11:15 AM, 11:28 AM, 12:04 PM, 12:14 PM, 12:33 PM, 12:45 PM, 1:17 PM, 1:41 PM, 1:47 PM, 1:52 PM, 1:59 PM, 2:10 PM, 2:28 PM, 2:32 PM, 2:37 PM, 2:52 PM, 2:59 PM, and 3:08 PM. On 5/3/22 at 9:56 AM, an activity was observed to be provided by staff in the East unit dining room. Resident 16 was not participating in the activity. Resident 16's medical record was reviewed on 5/3/22. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 16 had a Brief Interview for Mental Status (BIMS) score of 2. A BIMS score of 0 to 7 indicates severely impaired cognition. A care plan Focus initiated on 7/29/21, documented [Name of resident 16 removed] is an elopement risk/wanderer. The care plan interventions included: a. Distract resident 16 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Initiated on 7/29/21. b. Monitor location as necessary. Document wandering behavior and attempted diversional interventions in behavior log. Initiated on 7/29/21. c. Provide structured activities: toileting, walking inside and outside, reorientation strategies including

Based on observation, interview, and record review, it was determined, the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 3 out of 26 sampled residents, the facility was unable to demonstrate development and implementation of interventions for managing residents' dementia with behavioral disturbances. Resident identifiers: 3, 16, and 45. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations were made of resident 3, while on the East wing unit. The following observations were noted; On 5/2/22 at 9:40 AM, resident 3 yelled shut the door. Resident 3 then slammed her bedroom door closed. On 5/2/22 at 10:53 AM, resident 3 was observed to accept a Tylenol pill from the nurse. Resident 3 then asked the nurse when they could be provided with the next Tylenol. Resident 3 then stated, I want to sleep. On 5/2/22 at 12:58 PM, resident 3, using her wheelchair, went to the nurses' station. Resident 3 stated they wanted a Tylenol. Resident 3 then stated they wanted candy. No staff acknowledged resident 3. On 5/2/22 at 1:25 PM, resident 3 returned to the nurses' station. Resident 3 asked staff for candy. Certified Nursing Assistant (CNA) 9 stated resident 3 would have to wait for candy. At 1:28 PM, while still at the nurses' station resident 3 then asked the surveyor for candy. On 5/3/22 at 10:25 AM, resident 3, using her wheelchair, went to the nurses' station. Resident 3 asked Licensed Practical Nurse (LPN) 1 for candy. LPN 1 stated there was no candy, and resident 3 then stated they were going to bed. Resident 3 returned to her room, and LPN 1 then entered resident 3's room. Resident 3 stated they wanted a candy bar. LPN 1 noted to have no response to resident 3. Resident 3 then asked for Tylenol, and LPN 1 asked resident 3 if they were in pain. Resident 3 responded, yes. LPN 1 did not have resident 3 elaborate on pain and did not provide resident 3 with any pain intervention, either pharmacological or non-pharmacological. After several seconds, resident 3 then asked LPN 1 for candy, and LPN 1 stated they did not have any candy. On 5/3/22 at 11:15 AM, resident 3, using their wheelchair, went to the nurses' station. Resident 3 asked for candy. No staff were at the nurses' station as resident 3 asked for candy. Resident 3 then stated loudly, Tylenol. A staff member walked by, and informed resident 3 it was not time for Tylenol, and the staff member stated they did not have any candy. The staff member did not ask resident 3 if they were in pain. On 5/3/22 at 11:23 AM, resident 3 was observed to yell from their room, Shut the door. Resident 3 then got up from her bed, and slammed her bedroom door shut. On 5/3/22 at 12:05 PM, resident 3 was observed, in the dining room, to eat 2 bites of her mashed potatoes. Resident 3 then stated to staff, I'm going to bed. Resident 3 left dining room by themselves, and went to their bedroom. On 5/3/22 at 12:21 PM, resident 3 left her bed, and while using her wheelchair, went to the nurses' station. Resident 3 asked LPN 1 for Tylenol, and resident 3 was informed it was not time for Tylenol. Resident 3 was not asked if they were in pain. Resident 3 then asked LPN 1 for candy, and LPN 1 responded there was no candy available. On 5/3/22 at 12:37 PM, resident 3, using their wheelchair, returned to the nurse's station. Resident 3 then stood from their wheelchair and while they held onto the counter resident 3 asked LPN 1 for Tylenol. LPN 1 did not ask resident 3 if they were in pain. Resident 3 was told they would have to wait until 2:00 PM for Tylenol. Resident 3 then asked LPN 1 for candy, and LPN 1 responded they did not have any candy. On 5/3/22 at 2:30 PM, resident 3 was observed at the nurses' station. Resident 3 asked staff for Tylenol, and staff did not respond. On 5/3/22 at 2:36 PM, resident 3 was observed at the nurses' station. Resident 3 asked staff for Tylenol, and staff did not respond. Resident 3 then asked for candy, and staff did not respond. On 5/3/22 at 2:54 PM, resident 3 was observed at the nurses' station. Resident 3 asked staff for Tylenol, and staff did not respond. Resident 3 then asked for candy, and staff did not respond. On 5/4/22 at 10:08 AM, resident 3 was at the nurses' station. Resident 3 accepted a Tylenol from LPN 1. LPN 1 asked resident 3 if they were in pain, and resident 3 responded yes, and stated their pain level was at a 10 out of 10. Resident 3 stated the pain was everywhere in her head. As of 10:29 AM, LPN 1 did not follow-up with resident 3 to identify if the Tylenol medication was effective. On 5/4/22 at 10:29 AM, resident 3 returned to the nurses' station. Resident 3 asked LPN 1 for Tylenol, and resident 3 was told it was not time for Tylenol. Resident 3 then asked LPN 1 for candy, and LPN 1 responded there was no candy. LPN asked resident 3 if they would go to the activity, and resident 3 said they were going to bed. On 5/4/22 at 12:31 PM, resident 3 returned to the nurses' station. Resident 3 asked for Tylenol, and CNA 9 informed resident 3 it was not time for Tylenol. CNA 9 stated resident 3 would have to wait until 2 PM. CNA 9 did not ask resident 3 if they were experiencing pain. On 5/4/22 at 12:34 PM, resident 3, while standing from their wheelchair, began to yell Tylenol. Resident 3 then stated they wanted to eat, and stated, Feed me. On 5/5/22 at 10:35 AM, resident 3 was at the entrance to the dining room. Recreational Therapist (RT) 1 was attempting to entertain resident 3. After 1 minute, resident 3 stated they were going to bed. As resident 3 left the dining room to go to their room, resident 3 stopped at the nurses' station and asked LPN 1 for Tylenol, and LPN 1 informed resident 3 it was not time for Tylenol. LPN 1 asked resident 3 if they enjoyed the activity, and resident 3 responded No. Resident 3 then stated they were going to bed. On 5/5/22 at 10:38 AM, resident 3 returned to the nurses' station and said, Please Tylenol. LPN 1 responded to resident 3 that it was not time for Tylenol and that resident 3 could have Tylenol at 2:00 PM. Resident 3 was not asked if they were in pain. On 5/5/22 at 11:01 AM, resident 3 left their room and returned to the nurses' station, Resident 3 stood from their wheelchair, and while holding onto the counter of the nurses' station, resident 3 asked for Tylenol. LPN 1 stated it was not time for Tylenol, and resident 3 then asked for an ibuprofen. LPN 1 did not ask resident 3 if they were in pain, but told resident 3 it was not time for any medications. Resident 3 then stated they had a headache, and LPN 1 responded, Try not to scream. That may help your headache. On 5/5/22 at 11:20 AM, other residents were gathered to have coffee prior to lunch and were watching a movie. Resident 3 was not offered or encouraged to join in the dining room. At this time resident 3 remained in their bed. On 5/5/22 at 11:32 AM, resident 3 returned to the nurses' station. Resident 3 asked staff for Tylenol. LPN 1 stated resident 3 would have to wait until 2:00 PM for Tylenol. Resident 3 was offered a drink, and resident 3 responded, Yes and Tylenol. On 5/5/22 a review of resident 3's medical record was completed. The following were noted, Resident 3 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 650 mg (milligrams) by mouth three times a day for Headache -Start Date- 02/24/2022 1900 (7:00 PM). a. In May 2022, for 86% of the acetaminophen medication administrations, resident 3's pain level was documented at 0 out of 10. b. In April 2022, for 93% of the acetaminophen medication administrations, resident 3's pain level was documented at 0 out of 10. c. In March 2022, for 89% of the acetaminophen medication administrations, resident 3's pain level was documented at 0 out of 10. Resident 3 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] =repositioning/ limb, elevation; 2=reassurance/ emotional support; 3=distraction/ diversionary activities; 4=ROM (range of motion)/ ambulation/ stretching; 5=rest period/ quiet environment; 6=deep breathing/ relaxation exercises; 7=massage/ therapeutic touch; 8=application of ice/ heat pack; 9=laughter/ socialization; 10=Aroma therapy; 11=NO PAIN PRESENT. every shift for pain record non pharmacological code and number of episodes a. In May 2022, resident 3's pain level was documented at a level of 0 out of 10 for 100% of the occurrences, and No Pain Present was coded as the non-pharmacological pain intervention. b. In April 2022, resident 3's pain level was documented at a level of 0 out of 10 for 93% of the occurrences, and resident 3's pain level was coded as 1 out of 10 at 7% of the occurrences. Resident 3 was not offered non-pharmacological pain interventions in April 2022. c. In March 2022, resident 3's pain level was documented at a level of 0 out of 10 for 67% of the occurrences, and resident 3's pain level was coded as 1 or 2 out of 10 at 10% of the occurrences. On 70% of the occurrences resident 3 was not provided with any non-pharmacological pain interventions. Within the CNA charting of Activities of Daily Living (ADL) task reporting was a Behavior Monitoring section. The CNA documentation of behavior monitoring of resident 3 for the past 30 days was reviewed. The following was noted; a. At 83% of the occurrences of behavior monitoring documentation, the CNA staff coded, Not Applicable, or None of the above observed b. At 11% of the occurrences of behavior monitoring documentation, the CNA staff coded, Yelling. c. On 1 of the 80 occurrences of behavior monitoring documentation, the CNA staff coded, Repeats movement. d. On 4 of the 80 occurrences of behavior monitoring documentation, the CNA staff coded, Wandering. [Note: On more than 80% of the occurrences of staff behavior monitoring documentation staff did not document that resident 3 exhibited any behaviors.] Resident 3 had a Care Plan focus which read, RECREATION: [Name of resident 3 removed] exhibits alteration in thought process manifested by moderate cognitive impairment r/t (related to) dementia; needs reminders/ prompts/cues to choose activities; mood problem: anxiety; has little interest/pleasure in doing things. Date Initiated: 02/18/2022- Revision on: 02/18/2022. Interventions related to this Care Plan included; a. Check for satisfaction with leisure choices & supply with leisure materials PRN (as needed). Post calendar in room. b. Provide with opportunities to recall long/short term memories during activities. c. Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. Encourage involvement in activities & provide positive praise to increase interest/pleasure during activities. d. Invite, encourage and involve in activities of importance/interest including:family/friend phone calls/visits, TV/movies, music, socials, cards, bingo, games, arts/crafts, painting/drawing, outdoors, reminisce, &/or special events. e. Engage in social/reminisce/discussion activities in accordance to past occupation/life role at a sewing company. Resident 3 had a Care Plan focus which read, [Name of resident 3 removed] has impaired cognitive function/dementia or impaired thought processes r/t Dementia. Date Initiated: 03/06/2022- Revision on: 03/06/2022. Interventions related to this Care Plan focus included; a. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/06/2022. b. Ask yes/no questions in order to determine the [name of resident 3 removed] needs. Date Initiated: 03/06/2022. c. Communicate with the resident/family/caregivers regarding residents capabilities and needs. Date Initiated: 03/06/2022. d. COMMUNICATION: Use [name of resident 3 removed] preferred name, [name of resident 3 removed]. Identify yourself at each interaction. Face [name of resident 3 removed] when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. [Name of resident 3 removed] understands consistent, simple, directive sentences. Provide [name of resident 3 removed] with necessary cues- stop and return if agitated. Date Initiated: 03/06/2022. e. Cue, reorient and supervise as needed. Date Initiated: 03/06/2022. f. Present just one thought, idea, question or command at a time. Date Initiated: 03/06/2022 [Note: The Care Plan did not indicate resident 3's Tylenol and candy seeking behaviors, and did not provide staff with possible interventions for this behavior.] On 5/3/22 at 12:56 PM, LPN 1 was interviewed. LPN 1 stated resident 3 did have a behavior of constantly asking for Tylenol and candy. LPN 1 stated when they assessed resident 3's pain level they would listen to the resident, and also look for physical indicators of pain to understand resident 3's pain level. When asked about interventions for resident 3's Tylenol and candy seeking behavior, LPN 1 stated, I don't know what has been tried. LPN 1 stated staff now tried to redirect resident 3 or just provided resident 3 with a reminder that it was not time for medication or candy. On 5/3/22 at 1:23 PM, CNA 9 was interviewed. CNA 9 stated resident 3 required extensive assistance with cares like using the bathroom, getting dressed, and eating, When she wants to eat. CNA 9 stated resident 3 required consistent supervision, and CNA 9 stated We have to watch her more now. CNA 9 stated resident 3 could get, worked up, from her behaviors like when resident 3 wanted a pain pill, wanted candy, wanted a drink, or wanted to sleep. CNA 9 stated if staff had time they tried to go down to resident 3's room and talk with her, but that did not happen regularly. CNA 9 then stated, staff had to remind resident 3 consistently about what was already provided like her pain medication. At this time Unit Manager (UM) 2 provided input, and stated, She is a normal dementia patient. She just can't remember. On 5/5/22 at 12:05 PM, Recreational Therapist (RT) 1 was interviewed. RT 1 stated all dementia resident Care Plans were, based on the healing heart program. RT 1 stated the healing heart program was a part of the facility staff's dementia training, and RT 1 stated the different color of the healing heart program correlated with a different level of functioning. RT 1 stated the goals and interventions of a resident's recreation Care Plan were based on the resident's level of functioning. RT 1 stated the levels within the healing heart program could be a green healing heart which meant the resident was independent, a yellow healing heart which indicated the resident was higher functioning and needed a little more stimulation, a red healing heart indicated moderate dementia, or a lavender healing heart indicated the resident had advanced dementia and would need more sensory based recreation. RT 1 was asked what level of the healing heart program resident 3 fell within, and RT 1 stated they did not know. RT 1 stated the RT staff had forgotten to review resident 3's healing heart recreation level at her recent assessment. 2. Resident 45 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations were made of resident 45, while on the East wing unit. The following observations were noted; On 5/2/22 at 8:25 AM, resident 45 was observed to pace in their wheelchair through halls, and entered other residents' rooms. On 5/2/22 at 10:21 AM, resident 45 continued to pace through the hall in her wheelchair, and sat in front of other residents' room doors. At this time, other residents on the East wing unit were gathered, and brought to the dining room for an activity. On 5/2/22 at 11:36 AM, resident 45 was assisted to the shower room, and was heard to yell, You are hurting me. Following resident 45's time in the shower room, resident 45 was observed to mumble more angrily and loudly at staff and residents. Resident 45 continued to pace into and out of other residents' rooms. At 11:45 AM, resident 45 was attempted to be directed toward the dining room, and resident 45 began to yell. Resident 45 was then allowed to continue to pace the hallways. Other residents were brought to the dining room to be seated for lunch service. On 5/2/22 at 12:59 PM, resident 45 was observed in her room. Resident 45 hollered at her roommate, resident 3. Resident 3 told resident 45, Stop. A resident from a nearby room then came out to the hallway and yelled, Can you make them stop screaming? At this time CNA 9 then entered the room of resident 45 and resident 3. Resident 45 continued to holler, and resident 3 began to ask for candy. CNA 9 left resident 45 and resident 3's room. Resident 45 continued to holler. CNA 9 stated, She can be very agitated, and we just try to calm her down. CNA 9 stated no, CNA 9 was not able to calm down resident 45 right now. On 5/2/22 at 1:34 PM, resident 45 was within their room and began to holler. A CNA entered resident 45's room and resident 45 continued to holler, with a howling type scream, until 1:42 PM. On 5/3/22 at 10:52 AM, resident 45 was observed in the sunroom area of the East wing unit. Resident 45 had another resident yell at her, Get out of here. This is my area. Not yours. Resident 45 then stated with a stutter, I guess I've been left here to die. On 5/3/22 at 10:55 AM, resident 45 paced into a resident room that was not her own. Staff attempted to redirect resident 45, and resident 45 began to holler, with a howling type scream. Resident 45 continued to holler until the staff member walked away from resident 45. Resident 45 then continued to pace through the hall. On 5/3/22 at 11:13 AM, resident 45 paced through the hallway. Staff attempted to redirect resident 45 from bumping into another resident, and resident 45 hollered. Resident 45 then stated to the staff member in stuttered voice, Shut up. That is not funny. On 5/3/22 at 11:22 AM, staff attempted to help resident 45 to change her shirt in resident 45's room. Resident 45 hollered, in a howling tone, No. A resident who walked down the hall then yelled at the room, Shut up. On 5/3/22 at 12:08 PM, resident 45 was assisted to her room to be provided assistance with lunch. Resident 45 began to scream while the CNA attempted to feed resident 45. Resident 45's roommate, resident 3, who was laid in their bed yelled, I want to sleep. The CNA who assisted resident 45 sat on the resident's bed while resident 45 continued to yell for 2 minutes. On 5/3/22 at 1:18 PM, resident 45 was observed in her bed. Resident 45 was alone in their room and had tried to take off their pants. Resident 45 was observed to be yelling, You are hurting me. A CNA who walked by, looked into the room and then continued to walk toward the other end of the East wing unit. On 5/4/22 at 10:03 AM, residents on the East wing unit were gathered in the dining room for snacks and hydration. Resident 45 remained in the hallway and mumbled to herself no staff attempted to redirect or invite resident 45 to the dining room. On 5/4/22 at 12:45 PM, resident 45 was observed in her room. Resident 45 pointed at her roommate, resident 3, and screamed, with a stuttered voice, You are a [OBSCENITY] . CNA 9 was within resident 45 and resident 3's room. CNA 9 was assisting resident 3 to consume ice cream, and resident 45 continued to scream, You're a [OBSCENITY] , and, I'm gonna kick your ass. On 5/4/22 at 12:59 PM, resident 45 was observed within her room, hollering, with a howling type scream. A resident from a different room came to the hall and yelled, Is someone going to do something about that screaming? I want to sleep. On 5/5/22 at 8:17 AM, resident 45 was observed to be in her wheelchair and seated in her room. Resident 45 was pointing at her roommate, and resident 45 called her roommate a [OBSCENITY] several times. Resident 45 then left her room and paced in the hall while, in a stutter voice, she stated, I'm sick of the baby. On 5/5/22 at 10:20 AM, residents were gathered in the East wing dining room for an activity. Resident 45 remained in the hallway and mumbled to herself. Other residents were gathered in the dining room, in a circle, while they conversed and had a snack. At 10:38 AM, resident 45 remained in the same position in the hallway, and mumbled to herself. No staff interacted with resident 45 during this time. On 5/5/22 at 10:41 AM, CNA 11 was observed to attempt to redirect resident 45 toward her room. Resident 45 then began to holler. CNA 11 stated that resident 45 seemed, agitated all the time. From 10:41 AM until 10:49 AM, CNA 11 remained in resident 45's room, and attempted to calm the resident. Resident 45 continued to holler from 10:41 AM until 10:49 AM. At this time, CNA 11 placed the call light on and LPN 1 went to resident 45's room to assist. As the door was open, resident 45 was observed to repeatedly yell, You are hurting me, and, Stop. On 5/5/22 at 10:51 AM, CNA 11 left resident 45's room. CNA 11 was interviewed about the incident. CNA 11 stated this was her first shift on the East wing unit, and CNA 11 stated they had not previously worked with resident 45. CNA 11 stated they did not know any of resident 45's behaviors at the beginning of their shift, and CNA 11 was unaware of interventions that could be tried if resident 45 began to experience behaviors. CNA 11 stated they learn from this interaction with resident 45 that if resident 45 experienced behaviors it was best to step away. On 5/5/22 at 10:54 AM, LPN 1 was interviewed. LPN 1 stated there were no guides that described to the CNA's all the resident's different behaviors and interventions. LPN 1 stated, we generally have the same CNAs. LPN 1 stated, for CNA 11, since it was her first day LPN 1 would have liked the CNA to come early to their shift. At that time LPN 1 would have provided pointers or information on how certain residents responded to interactions, but CNA 11 had ran late for the start of her shift. LPN 1 stated they were unable to provide CNA 11 with any information prior to the start of CNA 11's shift. On 5/5/22 a review of resident 45's medical record was completed. The following were noted; Resident 45 had a Care Plan focus, related to the activities department, which read, RECREATION: [Name of resident 45 removed] exhibits alteration in thought process manifested by cognitive impairment r/t dementia; needs reminders/prompts/cues to choose activities; communication difficulties: fragmented thought process; mood problem: psychotic disorder/depression; has physical/verbal behaviors at times. Date Initiated: 04/11/2022- Revision on: 04/11/2022. Interventions related to this Care Plan focus included; a. Check for satisfaction with leisure choices & supply with leisure materials PRN. b. Post calendar in room. c. Provide with opportunities to recall long term memories during activities. d. Encourage positive statements/feelings/gestures to increase mood during activities. e. Use validation to help re-direct behaviors and be calm in approach. f. Provide 1:1(one on one) visit 1 x weekly. g. Engage in red healing heart activities PRN. Engage in my ways preference including: dancing, chicken in a biscuit, bottled Dr. Pepper, listening to music and balloon ball. Deep breathing and taking the time to acknowledge her helps to reduce agitation. h. Invite, encourage and involve in activities of importance/interest including: family/friend phone calls/visits, TV/movies, music, pets, socializing, outdoors, bingo, painting/drawing, adapted games/sports (balloon volleyball), reminisce, &/or special events. i. Support and engage in social/reminisce/discussion activities in accordance to past occupation/life role as a volunteer. [Note: Within resident 45's Care Plan, there was no Care Plan focus related to cognitive function/dementia or impaired thought processes as of 5/3/22.] Resident 45 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Within the April 2022 MAR and Treatment Administration Record for behavior monitoring, resident 45 was documented to have exhibited behaviors on 97% of the occurrences. The behaviors charted included one to three of the following; Afraid/Panic, Anger or Screaming/Yelling. At 18% of the documented occurrences of resident 45's behaviors staff did not provide any interventions. A Skilled Nursing Note charted on 4/3/22, read Note Text: [Name of resident 45 removed] current reason for skilled stay is Resident is receiving skilled nursing care for medication management, LTC (long term care) and assists with ADL's r/t dx/PMH (diagnoses/ past medical history) of vascular dementia with behavioral disturbance, hallucinations, delusions . Alertness/ Cognition/ Orientation: Resident a/o x1 (alert and oriented times 1) to self. She is unable to verbalize needs and wants - she starts a sentence then it turns into gibberish. Longterm and shortterm memory impairment.; Mood/Adjustment to Facility: Resident presents asagitated (sic) with frequent yelling - she is difficult to redirect . An Alert Note charted on 4/20/22, read Note Text: At 0010 (12:10 AM) resident was heard screaming in her room. She was sitting on the edge of her bed hitting her right arm. She was assisted to a lying position by nurse and CNA's. Aides (CNA) changed the residents brief while she continued to hit herself and yell. Nurse attempted to administer Tylenol but patient refused. She calmed down and is currently sleeping in bed . An Orders Administration Note for resident 45's [MEDICATION(S)] medication, charted on 4/26/22, read Resident in hallway yelling at everyone. On 5/4/22 at 12:49 PM, CNA 9 was interviewed. CNA 9 stated resident 45 did best when she could avoid large, loud interactions. CNA 9 stated if resident 45 was experiencing a behavior of yelling, crying or appeared agitated, CNA 9 would redirect resident 45 to a quiet area. CNA 9 stated at times this could be difficult because the CNA staff were working with other residents or leading other activities with a group of the East wing residents. On 5/5/22 at 12:05 PM, RT 1 was interviewed. RT 1 stated resident 45 was still a newer admit to the facility, and the Activities Department had not completed their quarterly assessment on resident 45. RT 1 stated it could be difficult to include resident 45 in any group activities, but resident 45 enjoyed the time she spent with her son. RT 1 stated the indication on resident 45's care plan that they were a, red healing heart, actually came from resident 45's stay at a sister facility. RT 1 stated resident 45 had not yet had a formal evaluation completed by this facility. RT 1 stated resident 45's care plan would have to be updated and did not reflect resident 45's evaluation at this facility. 3. Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 6:42 AM, the survey team was completing Coronavirus disease screening at the desk in the main lobby. A banging on the door inside the East unit was heard. The Medical Records staff member stated that she thought the sound was from resident 16. On 5/3/22, the following observations were conducted of resident 16 banging on the locked door from the East unit to the main lobby. During these times resident 16 was not provided redirection from staff. At 8:57 AM, 9:03 AM, 9:11 AM, 9:43 AM, 9:58 AM, 10:21 AM, 10:35 AM, 10:42 AM, 11:15 AM, 11:28 AM, 12:04 PM, 12:14 PM, 12:33 PM, 12:45 PM, 1:17 PM, 1:41 PM, 1:47 PM, 1:52 PM, 1:59 PM, 2:10 PM, 2:28 PM, 2:32 PM, 2:37 PM, 2:52 PM, 2:59 PM, and 3:08 PM. On 5/3/22 at 9:56 AM, an activity was observed to be provided by staff in the East unit dining room. Resident 16 was not participating in the activity. Resident 16's medical record was reviewed on 5/3/22. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 16 had a Brief Interview for Mental Status (BIMS) score of 2. A BIMS score of 0 to 7 indicates severely impaired cognition. A care plan Focus initiated on 7/29/21, documented [Name of resident 16 removed] is an elopement risk/wanderer. The care plan interventions included: a. Distract resident 16 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Initiated on 7/29/21. b. Monitor location as necessary. Document wandering behavior and attempted diversional interventions in behavior log. Initiated on 7/29/21. c. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Initiated on 10/12/21. d. Assess for fall risk. Initiated on 3/4/22 e. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Initiated on 3/4/22. f. Monitor for fatigue and weight loss. Initiated on 3/4/22. A care plan Focus initiated on 11/14/21, documented RECREATION {name of resident 16 removed]exhibits alteration in thought process manifested by cognitive impairment r/t dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; on hospice. A care plan Goal initiated on 3/23/22, documented [Name of resident 16 removed] will accept, as desired, at least 1 Therapeutic 1:1 visit 1x weekly for cognitive activity through next review date. The care plan Interventions included, but not limited to: a. Invite, encourage and involve in activities of importance/interest including: family/friend phone calls/visits, TV/movies, reading, cards, games, caring for baby doll, painting/drawing, gardening seasonal, music, pets, news, socials, outdoors, church support, reminisce, and/or social events. Initiated on 6/14/21. b. Engage in red healing heart activities as needed. Engage in my ways preference including: walking, chocolate, socializing with peers, and family visits. Providing her with a doll, socializing with her friends helps to reduce agitation and wandering. Initiated on 8/6/21. c. Check for satisfaction with leisure choices and supply with leisure materials as needed. Post calendar in room. Provide with opportunities to recall long term memories during activities. Provide 1:1 visit 1x weekly. Provide adaptations to activities as needed. Initiated on 3/23/22. The Task: Activity Participation 1:1 was reviewed for the last 30 days. Resident 16 was provided an outdoor walk on 4/8/22. The Task: Activity Participation Group was reviewed for the last 30 days. Resident 16 participated in nine group activities and actively participated in three group activities. On 5/4/22, the following observations wer[TRUNCATED]

Based on interview and record review, it was determined, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F689 and F880 which were cited within the facility's 2018 and 2019 recertification survey. Also, the facility was found to be in non-compliance with F656 and F744 which were cited within the facility's 2019 recertification survey. Findings included: An annual recertification survey was completed on 9/19/18. During the survey deficiencies F580, F609, F622, F679, F684, F689, F697, F712, F756, F757, F758, F760, F773, F842, and F880 were cited. An annual recertification survey was completed on 12/5/19. During the survey deficiencies F604, F656, F676, F684, F689, F725, F744, F761, and F880 were cited. An abbreviated, complaint survey was completed on 12/14/20. During the survey deficiency F580, F600, F607, F609, F610, F744, F835, F865, and F943 were cited. 1. Based on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 7 out of 26 sampled residents, the facility did not ensure implementation of a resident's care plan interventions regarding limited range of motion and contractures; for three residents, the facility did not update and implement interventions for fall prevention; and, for three residents, the facility was unable to demonstrate development and implementation of dementia related care plans. Resident identifiers: 3, 15, 16, 32, 45, 48, and 53. [Cross Reference F656] 2. Based on observation, interview, and record review, it was determined, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 26 sampled residents, residents that had multiple falls with injuries were not provided interventions or adequate supervision to prevent falls from occurring. A resident had a fall that resulted in a left [CONDITION(S)] and the resident was hospitalized . In addition, a resident had a fall resulting in a hematoma to the forehead. Resident identifiers: 32, 48, and 53. [Cross Reference F689] 3. Based on observation, interview, and record review, it was determined, the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 3 out of 26 sampled residents, the facility was unable to demonstrate development and implementation of interventions for managing residents' dementia with behavioral disturbances. Resident identifiers: 3, 16, and 45. [Cross Reference F744] 4. Based on observation and interview, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff administering medications without following hand hygiene protocols, staff were observed to utilize communal vital signs equipment without sanitizing the equipment between resident usage, and residents were observed to consume food items off of other residents dirty meal trays and other residents were observed to consume food from the facility trash cans. Resident identifiers: 10, 16, 25, 33, 35, 40, 45, and 48. [Cross Reference F880] On 5/5/22 at 2:23 PM, the facility Administrator (ADM) was interviewed. The ADM stated the facility held QAA meetings monthly, except for one month within the past calendar year, when the facility dealt with a Coronavirus Disease outbreak. The ADM stated the facility held their QAA meetings on the third Tuesday of every month, and those in attendance included the ADM, the Medical Director, the Director of Nursing, the Unit Managers, Business Office Manager, Minimum Data Set (MDS) Coordinator, Social Services Director, Director of Rehabilitation, the Nurse Practitioner, and the Pharmacist. The ADM stated they meet personally with the Housekeeping Manager, Dietary Manager, and Maintenance Director to review any monthly audits that the departments had completed. The ADM stated the facility determined which topics would be discussed based on the facility's quality measures. Some areas that the facility typically reviewed during this meeting included, a review of the facility's financial's, the risk assessment report, fall risk, rehospitalization s, and a report of the [CONDITION(S)] meeting. The ADM stated other areas that had recently become QAA meeting topics included employee retention and MDS tracking with a focus on re-education of the facility's Certified Nursing Assistants. The ADM stated outside of the topics that were always reviewed, the facility also determined QAA meeting topics through observations and areas for improvement identified by facility staff. The ADM stated, two recent QAA meeting topics which were identified by facility staff included the documentation process for resident showers and bathing, as well as the facility's Urinary Tract Infection rate.

Based on observation and interview, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff administering medications without following hand hygiene protocols, staff were observed to utilize communal vital signs equipment without sanitizing the equipment between resident usage, and residents were observed to consume food items off of other residents dirty meal trays and other residents were observed to consume food from the facility trash cans. Resident identifiers: 10, 16, 25, 33, 35, 40, 45, and 48. Findings included: 1. On 5/4/22, observations were made of Registered Nurse (RN) 1 not sanitizing their hands between medication administrations to different residents. On 5/4/22 at 7:32 AM, an observation was made of RN 1 preparing resident medications. RN 1 was observed to not perform hand hygiene before preparing resident 35's medications. In addition, RN 1 was observed to not perform hand hygiene after the administration of resident 35's medications and before RN 1 began the preparation of resident 40's medications. On 5/4/22 at 7:57 AM, an interview was conducted with RN 1. RN 1 stated that before preparing medications to pass to the residents she would sanitize her hands. RN 1 stated that all staff that handle medications should sanitize before and after all medication administrations. On 5/4/22 at 8:12 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated she had trained her staff on the principles of infection control, and all of the staff were expected to sanitize their hands before providing direct care, in between residents, and after providing direct care. UM 2 stated that she would expect the nurses to perform hand hygiene between passing medications to residents, as well as in between medications while preparing them. 2. On 5/4/22, observations were made of facility staff utilizing communal vital signs equipment without sanitizing the equipment between use on residents. The following observations were conducted of staff obtaining resident vital signs on 5/4/22: a. At 2:19 PM, Certified Nursing Assistant (CNA) 8, who worked on the East wing unit, was observed to clean the vital signs equipment at the nurses station. b. At 2:21 PM, CNA 8, who worked on the East wing unit, was observed to obtain vital signs from the resident in room [ROOM NUMBER] bed B. CNA 8 did not clean the blood pressure (BP) cuff or the pulse oximeter after use. [Note: CNA 8 was observed to use a wrist BP cuff.] c. At 2:23 PM, CNA 8, who worked on the East wing unit, was observed to obtain vital signs from the resident in room [ROOM NUMBER] bed B. CNA 8 did not clean the BP cuff or the pulse oximeter after use. d. At 2:26 PM, CNA 8, who worked on the East wing unit, was observed to obtain vital signs from the resident in room [ROOM NUMBER] bed B. CNA 8 did not clean the BP cuff or the pulse oximeter after use. e. At 2:30 PM, CNA 1, who worked on the West wing unit, was observed to leave a resident's room with the vital signs machine, which included an automatic blood pressure cuff, pulse oximeter and thermometer. Without sanitizing the vital signs machine, CNA 1 placed the equipment into a purple fabric bag. f. At 2:41 PM, CNA 6, who worked on the East wing unit, was observed to obtain vital signs from the resident in room [ROOM NUMBER] bed A during the activity. CNA 6 did not clean the BP cuff or the pulse oximeter after use. g. At 2:43 PM, CNA 6, who worked on the East wing unit, was observed to obtain vital signs from the resident in room [ROOM NUMBER] bed A during the activity. CNA 6 did not clean the BP cuff or the pulse oximeter after use. On 5/5/22 at 12:15 PM, an interview was conducted with CNA 9. CNA 9 stated that she would clean the vital signs equipment every time before she used the vital signs equipment because she was not sure if the staff member prior cleaned the vital signs equipment before putting it away. CNA 9 stated that after she had obtained the resident vital signs she would clean the vital signs equipment prior to putting them away. On 5/5/22 at 12:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the vital signs equipment should be cleaned between every resident. LPN 1 stated that staff should use the purple top germicidal wipes to clean the vital signs equipment and they should wait for them to dry. On 5/5/22 at 1:21 PM, an interview was conducted with UM 1. UM 1 stated the vital signs equipment should be cleaned between each resident use. UM 1 stated the staff should use the purple top germicidal wipes to clean the vital signs equipment. UM 1 stated the cleaning procedure was the same for both sides of the facility. 3. Observations were made of residents consuming food from other residents dirty trays and from facility trash cans. On 5/2/22 at 8:31 AM, while in the dining room, resident 45 was observed to eat food from other resident's used trays after the breakfast meal. On 5/2/22 at 8:46 AM, resident 33 stated that she was hungry. Resident 33 was observed to grab a bowl from the dirty dishes cart and started eating the contents of the bowl. CNA 10 was observed to try and get the bowl from resident 33. On 5/2/22 at 10:57 AM, resident 33 was observed to consume crackers. Resident 33 was then observed to lick her fingers, and then pick cracker crumbs off of a resident seated next to her. Resident 33 consumed the crumbs as she picked them off of the other resident's clothing. On 5/2/22 at 12:33 PM, resident 45 was observed, in their wheelchair, to wander out of resident 48's room. As resident 45 was leaving resident 48's room they were consuming pie crust. On 5/2/22 at 12:39 PM, an interview was conducted with resident 48. Resident 48 stated that resident 45 ate his roommates lunch. [Note: Resident 45's roommate was blind.] On 5/3/22 at 12:23 PM, resident 16 was observed to be pacing in her wheelchair. Resident 16 was observed to grab cake from a resident's used lunch tray, and the resident began to eat the cake as resident 16 continued to pace through the hallway. On 5/3/22 at 12:42 PM, resident 25 was observed to pace around the dining room following lunch service. Resident 25 was observed consuming leftover food from other residents' trays, as well as, consuming beverages from other resident's used cups. On 5/3/22 at 12:50 PM, resident 45, while in their wheelchair, was observed to pace into other residents' rooms. Resident 45 was observed to enter resident 16's room, and resident 45 consumed a puree substance from resident 16's used meal tray. On 5/3/22 at 12:53 PM, resident 45 was observed to pace through the hall while consuming a pudding like substance from a cup. Resident 45 then left their used cup near a window in the sunroom area. After the cup was left near the window, resident 33 approached the cup and began to consume some leftover pudding from the used cup. On 5/4/22 at 12:37 PM, resident 33 was observed to approach a trash can in the communal dining room. Resident 33 was observed to place her hand into the trash can, and began to lick her fingers as she gathered food scraps from the trash can. On 5/4/22 at 12:44 PM, resident 10 was observed to wander into the dining room, and resident 10 began to consume a different resident's left over snack from the table.

Based on interview and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease-2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 2 out of 26 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal, acceptance, or education of the benefits and potential risks associated with the COVID-19 vaccination. Resident identifiers: 10 and 43. Findings included: 1. Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 43's medical record was reviewed on 5/5/22. A review of the immunization section of the medical record documented that resident 43's COVID-19 consent status was refused. A COVID-19 Responsible Party Consent Form was provided and not included within resident 43's medical record. 2. Resident 10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 10's medical record was reviewed on 5/5/22. A review of the Immunization section of the medical record revealed no documentation regarding resident 10's COVID-19 immunization status. No documentation was located indicating that resident 10 or the resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccination. On 5/5/22 at 2:46 PM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated the immunization consents were to be done on admission. UM 2 stated the immunization consents were located in the admission packed. UM 2 stated that once the consents were signed they were uploaded in the resident medical record and the nurse would input the dates under the immunization tab.

Based on observation, interview, and record review, it was determined, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion. Specifically, for 1 out of 26 sampled residents, a resident with limited range of motion (ROM) was not provided with the prescribed interventions for prevention of further decreased range of motion. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 8:45 AM, resident 15 was observed seated in the dining room, in a reclining wheel chair with their legs bent to the side, and a pillow was placed behind resident 15's legs. Resident 15 did not have any towels placed in their hands during this observation. At the time of this observation resident 15 was being provided with total assistance with breakfast meal consumption. On 5/4/22 at 9:05 AM, resident 15 was observed seated in their wheelchair in their bedroom. Resident 15 was looking out the window, and at the time of this observation resident 15 did not have a pillow behind her legs and did not have towels or cloths in her hands. On 5/4/22 at 11:09 AM, resident 15 was observed in their wheelchair and seated in the hallway. Resident 15 was making a whining noise and was wincing. Registered Nurse (RN) 1 did acknowledge resident 15 and stated that resident 15 had just received their [MEDICATION(S)] medication, and RN 1 stated resident 15 should feel less pain soon. At the time of this observation resident 15 did not have towels or cloths in her hands and did not have a pillow behind her legs. On 5/5/22, a review of resident 15's medical record was completed. The following were noted; Resident 15's Treatment Administration Record had an order which read, Hand towels to be placed in bilateral hands every shift for contractures -Start Date- 03/10/2022 1800 (6:00 PM). Resident 15 had a Care Plan Focus which read, [Name of resident 15 removed] has contractures in bilateral upper extremities and hands. Date Initiated: 03/10/2022. Interventions in place regarding this Care Plan Focus included; a. Hand towel encouraged to be placed in bilateral hands. Date Initiated: 03/10/2022; Revision on: 04/22/2022. b. Provide gentle ROM to upper and lower extremities. Date Initiated: 03/10/2022. c. PT (physical therapy), OT (occupational therapy), ST (speech therapy) to eval (evaluate) and treat as needed. A Nursing Note dated 1/26/22, read Note Text: CNA's (Certified Nursing Assistant) notified nurse that [name of resident 15 removed] left leg is contracted. When trying to straighten it she seems to be in pain. There is no redness, swelling or bruising. Talked to NP (Nurse Practitioner), x-ray ordered. A Nursing Note dated 1/27/22, read Note Text: Xray ordered of leg and hip due to contracture. Results received showing arthritis, no fractures. NP notified of results, no new orders at this time. POA(Power of Attorney) notified. A Skilled Nursing Note dated 3/23/22, read Note Text: [Name of resident 15 removed] current reason for skilled stay is Medication management, ADL (Activities of Daily Living) care, Alzheimer disease . Alertness/ Cognition/ Orientation: resident is alert to self; Mood/Adjustment to Facility: resident yells out at night 'help'. resident currently resting in bed . Musculoskeletal: contractures, nonambulatory, generalized weakness . The resident's functional status ability is: The resident is dependent with bed mobility; transfers did not occur; dependent with eating; dependent with toileting; walking did not occur; and locomotion did not occur. A Skilled Nursing Note dated 3/30/22, read Note Text: [Name of resident 15 removed] current reason for skilled stay is Patient Requires ongoing skilled Nursing Care r/t (related to) Alzheimer's type Dementia, rendering her in need of Supervision and assist with daily grooming and hygiene tasks, as well as medication management and administration . Alertness/ Cognition/ Orientation: Semi-alert and responsive. Oriented to self and immediate environment at times . Musculoskeletal: Non ambulatory, Contractures, generalized weakness . The resident's functional status ability is: The resident is dependent with bed mobility; transfers did not occur; dependent with eating; dependent with toileting; walking did not occur; and locomotion did not occur. A Skilled Nursing Note dated 4/5/22, read Note Text: [Name of resident 15 removed] current reason for skilled stay is Patient Requires ongoing skilled Nursing Care r/t Alzheimer's type Dementia, rendering her in need of Supervision and assist with daily grooming and hygiene tasks, as well as medication management and administration . Alertness/ Cognition/ Orientation: Alert to self; Mood/Adjustment to Facility: Resident currently resting calmly in bed. Occasionally yells out . Musculoskeletal: Non ambulatory, generalized weakness, contractures . The resident's functional status ability is: The resident requires extensive assist with bed mobility; extensive assist with transfers; extensive assist with eating; extensive assist with toileting; extensive assist with walking; and extensive assist with locomotion. On 5/4/22 at 9:05 AM, CNA 6 was interviewed. CNA 6 stated they had worked with resident 15, for a long time. CNA 6 stated staff placed pillows behind resident 15's legs when resident 15 was in her wheelchair because of contractures. CNA 6 stated resident 15's contractures in her legs were getting worse. CNA 6 stated they did not know if resident 15 was having worsening ROM to her upper extremities or hands and CNA 6 stated they did not know of any interventions resident 15 had in place to prevent contractures or worsening ROM to their upper extremities. CNA 6 stated, You would have to ask the nurse. On 5/4/22 at 9:15 AM, CNA 3 was interviewed. CNA 3 stated staff placed pillows behind resident 15's legs while resident 15 was in their wheelchair to provide resident 15 with comfort and to prevent her legs from hitting the back of the chair. CNA 3 stated resident 15 did not have any issues with limited ROM in their upper extremities and there were no interventions in place for preventing decreased ROM to resident 15's upper extremities. CNA 3 stated resident 15 only had contractures to their knees. On 5/4/22 at approximately 9:20 AM, RN 1 was interviewed. RN 1 stated resident 15 did have contractures to her upper extremities and staff were to place cloths in resident 15's hands. RN 1 stated the CNA staff were to place the cloths in resident 15's hands daily to help prevent her hands from closing more and RN 1 stated CNA staff were also to provide resident 15 with exercises for her hands to prevent worsening ROM. RN 1 stated resident 15's contractures were in her hands as well as her legs, and resident 15 was on comfort care measures so the staff were trying to keep resident 15 comfortable. RN 1 stated the contractures do appear to cause resident 15 pain. RN 1 stated the presence of contractures was within resident 15's Care Plan and this would then relate with the CNA's Brain, which was a sheet that described the cares each resident on the unit required. Resident 15's section of the CNA Brain read, Dressing/splint care: Dressing [name of resident 15 removed] requires up to extensive to total assist of one to two staff to dress upper body and is dependent on dressing lower body and donning her shoes. [Note: Within resident 15's section of the CNA Brain there was no mention of contractures or limited ROM with applicable interventions.] On 5/4/22 at 9:41 AM, CNA 7, who worked for the facility as an agency CNA, was interviewed. CNA 7 stated resident 15 had issues with ROM. CNA 7 stated resident 15 would demonstrate that they were in pain and complained unless the resident was left in a specific position. CNA 7 stated resident 15 did not have any contractures. CNA 7 stated once resident 15 was placed in her wheelchair she wanted to be left in one position. CNA 7 stated if resident 15 did have contractures or had any interventions in place for limited ROM the CNAs would be prompted of this on their ADL task reporting, or the CNA could learn of a resident's contractures or limited ROM interventions through report from the night shift CNA. On 5/4/22 at 11:49 AM, Unit Manager (UM) 2 was interviewed. UM 2 stated resident 15 was observed to have contractures to her lower extremities around the end of January 2022. UM 2 stated when a CNA observed resident 15's legs were contracted the facility did x-rays to ensure there were no issues, and UM 2 stated the x-rays indicated osteoporotic changes. UM 2 stated resident 15 did not have any limited ROM or contractures to their upper extremities. Upon review of resident 15's care plan, UM 2 stated, resident 15 did have a care plan initiated in March of 2022 which indicated resident 15 had bilateral upper extremity contractures. UM 2 stated staff should place towels in resident 15's hands and provide resident 15 with ROM exercises. UM 2 stated CNA staff would implement both of these interventions, and the CNAs should be aware of the interventions through review of the CNA Brain. UM 2 then reviewed the CNA Brain, and stated the interventions to prevent further decreased ROM in resident 15's upper extremities were not present on the CNA Brain.

Based on interview and record review, it was determined, the irregularities noted by the pharmacist during the drug regimen review were not reported to the attending physician and the facility's Medical Director (MD) and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 2 out of 26 sampled residents, recommendations were not acted upon timely after the pharmacist made the recommendation. Resident identifiers: 4 and 18. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, dementia with behavioral disturbance, need for assistance with personal care, type 2 diabetes mellitus with [CONDITION(S)], essential hypertension, [CONDITION(S)], chronic diastolic heart failure, and chronic kidney disease. Resident 4's medical record was reviewed on 5/3/22. The Pharmacy Consultation Report dated 2/15/22, documented Please monitor a [MEDICATION(S)] concentration on the next convenient lab (laboratory) day, every 6 months, and as clinically indicated. The Physician's Response documented I accept the recommendation(s) above, please implement as written. The Consultation Report was signed and dated by the physician in March 2022. The Pharmacy Consultation Report dated 3/11/22, documented [Name of resident 4 removed] has orders for labs pursuant to a pharmacy recommendation, but at the time of this review they were not available in the medical record. The missing lab values include: [MEDICATION(S)] level. Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. The Doctor of Nursing Practice (DNP) signed the recommendation on 3/21/22. A physician's order dated 3/21/22, documented a complete blood count, comprehensive metabolic panel, glycated hemoglobin, intact [MEDICATION(S)], Phosphorus, Vitamin D level, ammonia, and [MEDICATION(S)] lab draw one time only. [Note: The lab draw was completed on 3/22/22. That indicated a delay of 35 days from the initial recommendation to the placement of the lab order for resident 4's [MEDICATION(S)] level.] 2. Resident 18 was admitted to the facility on [DATE] with medical diagnoses that included, but were not limited to, Alzheimer's disease, dementia, major depressive disorder, hypertension, hereditary and idiopathic [CONDITION(S)], cognitive communication deficit, mild protein-calorie malnutrition, abnormalities of gait and mobility, and need for assistance with personal cares. A review of resident 18's medical record was completed on 5/5/22. The following were noted; Resident 18 had a Pharmacy Consultation Report dated 2/15/22, which read, Comment: [Name of resident 18 removed] receives [MEDICATION(S)] .Recommendation: Please monitor a [MEDICATION(S)] trough concentration on the next convenient lab day, every 6 months, and as clinically indicated. Resident 18 had a Pharmacy Consultation Report dated 2/15/22, which read, [Name of resident 18 removed] receives potentially duplicate therapy of [MEDICATION(S)] 40mg (milligram) QD (every day) and famotidine 20mg BID (twice a day). Please reevaluate the need for both agents, perhaps giving consideration to discontinuing use of [MEDICATION(S)]. Resident 18 had a Pharmacy Consultation Report dated 3/11/22, which read, Comments: [Name of resident 18 removed] has orders for labs pursuant to a pharmacy recommendation, but at the time of this review they were not available in the medical record. The missing lab values include: [MEDICATION(S)] level . Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. Resident 18 had a Pharmacy Consultation Report dated 3/11/22, which read, [Name of resident 18 removed] receives potentially duplicate therapy of [MEDICATION(S)] 40mg QD and Famotidine 20mg BID. Recommendation: Please reevaluate the need for both agents, perhaps giving consideration to discontinuing use of [MEDICATION(S)]. If dual therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. Resident 18 had a Medication Administration Record (MAR) order, which read, [MEDICATION(S)] Sprinkles Capsule Sprinkle 125 MG ([MEDICATION(S)]) Give 250 mg by mouth four times a day for UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE -Start Date- 01/28/2022. An order within resident 18's Lab/Diagnostic Administration Report placed on 3/22/22 read, [MEDICATION(S)] one time only for 1 Day. [Note: A Pharmacy Consultation Report from 2/15/22, indicated resident 18's physician should monitor a [MEDICATION(S)] trough concentration on the next convenient lab day and every 6 months. That indicated a delay of 35 days from the initial recommendation to the placement of the lab order for resident 18's [MEDICATION(S)] level.] Resident 18 had a MAR order which read, Famotidine Tablet 20 MG. Give 1 tablet by mouth two times a day for heartburn -Start Date- 12/01/2021. Resident 18 had a MAR order which read, [MEDICATION(S)] Tablet Delayed Release 40 MG ([MEDICATION(S)] Sodium). Give 1 tablet by mouth one time a day for GERD (gastroesophageal reflux disease) -Start Date- 12/02/2021 -D/C (discontinue) Date- 03/21/2022. [Note: A Pharmacy Consultation Report from 2/15/22, indicated resident 18's physician should reevaluate the need for dual GERD treatments. That indicated a delay of 34 days from the initial recommendation to the adjustment to resident 18's medication management of GERD.] A Nursing Note, written by Unit Manager (UM) 1, and dated 3/21/22 read, Note Text: Pharm (Pharmacy) rec (recommendation) requests [MEDICATION(S)] lab r/t (related to) [MEDICATION(S)] use. MD ordered, POA (Power of Attorney) notified and consented. On 5/4/22 at 8:54 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if the DNP told her to draw a lab on a resident she would write the order and put the requisition form in the lab book. LPN 1 stated the outside lab staff were at the facility every Tuesday. LPN 1 stated that she could order a lab for an immediate draw if ordered. LPN 1 stated the outside lab staff would draw the labs and would let her know who was completed by giving her the pink copy of the requisition form. LPN 1 stated that resident 4 often refused labs to be drawn but the refusal would be documented. LPN 1 stated the DNP would review the labs through the outside lab portal. On 5/4/22 at 9:57 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated the pharmacist would attend the quality assurance meetings monthly with the MD and clinical team. UM 1 stated the pharmacist would make recommendations based off of the meeting and the pharmacist would email the recommendations to the DON and the UMs. UM 1 stated the recommendations were reviewed by the DON and the UMs. UM 1 stated that she would ensure that the recommendations were signed off by the MD. UM 1 stated there was an issue with the pharmacy recommendations that was identified with the new DON. UM 1 stated the old DON had a different process. UM 1 stated the old DON left in February 2022. UM 1 stated there were months that the pharmacy recommendations were not being followed through with.

Based on interview and record review, it was determined, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 26 sampled residents, a resident's hypertensive medications were not held when the blood pressure (BP) measurements were outside of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4's medical record was reviewed on 5/3/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] time a day for hypertension. Hold if systolic blood pressure (SBP) < (less than) 110 or diastolic blood pressure (DBP) <60. Notify the MD if SBP > (greater than) 170. A review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pharmacy Consultation Report dated 3/11/22, documented [Name of resident 4 removed] has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] also has unclear hold directions. Please clarify the MAR. The Doctor of Nursing Practice (DNP) signed the recommendation on 3/21/22. A review of the March and April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 3/23/22, SBP 178 b. On 3/24/22, SBP 174 c. On 3/29/22, SBP 188 d. On 4/4/22, SBP 176 e. On 4/5/22, SBP 178 f. On 4/23/22, SBP 173 g. On 4/24/22, SBP 186 A review of the April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 4/1/22, DBP 59 b. On 4/10/22, DBP 55 c. On 4/15/22, DBP 58 A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for SBP <110 or <60. Notify the MD if SBP >170. A review of the February, March, and April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/8/22, SBP 185 b. On 2/10/22, SBP 174 c. On 2/27/22, SBP 176 d. On 3/12/22, SBP 177 e. On 3/17/22, SBP 173 f. On 3/18/22, SBP 174 g. On 3/29/22, SBP 188 h. On 4/4/22, SBP 178 On 5/4/22 at 8:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the medication parameters would be on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 stated the system would not alert the nurse if the parameters were outside of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <60 was usually not a parameter. LPN 1 stated the general parameters were to notify the MD if the SBP was <110 or the pulse was <60. LPN 1 stated she would not hold the medication if the vital signs were outside the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 stated if the MD was in the facility she would notify verbally. LPN 1 stated if the vital signs were below the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 stated if a medication was held the MD or DNP were automatically notified by review of the documents. LPN 1 stated the DNP was in the facility almost daily and the DNP would review the residents MAR. LPN 1 further stated the order summary on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/22 at 8:40 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . UM 1 stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . UM 1 stated she was unsure why all the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/4/22 at 10:24 AM, a followup interview was conducted with UM 1. UM 1 stated the MD or DNP would be notified through the secure text system. UM 1 stated the secure text system auto deleted after the message was taken care of. UM 1 stated the DBP <60 should have been for the pulse.

Based on interview and record review, it was determined, the facility did not obtain laboratory (lab) services to meet the needs of its residents. Specifically, for 1 out of 26 sampled residents, a resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifier: 40. Findings included: Resident 40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 40's medical record was reviewed on 5/4/22. A care plan focus dated 2/28/21, documented [Name of resident 40 removed] is at risk for infection r/t (related to) dementia, dysphagia and [CONDITION(S)]. An intervention documented Complete diagnostic imaging and labs as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation could be located indicating that the [MEDICATION(S)] level had been drawn, as ordered by the physician, on the scheduled date of 2/5/22. On 5/4/22 at 12:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she did not work during the first week of February 2022. RN 1 stated she did not remember if resident 40 had his labs drawn. RN 1 stated I know this is a big one, we wouldn't have skipped it, whoever was working. On 5/4/22 at 12:23 PM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated the first week of February was when the labs for resident 40 should have been done. UM 2 requested additional time to review resident 40's medical record. On 5/4/22 at 1:05 PM, a followup interview was conducted with UM 2. UM 2 confirmed that the physician ordered labs had not been drawn in February 2022. UM 2 stated that she had called the facility physician for a new order so the labs could be drawn immediately.

Based on interview and record review, it was determined for 4 of 6 sample residents that the facility did not ensure that residents were free from abuse. Specifically, three residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was appropriate or safe. In addition, interventions were inconsistent with regard to how facility staff addressed the behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). The facility's failure to protect residents from sexual abuse was determined to constitute Immediate Jeopardy to resident safety for residents 2 and 3. In addition, one resident with wandering behaviors was subjected to physical and verbal abuse by other residents. Resident identifiers: 2, 3, 4 and 5. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator, Director of Nursing (DON), two corporate nurses, and the corporate Regional Vice President (RVP) on 12/8/20 at 11:30 AM. At that time, the Administrator, DON, corporate nurses and RVP were were informed of the findings of Immediate Jeopardy pertaining to F600 and asked to develop an immediate plan to ensure that the residents of the facility were free from abuse. On 12/10/20 the Administrator provided the following written allegation of removal of the Immediate Jeopardy: . 1. ACTIONS TAKEN TO REMOVE IMMEDIACY a. Male resident referred to psychiatrist for evaluation by DON/designee. Male resident will have a comprehensive assessment by IDT (Interdisciplinary) team using a behavioral root cause analysis tool to identify triggers, and develop care plan to address those triggers. Care plan will be updated to include approaches for the resident and strategies to prevent behaviors. Psychiatrist states resident meets criteria for inpatient psychiatric hospitalization treatment. Psychiatrist is currently referring resident to psychiatric facility for treatment. b. Female resident is being monitored for behavior changes by DON/Designee. Female resident will have a comprehensive assessment completed by IDT team using a behavioral root cause analysis tool to identify triggers, and develop care plan to address those triggers. Care plan will be updated to include approaches for the resident and strategies to prevent behaviors. c. Male resident moved from dementia unit to long-term side of facility and placed on a 24/7 1:1 by DON/Designee. Comprehensive examination completed by the psychiatrist on 12/8/20 who states that resident meets criteria for inpatient psychiatric hospitalization treatment. Psychiatrist is currently referring resident to psychiatric facility for treatment. Until resident can be transferred to Psychiatric hospital, he will remain on a 24/7 1:1. Resident will be reevaluated by facility IDT and medical director prior to returning to Willow Wood to ensure an appropriate plan of care has been developed. d. BIMS (Brief Interview for Mental Status) score and pHQ9 (Patient Health Questionnaire) will be completed on male and female resident by DON/Designee. e. Head to toe assessment completed on male and female resident to assess for physical injuries by DON/Designee. f. Current residents on the Journey's Unit will have a comprehensive behavioral analysis assessment i.e. BARS (Brief Agitation Rating Scale) completed to identify high risk behaviors. Any resident who triggers will have a comprehensive assessment by IDT team using a behavioral analysis tool to identify triggers, and develop care plan to address those triggers. Care plan will be updated to provide interventions staff can easily understand and are capable of implementing. Staff will be educated by DON/Designee to care planned interventions. g. Head to toe skin assessment initiated on Journey's Community residents to identify for physical signs of abuse by DON/Designee. h. Current residents with a BIMs >9 were interviewed by Administrator/designee to determine if they feel safe and do not have any issues or concerns with the care they receive. i. Current residents with BIMS <9, will have a BARs (Brief Agitation Rating Scale) assessment, staff assessment of PHQ9 and head to toe skin assessment by DON/Designee to identify for signs of symptoms of abuse. SPECIFIC ACTIONS TAKEN BY FACILITY On 12/8/20 we completed a head to toe assessment, resident was moved to Long Term Care side of facility and placed on a 1:1, Psychiatrist completed a telehealth visit with resident and changed medications. On 12/9/20 a BIMS, BAR, PHQ9 was completed with a behavioral analysis and care plan updated with triggers identified and strategies to prevent further behaviors. On 12/9/20 a BIMS, BAR, PHQ9 was complete, behavioral analysis completed with triggers identified and care plan updated with strategies to prevent further behaviors. On 12/8/20 male was moved from dementia unit to long term care side of facility and placed on a 1:1. Male resident was discharged to a behavioral unit on 12/10/20 at 13:50 (1:50 PM). All residents in the building BIMs and PHQ9 was redone and completed by SSW (Social Services Worker) on 12/9/20 (and) 12/10/20. All residents in the building had a head to toe completed assessment on 12/9/20 with no evidence of physical abuse identified. On 12/9/20 all journey's unit residents had a BARS completed by the SSW and 8 residents were identified and the IDT met to complete the behavioral analysis, identify triggers, updated the care plan with strategies and interventions for the staff to prevent further behaviors. All Journey's residents had a head to toe completed assessment on 12/9/20 with no evidence of physical abuse identified. On 12/8/20 and 12/9/20 all current residents with a BIMs >9 were interviewed to determine if they feel safe or have any concerns with their care they receive. No concerns identified. On 12/9/20 residents with a BIMS<9 had a BARS assessment completed and a head to toe assessment completed. A PHQ9 was completed on 12/10/20. No signs or symptoms of abuse was identified. j. Current staff who work on the Journey's Unit will be educated by Administrator/designee about the Corporate Compliance Hotline, and other policies protecting employees from retaliation. Any staff who have not been educated will be educated prior to starting their shift by Administrator/Designee. k. Current staff who work on the Journey's Unit will be interviewed by the Administrator/designee to determine if they feel the residents are safe at the facility, and how the care is being provided at the facility. l. Current staff will be educated on abuse Policy and Procedures, when to report abuse, and how to respond to abuse by Administrator/Designee. Current staff will complete competency test to verify understanding of policy and procedures, when to report abuse, and how to respond to abuse. Any staff who have not been educated will be educated prior to starting their shift by Administrator/Designee. m. Current nursing staff will be educated on documentation of events using facility incident reports and timely communication of any events to facility management. Any staff who have not been educated will be educated prior to starting their shift by Administrator/Designee. m. (sic). NHA (Nursing Home Administrator), DON, and Social Worker will be educated on identifying abuse, investigating abuse and timely reporting by RVP/Designee. n. Policies and Procedures on Abuse will be reviewed for accuracy and completeness by Administrator/Designee. 2. MONITORING a. NHA/Designee will round the facility to audit for abuse. This audit includes resident and staff interviews and observations. Audit will continue daily for 14 days, then weekly following. b. NHA/DON will review clinical notes and incident reports in clinical morning meeting to identify for any potentially abuse incidents. Current nursing staff will be educated on documentation of events using facility incident reports and timely communication of any events to facility management. c. Audit trends will be presented to Facility QAPI (Quality Assurance Performance Improvement) meeting for review and recommendations. On 12/14/20 the State Survey Agency reviewed the immediate plan of correction for removal of the Immediate Jeopardy involving abuse and confirmed the abatement of the Immediate Jeopardy as of the alleged date of abatement, 12/10/20 at 7:00 PM. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 12/1/2020. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that resident 2 had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated that resident 2 had severe cognitive impairment. The MDS indicated that during the look back period of the assessment, resident 2 had exhibited physical behavioral symptoms, verbal behavioral symptoms, and other behavioral symptoms (such as hitting self, public sexual acts etc). The MDS also indicated that resident 2 had exhibited rejection of care and wandering. The following events were noted in the progress notes: a. 7/8/2020- Res (resident) exhibiting some physically aggressive movements directed towards and in defense of (another resident). Parties are benefiting from as much staff one on one as available. b. 7/19/2020- (Resident 2) has been very anxious and agitated throughout the day. (Resident 2) initially refused all medications throughout the morning,but later accepted them during the afternoon. (Resident 2) has needed frequent redirection out of the nurses station, and out of other client's rooms. (Resident 2) has also needed to be redirected from disrobing in the hallway. c. 7/28/2020- pt (patient) aggressive with other residents saying I am going to kick your ass pt tried to kick another resident. pt redirected with the incident. later pt was trying to enter other residents room and when staff approached he threatened staff with violence, CNA (Certified Nursing Assistant) to assist with trying to get him out of the other residents room pt was agitated and struck RN (Registered Nurse) in the jaw with a closed fist. MD (physician), NP (Nurse Practitioner), and DON notified. no new orders given. pt offered food for possible hunger. will monitor for physical and emotional needs. d. 7/28/2020- (Resident 2) has been mainly quiet and cooperative but has times when aggressive toward staff. He has difficulty hearing which may contribute to this. Usually passes when left alone to calm. Tends to keep to himself except when walking in the halls. Will sit calmly in public areas. Needs assistance with cares. No mental health services in place due to dementia. Wife keeps in contact by phone calls. She reports he would have episodes of aggressive behavior at home also when he would not get what he wanted or could not understand situation. She did relate that (resident 2) did grow up in Holland during WWII and actually served in the German army as a young man due to the occupation, that he saw horrible things that bothered him and affects how he deals with any stress. e. 7/29/2020- Resident had a loud outburst with another resident, deescalated quickly with some quick redirection given. Both parties walked away in opposite directions. f. 8/14/2020- While aide was doing am (morning) vitals, Blood pressure cuff was being inflated and this irritated (resident 2)- (resident 2) did grab and twist the Aides thumb-causing a soft injury. g. 8/19/2020- Res did act with physical aggression towards a female caregiver- He in fact struck her with his fist hitting her jaw and chest, this happened while aide was attempting to give cares to the room mate. Family, Admin (Administrator) and provider notified. h. 8/30/2020- At approximately 1700 (5:00 PM), I found (resident 2) in the nurses station yelling at a staff member who was attempting to redirect him. (Resident 2)was yelling that he was calling the police. (Resident 2) began raising his fists at the staff member. I (RN 3) stood between (resident 2) and the staff member. (Resident 2) then hit me (RN 3) on the right side of the face. I (RN 3) attempted to verbally redirect (resident 2), who then hit me (RN 3) in the abdomen. I (RN 3) contacted (name of physician), who gave a one time order for [MEDICATION NAME] 0.5 mg (milligrams). (Resident 2) accepted the medication. (Resident 2) continues to present as anxious, and is verbally hostile toward other clients at this time. i. 10/9/2020- Patient was highly agitated after dinner, and was arguing with (name of another resident) in the hallway. They were shouting at each other, r/t (related to) (resident 2) accusing (name of another resident) of flirting with a female patient. After this incident, (resident 2) was unable to be redirected and during his waking hours. Nursing staff were unable to assist him in the shower. j. 10/17/2020- Resident 2 did get angry in am as staff were redirecting a female resident to leave his room. Patient wanted to (sic) female resident to stay with him for inappropriate reason, after some redirection he allowed staff to remove patient from his room, patient has calmed down since . k. 10/20/2020- .(Resident 2) and (another resident) were in the hallway and got into an argument and (resident 2) took off his belt and whipped (name of other resident) on the knuckles of the second and third fingers of the left hand . Staff tried to confiscate (resident 2's) belt but patient became agitated and refused. l. 10/25/2020- During the afternoon, (resident 2) and another client began shouting physical threats at each other. (Resident 2) was brandishing a plastic Halloween decoration. Staff stepped in between and were able to redirect (resident 2) and the other client . m. 10/26/2020- (Resident 2) is in a room by himself due to difficulties with roommates. He is alert and oriented to himself and immediate surroundings. He has periods of acute confusion and delusions that often are about some one hurting his wife or family members that are long dead. He has been known to become verbally and physically aggressive toward others, both resident and staff when he is confronted. Does not accept explanation or redirection easily. Does have a history of temper outbursts both physically and verbally as he has aged and confusion started. Wife reports that he did grow up in Holland during WWII and saw the action, served in the military there which seems to be coming back to upset him now. He has not had any treatment for [REDACTED]. She still cares for him greatly and does keep contact by phone at this time. (Resident 2) does not participate in group programs. Often will stay in room for much of the time. Does sit in TV area where often naps. n. 10/27/2020- Patient was found in his room trying to get a female patient in to his bed with him. Female patient appeared uncomfortable and discontent. Staff attempted to remove female patient from room and (resident 2) became very upset yelling and attempting to hit staff members. o. 10/27/2020- (Resident 2) discussed in clinical meeting about relationship with (female resident). Staff educated in ways to intervene if needed when with (female resident). p. 11/1/2020- At approximately 1430 (2:30 PM), I heard (resident 2) shouting at another client. I found (resident 2) pointing a broom from the housekeeping cart at the other client. And stating that he had 'stolen money' from (resident 2). q. 11/14/2020- Female res was observed laying on his bed, he was sitting next to her (Both fully clothed) Aide walked in and witnessed (resident 2) fondling her private parts, (she was apparently consenting) (resident 2) asked aide to leave-the aide requested (resident 2) come take a phone call. The 3 walked to the nurses station. And then the Aide explained what he had seen . r. 11/16/2020- pt has been trying to get other female residents into his room. When staff attempt to redirect him or the female he is with, he becomes verbally aggressive and threatens physical aggression. s. 11/24/2020- Res has been taking another female res into room and down the hall to kiss on the res. This res is alert to self and not fully understanding of what is happening. He has talked to his wife several times, whom (sic) is very upset about the behavior. When trying to separate them he become (sic) very aggressive. t. 11/28/2020- Res given a 5 mg IM (intramuscular) injection of [MEDICATION NAME] lt (left) Glut (glute). This order came after res had very aggressive verbal and physical episode directed toward all the staff- this came about after res was separated from a female res. Prn (as needed) order came from on call NP . u. 12/1/2020- Resident delusional during this shift. Resident believed he was managing a company and got very agitated wanted everyone out of the building, tried calling the police and attempted to hit staff several times. v. 12/2/2020 at 12:44 AM- Resident had an episode of delusions and agitation from approx (approximately) 1800-2100 (6:00 PM to 9:00 PM). Resident stated 'I am the manager of this station and I am calling the cops, because there is a thief in this place'. Resident sat at nurses station messing with the computers and phone. Resident threatened to hit staff, while staff attempted to redirect resident or remove from environment. Resident was left alone. w. 12/2/2020 at 1:28 PM- Res was observed in the hall near room [ROOM NUMBER] and and (sic) the male res of this room apparently looked at (resident 2) as he was walking by. (Resident 2) yelled at him and said 'stop staring' (resident 2) then moved aggressively toward and spoke vulgarly and seemed to be trying to pick a fight with the other gentleman who was responding with quietness and reserve . x. 12/3/2020 at 1:12 PM- (Resident 2) was angry with another male res, he appeared to be picking a fight with him, the other male wasn't interested in fighting- and was attempting to ignore him, (resident 2) moved closer, an aide moved between them and (resident 2) raised his fist and around the aide he closed fist struck the other male once in the face. They were separated. y. 12/3/2020 at 5:23 PM- (Resident 2) is actively arguing with almost everybody- seems to want to pick a fight with most staff and several male res. He is in a very confused state of mind. Attempts to redirect and give him some coffee or a treat are only temporarily effective. message out to Provider for redress, one idea could be a new script (prescription) for these kind of episodes (Res had a [MEDICATION NAME] order observed from April 2020). z. 12/3/2020 at 7:14 PM- Resident delusional during this shift. Overheard him on phone conversation with family. He was requesting they bring him a gun, and also a knife. He said 'it would just be good to have as I'm now back on the Police Force.' Also stated that Yes, he had to take someone down today. aa. 12/4/2020 at 5:17 PM- (Resident 2) is having a highly reactionary episode , He is attempting to argue with staff and res. staff is attempting to redirect with: coffee, cookies, walking down the hall, just walking away from him, listening to him, agreeing with him when appropriate. N/o (new order) rec'd (received) from NP, start [MEDICATION NAME] 25 mg po (orally). First dose pulled from e-kit (emergency kit). Res did easily take it with juice and a cookie. bb. 12/5/2020 at 1:14 PM- (Resident 2) is acting aggressive with staff and towards a particular other male res. (Three) of we staff have stepped in-between them several times in the last 20 mins- It has been very frustrating for the other male res- who isn't doing anything to provoke (resident 2)- except stand where (resident 2) can see him. In fact this other gentleman is trying everything to stay away from (resident 2). (Resident 2) has had 2-3 conversations with his wife today, with some arguing happening- then she calls back expressing concern for setting (resident 2) off by not agreeing with every request that (resident 2) presents to her (like come get me, come take me home) etc. cc. 12/6/2020 at 12:30 PM- Throughout the shift, (resident 2) had been yelling at other clients and making threats against them. At lunch time, (resident 2) began to threaten a staff member who had been passing out trays. (Resident 2) came up to her and postured to hit her. I (RN 3) stood between (resident 2) and the staff member. (Resident 2) raised his right fist, and held a fork at me (RN 3) with his left hand. (Resident 2) stated to me; 'Get out of my way, I'll hit you and I'm quicker than you are.' I (RN 3) talked to (resident 2) and explained that the staff member was passing trays for lunch. (Resident 2) returned to his seat, but continued to yell at and threaten other clients throughout the afternoon. dd. 12/6/2020 at 7:20 PM- Throughout the afternoon, (resident 2) had been singling out a female client and yelling at her whenever she walked by him. Staff had been standing by throughout the shift and directing her away from (resident 2). At 1619 (4:19 PM), (resident 2) had been speaking on the phone with his wife when this client walked by. (Resident 2) grabbed her by her wrist and held her. The client called out, and (resident 2) stated, 'She just took my wallet. Did you see that.' A nearby staff member separated (resident 2) from this client. ee. 12/6/2020 at 7:31 PM- (Resident 2) was determined by the nurse manager and the LIP (Licensed Independent Practitioner) to be too aggressive toward other clients on the unit. (Resident 2) was sent to (name of hospital) ED (emergency department) by (name of ambulance company) at 1849 (6:49 PM) this evening. (Note: This was after the survey agency had initiated an investigation into resident 2's behaviors.) ff. 12/7/2020 at 6:25 PM- DON spoke with (name of physician) at (name of local hospital)'s ER (emergency room ) regarding resident's stay there. MD reports that (resident 2) has been pleasant and cooperative all day. He was seen by psychiatrist, (name of psychiatrist), et (and) several changes were made to his medications including increasing [MEDICATION NAME] and [MEDICATION NAME]. New order for PRN [MEDICATION NAME] order not to exceed 2 weeks. NP aware of resident's return. gg. 12/7/2020 at 8:34 PM- Approx. 1930 (7:30 PM) CNA reported to Nurse about resident's physical aggression towards staff. CNA stated Resident had punched CNA's face. Resident was redirected and deescalated by another CNA back to room. hh. 12/8/2020 at 8:45 PM- (Resident 2) readmitted to (facility) memory care unit in the evening of 12/07/20 from a short hospital stay r/t aggressive behaviors. (Resident 2) has been having increasing amounts of physical and verbal aggression towards staff and peers and was sent out for evaluation. Upon return he is to be closely monitored for behavioral incidences. D/t (due to) (resident 2) background, he needs gentle redirection. (Resident 2) has a firm and competitive personality which can clash with figures of authority. He often believes he should be in charge of others around him. Should (resident 2) begin to escalate he seems to respond best to 1 on 1 intervention from staff who he is comfortable with talking to in order to express his thoughts and feelings. ii. 12/8/2020 at 11:00 AM - (Resident 2) current reason for skilled stay is Resident readmitted [DATE], he needs Memory Care r/t dx (diagnosis) of Dementia w/ (with) behaviors. jj. 12/8/2020 at 4:08 PM- Participated in tele-health consult with (name of psychiatrist) who is a psychiatrist regarding (resident 2) and his escalated behaviors. Discussed his admission and changes in meds (medications) and his status through that time, recent increase in verbal and physical aggression with medication changes. He will review paperwork further and give updated medication recommendations plus try to secure a gero-psych unit bed for resident for further treatment. Resident 2's care plan was reviewed. A focus area on the care plan stated that resident 2 has a behavior issue of agitation which can lead to physical (and) verbal aggression. Interventions for prevention included administer medications, allow the resident to walk in the evening, anticipate the resident's needs, provide dementia training to staff, physician evaluation, and talk through anxiety. The care plan did not indicate specific interventions for staff to implement once resident 2 became physically aggressive. In addition, despite multiple episodes of physical and verbally aggressive behaviors toward staff and residents, the care plan was only updated on 7/28/20 and 11/20/20. An additional focus area on the care plan stated that resident 2 has exhibited sexually based behaviors toward some female residents by inviting them into his room and bed and also by touching under clothing. Interventions listed included discouraging female residents from visiting his room, redirect to public areas for staff monitoring, engage in small group activity to distract attention to appropriate activity, staff to monitor one to one visits with females and separate if sexually forward or female declines attention. The care plan did not address reporting or investigating incidences of sexual behaviors toward other residents. The medical record did not include assessments of how it was determined that resident 2 could consent to a sexual relationship given his severe cognitive impairment. On 12/8/20 a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 was questioned about resident 2's aggressive behaviors. LPN 1 stated that the behavior occurs with randomness. LPN 1 also stated that the resident liked to bully others and expected attention when he spoke. LPN 1 further stated that resident 2 doesn't like to be ignored. LPN 1 was questioned about actions that were taken when resident 2 became aggressive with staff and other residents. LPN 1 stated that he had put himself between resident 2 and another staff member to avoid someone being injured when resident 2 was aggressive. LPN 1 stated that he had been struck in the jaw by resident 2. LPN 1 stated that whenever there was an incident of resident to resident aggression, the nurses tell facility management, the physician and the residents' families. LPN 1 also stated that if there was physical aggression, an investigation was done. LPN 1 also stated that every time something happens a care plan is reviewed on the resident to see what has been tried in the past to avoid these behaviors, and new strategies are considered. On 12/8/20 a telephone interview was conducted with RN 3. RN 3 stated that resident 2's aggression is too much. RN 3 stated that when a resident to resident incident occurred he would contact the Director of Nursing, administration and LIP. RN 3 stated he believed the administration looks at things. RN 3 stated that the staff was limited as to what they could give to resident 2 for medication to control the aggressive behaviors. RN 3 stated that when altercations happened between resident 2 and other residents he calls resident 2's wife to help redirect the resident. RN 3 stated that when resident 2 tried to engage in sexual behavior, RN 3 tried to redirect the resident verbally. RN 3 also stated that with a particular client who willingly participated, staff did not try to break them apart. RN 3 stated he believed it was in the care plan to let resident 2 engage in sexual activity with other residents. RN 3 stated that sexual behavior was not under the rubric for an incident report. RN 3 also stated that no one has ever seen resident 2 assault any of the female residents he was with. On 12/8/20 a telephone interview was conducted with RN 1. RN 1 reported that resident 2 had some serious behavior problems and that when the physician was notified he only prescribed as needed medications, so the root of the problem was not addressed. RN 1 stated that resident 2 often packed and unpacked his belongings wanting to go home, so the staff would use that behavior as a form of redirection. RN 1 stated that resident 2 used to have a roommate, however, the roommate had to be moved because of the frequent altercations between that resident and resident 2. RN 1 stated that resident 2's room was on the far end of the hallway so close supervision was not possible due to staffing. RN 1 was asked what instruction she was given for reporting events. RN 1 stated if an altercation happened the DON and administration were notified. RN 1 did not know if the incident was care planned beyond that. RN 1 also stated that management generally did not have a presence on the locked unit where resident 2 resided, unless there was a problem and management didn't know what was going on there. RN 1 was asked about resident 2 having intimate relationships with other female residents. RN 1 stated that resident 2 was very affectionate, liked kissing on the mouth, and had multiple female residents that he had tried to get into his room. RN 1 stated that there was one female resident in particular that resident 2 was fond of and ultimately consent was obtained by the families of the two residents to allow them to be intimate. RN 1 stated that resident 2 had a female resident in his room that was not consenting and was crying so the staff had to find a way to get her out of the room. When RN 1 was asked about what action was taken, she stated that an incident report was completed and the DON and administration were notified. On 12/8/20 a telephone interview was conducted with RN 2. RN 2 stated that resident 2 was generally pleasant, but that the resident got confused. RN 2 stated that resident 2 frequently asked for his wife. RN 2 also stated that when resident 2 got threatening or violent, staff would try to redirect him by focusing on other things. RN 2 stated that if an event occurred, she called the DON and wrote an incident report. RN 2 recounted an incident where resident 2 struck an aide. RN 2 stated that it was reported to the DON. When asked about resident 2's sexual behaviors RN 2 stated that if the residents get too cozy they (the staff) try to break it up. RN 2 further stated that she hadn't seen resident 2's sexual behaviors with other residents as a problem. On 12/8/20 a telephone interview was conducted with RN 4. RN 4 stated that resident 2 had short term memory loss. RN 4 stated that when resident 2 got angry the staff called his wife. RN 4 stated that she used the dorm rule and reminded resident 2 about it when it came to his sexual behaviors. RN 4 stated that the dorm rule meant no boys in girls rooms and no girls in boys rooms. When asked about guidance for reporting events she stated that she had not been given any direction about when and what to report. On 12/7/2020 at 2:47 PM, a phone interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated that he worked at the facility since August 2020. CNA 5 stated that he had abuse training when he was in school in 2019. CNA 5 stated that he would report neglect, physical, verbal, financial, and emotional abuse. CNA 5 stated that he would report any resident to resident altercation or resident aggression to the nurse. CNA 5 stated that resident 2 was aggressive toward other residents. CNA 5 stated that he tried to redirect resident 2 when he was aggressive toward other residents. CNA 5 stated that he tried to talk resident 2 down, by distracting him and discussing other things. CNA 5 stated that he brought up random things to distract resident 2 to decrease his aggression, like (TRUNCATED)

Based on interview and record review, it was determined for 4 of 6 sample residents that the facility did not ensure that residents were free from abuse. Specifically, three residents with severe cognitive impairment were engaged in sexual relationships, with no assessments to determine if this was appropriate or safe. In addition, interventions were inconsistent with regard to how facility staff addressed the behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These incidences of potential abuse were not identified or investigated by facility staff. The facility's failure to identify and investigate incidences of potential sexual abuse was determined to constitute Immediate Jeopardy to resident safety for residents 2 and 3. Additionally, one resident had multiple physical abuse incidents. Resident identifiers: 2, 3, 4 and 5. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator, Director of Nursing (DON), two corporate nurses, and the corporate Regional Vice President (RVP) on 12/8/20 at 11:30 AM. At that time, the Administrator, DON, corporate nurses and RVP were were informed of the findings of Immediate Jeopardy pertaining to F600 and asked to develop an immediate plan to ensure that the residents of the facility were free from abuse. On 12/10/20 the Administrator provided the following written allegation of removal of the Immediate Jeopardy: . 1. ACTIONS TAKEN TO REMOVE IMMEDIACY a. Male resident referred to psychiatrist for evaluation by DON/designee. Male resident will have a comprehensive assessment by IDT (Interdisciplinary) team using a behavioral root cause analysis tool to identify triggers, and develop care plan to address those triggers. Care plan will be updated to include approaches for the resident and strategies to prevent behaviors. Psychiatrist states resident meets criteria for inpatient psychiatric hospitalization treatment. Psychiatrist is currently referring resident to psychiatric facility for treatment. b. Female resident is being monitored for behavior changes by DON/Designee. Female resident will have a comprehensive assessment completed by IDT team using a behavioral root cause analysis tool to identify triggers, and develop care plan to address those triggers. Care plan will be updated to include approaches for the resident and strategies to prevent behaviors. c. Male resident moved from dementia unit to long-term side of facility and placed on a 24/7 1:1 by DON/Designee. Comprehensive examination completed by the psychiatrist on 12/8/20 who states that resident meets criteria for inpatient psychiatric hospitalization treatment. Psychiatrist is currently referring resident to psychiatric facility for treatment. Until resident can be transferred to Psychiatric hospital, he will remain on a 24/7 1:1. Resident will be reevaluated by facility IDT and medical director prior to returning to Willow Wood to ensure an appropriate plan of care has been developed. d. BIM (Brief Interview for Mental Status) score and pHQ9 (Patient Health Questionnaire) will be completed on male and female resident by DON/Designee. e. Head to toe assessment completed on male and female resident to assess for physical injuries by DON/Designee. f. Current residents on the Journey ' s Unit will have a comprehensive behavioral analysis assessment i.e. BARS (Brief Agitation Rating Scale) completed to identify high risk behaviors. Any resident who triggers will have a comprehensive assessment by IDT team using a behavioral analysis tool to identify triggers, and develop care plan to address those triggers. Care plan will be updated to provide interventions staff can easily understand and are capable of implementing. Staff will be educated by DON/Designee to care planned interventions. g. Head to toe skin assessment initiated on Journey ' s Community residents to identify for physical signs of abuse by DON/Designee. h. Current residents with a BIMs >9 were interviewed by Administrator/designee to determine if they feel safe and do not have any issues or concerns with the care they receive. i. Current residents with BIMS <9, will have a BARs (Brief Agitation Rating Scale) assessment, staff assessment of PHQ9 and head to toe skin assessment by DON/Designee to identify for signs of symptoms of abuse. SPECIFIC ACTIONS TAKEN BY FACILITY On 12/8/20 we completed a head to toe assessment, resident was moved to Long Term Care side of facility and placed on a 1:1, Psychiatrist completed a telehealth visit with resident and changed medications. On 12/9/20 a BIMS, BAR, PHQ9 was completed with a behavioral analysis and care plan updated with triggers identified and strategies to prevent further behaviors. On 12/9/20 a BIMS, BAR, PHQ9 was complete, behavioral analysis completed with triggers identified and care plan updated with strategies to prevent further behaviors. On 12/8/20 male was moved from dementia unit to long term care side of facility and placed on a 1:1. Male resident was discharged to a behavioral unit on 12/10/20 at 13:50 (1:50 PM). All residents in the building BIMs and PHQ9 was redone and completed by SSW (Social Services Worker) on 12/9/20 (and) 12/10/20. All residents in the building had a head to toe completed assessement on 12/9/20 with no evidence of physical abuse identified. On 12/9/20 all journey's unit residents had a BARS completed by the SSW and 8 residents were identified and the IDT met to complete the behavioral analysis, identify triggers, updated the care plan with strategies and interventions for the staff to prevent further behaviors. All Journey's residents had a head to toe completed assessement on 12/9/20 with no evidence of physical abuse identified. On 12/8/20 and 12/9/20 all current residents with a BIMs >9 were interviewed to determine if they feel safe or have any concerns with their care they receive. No concerns identified. On 12/9/20 residents with a BIMS<9 had a BARS assessement completed and a head to toe assessment completed. A PHQ9 was completed on 12/10/20. No signs or symptoms of abuse was identified. j. Current staff who work on the Journey ' s Unit will be educated by Administrator/designee about the Corporate Compliance Hotline, and other policies protecting employees from retaliation. Any staff who have not been educated will be educated prior to starting their shift by Administrator/Designee. k. Current staff who work on the Journey ' s Unit will be interviewed by the Administrator/designee to determine if they feel the residents are safe at the facility, and how the care is being provided at the facility. l. Current staff will be educated on abuse Policy and Procedures, when to report abuse, and how to respond to abuse by Administrator/Designee. Current staff will complete competency test to verify understanding of policy and procedures, when to report abuse, and how to respond to abuse. Any staff who have not been educated will be educated prior to starting their shift by Administrator/Designee. m. Current nursing staff will be educated on documentation of events using facility incident reports and timely communication of any events to facility management. Any staff who have not been educated will be educated prior to starting their shift by Administrator/Designee. n (sic). NHA (Nursing Home Administrator), DON, and Social Worker will be educated on identifying abuse, investigating abuse and timely reporting by RVP/Designee. o. Policies and Procedures on Abuse will be reviewed for accuracy and completeness by Administrator/Designee. 2. MONITORING a. NHA/Designee will round the facility to audit for abuse. This audit includes resident and staff interviews and observations. Audit will continue daily for 14 days, then weekly following. b. NHA/DON will review clinical notes and incident reports in clinical morning meeting to identify for any potentially abuse incidents. Current nursing staff will be educated on documentation of events using facility incident reports and timely communication of any events to facility management. c. Audit trends will be presented to Facility QAPI (Quality Assurance Performance Improvment) meeting for review and recommendations. On 12/14/20 the State Survey Agency reviewed the immediate plan of correction for removal of the Immediate Jeopardy involving abuse and confirmed the abatement of the Immediate Jeopardy as of the alleged date of abatement, 12/10/20 at 7:00 PM. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 12/1/2020. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that resident 2 had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated that resident 2 had severe cognitive impairment. The MDS indicated that during the look back period of the assessment, resident 2 had exhibited physical behavioral symptoms, verbal behavioral symptoms, and other behavioral symptoms (such as hitting self, public sexual acts etc). The MDS also indicated that resident 2 had exhibited rejection of care and wandering. The following events were noted in the progress notes: a. 7/8/2020- Res exhibiting some physically aggressive movements directed towards and in defense of (another resident). Parties are benefiting from as much staff one on one as available. b. 7/19/2020- (Resident 2) has been very anxious and agitated throughout the day. (Resident 2) initially refused all medications throughout the morning,but later accepted them during the afternoon. (Resident 2) has needed frequent redirection out of the nurses station, and out of other client's rooms. (Resident 2) has also needed to be redirected from disrobing in the hallway. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. c. 7/28/2020- pt (patient) aggressive with other residents saying I am going to kick your ass pt tried to kick another resident. pt redirected with the incident. later pt was trying to enter other residents room and when staff approached he threatened staff with violence, CNA (Certified Nursing Assistant) to assist with trying to get him out of the other residents room pt was agitated and struck RN (Registered Nurse) in the jaw with a closed fist. MD (physician), NP (Nurse Practitioner), and DON (Director of Nursing) notified. no new orders given. pt offered food for possible hunger. will monitor for physical and emotional needs. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. d. 7/28/2020- (Resident 2) has been mainly quiet and cooperative but has times when aggressive toward staff. He has difficulty hearing which may contribute to this. Usually passes when left alone to calm. Tends to keep to himself except when walking in the halls. Will sit calmly in public areas. Needs assistance with cares. No mental health services in place due to dementia. Wife keeps in contact by phone calls. She reports he would have episodes of aggressive behavior at home also when he would not get what he wanted orcould not understand situation. She did relate that (resident 2) did grow up in Holland during WWII and actually served in the German army as a young man due to the occupation, that he saw horrible things that bothered him and affects how he deals with any stress. e. 7/29/2020- Resident had a loud outburst with another resident, deescalated quickly with some quick redirection given. Both parties walked away in opposite directions. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. f. 8/14/2020- While aide was doing am (morning) vitals, Blood pressure cuff was being inflated and this irritated (resident 2)- (resident 2) did grab and twist the Aides thumb-causing a soft injury. g. 8/19/2020- Res (resident) did act with physical aggression towards a female caregiver- He in fact struck her with his fist hitting her jaw and chest, this happened while aide was attempting to give cares to the room mate. Family, Admin (Administrator) and provider notified. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. h. 8/30/2020- At approximately 1700 (5:00 PM), I found (resident 2) in the nurses station yelling at a staff member who was attempting to redirect him. (Resident 2)was yelling that he was calling the police. (Resident 2) began raising his fists at the staff member. I (RN 3) stood between (resident 2) and the staff member. (Resident 2) then hit me (RN 3) on the right side of the face. I (RN 3) attempted to verbally redirect (resident 2), who then hit me (RN 3) in the abdomen. I (RN 3) contacted (name of physician), who gave a one time order for [MEDICATION NAME] 0.5 mg (milligrams). (Resident 2) accepted the medication. (Resident 2) continues to present as anxious, and is verbally hostile toward other clients at this time. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. i. 10/9/2020- Patient was highly agitated after dinner, and was arguing with (name of another resident) in the hallway. They were shouting at eachother, r/t (related to) (resident 2) accusing (name of another resident) of flirting with a female patient. After this incident, (resident 2) was unable to be redirected and during his waking hours. Nursing staff were unable to assist him in the shower. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. j. 10/17/2020- Resident 2 did get angry in am as staff were redirecting a female resident to leave his room. Patient wanted to (sic) female resident to stay with him for inappropriate reason, after some redirection he allowed staff to remove patient from his room, patient has calmed down since . No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. k. 10/20/2020- .(Resident 2) and (another resident) were in the hallway and got into an argument and (resident 2) took off his belt and whipped (name of other resident) on the knuckles of the second and third fingers of the left hand . Staff tried to confiscate (resident 2's) belt but patient became agitated and refused. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. l. 10/25/2020- During the afternoon, (resident 2) and another client began shouting physical threats at each other. (Resident 2) was brandishing a plastic Halloween decoration. Staff stepped in between and were able to redirect (resident 2) and the other client . No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. m. 10/26/2020- (Resident 2) is in a room by himself due to difficulties with roommates. He is alert and oriented to himself and immediate surroundings. He has periods of acute confusion and delusions that often are about some one hurting his wife or family members that are long dead. He has been known to become verbally and physically aggressive toward others, both resident and staff when he is confronted. Does not accept explanation or redirection easily. Does have a history of temper outbursts both physically and verbally as he has aged and confusion started. Wife reports that he did grow up in Holland during WWII and saw the action, served in the military there which seems to be coming back to upset him now. He has not had any treatment for [REDACTED]. She still cares for him greatly and does keep contact by phone at this time. (Resident 2) does not participate in group programs. Often will stay in room for much of the time. Does sit in TV area where often naps. n. 10/27/2020- Patient was found in his room trying to get a female patient in to his bed with him. Female patient appeared uncomfortable and discontent. Staff attempted to remove female patient from room and (resident 2) became very upset yelling and attempting to hit staff members. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. o. 10/27/2020- (Resident 2) discussed in clinical meeting about relationship with (female resident). Staff educated in ways to intervene if needed when with (female resident). No documentation could be found to indicate what interventions the staff had been educated on. p. 11/1/2020- At approximately 1430 (2:30 PM), I heard (resident 2) shouting at another client. I found (resident 2) pointing a broom from the housekeeping cart at the other client. And stating that he had 'stolen money' from (resident 2). No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. q. 11/14/2020- Female res (resident) was observed laying on his bed, he was sitting next to her (Both fully clothed) Aide walked in and witnessed (resident 2) fondling her private parts, (she was apparently consenting) (resident 2) asked aide to leave-the aide requested (resident 2) come take a phone call. The 3 walked to the nurses station. And then the Aide explained what he had seen . No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. r. 11/16/2020- pt has been trying to get other female residents into his room. When staff attempt to redirect him or the female he is with, he becomes verbally aggressive and threatens physical aggression. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. s. 11/24/2020- Res has been taking another female res into room and down the hall to kiss on the res. This res is alert to self and not fully understanding of what is happening. He has talked to his wife several times, whom (sic) is very upset about the behavior. When trying to separate them he become (sic) very aggressive. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. t. 11/28/2020- Res given a 5mg IM (intramuscular) injection of [MEDICATION NAME] lt (left) Glut (glute). This order came after res had very aggressive verbal and physical episode directed toward all the staff- this came about after res was separated from a female res. Prn (as needed) order came from On call NP . No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. u. 12/1/2020- Resident delusional during this shift. Resident believed he was managing a company and got very agitated wanted everyone out of the building, tried calling the police and attempted to hit staff several times. v. 12/2/2020 at 12:44 AM- Resident had an episode of delusions and agitation from approx (approximately) 1800-2100 (6:00 PM to 9:00 PM). Resident stated 'I am the manager of this station and I am calling the cops, because there is a thief in this place'. Resident sat at nurses station messing with the computers and phone. Resident threatened to hit staff, while staff attempted to redirect resident or remove from environment. Resident was left alone. w. 12/2/2020 at 1:28 PM- Res was observed in the hall near room [ROOM NUMBER] and and (sic) the male res of this room apparently looked at (resident 2) as he was walking by. (Resident 2) yelled at him and said 'stop staring' (resident 2) then moved aggressively toward and spoke vulgarly and seemed to be trying to pick a fight with the other gentleman who was responding with quietness and reserve . No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. x. 12/3/2020 at 1:12 PM- (Resident 2) was angry with another Male res, he appeared to be picking a fight with him, the other male wasn't interested in fighting- and was attempting to ignore him, (resident 2) moved closer, an aide moved between them and (resident 2) raised his fist and around the aide he closed fist struck the other male once in the face. They were separated. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. y. 12/3/2020 at 5:23 PM- (Resident 2) is actively arguing with almost everybody- seems to want to pick a fight with most staff and several male res. He is in a very confused state of mind. Attempts to redirect and give him some coffee or a treat are only temporarily effective. message out to Provider for redress, one idea could be a new script (prescription) for these kind of episodes (Res had a [MEDICATION NAME] order observed from April 2020). No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. z. 12/3/2020 at 7:14 PM- Resident delusional during this shift. Overheard him on phone conversation with family. He was requesting they bring him a gun, and also a knife. He said 'it would just be good to have as I'm now back on the Police Force.' Also stated that Yes, he had to take someone down today. aa. 12/4/2020 at 5:17 PM- (Resident 2) is having a highly reactionary episode , He is attempting to argue with staff and res. staff is attempting to redirect with: coffee, cookies, walking down the hall, just walking away from him, listening to him, agreeing with him when appropriate. N/o (new order) rec'd (received) from NP, start [MEDICATION NAME] 25 mg po .First dose pulled from e-kit (emergency kit). Res did easily take it with juice and a cookie. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. bb. 12/5/2020 at 1:14 PM- (Resident 2) is acting aggressive with staff and towards a particular other male res. (Three) of we staff have stepped in-between them several times in the last 20 mins (minutes)- It has been very frustrating for the other male res- who isn't doing anything to provoke (resident 2)- except stand where (resident 2) can see him. In fact this other gentleman is trying everything to stay away from (resident 2). (Resident 2) has had 2-3 conversationswith his wife today, with some arguing happening- then she calls back expressing concern for setting (resident 2) off by not agreeing with every request that (resident 2) presents to her (like come get me, come take me home) etc. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. cc. 12/6/2020 at 12:30 PM- Throughout the shift, (resident 2) had been yelling at other clients and making threats against them. At lunch time, (resident 2) began to threaten a staff member who had been passing out trays. (Resident 2) came up to her and postured to hit her. I (RN 3) stood between (resident 2) and the staff member. (Resident 2) raised his right fist, and held a fork at me (RN 3) with his left hand. (Resident 2) stated to me; 'Get out of my way, I'll hit you and I'm quicker than you are.' I (RN 3) talked to (resident 2) and explained that the staff member was passing trays for lunch. (Resident 2) returned to his seat, but continued to yell at and threaten other clients throughout the afternoon. dd. 12/6/2020 at 7:20 PM- Throughout the afternoon, (resident 2) had been singling out a female client and yelling at her whenever she walked by him. Staff had been standing by throughout the shift and directing her away from (resident 2). At 1619 (4:19 PM), (resident 2) had been speaking on the phone with his wife when this client walked by. (Resident 2) grabbed her by her wrist and held her. The client called out, and (resident 2) stated, 'She just took my wallet. Did you see that.' A nearby staff member separated (resident 2) from this client. No documentation could be found to indicate that the facility had investigated this incident in an effort to prevent further incidences of potential abuse from occurring. ee. 12/6/2020 at 7:31 PM- (Resident 2) was determined by the nurse manager and the LIP (Licensed Independent Practitioner) to be too aggressive toward other clients on the unit. (Resident 2) was sent to (name of hospital) ED (emergency department) by (name of ambulance company) at 1849 (6:49 PM) this evening. (Note: This was after the survey agency had initiated an investigation into resident 2's behaviors.) Resident 2's care plan was reviewed. A focus area on the care plan stated that resident 2 has a behavior issue of agitation which can lead to physical (and) verbal aggression. Interventions for prevention included administer medications, allow the resident to walk in the evening, anticipate the resident's needs, provide dementia training to staff, physician evaluation, and talk through anxiety. The care plan did not indicate specific interventions for staff to implement once resident 2 became physically aggressive. In addition, despite multiple episodes of physical and verbal aggressive behaviors toward staff and residents, the care plan was only updated 7/28/20 and 11/20/20. An additional focus area on the care plan stated that resident 2 has exhibited sexually based behaviors toward some female resident by inviting into his room and bed and also by touching under clothing. Interventions listed included discouraging female residents from visiting his room, redirect to public areas for staff monitoring, engage in small group activity to distract attention to appropriate activity, staff to monitor one to one visits with females and separate if sexually forward or female declines attention. The care plan did not address investigation or reporting incidences of sexual behaviors toward other residents. The medical record did not include assessments of how it was determined that resident 2 could consent to a sexual relationship given his severe cognitive impairment. On 12/8/20 a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 was questioned about resident 2's aggressive behaviors. LPN 1 stated that whenever there was an incident of resident to resident aggression, the nurses tell facility management, the physician and the residents' families. LPN 1 also stated that if there was physical aggression, an investigation was done. On 12/8/20 a telephone interview was conducted with RN 3. He stated that resident 2's aggression is too much. RN 3 stated that when a resident to resident incident occurred he would contact the Director of Nursing, administration and the physician. RN 3 stated he believed the administration looks at things. RN 3 stated he believed it was in the care plan to let resident 2 engage in sexual activity with other residents. RN 3 stated that sexual behavior was not under the rubric for an incident report. On 12/8/20 a telephone interview was conducted with RN 1. RN 1 reported that resident 2 had some serious behavior problems and that when the physician was notified he only prescribed as needed medications, so the root of the problem was not addressed. RN 1 stated that resident 2 often packed and unpacked his belongings wanting to go home, so the staff would use that behavior as a form of redirection. RN 1 stated that resident 2 used to have a roommate, however, the roommate had to be moved because of the frequent altercations between that resident and resident 2. RN 1 stated that resident 2's room was on the far end of the hallway so close supervision was not possible due to staffing. RN 1 was asked what instruction she was given for reporting events. RN 1 stated if an altercation happened the DON and administration were notified. RN 1 did not know if the incident was care planned beyond that. RN 1 also stated that management generally did not have a presence on the locked unit where resident 2 resided, unless there was a problem and management didn't know what was going on there. RN 1 was asked about resident 2 having intimate relationships with other female residents. RN 1 stated that resident 2 was very affectionate, liked kissing on the mouth, and had multiple female residents that he had tried to get into his room. RN 1 stated that there was one female resident in particular that resident 2 was fond of and ultimately consent was obtained by the families of the two residents to allow them to be intimate. RN 1 stated that resident 2 had a female resident in his room that was not consenting and was crying so the staff had to find a way to get her out of the room. When RN 1 was asked about what action was taken, she stated that an incident report was completed and the DON and administration were notified. 2. Resident 3 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 3's electronic medical record review was completed on 12/14/2020. Resident 3 had a Power of Attorney (POA). On 9/5/18, resident 3 had a Montreal Cognitive Assessment (MoCA) performed. Resident 3 had a score of 7, revealing moderate dementia with significant impairment of cognition/function. Resident 3's Minimum Data Set (MDS) revealed that resident 3's Brief Interview for Mental Status (BIMS) score on 5/9/2020 was a 3, which indicated severe cognitive impact or impairment. A follow-up BIMS was performed on 11/5/2020 with a score of 3. On 11/27/2020 at 2:00 PM, a social services quarterly note revealed that resident 3 is not able to find her own room. She does walk in the halls daily and at times is in and out of others rooms Appears to like the company of gentlemen more than ladies though does not currently seem attached to any specific male resident. Less oriented than previously and more difficulty answering questions for evaluations .Is not capable of participating in care planning meetings . Resident 3's nursing care plan, initiated on 3/14/19, revealed that resident 3 had a close relationship with another dementia resident that is evolving to a 'boyfriend/girlfriend' level with physical contact between them. The goal stated that all physical contact between (resident 3) and her romantic interest will be addressed in a dignified and private manner for their interactions. The Interventions were to Provide information and education to both families with regard to their relationship, changes that can occur with dementia and need (TRUNCATED)

Based on observation, interview and record review, it was determined the facility did not ensure that 2 of 6 sample residents received adequate supervision and assistance to prevent accidents. In addition, the facility did not ensure that the resident's environment remained as free from accident hazards as possible. Specifically, resident 2 received a significant injury while ambulating independently and resident 3's bed was not placed in the lowest position. The deficient practice for resident 2 will be cited at a harm level. Resident identifiers: 2 and 3. Findings include: HARM: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/27/17 at 7:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 2 was sent to the hospital after sustaining a fall that resulted in a laceration to her head. On 11/27/17 at 7:12 AM, resident 2 was observed to be ambulating independently in her room without assistance. (Note: LPN 1 was administering medication to another resident directly outside of resident 2's room. LPN 1 was facing resident 2's room at that time.) On 11/27/17 at 7:16 AM, resident 2 was observed to be ambulating independently in her room. Resident 2 had an unsteady, shuffling gate. Resident 2 was holding up her incontinence brief that appeared to be wet. (Note: Several staff members, Certified Nurse Assistants (CNAs), LPN 1, and activity personnel walked past resident 2's room without providing assistance to prevent resident 2 from falling.) Resident 2's quarterly Minimum Data Set (MDS) Assessment completed by the facility staff on 11/4/17 was reviewed. The facility staff assessed resident 2 as rarely/never understood and was moderately impaired cognitively. Additionally, resident 2 was assessed as requiring extensive assistance with a one person physical assist for transfers, dressing, toileting, and personal hygiene. Resident 2 was assessed as being unstable when moving from a seated to standing position, walking, turning around, and when moving on and off the toilet. Furthermore, the facility staff indicated that resident 2 required limited assistance of one person when walking in her room. On 7/28/17, an ADL (activities of daily living) self-care performance related to: Schizophrenia care plan was developed. The ADL care plan was revised on 11/7/17. The goal that was developed was (Resident 2) will maintain current level of ADL function, allowing staff to put on her habit daily through the review date. The interventions developed to achieve the goal included, Assist with placement of Habit; .Dressing: The resident requires limited assistance by (1) staff to dress; .Personal Hygiene/Oral Care: The resident requires extensive assist of (1) staff for personal hygiene and oral care; Toilet use: (Resident 2) requires set up to extensive assist of (1) staff for toilet use; and Transfer: (Resident 2) requires set up to extensive assistance of (1-2) staff for transferring . On 8/18/17, an .at risk for falls related to: Gait/balance problems, Unaware of safety needs. She will frequently stated 'my spiritual sister wants me to walk.' . care plan was developed. The goal documented was (Resident 2) will be free of minor injury through the review date. The interventions developed to achieve the goal included: Ensure that (resident 2) is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair); Anticipate and meet (resident 2's) needs; Be sure (resident 2's) call light is within reach and encourage her to use it for assistance as needed. (Resident 2) needs prompt response to all requests for assistance. A Fall Risk Evaluation was completed for resident 2 on 9/16/17 and received a score of 16 which indicated that resident 2 was at risk for falls. On 9/15/17 at 10:20 PM, the facility Clinical Social Worker (CSW) documented, Resident had an unwitnessed fall. Resident had dismantled her tab alarm on her chair. RN (Registered Nurse) and CNA immediately assisted resident and assessed for injury. RN reported no injury. RN reported that (resident 2) had been redirected all night while trying to get out of her chair. RN will follow up with incident report. (Note: An incident report was not available for review. There was not an investigation into the unwitnessed fall which included interviews with staff or whether interventions to prevent falls had been in place.) On 9/16/17 at 1:29 AM, a licensed nurse documented, Resident was sitting in her wheelchair with her tab alarm on, She had just been rounded on 20 min (minutes) prior by CNA. LN (Licensed Nurse) was standing at med (medication) cart and heard a thump, They turned and resident was FOF (found on floor) on her left side. Resident was assessed and had no visible injuries. Neuro (neurological) checks initiated. MD (Medical Doctor), POA (Power of Attorney), and DON (Director of Nursing) notified. Review of the incident report indicated that resident 2 was oriented to herself, was confused, and had a gait imbalance, impaired memory, and weakness. The nurse documented that resident 2 was to have assistance when ambulating and that she used a walker. The investigation could not be located. On 9/16/17 at 3:33 PM, an LN documented, .She was unhappy when instructed to wait for CNA to assist with dressing this morning, et (and) RN observed her slowly slide off edge of recliner in room this morning and seat herself on the floor to try and put her socks and shoes on. CNA in room to assist re-seating resident et assist with dressing.She has been trying to get up without assist all afternoon, she believes that 'Mother is here waiting for me/telling me I need to walk' (Note: An incident report was not available for review. The investigation could not be located.) On 9/16/17, resident 2's care plan related to her risk for falls was revised to include, Ensure that (resident 2) is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). (Note: The facility staff were to assist resident 2 with getting dressed.) On 9/19/17 at 11:43 AM, a LN documented, This Rn (Registered Nurse) was standing at the nursing cart in front of resident's room. Looked into room to make sure resident was there to give a medication and resident was sitting in her w/c with the over bed table in front of her. Turned back towards the nursing cart and hear (sic) the alarm go off. Witnessed the resident slide off of her wheelchair and on to the floor. Resident did not hit her head. Resident ended up leaning against the bed. Assisted back into the wheelchair. Family, MD and DON notified. Review of the incident report revealed that resident 2's safety alarm was reset. The LN did not document what resident 2's mental status was, what predisposing environmental factors were, what predisposing physiological factors were or what situation factors were. The investigation could not be located. On 9/21/17 at 9:58 AM, a LN documented, Resident fell in her room at 0938 (9:38 AM), was not seen, CNA heard fall, Lying on L (left) side on entry between WC (wheelchair) et bed. no fractures notable, assisted to seated position, vital signs taken, resident denies pain. Up into WC, noted pressure alarm did not make noise, tightened battery compartment et alarm now functioning. Resident has bump to head L side forehead at hairline, she stated it is tender to touch. L(NAME) (level of consciousness) WNL (within normal limits) for resident speech clear, vitals (vital signs) WNL. Resident expressed understanding of call light system. Call light in resident reach, Neuro checks restarted. Resident has been asked to call for assist (assistance) with all needs. Copied text above was sent to (the on-call physician), DON, Admin (Administrator). Contacted (nurse at hospice company) et she will call case manager with information as well as (the hospice physician). Spoke to (resident 2's power of attorney), she expressed that anything she and the sisters can buy to aid us with safety for resident to let her know. (Note: An incident report was not available for review. The investigation could not be located.) On 9/21/17, resident 2's care plan related to her risk for falls was revised to include a medication review. On 10/11/17 at 6:03 AM, a LN documented, CNA was checking on resident in bathroom found sitting on her bottom on the floor no injuries v/s (vital signs) WNL stated (sic) NEURO's no injuries placed on alert charting denies pain and able to move all extremities.MD POA and DON notified. Review of the incident report completed revealed that resident 2 was oriented to person and situation. Additionally, the LN documented, When resident is in the restroom she requests that staff leave the light off. The investigation could not be located. On 10/11/17, resident 2's care plan related to her risk for falls was revised to include, Has new smaller fabric chair and a motion light in bathroom. 11/7/17 at 2:12 AM, a LN documented, Resident had unwitnessed fall tried to stand up from WC while it was not locked she fell when WC rolled back Neuro's started no injuries noticed denied pain able to move all extremities. Nurse was standing right in front of her room at the medication cart heard something turned around and saw the WC rolling backwards and her on the floor. MD DON and POA notified . Review of the incident report revealed that resident 2 was oriented to person and situation and that with in (sic) 15 min (minutes) she was alert X (times) 4 (person, place, time, and situation). The LN documented that resident 2's WC was not locked when resident 2 tried to stand up. The investigation could not be located. On 11/7/17, resident 2's care plan related to her risk for falls was revised to include, Ensure that (resident 2) is wearing appropriate footwear when ambulating or mobilizing in w/c; Anticipate and meet (resident 2's) needs; and Be sure (resident 2's) call light is within reach and encourage her to use it for assistance as needed. (Resident 2) needs prompt response to all requests for assistance. On 11/14/17 at 9:20 PM, a LN documented, Resident was up walking in her room nurse asked her to sit down locked her WC and attached her alarm to the back of her. She have (sic) been leaning so nurse place a pillow on the side of her. Then CNA called for nurse stated that resident was laying in front of her WC on the pillow as if she was laying in her bed. Nurse assessed her no injuries resident was alert stated she did not hit her head and that she slid out of the chair did not fall from it. V/S WNL POA called MD called . Review of the incident report revealed that resident 2 was alert and oriented to person, place, time and situation. The investigation could not be located. 11/15/17 at 9:42 AM, a LN documented, .Pt (patient) was found in bathroom this am (morning) on the floor around 0930 (9:30 AM). Pt denies any pain or discomfort. Assessment found no injuries. Discussed with the patient that she is too weak on her left side to be trying to stand or walk. Reviewed use of call light and placed call light within reach. Pt also has table alarm in place. MD and POA notified Review of the incident report revealed that resident 2 was alert and oriented to person, place and time. The incident description was documented as, Pt found on bathroom floor in a sitting position. Pt denies any pain or discomfort. Pt states she did not hit her head. Pt states she was trying to pull her pull-up (incontinence brief) down and slid to floor. The LN documented that resident 2 had a gait imbalance and had weakness. The LN further documented that resident 2 was ambulating without assistance. The investigation could not be located. On 11/15/17, resident 2's care plan related to her risk for falls was revised to include, Hospice to eval (evaluate) for TIA (Trans Ischemic Attack) r/t (related to) to (sic) leaning. On 11/16/17, resident 2's care plan related to her risk for falls was again revised. An additional intervention to obtain a urinalysis was initiated. On 11/17/17 at 9:38 PM, a LN documented, CNA alerted nurse that resident had dried blood on her. Resident seen on the bed. When asked resident what happened she stated she hit her head on the table near her bed. No blood seen on the table or floor. Alert and oriented to self and situation. Nurse assessed resident right away. Dried blood and clumps on resident's undergarment, back of neck, nap (sic) and hair. While cleaning resident's hair. There was fresh blood in hair on the back of her head. Open area laceration noted approximately 1.5 cm (centimeters) long X (by) .5 cm wide. EMS (Emergency Medical Services) called at 0600 (6:00 AM) to be transported. Notified DON, NP (Nurse Practitioner), and POA at 0608 (6:08 AM). (Blood pressure) 104/59, (pulse) 76, (respirations) 18, (oxygen saturation) 96% on RA (room air). Neuros (neurological checks) started and given to EMS. The investigation could not be located. The hospital discharge summary, dated 11/18/17, was reviewed. The admitting physician documented that resident 2 sustained a subarachnoid hemorrhage following injury, no loss of consciousness (and) initial encounter Laceration without foreign body of scalp . On 11/21/17 at 9:28 PM, a LN documented, Resident was found sitting on her bottom on the floor no injuries and resident stated to staff and POA that she did not fall she sit (sic) on the floor looking for her pin she dropped. Alert denies pain and discomfort able to move all extremities. MD and DON notified call POA and allowed resident to talk to POA. Review of the incident report revealed that resident 2 was Alert and oriented to person, place, situation, and time. The LN further documented that resident 2 .dropped something and was trying to find it staff educated her to use call light and allow staff to find it . The investigation could not be located. On 11/21/17, resident 2's care plan related to her risk for falls was again revised. An additional intervention of Check on whereabouts frequently to make sure she's not ambulating alone was initiated. On 11/27/17 at 9:38 PM, the DON documented in a progress note, CNA alerted nurse that resident had dried blood on her. Resident seen on the bed. When asked resident what happened, she states she hit her head on the table near her bed. No blood seen on the table or floor. Alert and oriented to self and situation. Nurse assessed resident right away. Dried blood and clumps on resident's undergarment, back of neck, nap (sic) of hair. While cleansing resident hair. There was fresh blood in hair on the back of her head. Open area laceration noted approximately 1.5 cm long X (by) .5 cm wide. EMS (Emergency Medical Services) called at 0600 (6:00 AM) to be transported. Notified DON, NP (Nurse Practitioner), and POA at 0608 (6:08 AM). (Blood pressure) 104/59, (Pulse) 76, (Respirations) 18, (Oxygen saturation) 96% on RA (room air). Neuros started and given to EMS. Review of the incident, completed on 11/27/17, documented, (Resident 2) found to have dried blood under her habit. Originally it was thought this could be from a fall (unable to read) to figure out why this could have been missed on the head to toe assessment. Sent to hospital foe (sic) evaluation. Asked (resident 2) what had happened when she cut her head. We thought it was from a fall several days ago. (Resident 2) reenacted the fall, told us how it happened, stated that she had gotten herself up. Said she did not tell anyone. The immediate action taken was Had made report to state about fall with injury not knowing that (resident 2) had fallen, told no one, and gotten herself up. She was assessed as being alert and oriented to person, place, situation, and time (Note: the incident report was generated on 11/27/17, ten days after the incident occurred). Resident 2 was further assessed as having a gait imbalance and was ambulating without assist. There was not an investigation which included interviews with staff that were assigned to care for resident 2 or whether interventions to prevent falls had been in place. On 11/27/17 at 11:30 AM, CNA 2 was interviewed. CNA 2 stated that resident 2 required assist with all ADLs. CNA 2 stated that facility staff were to watch her closely and ask her if she needed help when ambulating in her room or when going to the bathroom. On 11/27/17 at 11:40 AM, LPN 1 was interviewed. LPN 1 stated that resident 2 required assistance of one person for all of her activities of daily living. LPN 1 stated that the staff were to round on resident 2 frequently to make sure that she was not ambulating without assistance in her room. On 11/27/17 at 1:26 PM, CNA 1 was interviewed. CNA 1 stated that resident 2 required the extensive assistance of one person for toileting and stand by assist for walking and transfers. CNA 1 stated that resident 2 was not safe to ambulate alone. CNA 1 stated that resident 2 was, constantly up and down. CNA 1 stated that resident 2 was able to dismantle personal safety alarms when staff had attempted to use them on the resident. CNA 1 stated that the CNA staff were instructed to keep an eye on resident 2 with frequent checks. On 11/27/17 at 1:43 PM, an interview was conducted with the DON. The DON stated that resident 2 needed assistance or stand-by assistance with her ADLs. The DON stated that the staff were to check on resident 2 to see what she was doing in her room as the staff were able to. The DON stated that resident 2 could use one-on-one (staff to resident ratio supervision) but that the facility does not do one-on-one. POTENTIAL FOR HARM 2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/27/17 at 7:08 AM, LPN 1 was interviewed. LPN 1 stated that resident 3 had a recent admission to the hospital after being found on the floor beside his bed which resulted in a pelvic fracture. LPN 1 stated that resident 3's bed was in the lowest position at the time resident 3 was found on the floor. On 11/27/17 at 7:18 AM, resident 3 was observed to be laying in bed. The bed had been raised to at approximately 2 feet (ft) to 2 1/2 ft from the floor. Resident 3's medical record was reviewed on 11/27/17. Review of the significant change MDS dated [DATE], revealed that resident 3 had memory problems and required extensive assistance of one person for bed mobility, transfers and toileting. On 8/5/17, an ADL self-care performance deficit related to: Dementia care plan was developed. The goal, developed on 11/20/17, was (Resident 3) will improve current level of function through the review date. The interventions developed to achieve the goal included, .Bed Mobility: (Resident 3) requires set up to extensive assistance by (1-2) staff to turn and reposition in bed . and .Transfer: (Resident 3) requires set up to extensive assistance of (1-2). On 10/6/17, the facility documented a focus area on the care plan as, (Resident 3) is at risk for falls related to: Confusion, Unaware of safety needs. Found (Resident 3) sitting on floor next to bed. Bed in low position. Sent (to) hospital due to fractured pelvis and L1 FX (fracture). The goal that was developed was (Resident 3) will be free of major injury through the review date. The interventions developed to achieve the goal included: Ensure that (Resident 3) is wearing appropriate footwear when ambulating; Be sure (resident 3's) call light is within reach and encourage him to use it for assistance as needed. (Resident 3) needs prompt response to all requests for assistance; (Resident 3) needs a safe environment with floors free from spills and/or clutter; adequate glare-free light; a working and reachable call light, the bed in low position at night, personal items within reach; Monitor and document episodes of (the facility staff did not document what the episodes were); and Non-Medication Interventions in place routinely: Approach in a slow non-threatening manner. On 10/27/17 at 8:51 PM, a LN documented, Communication sent to DON, Admin, et facility physicians: Resident was heard yelling from vacant room down hall from nurses station this evening approx (approximately) 1635 (4:35 PM). Found him just inside doorway of vacant room sitting up on floor, another resident was standing in doorway stated he saw him catch foot on closet door et fall. States that (resident 3) did not hit head on falling. Vital signs WNL when checked, resident has small abrasion to L anter (anterior) knee. No other injuries notable. Resident refused PRN (as needed) pain interventions. Review of the incident report revealed the facility staff documented the incident description as, Heard resident screaming/yelling while in another resident room. Found resident in vacant resident room by bed. Another resident was standing in doorway, stated resident caught foot on closet door et fell Assisted resident to stand with CNA aid (sic) et performed skin check et vital signs. Resident speaking Bosnia(n), no interpreter available. The LN further documented, Resident had been following staff through afternoon, unsure if he was attempting to follow RN (Registered Nurse) into other patient room et lost sight of room. On 10/30/17, resident 3's fall risk care plan was revised to include the following interventions: Refer to PT (Physical Therapy); (and) Anticipate and meet (resident 3's) needs. On 11/1/17 at 3:17 PM, the DON documented an investigation into the incident that occurred on 10/27/17. The DON documented, Fall review: (Resident 3) was found at 4:30 pm with another resident standing over him and he was on the floor. The resident standing over him stated that (resident 3) had tripped on the closet. Has small abrasion to left knee. Verified that all persons were notified, MD, Family, DON. Care plan intervention of making sure he has appropriate footwear addressed as care plan intervention. On 11/14/17 at 10:58 AM, a LN documented, Late Entry: Resident had an unwitnessed fall around 0830 (8:30 AM). Pt (Patient) was found sitting on floor next to his bed. Pt c/o (complained of) pain in R (right) leg. During assessment a round lump/protrusion was noted on R trochanter area. Pt was also found to have a small skin tear to R elbow. Cleansed and covered with tegaderm. Pt was placed back in bed and unit manager was notified.Upon further assessment it was determined to send to ER (emergency room ) at (local hospital) via ambulance. ER was called and report given to (name redacted). Family and MD notified. Ambulance arrived and transported without incident. Review of resident 3's discharge summary from the hospital was conducted. The hospital physician documented that resident 3 sustained a non-operative pelvic fracture. On 11/27/17 at 11:30 AM, CNA 2 was interviewed. CNA 2 stated that resident 3 required assistance for all ADLs. CNA 2 stated that resident 3 was not to have the bed all the way down to prevent additional injuries if the resident had rolled out of bed. On 11/27/17 at 11:40 AM, LPN 1 was interviewed. LPN 1 observed resident 3's bed approximately 2 to 2 1/2 ft off of the floor. LPN 1 stated that resident 3 required assistance with all ADLs. LPN 1 stated that resident 3's bed to was to be in the lowest possible position (approximately six inches off the floor) to prevent injuries if he rolled out of bed or attempted to get out of bed without assistance. On 11/27/17 at 1:27 PM, CNA 1 was interviewed. CNA 1 stated resident 3 required the extensive assistance of 1-2 people for dressing and transfers due to combativeness. CNA 1 stated that resident 3 required the extensive assistance of one person for toileting, bathing, and grooming. CNA 1 stated that staff were supposed to keep resident 3's bed in the lowest position to prevent falling. However, CNA 1 stated that some staff members left the bed at a medium height level because they believed it was easier for the resident to get out of bed at that height. On 11/27/17 at 1:43 PM, an interview was conducted with the DON. The DON stated that resident 3 needed a lot of help and was really agitated. The DON stated that resident 3's bed was to be in the lowest position and was not aware that the bed had been elevated in the morning. (Cross refer to F282)

Based on observation, interview and record review it was determined that for 2 of 52 sampled residents the facility did not provide care to prevent the development of pressure ulcers. Specifically, two residents who were admitted to the facility without a pressure ulcer developed a pressure ulcer in the facility. These findings were found to have occurred at a harm level. Resident identifiers: 28 and 46. Findings include: 1. Resident 46 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/20/17 resident 46's medical records were reviewed. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a functional status for transfers, bed mobility, walking in corridor, dressing, toilet use, and personal hygiene of extensive assistance with a 2 to 3 person physical assist. Review of resident 46's nursing progress notes revealed the following: a) On 4/2/17 at 5:40 PM, NO SKIN ISSUES NOTED AT THIS TIME. b) On 4/23/17/17 at 3:33 AM, RES (resident) has purple spot on her buttox (sic). Created TO (telephone order): Cleanse buttox (sic) (with) wound cleaner allow to dry cover blisted (sic) area (with) Hydracoloid (sic) dressing prn (as needed). c) On 5/3/17 at 4:51 AM, New [MEDICATION NAME] applied to site at buttocks, near the beginning of the gluteal cleft, during CNA (certified nursing assistant) rounds, and then turned towards her right side in order to encourage maximal perfusion. d) On 6/10/17 at 5:12 AM, Resident has a DTI (deep tissue injury) on her buttocks and is turned (every 2 hours), and a TX (treatment) is in place. e) On 6/13/17 at 7:46 PM,New order received to obtain a low air flow mattress. Staff to monitor and assess effectiveness. Review of resident 46's physician orders [REDACTED]. a) Wound on coccyx, cleanse with wound cleaner, mix Zinc and A&D ointment together and apply to wounds, and cover with foam dressing, daily in the AM and PM. The order was initiated on 6/16/17. b) Cleanse buttox (sic) (with) wound cleaner allow to dry cover blisted (sic) area (with) Hydracoloid (sic) dressing prn, change every 3 days in the AM and PM. The order was initiated on 4/23/17. c) Med Pass 2.0 60 ml (milliliter) BID (two times a day). The order was initiated on 6/7/17. d) Multivitamin 1 tablet by mouth daily. The order was initiated on 6/7/17. e) Head to toe skin checks each week. The order was initiated on 6/15/17. f) Encourage resident to turn/reposition every 2 hours. The order was initiated on 6/15/17. Review of resident 46's Treatment Administration Record (TAR) revealed weekly skin checks documented on each Wednesday for the month of May 2017 and June 2017. Review of resident 46's Weekly Skin Integrity forms revealed the following: a) On 4/26/17 the weekly skin check first documented the presence of a pressure ulcer. The assessment stated, small open area on buttocks. Tx (treatment) in place, No s/s (signs and symptoms) of infection. No measurements or assessment of the pressure ulcer were documented. b) On 5/3/17 the weekly skin check indicated no skin integrity problems. c) On 5/17/17 the weekly skin check documented breakdown on buttocks. No measurements or assessment of the pressure ulcer were documented. d) On 5/24/17 the weekly skin check documented breakdown on buttocks. No measurements or assessment of the pressure ulcer were documented. e) On 5/31/17 the weekly skin check documented skin breakdown but they addressed on buttocks. No measurements or assessment of the pressure ulcer were documented. f) On 6/7/17 the weekly skin check documented skin breakdown on buttocks. No measurements or assessment of the pressure ulcer were documented. g) On 6/14/17 the weekly skin check documented open ulcer on buttocks. No measurements or assessment of the pressure ulcer were documented. On 6/14/17 a Wound Assessment Details Report was completed for resident 46's coccyx wound. The report staged the wound as a Stage 3 pressure ulcer with scant serosanguineous exudate. The wound measured 0.5 cm (centimeters) X (by) 0.5 cm X .1 cm (length X width X depth). No undermining or tunneling noted. Review of resident 46's care plan revealed a specific care plan related to Impaired Skin Integrityon the buttocks was initiated on 6/16/17. Approaches listed included to use turn sheet to turn resident to avoid shearing forces on skin, and Wound on coccyx; Cleanse with wound cleaner, mix Zinc and A&D ointment together and apply to wounds, cover with a foam dressing. No care plan could be located to indicate a wound care plan had been initiated prior to 6/16/17. Review of Skin and Weight Notes were reviewed. On 5/2/17 and 6/2/17 facility staff documented that resident 46 had some breakdown on buttock, and that a treatment was in place. However, no wound assessment or measurements were noted. Review of Skin and Weight Meeting notes for resident 46 revealed the following: a) On 4/24/17 there was no documentation of resident 46's Pressure Ulcer (PU). b) On 5/5/17, [MEDICAL CONDITION] IN BLE (bilateral lower extremities) CONTINUES TO BE MANAGED WELL WITH [MEDICATION NAME]. NO OTHER SKIN ISSUES NOTED AT THIS TIME. (Note: The weekly skin integrity forms indicated that resident 46 had an open area during this time.) c) On 5/11/17, there was no documentation of resident 46's PU. d) On 5/18/17, [MEDICAL CONDITION] in BLE (bilateral lower extremities) is being treated with TED ([MEDICAL CONDITION]-embolic-deterrent) hose. No other skin issues noted. (Note: The weekly skin integrity forms indicated that resident 46 had an open area during this time.) e) On 5/25/17, Res (resident) currently has no skin issues. (Note: The weekly skin integrity forms indicated that resident 46 had an open area during this time.) f) On 6/1/17, Res continues with [MEDICAL CONDITION] in BLE, but has no other skin issues. (Note: The weekly skin integrity forms indicated that resident 46 had an open area during this time.) g) On 6/8/17, there was no documentation for resident 46. (Note: The weekly skin integrity forms indicated that resident 46 had an open area during this time.) h) On 6/15/17, there was no documentation for resident 46. (Note: The weekly skin integrity forms indicated that resident 46 had an open area during this time.) On 6/21/17 at 9:04 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she reported new PU issues to the Director of Nursing (DON) and the wound nurse. RN 2 stated that during her weekly skin checks all clothing and dressings were removed and the resident was inspected for any areas of concern. On 6/21/17 at 8:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 46's PU wasn't reported to her and that she accidentally identified the PU on 6/8/17 through an Interdisciplinary Team (IDT) notes review. The DON stated that the process for wound management was that the floor nurse was to report any PU to the DON and the DON would make arrangements for the wound physician to assess the wound. The DON stated that the wound nurse (WN) was also informed of the resident's PU by the DON for follow-up and weekly monitoring. The DON stated that the weekly monitoring occurred on Wednesdays. The DON stated that the wound physician was informed of resident 46's PU on 6/13/17. The DON further stated that prior to 6/14/17 weekly wound assessments were not done for this resident. On 6/21/17 at 11:30 AM an observation was made of resident 46's PU dressing being changed. In attendance at this dressing change were RN 2, the WN, and the DON. RN 2 was assisting the WN with the dressing change while the DON was documenting and taking pictures. RN 2 was positioned towards the head of resident 46, assisting the resident to maintain a right lateral position for the dressing change. An observation was made of the old dressing being removed by RN 2. The WN was observed to apply new gloves and cleanse the wound with a sterile 4 by (x) 4 gauze saturated in dermal wound cleanser. Wound measurements were obtained by the WN and measured 0.5 cm (centimeters) x 0.1 cm x 0.1 cm (length x width x depth). The wound was observed to have a white scab with no open areas visible. The WN stated that she staged it as a 0.1 depth even though it was closed, so that the would would remain on the assessment schedule. The WN stated that wounds tended to open back up quickly so she liked to extend the assessment time to allow it to fully heal. The WN was observed to apply Zinc and A&D ointment to the wound with a gloved finger. The WN was then observed to apply a Flivasorb adhesive foam bandage over the top. RN 2 stated, the wound has really improved since we started doing BID (twice daily) dressing changes. The WN stated that the dressing had been changed to BID since the wound physician assessed the wound, approximately a week ago. 2. Resident 28 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/19/17, resident 28's medical record was reviewed. On 5/19/17, a MDS initial assessment was completed for resident 28. The MDS indicated that resident 28 required extensive assistance by at least one person for bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS also indicated that resident 28 did not currently have a pressure ulcer, but was at risk for developing one. In addition, the MDS indicated that a pressure ulcer and nutritional care plans should have been developed for resident 28. No care plan for resident 28 regarding the prevention and/or treatment of [REDACTED]. The nutritional care plan for resident 28 documented that the resident was at nutritional risk due to her diagnoses. The only goals listed were meet estimated nutritional needs for resident and avoid significant wt (weight) changes . The only approaches listed on the nutritional care plan were Continue diet as ordered and continue offering hs (nightly) snack . On 5/11/17, a Braden scale was completed for resident 28. Facility staff documented that resident 28 was assessed as being low risk for developing a pressure sore. Resident 28's Nursing Admission assessment dated [DATE] was reviewed. The assessment indicated that resident 28's peri area is red. The assessment also indicated that resident 28 was having pain on her buttocks. A physician's progress note dated 5/12/17 was reviewed. The progress note indicated that resident 28's skin was normal, warm and dry, no rashes or [MEDICAL CONDITION]. Nurses notes dated 5/12/17 documented that resident 28 required extensive assistance by at least two staff members for transferring, and extensive assistance by at least 1 staff member when toileting and showering. A weekly skin integrity tool for resident 28 dated 5/13/17 indicated that resident 28's skin was clean, dry, and intact. A weekly skin integrity tool for resident 28 dated 5/20/17 indicated that resident 28 had mild redness to buttocks, barrier cream applied. A weekly skin integrity tool for resident 28 dated 5/27/17 indicated that resident 28 had redness to buttocks barrier cream applied. Facility staff were unable to provide weekly skin integrity tools for resident 28 for the month of June 2017. On 6/9/17 a physician's telephone order was written for resident 28 to have zinc oxide used in her gluteal cleft. A Wound Assessment Details Report dated 6/21/17 for resident 28 was reviewed. The report revealed that resident 28 had acquired the pressure ulcer on her coccyx during her stay at the facility. The report also revealed that the pressure ulcer was a stage 2, and was 1.5 centimeters (cm) by 1.0 cm by 0.2 cm. The report indicated that resident 28's pain score was a 6 out of 10 at the time of the assessment. A nutrition assessment dated [DATE] by the facility Registered Dietitian (RD) was reviewed. The RD documented that the resident weighed 190 pounds at the time of the assessment. The RD documented that the resident was eating 25 to 50 percent of her meals, and that the resident's current po (by mouth) intake (was) suboptimal and may not be adequate for est (estimated) needs . Noted res (resident) is obese and some wt (weight) loss would be recommend (sic). The RD did not address resident 28's skin integrity, or recommend interventions to prevent further skin breakdown or maintain current protein stores. The RD documented that resident 28 was at risk of malnutrition. In addition, in the assessment the RD inaccurately assessed resident 28's mobility as being able to propel herself in the wheelchair, instead of the resident's ability to get herself out of her bed or chair. The RD did not address that the resident required extensive assistance by staff for repositioning, which put her at increased risk for developing a pressure ulcer. (Note: It should be noted that no RD notes were made after 5/17/17 to indicate that the RD was aware of resident 28's changing nutritional needs for optimal health. It should also be noted that resident 28 was [AGE] years of age at the time that the RD stated weight loss was recommended). On 6/6/17, resident 28 had a Comprehensive Metabolic Panel (CMP) drawn. The CMP indicated that resident 28's total protein was 6.0 grams per deciliter (g/dl), which was under the normal range listed on the laboratory sheet of 6.3 to 8.2 g/dl. In addition, the CMP indicated that resident 28's [MEDICATION NAME] was 3.1 g/dl, which was under the normal range listed on the laboratory sheet of 3.5 to 5.0 g/dl. On 6/20/17, resident 28 had a follow up CMP drawn. The CMP indicated that resident 28's total protein was lower than the level drawn 14 days prior, and was now at 5.8 g/dl. In addition, the CMP indicated that resident 28's [MEDICATION NAME] was lower than the level drawn 14 days prior and was now at 2.7 g/dl. Weights for resident 28 were obtained. Facility staff documented that on 5/22/17, which was 11 days after admission, resident 28 weighed 192 pounds. On 5/30/17, facility staff documented that resident 28 now weighed 176 pounds. The weekly skin and weight meeting notes for May and June 2017 were reviewed. a) On 5/25/17, facility staff documented that the resident was being changed to weekly weights due to an 8 percent weight loss in one month. No other interventions were put into place. b) On 6/1/17, facility staff did not document that resident 28 was discussed. c) On 6/8/17, facility staff documented that the resident had gained 0.5 percent of her body weight in one week, and was to continue on weekly checks. d) On 6/15/17, facility staff documented that resident 28 had lost 0.2 percent of her body weight in one week, and was to continue on weekly checks. (Note: No mention was made in the skin and weight meeting notes regarding the redness on resident 28's buttocks and therefore no additional interventions were initiated during those meetings to prevent further breakdown of resident 28's skin. In addition, no interventions were put into place to address resident 28's weight loss.) A physician's progress note dated 6/20/17 was reviewed. The progress note indicated that resident 28 has a less than dime-sized stage II decubitus ulcer, it is very superficial with really only a partial thickness erosion of skin, there is no evidence of infection, the ulcer was slightly to the right of the sacrum, on the right edge of the right sacral ala. On 6/21/17 at approximately 2:00 PM, an observation was made of resident 28's wound while the WN changed the resident's dressing. The WN removed the dressing and stated that the wound looked worse than the previous week, since the skin had now opened up. The pressure ulcer was approximately the size of a dime and the top layer of skin was now open. physician's orders [REDACTED]. On 6/20/17, after the stage 2 pressure ulcer was identified, orders were put into place for a low air flow loss mattress, a roho cushion in her wheelchair, repositioning every 2 hours, and a [MEDICATION NAME] and [MEDICATION NAME] dressing to the resident's wound. On 6/26/17 at 12:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 28 could not reposition herself either in bed or in the wheelchair, and was dependent on staff to do this for her. On 6/26/17 at 12:55 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 28 could not reposition herself either in bed or in the wheelchair, and was dependent on staff to do this for her. On 6/26/17 at 8:50 AM, an interview was conducted with the facility RD. The RD stated that her only responsibility at the facility was to enter quarterly notes for the residents. The RD stated that she was not notified of changes in resident condition, new pressure ulcers, or significant weight loss in residents. The RD stated that she did not attend the weekly skin and weight meetings conducted at the facility. The RD stated that the staff members that attended the skin and weight meeting usually addressed any nutritional and/or skin concerns. The RD stated she was unaware of resident 28's significant weight change in May 2017 or resident 28's current skin condition. On 6/26/17 at 12:25 PM, an interview was conducted with the DON. The DON stated that the facility had not been tracking redness and/or stage 1 pressure ulcers as part of a program to ensure that appropriate treatments were in place to prevent the ulcers from worsening. In addition, the DON stated that the skin and weight committee did not routinely recommend [MEDICATION NAME] or total protein be checked for residents, because that was up to the physician. On 6/26/17 at 9:40 AM, the DON was re-interviewed. The DON confirmed that the facility RD did not attend the skin and weight meetings, nor did she review the notes and recommendations made. The DON stated that she did not notify the RD of any significant weight changes or changes in skin because the RD's responsibility was only to do quarterly notes for everyone. (Cross refer to F279 and F325)

Based on interview, observation, and record review, the facility did not ensure that 5 of 52 sample residents maintained acceptable parameters of nutritional status. Specifically, one resident with an open wound and increased protein needs experienced a weight loss without timely and appropriate interventions. This resident will be cited at a harm level. In addition, 4 other residents were not identified as having nutrition concerns and/or did not have timely and appropriate nutrition interventions. Resident identifiers: 17, 18, 28, 49, 89. Findings include: HARM 1. Resident 28 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/19/17, resident 28's medical record was reviewed. On 5/19/17, a MDS initial assessment was completed for resident 28. The MDS indicated that resident 28 required extensive assistance by at least one person for bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS also indicated that resident 28 did not currently have a pressure ulcer, but was at risk for developing one. In addition, the MDS indicated that a pressure ulcer and nutritional care plans should have been developed for resident 28. No care plan for resident 28 regarding the prevention and/or treatment of [REDACTED]. The nutritional care plan for resident 28 documented that the resident was at nutritional risk due to her diagnoses. The only goals listed were meet estimated nutritional needs for resident and avoid significant wt (weight) changes . The only approaches listed on the nutritional care plan were Continue diet as ordered and continue offering hs (nightly) snack . On 5/11/17, a Braden scale was completed for resident 28. Facility staff documented that resident 28 was assessed as being low risk for developing a pressure sore. Resident 28's Nursing Admission assessment dated [DATE] was reviewed. The assessment indicated that resident 28's peri area is red. The assessment also indicated that resident 28 was having pain on her buttocks. A physician's progress note dated 5/12/17 was reviewed. The progress note indicated that resident 28's skin was normal, warm and dry, no rashes or [MEDICAL CONDITION]. Nurses notes dated 5/12/17 documented that resident 28 required extensive assistance by at least two staff members for transferring, and extensive assistance by at least 1 staff member when toileting and showering. A weekly skin integrity tool for resident 28 dated 5/13/17 indicated that resident 28's skin was clean, dry, and intact. A weekly skin integrity tool for resident 28 dated 5/20/17 indicated that resident 28 had mild redness to buttocks, barrier cream applied. A weekly skin integrity tool for resident 28 dated 5/27/17 indicated that resident 28 had redness to buttocks barrier cream applied. Facility staff were unable to provide weekly skin integrity tools for resident 28 for the month of June 2017. On 6/9/17 a physician's telephone order was written for resident 28 to have zinc oxide used in her gluteal cleft. A Wound Assessment Details Report dated 6/21/17 for resident 28 was reviewed. The report revealed that resident 28 had acquired the pressure ulcer on her coccyx during her stay at the facility. The report also revealed that the pressure ulcer was a stage 2, and was 1.5 centimeters (cm) by 1.0 cm by 0.2 cm. The report indicated that resident 28's pain score was a 6 out of 10 at the time of the assessment. A nutrition assessment dated [DATE] by the facility Registered Dietitian (RD) was reviewed. The RD documented that the resident weighed 190 pounds at the time of the assessment. The RD documented that the resident was eating 25 to 50 percent of her meals, and that the resident's current po (by mouth) intake (was) suboptimal and may not be adequate for est (estimated) needs . Noted res (resident) is obese and some wt (weight) loss would be recommend (sic). The RD did not address resident 28's skin integrity, or recommend interventions to prevent further skin breakdown or maintain current protein stores. The RD documented that resident 28 was at risk of malnutrition. In addition, in the assessment the RD inaccurately assessed resident 28's mobility as being able to propel herself in the wheelchair, instead of the resident's ability to get herself out of her bed or chair. The RD did not address that the resident required extensive assistance by staff for repositioning, which put her at increased risk for developing a pressure ulcer. (Note: It should be noted that no RD notes were made after 5/17/17 to indicate that the RD was aware of resident 28's changing nutritional needs for optimal health. It should also be noted that resident 28 was [AGE] years of age at the time that the RD stated weight loss was recommended). On 6/6/17, resident 28 had a Comprehensive Metabolic Panel (CMP) drawn. The CMP indicated that resident 28's total protein was 6.0 grams per deciliter (g/dl), which was under the normal range listed on the laboratory sheet of 6.3 to 8.2 g/dl. In addition, the CMP indicated that resident 28's [MEDICATION NAME] was 3.1 g/dl, which was under the normal range listed on the laboratory sheet of 3.5 to 5.0 g/dl. On 6/20/17, resident 28 had a follow up CMP drawn. The CMP indicated that resident 28's total protein was lower than the level drawn 14 days prior, and was now at 5.8 g/dl. In addition, the CMP indicated that resident 28's [MEDICATION NAME] was lower than the level drawn 14 days prior and was now at 2.7 g/dl. Weights for resident 28 were obtained. Facility staff documented that on 5/22/17, which was 11 days after admission, resident 28 weighed 192 pounds. On 5/30/17, facility staff documented that resident 28 now weighed 176 pounds. The weekly skin and weight meeting notes for May and June 2017 were reviewed. a) On 5/25/17, facility staff documented that the resident was being changed to weekly weights due to an 8 percent weight loss in one month. No other interventions were put into place. b) On 6/1/17, facility staff did not document that resident 28 was discussed. c) On 6/8/17, facility staff documented that the resident had gained 0.5 percent of her body weight in one week, and was to continue on weekly checks. d) On 6/15/17, facility staff documented that resident 28 had lost 0.2 percent of her body weight in one week, and was to continue on weekly checks. (Note: No mention was made in the skin and weight meeting notes regarding the redness on resident 28's buttocks and therefore no additional interventions were initiated during those meetings to prevent further breakdown of resident 28's skin. In addition, no interventions were put into place to address resident 28's weight loss.) A physician's progress note dated 6/20/17 was reviewed. The progress note indicated that resident 28 has a less than dime-sized stage II decubitus ulcer, it is very superficial with really only a partial thickness erosion of skin, there is no evidence of infection, the ulcer was slightly to the right of the sacrum, on the right edge of the right sacral ala. On 6/21/17 at approximately 2:00 PM, an observation was made of resident 28's wound while the WN changed the resident's dressing. The WN removed the dressing and stated that the wound looked worse than the previous week, since the skin had now opened up. The pressure ulcer was approximately the size of a dime and the top layer of skin was now open. physician's orders [REDACTED]. On 6/20/17, after the stage 2 pressure ulcer was identified, orders were put into place for a low air flow loss mattress, a roho cushion in her wheelchair, repositioning every 2 hours, and a [MEDICATION NAME] and [MEDICATION NAME] dressing to the resident's wound. On 6/26/17 at 12:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 28 could not reposition herself either in bed or in the wheelchair, and was dependent on staff to do this for her. On 6/26/17 at 12:55 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 28 could not reposition herself either in bed or in the wheelchair, and was dependent on staff to do this for her. On 6/26/17 at 8:50 AM, an interview was conducted with the facility RD. The RD stated that her only responsibility at the facility was to enter quarterly notes for the residents. The RD stated that she was not notified of changes in resident condition, new pressure ulcers, or significant weight loss in residents. The RD stated that she did not attend the weekly skin and weight meetings conducted at the facility. The RD stated that the staff members that attended the skin and weight meeting usually addressed any nutritional and/or skin concerns. The RD stated she was unaware of resident 28's significant weight change in May 2017 or resident 28's current skin condition. On 6/26/17 at 12:25 PM, an interview was conducted with the DON. The DON stated that the facility had not been tracking redness and/or stage 1 pressure ulcers as part of a program to ensure that appropriate treatments were in place to prevent the ulcers from worsening. In addition, the DON stated that the skin and weight committee did not routinely recommend [MEDICATION NAME] or total protein be checked for residents, because that was up to the physician. On 6/26/17 at 9:40 AM, the DON was re-interviewed. The DON confirmed that the facility RD did not attend the skin and weight meetings, nor did she review the notes and recommendations made. The DON stated that she did not notify the RD of any significant weight changes or changes in skin because the RD's responsibility was only to do quarterly notes for everyone. POTENTIAL FOR HARM 2. Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 49's medical record was reviewed on 6/19/17. On 9/20/16, the facility RD completed a Mini Nutritional Assessment for resident 49. The assessment was listed as a screening tool, and indicated that resident 49 was at normal nutritional status. The RD did not provide additional information in the assessment, such as whether or not she had interviewed and observed the resident, the resident's pertinent medications, any recent labs that should have been considered, what the follow up plans would include, etc. On 3/8/17, the facility RD completed an additional Mini Nutritional Assessment for resident 49. The facility RD indicated that the resident was now at risk of malnutrition, and had experienced a weight loss of approximately 3 pounds in the last 3 months. The RD did not provide additional information in the assessment, such as whether or not she had interviewed and observed the resident, any recent labs that should have been considered, the resident's current skin condition, what the follow up plans would include, etc. On 6/26/17 at 8:50 AM, an interview was conducted with the facility RD. The RD stated that the assessment was only a screening tool and that she had been instructed by the corporate dietitian that if the resident did not score high enough to be defined as malnourished, she did not have to complete a full assessment for the resident. 3. Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 89's medical record was reviewed on 6/19/17. Resident 89's nutritional care plan dated 5/31/17, documented that the resident was at nutritional risk due to his diagnoses. The only goals listed were meet estimated nutritional needs for resident and avoid significant wt (weight) changes . The only approaches listed on the nutritional care plan were Continue serving diet as ordered. and offer hs snack (every) evening. The care plan did not list specific interventions to address resident 89's potential for altered nutritional status. The approaches listed on the nutrition care plan were not specific and measurable. Resident 89's weights had been recorded by facility staff as follows: a) On 6/2/17, 147.4 pounds b) On 6/5/17, 144.4 pounds c) On 6/12/17, 144.4 pounds d) On 6/19/17, 144.0 pounds. On 5/31/17, the facility RD completed a Mini Nutritional Assessment for resident 89. The assessment indicated that resident 89 had experienced a severe decrease in food intake over the past 3 months, was experiencing severe dementia or depression, and was considered malnourished. The facility RD assessment also indicated that the resident was under his ideal body weight, and had a low [MEDICATION NAME]. The RD stated in her note she will follow progress (at) facility and that the resident's poor intake was due to his need to adjust to the new facility. The RD did not document any interventions to address resident 89's low weight and/or [MEDICATION NAME]. On 6/26/17 at 8:50 AM, the facility RD was interviewed. When asked what will follow progress meant in her note, the RD stated that she would follow up in 3 months. The RD stated that the facility staff members would monitor the resident in their skin and weight meetings and contact her if they had any concerns. The facility skin and weight meeting notes were reviewed. Resident 89 was not discussed in the 6/8/17 meeting. During the 6/15/17 meeting, facility staff documented that the resident was on monthly weight checks and had not had a weight change over the last month. (Note: This was incorrect according to the weights recorded by facility staff. The recorded weights indicated that the resident had lost 3.4 pounds in the last 17 days. In addition, the facility staff did not indicate which interventions, if any, they were implementing to address resident 89's low body weight and [MEDICATION NAME]. 4. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18's medical record was reviewed on 6/19/17. review of the resident's medical record revealed [REDACTED]. a) 2/6/17 = 91 pounds b) 2/13/17 = 91 pounds c) 2/20/17 = 93 pounds d) 2/27/17 = 95 pounds e) 4/18/17 = 102 pounds f) 6/5/17 = 104 pounds On 6/26/17 at 8:45 AM, the RD was interviewed. The RD was asked about a progress note written on 1/17/17 stating .res (resident) new to facility on 1/11/17, will follow progress over the next week . The RD stated that she did not follow up in one week as she documented in her progress note and the next time she wrote a progress note for the resident was the next quarterly assessment on 4/18/17. 5. Resident 17 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 17's medical record was reviewed on 6/19/17. review of the resident's medical record revealed [REDACTED]. a) 4/15/17 = 120 pounds b) 4/18/17 = 121 pounds c) 4/24/17 = 122 pounds d) 5/2/17 = 116 pounds e) 5/8/17 = 118 pounds f) 5/15/17 = 115 pounds g) 5/22/17 = 113 pounds h) 6/6/17 = 111 pounds (Note: Resident 17 was admitted on hospice services on 6/22/17.) The resident lost 9 pounds from 4/15/17 to 6/6/17, which was a 7.5 percent weight loss over less than 2 months, prior to the resident being admitted on hospice services. This weight loss met the federal criteria for a significant weight loss. Review of the resident's nutrition care plan dated 4/25/17 revealed two nutritional goals for the resident. The first goal was to meet estimated nutritional needs for resident and the second goal was to avoid significant wt. (weight) loss of greater than 5% in 30 days or 10% in 180 days. The care plan listed three approaches on the original care plan: continue mechanical soft meals three times a day, continue mighty shakes with meals three times a day, and offer 90 milliliters of Medpass twice a day between meals. The care plan had not been updated, nor had new interventions been implemented after resident 17 experienced a significant weight loss. The weekly skin and weight meeting notes for April, May and June 2017 were reviewed. No new interventions were listed in the skin and weight meeting notes to prevent further weight loss for resident 17. In addition, facility staff did not identify resident 17's significant weight loss through the skin and weight meeting process. On 6/26/17 the RD was interviewed. The RD stated that she wrote quarterly assessments on the residents and did not attend the weekly skin and weight meetings because she was in the facility early in the week and the skin and weight meetings were conducted later in the week. The RD stated resident 17 had mighty shakes and med pass ordered upon admission, which were the primary interventions she would usually implement for a resident experiencing weight loss. (Cross refer to F279, F314, F490, F501, and F520)

Based on observation, interview, and record review it was determined, for 14 of 43 sample residents, that the facility failed to provide adequate supervision and assistance devices to prevent accidents. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to altercations between residents, residents being injured from falls, and residents experiencing episodes of choking during meal times. (Residents 1, 4, 7, 13, 42, 65, 72, 77, 86, 87, 88, 89, 92, and 94) Additionally, a cabinet with cleaning chemicals was observed to be unlocked and unattended in the Special Needs Unit. The deficient practice identified for residents 1, 42, 86, 88, 89, 92, and 94 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for residents 4 and 77 was found to have occurred at a Harm Level and will not be included in the Immediate Jeopardy. The deficient practice identified for residents 7, 13, 65, 72, 87, and 89 was found to have occurred at a potential for harm and will also not be included in the Immediate Jeopardy. Resident 42 was sent to a local acute care hospital with a subdural hematoma after an altercation with resident 92. Resident 86 had a history of [REDACTED]. Staff were unaware of resident 86's history and staffing levels were inadequate to monitor resident 86's wandering behavior to ensure the safety of female residents residing on the unit. Resident 88 was observed to be pacing the halls of the Special Needs Unit on 3/15/16 at 3:00 AM when there were no staff on the unit to monitor the wandering behavior. Resident 88 was observed to be going in and out of other resident's rooms that resided on the Special Needs Unit without intervention from facility staff. Resident 89 had a history of [REDACTED]. Facility staff were unaware of resident 89's history and multiple observations were made of resident 89 assaulting facility staff. Additionally, record review revealed resident 89 had multiple incidents of assaulting residents residing on the Special Needs Unit. Additionally, resident 94, who had a history of [REDACTED]. Resident 1, who was assessed as requiring direct supervision while eating, was observed to have no direct supervision while dining and subsequently experienced a choking incident in the dining room with minimal staff intervention. Findings include: Immediate Jeopardy: Supervision in Secure Unit: 1. Resident 42 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/14/16 resident 92's medical record was reviewed. Review of the History and Physical revealed a form entitiled, Patient/Family Education dated 2/27/16 and 2/28/16. The form had a mark under the Special Precautions indicating assault, elopement, and high fall risk. Additionally, the form had a section titled Harm to others including aggressive, combative and quick to anger. Review of facility incident reports revealed that on 3/3/16 at 1:30 AM, resident 92 entered resident 42's room and proceeded to assault resident 42. The incident report completed by facility staff for resident 92 documented the following: 3/3/16 1:30 AM: This resident entered the room, proceeded to smash bedside table, where the injured resident was pushed into, cutting his R (right) side of jaw and neck. The incident report completed by facility staff for resident 42 documented the following: 3/3/16 1:00 AM: This nurse was informed by (name of employee) CNA (Certified Nursing Assistant), that resident was injured in his room. He was assaulted by another resident while he was laying in his bed. Upon entering residents room, noted the bedside table was broken into pieces, floor was strewn with papers and some clothing. The accused resident was still present in the room, trying to hit the resident. This nurse and (name of employee) CNA, walked accused resident out of room. Upon entering residents room again, I assessed residents injuries, noted cut along right side of (sic) Cut to L (left) proximal region of jaw extending past R ear to midjaw. Multiple cuts on R side of neck (Please see attached paper for complete narrative of incident). Review of the facility's Initial Entity Report submitted to the State Survey Agency after the resident to resident altercation revealed the following: (Name of Resident 92) entered (name of Resident 42)'s room. (Name of Resident 42) ordered (name of Resident 92) to get out. (Name of Resident 92) proceeded to smash bed side table in half and pushed (name of Resident 42) into broken table. (Name of Resident 42) cut the right side of his jaw and neck. (Name of Resident 42) was transported to the hospital. Attached to the Entity Report was additional documentation from the nurse working on 3/3/16. The facility nurse documented the following: While trying to inquire information regarding the incident, the resident stated 'He just came in, broke my table, then pushed me.' Resident roommate was stating at the same time, the accused resident was hitting resident with a piece of the table. I administered pain medication for pain, then proceeded to clean wounds to jaw with NS (normal saline) and apply nonadherent dsng (dressing) then wrap with a kerlix gauze. Resident remained comfortable in bed. I then again went in to assess resident (at) 0430 (4:30 AM), noted that wound was still bleeding, and that the surrounding tissue was 'hard.' Neuro (neurological) checks were in place and resident remained stable. I felt resident needed to be evaluated at a higher level of care. I notified MD and DON of transfer of patient to hospital for further evaluation. Review of the facility's abuse investigations revealed that the facility Administrator documented the following on 3/9/16: (Resident 92), age 75, was an admit to the Memory Care Unit on 3/2/16. He has a [DIAGNOSES REDACTED]. He does not have a history of aggressive behaviors. Review of the facility progress notes for resident 92 revealed the following entry dated 3/3/16 at 8:22 AM: .this resident entered the room, proceeded to smash the bedside table, where the injured resident (resident 42) was pushed into, cutting his R (right) side of jaw and neck. Notified MD (medical doctor) and family of incident. On 3/15/16 resident 42's medical record was reviewed. Review of the medical record revealed an Admission History and Physical, from a local acute care hospital, dated 3/3/16 at 5:45 AM. The following was documented: History of present illness: Patient has a history of cognitive deficits and dementia for which he is living in a Memory Care unit. During the night, he got into an altercation with another resident and ended up rolling out of bed and striking his right face against a bedside table. He is chronically anticoagulated with Serial Toe (sic) and experienced severe swelling of the right face. CT (Computerized Tomography) scan in the emergency room revealed a moderate sized right subdural hematoma as well as a small subarachnoid hemmorhage. On 3/15/16 at 3:00 AM and 3:10 AM, observations by the survey team revealed no facility staff on the Special Needs Unit. At 3:10 AM, CNA 1 and CNA 2 were then noticed to be outside in the back of the facility on break. Resident 88 was observed to be wandering up and down the hall in the Unit. Resident 84 was observed to be lying on a love seat in a common area, sleeping. Resident 84 was observed to roll off the love seat. Resident 84 was observed to pick herself up and get back onto the love seat to go back to sleep. At approximately 3:20 AM, CNA 1 entered the unit. The unit was observed, by survey staff, to be left unattended for approximately 20 minutes. On 3/15/16 at 3:00 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that she was the nurse working the night that resident 92 assaulted resident 42. RN 1 stated that she received a call from the CNA that was back on the unit that night. RN 1 stated that she went over to the unit and provided first aide to resident 42. RN 1 stated that she eventually sent resident 42 to the hospital where he had been admitted with a subdural hematoma. On 3/15/16 at approximately 3:25 AM, an interview was conducted with CNA 1. CNA 1 stated that the way that he knew that his residents were safe during his time outside was that he would come back into the facility after break, check on the residents and that they would all be in the same place as when he went out, so, he knew that the residents had been ok while on break. When CNA 1 was told of observations of resident 84 rolling onto the floor then getting back onto the love seat, CNA 1 stated, Well that's not good. When the question was asked a second time to CNA 1, how do you know your residents have been safe while outside on break?, CNA 1 answered, I guess I really don't know. On 3/15/16 at approximately 3:45 AM, CNA 1 was reinterviewed. CNA 1 stated that he was the CNA on the unit the night that resident 92 assaulted resident 42. CNA 1 stated that he had not seen the assault, due to being in another resident room, he had just heard a large crash and went to investigate. CNA 1 stated that the other CNA assigned to the building that night was just coming over to help him when the assault occurred. CNA 1 stated that he left CNA 2 in the room and went to the nurses station to call the RN that was working on the other end of the building. CNA 1 stated that when he entered resident 42's room, resident 42 was bleeding from his nose. CNA 1 stated that resident 92 kept attempting to enter resident 42's room while the RN, himself and the other CNA were providing first aide to resident 42. CNA 1 stated that both himself and CNA 2 had to redirect resident 92 away from resident 42's room mulitple times and attempt to get resident 92 to calm down while RN 1 provided care to resident 42. CNA 1 stated that since he was the only CNA assigned to the unit, during the night shift, he would be unable to keep residents safe from other residents that displayed aggressive and assaultive behaviors while he was in a resident room providing cares. CNA 1 stated that when he went over to the other end of the building to assist CNA 2, during the night, the residents on the unit were left unattended and unspervised. On 3/15/16 at 4:15 AM, CNA 2 was interviewed. CNA 2 stated that he was afraid of resident 92. CNA 2 stated that he could not ensure the safety of residents residing in the facility when he was providing care in resident rooms. CNA 2 further stated that when the facility only had 2 CNAs on during the graveyard shift (10:00 PM to 6:00 AM) that he could not keep all of the residents safe that resided in the facility. CNA 2 stated that he did not know the medical history of [REDACTED]. On 3/15/16 at approximately 5:00 AM, RN 1 was reinterviewed. RN 1 stated that she was unable to ensure the safety of all of the residents due to staffing levels. RN 1 stated that if the facility had a resident that was a sexual predator, she would be unable to ensure the safety of residents residing in the facility. RN 1 further stated that having 3 CNAs on during the graveyard shift would be optimal, but she had not worked the graveyard shift with anymore than 2 CNAs. Review of the facility staffing schedules revealed that the facility staffed 1 nurse and 2 CNAs to the building during the night shift (10:00 PM to 6:00 AM). The current census of the building, 3/15/16, was 65 residents, with 34 residents residing on the Special Needs Unit. 2. Resident 86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Pre-Admission Screening and Resident Review dated 2/1/16 revealed the following documentation: Resident 86 becomes hostile and combative with other patients. Patient has also been sexually aggressive towards others. Review of the facility incident reports revealed the following incidents: a. 3/2/16 at 8:00 AM: a female resident stated that (resident 86) came into her room early this morning and hit her arm with a hard object. Staff did not witness altercation. (Resident 86) does not remember altercation. b. 3/4/16 at 10:34 AM: (Resident 86) started hitting another male resident with water pitcher and dumped water on male resident. (Resident 86) and other male resident immediately separated from each other and re-directed. DON, MD and family notified of incident. c. 3/4/16 at 5:00 PM: Resident was in hallway entering dinning (sic) room when approached by another resident who was curious about his activity. He spun around lightly striking other resident in side of the head with back of his hand. Residents seperated (sic) and re directed. Without further incident. Family and MD notified. (It should be noted that the interviews of RN 1 and CNA 1 and CNA 2 address the concern that the facility staff working 10:00 PM to 6:00 AM were leaving residents unattended and unsupervised and that due to not having adequate staff, they would be unable to keep residents in the facility safe from a resident who had sexual aggression.) 3. Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/14/16 at approximately 1:15 PM, the following observations were made by the state survey agency and a Regional Office Surveyor (ROS): Resident 89 approached the ROS in an agitated and aggressive manner. Resident 89 was pointing to a sign in the unit and saying nonsensical words. Resident 89 stepped towards a resident residing on the unit. The ROS stepped between resident 89 and the other resident to prevent an altercation. Resident 89 then grabbed the ROS by the elbow, pinching her elbow. The ROS proceeded to walk with resident 89 down the hall to the nurses station to prevent resident 89 from escalating. Once at the nurses' station, resident 89 stepped towards a state surveyor, resident 89 lifted her hands indicating that she wanted to grab the state surveyor's hair. Resident 89 stated that she wanted to yank all of the state surveyor's hair out. A facility CNA approached resident 89 attempting to calm resident 89. Resident 89 grabbed the CNA's hands in an aggressive manner. The facility CNA was unable to calm the resident. Resident 89 then began to pound on the ROS's hand in an agitated and aggressive manner. On 3/14/16 at approximately 2:30 PM, resident 89 was observed to be sitting in a common room on the unit. Resident 89 was observed to be left unattended with three residents that reside on the Special Needs Unit. Resident 89 was left unattended for approximately five minutes. No facility staff were observed to be in the vacinity of resident 89. It should be noted that resident 89 was left unattended with Special Needs residents approximately one hour after being combative with multiple staff members and visitors within the facility. On 3/14/16 at approximately 4:30 PM, the following observation was made: Resident 89 was observed to enter resident room 52. The resident residing in room 52 became agitated and wanted resident 89 to leave the room. Resident 89 was observed to go into the room and shut the door. RN 2 was observed to approach room 52 and attempt to open the door. Resident 89 would not allow RN 2 to open the door. RN 2 re-attempted to open the door. Resident 89 opened the door and proceeded to grab RN 2 by the hair with her left hand and hit RN 2 in the back and rib area with her right hand. Resident 89 was observed to spit in RN 2's face and kick RN 2 in her legs. Facility staff were eventually able to persuade resident 89 to walk outside with the facility Director of Nursing. On 3/14/16 at 4:45 PM, RN 2 was interviewed. RN 2 stated that she was only one person, and I do my best to keep the residents safe but when it gets like this I can't keep the residents safe. On 3/14/16 at 2:15 PM, CNA 5 was interviewed. CNA 5 stated that she had not received training on how to manage aggressive and combative residents. CNA 5 stated that the facility staff would just step in and take the punches from the aggressive resident to prevent them from hitting other residents. On 3/14/16 at 2:20 PM, CNA 3 and CNA 4 were interviewed. CNA 3 and CNA 4 both stated that they were not informed of what behaviors residents exhibited that resided on the Special Needs Unit. Both CNA 3 and CNA 4 stated that they were unaware of what the resident's history was that caused the resident to be admitted to the facility and be placed on the unit. CNA 2 and CNA 3 stated that they assumed the residents were on the unit for dementia. On 3/14/16, resident 89's medical record was reviewed. Review of resident 89's history and physical revealed that resident 89 was admitted to a local acute care hospital from an Assisted Living Center after attempting to strangle a neighbor at the assisted living center. Resident 89's incident reports revealed the following: a. 3/14/16 at 10:00 AM - Resident has been verbally and physically abusive towards staff and other residents this shift; resident attemtpted (sic) to strangle staff member, pinched staff member. Resident pulled another staff members hair. Resident hit three seperate (sic) staff members at three different times, resident picked up cleaning sign and began swinging it at the nurse. Resident verbally agressive (sic) with other residents. b. 3/14/16 at 4:30 PM - Resident was in a male resident's room, he became agitated and began yelling at her to get out. The nurse went to the resident's room and asked (Resident 89) to leave. (Resident 89) became agitated and grabbed the nurse's hair. (Resident 89) went to hit the nurse so nurse had hold of residents hands. Resident was agrressive (sic). Nurse asked aide to go get DON who came and assisted resident outside to walk around. c. 3/20/16 at 10:00 AM - Aide was assisting resident with cares when resident became resistant. Resident reached arms out and scratched employees' forearms. Aide continued with resident cares. d. 3/20/16 at 5:44 PM - Resident was walking in the hallway when she walked up to peer and began pulling peers' hair. Peer began pulling resident's hair as well. The rec (recreation) therapist and RN seperated (sic) the two residents and redirected them. Resident stated she was fine and went for a walk outside with CNA. e. 3/26/16 at 6:55 PM - (Resident's name) was pushing other resident in wheelchair. (Resident's name) was showing mild restlessness and was ligthly (sic) escalating. Other resident yelled 'stop' and (resident's name) tapped resident directly on top of head . No psychosocial assessment could be located in resident 89's medical record. On 3/14/16 resident 89's initial care plan dated 3/4/16 was reviewed. No documentation could be located on the initial care plan to show that resident 89 had physical and verbal aggression, nor were there any measurable goals or interventions put into place for resident 89's behaviors. On 3/17/16 resident 89's Mood/Behavior care plan dated 3/14/16 was reviewed. The care plan revealed the following: Resident 89 had Mood/behavior: Verbal and physical aggression. Behaviors did not start until second week at (Name of Facility). Behaviors include fighting back staff care, confronting other residents, and being verbally abusive towards all. Additionally, written problems on the care plan updated on 3/16/16 revealed that resident 89 wanders, exit seeks, resistive to care, overly friendly with males. The goal for resident 89 was (Resident's name) will show a decrease in negative behaviors during this review period. The approaches for resident 89 were as follows: -Redirect (Resident's name) negative behaviors to leisure activities or positive conversation. -Remind (Resident's name) that such behaviors are not allowed in our community. -Remove the audience when (Resident's name) is being inappropriate if possible. On 3/15/16, an Ad Hoc Behavior Care Plan for resident 89 was created by the Certified Therapeutic Recreation Specialist (CTRS). The care plan by the CTRS included the following: When (Resident name) exhibits behavioral problems (Verbal; physical; wandering; yelling out; other) provide her with the following interventions: * Playing music for her in her room * Going on a long walk either in the secure courtyard or around the unit * Combing her hair * Folding laundry Falls: 1. Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/14/16 during the initial tour of the building, resident 94 was observed lying in bed, holding a cup of liquid, leaning to the left side of the bed. Resident 94 appeared to be sleeping while holding the cup of liquid. No observations were made of facility staff assisting resident 94 with her meal. On 3/14/16 at approximately 1:15 PM, resident 94's son was interviewed. During the interview, resident 94 was observed to have a large wet area, brown in color, on her hospital gown. Resident 94 stated that she had spilled hot cocoa on herself that morning during the breakfast meal. On 3/15/16 at approximately 3:00 PM, resident 94 was observed to exit the building, out of a secure door, with her walker. Resident 94 appeared to be unsteady and shaking. Resident 94 was observed to attempt to put a jacket on. The alarm for the secure door could be heard alarming inside of the facility. Resident 94 was without supervision from staff for approximately 3-4 minutes. After 3-4 minutes, a facility staff member was observed to look out of the window of the secure door. The state surveyor had to motion to the staff member that resident 94 needed assistance. The facility staff member was then observed to come outside and assist resident 94. On 3/16/16 during the morning meal, resident 94 was observed to be lying in bed with her feet extending off of the right side of the bed and her head extending off of the left side of the bed. Resident 94 was observed to have a cup of liquid. No observations were made of staff assisting resident 94 with positioning in the bed. On 3/16/16 at approximately 2:30 PM, resident 94 requested to speak with the surveyor. Resident 94 stated that she was not receiving assistance from staff. Resident 94 was lying in bed with her feet extending off of the left side of the bed and her head extending off of the right side of the bed. Resident 94 was without her oxygen. The state surveyor alerted RN 4 that resident 94 was without her oxygen. RN 4 entered resident 94's room and began conversing with resident 94. At this time resident 94 was observed to have a large wet area, brown in color, on her hospital gown. Resident 94 stated to RN 4 that she had spilled her hot cocoa on herself that morning. RN 4 then proceeded to make arrangements for resident 94 to have a shower. Resident 94 stated that she had not had a shower since arriving at the facility. On 3/16/16 at approximately 4:00 PM, the state survey team and ROS heard a commotion out in the hallway. At approximately 4:10 PM, the state survey team and the ROS heard an individual crying out and asking for help. The state survey team proceeded to resident 94's room and observed resident 94 to be face down on the floor on the west side of her bed. Resident 94 was observed to be bleeding. Resident 94's pants were wet with urine and the floor surrounding resident 94 was covered with urine. The ROS proceeded up the hall to alert facility staff regarding resident 94's fall. RN 4 was observed to enter resident 94's room to assess resident 94. RN 4 was observed to press on resident 94's neck area and ask resident 94 if she had any pain. Resident 94 was crying and stated that her neck did hurt. RN 4 and another staff member were observed to roll resident 94 over and onto her back. No observations were made of facility staff stabilizing resident 94's neck before rolling her over. RN 4 was observed to tell a facility staff member that 911 needed to be alerted so resident 94 could be sent to the hospital. RN 4 stated, Her son was just here visiting. I told him to come and get me when he left so we could get her back into bed. He didn't come and let me know he was leaving. At this time, a facility staff member closed the door to resident 94's room. Facility staff alerted a transport company at 4:20 PM. At 4:40 PM, the transport company arrived and resident 94's room door was re-opened. Resident 94 was observed to be lying on her back and facility staff were just finishing changing resident 94 and providing incontinence care. Resident 94 was observed to have a C (cervical) collar placed by emergency transport personnel and be placed on a stretcher for transport to a local acute care hospital. On 3/16/16 resident 94's medical record was reviewed. Review of the facility incident reports revealed the following incidents: a. 3/11/16 10:10 PM: Resident was found on the floor in a sitting position in front of her bed, with her feet in front of her and her arms at her side, her walker was on the floor in front of her and she had skid proof socks on. She stated that she was going to the hall and she fell and hit her head on her bed. She was assisted to her bed from her chair approx (approximately) ten min (minutes) before by CNA and her call light was in reach. She refused vital signs and MD notified. She has a skin tear on her right elbow and abrasion on top of her head, both sites cleaned, dried and TAO (Triple Antibiotic Ointment) applied and a bandaid to right elbow. Resident refused VS (vital signs). Assessment done and ROM (range of motion) WNL (within normal limits). She was a two person assist from floor to bed. First aid down and top of head (sic). b. 3/15/16 2:30 AM: RNC (Regional Nurse Consultant) observed resident following a state visitor out of the building. RNC with BOM (Business Office Manage) redirected resident inside to the therapy gym. (It should be noted that the state surveyors were not in the building at 2:30 AM on 3/15/16. Additionally, when resident 94 was observed to exit the building from a secured door on 3/15/16 at 3:00 PM, the state surveyor had been outside of the facility for approximately ten minutes before resident 94 was observed exiting the building.) c. 3/16/15 4:15 PM: State visitor alerted nurse that (Resident 94) had fallen and was on the floor. When nurse entered her room, she was face down on the side of her bed, her head was turned to her left side. She was visibly bleeding from her forehead. Three staff members carefully log rolled her onto her back and nurse attempted to cleanse her wound. (Resident 94) was hitting, biting and yelling at staff members. She would not allow nurse to do a thorough assessment. Sent to (name of local acute care hospital) via (Name of non -emergent transport company). 2 inch laceration to the left side of forehead. Review of the facility's Fall Risk Assessment, for resident 94, dated 3/3/16, revealed that facility staff assessed resident 94 as being at a high risk for falls. Review of the facility's Fall Risk Intervention Guideline / Tool dated 3/3/16 revealed the following documentation under Initial Assessment Comments: Had multiple falls at previous facility. Poor safety awareness. Review of resident 94's care plan dated 3/3/16 revealed an Admit / Short Term / Acute Care Plan with a goal of Potential for Fall/Entrapment/Other Injury - Resident will not sustain serious injury r/t (related to) falls or episodes of entrapment TNR (til next review). The approaches listed to help resident 94 achieve the stated goal included: Fall - Assist resident with Transfers / ADL's (Activities of Daily Living) as needed, Fall - Ensure call light is within resident reach, and answer promptly and Fall - Assist resident to the restroom and with peri care/incontinent episodes as needed. No documentation could be found to show that facility staff updated the care plan after resident 94 experienced the fall on 3/11/16. Resident 94's nurses notes revealed the following entries: a. 3/7/16 11:24 AM: . Staff propelled wheelchair for mobility. Resident needs 2 person extensive assist with bed mobility and transfers. b. 3/10/16 6:45 PM: Urine collected this afternoon for U/A (urinalysis) with C/S (culture and sensitivity) if indicated due to elevated WBC (white blood cell count). c. 3/11/16 3:11 AM: . She can ambulate using a walker with standby assist. d. 3/12/16 2:25 AM: At approx 2210 (10:10 PM) on 3/11/16 Resident was found on floor in a sitting position with her feet in front of her and her arms at her side, her walker was on the floor in front of her and she had skid proof socks on. She stated that she was going to the hall and she fell and hit her head on her bed. She was assisted to her bed from her chair approx ten min before by CNA and her call light was in reach. She refused Vital signs and MD notified of her refusal. Assessment was done and skin tear noted to right elbow and abrasion noted to top of head, first aid done, ROM WNL. She was assisted off the floor with a two person extensive assist. Left a voice mail with POA (power of attorney) to call back (name of Care Center). Call light is next to resident and frequent visual checks are being done to offer assistance and improve safety for her. e. 3/12/16 6:23 PM: Able to walk short distances with standby assist. Gait is unsteady. f. 3/14/16 6:09 AM: . Gait appears to be unsteady and staff assist. g. 3/14/16 5:32 PM: . Can ambulate using walker and staff stand by. h. 3/16/16 2:17 AM: .Ambulates using a walker and staff stand by. i. 3/16/16 8:22 AM: 1) Ampicillin 500 mg (milligrams) by mouth four times per day (for) 14 days for urinary tract infection. j. 3/16/16 1:12 PM: Resident is alert and oriented to self only this shift. She has been started on Ampicillin for a urinary tract infection this morning. k. 3/16/16 7:07 PM: State visitor alerted nurse that (Resident 94) had fallen and was on the floor. When nurse entered her room she was facedown on the side of her bed, her head was turned to the left side. She was visibly bleeding from her forehead a moderate amount of blood on the floor. Three staff members carefully log rolled her onto her back and nurse attempted to cleanse her wound. (Resident 94) was hitting, throwing punches, both arms were moving with full ROM, biting and yelling at staff members. She would not allow nurse to do a thourough (sic) assessment. (It should be noted that the facility collected a UA on resident 94 yet resident 94 was not started on antibiotics for her urinary tract infection until six days after the collection of her urine.) On 3/21/15 the

Based on observation, interview, and record review it was determined that the facility failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to altercations between residents, residents being injured from falls, and residents experiencing episodes of choking during meal times. (Residents 1, 42, 57, 61, 65, 67, 86, 88, 89, 92, and 94). The deficient practice identified for residents 1, 42, 86, 88, 89, 92, and 94 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for residents 57, 61, 65, and 67 was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. Resident 42 was sent to a local acute care hospital with a subdural hematoma after an altercation with resident 92. Resident 86 had a history of [REDACTED]. Staff were unaware of resident 86's history and staffing levels were inadequate to monitor resident 86's wandering behavior to ensure the safety of female residents residing on the unit. Resident 88 was observed to be pacing the halls of the Special Needs Unit on 3/15/16 at 3:00 AM when there were no staff on the unit to monitor the wandering behavior. Resident 88 was observed to be going in and out of other resident's rooms that resided on the Special Needs Unit without intervention from facility staff. Resident 89 had a history of [REDACTED]. Facility staff were unaware of resident 89's history and multiple observations were made of resident 89 assaulting facility staff. Additionally, record review revealed resident 89 had multiple incidents of assaulting residents residing on the Special Needs Unit. Additionally, resident 94, who had a history of [REDACTED]. Resident 1, who was assessed as requiring direct supervision while eating, was observed to have no direct supervision while dining and subsequently experienced a choking incident in the dining room with minimal staff intervention. Findings include: Immediate Jeopardy: Supervision in Secure Unit: 1. Resident 42 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/14/16 resident 92's medical record was reviewed. Review of the History and Physical revealed a form entitiled, Patient/Family Education dated 2/27/16 and 2/28/16. The form had a mark under the Special Precautions indicating assault, elopement, and high fall risk. Additionally, the form had a section titled Harm to others including aggressive, combative and quick to anger. Review of facility incident reports revealed that on 3/3/16 at 1:30 AM, resident 92 entered resident 42's room and proceeded to assault resident 42. The incident report completed by facility staff for resident 92 documented the following: 3/3/16 1:30 AM: This resident entered the room, proceeded to smash bedside table, where the injured resident was pushed into, cutting his R (right) side of jaw and neck. The incident report completed by facility staff for resident 42 documented the following: 3/3/16 1:00 AM: This nurse was informed by (name of employee) CNA (Certified Nursing Assistant), that resident was injured in his room. He was assaulted by another resident while he was laying in his bed. Upon entering residents room, noted the bedside table was broken into pieces, floor was strewn with papers and some clothing. The accused resident was still present in the room, trying to hit the resident. This nurse and (name of employee) CNA, walked accused resident out of room. Upon entering residents room again, I assessed residents injuries, noted cut along right side of (sic) Cut to L (left) proximal region of jaw extending past R ear to midjaw. Multiple cuts on R side of neck (Please see attached paper for complete narrative of incident). Review of the facility's Initial Entity Report submitted to the State Survey Agency after the resident to resident altercation revealed the following: (Name of Resident 92) entered (name of Resident 42)'s room. (Name of Resident 42) ordered (name of Resident 92) to get out. (Name of Resident 92) proceeded to smash bed side table in half and pushed (name of Resident 42) into broken table. (Name of Resident 42) cut the right side of his jaw and neck. (Name of Resident 42) was transported to the hospital. Attached to the Entity Report was additional documentation from the nurse working on 3/3/16. The facility nurse documented the following: While trying to inquire information regarding the incident, the resident stated 'He just came in, broke my table, then pushed me.' Resident roommate was stating at the same time, the accused resident was hitting resident with a piece of the table. I administered pain medication for pain, then proceeded to clean wounds to jaw with NS (normal saline) and apply nonadherent dsng (dressing) then wrap with a kerlix gauze. Resident remained comfortable in bed. I then again went in to assess resident (at) 0430 (4:30 AM), noted that wound was still bleeding, and that the surrounding tissue was 'hard.' Neuro (neurological) checks were in place and resident remained stable. I felt resident needed to be evaluated at a higher level of care. I notified MD and DON of transfer of patient to hospital for further evaluation. Review of the facility's abuse investigations revealed that the facility Administrator documented the following on 3/9/16: (Resident 92), age 75, was an admit to the Memory Care Unit on 3/2/16. He has a [DIAGNOSES REDACTED]. He does not have a history of aggressive behaviors. Review of the facility progress notes for resident 92 revealed the following entry dated 3/3/16 at 8:22 AM: .this resident entered the room, proceeded to smash the bedside table, where the injured resident (resident 42) was pushed into, cutting his R (right) side of jaw and neck. Notified MD (medical doctor) and family of incident. On 3/15/16 resident 42's medical record was reviewed. Review of the medical record revealed an Admission History and Physical, from a local acute care hospital, dated 3/3/16 at 5:45 AM. The following was documented: History of present illness: Patient has a history of cognitive deficits and dementia for which he is living in a Memory Care unit. During the night, he got into an altercation with another resident and ended up rolling out of bed and striking his right face against a bedside table. He is chronically anticoagulated with Serial Toe (sic) and experienced severe swelling of the right face. CT (Computerized Tomography) scan in the emergency room revealed a moderate sized right subdural hematoma as well as a small subarachnoid hemmorhage. On 3/15/16 at 3:00 AM and 3:10 AM, observations by the survey team revealed no facility staff on the Special Needs Unit. At 3:10 AM, CNA 1 and CNA 2 were then noticed to be outside in the back of the facility on break. Resident 88 was observed to be wandering up and down the hall in the Unit. Resident 84 was observed to be lying on a love seat in a common area, sleeping. Resident 84 was observed to roll off the love seat. Resident 84 was observed to pick herself up and get back onto the love seat to go back to sleep. At approximately 3:20 AM, CNA 1 entered the unit. The unit was observed, by survey staff, to be left unattended for approximately 20 minutes. On 3/15/16 at 3:00 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that she was the nurse working the night that resident 92 assaulted resident 42. RN 1 stated that she received a call from the CNA that was back on the unit that night. RN 1 stated that she went over to the unit and provided first aide to resident 42. RN 1 stated that she eventually sent resident 42 to the hospital where he had been admitted with a subdural hematoma. On 3/15/16 at approximately 3:25 AM, an interview was conducted with CNA 1. CNA 1 stated that the way that he knew that his residents were safe during his time outside was that he would come back into the facility after break, check on the residents and that they would all be in the same place as when he went out, so, he knew that the residents had been ok while on break. When CNA 1 was told of observations of resident 84 rolling onto the floor then getting back onto the love seat, CNA 1 stated, Well that's not good. When the question was asked a second time to CNA 1, how do you know your residents have been safe while outside on break?, CNA 1 answered, I guess I really don't know. On 3/15/16 at approximately 3:45 AM, CNA 1 was reinterviewed. CNA 1 stated that he was the CNA on the unit the night that resident 92 assaulted resident 42. CNA 1 stated that he had not seen the assault, due to being in another resident room, he had just heard a large crash and went to investigate. CNA 1 stated that the other CNA assigned to the building that night was just coming over to help him when the assault occurred. CNA 1 stated that he left CNA 2 in the room and went to the nurses station to call the RN that was working on the other end of the building. CNA 1 stated that when he entered resident 42's room, resident 42 was bleeding from his nose. CNA 1 stated that resident 92 kept attempting to enter resident 42's room while the RN, himself and the other CNA were providing first aide to resident 42. CNA 1 stated that both himself and CNA 2 had to redirect resident 92 away from resident 42's room mulitple times and attempt to get resident 92 to calm down while RN 1 provided care to resident 42. CNA 1 stated that since he was the only CNA assigned to the unit, during the night shift, he would be unable to keep residents safe from other residents that displayed aggressive and assaultive behaviors while he was in a resident room providing cares. CNA 1 stated that when he went over to the other end of the building to assist CNA 2, during the night, the residents on the unit were left unattended and unspervised. On 3/15/16 at 4:15 AM, CNA 2 was interviewed. CNA 2 stated that he was afraid of resident 92. CNA 2 stated that he could not ensure the safety of residents residing in the facility when he was providing care in resident rooms. CNA 2 further stated that when the facility only had 2 CNAs on during the graveyard shift (10:00 PM to 6:00 AM) that he could not keep all of the residents safe that resided in the facility. CNA 2 stated that he did not know the medical history of [REDACTED]. On 3/15/16 at approximately 5:00 AM, RN 1 was reinterviewed. RN 1 stated that she was unable to ensure the safety of all of the residents due to staffing levels. RN 1 stated that if the facility had a resident that was a sexual predator, she would be unable to ensure the safety of residents residing in the facility. RN 1 further stated that having 3 CNAs on during the graveyard shift would be optimal, but she had not worked the graveyard shift with anymore than 2 CNAs. Review of the facility staffing schedules revealed that the facility staffed 1 nurse and 2 CNAs to the building during the night shift (10:00 PM to 6:00 AM). The current census of the building, 3/15/16, was 65 residents, with 34 residents residing on the Special Needs Unit. 2. Resident 86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Pre-Admission Screening and Resident Review dated 2/1/16 revealed the following documentation: Resident 86 becomes hostile and combative with other patients. Patient has also been sexually aggressive towards others. Review of the facility incident reports revealed the following incidents: a. 3/2/16 at 8:00 AM: a female resident stated that (resident 86) came into her room early this morning and hit her arm with a hard object. Staff did not witness altercation. (Resident 86) does not remember altercation. b. 3/4/16 at 10:34 AM: (Resident 86) started hitting another male resident with water pitcher and dumped water on male resident. (Resident 86) and other male resident immediately separated from each other and re-directed. DON, MD and family notified of incident. c. 3/4/16 at 5:00 PM: Resident was in hallway entering dinning (sic) room when approached by another resident who was curious about his activity. He spun around lightly striking other resident in side of the head with back of his hand. Residents seperated (sic) and re directed. Without further incident. Family and MD notified. (It should be noted that the interviews of RN 1 and CNA 1 and CNA 2 address the concern that the facility staff working 10:00 PM to 6:00 AM were leaving residents unattended and unsupervised and that due to not having adequate staff, they would be unable to keep residents in the facility safe from a resident who had sexual aggression.) 3. Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/14/16 at approximately 1:15 PM, the following observations were made by the state survey agency and a Regional Office Surveyor (ROS): Resident 89 approached the ROS in an agitated and aggressive manner. Resident 89 was pointing to a sign in the unit and saying nonsensical words. Resident 89 stepped towards a resident residing on the unit. The ROS stepped between resident 89 and the other resident to prevent an altercation. Resident 89 then grabbed the ROS by the elbow, pinching her elbow. The ROS proceeded to walk with resident 89 down the hall to the nurses station to prevent resident 89 from escalating. Once at the nurses' station, resident 89 stepped towards a state surveyor, resident 89 lifted her hands indicating that she wanted to grab the state surveyor's hair. Resident 89 stated that she wanted to yank all of the state surveyor's hair out. A facility CNA approached resident 89 attempting to calm resident 89. Resident 89 grabbed the CNA's hands in an aggressive manner. The facility CNA was unable to calm the resident. Resident 89 then began to pound on the ROS's hand in an agitated and aggressive manner. On 3/14/16 at approximately 2:30 PM, resident 89 was observed to be sitting in a common room on the unit. Resident 89 was observed to be left unattended with three residents that reside on the Special Needs Unit. Resident 89 was left unattended for approximately five minutes. No facility staff were observed to be in the vacinity of resident 89. It should be noted that resident 89 was left unattended with Special Needs residents approximately one hour after being combative with multiple staff members and visitors within the facility. On 3/14/16 at approximately 4:30 PM, the following observation was made: Resident 89 was observed to enter resident room [ROOM NUMBER]. The resident residing in room [ROOM NUMBER] became agitated and wanted resident 89 to leave the room. Resident 89 was observed to go into the room and shut the door. RN 2 was observed to approach room [ROOM NUMBER] and attempt to open the door. Resident 89 would not allow RN 2 to open the door. RN 2 re-attempted to open the door. Resident 89 opened the door and proceeded to grab RN 2 by the hair with her left hand and hit RN 2 in the back and rib area with her right hand. Resident 89 was observed to spit in RN 2's face and kick RN 2 in her legs. Facility staff were eventually able to persuade resident 89 to walk outside with the facility Director of Nursing. On 3/14/16 at 4:45 PM, RN 2 was interviewed. RN 2 stated that she was only one person, and I do my best to keep the residents safe but when it gets like this I can't keep the residents safe. On 3/14/16 at 2:15 PM, CNA 5 was interviewed. CNA 5 stated that she had not received training on how to manage aggressive and combative residents. CNA 5 stated that the facility staff would just step in and take the punches from the aggressive resident to prevent them from hitting other residents. On 3/14/16 at 2:20 PM, CNA 3 and CNA 4 were interviewed. CNA 3 and CNA 4 both stated that they were not informed of what behaviors residents exhibited that resided on the Special Needs Unit. Both CNA 3 and CNA 4 stated that they were unaware of what the resident's history was that caused the resident to be admitted to the facility and be placed on the unit. CNA 2 and CNA 3 stated that they assumed the residents were on the unit for dementia. On 3/14/16, resident 89's medical record was reviewed. Review of resident 89's history and physical revealed that resident 89 was admitted to a local acute care hospital from an Assisted Living Center after attempting to strangle a neighbor at the assisted living center. Resident 89's incident reports revealed the following: a. 3/14/16 at 10:00 AM - Resident has been verbally and physically abusive towards staff and other residents this shift; resident attemtpted (sic) to strangle staff member, pinched staff member. Resident pulled another staff members hair. Resident hit three seperate (sic) staff members at three different times, resident picked up cleaning sign and began swinging it at the nurse. Resident verbally agressive (sic) with other residents. b. 3/14/16 at 4:30 PM - Resident was in a male resident's room, he became agitated and began yelling at her to get out. The nurse went to the resident's room and asked (Resident 89) to leave. (Resident 89) became agitated and grabbed the nurse's hair. (Resident 89) went to hit the nurse so nurse had hold of residents hands. Resident was agrressive (sic). Nurse asked aide to go get DON who came and assisted resident outside to walk around. c. 3/20/16 at 10:00 AM - Aide was assisting resident with cares when resident became resistant. Resident reached arms out and scratched employees' forearms. Aide continued with resident cares. d. 3/20/16 at 5:44 PM - Resident was walking in the hallway when she walked up to peer and began pulling peers' hair. Peer began pulling resident's hair as well. The rec (recreation) therapist and RN seperated (sic) the two residents and redirected them. Resident stated she was fine and went for a walk outside with CNA. e. 3/26/16 at 6:55 PM - (Resident's name) was pushing other resident in wheelchair. (Resident's name) was showing mild restlessness and was ligthly (sic) escalating. Other resident yelled 'stop' and (resident's name) tapped resident directly on top of head . No psychosocial assessment could be located in resident 89's medical record. On 3/14/16 resident 89's initial care plan dated 3/4/16 was reviewed. No documentation could be located on the initial care plan to show that resident 89 had physical and verbal aggression, nor were there any measurable goals or interventions put into place for resident 89's behaviors. On 3/17/16 resident 89's Mood/Behavior care plan dated 3/14/16 was reviewed. The care plan revealed the following: Resident 89 had Mood/behavior: Verbal and physical aggression. Behaviors did not start until second week at (Name of Facility). Behaviors include fighting back staff care, confronting other residents, and being verbally abusive towards all. Additionally, written problems on the care plan updated on 3/16/16 revealed that resident 89 wanders, exit seeks, resistive to care, overly friendly with males. The goal for resident 89 was (Resident's name) will show a decrease in negative behaviors during this review period. The approaches for resident 89 were as follows: -Redirect (Resident's name) negative behaviors to leisure activities or positive conversation. -Remind (Resident's name) that such behaviors are not allowed in our community. -Remove the audience when (Resident's name) is being inappropriate if possible. On 3/15/16, an Ad Hoc Behavior Care Plan for resident 89 was created by the Certified Therapeutic Recreation Specialist (CTRS). The care plan by the CTRS included the following: When (Resident name) exhibits behavioral problems (Verbal; physical; wandering; yelling out; other) provide her with the following interventions: * Playing music for her in her room * Going on a long walk either in the secure courtyard or around the unit * Combing her hair * Folding laundry Falls: 1. Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/14/16 during the initial tour of the building, resident 94 was observed lying in bed, holding a cup of liquid, leaning to the left side of the bed. Resident 94 appeared to be sleeping while holding the cup of liquid. No observations were made of facility staff assisting resident 94 with her meal. On 3/14/16 at approximately 1:15 PM, resident 94's son was interviewed. During the interview, resident 94 was observed to have a large wet area, brown in color, on her hospital gown. Resident 94 stated that she had spilled hot cocoa on herself that morning during the breakfast meal. On 3/15/16 at approximately 3:00 PM, resident 94 was observed to exit the building, out of a secure door, with her walker. Resident 94 appeared to be unsteady and shaking. Resident 94 was observed to attempt to put a jacket on. The alarm for the secure door could be heard alarming inside of the facility. Resident 94 was without supervision from staff for approximately 3-4 minutes. After 3-4 minutes, a facility staff member was observed to look out of the window of the secure door. The state surveyor had to motion to the staff member that resident 94 needed assistance. The facility staff member was then observed to come outside and assist resident 94. On 3/16/16 during the morning meal, resident 94 was observed to be lying in bed with her feet extending off of the right side of the bed and her head extending off of the left side of the bed. Resident 94 was observed to have a cup of liquid. No observations were made of staff assisting resident 94 with positioning in the bed. On 3/16/16 at approximately 2:30 PM, resident 94 requested to speak with the surveyor. Resident 94 stated that she was not receiving assistance from staff. Resident 94 was lying in bed with her feet extending off of the left side of the bed and her head extending off of the right side of the bed. Resident 94 was without her oxygen. The state surveyor alerted RN 4 that resident 94 was without her oxygen. RN 4 entered resident 94's room and began conversing with resident 94. At this time resident 94 was observed to have a large wet area, brown in color, on her hospital gown. Resident 94 stated to RN 4 that she had spilled her hot cocoa on herself that morning. RN 4 then proceeded to make arrangements for resident 94 to have a shower. Resident 94 stated that she had not had a shower since arriving at the facility. On 3/16/16 at approximately 4:00 PM, the state survey team and ROS heard a commotion out in the hallway. At approximately 4:10 PM, the state survey team and the ROS heard an individual crying out and asking for help. The state survey team proceeded to resident 94's room and observed resident 94 to be face down on the floor on the west side of her bed. Resident 94 was observed to be bleeding. Resident 94's pants were wet with urine and the floor surrounding resident 94 was covered with urine. The ROS proceeded up the hall to alert facility staff regarding resident 94's fall. RN 4 was observed to enter resident 94's room to assess resident 94. RN 4 was observed to press on resident 94's neck area and ask resident 94 if she had any pain. Resident 94 was crying and stated that her neck did hurt. RN 4 and another staff member were observed to roll resident 94 over and onto her back. No observations were made of facility staff stabilizing resident 94's neck before rolling her over. RN 4 was observed to tell a facility staff member that 911 needed to be alerted so resident 94 could be sent to the hospital. RN 4 stated, Her son was just here visiting. I told him to come and get me when he left so we could get her back into bed. He didn't come and let me know he was leaving. At this time, a facility staff member closed the door to resident 94's room. Facility staff alerted a transport company at 4:20 PM. At 4:40 PM, the transport company arrived and resident 94's room door was re-opened. Resident 94 was observed to be lying on her back and facility staff were just finishing changing resident 94 and providing incontinence care. Resident 94 was observed to have a C (cervical) collar placed by emergency transport personnel and be placed on a stretcher for transport to a local acute care hospital. On 3/16/16 resident 94's medical record was reviewed. Review of the facility incident reports revealed the following incidents: a. 3/11/16 10:10 PM: Resident was found on the floor in a sitting position in front of her bed, with her feet in front of her and her arms at her side, her walker was on the floor in front of her and she had skid proof socks on. She stated that she was going to the hall and she fell and hit her head on her bed. She was assisted to her bed from her chair approx (approximately) ten min (minutes) before by CNA and her call light was in reach. She refused vital signs and MD notified. She has a skin tear on her right elbow and abrasion on top of her head, both sites cleaned, dried and TAO (Triple Antibiotic Ointment) applied and a bandaid to right elbow. Resident refused VS (vital signs). Assessment done and ROM (range of motion) WNL (within normal limits). She was a two person assist from floor to bed. First aid down and top of head (sic). b. 3/15/16 2:30 AM: RNC (Regional Nurse Consultant) observed resident following a state visitor out of the building. RNC with BOM (Business Office Manage) redirected resident inside to the therapy gym. (It should be noted that the state surveyors were not in the building at 2:30 AM on 3/15/16. Additionally, when resident 94 was observed to exit the building from a secured door on 3/15/16 at 3:00 PM, the state surveyor had been outside of the facility for approximately ten minutes before resident 94 was observed exiting the building.) c. 3/16/15 4:15 PM: State visitor alerted nurse that (Resident 94) had fallen and was on the floor. When nurse entered her room, she was face down on the side of her bed, her head was turned to her left side. She was visibly bleeding from her forehead. Three staff members carefully log rolled her onto her back and nurse attempted to cleanse her wound. (Resident 94) was hitting, biting and yelling at staff members. She would not allow nurse to do a thorough assessment. Sent to (name of local acute care hospital) via (Name of non -emergent transport company). 2 inch laceration to the left side of forehead. Review of the facility's Fall Risk Assessment, for resident 94, dated 3/3/16, revealed that facility staff assessed resident 94 as being at a high risk for falls. Review of the facility's Fall Risk Intervention Guideline / Tool dated 3/3/16 revealed the following documentation under Initial Assessment Comments: Had multiple falls at previous facility. Poor safety awareness. Review of resident 94's care plan dated 3/3/16 revealed an Admit / Short Term / Acute Care Plan with a goal of Potential for Fall/Entrapment/Other Injury - Resident will not sustain serious injury r/t (related to) falls or episodes of entrapment TNR (til next review). The approaches listed to help resident 94 achieve the stated goal included: Fall - Assist resident with Transfers / ADL's (Activities of Daily Living) as needed, Fall - Ensure call light is within resident reach, and answer promptly and Fall - Assist resident to the restroom and with peri care/incontinent episodes as needed. No documentation could be found to show that facility staff updated the care plan after resident 94 experienced the fall on 3/11/16. Resident 94's nurses notes revealed the following entries: a. 3/7/16 11:24 AM: . Staff propelled wheelchair for mobility. Resident needs 2 person extensive assist with bed mobility and transfers. b. 3/10/16 6:45 PM: Urine collected this afternoon for U/A (urinalysis) with C/S (culture and sensitivity) if indicated due to elevated WBC (white blood cell count). c. 3/11/16 3:11 AM: . She can ambulate using a walker with standby assist. d. 3/12/16 2:25 AM: At approx 2210 (10:10 PM) on 3/11/16 Resident was found on floor in a sitting position with her feet in front of her and her arms at her side, her walker was on the floor in front of her and she had skid proof socks on. She stated that she was going to the hall and she fell and hit her head on her bed. She was assisted to her bed from her chair approx ten min before by CNA and her call light was in reach. She refused Vital signs and MD notified of her refusal. Assessment was done and skin tear noted to right elbow and abrasion noted to top of head, first aid done, ROM WNL. She was assisted off the floor with a two person extensive assist. Left a voice mail with POA (power of attorney) to call back (name of Care Center). Call light is next to resident and frequent visual checks are being done to offer assistance and improve safety for her. e. 3/12/16 6:23 PM: Able to walk short distances with standby assist. Gait is unsteady. f. 3/14/16 6:09 AM: . Gait appears to be unsteady and staff assist. g. 3/14/16 5:32 PM: . Can ambulate using walker and staff stand by. h. 3/16/16 2:17 AM: .Ambulates using a walker and staff stand by. i. 3/16/16 8:22 AM: 1) [MEDICATION NAME] 500 mg (milligrams) by mouth four times per day (for) 14 days for urinary tract infection. j. 3/16/16 1:12 PM: Resident is alert and oriented to self only this shift. She has been started on [MEDICATION NAME] for a urinary tract infection this morning. k. 3/16/16 7:07 PM: State visitor alerted nurse that (Resident 94) had fallen and was on the floor. When nurse entered her room she was facedown on the side of her bed, her head was turned to the left side. She was visibly bleeding from her forehead a moderate amount of blood on the floor. Three staff members carefully log rolled her onto her back and nurse attempted to cleanse her wound. (Resident 94) was hitting, throwing punches, both arms were moving with full ROM, biting and yelling at staff members. She would not allow nurse to do a thourough (sic) assessment. (It should be noted that the facility collected a UA on resident 94 yet resident 94 was not started on antibiotics for her urinary tract infection until six days after the collection of her urine.) On 3/21/15 the hospital History and Physical Report dated 3/16/16 revealed the following: History of Present Illness: (Resident 94) is an 87 - year - old female who has been staying at Willow Wood Skilled nursing fac

Based on interview, observation and record review it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, two areas of deficient practice were identified to have occurred at an Immediate Jeopardy level and at a Harm level. The deficient practice identified for residents 1, 42, 86, 88, 89, 92, and 94 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for residents 4 and 77 was found to have occurred at a Harm level. Resident identifiers: 1, 4, 7, 13, 42, 65, 72, 77, 86, 87, 88, 89, 92, and 94. Findings include: 1. The facility administration failed to ensure that residents received adequate supervision and assistive devices to prevent accidents. This failure resulted in a finding of Immediate Jeopardy for 7 residents and Harm for three residents. Resident identifiers: 1, 4, 42, 77, 86, 88, 89, 92, and 94. (Cross refer to F323) 2. The facility administration failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to altercations between residents, residents being injured from falls, and residents experiencing episodes of choking during meal times. (Residents 1, 42, 57, 61, 65, 67, 86, 88, 89, 92, and 94). The deficient practice identified for residents 1, 42, 86, 88, 89, 92, and 94 was found to have occurred at an Immediate Jeopardy level. (Cross refer to F353) 3. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F520) On 3/22/16, Administrator 2 was interviewed. Administrator 2 stated that he needed to make copies for the survey staff to see what the survey staff were investigating prior to survey staff conducting interviews with employees. Administrator 2 stated that he needed to coach the staff on how to answer questions because, The staff tell you guys things that they shouldn't. Administrator 2 further stated that he needed to be able to manage the survey.

Based on interview, observation and record review it was determined that the facility failed to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, two areas of deficient practice were identified to have occurred at an Immediate Jeopardy level and at a Harm level. The deficient practice identified for residents 1, 42, 86, 88, 89, 92, and 94 was found to have occurred at an Immediate Jeopardy level. The deficient practice identifed for residents 4 and 77 was found to have occurred at a Harm level. Resident identifiers: 1, 4, 7, 13, 42, 65, 72, 77, 86, 87, 88, 89, 92, and 94 Findings include: 1. The facility administration failed to ensure that residents received adequate supervision and assistive devices to prevent accidents. This failure resulted in a finding of Immediate Jeopardy for 7 residents and Harm for three residents. Resident identifiers: 1, 4, 42, 77, 86, 88, 89, 92, and 94. (Cross refer to F323) 2. The facility administration failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to altercations between residents, residents being injured from falls, and residents experiencing episodes of choking during meal times. (Residents 1, 42, 57, 61, 65, 67, 86, 88, 89, 92, and 94). The deficient practice identified for residents 1, 42, 86, 88, 89, 92, and 94 was found to have occurred at an Immediate Jeopardy level. (Cross refer to F353) 3. The facility administration failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (Cross refer to F490) On 3/23/16, the facility Administrator was interviewed. The Administrator stated that the QA (Quality Assurance) committee had had consistent discussions regarding staffing not being where we want it to be. Additionally, the Administrator stated that the Nurse Practitioner had spent more time in the building than the Medical Director and that the Medical Director had just been overseeing the QA meeting but promoting team involvement. On 3/22/16, Administrator 2 was interviewed. Administrator 2 stated that he needed to make copies for the survey staff to see what the survey staff were investigating prior to survey staff conducting interviews with employees. Administrator 2 stated that he needed to coach the staff on how to answer questions because, The staff tell you guys things that they shouldn't. Administrator 2 further stated that he needed to be able to manage the survey.