Every finding on record at Parkview Manor

Based on interview, record review, and facility policy review, the facility failed to ensure allegations of verbal and physical abuse were reported to the State Agency within two hours of staff knowledge for 1 of 3 residents (Resident #1) reviewed for Resident's Rights. The facility reported a census of 50 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 3/17/26, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated severe cognitive impairment. The list of diagnoses included: Cerebral Vascular Accident (CVA or stroke) with weakness or decreased sensation affected the right dominant side, non-Alzheimer's dementia, aphasia (acquired communication disorder caused by brain damage that impairs speaking, understanding, reading and writing), anxiety disorder, and depression. The MDS indicated that Resident #1 used a walker to ambulate with set up assistance and required staff supervision while eating.Review of the Care Plan, revised on 3/19/26, revealed a Focus area for Resident #1 having behaviors of frequently calling out with repetitive words and instructed that when Resident #1 is calling out, staff will ensure all needs are met. Once all needs are met, staff will initiated planned ignoring to attempt to decrease unwanted behaviors and staff will praise when positive behaviors are displayed. Review of the Care Plan, revised on 3/19/26, revealed that Resident #1 was a recipient of an allegation of physical and verbal abuse. Interventions instructed the following: a. 2/28/26 incident: Social Services Designee (SSD) to complete psychosocial well-being visits weekly x4 and as needed as Resident #1 allows. Resident #1 separated from the accused (accused no longer works in facility). Psych services to assess and treat as Resident #1 allows. Assessment [skin] completed with no injuries or pain observed. Appropriate departments and Power of Attorney (POA) updated. Date initiated: 3/02/26. b. Encourage visits with SSD to promote healing and recover for Resident #1. Date initiated: 3/02/26. c. Interdisciplinary Team to identify root cause analysis to prevent reoccurrence. Date initiated: 3/02/26. d. Medication review for Resident #1 as needed. Date initiated: 3/02/26. e. Nursing to evaluate Resident #1 for any acute medical conditions as indicated. Date initiated: 3/02/26. f. Nursing and/or Social Services to notify Medical Director and resident representative of any incidents. Date initiated: 3/02/26. g. Physical exam for Resident #1 by provider if indicated. Date initiated 3/02/26. h. Psychiatric consult or referral will be completed as indicated, and only if appropriate and approved by Resident #1 and/or the resident's representative. Date initiated 3/02/26.i. Staff to assess body to identify any potential injuries to Resident #1. Date initiated: 3/02/26.Review of a General Progress Note, dated 3/01/26 at 10:00 AM, revealed the following entry in Resident #1's records: Notified by Administrator that abuse allegations were made against a nurse involving the resident in the dining room. It was witnessed by Dietary Aides that the nurse was observed grabbing resident under his right arm forcefully attempting to remove resident from the dining room due to resident yelling. Resident assessed by the Director of Nursing (DON) for injuries, no bruising or marks noted, and resident denied pain at this time. Resident able to ambulate as before and continued to watch TV with no visible distress noted. Interviews conducted with staff that were present. Alleged nurse refused to speak with the Administrator, turning her keys in and left. POA and provider were updated with the situation. State Agency notified. Social Worker notified to start psychosocial visits. Review of the facility provided document, dated 3/01/26 at 10:00 AM, detailed an alleged abuse incident involving Resident #1 and Staff A, Licensed Practical Nurse (LPN) that occurred in the dining room, summarizing that it was witnessed by Dietary Aides, Staff B and Staff C, that Staff A was observed grabbing Resident #1 under his right arm forcefully attempting to remove resident from the dining room due to resident yelling. During an interview on 4/15/26 at 9:00 AM, Staff B, Dietary Aide, confirmed working on 2/28/26 in the dining room during breakfast and reported that Resident #1 was sitting in the dining room and repeatedly called out to staff, Hey man, I'm hungry!, before his breakfast was served. Staff B stated that she heard Staff A, LPN, tell Resident #1 to, shut up, more than one time, as Staff A walked past Resident #1 and delivered medications to other residents. Staff B stated she also witnessed on the morning of 2/28/26, Staff A tell Resident #1 to Come on, get up! and observed Staff A, yank Resident #1 up from his seat in the dining room, by the right upper arm, then turn him away from the table in a rough manner, and continued to hold onto Resident #1's right upper arm, as Staff A marched him out of the dining room to the common area. Staff B reported that she had heard Staff A tell Resident #1 to shut up on other occasions, before this incident, but had not witnessed any rough handling prior to 2/28/26. Staff B stated that the incident she witnessed between Staff A towards Resident #1, looked and sounded like abuse. Staff B denied telling anyone about what she had witnessed until that evening when she spoke to another kitchen staff about incident and was informed to write a statement. Staff B reported she received education and was instructed to notify her Supervisor immediately with any concerns for abuse. During an interview on 4/15/26 at 12:19 PM, Staff C, Dietary Aide, confirmed working on 2/28/26 in the dining room during breakfast. Staff C reported that he observed Resident #1 ambulating independently in and out of the dining room before breakfast was to be served Staff C stated that he witnessed Resident #1 standing in front of his dining room chair and Staff A, LPN, approached Resident #1, getting very close to him, and started yelling at him, they're not ready for you, go back out. Staff C stated he then witnessed Staff A pull on Resident #1's right forearm, which caused Resident #1's legs to cross, Resident #1 grabbed his walker, then Resident #1 sat himself down in the dining room chair, and Staff A walked away. Staff C reported that he talked to another Dietary staff that day about what he witnessed, talked to the Administrator the following day, and was instructed to write a witness statement of incident by the Administrator. Staff C stated that the way Staff A spoke to Resident #1 had been rude and said the way Staff A pulled Resident #1's arm appeared to be abusive. Staff C reported he received education and was instructed to notify his Supervisor or the Administrator immediately for any concerns of abuse. During an interview on 4/15/26 at 1:15 PM, Activities Director, reported that she worked on the morning of 2/28/26 and witnessed Resident #1 walk from common area towards the dining room and was stopped by Staff A, LPN, who stood at a medication cart that partially blocked the entrance to dining room, Activities Director heard Staff A say to Resident #1, you can't go in there because you're annoying everyone else in the dining room, if you can stop annoying everyone, you can go back in. The Activities Director stated that she then went and called the Administrator to told her what she heard Staff A say to Resident #1. The Activities Director denied seeing Staff A touch Resident #1 or handle Resident #1 in a rough manner. During an interview on 4/16/26 at 2:20 PM, the Director of Nursing (DON), reported she was notified on the morning of 3/01/26, by the facility Administrator, that there was accusation of Staff A handling Resident #1 in a rough manner on 2/28/26. The DON revealed an expectation that all staff report any concern for abuse immediately to ensure resident safety. Review of the facility investigation of self reported incident, dated 3/01/26, revealed that on 3/01/26 at approximately 8:25 AM, the facility Administrator arrived to facility to follow up regarding a report received the previous day alleging that Staff A had raised her voice at residents during her shift and was provided an envelope by kitchen staff written by Staff B, Dietary Aide. which informed that on 2/28/26, Staff A yelled, shut up at Resident #1 and that Staff A removed Resident #1 from his dining room chair, grasped his right upper arm and forcefully escorted him out of the dining room. The investigation indicated that the State Agency was notified on 3/01/26 at approximately 9:32 AM. The investigation indicated the following steps were taken by facility related to allegation of abuse: a. Completed witness interviews and interviews of working staff. b. Staff mandatory re-education on abuse prevention and reporting procedures was initiated immediately.c. Risk Management completed. d. Psych consult/referral. e. MDS/Care Plan updated. f. The incident will be reviewed during the next Quality Assurance and Performance Improvement (QAPI) committee meeting. Review of the facility policy, titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated 3/18/26, directed the following: Review of the Section titled, Reporting:a. All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Administrator.b. All allegations of resident abuse shall be reported to the appropriate state entity not later than two (2) hours after the allegation is made.

Based on record review, staff interviews, and the facility policy, the facility failed to update a care plan to reflect a resident's risk for exploitation for 1 of 4 residents reviewed for inadequate nursing supervision (Resident #1). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored an 8 out of 15 on the Brief interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS indicated resident independent with mobility and used a walker. The MDS revealed medical diagnoses for metabolic encephalopathy, non-Alzheimer's dementia, depression, and adjustment disorder with mixed disturbance of emotions and conduct. The Care Plan revealed a focus area revised on 12/9/25 for Resident #1 drawn to other female residents and female staff. Resident #1 will show affection to residents by holding hands, hugging and a kiss on the cheek. Found in bed with female staff. The interventions dated 12/9/25 indicated social worker visits twice weekly; staff will monitor resident to ensure affection is displayed in an appropriate manner. The General Progress Note late entry dated 12/7/25 at 3:16 PM revealed Director of Nursing (DON) notified by Certified Nurse Aide (CNA), [name redacted] that Resident #1 was found unclothed in another female resident's bed. DON observed both resident's unclothed and kissing in the female resident's bed, no penetration observed by DON or [name redacted]. Resident stated the female resident was his girlfriend and they didn't do anything wrong. Full head-to-toe skin assessment completed by DON, no bruising or marks noted. Staff assisted both residents to get dressed attempting to separate residents, but residents continued to stay in bed. Staff were able to convince Resident #3 to use the bathroom, and staff were able to convince male resident to come to lobby to get a snack. Voicemail left with Power of Attorney (POA) to return phone call. Staff continued to monitor both residents and staff were able to keep residents apart. Both residents ate lunch at the same table without incident. Voicemail left with POA.The Facility Verbal Informed Sexual Consent Assessment Tool dated 12/10/25 revealed the following questions and answers: a .Legal/Illegal Questions 1. Do you know of any sexual behaviors that are against the law? No answer documented 2. Is it okay to watch a porno film? Yes 3. Is it okay to pay money to have sex? 4. Yes, I guess it is. Yes it is ok where or who makes a difference. You don't want to do in a a grocery store and not get a (unable to read handwriting) 5. It is okay for an adult to have sex with a child? No 6. What is a child? 12 or under because over 12 has an idea what is going on [NAME] (because) the size of the my penis to the size of her vagina can hurtb. The Four Principles of Sexual Informed Consent: 1. Does the Resident demonstrate the following: 2. Cognitive ability to make informed decisions by scoring an 8-12 (moderately impaired) or 13-15 (cognitively intact) on the BIMS assessment. If the resident's BIMS score 7 or below, does the interviewer observe that the resident is capable of giving informed consent by being able to understand content of interview questions? If they have a Guardian and guardianship paperwork has specified orders allowing the guardian to make decisions about the resident's sexual behavior, the guardian must also be okay with the resident engaging in sexual behavior. BIMS score: 08 3. An awareness of the nature of sexual acts and the ability to choose to engage or abstain- Yes 4. An understanding of how to avoid STDs- Yes 5. The ability to identify harmful situations and to avoid being exploited- Noc. Based on the answers to the assessment questions and the resident's ability to demonstrate the Four Principles of Sexual Informed Consent (above), the resident falls into one of the three groups: 1. Resident fulfills requirements of principles and can give verbal informed sexual consent. This determination is made only if all 4 of the above principles area answered yes- left blank 2. Resident cannot give verbal informed sexual consent at this time as he/she has not fulfilled the requirements of principles as evidenced by: left blank 3. The resident's ability to provide verbal informed sexual consent is vague and could not be determined at this time as evidenced by: left blankThe facility lacked documentation the Care Plan updated to reflect the above assessment. During an interview on 12/17/25 at 1:41 PM, the Administrator queried on the verbal informed sexual consent assessment for Resident #1 and the Administrator stated they perceived that Resident #1 would had not been able to give verbal consent based the informed verbal sexual consent assessment. The Administrator stated she thought Resident #1 could be the victim in the incident that occurred between Resident #1 and Resident #3. The Administrator stated it was a difficult situation and it should be care planned, but didn't know how to word it. During an interview on 12/17/25 at 2:34 PM, Social Services queried on the completion of the verbal informed consent assessment and Social Services stated she missed the question on the back page. Social Services asked the determination of the assessment and Social Services stated based on the assessment, Resident #1 didn't have the judgement and would not know if he would avoid harmful situations or exploitation. Social Services queried if the care plan needed to reflect the determination of the assessment and Social Services stated yes, the care plan should be updated for Resident #1 being at risk of exploitation. During an interview on 12/17/25 at 2:57 PM, the DON queried on the verbal informed consent assessment and the DON stated Social Services and the Administrator took care of it. The DON reviewed the assessment and stated Resident #1 could not give verbal consent and at time Resident #1 didn't understand what was harmful to him. The DON confirmed the care plan needed updated to reflect he was not able to give verbal consent. The Facility Comprehensive Care Plans Policy (no date indicated) revealed The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, facility policy review, and resident and staff interviews, the facility failed to prevent a resident-to-resident incident that resulted in an injury. Resident #1 hit Resident #2 with a walker which resulted in a nasal fracture. The facility reported a census of 56. Findings include:1. Review of the Minimum Data Set (MDS), dated [DATE] identified Resident #1 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The MDS list of diagnoses included metabolic encephalopathy, seizure disorder and age-related cognitive decline. The MDS identified Resident #1 walked independently up to 150 feet, and utilized a walker for mobility. Review of the Care Plan, date initiated: 3/24/25, revealed a Focus area to address [name redacted, Resident #1] has a history/potential of Sundowning (a worsening of symptoms like confusion, anxiety and agitation in the individuals with dementia that occurs in the late afternoon and evening) in the early-late afternoon. Interventions identified, included, in part:a. Anticipate and attempt to meet needs. Date Initiated: 9/19/25.b. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 9/19/25.The Care Plan, date initiated: 5/30/25, included a Focus area to address [name redacted] has potential/history of being physically aggressive r/t dx (diagnosis) of Dementia and he has poor impulse control. Physically aggressive toward another resident 10/12 and causing serious injury. Interventions included, in part:a. Administer medications as ordered. Monitor for side effects and effectiveness. Date Initiated: 5/30/25.b. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 5/30/25.c. Assess and address for contributing sensory deficits. Date Initiated: 5/30/25.d. Assess and anticipate needs: foods, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 5/30/25.e. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 5/30/25.f. Modify environment: Adjust room temperature to comfortable level, Reduce noise, dim lights, place familiar objects in room, keep door closed, etc. Date Initiated: 5/30/25A review of the progress notes revealed the following Nurses Note entered on 6/13/25 at 11:30 PM, CNA (Certified Nursing Assistant) stated resident [Resident #1] fell after he made an attempt to hit another resident. The resident [Resident #1] stated the other resident involved in verbal altercation was talking bad to the female residents that were also sitting near the nurse's station. Review of the Facility Incident Report, Submission Date: 10/16/25 at 9:36 AM [State Agency notified of incident by phone on 10/12/25 at 5:20 PM] Incident Summary: [Name redacted, Resident #1].with the following diagnosis: Metabolic Encephalopathy, Type 2 Diabetes Mellitus Without Complications, Age-Related Cognitive Decline, Cognitive Communication Deficit, Muscle Weakness, Difficulty in Walking, Not Elsewhere Classified, Not Elsewhere Classified BIMS-03. Name redacted, Resident #2].with the following diagnosis: Senile Degeneration of Brain, Not Elsewhere Classified, Other Giant Cell Arteritis, Polymyalgia Rheumatica, Inflammatory Liver Disease, Unspecified, Nontoxic Multinodular Goiter, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems BIMS-08. On October 12, 2025, at approximately 4:52 PM, [name redacted] Director of Nursing, reported to me, [name redacted], Administrator, that [name redacted Resident #1] had used his walker to strike [name redacted, Resident #2] in the face. It was reported that [name redacted], Dietary Aide, witnessed the incident. Staff immediately intervened, separating from the residents. [Name redacted, Resident #2] was assessed by the nursing staff and transported by ambulance to [name of hospital redacted]. Family/POA/Guardians notified. Nurse Practitioner notified. State Agency notified via phone October 12th, 2025, at approximately 05:20pm.[Name redacted, Resident #1] was placed on 1:1 supervision for 72 hours. [Law enforcement name redacted] notified. Corrective Action Description: Following the conclusion of the investigation, On October 12, 2025, at approximately 4:35 PM, [name redacted, Resident #2] was observed seated in the dining room next to [name redacted, Resident #1] as dining service was about to begin. [Name redacted, Dietary Aide] entered the dining room from the kitchen with the drink cart and witnessed [name redacted, Resident #1] stand, pick up his walker, and strike [name redacted, Resident #2] in the face. No yelling, raised voices, or disturbances were observed prior to the incident. At the time of the incident, [name redacted], Certified Medication Aide, was stationed outside the dining room near the open doors at the medication cart. She heard [name redacted, Resident #2] cry out and immediately intervened. [Name redacted, Resident #1] was standing over [name redacted, Resident #2], attempting to throw glasses and silverware at her. [Name redacted, CMA] placed herself between [name redacted, Resident #2] and [name redacted, Resident #1] to protect [name redacted, Resident #2]. [Name redacted], Certified Nursing Aide, also responded to the dining room and successfully de-escalated [name redacted, Resident #1]. [Name redacted, Resident #2] was escorted toward the nurse's station for her safety. [Name redacted, Resident #2] was assessed by the nursing staff and transported by ambulance to [hospital name redacted] for further evaluation. Evaluation at [hospital name redacted] confirmed that [Name redacted, Resident #2] sustained a nasal fracture. She was subsequently discharged and returned to [name of facility redacted]. [Name redacted, Resident #2] was interviewed on October 13, 2025, at approximately 8:00 AM. During the initial interview, she was unable to recall the incident. Later that afternoon, she regained memory of the event. [Name redacted, Resident #1] was interviewed on October 13th, 2025, at approximately 9:00am. He was unable to recall the incident. Psychosocial visits initiated for both residents involved. Diagnostic labs were initiated for [name redacted, Resident #1] and no abnormal results were found to indicate any underlying health concerns. Change of Condition completed on both residents. Incident Report completed and reviewed. Nurse's notes reviewed. MDS/Care Plan reviewed and updated as indicated for both residents involved. No additional behavioral episodes have been observed in [name redacted, Resident #1] following the incident.During an observation on 10/27/25 at 10:35 AM, Resident #1 rested comfortably in his room. Resident #1 stated he did not recall the incident on 10/12/25. During an interview on 10/28/25 at 11:42 AM, Staff B, Certified Medication Assistant (CMA) reported on 10/12/24 around supper time, she stood outside the dining room door with the medication cart. She heard Resident #2 scream and when she ran up to her, Resident #1 stood over her attempting to hit Resident #2 again. Staff B stated she shielded Resident #2 and deflected items that Resident #1 threw at Resident #1 (cups and silverware). Staff B then took Resident #2 to the nurse's station to put an ice pack on her face and administered Tylenol. Resident #2 was sent out to the hospital and when she returned, she had a fracture to her nose. Staff B reported Resident #1 tried to hit another resident a few months ago where he held his walker above the resident's head, but staff stopped him. When asked what interventions staff take when Resident #1 has these behaviors, she reported they were to take him to a table by the nurse's station, have him eat his meals there with staff nearby and to provide one on one care.During an interview on 10/28/25 at 12:58 PM, Staff D, Licensed Practical Nurse (LPN) reported she worked when Resident #1 hit Resident #2 with his walker. She reported she was not in the dining room when it happened, but she and Staff C, Certified Nursing Assistant (CNA) ran into the dining room. Staff D witnessed Resident #1 throw a plastic mug at Resident #2. Resident #1 had lifted up his walker up in the air and said to Resident #2, You got what you deserve, B___! Staff D stated she pulled the walker away from Resident #1, and the CNA's took Resident #2 out of the dining room. Staff D stated Resident #2 had a small amount of blood coming from her nose. Resident #2 was sent out to the hospital. Resident #1 was taken back to his room rest of the evening where a CNA sat with him for the rest of the shift. She has witnessed Resident #1 with behaviors in the afternoon where he would become belligerent. She recalled he tried to hit two other residents with his walker a few months ago, but staff were able to stop him. She reported after the incident [on 10/12/25] Resident #1 went into the dining room and asked Resident #2 you want more, B___? or Get out of my seat. Staff D stated she removed him from the dining room and had him sit at the table across from the nurse's station and had him eat there. Then this past Saturday [10/25/25], Resident #1 walked up to Resident #2 and asked you want some more?During an interview on 10/28/25 at 2:15 PM, Staff E, CNA reported she did not witness the above incident but had witnessed Resident #1 pick up his walker and attempt to hit another male resident with it. Staff were able to stop him. When asked what is care planned for Resident #1 when he has his Sundowners behaviors, she reported the staff should separate him from the other resident, redirect him by taking him to his room, get him a snack or drink.During an interview on 10/28/25 at 2:21 PM, the Administrator reported the following: The incident involving Resident #1's physical aggression toward Resident #2 appeared to be the result of multiple contributing factors. While Resident #1 had a history of verbal aggression, this was his first documented episode of physical aggression. The IDT (Interdisciplinary team) reviewed the circumstances and identified the following root causes:a. Age-related cognitive decline: Resident #1 has shown signs of cognitive impairment, which may affect his judgment, impulse control, and ability to process social interactions appropriately.b. Psychosocial stressors: His recent placement in a nursing home environment may have triggered emotional distress.c. Social isolation: He has had little to no contact with family or friends and has not received visitors, contributing to feelings of loneliness and abandonment.d. Possible depression: These factors suggest the presence of depression, which may have intensified his agitation and led to the escalation in behavior.e. The combination of cognitive decline and emotional distress likely contributed to the incident.During an interview on 10/28/25 at 3:27 PM, Staff F, Dietary Aide, reported he worked on the day of the incident between Resident #1 and Resident #2. Staff F recalled before supper, he witnessed Resident #1 pick up his walker and hit Resident #2 in the face. Staff F stated Resident #2 had called Resident #1 a racial slur prior to his hitting her. Staff F stated the aides stopped Resident #2 from hitting Resident #1 and took her to the out of the dining room to the area near the nurse's station. During an interview on 10/29/25 at 10:34 AM, Staff C, CNA stated she worked the day of the incident where Resident #1 hit Resident #2 with his walker. She stated she could not recall the exact date. Staff C stated she was in the main lobby area when she heard yelling from the dining room. She explained she and Staff B, CMA ran into the dining room and witnessed Resident #2 throw a plastic cup at Resident #1 but it did not hit him. Resident #1 stood up and reached his hand up to hit Resident #2 again. At this point they did not realize he had already hit her in the first place. Staff C explained as Staff B tried to shield Resident #2 from Resident #1, she re-directed Resident #1 as Resident #2 was taken out of the dining room. Later Resident #1 had one to one care for the rest of the shift. When asked what interventions were care planned for Resident #1 when he had behaviors, she stated she did not know as she only works weekends.During an interview on 10/29/25 at 8:11 AM, the Director of Nursing (DON) reported she received a phone call from Staff A, Registered Nurse (RN) who reported Resident #2 did not want Resident #1 to sit beside her in the dining room and threw a mug at him, which bounced off his arm, Resident #1 then picked up his walker and threw it at her face and it hit her nose. There was bleeding. The DON stated interventions were added to Resident #1's Care Plan, which included a psychiatric evaluation, increased staff monitoring, encouraged him to eat at the table out of the dining room. The DON stated he does occasionally go to the dining room to eat meals, but if staff see that Resident #2 gets upset with him there, they move him out to the table by the nurse's station. She has witnessed Resident #1 getting upset with Resident #2 and yelling, I didn't hit you. Prior to the above incident, Resident #1's Care Plan included staff encouragement of activities such as putting music on, provide snacks, distraction or if nice outside take him outside. During an interview on 10/30/25 at 8:39 AM, the DON reported when meals are ready to be served, staff who are assigned to be at the assist tables should be in the dining room. She stated the on the day of the incident [10/12/25] between Resident #1 and Resident #2 there were no aides in the dining room as the meal was not being served at the time. She stated he med aides do stand outside the door of the dining room, but the aides are usually not in the dining room until the meals are being served.2. Review of the Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 8 out of 15, which indicated a moderate cognitive impairment. Review of the Behavior section of the assessment revealed Resident #2 experienced hallucination and delusions, with no physical or verbal behavioral symptoms. The diagnoses list included, in part: senile degeneration of the brain, major depressive disorder, history of falling, anxiety disorder. Review of Resident #2 Care Plan revealed the following Focus areas:a. On the Care Plan, dated 3/9/23, [Name redacted, Resident #2] has episodes of behaviors and potential behaviors as evidenced by being combative, negative verbalizations, name calling, DX (diagnosis) dementia, anxiety and depression. Refuses showers at time. Interventions included, in part: Intervene as necessary to protect the rights and safety of other residents. Approach/speak in a calm manner, Divert attention if needed. Remove from the situation and take to alternate location as needed. b. On the Care Plan, dated 5/20/25, [Name redacted, Resident #2] has experienced a traumatic event in the past, that currently affects their mental and psycho-social well-being. [Name redacted, Resident #2] was abuse by her mom and distant relative. [Resident #2] witnessed horrific events of the holocaust. Review of Emergency Department Provider Notes dated 10/12/25 at 8:13 PM revealed, in part Preliminary impression at the time of hand off: Blunt facial trauma. Radiology Results: IMPRESSION: Minimally displaced fracture of the right nasal bone. Otherwise, no acute facial bone abnormality. Plan/Follow up Items: discharged to home. Review of Resident #2 Care Plan, dated 10/13/25 revealed a Focus area to address [Name redacted, Resident #2] has a fractured nasal bone r/t (related to) another resident striking her. Interventions included, in part: Ensure [name redacted, Resident #2] feels safe, and encourage to continue normal routine. Date Initiated: 10/12/25. Review of a Progress Notes revealed the following:a. On 10/14/25 at 1:42 PM the Social Worker documented the resident appeared visibly shaken and expressed discomfort due to facial injury. Resident verbalized feelings of fear, confusion, and vulnerability.b. On 10/21/25 at 4:57 PM the Social Worker documented the resident shared that they make efforts to avoid contact with the other resident and continue to feel fearful when encountering him.During an observation and interview on 10/27/25 at 1:47 PM, Resident #2, rested in bed, a light purple bruise noted below her right eye. Resident #2 stated there had been an incident where a man hit her with porcelain. She could not recall the date. Resident #2 stated it hurt and she was very upset and afraid when she sees him in the hallway. Review the facility policy, titled Abuse Prevention, Revised Date: 10/21/22 revealed a Policy statement which declared The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.The Definition section of the policy defined abuse as Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The policy Procedure included statement under Protection which directed: 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident are and treatments shall be monitored by all staff, on an on-going basis, so that residents are free from abuse, or mistreatment. Care will be monitored so that the residents care plan is followed.

Based on record review, staff interviews, and policy review the facility failed to carry out provider orders for 10 of 24 residents reviewed (R#1, R#8, R#13, R#17, R#26, R#29, R#30, R#40 R#43, R#45). The facility reported a census of 50 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #1 assessment, dated 7/22/25 listed diagnoses for Resident #1 included dementia, disorder of thyroid. A Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. The Care plan initiated 3/20/24 for Resident #1 relayed has medications listed with black box warning referring to risks and potential adverse reactions. Intervention included to obtain and report laboratory draws and result as ordered. A Clinic Note date of service 10/10/24 for Resident #1 revealed, the provider directed routine labs every six months, last labs collected in April 2024, directed to collect labs as ordered on the next lab day. During an interview on 8/12/25 at 12:49 PM, the Director of Nurses (DON) stated the labs ordered 10/10/24 were missed and that in October there was not a process. The DON explained the current process is the provider was to alert the floor nurse of orders. The nurse should have added the order to the Nurses, Medication Administration Record (MAR). The DON relayed the lab order was put on the regular MAR and a Medication Aide signed the lab as it was being completed in error. 2. The MDS dated [DATE] for Resident #30 documented diagnoses included diabetes, lung disease, lack of coordination, unsteadiness on feet, aphasia and dysphagia referring to difficulty talking and swallowing. The Care Plan focus initiated 3/6/25 for Resident #30 documented diagnoses of diabetes, with a goal of no related complications. Interventions included to take medications as ordered by the doctor, included to monitor and document side effects and effectiveness. The Care Plan directed to obtain and monitor lab, diagnostic work as ordered, report results to the provider and follow up as indicated. The Clinic Note dated 1/20/25 for Resident #30 documented lab ordered in November 2024 outstanding, will remind of outstanding labs. Review of a Clinic Note dated 3/24/25 for Resident #30 revealed collection of labs on lab day in November 2024 and again on 1/20/2025 documented reviewed labs collected, were dated 1/26/25.The Clinic Note dated 5/27/25 for Resident #30 documented last labs collected 3/2025, recheck diabetes labs in three (3) months, due by 6/30/25 added additional thyroid lab. Review of a Clinic Note dated 7/28/25 revealed the last lab work was collected 3/2025, lab orders provided in May 2025 were not completed, new orders provided included to collect the labs by the end of this week. During an interview on 8/12/25 at 1:10 PM, the DON voiced the labs ordered per the clinician visit note for Resident # 30 on 11/14/24 were not done. The DON relayed it appeared the order was again put on the standard MAR and signed off as completed in error. 3. The MDS dated [DATE] for Resident #43 documented diagnoses included cancer, heart disease, vascular disease, diabetes, stroke, and respiratory disease. The Care Plan initiated 7/17/24 for Resident #43 directed to obtain and report lab results as ordered by the physician or nurse practitioner, to obtain and report laboratory draws, results as ordered. The Clinic Note dated 5/27/25 for Resident #43 documented last labs collected 3/2025 and directed additional labs the week of 6/30/2025. The Clinic Note dated 7/28/25 for Resident #43 documented Last labs were collected in 03/2025. Previous lab orders provided at last visits for collection during the week of 06/30/2025 were not collected. Directed to collect by the end of the week. During an interview on 8/13/25 at 12:55 PM, the Administrator stated this resident is one that could have refused lab work and was not documented, relayed will need to get better with documentation. 4. The MDS dated [DATE] for Resident #45 documented diagnoses included diabetes and seizure disorder. The Care Plan initiated 2/14/25 for Resident #45 documented a focus for diabetes with a goal to avoid complications. Also relayed had potential for nutritional problem, directed to obtain and monitor lab/diagnostic work as ordered. Report results to the provider and follow up as indicated. The Clinic Note dated 3/17/25 for Resident #45 relayed are no recent labs available on Resident #45. Please collect on next lab day, outline of labs listed. The Clinic Note dated 4/21/25 for Resident #45 documented no recent labs available, lab orders provided last visit were not collected. Please collect the next facility lab day. In an email communication on 8/11/25 at 11:04 AM, the DON responded and explained the facility process, relayed when our providers make their weekly rounds, they look to see who needs labs and they write the orders. Lab draws are on Monday unless it’s a stat lab, needed right away. The Administrator or DON takes the lab to the hospital and they fax the results to us and to the providers. We notify the family of results and follow up with the provider to see if they want any new orders. During an interview on 8/12/25 at 1:19 PM, the DON stated she cannot explain what occurred, as to why labs were not done, relayed, labs should have been put on the Medication Administration Record (MAR) and done by the nurse on lab day Monday or Tuesday. The DON relayed would be looking into and working on a better plan regarding labs. 5. Review of Resident #8’s MDS dated [DATE] revealed a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnoses included coronary artery disease, hypertension, renal insufficiency, depression, anxiety disorder, arthritis, hip fracture, and pain in left hip. Review of Care Plan dated 6/25/25 revealed Resident #8 is at risk for falls with interventions including placing non-slide strips in front of her closet, ensuring Resident #8 is wearing appropriate footwear when ambulating and staff setting out gripper socks for Resident #8 each night. Resident #8 has a left displaced femur fracture related to a fall with interventions including following physician’s orders for weight bearing status and for nursing staff to see physician’s orders and/or Physical Therapy treatment plan. Review of Resident #8’s Electronic Health Record (EHR) revealed the following nursing progress notes:a. 5/26/25 at 6:30 AM Resident #8 was found on the floor sitting in front of her recliner, Resident #8 stated “I was trying to get up out of my chair and lost my balance. I fell on my left side, my arm and leg hurt a little bit but I’m able to move everything. I’m unsure if I hit my head. My head does not hurt.” Initiated neuros, called on call provider to make aware of situation and Resident #8’s status. Assessed for injury; none. Educated Resident #8 on the importance of wearing proper footwear (socks and shoes, gripper socks) while transferring and to utilize the call light if assistance is needed. b. 5/26/25 at 9:40 AM Resident #8 is complaining of increased pain in her left leg/hip since the fall. Resident #8 is able to move leg but states that it hurts when she stands on it. Call placed to on-call Physician and requested an x-ray of the left hip/leg. Physician gave the okay for x-ray service to come and perform a bedside x-ray due to advanced age and limited mobility. Resident #8 aware. c. 5/26/25 at 1:30 PM X-ray service arrived and performed an x-ray of Resident #8’s left hip and left femur. Results are as follows: right hip arthroplasty, Displaced fracture involving the greater trochanter but no obvious periprosthetic extension. The on call Physician notified of results and received an order to send Resident #8 to the ER for further evaluation and treatment. Review of Resident #8’s ER report dated 5/26/25 at 10:00 PM, revealed the on-call Orthopedics Physician reviewed further imaging and noted this fracture would typically be managed nonoperatively, weightbearing as tolerated, and Resident #8 will need to follow-up with Orthopedics. Resident #8 was admitted to the hospital for pain management. Review of Resident #8’s Hospital Discharge Summary Notes dated 5/29/25 at 9:07 AM, revealed Resident #8 is requiring narcotics as pain is still significant with ambulation. Resident #8 required scheduled oxycodone each morning to tolerate Physical Therapy. Resident #8 is stable for discharge back to facility with Physical Therapy (PT) and Occupational Therapy (OT) Services. Resident #8 requires continued assessment and treatment to establish an appropriate level of assistance and to follow-up with Orthopedics. Resident #8’s EHR revealed a Nursing Progress note dated 6/3/25 at 2:25 PM, stated, phone call received from Orthopedic Clinic, stating Resident #8’s previous Orthopedic surgeon would like Resident #8 to follow up. Passed this message along to staff with scheduling to get this appointment made. Review of Facility’s Provider Progress Note dated 6/16/25, revealed Resident #8 was seen on this day for follow-up hospitalization for a ground level fall resulting in fracture of left hip. Resident #8 reports pain is well-controlled and feeling well overall. Resident #8 is actively working with PT/OT; Resident #8's pain has been well-controlled, continue with PT/OT and follow-up visits with Orthopedics. Continued review of Resident #8’s EHR failed to reveal nursing documentation or Orthopedic Clinic notes indicating Resident #8 had been seen for a follow-up for the fracture. On 8/13/25 at 1:05 PM, documentation for Resident #8’s follow-up Orthopedic visit was requested from the Director of Nursing (DON) and Facility Administrator. On 8/13/25 at 2:07 PM, DON stated via email, A follow-up appointment was not made for Resident #8, the nurse reports putting the request under the Activity’s door for our appointment/transportation person. 6. The MDS for Resident #13 MDS dated [DATE] revealed a BIMS of 13, indicating cognitively intact and diagnoses of hypertension, hyperlipidemia, history of stroke, seizure disorder, anxiety disorder and depression. Review of Resident #13's Care Plan initiated 9/3/24, documented a focus for risk of falls due to gait/balance problems, with interventions of requesting labs including seizure medications. Review of Clinic Note dated 9/13/24 for Resident #13 documented Lipid and Dilantin levels obtained 9/2024, due for routine labs on next facility lab day. Review of Clinic Note dated 3/24/25 for Resident #13 documented last labs were collected 9/2024 and directed to collect labs as ordered on the next lab day including level for monitoring seizure medications. Review of Clinic Note dated 5/27/25 for Resident #13 documented last labs were collected 9/2024 and directed to collect labs as ordered on the next lab day including level for monitoring seizure medications, orders provided last visit. Review of Clinic Note dated 7/28/25 for Resident #13 documented last labs were collected 9/2024 and directed to collect labs as ordered on the next lab day including level for monitoring seizure medications, orders provided last visit. Review of Nursing Progress notes and Order Summary for Resident #13 dated 9/13/24 to 7/28/25 failed to provide directed labs had been ordered or collected. 7. Review of Resident #17's MDS dated [DATE] revealed BIMS of 14, indicating cognitively intact and diagnoses of heart failure, hypertension, renal insufficiency, hyperlipidemia, depression, chronic atrial fibrillation, and insomnia. Review of Resident #17's Care Plan initiated 4/13/2020 directed to obtain and monitor lab and diagnostic work as ordered, reporting results to MD and follow up as indicated. A focus dated 6/1/23 indicating Resident #17 having episodes of insomnia due to not sleeping through the night, resulting in complaints of tiredness and need for naps during the day. Review of Clinic Note dated 10/24/24 for Resident #17 documented proceed with ordered sleep study for evaluation as result of Insomnia, Snoring and Daytime Hypersomnia. Review of Resident's condition, assessment, finding and pertinent laboratory and or diagnostic tests were discussed with nursing staff, understanding voice and acceptance of proposed place of care indicated. Review of Clinic Note dated 1/6/25 for Resident #17 documented at time of last visit on 10/24/24, an order was placed for a sleep study, will check on the status of this. Review of Resident's condition, assessment, finding and pertinent laboratory and or diagnostic tests were discussed with nursing staff, understanding voice and acceptance of proposed place of care indicated. Review of Clinic Note dated 5/5/25 for Resident #17 documented at time of visit on 10/24/24, an order was placed for a sleep study, chart review shows that scheduling has been unsuccessful at reaching facility to get this scheduled. Will have nurse reach out and see about getting this coordinated. Review of Cardiology Progress Note dated 5/14/25 documented Resident #17 does not sleep well and wakes up frequently through the night, has high blood pressure and would benefit getting a sleep study done and test has been ordered. Resident #17 will be notified of those results when received. Review of Clinic Note dated 7/7/25 for Resident #17 documented at time of visit on 10/24/24, an order was placed for a sleep study, chart review shows that scheduling has been unsuccessful at reaching facility to get this scheduled. Will have nurse reach out and see about getting this coordinated. Updated order placed. Review of Resident's condition, assessment, finding and pertinent laboratory and or diagnostic tests were discussed with nursing staff, understanding voice and acceptance of proposed place of care indicated. Review of Resident #17's Nursing Progress Notes revealed the following: 3/16/25 at 1:59 AM, Resident #17 stated she was supposed to have a sleep study two years ago and hasn't. This nurse stated the information would be pass on. 5/6/25 at 5:23 PM, Call received from Provider's office for Sleep Study order at local hospital, will call to set up Sleep Study. 7/8/25 at 9:30 AM, Received orders from Provider for Sleep Study, will call Facility with further direction. Resident aware. Review of Order Summary for Resident #17 dated 10/24/24 to 7/7/25 failed to provide directed Sleep Study had been ordered or completed. 8. The MDS dated [DATE] for Resident #26 revealed BIMS of 13, indicating cognitively intact and diagnoses of hypertension, renal insufficiency, hyperlipidemia, and hyponatremia (low sodium levels related to kidney disease and diabetes). Review of Care Plan initiated 3/31/22 for Resident #26 revealed, obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated related to Resident #26's nutritional problem due to hyponatremia, hypertension, and Stage 3 chronic kidney disease. Review of Clinic Note dated 12/19/24 for Resident #26 documented, Resident #26 has had a steady weight gain since her admission in 2022, as a result of her diagnosis of Heart Failure, weight monitoring frequency should increase to daily weight checks with an order for Furosemide 20mg by mouth daily as needed for weight gain of 3lbs or greater in 24 hours or 5lbs or greater in one week. A Clinic Noted dated 2/17/25 documented, Resident #26 has had a steady weight gain since her admission in 2022, as a result of her diagnosis of Heart Failure, weight monitoring frequency should increase to daily weight checks. Review of PCC in which they have not been weighing consistently on a daily basis as ordered, provided reminder. Routine labs every 6 months, please collect on next facility lab day. Review of Resident #26's weights revealed consistent daily weights were started on 2/11/25. Review of Resident #26's EHR failed to indicate as needed Furosemide was administered on the Medication Administration Record (MAR) and/or Nursing Progress Notes as ordered for weight gain of 3lbs or greater in 24 hours or 5lbs or greater in one week, for the following dates and weight changes: a. 3/22/25 169lbs, 3/23/25 172.2lbs (increase of 3lbs in 24 hours), 3/24/25 174lbs (increase of 5lbs in 48 hours) b. 4/21/25 172.6lbs, 4/22/25 176lbs (increase of 4lbs in 24 hours) c. 5/8/25 171.4lbs, 5/9/25 174lbs (increase of 3lbs in 24 hours) Review of Resident #26's labs ordered 2/17/25, collected on 3/26/25 and resulted on 3/27/25 documented, I have reviewed these results, repeat CBC with diff in 2 weeks. Review of Resident #26's Nursing Progress note created on 3/29/25 with effective date 3/27/25 revealed lab results reviewed by Facility Provider, no new orders at this time. Review of Clinic Note dated 4/21/25 for Resident #26 documented, last labs were collected 3/26/25, recommended at that time to collect repeat CBC in 2 weeks. I do not see this has been done, please collect CBC, BMP, and A1c on next facility lab day. Review of Clinic Note dated 6/3/25 for Resident #26 documented, last requested labs were collected 6/30/2025. 9. Review of MDS dated [DATE] for Resident #29 revealed BIMS of 11, indicating moderate cognitive impairment and diagnoses of hypertension, hyperlipidemia, non-Alzheimer’s dementia, chronic atrial fibrillation, and congestive heart failure. Review of Care Plan initiated 1/19/23 with focus of Resident #29's diuretic therapy with interventions to administer diuretic medications as ordered by Physician. A Clinic Note dated 10/3/24 for Resident #29 documented orders for daily weight monitoring and administer additional Furosemide 20mg with weight increase of 3lbs or more in 24-hour time period, provided to DON. A Clinic Note dated 12/12/24 for Resident #29 documented weights show trend increase, at time of last visit on 10/3/24, an order for daily weight monitoring as a result of weight increase trend with recommendation to add an additional 20mg Furosemide with weight increase of 3lbs or more in 24 hours’ time however, orders were not completed as requested. Review of Clinic Noted dated 2/10/25 for Resident #29 documented Provider has continued request for daily weight monitoring. At time of last visit on 10/3/24 and 12/12/24, an order for daily weight monitoring as a result of weight increase trend with recommendation to add an additional 20mg Furosemide with weight increase of 3lbs or more in 24 hours’ time however, daily weight monitoring has not been occurring. Reminded facility of the importance of this order. Review of Resident #29's EHR failed to indicate as needed Furosemide was administered on the MAR and/or Nursing Progress Notes as ordered for weight gain of 3lbs or greater in 24 hours or 5lbs or greater in one week, for the following dates and weight changes: a. 2/24/25 208lbs, 2/25/25 215lbs (increase of 7lbs in 24 hours) b. 3/1/25 210lbs, 3/2/25 215lbs (increase of 5lbs in 24 hours) c. 3/15/25 208lbs, 3/16/25 214lbs (increase of 6lbs in 24 hours) d. 3/29/25 210lbs, 3/30/25 215lbs (increase of 5lbs in 24 hours) e. 5/11/25 212lbs, 5/12/25 215lbs (increase of 3lbs in 24 hours) f. 6/2/25 212lbs, 6/3/25 215lbs (increase of 3lbs in 24 hours) g. 7/15/25 205.4lbs, 7/16/25 209lbs (increase of 4lbs in 24 hours) 10. The MDS dated [DATE] for Resident #40 revealed BIMS of 14, indicating cognitively intact and diagnoses of hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, thyroid disorder and depression. Review of Resident #40's Care plan initiated 6/28/25 documented focus on potential for nutritional problems due to Type 2 diabetes mellitus, hyperlipidemia, and chronic kidney disease with interventions to obtain and monitor labs/diagnostic work as ordered. report results to MD and follow up as indicated, Registered Dietitian to evaluate and make diet change recommendations as needed, and weigh and record weight per facility protocol. Review of Clinic Note dated 12/19/24 for Resident #40 documented weight loss noted over the last 60 days, referral to Facility Dietitian, diabetic labs ordered to be collected on next facility lab day. Review of Clinic Note dated 2/17/25 for Resident #40 documented weight loss noted over the last 60 days, weight loss was noted at time of last visit when it was recommended that Resident #40 be referred to facility Dietitian. Chart review shows this has not been done, will reach out to facility to have referral created for evaluation. Diabetic labs recommended to be obtained at time of last visit, these have not been completed, collect diabetic labs on next facility lab day. Review of Clinic Note dated 4/21/25 for Resident #40 documented weight loss noted over last 60 days, this was noted at time of last visit 2/17/25 when it was recommended that patient be referred to facility dietitian. Chart review shows this has not been done, will reach out to facility to have referral created for evaluation. Diabetic labs collected 4/21/25, new orders provided for further labs to be collected on next facility lab day. Review of lab results dated 4/29/25 for Resident #40 documented reviewed lab results, Resident #40 would benefit from protein supplementation, previously advised dietitian referral. A Clinic Note dated 6/30/25 for Resident #40 documented previous routine labs resulted 4/21/25 reviewed, previously advised Dietitian referral, Resident #40 would benefit from protein supplementation Review of Nutritional Evaluation dated 4/30/25 for Resident #40 documented Dr's office provided Registered Dietitian referral for supplements secondary weight loss and hyponatremia, recommend liquid protein three times daily and Mighty Shakes at lunch and supper for additional calories and protein. Review of Physicians Orders for Resident #40 revealed an order dated 5/1/25 for liquid protein three times daily and Mighty Shakes at lunch and supper dated 4/30/25. In an email on 8/11/25 at 11:04 AM the DON responded and explained the facility process, relayed when our providers make their weekly rounds, they look to see who needs labs and they write the orders. Lab draws are on Monday unless it’s a stat lab, needed right away. The Administrator or DON takes the lab to the hospital and they fax the results to us and to the providers. We notify the family of results and follow up with the provider to see if they want any new orders. During an interview on 8/12/25 at 1:19 PM with the DON relayed cannot say what occurred, labs should have been put on the Medication Administration Record (MAR) and done by the nurse on lab day Monday or Tuesday. The DON relayed would be looking into and working on a better plan regarding labs. During an interview on 8/13/25 at 12:59 PM and email communication on 8/14/25 at 12:56 PM, Facility Administrator stated when the Provider is in the facility doing rounds the DON or MDS Coordinator are with the provider, any orders or recommendations are then communicated to that person. The Provider will also write these orders on a carbon copy form, this form is given to the nurse assigned to that resident hall during this shift, once the nurse receives the orders they are responsible for transcribing and processing these orders. The Provider will dictate their visit into EPIC (hospital electronic health system), when this is completed it is expected the Medical Records Department will export these Clinic Notes into the appropriate resident's PCC. At the time of the interview the Administrator confirmed the completed dictated Clinic Notes are not reviewed by nurses to note/sign or acknowledge the Clinic Note is reviewed and orders are received. The Administrator acknowledged the missed lab orders, sleep study, Orthopedic follow-up, blood glucose monitoring, weight monitoring with as needed Diuretics, weight and nutrition concerns and stated there is a systemic issue with the Facility Providers and Facility as well as the reliance on Agency Staff in the past and the inconsistency it brings. When nursing staff are frequently changing, it can disrupt continuity of care and hinder effective communication between Providers and the team. This inconsistency can lead to delays or misinterpretations in implementing provider orders. The Administrator stated she would expect nursing staff to treat provider orders with urgency and accuracy, ensuring they are processed promptly and implemented as intended. Clear documentation, timely follow-through, and proactive communication are key. It is essential to for nurses to feel empowered to ask questions or seek clarification when needed, especially when orders are complex or require coordination across discipline. Review of facility policy titled Physician Orders Policy, reviewed 9/28/22 directed: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines. 1.Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, & Physician’s Assistants) authorized to prescribe Orders.2. Orders must be Recorded in the Medical Record by the Licensed Nurse authorized to transcribe such Orders.3. Physician Orders must be documented clearly in the Medical Record. The required components of a Complete Order:a. Date and Time of Orderb. Name of Practitioner Providing Orderc. Name and Strength of Medication/Treatment d. Quantity/Duratione. Dosage/Frequency f. Route of Administrationg. Indication/Diagnosis h. Stop Date, if Indicated4. Physician Orders that are missing required components, are illegible or unclear must be clarified prior to implementation.5. Physician Order Sheet (POS) will be maintained with current Physician Orders as New Orders are received. Discontinued Orders will be marked as discontinued with the date, and all new Orders will be written in the appropriate area on the POS with the date the order was received.6. Physician Orders will be transcribed to the appropriate Administration Record (MAR/eMAR or TAR/eTAR).7. Medications will be ordered from the Pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy, if available

Based on observation, staff interviews, resident interview and facility assessment review, the facility failed to treat residents with dignity and respect for 2 of 21 reviewed (Resident #29 and Resident #41) reviewed for dignity. The facility reported a census of 50 residents. Findings included:. 1. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #29 list of diagnoses included heart failure, dementia and anxiety. The Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicated moderate cognitive impairment.Review of the Care Plan revealed a Focus area, dated 1/19/23 for Resident #29 to address self-care performance deficit, alerted needed encouragement to change clothes, needs clean clothes put out daily and she can then dress, encourage to change clothes daily, goals included to assist with facial hair and maintain resident's dignity.During an observation on 8/7/25 at 2:43 PM, Resident #29 sat in common area, wearing a thin shirt without wearing a bra, and noticeable yellowish food stains. Resident #29's hair appeared unbrushed. During an interview on 8/7/25 at 2:45 PM Resident #29 relayed was not feeling good, had a bothering rash pointed chest area. Licensed Practical Nurse (LPN) Staff C came from behind the nurse station and escorted Resident #29 to her room with a medicated powder. During an observation on 8/7/25 at 2:50 PM LPN, Staff C, LPN and Resident #29 came from residents' room, LPN Staff C escorting resident back to the common area. Resident #29 pointed to the stains on her shirt said she did not have any other short sleeve shirts. Staff C shared the rash worsened and would be contacting the provider. Staff B, LPN intervened when quired about the clothing and brought Resident B several short sleeve shirts to choose. Resident expressed gratitude.During an interview on 8/11/25 at 12:28 LPN, nurse, Staff B stated the facility had a large storage boutique downstairs from donations for residents to have as needed and felt any resident who needed clothing could be supported. 2. Review of the MDS assessment dated [DATE] identified Resident #41 list of diagnoses included cancer, renal disease, diabetes, anxiety and depression. The BIMS score of 15 out of 15 indicated intact cognition.Review of the Care Plan revealed a Focus area, dated 2/19/25 for Resident #41 to address a history of trauma and loss is at risk for psychosocial well-being concerns, a goal included to remain free of signs of distress.During an interview on 8/4/25 at 2:38 PM, Resident #41 shared an experience that caused her to be upset and did not think was handled right. She explained there was a room search and several personal items that were important were bagged up and taken, which included special scissors and tweezers, she had for over 40 years. Resident #41 stated she was told she needed to get a lock box, which her family supplied. She stated the items were lost by staff and she had to repeatedly ask, before they were found up to three weeks later. During an interview on 8/12/25 at 5:00 PM, Staff H, Social Services, stated the wide spread room search was for resident's safety. Staff H stated she had been aware of Resident #41 being upset that her scissors and tweezers were taken and misplaced by staff. Staff H explained they were eventually found and given back. Staff H stated she was aware the items were important to Resident #4 and was upset about them being lost. During an interview on 8/12/24 at 5:30 PM, the Administrator relayed the search was necessary to take items of risk for other resident safety. She explained they would have replaced the lost items had not been found.Review of the facility assessment dated [DATE], revealed Person Centered and Person Directed Care required affording people dignity compassion and respect, offering of personalized care, support or treatment.

Based on observations, clinical record review, staff interview and resident interview the facility failed to ensure resident call lights were within reach for 2 of 24 residents reviewed (Resident #30,Resident# 36). The facility reported the census is 50.Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #30 revealed a Brief Interview of Mental Status (BIMS) score of 4 out of 12, which indicated a severe cognitive impairment. The list of diagnoses included dementia, diabetes, lung disease, lack of coordination, unsteadiness on feet, aphasia and dysphagia referring to difficulty with language and swallowingReview of the Care plan revealed a Focus area, initiated 11/11/24 to address Resident #30 communication problem, cognitive impairment secondary to dementia directed staff to allow time for response, ask yes/no questions, use simple, brief, consistent words and cues. The Care Plan did not address the call light for resident use. During an observation on 8/4/25 at 2:18 PM, Resident #30 lying perpendicular on his bed, with head against the wall, and feet, off the side of the bed, relayed would like help. The call light was on the floor around a nearby table leg, not within reach.During an observation on 8/5/25 at 1:55 PM, Resident #30 in his room, with the call light cord hanging on the wall at the wall connection for the cord, out of his reach. During an interview on 8/5/25 at 1:56 PM, Resident #30 acknowledged the call light was not within reach, and hung on the wall at the connection site. During an observation on 8/7/25 at 2:18 PM, Resident #30 call light continued to hang on the wall at the wall connection, not accessible to resident sitting on the bed. 2. Review of the MDS dated [DATE] for Resident #36 documented a BIMS score of 9 out of 15, which indicated a moderate cognitive impairment. The MDS documented Resident #36 needed partial/moderate assistance to sit to lye, sit to stand and for chair to bed transfers. Review of the Care Plan revealed a Focus area, initiated 2/3/25 Resident #36 to address a selfcare performance deficit, required staff assistance to turn and reposition, assist of one with walker and wheel chair, one person assist with personal hygiene toilet use and transfers. The Care Plan documented risk for falls and to be sure the call light is within reach, encourage use and needs prompt response to all requests for assistance.During an observation on 8/4/25 at 3:12 PM, Resident #36 in her room in a recliner with her head slouched down near the seat and bottom partly off the chair seat. The call light rested on a chair next to the recliner, out of the residents reach. The resident stated she wanted help to lie down in bed.During an interview [NAME] 8/4/25 at 3:13 PM, Staff B, Licensed Practical Nurse (LPN) entered Resident #36 room with visiting Nurse Practitioner, Staff A acknowledged resident could not reach the call light, proceeded to help Resident #36 to bed as requested.During an interview on 08/11/25 at 12:42 PM, the Director of Nursing stated all residents should have a call light accessible to them and the expectation is for staff to ensure call lights are accessible to all residents.

Based on clinical record review, staff interviews, and policy review the facility failed to accurately document resident's cardiopulmonary resuscitation (CPR) status for 1 of 24 (Resident #34) residents reviewed. Findings include:Review of Resident #34's electronic health record (EHR) revealed a profile page with indicated a status of Do not Resuscitate (DNR). Review of Resident #34's scanned EHR documents revealed a DNR IPOST for different resident. Review of Resident #34's Physician Orders, revealed a verbal order dated [DATE] stating Resident #34's DNR code status. Review of Resident #34's Care Plan dated [DATE] revealed, Resident #34 and his responsible party, requested a code status for CPR/initiate CPR.On [DATE] at 12:36 PM, a review of facility provided binder containing resident's IPOST, revealed Resident #34's IPOST indicated CPR status. Verbal consent for signature received by Resident #34's legal healthcare representative on [DATE] and signed by facility physician on [DATE]During an interview on [DATE] at 11:58 AM, Staff C, Licensed Practical Nurse (LPN), stated a resident's code status is found on their profile page, under their name in PCC and there is also a binder at the nurses station that has all the resident's IPOST. During an interview on [DATE] at 10:18 AM, Staff I, LPN, stated she checks code status on Resident's PCC profile page and there is also an IPOST binder at the nurses station. Staff I, LPN, stated depending on the situation is where she would look. If she is at a computer when she is notified of a situation, she would look there. If she was closer to the nurses station and not logged in she would find the resident's IPOST for code status. Review of the facility policy titled, Code Status (DNR)(CPR) Validation - Quick Reference Guide, dated [DATE] All Code Status orders must be validated upon admission and reviewed quarterly. Code Status orders must have the required state approved DNR form signed by all appropirate parties prior to entering a No CPR order in [name of EHR brand redaced]

Based on observation, staff interviews, and the facility housekeeping assistant job description, the facility failed to thoroughly mop the dining room floor after each meal service and clean the ceiling fans in the dining room on a routine basis. The facility reported a census of 50 residents.Findings include:During an observation on 8/11/25 at 1:58 PM, after dining service finished, the floor noted to be sticky around the walls by the baseboards near the front entrance of the dining room. Dried liquids marks under and around the dining room tables near the front entrance of the dining room. A dried pink liquid stain observed under a chair in the dining room. Two of the ceiling fans closest to the entrance door were covered in dust and had a ring of dust around the ceiling fans on the ceiling. During an observation at breakfast service on 8/12/25 at 7:58 AM, the floors remained sticky near the baseboards along the wall near the front entrance of the dining room. The floor had dried liquids stains and a pink stain on the floor in the same places as yesterday. Thick dust remained on the ceiling fans and ceiling. During an interview on 8/12/25 at 10:39 AM, Staff F, Housekeeping queried on when housekeeping mopped the dining room and Staff F stated after breakfast and lunch. Staff F stated she Staff G, Housekeeping spot mopped the dining room floor yesterday after lunch because they can't get into the dining room until 1:15 PM and then the residents played Bingo in the dining room. Staff G stated on Monday and Wednesdays housekeeping spot mopped after lunch due to activities in the afternoon. Staff F asked who cleaned the fixtures such as the ceiling fans, and Staff F stated another housekeeper cleaned the ceiling fans recently. During an interview on 8/12/25 at 10:54 AM, Staff G, Housekeeping queried when housekeeping mopped the dining room floor and Staff G stated everyday after breakfast and lunch. Staff G stated she didn't know who mopped after dinner. Staff G stated housekeeping staff spot mopped the dining room floor after lunch because the residents got out of the dining room late and played Bingo. Staff G stated if residents were not in the dining at 12:45 PM, housekeeping could fully mop the dining room floor after lunch. Staff G asked who cleaned the ceiling fans in the dining room, and Staff G stated housekeeping did them a week or two ago. During an interview on 8/12/25 at 11:01 AM, the Housekeeping Supervisor stated the dining room floor mopped three times a day. The Housekeeping Supervisor stated housekeeping mopped the dining room floor after breakfast and lunch and dietary staff cleaned after dinner service. The Housekeeping Supervisor queried on how often the ceiling fans cleaned in the dining room and the Housekeeping Supervisor stated weekly. The Housekeeping Supervisor observed the ceiling fans and the sticky floors in the dining room and stated he appreciated bringing to his attention. The Housekeeping Supervisor confirmed the ceiling fans needed cleaned and the floors sticky around the baseboards. During an interview on 8/12/25 at 3:34 PM, the Administrator informed of the sticky floors and dusty ceiling fans in the dining room and the Administrator stated the Housekeeping Supervisor already told her the fans were filthy. The Administrator stated housekeeping cleaned them and the Housekeeping Supervisor spoke with his team about the dining room floors. The Administrator stated if lunch ran late, housekeeping staff spot mopped and after dinner dietary staff spot mopped. Per email on 8/12/25 at 4:25 PM, the Administrator documented the facility didn't have a formal housekeeping policy for cleaning and sanitizing common areas. Review of the facility Job Description: Housekeeping Assistant dated 5/22 revealed, in part: Essential Functions of Housekeeping Assistant: Sweep and mop floors; Clean furniture, equipment, fixtures, and hardware

Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to store medications that required refrigeration at an appropriate temperature. The facility reported a census of 50 residents. Findings include:During an observation on 8/11/25 at 2:12 PM, the thermometer on the inside of the medication storage refrigerator revealed 50 degrees. The freezer compartment on the mini refrigerator was covered with dried ice that almost filled the entire freezer compartment except for 2 ice bags that sat on the dried ice. The refrigerator held multiple insulin pens and other medications. The Refrigerator/Freezer Temperature Record for August 2025 revealed PM temperatures: a. 8/1/25 at 46 degreesb. 8/2/25 at 48 degreesc. 8/3/25 at 47 degreesd. 8/4/25 at 50 degreese. 8/5/25 - no temp documentedf. 8/6/25- 48 degreesg. 8/7/25 at 48 degreesh. 8/8/25 no temp documentedi. 8/9/25 at 50 degreesj. 8/1/25 at 48 degreesDuring an interview on 8/11/25 at 2:22 PM, Staff E, Registered Nurse (RN) queried on what the medication storage refrigerator temperature needed to be at and Staff E stated around 40 degrees. Staff E informed the thermometer read 50 degrees and Staff E stated she would look into it.During an interview on 8/11/25 at 2:28 PM, the Director of Nursing (DON) queried on what temperature the medication storage refrigerator temperature needed kept at and the DON stated she didn't know off the top of her head but definitely below 50 degrees. The DON showed the temperature log and informed the freezer section of the refrigerator full of ice and the DON stated they would need to defrost it and they would put the medications in another refrigerator in the other medication storage room. The Facility Medication Storage in the Facility Storage of Medication Policy dated 11/18 revealed: Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit with a thermometer to allow temperature monitoring.

Based on clinical record review, facility policy review, staff and resident interviews, the facility failed to ensure staff treated residents with dignity and respect while providing incontinence cares for 2 of 6 residents reviewed for dignity(Residents #2 and #7). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 2/4/25, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, multiple sclerosis (a disease which causes impairment in the nerves), and diabetes. The MDS stated the resident required partial/moderate assistance with toileting hygiene and listed her Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. The facility policy Resident Rights reviewed 4/26/23, stated the facility would treat residents with kindness, respect, and dignity. Review of Care Plan, dated 7/3/24, revealed a Focus area to address [Name redacted] has a psychosocial well-being problem due to past trauma in her life Anxiety. Interventions included, in part: Allow [name redacted] time to answer questions and to verbalize feelings, perceptions, and fears. Review of the Care Plan, dated 7/15/24 revealed a Focus area to address [Name redacted] is ADL self-care performance deficit. Interventions included, in part TOILET USE; partial, needs cueing and reminders to toilet and help with incontinence care, date initiated: 7/15/24. A 3/9/25 Nurses Note stated Resident #2 and her roommate reported that the Certified Nursing Assistant (CNA) was very rough and mean when she entered the room to help the resident. The resident stated she just pulled my pants down and pushed me over. The resident was very distraught and the nurse informed her she would speak with the CNA and pass the information along to management. Both residents stated they did not want the CNA to return to their room. After speaking with the CNA, the nurse heard her in the same resident room trying to turn off the call light speaking in a snippy and hostile manner. During an interview on 3/25/25 at 9:45 a.m., Resident #3 (Resident #2's roommate) stated Staff A came into the resident's room in the middle of the night and Resident #2 was asleep and she could hear her snoring. Resident #3 stated Staff A flipped the blankets down and pulled Resident #2's pants down. Resident #2 told Staff A no and she swatted her hand at Staff A and said oww. Resident #3 stated that Staff A then said that we all had to do things we didn't want to do. Staff A then placed the brief on Resident #2 and Resident #2 told her to get out and she left the room. Review of Staff A's Time Card documented she punched in on 3/8/25 at 10:00 p.m. and punched out at 6:00 a.m. During an interview on 3/25/25 at 3:47 p.m., Staff D Licensed Practical Nurse (LPN) stated she was called into Resident #2's room by her roommate and they both said they did not appreciate how the CNA behaved towards Resident #2. They stated she did not warn her before rolling her and was harsh with her wording. She said both residents were not happy and did not want her to return. She stated later in the shift she heard Staff A in Resident #2 and #3's room and she was speaking in a short manner and not using proper bedside manner right after she had spoken to her about it. She said she could not make out the words she was saying. Staff D stated she texted the Director of Nursing(DON) towards the end of her shift regarding Staff A. 2. The MDS assessment tool, dated 2/12/25, listed diagnoses for Resident #7 which included morbid (severe) obesity, anxiety, and depression. The MDS stated the resident required partial/moderate assistance rolling left and right and substantial/maximal assistance with toileting hygiene. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 9/14/22 Care Plan entry directed staff to assist the resident with cleansing after each incontinent episode. During an interview on 3/25/25 at 3:02 p.m., Resident #7 stated Staff A came into her room and asked her to roll over. She stated she felt Staff A's manner towards her was almost like she was mad. She stated she told Staff D about it and she did not have her come in her room anymore. During an interview on 3/26/25 at 12:47 p.m. Staff F CNA stated that Resident #7 told her that Staff A was rude and rough when rolling her and was throwing her during rolling. Staff F stated she reported this the the nurse about 2 weeks ago but was not sure which nurse. During an interview on 3/26/25 at 4:00 p.m., the Administrator stated if someone was mean, rude, or rough, they completed an observation of that worker. She was under the impression the concerns with Staff A were were more related to cultural differences. She stated staff did not tell her she was mean or rough. Staff did not report any concerns with Resident #7. She stated if staff reported such concerns they would take it seriously. They would investigate and suspend that person and report it to the State Agency within 2 hours. She stated she did not know about the situation with Resident #2 until they were scanning over the weekend progress notes on Monday morning 3/10/25. She stated she would not have wanted Staff A to continue working(after the allegation was made).

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to report allegations of abuse for 2 of 2 residents reviewed for abuse (Residents #2 and #7). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/4/25, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, multiple sclerosis(a disease which causes impairment in the nerves), and diabetes. The MDS stated the resident required partial/moderate assistance with toileting hygiene and listed her Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. The facility Abuse Prevention policy, dated 10/21/22, declared: a. The facility was committed to protecting the residents from abuse by anyone including facility staff. b. The facility would report alleged abuse violations to the State Survey Agency immediately but not later than 2 hours after the allegation was made. Review of Care Plan, dated 7/3/24, revealed a Focus area to address [Name redacted] has a psychosocial well-being problem due to past trauma in her life Anxiety. Interventions included, in part: Allow [name redacted] time to answer questions and to verbalize feelings, perceptions, and fears. Review of the Care Plan, dated 7/15/24 revealed a Focus area to address [Name redacted] is ADL self-care performance deficit. Interventions included, in part TOILET USE; partial, needs cueing and reminders to toilet and help with incontinence care, date initiated: 7/15/24. A 3/9/25 Nurses Note stated Resident #2 and her roommate reported that the Certified Nursing Assistant (CNA) was very rough and mean when she entered the room to help the resident. The resident stated she just pulled my pants down and pushed me over. The resident was very distraught and the nurse informed her she would speak with the CNA and pass the information along to management. Both residents stated they did not want the CNA to return to their room. After speaking with the CNA, the nurse heard her in the same resident room trying to turn off the call light speaking in a snippy and hostile manner. During an interview on 3/25/25 at 9:45 a.m., Resident #3 (Resident #2's roommate) stated Staff A came into the resident's room in the middle of the night and Resident #2 was asleep and she could hear her snoring. Resident #3 stated Staff A flipped the blankets down and pulled Resident #2's pants down. Resident #2 told Staff A no and she swatted her hand at Staff A and said oww. Resident #3 stated that Staff A then said that we all had to do things we didn't want to do. Staff A then placed the brief on Resident #2 and Resident #2 told her to get out and she left the room. Review of Staff A's Time Card documented she punched in on 3/8/25 at 10:00 p.m. and punched out at 6:00 a.m. The facility lacked documentation they reported the allegation to the State Agency (SA) prior to 3/10/25. During an interview on 3/25/25 at 3:47 p.m., Staff D Licensed Practical Nurse (LPN) stated she was called into Resident #2's room by her roommate and they both said they did not appreciate how the CNA behaved towards Resident #2. They stated she did not warn her before rolling her and was harsh with her wording. She said both residents were not happy and did not want her to return. She stated later in the shift she heard Staff A in Resident #2 and #3's room and she was speaking in a short manner and not using proper bedside manner right after she had spoken to her about it. She said she could not make out the words she was saying. Staff D stated she texted the Director of Nursing (DON) towards the end of her shift regarding Staff A. 2. The MDS assessment tool, dated 2/12/25, listed diagnoses for Resident #7 which included morbid(severe) obesity, anxiety, and depression. The MDS stated the resident required partial/moderate assistance rolling left and right and substantial/maximal assistance with toileting hygiene. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 9/14/22 Care Plan entry directed staff to assist the resident with cleansing after each incontinent episode. During an interview on 3/25/25 at 3:02 p.m., Resident #7 stated Staff A came into her room and asked her to roll over. She stated she felt Staff A's manner towards her was almost like she was mad. She stated she told Staff D about it and she did not have her come in her room anymore. During an interview on 3/26/25 at 12:47 p.m. Staff F CNA stated that Resident #7 told her that Staff A was rude and rough when rolling her and was throwing her during rolling. Staff F stated she reported this the the nurse about 2 weeks ago but was not sure which nurse. The facility lacked documentation they reported the allegation to the State Agency. During an interview on 3/26/25 at 4:00 p.m., the Administrator stated if someone was mean, rude, or rough, they completed an observation of that worker. She was under the impression the concerns with Staff A were were more related to cultural differences. She stated staff did not tell her she was mean or rough. Staff did not report any concerns with Resident #7. She stated if staff reported such concerns they would take it seriously. They would investigate and suspend that person and report it to the State Agency within 2 hours. She stated she did not know about the situation with Resident #2 until they were scanning over the weekend progress notes on Monday morning 3/10/25. She stated she would not have wanted Staff A to continue working (after the allegation was made).

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to investigate allegations of abuse and failed to ensure separation between the alleged perpetrator of abuse and residents for 2 of 2 residents reviewed for abuse(Residents #2 and #7). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 2/4/25, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, multiple sclerosis(a disease which causes impairment in the nerves), and diabetes. The MDS stated the resident required partial/moderate assistance with toileting hygiene and listed her Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition. The facility Abuse Prevention policy, dated 10/21/22, stated the facility was committed to protecting the residents from abuse by anyone including facility staff. The policy stated the facility would investigate allegations of abuse and suspend employees accused of abuse during the investigation. Review of Care Plan, dated 7/3/24, revealed a Focus area to address [Name redacted] has a psychosocial well-being problem due to past trauma in her life Anxiety. Interventions included, in part: Allow [name redacted] time to answer questions and to verbalize feelings, perceptions, and fears. Review of the Care Plan, dated 7/15/24 revealed a Focus area to address [Name redacted] is ADL self-care performance deficit. Interventions included, in part TOILET USE; partial, needs cueing and reminders to toilet and help with incontinence care, date initiated: 7/15/24. A 3/9/25 Nurses Note stated Resident #2 and her roommate reported that the Certified Nursing Assistant(CNA) was very rough and mean when she entered the room to help the resident. The resident stated she just pulled my pants down and pushed me over. The resident was very distraught and the nurse informed her she would speak with the CNA and pass the information along to management. Both residents stated they did not want the CNA to return to their room. After speaking with the CNA, the nurse heard her in the same resident room trying to turn off the call light speaking in a snippy and hostile manner. During an interview on 3/25/25 at 9:45 a.m., Resident #3(Resident #2's roommate) stated Staff A came into the resident's room in the middle of the night and Resident #2 was asleep and she could hear her snoring. Resident #3 stated Staff A flipped the blankets down and pulled Resident #2's pants down. Resident #2 told Staff A no and she swatted her hand at Staff A and said oww. Resident #3 stated that Staff A then said that we all had to do things we didn't want to do. Staff A then placed the brief on Resident #2 and Resident #2 told her to get out and she left the room. Staff A's Time Card documented she punched in on 3/8/25 at 10:00 p.m. and punched out at 6:00 a.m. The facility lacked documentation of an investigation initiated prior to 3/10/25 and lacked documentation Staff A was separated from residents from the time of the allegation to the end of her shift on 3/9/25. During an interview on 3/25/25 at 3:47 p.m., Staff D Licensed Practical Nurse (LPN) stated she was called into Resident #2's room by her roommate and they both said they did not appreciate how the CNA behaved towards Resident #2. They stated she did not warn her before rolling her and was harsh with her wording. She said both residents were not happy and did not want her to return. She stated later in the shift she heard Staff A in Resident #2 and #3's room and she was speaking in a short manner and not using proper bedside manner right after she had spoken to her about it. She said she could not make out the words she was saying. Staff D stated she texted the Director of Nursing(DON) towards the end of her shift regarding Staff A. 2. The MDS assessment tool, dated 2/12/25, listed diagnoses for Resident #7 which included morbid(severe) obesity, anxiety, and depression. The MDS stated the resident required partial/moderate assistance rolling left and right and substantial/maximal assistance with toileting hygiene. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 9/14/22 Care Plan entry directed staff to assist the resident with cleansing after each incontinent episode. During an interview on 3/25/25 at 3:02 p.m., Resident #7 stated Staff A came into her room and asked her to roll over. She stated she felt Staff A's manner towards her was almost like she was mad. She stated she told Staff D about it and she did not have her come in her room anymore. During an interview on 3/26/25 at 12:47 p.m. Staff F CNA stated that Resident #7 told her that Staff A was rude and rough when rolling her and was throwing her during rolling. Staff F stated she reported this the the nurse about 2 weeks ago but was not sure which nurse. The facility lacked documentation of an investigation initiated regarding Resident #7's allegation and lacked documentation Staff A was separated from residents at the time of the allegation. During an interview on 3/26/25 at 4:00 p.m., the Administrator stated if someone was mean, rude, or rough, they completed an observation of that worker. She was under the impression the concerns with Staff A were were more related to cultural differences. She stated staff did not tell her she was mean or rough. Staff did not report any concerns with Resident #7. She stated if staff reported such concerns they would take it seriously. They would investigate and suspend that person and report it to the State Agency within 2 hours. She stated she did not know about the situation with Resident #2 until they were scanning over the weekend progress notes on Monday morning 3/10/25. She stated she would not have wanted Staff A to continue working(after the allegation was made).

Based on clinical record review, policy review, and staff interview, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 1 discharges reviewed (Resident #8). The facility reported a census of 49 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A 2/4/25 Health Status Note stated the resident had increasing behaviors and the facility sent him to the hospital for evaluation. The facility lacked documentation of resident representative and ombudsman notification of discharge. On 3/27/25 at 10:21 a.m., via email, the Administrator stated the facility did not notify the ombudsman of the resident's discharge. The facility policy Notification of Transfer and Discharge, dated 3/17/25, stated the facility would provide the resident and resident representative notice of an impending transfer or discharge. The facility would notify the resident and resident representative(s) of the impending transfer or discharge and the reasons for the move in writing and in a language and manner they would understand. The facility would also send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman.

Based on clinical record review, policy review, and staff interview, the facility failed to provide the resident and/or the resident's representative(s) a notice of bed-hold policy for 1 of 1 discharges reviewed (Resident #8). The facility reported a census of 49 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Resident Bed Hold, dated 11/15/22, stated the facility would provide written information to the resident and/or the resident representative regarding the bed hold policy prior to transferring the resident to the hospital. The facility would provide written information about these policies prior to and upon transfer for such absences. A 2/4/25 Health Status note stated the facility planned to transfer the resident to the hospital. The note lacked documentation of family notification of the transfer or bed hold information provided to the family. The 2/4/25 Discharge Evaluation lacked documentation regarding bed hold. The facility lacked documentation they provided the resident and/or the resident's representative(s) a notice of bed-hold policy at the time of the resident's discharge. On 3/27/25 at 10:42 a.m. via email, the Administrator stated it was her understanding the nurse on duty communicated with the family regarding the resident's discharge to the hospital and this would have included bed hold information.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the completion of proper notices and documentation after they did not allow a resident to return to the facility after a hospitalization for 1 of 1 discharged residents reviewed(Resident #8). The facility reported a census of 49 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The MDS stated the resident had no behaviors during the review period. The facility policy Notification of Transfer and Discharge, dated 3/17/25, stated the facility would provide the resident and resident representative notice of an impending transfer or discharge which would include the reason for discharge and information regarding appeal rights. A 10/24/24 Nurses Notes stated the resident admitted to the facility and was pleasant and cooperative. A 12/14/24 Behavior Note stated the resident's family member stated the resident sounded depressed. The Director of Nursing (DON) spoke to the resident and he stated he had no plan to harm himself but did not feel like himself. The facility lacked documentation of any further behaviors displayed by the resident from his admission until 2/2/25. A 2/2/25 Nurses Note stated the resident had increased behaviors. A 2/4/25 8:37 a.m. Health Status note documented the resident was behaviorally different from baseline after his electroconvulsive therapy (ECT) treatment yesterday. Throughout the evening and overnight, the resident's behaviors became increasingly erratic and included, urinating on the floor, and taking all of his clothes off. The facility obtained an order to send him to the hospital for evaluation. The resident's clinical record lacked the following: a. documentation related to the clinical decision making process regarding the resident's inability to return to the facility. b. documentation of provider consultation in the decision making to not allow the resident to return. c. documentation of which specific needs the facility could not provide the resident. d. documentation that the facility provided the family with information regarding appeal rights including the name, address(mailing and email), and telephone number of the entity which received such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. During an interview on 3/25/25 at 1:51 p.m. Staff B, Licensed Practical Nurse (LPN) stated prior to the night the resident had his change in condition, they did not have problems with him. She stated after he came back from his ECT appointment, he couldn't move his legs and he was in a wheelchair. She stated he lost it and was not in the same mental status. He threw his shoes and needed to have one on one supervision. She stated he was very out of character and they had to provide individual supervision to keep him from falling. On 3/25/25 at 2:09 p.m., Staff C, Certified Nursing Assistant (CNA) stated normally Resident #8 would joke around and seemed like a regular person. He stated the day before he discharged from the facility, he went to the hospital for a treatment and when he came back he said he felt drunk but had not been drinking. Staff C stated he became more loud and obnoxious and unaware of what was going on. Staff C stated he had to lead him out of another resident's room and he undressed himself in the dining room. Staff C stated this was not like him. During an interview on 3/25/25 at 3:47 p.m., Staff D, LPN stated Resident #8 did not need a whole lot of help and she never had problems with him or observed behavioral issues. On 3/26/25 at 12:47 p.m. Staff F CNA stated she loved Resident #8 and he was usually so relaxed and calm. She said he was friends with another resident and played cards at night. She stated however that the last night he was at the facility he was not himself. He was in the hallway and had his shorts off and threw them across the hallway. She stated this was very odd for him and her jaw dropped. She stated she had to sit with him for an hour because he kept getting up. She stated the nurse took his vitals and they were fine and they didn't think they could send him out in the middle of the night based solely on his behaviors. She stated the kitchen staff arrived and made him an early breakfast because he said he was hungry but he then refused the meal and threw the food items. During an interview 3/26/25 at 3:36 p.m., the Social Worker stated it was difficult to have the resident in the facility because they could not carry out one on one supervision. She stated they had a meeting with the family and told them if something else happened they did not know if they could bring him back. On 3/26/25 at 4:00 p.m., the Administrator stated the made the decision they were not going to take the resident back and stated the company's regional consultant gave them specific reasons but she did not have documentation of those reasons. During an interview on 3/27/25 at 1:18 p.m., the Administrator stated she did not have documentation related to the decision making process with regard to Resident #1 not being allowed to return to the facility. She stated she thought that the paperwork including appeal notices did not need to be completed if the resident was out of the facility more than 10 days.

Based on clinical record review, policy review, and staff interview, the facility failed to provide emergency services in a timely manner (Resident #8). The facility reported a census of 49 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #8 which included bipolar disorder, anxiety, and depression and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The MDS stated the resident had no behaviors during the review period. The facility policy Notification of a Change in Condition, revised 4/26/23, stated the facility would notify the provider of a resident's change in condition including unusual behavior. A 2/2/25 Nurses Note stated the resident had increased behaviors. A 2/4/25 8:37 a.m. Health Status note stated the resident was behaviorally different from baseline after his electroconvulsive therapy (ECT) treatment yesterday. Throughout the evening and overnight, the resident's behaviors became increasingly erratic and included, urinating on the floor and taking all of his clothes off. The facility obtained an order to send him to the hospital for evaluation. On 3/25/25 at 2:09 p.m., Staff C CNA stated normally Resident #8 would joke around and seemed like a regular person. He stated the day before he discharged from the facility, he went to the hospital for a treatment and when he came back he said he felt drunk but had not been drinking. Staff C stated he became more loud and obnoxious and unaware of what was going on. Staff C stated he had to lead him out of another resident's room and he undressed himself in the dining room. Staff C stated this was not like him. On 3/25/25 at 3:47 p.m., Staff D LPN stated Resident #8 did not need a whole lot of help and she never had problems with him or observed behavioral issues. On 3/26/25 at 12:47 p.m. Staff F CNA stated she loved Resident #8 and he was usually so relaxed and calm. She said he was friends with another resident and played cards at night. She stated however that the last night he was at the facility he was not himself. He was in the hallway and had his shorts off and threw them across the hallway. She stated this was very odd for him and her jaw dropped. She stated she had to sit with him for an hour because he kept getting up. She stated the nurse took his vitals and they were fine and they didn't think they could send him out in the middle of the night based solely on his behaviors. She stated the kitchen staff arrived and made him an early breakfast because he said he was hungry but he then refused the meal and threw the food items. The facility lacked documentation of an assessment carried out or physician notification when staff identified a change in mentation in the middle of the night on 2/3/25 to 2/4/25. The facility lacked documentation of physician notification of the changes prior to 2/4/25 at 8:27 a.m. On 3/27/25 at 10:45 a.m., the Director of Nursing (DON) stated if a resident had a change in mental status, nurses should notify the provider immediately and have them sent out if there was a complete change from baseline.

Based on clinical record review, policy review, provider and staff interviews, the facility failed to develop interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition from the facility to a post-discharge setting. (Resident #3) The facility reported census was 47. Findings include: The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #3 included: diabetes mellitus, and neurogenic bladder. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS assessed Resident #3 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was occasionally incontinent of bladder. The MDS documented Resident #3 had taken a hypoglycemic (medication used to lower blood sugar, includes insulin). A review of the clinical record revealed a Nurses Note, dated 8/30/24 at 9:55 a.m., documenting Resident #3 given discharge information. Reviewed signs and symptoms of high and low blood sugar and to check blood sugar and to continue to check blood sugars before meals and that should track for new physician and take to first appointment, Reviewed infections signs and symptoms and to notified doctor if experiencing any S& (sign and symptoms) for further instruction regarding care. Shower bench going with resident and all belongings have been packed and put on transport van. Medication scripts being faxed to [pharmacy name redacted] in [name of town redacted]. During an interview on 10/9/24 at 9:40 a.m. Staff I, Social Worker, stated she met with representatives with Resident #3's Managed Care Organization discuss the discharge plans. Staff I was unable to provide the date and time of this meeting, and used email exchanges for reference. Staff I described Resident #3's discharge placement as a host home with two adult foster parents. Staff I stated Resident #3 was in need of a shower chair, home health services and medication administration assistance. Following the meeting, Staff I stated she was able to obtain the shower chair, but home health services could not be provided until Resident #3 was seen by a physician, not affiliated with the facility. Staff I seemed to believe she would not be the one to set up this appointment and was unaware who may of made the referral and when the appointment was, leaving home health services for Resident #3 uncertain. Staff I stated the Director of Nursing (DON) was working on the medications which included the need for insulin and supplies. Staff I stated the pharmacy they use was unable to provide insulin supplies so they had to change pharmacies last minute. Staff I was unaware of any issues related to the pharmacy change and was uncertain who would be administering the insulin and whether they were trained. Resident #3 was discharged on [DATE] without having home health services arranged or of a clear understanding how the medications would be given. During an interview on 10/9/24 at 10:47 a.m. Staff J, Registered Nurse, stated she attended a care conference in which Resident #3's discharge plans were discussed. Staff J recalls the Nurse Practitioner (NP) sending scripts to their pharmacy and there being an issue with the insulin and insurance. The NP then sent scripts to another pharmacy and there was an issue in the way the insulin was ordered and the NP had to re-order the insulin. Staff J stated she didn't know anything more about the discharge. During an interview on 10/14/24 at 12:56 p.m. Staff CM, Case Manager, stated they had found placement for Resident #3 in a host home through a community provider. The home had a married couple who would provide supervision and support 24/7. Staff CM stated they had met with the facility and began planning the discharge, but prior to the discharge, Resident #3 was hospitalized and diagnosed with diabetes mellitus requiring the use of insulin. Staff CM stated she suggested moving the discharge back, but the facility wanted to move forward. The discharge was scheduled on a Friday (8/30/24), which can be problematic if there are any issues. The plan was to have a 30 day supply of medications sent home with Resident #3. Apparently there was an issue and they had to switch pharmacies as well as discovering the insulin dosage and type of administration type was wrong. Staff CM stated the facility never contacted her about any issues and by Sunday or Monday she reached out and found out about the problems. Staff CM stated she found out about the incorrect insulin dosage and how they sent out insulin bottles instead of a quick pen. Staff CM stated she spent several hours trying to get the right scripts sent to the pharmacy. Staff CM stated she also questioned whether Resident #3 was properly trained on insulin administration as he kept bending needles. Staff CM stated they were able to get an appointment scheduled with a physician and home health services started in the home. Staff CM stated there was a lack of communication and proper planning by the facility to insure a smooth transition. A review of the clinical record revealed a lack of documentation regarding discharge planning for Resident #3 prior to the discharge on 8/30/24 at 9:55 a.m. During an interview on 10/14/24 at 1:34 p.m. Staff HH, Host Home, stated there was a lot of miscommunication surrounding the discharge of Resident #3. Staff HH stated as a result Resident #3 went without his medications, including his insulin for over a week. Staff HH stated Resident #3 is doing fine now. A facility policy, dated April 2017, titled Discharge Planning Process review revealed A Policy Interpretation and Implementation section directing the Interdisciplinary Team, which includes the resident and/or representative: 1. Evaluate the resident ' s discharge potential and needs; 2. Develop a discharge plan as part of the comprehensive care plan which includes: a. The resident ' s goals of care and treatment preferences; b. The resident ' s interest in being discharged or transferred; c. Needs of the resident upon discharge; d. Capacity of the resident and care givers to meet the needs of the resident upon discharge/transfer; e. Is the discharge/transfer feasible - who made this decision and why; f. Names of the Interdisciplinary Team involved in developing the discharge plan; g. Documented and dated resident ' s involvement and h. Date when the discharge plan was reviewed and updated 3. Share the discharge plan with the resident and/or representative 4. Update the discharge plan as needed 5. Prepare the resident and/or representative for discharge 6. Document reason for discharge or transfer 7. Provide required information 8. Complete a discharge summary

Based on record review, resident and staff interviews, call light logs, facility policy and resident council minutes the facility staff failed to respond to call lights within a reasonable amount of time. Residents reported having to wait from 30 minutes to over an hour for the call light to be answered numerous times (Resident #10, #22, #34, & #50). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #22 revealed a diagnosis of obesity and a chronic wound to the left foot therefore required the assistance of 1 for dressing and personal hygiene. Resident # 22 had a Brief Interview for Mental Status (BIM) score of 15 suggesting an intact cognition. During an interview on 8/05/24 at 9:19 AM, Resident #22 stated the staff are often slow at answering her call light, 30 mins to 2 hours. Resident #22 stated if it's longer than 45 minutes, she will call the front desk, if no answer, then she will call the social worker. Resident #22 stated she can make it to the bathroom but needed assistance in the bathroom and had waited for over an hour on the toilet and the staff told her they had forgotten she was down that hall. 2. The MDS dated [DATE] for Resident #10 revealed a diagnosis of heart failure, had a history of falls and required moderate assistance with dressing, toileting and maximal assistance with personal hygiene needs. Resident #10 had a BIM score of 13 suggesting an intact cognition. During an interview on 8/5/24 at 10:48 AM, Resident #10 stated she would put her call light on for assistance to change her clothes and it may take the staff more than a half an hour to respond. On 8/8/24 at 11:30 a.m., the Administrator stated she did not have the ability to print call light logs but stated the surveyor could view them at the computer at the nursing station. The logs included the following response times: Resident #10 On 7/30/24, the call light response time was 40 minutes, from 5:28 p.m. to 6:09 p.m. On 8/1/24, the call light response time was 23 minutes, from 4:13 p.m. to 4:37 p.m. 48888 3. The MDS, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Resident #50 required substantial to maximal staff assistance with bed mobility and transfers to and from bed. Resident #50 had frequent pain symptoms, post spinal fusion surgery, and had a documented Stage 3 pressure injuries to sacrum. Diagnoses included: multiple injuries, subsequent encounter, monoplegia of upper limb affecting left non-dominant side, necrotizing vasculopathy, post-laminectomy syndrome, and contusion of lung. The Care Plan, initiated 7/08/24, revealed Resident #50 at risk for falls, staff instructed that Resident #50 needed prompt response to all requests for assistance. On 8/06/24 at 9:31 AM, Resident #50 reported a concern with long call light wait time and stated it depended upon the staff working as some may be prompt to answer and other take 30 minutes to an hour or more to assist him when call light is pressed. On 8/8/24 at 11:30 a.m., the Administrator stated she did not have the ability to print call light logs but stated the surveyor could view them at the computer at the nursing station. The logs included the following response times: Resident #50 On 8/1/24, the call light response time was 19 minutes, from 1:44 p.m. to 2:03 p.m. On 8/4/24, the call light response time was 21 minutes, from 9:51 a.m. to 10:12 a.m. On 8/5/24, the call light response time was 19 minutes, from 2:55 p.m. to 3:14 p.m. 35434 4. The 6/26/24 Resident Council Minutes, stated the issue of call light response was not resolved. The 7/25/24 Resident Council Minutes stated the issue of call lights was resolved but stated it depends on staff. The minutes did not contain further details about the issue. 5. The MDS assessment tool, dated 5/26/24, listed diagnoses for Resident #34 which included diabetes, respiratory failure, and morbid obesity and listed the resident's Brief Interview for Mental Status(BIMS) score of 14 out of 15, indicating intact cognition. A 9/14/22 Care Plan entry stated the resident had bladder incontinence. On 8/6/24 at 9:01 a.m., Resident #34 stated call lights were terrible. She stated a lot of times one had to wait for an hour for help and this could happen any time of the day. She stated this last week she waited at least 30 minutes a couple times and used her phone to time this. She stated about a week ago, she had an incontinent episode due to the long wait time and when this happened she felt not very good. An 8/8/24 Care Plan entry encouraged staff to assist the resident to the toilet. On 08/08/24 at 11:30 a.m., the Administrator stated she did not have the ability to print call light logs but stated the surveyor could view them at the computer at the nursing station. The logs included the following response times: Resident #34 On 7/31/24, the call light response time was 26 minutes, from 9:40 a.m. to 10:07 a.m. On 8/1/24, the call light response time was 36 minutes, from 12:35 p.m. to 1:11 p.m. On 8/8/24 at 9:49 a.m., Staff I Certified Nursing Assistant(CNA) stated lately staffing was not as good. She stated staff were sometimes unable to answer call lights within 15 minutes when they were in a room with another resident. She stated if there were many call lights alerted, the response time could be up to 30 minutes. On 8/8/24 at 10:40 a.m., the Director of Nursing(DON) stated staff should respond to call lights within 15 minutes. On 8/8/24 at 1:59 p.m., the Administrator stated staff should answer call lights within 15 minutes. Via email correspondence on 8/8/24 at 2:40 p.m., the Administrator stated the facility did not have a policy which addressed call lights.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to carry out a treatment as ordered for 1 of 3 residents reviewed(Resident #34). The facility reported a census of 53 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Minimum Data Set(MDS) assessment tool, dated 5/26/24, listed diagnoses for Resident #34 which included diabetes, respiratory failure, and morbid obesity. The MDS stated the resident had a Stage 4 pressure ulcer and listed the resident's Brief Interview for Mental Status(BIMS) score of 14 out of 15, indicating intact cognition. The 11/15/22 Wound Management policy, dated 11/15/22, stated the facility would provide treatments in accordance with the physician orders. A 1/24/23 Care Plan entry list stated the resident had a Stage 4 pressure ulcer. A 6/15/23 Care Plan entry directed staff to treat as per the orders. The 7/30/24 Specialty Physician Wound Evaluation and Management Summary stated the resident had a Stage 4 Pressure Wound of the left ischium(the lower back hip bone) and directed staff to apply skin prep once daily for 16 days. The July and August 2024 Treatment Administration Records(TARs) listed a 6/13/24 order for skin prep to the wound on the left ischium every day shift. The 7/3/24 and 7/4/24 entries were blank and lacked initials to indicate staff completed the dressing. The 7/26/24 entry contained scribbled out initials which were illegible. The 8/5/24 entry contained the initials of Staff J Registered Nurse(RN) and the 8/6/24 entry had the initial of Staff G Licensed Practical Nurse(LPN). The TARs lacked documentation of an order for Maxorb (type of wound dressing used to treat draining wounds) to the wound. On 8/6/24 at 9:01 a.m. Resident #34 stated that staff did not carry out treatments as they should on her buttock. She stated she missed treatments. On 8/7/24 at 10:44 a.m. Staff G LPN agreed to complete the resident's wound treatment and measurements. Staff G stated that she would measure the open areas. The resident laid on her back and Staff G uncovered her and lifted up her abdominal folds. Staff G inspected under the folds and stated she was clear. Staff G then covered the resident back up. She stated she did not think the resident had an area on her bottom. Staff G rolled the resident over on her right side and she had a red open wound on her left ischium. Staff G stated she would retrieve dressing supplies and she left the room. Upon return, Staff G measured the wound which had a red wound bed with yellow slough on the top and the bottom as 3.2 centimeters(cm) x 1.3 cm x 0.3 cm(length x width x depth). She then applied Maxorb to the wound and covered it with a foam dressing. After the dressing change, Staff G stated she did not complete a treatment on 8/6/24 to the resident's ischium. When queried regarding the presence of her initials on the entry for the resident's 8/6/24 skin prep, she stated the physician carried out the treatment. On 8/7/24 at 4:06 p.m., via phone, Staff J Registered Nurse(RN) stated on 8/5/24, she signed off the resident's skin prep as complete with the intention of completing it later in the day. She stated after 2.5 hours of the shift though, the facility terminated her contract and she was unable to complete this On 8/8/24 at 10:40 a.m. the Director of Nursing(DON) stated she expected staff to carry out all treatment orders.

Based on observation, interview, clinical record review, and facility policy review, the facility failed to elevate the head of bed during administration of enteral feeding and failed to label supplemental formula bag with the date and time that enteral feeding had started for 1 of 2 residents (Resident #33) reviewed for enteral/tube feeding. The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Resident #33 required partial to moderate staff assistance to turn and reposition in bed and had been dependent upon staff to transfer. Diagnoses included alcohol induced acute pancreatitis without necrosis or infection, malnutrition, generalized peritonitis, sacroiliitis, autoimmune thyroiditis, and gastrostomy status. Resident #33 required feeding tube prior to and while a resident at facility, she received 25% or less proportion of total calories through tube feeing. The Care Plan, initiated 6/12/24, revealed Resident #33 had an alternative nutritional intake via tube feeding with the goal that resident will remain free of side effects or complications related to tube feeding through the review date. An intervention instructed staff to elevate the head of bed 45 degrees during and for thirty minutes after tube feed. The Order Summary, dated August 2024, revealed an active order, with the start date of 6/13/24, to change out enteral feed set (bags, formula, piston syringe, and cylinder) every 24 hours on overnight shift. This order instructed staff to label bags with time and date for gastrostomy tube (g-tube) care. The facility document titled, Visual/Bedside Kardex Report, dated 8/07/24, for Resident #33, instructed staff to elevate the head of bed to 45 degrees during and thirty minutes after tube feed. On 8/07/24 at 7:56 AM, Resident #33 laid flat in bed, the head of bed remained in lowest position, tube feeding noted to be running at 35 milliliters (mL) per hour with a water flush of 40 mL every hour. Noted label on formula bag which indicated tube feeding administration had been initiated at 12:00 AM on 8/07/24. On 08/07/24 at 8:14 AM, Staff K, Certified Nursing Assistant (CNA) informed that Resident #33 should never be flat in her bed during tube feeding due to risk for aspiration. Staff K stated that Resident #33 never refused cares or repositioning from staff that she is aware of. On 8/07/24 at 8:20 AM, Director of Nursing (DON), entered Resident #33's room, Resident #33 continued to lay flat in bed, with head of bed at lowest position, DON informed that the resident's head of bed should be up more during tube feeding administration and proceeded to elevate the head of bed to resident's preference. DON revealed the expectation that staff elevate Resident #33's head of bed to her preference or comfort and that Resident #33 should not lay flat during administration of tube feeding. On 8/08/24 at 8:40 AM, Resident #33 laid in bed with head of bed slightly elevated, noted tube feeding running via pump at 35mL per hour, with 40mL water flush per hour. The bag of supplemental formula that hung from the pump lacked label or identification of date and time that tube feeding administration had been initiated. On 08/08/24 at 8:43 AM, Staff G, Licensed Practical Nurse (LPN) entered Resident #33's room and had been unable to find a label with date and time to Resident #33's supplemental formula feeding being administered. On 08/08/24 at 10:42 AM, DON revealed expectation that supplemental formula hung for tube feeding administration be labeled with date and time initiated. The facility provided a document of procedures followed for enteral feedings, titled Tube Feedings, dated 2019, which instructed staff to position the patient with head of the bed elevated to at least 30 degrees or upright in a chair to prevent aspiration. The document additionally instructed staff to label the enteral administration set with the date and time that it is hung.

Based on clinical record review, family and staff interviews, observations, and policy review, the facility failed to maintain a safe environment free from resident abuse for 8 of 9 residents reviewed for abuse (Resident #2, #3, #4, #5, #6, #8, #11, #15). Clinical record review revealed on 9/26/23 at 4:00 p.m., Resident #6 fell and sustained a hematoma to her head. After the initial hour of assessments, the facility staff neglected to conduct follow up assessments and neurological assessments (as per ordered by the provider) throughout the evening, night and next morning. On 9/27/23 the day shift Certified Nurses Aide (CNA) requested for a nurse to assess Resident #6 who was unconscious, (16 hours after last assessment).The facility sent the resident to the emergency room where the resident was assessed to have a Subdural Hematoma (brain bleed), fracture of right clavicle, urinary tract infection (UTI), Tachycardia (fast heart rate) and Fever. Resident #2 was physically aggressive with Resident #8, kicked Resident #5, and struck Residents #4, #11, and #15, and kicked and punched Resident #3. Resident #5 struck Resident #2. Staff X was physically rough with Resident #3 when removing him from the medication cart area. The above incidents spanned over a time frame from at least June of 2023 until October 2023. Staff reported that residents were scared of Resident #2 when he would arrive in a common area. The facility reported a census of 50 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of September 26, 2023 on December 19, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on December 19, 2023 by implementing the following actions: 1) The Director of Nursing (DON)/Designee educated staff 12/19/23 on A) Abuse Prevention B) Neurological evaluations with un-witnessed falls, head injuries. C) Change in Condition notifications with physician and responsible parties. D) follow up evaluations with falls/changes in conditions 2) DON/Designee audited falls/changes in condition for proper follow up evaluations and neurological evaluations 3) DON/Designee will be notified with falls for proper follow up. A) Will review for proper evaluations and notifications as well as appropriate interventions. The scope lowered from J to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed the diagnosis Diabetes Mellitus, hypertension, renal insufficiency, aphasia (loss of ability to understand or express speech), altered mental status. Resident #6 required limited assistance for bed mobility, transfers, toileting, and for personal care. Resident #6 used a wheeled walker to ambulate and was frequently incontinent of urine. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 1 which suggested a severe cognitive impairment. The Care Plan dated 9/15/23, instructed the staff to ambulate Resident #6 with a wheeled walker, provide assistance with transfer, toileting, personal hygiene and dressing with the assistance of 1 staff member. Resident #6 was identified as a fall risk and staff was directed to check frequently and assist as needed. Progress notes 9/26/23 at 4 p.m. for Resident #6 revealed: a. Staff I, Licensed Practical Nurse (LPN) notified that Resident #6 fell . b. Assessment complete and Neuro checks were initiated. c. A 4 cm x 5 cm bruise and swelling noted to the right side of forehead. d. Resident #6 was confused at the time and Urinary tract infection (UTI) was suspected. e. Three staff assisted the resident in a wheelchair, to the nurses station for 1 on 1 supervision. f. Family was notified. g. Staff J, Advance Registered Nurse Practitioner (ARNP) was notified. h. A new order for one time dose of 12.5 mg Hydralazine due to blood pressure (BP) of 165/101 and obtain a urine sample. Neurological Evaluation form directed staff to complete post fall if resident hit head or unwitnessed fall: every 15 minutes for 1 hour every 30 minutes for hour every hour for 2 hours every 2 hours for 8 hours every 4 hours for 12 hours every shift for 72 hours. The Neurological Evaluation for Resident #6 revealed with start date of 9/26/23 documented as follows: a. Neurological assessments were initiated on 9/26/23 at 4 p.m. b. At 4:00 p.m. blood pressure (BP) 165/101,pulse (P) 92, Respiration (R) 18 (temperature was not assessed), LOC (level of Consciousness) 4+ (Lethargic, sleepy or drowsy), Pupils 4 and reactive to light (+), Hand grips refused, Lacked pain assessment. c. At 5:15 p.m. BP 129/95, P 98, R 18, LOC 4+ Lethargic, pupils 4+ Hand grasps AB (absent) d. Lack of documentation for the following assessment date and time: 1. On 9/26/23 at 5:45, 6:45, 7:45, 9:45, and 11:45 p.m. 2. On 9/27/23 at 1:45, 3:45, and 7:45 a.m. e. 9/27/23 at 11:15 a.m. revealed: BP 154/48, P 116, R 16, LOC 3+ stuporous (not awake), lacked assessment of pupil size, responsiveness, hand grips and pain assessment. f. The Neurological assessment initiated on 9/26/23 at 4 p.m. lacked documentation of last every four hour assessment, and lacked documentation of the required assessments for the every 72 hour evaluations. Progress note dated 9/27/23 at 11:10 a.m. for Resident #6 revealed: a. Staff M, RN asked by staff to assess Resident #6. b. Resident eyes closed, did not respond to name or touch. c. Vital Signs: temperature (T) 100.4, P 114, R 16, BP 158/48. d. Unable to arouse the resident. Progress note dated 9/27/23 at 11:25 a.m. for Resident #6 revealed that Staff M, RN notified the family who requested transport to the Emergency department for evaluation and the ambulance was notified. The Situation, Background, Assessment, and Recommendation (SBAR) dated 9/27/23 at 11:25 a.m., completed by Staff M, RN, the findings included: a. Unresponsiveness b. The condition, symptom, sign had not occurred before c. Pain: does the resident have pain? yes non-verbal occasional moan or groan, facial grimacing d. testing none e. Interventions none f. Family was notified on 9/27/23 at 11:25 a.m. g. On 9/27/23 at 11:38 a.m. Staff J, ARNP notified. Progress note dated 9/27/23 at 11:55 a.m. revealed that Resident #6 was transported to the local hospital. During an interview on 12/18/23 at 3:29 p.m. Staff P, CNA stated Resident #6 was pleasantly confused on 9/26/23, which was her normal. Staff P stated she was in the hall when she heard a loud thunk and started searching rooms. Staff P stated she found Resident #6 face down in her room with a big goose egg on her forehead. Staff P stated she stayed with the resident while Staff O, CNA went to get Staff I, Licensed Practical Nurse (LPN). Staff P stated Resident #6's face was grimaced, she acted confused, moving to try to sit up and dazed, eyes not tracking and not responsive to her name. Staff P stated Staff O returned with Staff I who took vital signs then instructed the CNA's to get her up to the recliner. Staff P stated Resident #6 was not acting like herself, and the CNA's checked on her every 15 minutes, then Staff I instructed CNA's to place her in a wheelchair and take her to the nurses station. Staff P stated they were instructed by Staff K, RN to take Resident #6 to bed about 7 p.m. and she was normally a 1 person assist but at that time was a 2 person assist with a gait belt. During an interview on 12/18/23 at 3:47 p.m. Staff O, CNA stated on 9/26/23 about 4 p.m. she was caring for a resident and heard a loud thump. Staff O stated, I knew it was a body hitting the floor. Staff O stated she assisted Staff P, CNA and found Resident #6 on the floor, on her right side, 4-5 steps from her recliner with the walker at her feet. Staff O stated Resident #6 rolled over and had a bruise to her head and did not recognize her name. Staff O stated she went after Staff I, LPN who took Resident #6 vitals but she did not have a flashlight to assess neuro ' s, did not assess the residents arms or legs, and gave direction to Staff O and Staff P to get the resident up to the recliner. Staff O stated Resident #6 did not eat supper and was directed to put Resident #6 to bed at 7 p.m. by Staff K, RN who stated it was ok to put her to bed. Staff O stated she had been a CNA for 9 years and Resident #6 was not ok and she asked Staff I and Staff K if they were going to send her to the hospital. Staff O stated she and Staff P checked on her often to be sure she was still breathing due to Resident #6 did not arouse again after being put to bed. Staff O stated Staff K did not go into Resident #6's room to assess her. During an interview on 12/18/23 at 1:09 p.m. Staff I, LPN stated she worked on 9/26/23, 6 a.m. to 6 p.m. and was notified by staff CNA's that Resident #6 had an unwitnessed fall in her room about 4 p.m. Staff I stated, She had a goose egg on her forehead. Staff I stated it took 3 staff to get Resident #6 off the floor. Staff I stated she had notified Staff J, Advanced Registered Nurse Practitioner (ARNP) and was told to monitor the resident. Staff I stated she initiated a neurological sheet with the date and times neuro checks were to be completed and it was given to the 6 p.m. to 6 a.m. staff nurse in report, Staff K, Registered Nurse (RN). Staff I stated Resident #6 was restless, could not sit still, and cried. During an interview on 12/18/23 at 1:20 p.m., Staff J, ARNP, stated she had received a call on 9/26/23, informed that Resident #6 fell , hit her head and the neurological test was normal. Staff J stated an order was given to monitor the resident and expected a call if there were changes or an inability to awaken the resident. Staff J stated she did not receive a follow up call, no one identified that Resident #6 was crying, restlessness that would suggest pain or confusion. Staff J stated, I would have sent her out if I felt she had further injuries or if in pain. Staff J stated she had provided training to nursing staff in the past to include tube feeding, neuro and dementia pain assessments. Staff J stated, There is a big gap in the knowledge of the nurses here. During an interview on 12/19/23 at 3:47 p.m. Staff A, CNA stated she worked on 6/27/23 at 6 a.m., rounded with the the night shift CNA's who reported that they did not hear Resident #6 get up to the bathroom during the night so they did not go in. Staff A stated Resident #6 looked like she was in discomfort and asked Staff K, RN what happened to her, and was told by Staff K that he had given Resident #6 pain medication. Staff A stated she proceeded to give Resident #6 a bed bath. Staff A stated Resident #6 moaned when turned. Staff A stated Resident #6 did not eat so she left her in bed, changed her once and then went to get Staff M, RN around 11 a.m. to make an assessment due to Resident #6 looked rough. During an interview on 12/18/23 at 3:01 p.m. Staff M, RN stated she had worked as the previous Director of Nursing (DON) in the facility and worked on 9/27/23 as the day nurse, 6 a.m. to 6 p.m. Staff M stated she had received report at 6 a.m. from Staff K, RN that Resident #6 had a fall but Staff K did not share the extent of the fall. Staff M stated she was caring for a very sick resident down a different hall all morning until Staff A, CNA came to find her around 11 a.m. and stated Resident #6 was not waking up. Staff M stated she found Resident #6 unresponsive and notified Staff J, ARNP and the resident's family then transferred the resident to the hospital. Staff M stated she found the neuro sheet under a stack of papers at the nurses station. Staff M stated she interviewed Staff K over the phone who stated he had not assessed Resident #6 as she was asleep. Staff M stated it was normal practice for staff to call and notify the DON if there was a fall and there was no notification given to her. During an interview on 12/19/23 at 8:52 a.m., Resident #6's son stated his mother was quarantined in her room behind a closed door due to COVID and had two falls, a week apart. The son stated the family was notified of both falls but felt this last fall on 9/26/23 was down played. The son stated he received a call on 9/27/23 asking if the family would want her evaluated at the local hospital due to a possible UTI. The son stated he went to the hospital, I could not believe it, I could not recognize her ''. The son stated he spoke with his brother since this was more than a UTI and felt it was more than the local hospital could handle, therefore had Resident #6 transferred to the tertiary hospital for higher level of care. The son stated he was not going to send his mother back to this facility, requested the hospital Hospice to assist with the location of a facility, then transferred mother to a different facility until she passed from her injuries 2 weeks later on 10/28/23. Tertiary Hospital Record Review for Resident #6 dated 9/27/23 revealed: a. Subdural Hematoma (blood between the brain and its outermost covering). b. Bruises to right head and right shoulder c. Acute Encephalopathy (brain disease that alters brain function causes infection, tumor, and stroke) d. Fracture of the right clavicle e. UTI (urinary tract infection) f. Unresponsive to sternal rub (chest bone) g. Tachycardia (fast heart rate) h. Febrile (high body temperature) i. Vital Signs Blood pressure 138/79, Pulse 113, Respirations 20, Temperature 100.6 j. admitted to the tertiary hospital During an interview on 12/19/23 at 8:59 AM Staff N, Medical Examiner Investigator stated the cause death for Resident #6 was a result of complications from blunt force trauma injuries to head and clavicle, date of death [DATE]. The policy titled Neurological Evaluation dated 3/28/23 revealed: a. A neurological evaluation will be performed by a licensed nurse when a resident's status warrants suspected head injury, CVA (stroke) and/or unwitnessed fall to identify a change of condition related to a possible head injury. b. Concern over change in mental status c. A change in level of consciousness d. Inspect pupil reaction with flashlight, e. Observe if resident moves all extremities f. Observe if the resident obeys commands & pain g. Notify physician for pupil reaction changes, decrease level of consciousness, changes in vital signs and or change of condition 35434 2. The Quarterly Minimum Data Set(MDS) assessment tool, dated 6/8/23, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, traumatic brain injury, and communication deficit. The MDS stated the resident had physical behavioral symptoms directed towards others(e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 1-3 days in the 7 day review period and listed the resident's Brief Interview for Mental Status(BIMS) score as 4 out of 15, indicating severely impaired cognition. The facility policy Abuse Prevention, revised 10/21/22, define abuse as willful infliction of injury resulting in physical harm, pain, mental anguish or emotional distress and stated abuse included resident-to-resident and staff-to-resident interactions. The policy defined neglect as the failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presented either imminent danger to the health, safety, or welfare of a consumer or a substantial probability that death or serious physical injury would result. The policy stated the facility was committed to protecting the resident from abuse. The Significant Change in Status MDS assessment tool, dated 3/31/23, listed diagnoses for Resident #8 which included non-Alzheimer's dementia, repeated falls, and adult failure to thrive. The MDS listed the resident's BIMS score as 2 out of 15, indicating severely impaired cognition. The Admission MDS assessment tool, dated 6/7/23, listed diagnoses for Resident #5 which included diabetes, anxiety disorder, and insomnia. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The Admission MDS assessment tool, dated 6/30/23, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, encephalopathy(disease of the brain), and constipation. The MDS listed the resident's cognition as severely impaired. The Quarterly MDS assessment tool, dated 5/25/23, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety disorder, and depression. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired cognition. The Quarterly MDS assessment tool, dated 5/10/23, listed diagnoses for Resident #15 which included diabetes, anxiety, and depression. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The Annual MDS assessment tool, dated 5/22/23, listed diagnoses for Resident #4 which included seizure disorder, anxiety disorder, and weakness. The MDS listed the resident's BIMS score as 0 out of 15, indicating severely impaired cognition. A 12/14/22 12:47 p.m. Nurses Note stated Resident #2 had increased behaviors and went into another resident's room and yelled at them, raised his fist at them, and defecated(had a bowel movement) in the hall. A 5/1/23 10:23 p.m. Nurses Note stated there were female residents who were afraid of Resident#2 and male residents who did not know what to do when he approached. A 5/26/23 3:48 p.m. Nurses Note stated Resident #2 attempted to hit a resident with his wheelchair. The other resident was scared and was consoled by staff. A 6/7/23 5:21 a.m. Progress Note for Resident #2 stated the resident had Resident #8 cornered in his room and was physically abusive towards him. The note stated Resident #8 reported that Resident #2 kicked him in the legs and the resident's legs were a little red but unsure if it was related to the incident. A untitled, undated facility document stated on 7/3/23 Resident #2 kicked Resident #5 and hit his finger. A 7/5/23 10:41 p.m. Nurses Note for Resident #2 stated Resident #2 was found in his room on the floor along with Resident #3. It appeared that a physical altercation between the 2 was what led to both men being on the floor. An Entity Self-Report stated Resident #2 and Resident #3 ended up on the floor during a physical altercation and Resident #2 struck Resident #3 with a closed fist. A 7/9/23 12:50 p.m. Behavior Note stated the Resident #2 was observed attempting to trip another resident. A 7/14/23 3:40 p.m. Nurses Note stated another resident reported Resident #2 kicked another resident (Resident#5) in the side of the right knee while he was walking past so the other resident slapped Resident #2 in the face. A 7/19/23 10:51 a.m. Behavior Note stated Resident #2 started hitting Resident #11 and then she hit him back with a newspaper. A 8/5/23 Incident Report stated Resident #2 hit another resident(Resident #15) on the hand after the other resident bumped his wheelchair when going around him. A 8/7/23 6:45 a.m. Incident Note stated Resident #2 kicked another resident(Resident #3) who just happened to be standing there and it was unprovoked. An 8/8/23 10: 25 a.m. Behavior Note stated a staff member intervened as the resident was going to hit another resident sitting at the table. An 8/8/23 1:12 p.m. Behavior Note stated the resident transferred to the ER due to behaviors. An 8/9/23 7:15 a.m. Nurses Note stated the resident returned from the ER and had an order to increase Trazadone(a sedative). An 8/10/23 1:45 p.m. Incident Note stated the resident kicked Resident #4. An 8/11/23 untitled document, written by Staff CC Certified Medication Assistant(CMA) stated on 8/10/23, Resident #2 aggressively swung his foot and kicked Resident #4 on her foot and Resident #4 screamed out in pain. An 8/13/23 Incident Report stated Resident #2 punched Resident #3 on the left side of his face. A 9/5/23 Witness Statement, written by Staff O Certified Nursing Assistant(CNA), stated Resident #2 kicked Resident #3 in the left leg around the shin and knee area. A 10/2/23 Incident Note stated Resident #2 was a victim of physical aggression. He sat in the common area with blood running down his face and stated he thought he was punched. A 10/2/23 Activities Note for Resident #5 stated Resident #5 was the aggressor in the above incident with Resident #2. Resident #5 stated that he and Resident #2 were arguing about a seat and that he hit Resident #2 at least twice with an open hand. A 10/8/23 6:30 p.m. Nurses Note stated Resident #2 approached another resident and slammed his hand down on the table beside her and told her to be quiet and shut up you idiot. A 10/14/23 11:49 a.m. Nurses Note stated another resident was making loud noises and Resident #2 went over and smacked her. A 10/14/23 Incident Report stated staff observed Resident #2 slap Resident #4's arm. A 10/17/23 Social Services note stated the resident would transfer to another facility. Care Plan entries for Resident#2 directed staff with the following interventions: 3/7/23 Zoloft(an antidepressant) 50 milligrams initiated and 15 minute checks and redirection as needed. 4/13/23 Analyze key times, places, circumstances, triggers and deescalate the behavior and document. Juice, snacks and complements have been successful. 5/1/23 Assess for the cause of the situation. 5/25/23 Assess for pain and verbal and non-verbal indications. 6/1/23 and 7/5/23 Medication adjustments made. 6/15/22 The resident has hit staff and other residents and the facility attempted to relocate. 7/15/23 Looking for other placement for the resident. 7/19/23 Facility finding additional resources for the resident to deal with his aggression. 8/5/23 Daughter requested evaluation for infection. 8/7/23 and 8/8/23 Sent out to the hospital for evaluation. 8/9/23 15 minute checks to continue until other placement found for the resident. 8/10/23 The facility would contact the Medical Director for insight to assist with keeping the resident and others safe. 8/10/23 One time dose of lorazepam (an anti-anxiety medication) and quieter eating environment. 10/30/23 Adjustments to pain medication and antidepressants to address issues that may cause behaviors. 10/30/23 Reach out to [name redacted, assisting agency] for assistance. 10/30/23 Observe interaction with other residents and keep other residents safe and remove them from the situation. 10/30/23 TV in room to entertain. 10/30/23 When noting onset of agitation, intervene before agitation escalates. On 12/7/23 at 10:58 a.m. via phone Staff O Certified Nursing Assistant (CNA) stated Resident #2 was aggressive and unpredictable. She stated there were multiple times when he harmed other residents. They tried to implement 15 minute checks but he would still do this (harm other residents). She stated there were some residents who were fearful because of him. On 12/7/23 at 1:25 p.m., Staff J Advanced Registered Nurse Practitioner(ARNP) stated Resident #2 was aggressive and could be the sweetest and nicest or rough, angry, and downright mean. He would try to stick his foot out at others and had multiple behavioral issues which could have ended up with him getting hurt. She stated she wrote a discharge order for him to go to another facility for memory care. On 12/7/23 at 2:15 p.m., Staff H Registered Nurse (RN), Minimum Data Set(MDS) Coordinator stated Resident #2 was either pleasant or agitated and it didn't take very much for him to become agitated. She stated she knew of several people that he hit or kicked. She stated she did not know of any interventions which were effective and they tried managing his pain and therapy. They were unable to distract him and he did not interact well in activities. On 12/11/23 at 9:51 a.m., the Social Services Supervisor stated Resident #2 had a lot of behaviors and the residents were really scared of him. She stated there were not a lot of warning signs when he would get aggressive and stated at first he became aggressive with the more mobile people who could talk back. Towards the end of his stay though, he started to seek out residents who were more vulnerable She stated his behaviors lasted over a period of months and would go up and down. There were times when it got really bad and then got better. She stated there were a lot of aggressive behaviors which would endanger residents and staff. She stated they implemented 15 minute checks but it did not prevent him from hurting other residents. She stated she would be in her office and came out right away(if she heard something going on) but she could not stop him towards the end. On 12/11/23 at 10:09 a.m. via phone, Staff U former Administrator stated Resident #2 had a traumatic brain injury and they care planned many interventions to decrease his behaviors. She stated things would go well for a while and then he would strike out or hit another resident who was more verbal. She stated at the end of his stay he would target residents who could not protect themselves and stated it was a period of months that he was physically aggressive towards other residents. She stated it increased in June and July(2023) and he would strike someone so quickly they did not have the opportunity to stop him. She stated they discharged him to keep the other resident's safe and she was fearful he would hurt someone. On 12/12/23 at 9:57 a.m., Staff M former Director of Nursing(DON) stated Resident #2's behavior started to change and he would act out unprovoked and if another residents rolled by, he would strike out. He was difficult to redirect and aggressive with staff, which lasted up until the time of discharge. She stated they would try(an intervention) and it was at first successful but then stopped working. She felt there was a risk to other residents. On 12/21/23 at 2:54 p.m. the Assistant Director of Nursing(ADON) stated she remembered hearing about Resident #2 hurting other residents and none of the facility's interventions worked in preventing it from happening again. 3. The Admission MDS assessment tool, dated 6/30/23, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, encephalopathy(disease of the brain), and constipation. The MDS listed the resident's cognition as severely impaired. A 9/2/23 written statement by Staff W Certified Nursing Assistant(CNA) stated Staff X Certified Medication Aide(CMA) was verbally and physically aggressive with a resident and stated don't touch me I know where your hands have been while shoving the resident's hands and body away from him. Staff X then grabbed the resident's arm and forcefully redirected him. A 9/2/23 written statement by Staff DD Registered Nurse(RN) stated on 9/2/23 at approximately 6:30 a.m., Resident #3 began talking to Staff X and reached out to touch his arm. Staff X then grabbed the resident around the left biceps and placed his closed fist on the resident's back and physically moved him away from his medication cart. The resident had slight redness and a possible bruise beginning on his left upper arm. On 12/19/23 at 1:06 p.m., via phone, Staff W stated Staff X tried to pass medication and Resident #3 was being Resident #3. She stated Staff X turned Resident #3 hard enough that he had a bruise on his arm. Staff W stated Staff X was hateful and told the residents they stunk. On 12/19/23 at 2:06 p.m., via phone, Staff Y Scheduler stated on the day of the alleged incident with Resident #3, Staff X was getting ready to start the medication pass and Resident #3 walked over to Staff X's medication cart but before the resident touched anything Staff X told the resident to get the f---(expletive) away from his cart. Staff X then grabbed Resident #3's arm and jerked him away from the medication cart and put his fist in his back to push him away. She stated the resident was in shock and got defensive. She stated they removed the resident from the area and she notified the Administrator and Staff X left the facility immediately. On 12/21/23 at 8:52 a.m. via phone, Staff DD, RN stated Staff X prepared some medications and Resident #3 liked to be up in your face. Staff X was irritated and grabbed the resident's arm to lead him away. Staff DD stated there was some redness on his arm but no bruising. On 12/21/23 at 2:54 p.m. Staff V Assistant Director of Nursing (ADON) stated staff should not grab residents by the arm in a rough manner. On 1/3/23 at 11:46 a.m., Staff V stated residents should be safe from other residents and staff.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to conduct assessments and provide timely interventions for 6 out of 6 residents with a change of condition (Resident #13, #6, #1, #14, #8 & #10). The facility failed to assess Resident #13 after the Speech Therapist conducted a swallowing evaluation that revealed moderately severe dysphagia, and clinical signs of aspiration during the study on 10/11/23, and subsequently the resident was hospitalized [DATE] with Hypoxia (lack of oxygen), fever, acute aspiration pneumonia, Rhinovirus (common cold), Methicillan-resistant Staphylococcus Aureus (MRSA, a contagious antibiotic-resistant staph infection) positive in both nares, acute kidney injury and a leaking PEG feeding tube that required replacement. Clinical record review revealed on 9/26/23 at 4:00 p.m., Resident #6 fell and sustained a hematoma to her head. The facility staff initiated neurological assessments but failed to conduct follow-up neurological assessments and report changes to the provider for 16 hours. The facility then sent the resident to the ER where the resident was assessed to have a subdural hematoma (brain bleed), fracture of the right clavicle and urinary tract infection. The facility failed to provide an assessment for Resident #1 and #14 after a change of condition which required hospitalization and failed to provide an assessment and intervention for Resident #8 & #10 after identification of no bowel movements. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 11, 2023 on December 7, 2023 at 12:25 p.m. The facility staff removed the Immediate Jeopardy on December 11, 2023 by implementing the following actions: 1. DON Completed In-Service w/Licensed Staff on 12/7/23: a. Recognizing & Reporting Change in Condition. i. Completed eLearning Healthcare Academy Course on Recognizing/Reporting Resident Changes in Condition. b. Change of Condition Evaluation. c. Implementation of Interventions w/Change in Condition. d. Notification of Change in Condition Policy. e. Admission Readmission Orders Policy. 2. DON/Designee Completed 100% Audit on Residents on 12/7/23: a. Completed Change of Condition Evaluation. b. Implemented Interventions w/Change in Condition. c. Physician/NP/RR Notifications were Completed. d. Staff educated on Admission/Readmit orders e. Verify Admits/Readmission Medication Orders with Physician/NP. 3. DON/Designee will Orientate New Hires/Agency Employees on 12/7/23: a. Complete eLearning Course; Recognizing/Reporting Resident Changes in Condition. b. Change in Condition Evaluation. c. Implementation of Interventions w/Change in Condition. d. Following Notification Change in Condition Policy. e. Admission Readmission Orders Policy. The scope lowered from K to E at the time of the survey after ensuring the facility implemented educaiton and their policy and procedures. The facility reported a census of 50 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed a diagnosis of chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease (GERD), complete loss of teeth due to periodontal disease and tracheostomy with dependence on supplemental oxygen. Resident #13 had a Brief Interview for Mental Status (BIMS) of 15 suggesting an intact cognition. Care Plan dated 5/2/23 directed staff to observe, document and report any difficulty breathing, acute signs of respiratory insufficiency, respiratory infection and difficulty swallowing. Document titled Therapy and Nursing Communication (Speech Therapy Evaluation and Plan of Treatment) dated 10/11/23 for Resident #13. Staff EE, Speech Therapist (ST) evaluation and treat for correct diet revealed: a. Clinical impressions: Resident #13 demonstrated moderately severe oral pharyngeal dysphagia (difficulty swallowing) characterized by clinical signs of aspiration (robust and repeated coughing) for thin liquids and mechanical soft solids. b. Recommendation to continue puree diet with nectar thickened liquids (NTL), one bite at a time, sit upright after oral intake for 30 minutes. c. Strongly recommend to have Modified Barium Swallow (MBS) to rule out aspiration, determine most appropriate diet and therapeutic exercises for rehabilitation. Progress note dated 10/18/23 at 9:51 p.m. documentation by Staff J, Advanced Registered Nurse Practioner (ARNP) revealed Resident #13 had diminished lung sounds in bases of lungs and recommended for staff to continue to monitor for changes. Progress notes dated 11/6/23 at 8:30 p.m., documentation by Staff J, ARNP, revealed Resident #13 had: a. A history of swallowing difficulties that included aspiration pneumonia. b. Diminished lung sounds in the bases of both lungs. c. Teeth removed and had yet to be fitted for dentures. d. A plan for a swallow study ordered. e. Tube feedings as needed for nutrition. f. A recommendation for staff to continue to monitor for changes in condition. Nurses progress notes reviewed for Resident #13 dated 10/10/23 through 11/12/23 which lacked assessments by nursing staff, and the barium swallow evaluation appointment to rule out aspiration was not followed through. Progress note dated 11/12/23 at 1:54 p.m. for Resident #13 stated the nurse was notified in report that Resident #13 was sent out due to respiratory distress and oxygen sat in the 70's (oxygen saturation in the blood normal 95-100%). During an interview on 12/6/23 at 3:39 p.m. Staff EE, Speech Therapist (ST) stated that on 10/11/23 she informed the Staff FF, Therapy Director that Resident #13 had aspirated during the swallowing evaluation, she would notify the staff nurse who would notify the physician. During an interview on 12/7/23 at 9:52 a.m. Staff FF, Therapy Director, stated she was notified by Staff EE that Resident #13 had aspirated during the swallow study and the recommendations to continue the thickened liquids, puree diet and he needed a swallow study done. Staff FF stated she relayed this information to the nurse in charge and notified the dietary staff of the diet recommendations. Staff FF stated she also provided the information to the Utilization Review meeting staff and Staff M, former Director of Nursing (DON) was present. During an interview on 12/6/23 at 9:04 a.m. Staff H, MDS Coordinator stated she had notified the provider the day after Resident #13 transferred to the hospital and documented it due to not being documented in pointclickcare progress notes by the agency staff nurse who transferred Resident #13. Staff H stated she was surprised that Resident #13 was transferred as she was unaware of his issues. Staff H stated if a resident was having issues, they are to be placed on the Hot Chart sheet and the nurses are to assess the resident and document in the nurses notes. Staff H stated, Nobody consistently puts notes on the Hot Chart sheet. During an interview on 12/6/23 at 12:00 p.m. Staff M, Former DON, stated Resident #13 was evaluated by speech therapy and Staff FF Therapy Director informs nursing so it can be put in the book at the nursing station, updated on the medication orders and care plan by the MDS coordinator. Staff M stated she was not aware Resident #13 had aspirated and was not informed that he was transferred to the hospital and did not recall if the provider was notified. During an interview on 12/7/23 at 1:33 p.m., Staff J, Advanced Registered Nurse Practioner (ARNP), stated she had seen the speech therapy evaluation and was aware Resident #13 had aspirated during the evaluation. Staff J stated she would expect the nurses to assess Resident #13 after that evaluation, At least his heart and lungs. Staff J stated she did not receive a call with an update for Resident #1's condition and did not receive a call that he was transferred. Staff J stated, I would expect the nurse to call me, I did not know and feel terrible. Tertiary Hospital Record Review for Resident #13 dated 11/14/23 revealed: a. Treated in the emergency roiagnom on [DATE] with a high probability of imminent life deterioration due to acute respiratory failure. b. admitted to the Medical Intensive Care Unit (MICU). c. Hypoxia (lack of oxygen) d. Fever e. Acute aspiration pneumonia f. Rhinovirus with MRSA positive in both nares g. Acute kidney injury h. Leaking PEG feeding tube that required replacement. 2. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed the diagnosis Diabetes Mellitus, hypertension, renal insufficiency, aphasia (loss of ability to understand or express speech), altered mental status. Resident #6 required limited assistance for bed mobility, transfers, toileting, and for personal care. Resident #6 used a wheeled walker to ambulate and was frequently incontinent of urine. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 1 which suggested a severe cognitive impairment. The Care Plan dated 9/15/23, instructed the staff to ambulate Resident #6 with a wheeled walker, provide assistance with transfer, toileting, personal hygiene and dressing with the assistance of 1 staff member. Resident #6 was identified as a fall risk and staff was directed to check frequently and assist as needed. Progress notes 9/26/23 at 4 p.m. for Resident #6 revealed: a. Staff I, Licensed Practical Nurse (LPN) notified that Resident #6 fell . b. Assessment complete and Neuro checks were initiated. c. A 4 cm x 5 cm bruise and swelling noted to the right side of forehead. d. Resident #6 was confused at the time and Urinary tract infection (UTI) was suspected. e. Three staff assisted the resident in a wheelchair, to the nurses station for 1 on 1 supervision. f. Family was notified. g. Staff J, Advance Registered Nurse Practitioner (ARNP) was notified. h. A new order for one time dose of 12.5 mg Hydralazine due to blood pressure (BP) of 165/101 and obtain a urine sample. Neurological Evaluation form directed staff to complete post fall if resident hit head or unwitnessed fall: a. every 15 minutes for 1 hour b. every 30 minutes for hour c. every hour for 2 hours d. every 2 hours for 8 hours e. every 4 hours for 12 hours f. every shift for 72 hours. The Neurological Evaluation for Resident #6 revealed: a. Neurological assessments were initiated on 9/26/23 at 4 p.m. b. At 4:00 p.m. blood pressure (BP) 165/101,pulse (P) 92, Respiration (R) 18 (temperature was not assessed), LOC (level of Consciousness) 4+ (Lethargic, sleepy or drowsy), Pupils 4 and reactive to light (+), Hand grips refused, Lacked pain assessment. c. At 5:15 p.m. BP 129/95, P 98, R 18, LOC 4+ Lethargic, pupils 4+ Hand grasps AB (absent) d. Lack of documentation for the following assessment date and time: e. On 9/26/23 at 5:45, 6:45, 7:45, 9:45, and 11:45 p.m. f. On 9/27/23 at 1:45, 3:45, and 7:45 a.m. g. On 9/27/23 at 11:15 a.m. revealed: BP 154/48, P 116, R 16, LOC 3+ stuporous (not awake), lacked assessment of pupil size, responsiveness, hand grips and pain assessment. Progress note dated 9/27/23 at 11:10 a.m. for Resident #6 revealed: a. Staff M, RN asked by staff to assess Resident #6. b. Resident eyes closed, did not respond to name or touch. c. Vital Signs: temperature (T) 100.4, P 114, R 16, BP 158/48. d. Unable to arouse the resident. Progress note dated 9/27/23 at 11:25 a.m. for Resident #6 revealed that Staff M, RN notified the family who requested transport to the Emergency department for evaluation. The ambulance was notified. The Situation, Background, Assessment, and Recommendation (SBAR) dated 9/27/23 at 11:25 a.m., completed by Staff M, RN, the findings included: a. Unresponsiveness b. Condition, symptom, sign had not occurred before c. Pain: does the resident have pain? yes non-verbal occasional moan or groan, facial grimacing d. Testing none e. Interventions none f. Family was notified on 9/27/23 at 11:25 a.m. g. On 9/27/23 at 11:38 a.m. Staff J, ARNP notified. Progress note dated 9/27/23 at 11:55 a.m. revealed that Resident #6 was transported to the local hospital. During an interview on 12/18/23 at 3:29 p.m. Staff P, CNA stated Resident #6 was pleasantly confused on 9/26/23, which was her normal. Staff P stated she was in the hall when she heard a loud thunk and started searching rooms. Staff P stated she found Resident #6 face down in her room with a big goose egg on her forehead. Staff P stated she stayed with the resident while Staff O, CNA went to get Staff I, LPN. Staff P stated Resident #6's face was grimaced, she acted confused, moving to try to sit up and dazed, eyes not tracking and not responsive to her name. Staff P stated Staff O returned with Staff I who took vital signs then instructed the CNA's to get her up to the recliner. Staff P stated Resident #6 was not acting like herself, and the CNA's checked on her every 15 minutes, then Staff I instructed CNA's to place her in a wheelchair and take her to the nurses station. Staff P stated they were instructed to take Resident #6 to bed about 7 p.m. and she was normally a 1 person assist but at that time was a 2 person assist with a gait belt. During an interview on 12/18/23 at 3:47 p.m. Staff O, CNA stated on 9/26/23 about 4 p.m. she was caring for a resident and heard a loud thump. Staff O stated, I knew it was a body hitting the floor. Staff O stated she assisted Staff P, CNA and found Resident #6 on the floor, on her right side, 4-5 steps from her recliner with the walker at her feet. Staff O stated Resident #6 rolled over and had a bruise to her head and did not recognize her name. Staff O stated she went after Staff I, LPN who took Resident #6 vitals but she did not have a flashlight to assess neuro's, did not assess the residents arms or legs, and gave direction to Staff O and Staff P to get the resident up to the recliner. Staff O stated Resident #6 did not eat supper and was directed to put Resident #6 to bed at 7 p.m. by Staff K, RN who stated it was ok to put her to bed. Staff O stated she had been a CNA for 9 years and Resident #6 was not ok and she asked Staff I and Staff K if they were going to send her to the hospital. Staff O stated she and Staff P checked on her often to be sure she was still breathing due to Resident #6 did not arouse again after being put to bed. Staff O stated Staff K did not go into Resident #6 ' s room to assess her. During an interview on 12/18/23 at 1:09 p.m. Staff I, LPN stated she worked on 9/26/23, 6 a.m. to 6 p.m. and was notified by staff CNA ' s that Resident #6 had an unwitnessed fall in her room about 4 p.m. Staff I stated, She had a goose egg on her forehead. Staff I stated it took 3 staff to get Resident #6 off the floor. Staff I stated she had notified Staff J, ARNP and was told to monitor the resident. Staff I stated she initiated a neurological sheet with the date and times neuro checks were to be completed and it was given to the 6 p.m. to 6 a.m. staff nurse in report, Staff K, RN. Staff I stated Resident #6 was restless, could not sit still, and cried. During an interview on 12/18/23 at 1:20 p.m., Staff J, ARNP, stated she had received a call on 9/26/23, informed that Resident #6 fell , hit her head and the neurological test was normal. Staff J stated an order was given to monitor the resident and expected a call if there were changes or an inability to awaken the resident. Staff J stated she did not receive a follow up call, no one identified that Resident #6 was crying, restlessness that would suggest pain or confusion. Staff J stated, I would have sent her out if I felt she had further injuries or if in pain. Staff J stated she had provided training to nursing staff in the past to include tube feeding, neuro and dementia pain assessments. Staff J stated, There is a big gap in the knowledge of the nurses here. During an interview on 12/19/23 at 3:47 p.m. Staff A, CNA stated she worked on 6/27/23 at 6 a.m., rounded with the the night shift CNA's who reported that they did not hear Resident #6 get up to the bathroom during the night so they did not go in. Staff A stated Resident #6 looked like she was in discomfort and asked Staff K, RN what happened to her, and was told by Staff K that he had given Resident #6 pain medication. Staff A stated she proceeded to give Resident #6 a bed bath. Staff A stated Resident #6 moaned when turned. Staff A stated Resident #6 did not eat so she left her in bed, changed her once and then went to get Staff M, RN around 11 a.m. to make an assessment due to Resident #6 looked rough. During an interview on 12/18/23 at 3:01 p.m. Staff M, RN stated she had worked as the previous Director of Nursing (DON) in the facility and worked on 9/27/23 as the day nurse, 6 a.m. to 6 p.m. Staff M stated she had received report at 6 a.m. from Staff K, RN that Resident #6 had a fall but Staff K did not share the extent of the fall. Staff M stated she was caring for a very sick resident down a different hall all morning until Staff A, CNA came to find her around 11 a.m. and stated Resident #6 was not waking up. Staff M stated she found Resident #6 unresponsive and notified Staff J, ARNP and the resident's family then transferred the resident to the hospital. Staff M stated she found the neuro sheet under a stack of papers at the nurses station. Staff M stated she interviewed Staff K over the phone who stated he had not assessed Resident #6 as she was asleep. Staff M stated it was normal practice for staff to call and notify the DON if there was a fall and she did not receive any notification. During an interview on 12/19/23 at 8:52 a.m., Resident #6's son stated his mother was quarantined in her room behind a closed door due to COVID and had two falls, a week apart. The son stated the family was notified of both falls but felt this last fall on 9/26/23 was down played. The son stated he received a call on 9/27/23 asking if the family would want her evaluated at the local hospital due to a possible UTI. The son stated he went to the hospital, I could not believe it, I could not recognize her''. The son stated he spoke with his brother since this was more than a UTI and felt it was more than the local hospital could handle, therefore he had Resident #6 transferred to the tertiary hospital for higher level of care. The son stated he was not going to send his mother back to this facility, requested the hospital Hospice to assist with the location of a facility, then transferred mother to a different facility until she passed from her injuries 2 weeks later on 10/28/23. Tertiary Hospital Record Review for Resident #6 dated 9/27/23 revealed: a. Subdural Hematoma (blood between the brain and its outermost covering). b. Bruises to right head and right shoulder c. Acute Encephalopathy (brain disease that alters brain function causes infection, tumor, and stroke) d. Fracture of the right clavicle e. UTI (urinary tract infection) f. Unresponsive to sternal rub (chest bone) g. Tachycardic (fast heart rate) h. Febrile (high body temperature) i. Vital Signs Blood pressure 138/79, Pulse 113, Respirations 20, Temperature 100.6 j. admitted to the tertiary hospital During an interview on 12/19/23 at 8:59 AM Staff N, Medical Examiner Investigator stated the cause death for Resident #6 was a result of complications from blunt force trauma injuries to head and clavicle, date of death [DATE]. During an interview on 12/6/23 at 8:30 a.m. Staff S, DON stated her expectation of the nurse on admission was for the nurse to review the discharge orders, and after falls and change of condition, place the resident on the Hot Chart sheet and perform an assessment every shift until the DON instructs them to stop. The policy titled Neurological Evaluation dated 3/28/23 revealed: a. A neurological evaluation will be performed by a licensed nurse when a resident ' s status warrants suspected head injury, CVA (stroke) and/or unwitnessed fall to identify a change of condition related to a possible head injury. b. Concern over change in mental status c. A change in level of consciousness d. Inspect pupil reaction with flashlight, e. Observe if resident moves all extremities f. Observe if the resident obeys commands & pain g. Notify physician for pupil reaction changes, decrease level of consciousness, changes in vital signs and or change of condition 3. The MDS dated [DATE] for Resident #14 revealed a diagnosis of cerebral palsy, aphasia (inability to speak), dysphagia (difficulty swallowing), profound intellectual disabilities and a PEG tube feeding to receive nutrition and medications. The Care Plan dated 11/16/23 for Resident #14 instructed staff to observe closely for signs of pain, dehydration, no urine output, increased pulse, fever and observe and report signs of aspiration, abnormal lung sounds and abdominal distension. The care plan instructed to keep the head of the bed elevated due to the tube feeding and flush the peg tube with 200 ml (milliliters) of water every 6 hours and 30 ml of water before and after administering medications. Progress note dated 10/31/23 Resident #14's temperature (T) was 100.3 and the ARNP was aware, COVID testing was negative. Progress notes lacked nursing assessment dates 11/1/23 through 11/14/23. Progress note dated 11/14/23 at 9:40 p.m. Resident #14 was having gurgling sounds, T 99.9 heart rate 126 respirations 26 and Oxygen saturation 70%, resident was vomiting, abdomen distended. Lacked documentation of notification to ARNP and POA (power of attorney) at that time. Progress note dated 11/15/23 at 12:10 a.m. Staff J, ARNP notified of Resident #14's condition, notified POA who requested transfer to the hospital, Emergency Medical Services (EMS) notified. Tertiary Hospital Record Review for Resident #14 dated 11/15/23 revealed: a. Severe sepsis (body's extreme response to an infection) with septic shock (life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). b. Blood pressure 69/43 c. Lab [NAME] Blood Count (WBC) 24.9 (normal 3.7-10.5) 4. The MDS dated [DATE] for Resident #10 revealed a diagnosis of Alzheimer's disease, cognitive communication deficit, dysphagia and required assistance of one person for toileting. Progress notes for Resident #10 revealed a lack of bowel assessment and intervention for November and December 2023. Physician Orders for Resident #10 revealed Milk of Magnesia Suspension give 30 cc by mouth every 24 hours As Needed (PRN) for constipation. Elimination Flow sheet December 2023 for Resident #10 revealed: a. No documentation for Bowel Movement (BM) on day shift dated 1st, 2nd, 3rd, and 4th, 2023 b. Documentation for BM evening shifts dates 1st zero, 2nd small, 3rd no documentation, 4th zero c. Documentation for BM night shift dates 1st, 3rd, and 4th no documentation. 2nd zero BM. Medication Administration Record (MAR) for Resident #10 revealed: a. December 1-4, 2023 Milk of Magnesia Suspension give 30 cc by mouth every 24 hours PRN constipation per bowel protocol was not administered. b. November 2023 Milk of Magnesia Suspension give 30 cc by mouth every 24 hours PRN constipation per bowel protocol was not administered. Document titled Nursing Hot Sheet BM's for South Hall for Resident #10 revealed: a. Date 11/14/23 last BM on 11/10/23, no PRN given and no assessment of results. b. Date 11/27/23 last BM on 11/10/23, no PRN given, no assessment of results. c. Date 12/5/23 last BM on 12/2/23, no PRN given, no assessment of results. 5. The MDS dated [DATE] for Resident #8 revealed a diagnosis of dementia, heart disease, legally blind and required the assistance of 1 for toileting. Progress notes for Resident #8 revealed a lack of bowel assessment and intervention for November and December 2023. Elimination Flow Sheet dated December 2023 for Resident #8 revealed: a. No documentation of BM's on day shift 1-4th, 2023 b. Evening shift 1st zero, 2nd small, 3rd no documentation, 4th zero BM c. Night shift no documentation on 1st, 3rd and 4th. On the 2nd zero. Document titled Nursing Hot Sheet BM's for South Hall for Resident #8 revealed: a. Date 12/4/23 last BM 12/2/23 no PRN given and no assessment completed. b. Date 11/27/23 last BM 11/22/23 no PRN given and no assessment completed. Medication Administration Record (MAR) for Resident #8 revealed: a. December 2023 Senna Plus tablet 8.6-5.0 milligram (mg), give 1 tablet by mouth one time a day for bowel management was not given on 12/2/23. b. December 2023 no order for a PRN medication to treat constipation. c. November 2023 no order for a PRN medication to treat constipation. 35434 2. The Minimum Data Set(MDS) assessment tool, dated 10/25/23, listed diagnoses for Resident #1 which included schizophrenia, major depressive disorder, and dementia. The MDS stated the resident was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and chair to bed transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. A 10/31/23 Nurses Note stated the resident transferred to the hospital yesterday(10/30/23). A hospital Discharge Summary, dated 11/3/23, stated the resident's principal diagnosis was sepsis(an infection throughout the body) due to a urinary tract infection. An 11/3/23 2:50 p.m. Admission Note stated the resident arrived at the facility via ambulance. An 11/3/23 4:00 p.m. Nurses Note stated the resident had an order for doxycycline(an antibiotic) 100 milligrams(mg) due to urinary tract infection(UTI). An 11/6/23 Nurses Note, written by Staff H Advanced Registered Nurse Practitioner(ARNP) stated the resident recently returned from the hospital with a diagnosis of sepsis secondary to UTI. The Temperature Summary listed an 11/21/23 4:31 a.m. temperature of 103.6 degrees Fahrenheit. An 11/21/23 5:30 a.m. Activities Note stated the resident's daughter agreed to transfer the resident to the hospital for evaluation and treatment and the resident transferred to the ER at 5:30 a.m. The note did not include the reason for the transfer. An 11/21/23 Skilled Nursing Facility(SNF)/Nursing Facility(NF) to Hospital Transfer Form stated the resident transferred to due to a high temp of 103.6 degrees Fahrenheit. An 11/21/23 ED to Hosp-Admission Note stated the resident arrived this morning due to increasing agitation and decreased alertness overnight. Staff at the facility stated she became more sleepy and had not been to meals since the evening of 11/19/23. Staff stated last night she felt warm and had a temperature of 104 degrees Fahrenheit. The facility lacked documentation of a change in condition and assessments and intervention prior to 11/21/23. The facility lacked documentation of assessments carried out from 11/19/23-11/21/23. The resident's Temperature Summary lacked a temperature from 11/15/23-11/21/23. The resident's Care Plan as of 11/21/23 did not address the resident's history of urinary tract infection or sepsis. During an interview on 1/3/23 at 9:00 a.m., the Administrator stated the facility did not have a general assessment and intervention policy. On 12/21/23 at 2:54 p.m. the Assistant Director of Nursing(ADON) was queried about her expectations if a resident did not go to meals and was lethargic. She stated she would expect staff to carry out an assessment, complete vital sights and complete a full head to toe assessment. She stated staff should notify the provider and the family.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to implement their infection control policy to ensure MRSA (a contagious staph bacteria infection) was contained. Hospital record review revealed Resident #13 was hospitalized for hypoxia, aspiration pneumonia and was found to be positive for MRSA in the nares (nose). Due to the nursing staff that readmitted Resident #13 not reviewing the hospital discharge records, lab results were not reported and the facility did not provide personal protective equipment for staff use for 10 days. The facility also failed to follow infection control practices during a meal service for Resident #19 & #20. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 27, 2023 on December 7, 2023 at 12:25 p.m. The facility staff removed the Immediate Jeopardy on December 7, 2023 by implementing the following actions: 1. DON Completed In-Service with (w)/Licensed Staff on Enhanced Barrier Precautions Policy on 12/7/23. 2. DON Completed In-Service w/All Staff on Enhanced Barrier Precautions Policy on 12/7/23. 3. DON Completed 100% Audit on Residents to Ensure Enhanced Barrier Policy is being followed on 12/7/23. 4. DON/Designee will Orientate New Hires/Agency Employees on Enhanced Barrier Policy on 12/7/23. The facility reported a census of 50 residents. Findings Include: 1. The MDS dated [DATE] for Resident #13 revealed a diagnosis of chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease (GERD), complete loss of teeth due to periodontal disease and tracheostomy with dependence on supplemental oxygen. Resident #13 had a BIMS of 15 which suggested an intact cognition. During an observation on 12/4/23 at 10:43 a.m. Resident #13 was in bed, in his room, unable to speak due to congestion, harsh, productive cough with thick phlegm, and had oxygen tubing that should have been in his nose, located under his chin. During an observation on 12/4/23 at 12:20 p.m. Resident #13 was in the dining room at a table with 3 lady residents, his head on the table, coughing and did not eat the food offered. During an observation on 12/4/23 at 3:15 p.m. Resident #13 was in bed. Staff T, Registered Nurse (RN) was sitting on his bed, next to Resident #13, with a torn glove on the left hand, and provided a dressing change to his neck. Document provided by the tertiary hospital consult notes dated 11/14/23 from the infectious disease practioner revealed the present illness for Resident #13 was pneumonia from pseudomonas and positive for MRSA in nares. Progress note dated 11/27/23 at 3:21 p.m. revealed Resident #13 returned from the hospital at 2 p.m. following hospitalization for pneumonia, oxygen at 3 liters, and complaints of sore throat. Progress note dated 11/28/23 at 2:31 p.m. revealed Resident #13 had been out of room for meals, poor intake, and oxygen lowered from 6 liters to 3 liters. During an interview on 12/12/23 at 1:32 PM, Staff T, Registered Nurse, (RN) stated that she didn't want to work at this facility due to lack of staffing and lack of support during admits. Staff T stated, I feel there are too many residents for one nurse and I don't want to get caught in a situation where I'll be missing information on a resident. During an interview on 12/6/23 at 8:30 a.m., Staff S, Director of Nursing (DON) stated she was unable to locate Resident #13's recent hospital and discharge documents, but the expectation of the nursing staff completing admission was to review the discharge documents, place the resident on the Hot Chart sheet and document an assessment every shift until directed to stop by the DON. Staff S, reported she had worked at this facility as an agency nurse for 5 weeks, and as director for a week. Staff S stated she was unaware that Resident #13 had MRSA. During an interview on 12/7/23 at 1:33 PM, Staff J Advanced Registered Nurse Practitioner (ARNP) stated when Resident #13 returned from the hospital on 11/27/23, she had asked the Director of Nursing for the discharge orders, requested to have them posted on the PointClickCare computer system for review, and it was not posted until 12/6/23. Staff J stated she was not aware of the MRSA until she was informed on 12/6/23 in the afternoon. Policy titled Surveillance for Healthcare Associated Infections dated 10/7/21 revealed the procedure was to obtain a physician's diagnosis of infection or identify conditions that meet McGreer's Criteria & Centers for Disease Control (CDC) Guidelines for surveillance in long term care settings and to review laboratory reports for cultures with pathogens. Policy titled Contact Isolation Precautions dated 10/25/22 revealed that the facility will implement contact isolation precautions on residents as appropriate to reduce risk of transmitting infectious agents such as Multi-Drug Resistant Organisms (MDRO's) to include personal protective equipment (PPE) for staff. Policy titled Enhanced Barrier Precautions dated 2/28/22 revealed that the facility may expand the use of PPE during high contact resident care activities that provide opportunities for transfer of MDRO's to hands/clothing for facility residents with wound or indwelling medical devices regardless of the MDRO colonization as well as for residents with MDRO infection/colonization. The CDC webpage https://www.cdc.gov/mrsa/healthcare//index.html published 7/31/23 contained the following information regarding MRSA in a healthcare setting: a. MRSA is usually spread by direct contact. b. The only way to know if MRSA is the cause of an infection is to perform a culture (a laboratory test) of the bacteria. c. Successful MRSA prevention requires action both at the healthcare facility level, among healthcare providers and healthcare leadership. d. Based on the current evidence, CDC continues to recommend the use of Contact Precautions for MRSA-colonized or infected patients. 35434 2. During an observation on 12/6/23 at 9:10 a.m., Staff A Certified Nursing Assistant (CNA) ate a donut with her bare hands while she stood in front of the kitchen serving window. Without washing her hands, she picked up some clean napkins and handed them to Resident #19. Staff A then sat down next to Resident #20 and picked up one of her cups to assist her. Staff A then picked up a soiled napkin which was on the table next to another resident's empty plate and used it to wipe the table off in front of Resident #20's plate. When she did this, the soiled napkin touched Resident #20's plate. Staff A did not wash her hands during this interaction and then continued to assist Resident #20 to eat. On 12/6/23 at 3:37 p.m., Staff S Director of Nursing (DON) stated staff should not eat in the dining room and when notified of the above events related to Staff A, she stated this should not have happened and was not appropriate. On 1/3/23 at 10:55 a.m., the Administrator stated the facility did not have a policy related to infection control practices in the dining room.

Based on clinical record review, family and staff interviews, and policy review, the facility failed to provide appropriate pain management for 1 out of 5 residents reviewed (Resident #6). Clinical record review revealed on 9/26/23 at 4:00 p.m., Resident #6 fell and sustained a hematoma to her head. The facility staff failed to conduct a dementia pain assessment for 16 hours, or treat the resident's pain. The facility sent the resident to the emergency room (ER) where the resident was assessed to have a subdural hematoma (brain bleed), fracture of the right clavicle, and a urinary tract infection. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of September 26, 2023 on December 19, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on December 19, 2023 by implementing the following actions: 1) DON/Designee completed Inservice with licensed staff 12/19/2023 on A) Change in Condition B) Pain Management C) Interventions for Pain Management and Pain Relief. D) Physician notification of new pain 2) DON and or designee completed 100% audit on residents with any symptoms of pain A) Completed Pain interview B) Interventions were administered C) Dr/NP were notified as needed 3) DON/Designee will educate new hires on: A) Change in Condition B) Pain Management C) Interventions for Pain Management D) Physician Notification of new pain. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 50 residents. Findings Include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed the diagnosis Diabetes Mellitus, hypertension, renal insufficiency, aphasia (loss of ability to understand or express speech), altered mental status. Resident #6 required limited assistance for bed mobility, transfers, toileting, and for personal care. Resident #6 used a wheeled walker to ambulate and was frequently incontinent of urine. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 1 which suggested a severe cognitive impairment. The Care Plan dated 9/15/23, instructed the staff to ambulate Resident #6 with a wheeled walker, provide assistance with transfer, toileting, personal hygiene and dressing with the assistance of 1 staff member. Resident #6 was identified as a fall risk and staff was directed to check frequently and assist as needed. Progress notes 9/26/23 at 4 p.m. for Resident #6 revealed: a. Staff I, Licensed Practical Nurse (LPN) notified that Resident #6 fell . b. Assessment complete and Neuro checks were initiated. c. A 4 cm x 5 cm bruise and swelling noted to the right side of forehead. d. Resident #6 was confused at the time and Urinary tract infection (UTI) was suspected. e. Three staff assisted the resident in a wheelchair, to the nurse's station for 1 on 1 supervision. f. Family was notified. g. Staff J, Advance Registered Nurse Practitioner (ARNP) was notified. h. A new order for one time dose of 12.5 mg Hydralazine due to blood pressure (BP) of 165/101 and obtain a urine sample. The Medication Administration Record (MAR) for Resident #6 dated September 2023 revealed: a. Tylenol 650 mg administered on 9/26/23 at 5 p.m. lacked documentation of pain assessment. b. Tylenol 650 mg, to be given 2 times a day, lacked documentation on dates 9/1, 19, 20, 12, 22 26, 27 at 8 a.m. and 9/3/23 at 5 p.m. c. Acetaminophen 650 mg every 4 hours as needed for mild pain not administered in September. d. Pain level assessment lacked documentation on 9/1, 2, 3, 19, 20, 21, 22, 26, and 9/27/23. The Neurological Evaluation for Resident #6 documented: a. Neurological assessments were initiated on 9/26/23 at 4 p.m. b. At 4:00 p.m. blood pressure (BP) 165/101, pulse (P) 92, Respiration (R) 18 (temperature was not assessed), LOC (level of Consciousness) 4+ (Lethargic, sleepy or drowsy), Pupils 4 and reactive to light (+), Hand grips refused, Lacked pain assessment. c. At 5:15 p.m. BP 129/95, P 98, R 18, LOC 4+ Lethargic, pupils 4+ Hand grasps AB (absent) d. Lack of documentation for the following assessment date and time: 1. On 9/26/23 at 5:45, 6:45, 7:45, 9:45, and 11:45 p.m. 2. On 9/27/23 at 1:45, 3:45, and 7:45 a.m. e. 9/27/23 at 11:15 a.m. revealed: BP 154/48, P 116, R 16, LOC 3+ stuporous (not awake), lacked assessment of pupil size, responsiveness, hand grips and pain assessment. Progress note dated 9/27/23 at 11:10 a.m. for Resident #6 revealed: a. Staff M, RN asked by staff to assess Resident #6. b. Resident eyes closed, did not respond to name or touch. c. Vital Signs: temperature (T) 100.4, P 114, R 16, BP 158/48. d. Unable to arouse the resident. Progress note dated 9/27/23 at 11:25 a.m. for Resident #6 revealed that Staff M, RN notified the family who requested transport to the Emergency department for evaluation and the ambulance was notified. The Situation, Background, Assessment, and Recommendation (SBAR) dated 9/27/23 at 11:25 a.m., completed by Staff M, RN, the findings included: a. Unresponsiveness b. Condition, symptom, sign had not occurred before c. Pain: does the resident have pain? yes, non-verbal, occasional moan or groan, facial grimacing d. testing none e. Interventions none f. Family was notified on 9/27/23 at 11:25 a.m. g. On 9/27/23 at 11:38 a.m. Staff J, ARNP notified. Progress note dated 9/27/23 at 11:55 a.m. revealed that Resident #6 was transported to the local hospital. During an interview on 12/18/23 at 3:29 p.m. Staff P, CNA stated Resident #6 was pleasantly confused on 9/26/23, which was her normal. Staff P stated she was in the hall when she heard a loud thunk and started searching rooms. Staff P stated she found Resident #6 face down in her room with a big goose egg on her forehead. Staff P stated she stayed with the resident while Staff O, CNA went to get Staff I, LPN. Staff P stated Resident #6's face was grimaced, she acted confused, moving to try to sit up and dazed, eyes not tracking and not responsive to her name. Staff P stated Staff O returned with Staff I who took vital signs then instructed the CNA's to get her up to the recliner. Staff P stated Resident #6 was not acting like herself, and the CNA's checked on her every 15 minutes, then Staff I instructed CNA's to place her in a wheelchair and take her to the nurse's station. Staff P stated they were instructed to take Resident #6 to bed about 7 p.m. and she was normally a 1 person assist but at that time was a 2 person assist with a gait belt. During an interview on 12/18/23 at 3:47 p.m. Staff O, CNA stated on 9/26/23 about 4 p.m. she was caring for a resident and heard a loud thump. Staff O stated, I knew it was a body hitting the floor. Staff O stated she assisted Staff P, CNA and found Resident #6 on the floor, on her right side, 4-5 steps from her recliner with the walker at her feet. Staff O stated Resident #6 rolled over and had a bruise to her head and did not recognize her name. Staff O stated she went after Staff I, LPN who took Resident #6 vitals but she did not have a flashlight to assess neuro's, did not assess the resident's arms or legs, and gave direction to Staff O and Staff P to get the resident up to the recliner. Staff O stated she assisted Staff P to clean Resident #6 as she was incontinent, then placed her in a wheelchair to assist her to the nurse's station. Staff O stated Resident #6 did not eat supper and was directed to put Resident #6 to bed at 7 p.m. by Staff K, RN who stated it was ok to put her to bed. Staff O stated she had been a CNA for 9 years and Resident #6 was not ok and she asked Staff I and Staff K if they were going to send her to the hospital. Staff O stated she and Staff P checked on her often to be sure she was still breathing due to Resident #6 did not arouse again after being put to bed. Staff O stated Staff K did not go into Resident #6's room to assess her. During an interview on 12/18/23 at 1:09 p.m. Staff I, LPN stated she worked on 9/26/23, 6 a.m. to 6 p.m. and was notified by staff CNA's that Resident #6 had an unwitnessed fall in her room about 4 p.m. Staff I stated, She had a goose egg on her forehead. Staff I stated it took 3 staff to get Resident #6 off the floor. Staff I stated she had notified Staff J, ARNP and was told to monitor the resident. Staff I stated she initiated a neurological sheet with the date and times neuro checks were to be completed and it was given to the 6 p.m. to 6 a.m. staff nurse in report, Staff K, RN. Staff I stated Resident #6 was restless, could not sit still, and cried. During an interview on 2/18/23 at 2:59 p.m., Staff D, CNA stated she worked the evening shift on 9/26/23. Staff D stated Resident #6 was in a wheelchair at the nurse's station with a nasty bruise on her forehead and Resident #6 said it hurt when touched. During an interview on 12/19/23 at 3:47 p.m. Staff A, CNA stated she worked on 6/27/23 at 6 a.m., rounded with the night shift CNA's who reported that they did not hear Resident #6 get up to the bathroom during the night so they did not go in. Staff A stated Resident #6 looked like she was in discomfort and asked Staff K, RN what happened to her, and was told by Staff K that he had given Resident #6 pain medication. Staff A stated she proceeded to give Resident #6 a bed bath. Staff A stated Resident #6 moaned when turned. Staff A stated Resident #6 did not eat so she left her in bed, changed her once and then went to get Staff M, RN around 11 a.m. to make an assessment due to Resident #6 looked rough. During an interview on 12/18/23 at 3:01 p.m. Staff M, RN stated she had worked as the previous Director of Nursing (DON) in the facility and worked on 9/27/23 as the day nurse, 6 a.m. to 6 p.m. Staff M stated she had received report at 6 a.m. from Staff K, RN that Resident #6 had a fall but Staff K did not share the extent of the fall. Staff M stated she was caring for a very sick resident down a different hall all morning until Staff A, CNA came to find her around 11 a.m. and stated Resident #6 was not waking up. Staff M stated she found Resident #6 unresponsive and notified Staff J, ARNP and the resident's family then transferred the resident to the hospital. Staff M stated she found the neuro sheet under a stack of papers at the nurse's station. Staff M stated she interviewed Staff K over the phone who stated he had not assessed Resident #6 during the night as she was asleep. Staff M stated it was normal practice for staff to call and notify the DON if there was a fall and there was no notification given to her. During an interview on 12/19/23 at 8:52 a.m., Resident #6's son stated his mother was quarantined in her room behind a closed door due to COVID and had two falls, a week apart. The son stated the family was notified of both falls but felt this last fall on 9/26/23 was down played. The son stated he received a call on 9/27/23 asking if the family would want her evaluated at the local hospital due to a possible UTI. The son stated he went to the hospital, I could not believe it, I could not recognize her ''. The son stated he spoke with his brother since this was more than a UTI and felt it was more than the local hospital could handle, therefore had Resident #6 transferred to the tertiary hospital for higher level of care. The son stated he was not going to send his mother back to this facility, requested the hospital Hospice to assist with the location of a facility, then transferred mother to a different facility until she passed from her injuries 2 weeks later on 10/28/23. Tertiary Hospital Record Review for Resident #6 dated 9/27/23 revealed: a. Subdural Hematoma (blood between the brain and its outermost covering). b. Bruises to right head and right shoulder c. Acute Encephalopathy (brain disease that alters brain function causes infection, tumor, and stroke) d. Fracture of the right clavicle e. UTI (urinary tract infection) f. Unresponsive to sternal rub g. Tachycardia (fast heart rate) h. Febrile (high body temperature) i. Vital Signs Blood pressure 138/79, Pulse 113, Respirations 20, Temperature 100.6 j. admitted to the tertiary hospital During an interview on 12/19/23 at 8:59 AM Staff N, Medical Examiner Investigator stated the cause death for Resident #6 was a result of complications from blunt force trauma injuries to head and clavicle, date of death [DATE]. During an interview on 12/18/23 at 1:20 p.m., Staff J, ARNP, stated she had received a call on 9/26/23, informed that Resident #6 fell , hit her head and the neurological test was normal. Staff J stated an order was given to monitor the resident and expected a call if there were changes or an inability to awaken the resident. Staff J stated she did not receive a follow up call, no one identified that Resident #6 was crying, restlessness that would suggest pain or confusion. Staff J stated, I would have sent her out if I felt she had further injuries or if in pain. Policy titled Pain Management dated 11/15/22 revealed: a. Recognize when Resident is experiencing pain and identify circumstances when pain can be anticipated. b. Observe for nonverbal indicators, change in gait, increased pulse or blood pressure, decline in activity of daily living (ADL), increased restlessness, facial expressions (grimacing), behavioral changes, difficulty eating, and negative vocalizations (groaning or crying). c. Verbal descriptors d. Nursing will complete a Pain Evaluation Tool, appropriate for the resident's cognitive status. e. Nursing will reassess resident's pain management for effectiveness. f. Nursing will notify the practitioner if the resident's pain is not controlled by the current treatment regimen.

Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to carry out treatments and assessments to prevent the worsening of a pressure ulcer for 2 of 3 residents reviewed for pressure ulcers (Residents #1 and #9). Resident #1 had a wound to the left buttock and during the period of 11/3/23 until 11/21/23 the facility failed to complete regular assessments, treatments, and preventative interventions in order to promote healing of the area. The resident was also at risk for heel breakdown and the facility failed to document measures to prevent heel breakdown. Resident #9 had a history of a pressure ulcer to the buttock. The facility failed to document the completion of ordered treatments. Resident #9's ulcer reopened. The facility reported a census of 50 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Quarterly MDS assessment tool, dated 10/25/23, listed diagnoses for Resident #1 which included schizophrenia, major depressive disorder, and dementia. The MDS stated the resident was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and chair to bed transfers. The MDS stated the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. The facility policy Wound Management reviewed 11/14/22, directed staff to complete wound treatments in accordance with physician orders and document location, size, and characteristics of the wound. A 4/21/23 Care Plan entry stated the resident had the potential for impairment to the skin integrity of the perineal area related to fragile skin and incontinence. The Care Plan did not address the resident's actual skin impairment to the left buttocks or interventions to treat the area. The Care Plan did not address the resident's risk of pressure injury to the heels and lacked interventions such as boots or floating heels to prevent breakdown to the area. A 10/31/23 2:36 p.m. Nurses Note documented the resident transferred to the hospital on 10/30/23. A 10/30/23 hospital Wound Care note stated the resident had a wound on the left buttock of undetermined etiology (origin) with serosanguinous (watery,bloody) drainage. The note directed staff to cover the area with Mepilex AG (a type of dressing) dressing every 5-7 days and change if saturated sooner. The note directed staff to provide pressure redistribution and suspend heels off the surface with pillows and apply Mepilex (a type of protective dressing) border dressing to bony prominence's. A 10/30/23 hospital photograph of the resident's left buttock revealed an open wound with a red wound bed. An 11/2/23 hospital Pressure Ulcer/Injury Prevention note stated the resident had a Mepilex dressing to the right heel. An 11/3/23 2:50 p.m. Admission Note stated the resident returned to the facility via ambulance. An 11/3/23 admission Skin Observation Tool stated the resident had moisture associated skin damage (MASD) to the left buttock which measured 0.7 centimeters (cm) x 2.2 cm x 0.1 cm (length x width x depth). The document did not state the resident had skin impairment on the heel. An 11/15/23 Skin Observation Tool stated the resident had MASD to the left buttock which measured 0.7 x 2.2 x 0.1. The document did not state the resident had skin impairment on the heel. The facility lacked further skin assessments during the period of 11/3/23-11/15/23. The November Treatment Administration Record (TAR) listed an order for the gluteal fold to cleanse the area with wound wash and pat dry, apply calcium alginate (a wound treatment) to the wound bed and secure with border foam or Mepilex, change daily and prn(as needed). The following days were blank and lacked staff initials to indicate the completion of the treatment: 11/4/23, 11/5/23, 11/6/23, 11/8/23, 11/9/23, 11/12/23, 11/13/23, 11/14/23, and 11/20/23. An 11/21/23 Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form stated the resident transferred to due to a high temp of 103.6 degrees Fahrenheit. A hospital photograph, dated 11/21, displayed the resident's right heel with a border bandage applied with the date 10/30/23. An 11/21/23 hospital photograph of the right heel revealed the right medial heel had 2 areas of dark purple redness. An 11/21/22 hospital Wound Care Properties note stated the resident had a pressure injury to the right heel. A 3/15/23 Nutrition Note stated the resident's Stage 4 pressure ulcer on her left ischium (back portion of the pelvis) was improving. An 11/22/23 hospital Wound Care Note state the resident had a Stage 3 Pressure Ulcer to the left buttock. On 12/7/23 at 11:32 a.m. via phone, Staff HH stated when the resident arrived at the hospital on 11/21/23, she had a dressing to her heel which was dated 10/30/23. 2. The 9/8/23 Quarterly MDS assessment tool listed diagnoses for Resident #9 which included morbid obesity, anxiety, and depression. The MDS stated the resident required limited assistance of 1 staff member for bed mobility, transfers, walking, personal hygiene, and dressing, and extensive assistance of 1 staff for toileting and bathing. The MDS stated the resident was frequently incontinent of urine and occasionally incontinent of bowel and was at risk for developing pressure ulcers but had no unhealed pressure injuries. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. A 12/21/22 Care Plan entry directed staff to educate the resident regarding skin integrity, the risks, and how to take care of her wounds. The Care Plan lacked further interventions to treat and prevent the development of pressure ulcers. A 12/14/22 Nurses Note stated the resident had a Stage 4 pressure ulcer of the left buttock A 1/24/23 Care Plan entry stated the resident had a Stage 4 pressure ulcer to the left ischium (referring to the lower pelvic bone). An 11/20/23 Nurses Note, written by Staff J Advanced Registered Nursing Practitioner (ARNP)stated the resident reported soreness in the same site of a Stage 4 pressure ulcer which was healed for several months. The area appeared reddened and irritated and was most likely moisture associated dermatitis. The note directed staff to apply barrier cream to the affected areas twice per day as needed. The note stated the resident educated on the importance of reducing pressure applied to the area by not sitting up all day and lying on her side. An 11/28/23 Skin Observation Tool stated the area on the buttock reopened and had a treatment of Vaseline. The tool contained no further measurements or assessments. A 12/3/23 Skin Observation Tool stated the buttock area continued to be open. The tool contained no further measurements or assessments. A 12/3/23 eINTERACT SBAR Summary for Providers stated the resident had a change in condition related to a skin wound or ulcer. The document contained no further information or measurements regarding the wound. The November and December 2023 TARs listed an order for Vaseline Gel and directed staff to apply to the left ishium wound two times per day for pressure wound. The following entries were blank and lacked initials to indicate staff completed the treatment for both the morning and evening applications: 11/3/23, 11/5/23, 11/12/23, 11/21/23, 12/1/23, 12/6/23, 12/7/23, 12/8/23, 12/9/23, 12/11/23, 12/12/23, 12/14/23, 12/15/23 The following entries were blank and lacked initials to indicate staff completed the treatment for the evening application: 11/4/23, 11/8/23, 11/9/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/24/23, 11/28/23, 11/29/23, 11/30/23, 12/2, 12/4, 12/5, 12/10 The facility lacked further detailed assessments of the wound during the time period of 11/20/23-12/18/23 including wound measurements and characteristics of the wound. A 12/19/23 Skin Observation Tool stated the resident had a Stage 3 pressure ulcer to the left buttocks which measured 7 cm x 2 cm x 0.5 cm. On 12/19/23 at 1:40 p.m., Resident #9 stated staff missed completing her treatments at times and she missed it this morning as well. She stated this happened when temporary staff worked. On 12/20/23 at 10:20 a.m. Staff GG Licensed Practical Nurse (LPN) measured a left buttock wound as 4 cm x 2 cm. The wound bed was red and glossy looking. The resident stated she did not want poked to measure depth. On 12/7/23 at 1:25 p.m., Staff J stated she expected nurses to carry out wound treatments and assess wounds daily. On 12/7/23 at 2:15 p.m., Staff H Registered Nurse (RN), Minimum Data Set (MDS) Coordinator stated she measured Resident #1's buttock wound a couple times and she was supposed to split the assessments with the former ADON. She stated she was sure that some were missed. On 12/19/23 at 9:08 a.m., Staff V Assistant Director of Nursing (ADON) stated Resident #9 had an area on her bottom which closed but recently reopened again. On 12/21/23 at 2:54 p.m. Staff V stated staff should assess wounds when they completed a treatment or provided shower assistance and as ADON, she would complete weekly skin assessments. She stated staff should carry out treatments as ordered and she heard of treatments not completed. She stated from her point of view as a staff nurse, there was so much to complete and she attributed the missing treatments to this. She stated there was only 1 nurse to perform all the nursing duties and this was not enough. She stated recently they were approved for the facility to be staffed with 2 nurses. She stated having agency staff was also an issue as they did not arrive for their shifts. She stated the facility was trying to get more of their own staff in the facility.

Based on observation, staff interview, and facility policy the facility failed to provide adequate supervision for one of five residents that the facility staff identified as cognitively impaired but independently mobile. (Resident#13), which resulted in immediate jeopardy to resident health and safety. The resident that eloped from the facility had combative and wandering behaviors. The facility failed to execute the missing person's policy in a timely manner, and failed to ensure door alarms had been in working order. The resident had eloped from the facility, and had not been found for 2 hours and 45 minutes. The resident census had been 33 at the time of the incident. Findings Include: The Quarterly Minimum Data Set (MDS) Resident assessment dated [DATE] documented Resident#13 had severely impaired cognitive skills for daily decision-making. The MDS documented the resident had wandering behaviors four to six days per week. The resident had been independent with walking in his room, but required limited assistance when out of his room, and the resident did not require an assisted walking device. The resident had required assistance of one staff member for toilet use, and personal hygiene. The resident had [DIAGNOSES REDACTED]. The Resident's Care Plan with focus area initiated date of 9/28/20 documented as follows; the resident is at risk of elopement as evidence by; cognitive impairment, expresses desire to leave the facility, history of wandering, impaired safety awareness, new admission, and unfamiliar with surroundings. The Care Plan documented an intervention on 1/18/21 as follows; elopement intervention - alarm on west door to be checked twice a day, new alarm installed and placed where nurses could hear. The Care Plan documented a revision date of 12/11/20 with the following interventions; Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Identify the resident's pattern of elopement: is exit seeking purposeful, aimless, or escapist? Is the resident looking for someone or something? If the resident exits the building, do not leave unattended, walk with the resident and/or keep within eyesight. Monitor the residents location closely. Document elopement behavior and attempted diversional interventions in the progress notes, and behavior log. Motion sensor alarm on doorway of the resident's room to alert staff if he leaves his room at night. Provide structured activities for the resident such as, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The Care Plan documented the intervention without a date as follows; Notify supervisor, director of nursing, and administrator immediately of any successful exits from the building, and follow the facility elopement protocol. The Resident's Care Plan documented a focus area on 9/24/20 as follows; the resident had potential to be physically aggressive related to dementia, and history of harm to others, and poor impulse control. The Resident's Care Plan documented a focus area on 10/8/20 as follows; the resident had been prescribed [MEDICAL CONDITION] medication, due to continued outbursts and physical aggression. The Elopement-Wandering Risk Scale dated 9/2/20 and 11/9/20 documented a score of 14. The score according to the tool documented a resident with the score of 11 or above had a high risk to wander. The indicators included the resident had been ambulatory, could not communicate, had a history of [REDACTED]. During an interview on 1/25/21 at 1:45 p.m., the Director of Nursing reported the resident had changed the sound on the alarm. During an observation on 1/25/21 at 1:01 p.m., the resident stood very close to the nurse at the medication cart while the nurse had been setting up medications. During an observation on 1/25/21 at 1:45 p.m., the motion alarm sounded in Resident#13's bedroom, three people responded promptly, the resident stood at the entrance of his bedroom without signs of distress. During an observation on 1/26/21 at 9:00 a.m., the resident stood in the main dining area, and wandered around the tables getting close to other residents. During an observation on 1/27/21 at 1:33 p.m., the resident stood in the main dining room supervised by staff, the resident had non-skid socks on. During an observation on 1/27/21 at 4:00 p.m., a staff member provided the resident with one on one by walking alongside the resident down the hallway. During an observation on 1/28/21 at 11:00 a.m., the resident rested on the couch by the front door supervised by staff. During an observation on 1/28/21 at 2:00 p.m., the resident had been by the front door a staff redirected the resident. The Nurses Note dated 9/3/20 at 4:18 a.m. documented the resident wandered in and out of the isolation hall up to the nurse's station, and had been redirected back to his room by staff multiple times to no avail. The resident had gone into another resident's rooms, and had been redirected. The night shift spent one on one time with him to help with his anxiety and restlessness. The resident had slept since about 2:35 a.m The Nurses Note dated 9/3/20 at 10:44 a.m. documented the resident wandered frequently and required redirection. The Nurses Note dated 9/5/20 at 10:33 p.m. documented the resident had opened and walked over to the west door, a Certified Nurses Aide secured the resident, and returned him to his room. The charge nurse had been advised of the incident. The Nurses Note dated 9/24/20 at 9:02 p.m. documented the resident had been wandering in the facility without incident until approximately 8:30 p.m. Staff had attempted to redirect the resident from handling a pitcher of water in the nurses station, in response the resident hit the Certified Nurses Aide in the stomach, and then again in the back. The nurse redirected the resident out of the nurses station at that time. The resident then went down the west hall and stopped at the activity office door, and proceeded to break the lock and enter. The staff attempts of redirection only escalated the resident's aggressive behavior. The nurse walked with the resident towards his room to assist him to bed, halfway down the south hall the resident turned around to go back to the common area/nurses station. When the nurse asked the resident if he had been tired, the resident drew back his fist. In response, the nurse asked if the resident would hit her, and the resident stated, I wouldn't put it past me! The resident behavior continued to be unpredictable. The resident appeared to have targeted another male resident, and had followed him all over the common area in an aggressive or threatening manner. The said male resident had been directed to his room for safety at that time. A Certified Nurses Aide distracted the resident and the nurse gave Resident#13 Lorazepma (anti-anxiety medication) 0.5 milligrams intramuscularly injection at 9:20 p.m. without incident. The Nurses Note dated 9/26/20 at 4:40 p.m. documented the resident begun wandering at dinnertime in the dining room, refused to sit down, and stood closer than six feet to other residents. The resident had been given [MEDICATION NAME] as ordered. Approximately 30 minutes later the south door alarm had sounded, a nurse exited the front door of the building and visualized that Resident#1 had pushed open the south door and had exited the building, the nurse assisted the resident back into the building without incident. The Nurses Note dated 9/26/20 at 5:31 p.m. documented the resident continued to wander through the lobby. The resident had noted to become agitated when attempting to redirect the resident to maintain social distance from other residents. The resident stood right next to another resident and tensed up and balled up his fist when attempts had been made to redirect the resident. [MEDICATION NAME] intramuscularly administered per orders. The Nurses Note dated 10/3/20 at 9:32 a.m. documented staff reported at 7:35 a.m. the resident had been in the dining room and punched another resident in the face, breaking said resident's eyeglasses. The facility Nurse Practioner ordered Resident#13 to be sent to the emergency room for evaluation and treatment. The Nurses Note dated 10/13/20 at 9:14 a.m. a Certified Nurses Aide reported that the resident wandered into two different residents rooms during the shift. The Nurses Note dated 10/15/20 at 5:32 a.m. documented the resident had been restless on night shift and as needed medications had been administered, staff provided one on one, with continuous redirection needed. The door motion alarm had been in reach of the resident on the wall next to the resident's bedroom door, and the resident pushed multiple buttons causing the panic alarm to trigger. Many residents were awakened and in response, they were wandering the hall or upset because Resident#13 had been wandering/lurking in the hall. At approximately 5:00 a.m. Resident#13 swung at staff while staff had been attempting to redirect the resident. Resident#13 had been standing in the doorway of another resident's room. The Nurses Note dated 12/7/20 at 12:52 a.m. documented the resident had been elopement seeking that evening. The resident would lean into the doors long enough then they would open. Staff had repeatedly redirected the resident away from the door. The resident had hit staff members with a closed fist. One on one care had been done intermittently and required to prevent elopement. The primary care physician had been called with a message left for a request of medication for the residents behavior. The Nurses Note dated 12/7/20 at 4:01 a.m. documented the resident had been sent to the hospital at 3:50 a.m. per ambulance. The Nurses Note dated 12/7/20 at 10:35 a.m. documented the resident had been discharged from the emergency, and resident had departed at 10:30 a.m. with no new orders for the facility. The physician progress notes [REDACTED]. Context documented; staff reported the resident seemed to have his days and nights mixed up. Staff reported that the resident sleeps a lot during the day and he is up most of the night. The resident had [DIAGNOSES REDACTED]. The Nurses Note dated 1/15/21 11:29 p.m. documented the resident displayed behaviors, such as combative behaviors toward staff when attempting to redirect the resident from entering other residents rooms, refusing to stay in his own room, refusing to stay out of the nurses station or the copy room behind the nurses station. The resident would also yell at staff for physically ambulating next to him as a redirection intervention. The Nurses Note dated 1/17/21 at 11:23 p.m. documented that Resident#13 followed a female resident into her room. The resident had been redirected with some difficulty out of the room. Then Resident#13 became violent when asked to return to his room, he swung at the nurse twice, and advanced toward the nurse. The nurse grabbed both of the residents wrists, and both resident and nurse fell to the floor. The resident sustained [REDACTED]. The resident then calmed down, and a dressing had been placed on the skin tear. The Behavior Note dated 1/18/21 at 4:00 a.m. documented as follows; Resident#13 had not been found in his room. A search of the facility had been conducted, and the resident had not been found. The west door stop sign had been on the floor, and the alarm turned off. Search of grounds had been conducted twice with the resident found in a duplex sunroom sitting at a table with the lights off. The resident had been given a coat, and shoes then returned to the facility. The resident had an assessment temperature of 98.8 degrees Fahrenheit, feet warm and dry, skin warm, no new skin issues. The Nurses Note dated 1/18/21 at 6:30 a.m. documented the resident returned to his room, The Emergency Medical Tech and a facility nurse had assessed the resident. The residents feet had been warm, temperature 98.8 degrees Fahrenheit, and the socks were dry. During an interview on 1/27/21 at 10:07 a.m. Staff A, Registered Nurse (R.N.) reported he had been the night shift charge nurse on 1/17/21. Staff A reported Resident#13 had wandered all the time, and it can be hard to get him to stay in his room. Staff A reported the resident prefers to wear a shirt, long pants, and socks along with gripper socks. Staff A reported he had followed the resident into a room of a female resident. Staff A put an arm around Resident #13's waist to redirect him out of the room, then the resident swung at Staff A several times. Staff A reported he caught Resident#13's wrist, and they both fell . Staff A reported the resident did get a skin tear. Staff A stated the incident happened at about 11:30 p.m. on 1/17/21. Staff A reported the resident then went to wander in the lobby. Staff A reported he had been notified that Resident#13 had been missing at about 4:30 a.m. on 1/18/21. Staff A stated all the staff searched the building, which included the search of the basement, and the attached assisted living facility. Staff A stated he went down the west hall and noticed the velcro stop sign on the west door had been down, so he opened the door, the alarm did not sound. Staff A reported he saw footprints in the snow, and he followed them towards the condominiums west of the facility. Staff A reported he did open two storms doors to two of the condominiums but did not open the inner doors. Staff A reported the resident had actually been found in one of the condominiums sunrooms later on by another nurse who used her cell phone flashlight. Staff A stated the Emergency Medical Technician had checked over the resident as well as another facility staff member. Staff A reported he had been given education from the Director of Nursing on how the alarm is to be set. Staff A reported that now he does check the alarms to the west door every night. Staff A reported this had been the first time the resident had been out of the building. Staff A stated the resident would wander to the therapy area, lobby, and into other residents rooms. Staff A reported he had not been sure if the other nurses are checking the alarms on their shifts. Staff A stated the door alarms had not been part of the orientation, and he only does the door checks now because of Resident#13. Staff A stated Resident#13 had been at the front door to try to get out before. Staff A reported that he did not document the door checks. During an interview on 1/25/21 at 9:19 a.m. Staff B, Certified Nurses Aide (C.N.A) reported she worked the night shift (1/17/21 10:00 p.m. to 1/18/21 6:00 a.m.). Resident#13 had been in the main lobby, and had been upset. Staff B, reported she had given the resident some snacks, which seemed to help. Staff B reported at about 3:00 a.m. the resident headed back to his hallway. Staff B stated at 4:00 a.m. they noticed the resident had been missing, all the rooms had been searched, they found the key to the whirlpool room and unlocked it, searched the basement, and did not find the resident. Staff B reported the staff went to check the doors and noticed the west door alarm did not work, and saw footprints in the snow. Then followed them around on the sidewalk until the footprints stopped at a one story tan duplex west of the facility, the resident had been sitting in the sunroom of the duplex at a card table. Staff B reported that she put her shoes on the resident, and her coat, so they could walk the resident back inside the building. Staff B stated the resident had two pairs of socks on, long pants, and a short sleeve shirt. Staff B reported Staff C, R.N. had been with her. Staff B this was her second night working at the facility, and the alarm looked like it had been off, she reported she did not know how it worked. Staff B stated now all the alarms are checked at the beginning of the shift, and the end of shift. Staff B reported the resident had been found at about 6:00 a.m., and that 911 had been called to help look for the resident. Staff B reported all the other doors had been working that night. Staff B stated the resident did walk a lot throughout the night shift. Staff B reported the west hallway had been the COVID-19 isolation hallway. During an interview on 1/25/21 at 12:35 p.m. Staff C, R.N. reported had worked the night shift on 1/17/21, and Resident#13 had behaviors earlier in the shift when wandering into a females room. Staff C stated it had not been uncommon for the resident to wander into other residents rooms or to hit staff, and he had been sent to the hospital before due to psychological issues. Staff C reported the resident had been aggressive towards other residents before, and that is why the staff would worry when he would go into other residents rooms. Resident #13 would follow other staff members around, for instance he would follow a nurse around when doing medication administration. Staff C reported that a good intervention for the resident had been snacks. Staff C reported the resident could give you and uneasy feeling, and will get into people's personal space. Staff C stated the resident had an altercation with a staff member earlier in the shift on the elopement night. Staff C reported the resident had been wandering around the west wing double doors (doors had been closed due to them leading to the COVID-19 unit), and had attempted to get past the doors. Staff C reported the resident had been able to shut off his motion sensor alarm to his room, and would believe that he could shut off the alarm to the west door; the resident is able to read. Staff C reported the resident had last been seen at 3:30 a.m. prior to the elopement, at 4:00 a.m. the resident could not be found in his room and the staff immediately started looking, checking the building twice. Staff C reported they noticed the velcro stop sign had been down on the west door, and the alarm off. Staff C reported they followed footprints in the snow on the sidewalk outside the west door until they disappeared. Staff C stated she also drove around in her truck to look for the resident, and then went back to looking at the sidewalk. Staff C reported she had her flashlight on her cell phone, knocked on the door of sun porch attached to the condominiums west of the facility where she found the resident sitting in a chair. Staff C reported she found the resident close to 6:00 a.m., because the dietary staff that showed up to help us search started arriving at 5:30 a.m. for their shift. Staff C reported the resident had been wearing long flannel pants, a white t-shirt, and two pairs of socks. Staff C reported the emergency medical technician had assessed the resident, and there were no injuries. Staff C reported that they put warm clothing on the resident, and he continued to wander around the building. Staff C reported that they put three alarms on the west door, one of which is a motion alarm, and all the alarms are to be checked by the night shift. During an interview on 1/26/21 at 8:45 a.m. Staff D, R.N. reported she worked the day shift of 1/17/21, and that the maintenance staff are responsible for checking the door alarms. Staff D stated Resident #13 wanders a lot, spends most of his time at the nurses station, and follows staff around. Staff D reported the resident likes to wear non-skid socks. Staff D reported the west wing is designated as the COVID-19 unit. During an interview on 1/26/21 at 9:20 a.m. Staff E, Certified Medication Aide (C.M.A) reported the maintenance staff check the door alarms. Staff E stated Resident #13 can be aggressive towards staff, and his behavior can increase very quickly without warning. Staff E reported food is the best intervention for the resident. Staff E reported the resident had been sent to the emergency room for his behaviors. Staff E stated the resident could change the tone on his door alarm, but not sure, if he could have shut off the west door alarm. During an interview on 1/26/21 at 10:19 a.m. Staff F, C.N.A reported the maintenance staff look after the exit doors. Staff F stated Resident#13 had touched the buttons on his bedroom door alarm; it is a good reminder for him to go back to bed when he hears it. Staff F reported the resident wanders, and does open exit doors. During an interview on 1/26/21 at 2:17 p.m. Staff H, C.N.A reported the CNA's do not check the exit door alarms. Staff H stated Resident #13 had wandered a lot every day, and wears two pairs of socks. During an interview on 1/26/21 at 2:50 p.m. Staff G, Assisted Director of Nursing (ADON) reported Resident#13 had been known to change the tone on his bedroom motion alarm. Staff G stated the resident had a history of [REDACTED]. During an interview on 1/26/21 at 3:20 p.m. Staff J, C.N.A reported she worked the night shift. Staff J stated Resident#13 did change the tone on his bedroom alarm, and messed with the fire exit doors. Staff J reported the resident had worn two pairs of socks, the outer layer being gripper socks. Staff J reported the resident had calluses on his feet, and shoes hurt his feet, so he wore two pairs of socks. During an interview on 1/26/21 at 8:30 a.m. Staff K, Maintenance Supervisor stated after the elopement of Resident#13, a motion alarm had been added to the west door. Staff K reported that in the morning he would make sure that the door alarms sounded, and at the end of his day, he would visualize that the alarms are on and in place. During an interview on 1/27/21 at 11:47 a.m., the Director of Nursing (D.O.N) stated she had been notified at 5:15 a.m. on 1/18/21 that Resident #13 had been missing. The D.O.N reported she instructed the staff to check all the rooms, kitchen, chapel, and to look on the floor as he had a habit of laying on the floor. The D.O.N stated she had drove around the facility neighborhood, as she had not been far from the facility when she had been called. The D.O.N reported that she walked to the rooms, and opened the west door, foot prints had been in the snow, but did not have a flashlight, and the west door did not alarm when opened, the alarm had been off, and the velcro stop sign had been down. The D.O.N reported the staff had not been able to find him at 4:00 a.m., the last they had seen him had been when he headed west at 3:30 a.m., but staff did not say they saw him turn left towards south hall. The D.O.N reported the resident had been found by Staff C shortly after 6:00 a.m. and brought him in the building. The D.O.N reported the resident had on two pairs of socks, long pants, and a long sleeve t-shirt. The D.O.N reported she had told night shift to check the alarms on nights. The D.O.N stated the motion alarm at the residents' bedroom door had been in place prior to the elopement. The D.O.N reported the west door exit is the only door that did not have a 15-second egress code alert. The D.O.N reported she had not been aware of a motion alarm that the facility administrator had put in place. The D.O.N stated the maintenance supervisor had been responsible for checking the door alarms on Mondays through Fridays twice a day. During an interview on 1/27/21 at 9:36 a.m. the Administrator stated he had received, a call at 5:00 a.m. on 1/18/21 that Resident #13 had been missing from the facility. A building search had been done and one staff member had found footprints, staff had been searching on foot, one staff searching by car, and the west door alarm did not activate. The Administrator stated the D.O.N had called and reported the resident had been found, and had been checked over by the emergency medical technician, and the facility staff with no injuries reported. The Administrator reported that a motion sensor alarm had been added to the west door. The Administrator reported the nurses could carry a box with them that alerted them to when the motion alarm had been triggered. The Administrator reported the door alarms had been checked by the maintenance staff twice a day, but not on the weekends. During an interview on 1/27/21 at 1:59 p.m. the 911 County Dispatcher reported that a 911 call had been made on 1/18/21 at 5:47 a.m. from the nursing home for the missing Resident#13. During an interview on 2/2/21 at 9:25 a.m., the state climatologist reported that on 1/18/21 at 3:30 a.m. the temperature had been 20 degrees Fahrenheit. During an observation on 1/27/21 at 1:21 p.m. the survey team picked up the motion sensor device off the floor next to the west exit door, the device flashed red occasionally. All the other alarms had been in functioning status per observation. The survey team continued to hold the motion sensor alarm, no staff responded for a total of ten minutes. During an observation on 1/27/21 at 1:33 p.m. the motion sensor alarm box had been located at the nurses station the #2 labeled west door had been flashing, no staff had been monitoring the motion sensor alarm box. The survey team took the box to the administrator. During an interview at 1/27/21 at 1:35 p.m., the Administrator reported he had not been sure why the box had not been sounding, and that the motion alarm is mostly for the night shift. The Administrator reported he had in-serviced Staff D, R.N. on the device, and someone else. During an interview on 1/27/21 at 1: 52 p.m., the Administrator and D.O.N reported and agreed that the motion alarm should have been active at all times, and the sound had been off. The Missing Resident/Elopement Policy dated 11/1/18 documented the unit charge nurse is responsible for knowing the location of their residents. The policy documented the responsibility is for the charge nurse and all other staff. The Policy documented that at any time in which a resident is determined missing, the following procedure will be strictly followed: A. Alert: The supervisor/charge nurse will alert all other personnel by all paging Code Gray and location (including unit, floor and room number). B. Search; A search of the immediate area (building) will be initated under the director of nursing, shift supervisor/charge nurse. All rooms will be searched (including locked rooms). The nursing shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking areas, etc.) C. Contact: If the search of the immediate area (building) is unsuccessful, the nursing shift supervisor/charge nurse will immediately contact the: administrator and director of nursing, local police department, family/responsible representative, regional nurse and director of operations, attending physician, department of health notification as required. The Incident Description dated 1/18/21 documented as follows; the resident had not been found in room at 4:00 a.m . A search had been made of the building, every room, basement, and outside of the facility, and the resident could not be found. The Director of Nursing had been notified at 5:15 a.m., and arrived at the facility at 5:30 a.m. The room rounds had been completed again. Noted that the west door velcro stop sign had been on the floor, and the alarm had been turned off. Footsteps noted in snow on the sidewalk, and followed them until only sidewalk remained. Door to door search of duplexes done. Police notified when resident had not been found. Returned outside to check duplexes and found the resident at 6:15 a.m. in a sunroom in the dark sitting at a table. The resident had been given a coat and shoes and returned to the facility. A skin assessment completed. Vitals good. Body temperature 98.8 degrees Fahrenheit. No injures had been documented on the incident report. During an observation on 1/27/21 at 10:36 a.m. the west exit door of the facility to the location that the resident had been found (condominium sun room) included a sidewalk that went west out of the building, then turned south, then turned east, then turned west, for an approximate length of three hundred feet. The Logbook Documentation for test operation of doors and locks documented the west doors had been checked on 1/11/21 to 1/14/21 but not on 1/15/21. The facility was notified of the immediate jeopardy and given the IJ template on 1/27/21 at 3:45 p.m. The immediate jeopardy was removed on 1/28/21 as the facility provided education with all staff on monitoring residents at risk for elopement, elopement policy including notification of Administrator, DON and police, and ensuring door alarms are functioning. At the time of exit the scope and severity was lowered to a D.

Based on clinical record review, facility policy, and staff interviews, the facility staff failed to prevent resident to resident abuse from Resident #1 toward's Resident #2 in the facility's locked memory unit. The review sample size consisted of 5 residents. The unit census had 12 residents at the time of the incident. The facility reported a census of 52 residents. 1. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #1 with a BIMS (Brief Interview for Mental Status) of 3 which indicated severely impaired ability for daily decision making. The MDS indicated physical and verbal behavioral symptoms directed toward others. Resident #1 [DIAGNOSES REDACTED]. A care plan initiated 03/02/16 identified the resident had depression, instructed staff to monitor and report risk of harming others: increased anger, labile mood or agitation, and feeling threatened by others. The care plan instructed staff to keep routine consistent, provide consistent care givers as possible, identify self at each interaction, provide with necessary cues, stop and return if agitated. The care plan did not address the resident ' s aggression toward staff prior to the resident to resident altercation. The behavioral observation form dated 03/03/16 to 04/20/16 documented at least 10 incidents of the resident becoming aggressive with staff during cares, exhibiting exit seeking behaviors, refusing request by staff and one threat of self harm. Review of the Progress notes dated 03/02/16 to 04/04/20/16 revealed on 03/20/16 at 8:06 p.m. the day nurse stated had went back to the (memory care) unit related to complaints of aggression, the resident had been kicking and striking out. The primary care provider notified and had received orders to transfer the resident to the emergency room for assessment. At 8:51 p.m. the resident had been transferred to the emergency room . At 00:08 a.m. the resident returned with no orders with a report from the emergency room nurse no sign of symptoms of infection. The Progress note dated 04/07/16 at 3:20 p.m. the staff nurse reported had been called back to unit as resident insisted on leaving. The nurse stated had been able to get the resident to sit in chair but kept looking at watch. At 3:15 p.m. Resident #1 stood up and stated he/she is leaving now and headed toward the back door of the unit in an attempt to leave. When the resident approached the door, he/she kicked the door and pushed the nurse, threatened to punch the nurse. The CMA (certified medication assistant) then able to convince the resident to go back to his/her room. 2. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #2 with a BIMS (Brief Interview for Mental Status) of 9 which indicated severely impaired ability for daily decision making. Resident #2 [DIAGNOSES REDACTED]. A care plan with a target date of 02/25/16 identified the resident with impaired cognition related to progression of Alzheimer's. The staff were instructed to identify self at each interaction, reduce distractions, provided necessary cues, engage in simple structured activities, had history of inappropriate interactions with female residents and utilize a motion alarm on doorway to alert staff of resident leaving his/her room. A Progress note dated 04/20/16 at 1:35 a.m. Staff C noted Resident #1 observed at 12:00 midnight by Staff A, CNA hitting Resident #2 repeatedly. Staff A separated the residents and called for assistance. Resident #1 returned to his/her room. The staff nurse noted she had called the on-call primary care provider and received orders to transport both residents to the emergency room for evaluation and treatment. Review of Incident report form dated 04/20/16 regarding Resident #1 revealed the resident had been observed hitting another resident repeatedly in the head. An incident report dated 04/20/16 noted Resident #2 had been observed lying on the floor in his/her room with head in hallway and torso leaning against wall of bathroom. The staff noted the resident's underwear were near the knees and pajamas were near the ankles. The nurse questioned if the resident had pain and resident affirmed had pain. The nurse attempted to assess for potential hip injury, the resident complained of pain but no crying out or facial grimacing. Resident #2 stated Resident #1 had pushed him/her down. Observation of Resident #2 on 05/04/16 at 3:30 p.m. revealed the resident's face showed fading yellowish bruising across the forehead along the right mid cheek area. The verification of Investigation report dated 04/20/16 noted that Staff A heard yelling while she had been providing cares with another resident. The staff observed Resident #1 standing over Resident #2 who had been located on the floor in his/her bedroom facing the hallway. Resident #1 had been hitting Resident #2 in the head and face with a closed fist. The CNA asked Resident #1 to stop and stepped between the residents, redirecting Resident #1 back to his/her room. When the CNA went back to check on Resident #2, Resident #1 followed her standing behind her as she checked on Resident #2. The staff then called out for assistance and Staff B, CNA and Staff C, RN responded. In a handwritten witness report dated 04/20/16 at 1:05 a.m. Staff A noted she had been toileting a female resident when she heard a commotion and yelling. She stated she had finished toileting the resident and assisted back into her bed and placed the bed in the low position and floor mat in place went out to see what had been occurring. Staff A stated when she walked out of the other room Resident #2 had been on the floor in the doorway of his/her room and Resident #1 had been in Resident #2's room facing the hallway standing over Resident #2 hitting the resident in in the head and face with a closed fist. Staff A noted she told Resident #1 to stop and stepped between them. She noted she directed Resident #1 to his/her room, opened his/her bed and told him/her to put pajamas on and go to bed. She stated she went back to check on Resident #2. She stated Resident #1 came out of the room and stood behind her. She stated she directed Resident #1 again to go back to his/her room but the resident started to get upset so she called out front for the nurse and a male aide to come back to the unit. Staff A stated Resident #1 told her Resident #2 had come into his/her room and was hitting him. She stated Resident #2 had told her Resident #1 had pushed him/her down and was beating the crap out of him/her. In a hand written note dated 04/20/16 at 2:55 a.m. Staff B, CNA noted he went to the unit and assisted. He noted while helping the nurse and waiting for the EMT (emergency medical techs) to show up for transporting both residents to the emergency room . Staff B stated he assisted, and watched over Resident #1 to make sure no other harm could be done to anyone else. He stated he assisted the EMTs until they removed the resident, then returned to is normal duties. On 05/04/16 at 7:56 a.m. Staff C, Registered Nurse (RN) stated she had been the charge nurse on the 6 p.m., to 6 a.m. shift. She stated Staff A had been the only staff on the memory care unit called Yesterday. She stated Staff A had called her back to the unit. Staff C stated Staff B, CNA had gone to the unit with her. She stated Resident #2 had been on the floor lying by the bathroom door area. She stated the resident had been incontinent. She stated when she entered the unit Resident #2's pants were partially down, like he/she had been trying to use the bathroom. She stated Resident #1 had been in his/her room across the hallway. Staff C stated Staff A, CNA told her she had seen Resident #1 hitting Resident #2 in the face with his/her fist. Staff C stated Resident #2 had been complaining of rib pain at that point. She stated she did an assessment, neurological checks were okay and vital signs were normal. She stated she told Staff B to stay in the unit with Staff A while she went out and called the on-call care provider. She stated she received orders to send both residents to the emergency room for evaluation. Staff C stated she had talked to Resident #1 about the situation and the resident had denied anything happened. She stated Staff A had told her she had been in another residents ' room when the incident occurred. She stated Staff A had been the only scheduled staff on the unit, that they only have one staff scheduled back there on the night shift. Staff C stated Resident #1 had been aggressive with staff before and had tried to intimidate staff, backed staff into corners, but does not know if he/she physically attacked staff before. On 05/04/16 at 1:05 p.m. Staff A, CNA stated she had been working on the night shift in the unit on 04/20/16. She stated she had been with another resident, taking him/her to the bathroom and placed the resident on the toilet. She stated she heard a commotion but could not leave the resident she had been helping alone on the toilet. When she got the resident out of the bathroom and settled back in him/her bed she went out into the hallway. She stated she observed Resident #2 on the floor with Resident #1 standing over his/her throwing punches at the face of Resident #2. She stated she heard Resident#1's fist make connection with Resident #2's face. Staff A stated the time elapse from the time she first heard the commotion to the time she got out to the hallway had been at least 5-7 minutes. Staff A stated she had been the only staff back on the unit. She stated the facility staffed only one CNA in the unit on the night shift. Staff A stated she convinced Resident #1 to go to his/her room, handed the resident pajama's instructed the resident to put them on, then went out to check on Resident #2. She stated Resident #1 followed her out and stood behind her. She stated Resident #1 told her that Resident #2 came into his/her room and hit him/her. She stated that Resident #1 had actually been in Resident #2's room. Staff A stated she had to go to the unit door and yell out for staff assistance. She stated she yelled for the nurse and the male CNA to come and assist her with the residents. On 05/04/16 at 1:55 p.m. Staff D, CNA stated she had been working in the front hallways when she heard Staff A open the unit doors, yelled for assistance because Resident #2 had been on the floor and Resident #1 had beat him/her up. Staff D stated when she looked in the unit she saw Resident #2 on the floor. Review of the Abuse and Neglect policy and procedure with an issues date of 01/2016 instructed staff the purpose of the policy is that the resident had a right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion, to ensure the residents are treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The policy noted that the resident must not be subjected to abuse by anyone, including facility staff, other residents, consultants, volunteers, staff or other agencies serving the individual, family members, legal guardians or other individuals. Review of the facility's Managing Aggressive policy and procedure with a date of 01/01/14 instructed staff the purpose of the policy is to ensure the safety of resident and staff. The staff are instructed to: 1. Should a resident's behavior become abusive, hostile, assault or unmanageable in any way that would jeopardize the health/safety of the resident or others, the charge nurse must immediately: a. Provide safety for all concerned b. notify the resident's attending primary care provider c. notify the director of nursing d. notify the resident's representative 2. Emergency restraints may be unitized if a resident's unanticipated violet or aggressive behavior places the resident or others in imminent danger. 3. Should the resident pose immediate danger, or become violent or beyond control of facility, law enforcement may be called for assistance. 4. Every effort shall be made to calm the resident, personal safety must always be considered. 5. Unmanageable residents will be considered for discharge. 6. Complete documentation of the incident must be recorded in the resident's medical record and an Event Report or Risk Management report must be completed.

Based on clinical record review, staff schedules and staff interviews, the facility failed to ensure Residents #1, #2 and #4 received adequate supervision to prevent potential accidents and failed to adequately staff the memory care unit to safely meet residents ' needs. The facility reported a census of 52 residents and the sample of 5 residents. Findings included: 1. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #1 with a BIMS (Brief Interview for Mental Status) of 3 which indicated severely impaired ability for daily decision making. The MDS indicated physical and verbal behavioral symptoms directed toward others. Resident #1 [DIAGNOSES REDACTED]. A care plan initiated 03/02/16 identified the resident had depression, instructed staff to monitor and report risk of harming others: increased anger, labile mood or agitation, and feeling threatened by others. The care plan instructed staff to keep routine consistent, provide consistent care givers as possible, identify self at each interaction, provide with necessary cues, stop and return if agitated. The care plan did not address the resident ' s aggression toward staff prior to the resident to resident altercation. The behavioral observation form dated 03/03/16 to 04/20/16 documented at least 10 incidents of the resident becoming aggressive with staff during cares, exhibiting exit seeking behaviors, refusing request by staff and one threat of self harm. Review of the Progress notes dated 03/02/16 to 04/04/20/16 revealed on 03/20/16 at 8:06 p.m. the day nurse stated had went back to the (memory care) unit related to complaints of aggression, the resident had been kicking and striking out. The primary care provider notified and had received orders to transfer the resident to the emergency room for assessment. At 8:51 p.m. the resident had been transferred to the emergency room . At 12:08 a.m. the resident returned with no orders with a report from the emergency room nurse with no signs or symptoms of infection. The Progress note dated 04/07/16 at 3:20 p.m. the staff nurse reported had been called back to unit as resident insisted on leaving. The nurse stated had been able to get the resident to sit in chair but kept looking at watch. At 3:15 p.m. the resident stood up and stated he/she is leaving now and headed toward the back door of the unit in an attempt to leave. When the resident approached the door, he/she kicked the door and pushed the nurse, threatened to punch the nurse. The CMA (certified medication assistant) then able to convince the resident to go back to his/her room. 2. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #2 with a BIMS (Brief Interview for Mental Status) of 9 which indicated severely impaired ability for daily decision making. Resident #2 [DIAGNOSES REDACTED]. A care plan with a target date of 02/25/16 identified the resident with impaired cognition related to progression of Alzheimer's. The staff were instructed to identify self at each interaction, reduce distractions, provided necessary cues, engage in simple structured activities, had history of inappropriate interactions with female residents and utilize a motion alarm on doorway to alert staff of resident leaving his/her room. A Progress note dated 04/20/16 at 1:35 a.m. Staff C noted Resident #1 observed at 12:00 midnight by Staff A, CNA hitting Resident #2 repeatedly. Staff A separated the residents and called for assistance. Resident #1 returned to his/her room. The staff nurse noted she had called the on-call primary care provider and received orders to transport both residents to the emergency room for evaluation and treatment. An incident report dated 04/20/16 noted Resident #2 had been observed lying on the floor in his/her room with head in hallway and torso leaning against wall of bathroom. The staff noted the resident's underwear were near the knees and pajamas were near the ankles. The nurse questioned if the resident had pain and resident affirmed had pain. The nurse attempted to assess for potential hip injury, the resident complained of pain but no crying out or facial grimacing. Resident #2 stated Resident #1 had pushed him/her down. The verification of Investigation report dated 04/20/16 noted that Staff A heard yelling while she had been providing cares with another resident. The staff observed Resident #1 standing over Resident #2 who had been located on the floor in his/her bedroom facing the hallway. Resident #1 had been hitting Resident #2 in the head and face with a closed fist. The CNA asked Resident #1 to stop and stepped between the residents, redirecting Resident #1 back to his/her room. When the CNA went back to check on Resident #2, Resident #1 followed her standing behind her as she checked on Resident #2. The staff then called out for assistance and Staff B, CNA and Staff C, RN responded. Observation of Resident #2 on 05/04/16 at 3:30 p.m. revealed the resident's face showed fading yellowish bruising across the forehead along the right mid cheek area. On 05/04/16 at 7:56 a.m. Staff C, Registered Nurse (RN) stated she had been the charge nurse on the 6 p.m., to 6 a.m. shift. She stated Staff A had been the only staff on the memory care unit called Yesterday . She stated Staff A had called her back to the unit. Staff C stated Staff B, CNA had gone to the unit with her. She stated Resident #2 had been on the floor lying by the bathroom door area. She stated the resident had been incontinent. She stated when she entered the unit Resident #2's pants were partially down, like he/she had been trying to use the bathroom. She stated Resident #1 had been in his/her room across the hallway. Staff C stated Staff A, CNA told her she had seen Resident #1 hitting Resident #2 in the face with his/her fist. Staff C stated Resident #2 had been complaining of rib pain at that point. She stated she did an assessment, neurological checks were okay and vital signs were normal. She stated she told Staff B to stay in the unit with Staff A while she went out and called the on-call care provider. She stated she received orders to send both residents to the emergency room for evaluation. Staff C stated she had talked to Resident #1 about the situation and the resident had denied anything happened. She stated Staff A had told her she had been in another residents ' room when the incident occurred. She stated Staff A had been the only scheduled staff on the unit, that they only have one staff scheduled back there on the night shift. Staff C stated Resident #1 had been aggressive with staff before and had tried to intimidate staff, backed staff into corners, but does not know if he/she physically attacked staff before. On 05/04/16 at 1:05 p.m. Staff A, CNA stated she had been working on the night shift in the unit on 04/20/16. She stated she had been with another resident, taking him/her to the bathroom and placed the resident on the toilet. She stated she heard a commotion but could not leave the resident she had been helping alone on the toilet. When she got the resident out of the bathroom and settled back in him/her bed she went out into the hallway. She stated she observed Resident #2 on the floor with Resident #1 standing over his/her throwing punches at the face of Resident #2. She stated she heard Resident#1's fist make connection with Resident #2's face. Staff A stated the time elapse from the time she first heard the commotion to the time she got out to the hallway had been at least 5-7 minutes. Staff A stated she had been the only staff back on the unit. She stated the facility staffed only one CNA in the unit on the night shift. Staff A stated she convinced Resident #1 to go to his/her room, handed the resident pajamas instructed the resident to put them on, then went out to check on Resident #2. She stated Resident #1 followed her out and stood behind her. She stated Resident #1 told her that Resident #2 came into his/her room and hit him/her. She stated that Resident #1 had actually been in Resident #2's room. Staff A stated she had to go to the unit door and yell out for staff assistance. She stated she yelled for the nurse and the male CNA to come and assist her with the residents. On 05/04/16 at 1:55 p.m. Staff D, CNA stated she had been working in the front hallways when she heard Staff A open the unit doors, yelled for assistance because Resident #2 had been on the floor and Resident #1 had beat him/her up. Staff D stated when she looked in the unit she saw Resident #2 on the floor. 3. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #4 with moderately impaired ability for daily decision making with long and short term memory loss. Resident #4's [DIAGNOSES REDACTED]. A care plan with a target date of 02/25/16 identified the resident with impaired cognition related to dementia. The staff were instructed to identify self at each interaction, reduce distractions, provided necessary cues, engage in simple structured activities. The care plan did not address the resident's wandering and elopement seeking behaviors. Review of the progress notes revealed the resident had several incidents of exit seeking: a. On 04/02/16 at 10:44 Staff E, RN documented the resident agitated stating he/she wanted to leave the facility, redirection unsuccessful. The resident had exited onto the patio, flipped over a planter in an attempt to climb over the fence. When Staff E attempted to redirect, the resident struck the nurse across the mouth with the back of his/her hand. The CNA redirected the resident back into the facility and sat with resident while the nurse called family. At 8:09 p.m. Staff F, RN documented the resident continued to pace and exhibited exit seeking behaviors. b. On 04/03/16 at 1:59 p.m. Staff E documented the resident continued to be agitated with attempts to leave the facility and occasionally swinging at staff. c. On 04/04/16 at 9:50 a.m. Staff G, RN documented had been called back to the unit, the resident refused medications, standing beside the back exit door, refusing to leave the door. d. On 04/11/16 at 10:56 a.m. Staff E documented an order had been received to transfer the resident to the emergency room to evaluate and treat for aggressive and combative behaviors. At 11:15 a.m. Staff E documented had responded to door alarm, Resident #4 observed to exit the building and run through the yard and out into the street. The resident followed by the nursing staff. The resident had been extremely aggressive and combative with staff when attempting to get the resident to return to the building. Staff E documented the resident struck staff multiple times. After staff convinced the resident to return to the facility, the primary care provider had been notified and orders received to transfer the resident to the emergency room to evaluate and treat. On 05/04/16 at 8:50 a.m. Staff H, CMA stated during the morning administrative meeting one of the CNA's came and told the administrative staff that assistance had been needed in the memory care unit, so all went to find out the issue. She stated when they got outside, they heard Staff I, CMA (Yesterday unit manager) calling name. She stated Resident #4 had left the unit, was outside and Staff E, RN followed the resident. She stated he/she had gotten several blocks from the facility and Staff E had been trying to convince the resident to return to the unit. She stated it finally took several staff to get the resident to turn and go back to the facility. On 05/04/16 at 9:30 a.m. Staff G/CMA/CNA stated she had been to lunch around 10:15 to 10:45 a.m. and when she returned to the unit. Staff J, CNA (who had been the only staff in the unit) told her Resident #4 had been exhibiting exit seeking behaviors the whole time she had been out of the unit, that Staff E, the charge nurse had been aware of the behaviors and had been back to the unit to try to settle the resident down a couple of times. Staff G stated Staff J went out of the unit for her break. Staff G stated she convinced Resident #4 to sit at one of the tables while she talked to another resident's family member. Staff G stated at that time Resident #4 got up, went to the back door pushed open the door latch. After 15 seconds the door opened and the resident left out the door. She stated when the door alarmed she excused herself from the family member and took care of the alarm. She stated Staff E, came into the unit and yelled the back door was open so they both took off at a run. She stated Resident #4 had been out the door so Staff E went after the resident. She stated Staff E yelled at other staff to go the other way to try and cut the resident off. She stated the resident had gotten across the street and when Staff E tried to stop the resident, the resident would strike out at her. Staff G stated the resident had reached the road by the Recreational Center when a woman in a car stopped and asked if they needed assistance. She stated she got into the car with the woman and they blocked the road. Staff G stated she got out of the vehicle and finally convinced the resident to get into the car but when the resident realized the car had been going in the wrong direction the resident tried to open the car door. When she attempted to stop the resident from leaving the car, the resident swung at her and hit her in the face. She stated they let the resident out of the car and at that time the administrative staff were there to assisted to get the resident back to the facility. On 05/04/16 at 10:30 a.m. Staff E, RN stated she had been working out front when she heard an alarm go off in the unit. She stated she went to check it when she observed Resident #4 going out the back door of the unit so she followed the resident. She stated she yelled at the resident to stop but did not. She stated when she got close to the resident, he/she would swing at her. She stated she attempted to keep up with the resident but the resident kept going down the road. She stated the resident did get a few blocks prior to being convinced by Staff I, CMA to get into a car. Staff E stated when the resident realized they were headed back to the facility the resident attempted to jump out of the car. The driver stopped and the resident got out. Staff E stated by that time other staff got there so they took over while she went to call the primary care provider and family. On 05/04/16 at 10:45 a.m. Staff J, CNA stated she had been on the unit with Staff I, CMA as the second staff. She stated Staff I had been out of the unit when the resident started to exhibit exiting seeking behaviors. She stated he/she had tried to get out the front double doors at first. She stated Resident #4 shoved a female resident who had been standing by the front door. She stated he/she pushed the door open and started through the door, she yelled and Staff E, the charge nurse heard and came and turned the resident around and back into the unit. She stated when Staff I, CMA returned to the unit, the CMA told her to go on to lunch. She stated she told Staff I about the resident's behaviors but she told her to go anyway. She stated when she was at lunch the resident left the building. Review of resident placement revealed the East and South wing had 20 residents, North wing had 22 residents and the Yesterday (memory care) Unit had 12 residents at the time of the incidents. Review of the day shift schedules for February and April 2016 revealed two nurses scheduled for the 6 AM to 6 PM shift. The CNA schedule for February 2016 and April 2016 revealed two CNAs in the unit, two CNAs on the north wing and one to two CNA's on the South wing with one to two CMAs assigned to medication pass. Review of the February and April 2016 2-10 p.m. shift revealed two CNAs for the unit, two for North hall and one to two for south hall. Review of the daily assignment schedules revealed during February and April 2016 the 10 p.m. to 6 a.m. shift were covered by three (3) CNAs with one CNA in each area and one (1) nurse scheduled for the 6 PM 6AM Shift. On 05/05/16 at 12:30 p.m. The Facility Administrator stated the facility staffed according to Federal guidelines. When asked if he felt they were meeting resident needs in the memory care unit he stated he felt they were. When noted that both the attempted elopement of Resident #4 and the resident to resident altercation between Resident #1 and Resident #2 happened when there had been only one staff in the unit, the administrator acknowledged there might have been an issue.

br>Based on observation, record review, interviews with staff, residents and families and review of the facility's Alarm Response Report, the facility failed to display respect for residents when caring for them and failed to promptly respond to activated call lights for 2 of 6 residents reviewed (Resident #3, #4). The facility reported a census of 47 residents. Findings include: 1. Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 9/9/15. The MDS identified the resident ' s BIMS (Brief Interview of Mental Status) score as 13 out of 15. A score of 13 identified no cognitive impairment with recall ability or repetition. The MDS reflected the resident required limited physical assistance of one staff member for bed mobility, ambulation, and toilet use and extensive assist of one staff member for transfers, ambulation on the unit, dressing, and personal hygiene. The MDS assessment reflected the resident to be always incontinent of urine and occasionally incontinent of bowel. The MDS indicated no toiling program has been attempted and no toileting program in place to manage the resident's bowel and bladder incontinence. On 11/05/15 at 1:30 p.m. Resident #3 stated he/she had waited 20 minutes or more on 3 or more occasions for staff to answer the call light and to receive assistance to the bathroom. Resident #3 reported the wait caused him/her to be incontinent due to waiting so long and this caused him/her to be upset. Resident #3 would then eventually get up unassisted, while waiting for call light, and go to bathroom by him/herself, knowing that he/she was a fall risk, but could not wait any longer for the call light to be answered and be assisted. Resident #3 used a clock on the wall to determine call light response times. The resident reported the facility did not have enough staff available and this would cause him/her to become incontinent of urine. On 11/5/15 the resident ' s family member was interviewed and stated while visiting, the resident required assist to use the bathroom. The resident would put the call light on (activate) for assistance. The family member stated he/she waited with the resident for up to an hour for assistance and after no response to answer the call light; the family member assisted the resident to the bathroom. The family member stated this has happened more than a couple times. Review of the Alarm Response Report dated from 10/07/15 to 11/05/15 for Resident #3, revealed the response time varied from 16 minutes to 2 hours and 22 minutes, for the call light to be answered, on 33 occurrences. 2. Resident #4 had a MDS assessment with a reference date of 11/5/15. The MDS identified the resident had a BIMS score of 15 out of 15. A score of 15 indicated the resident had no cognitive problems. The resident required extensive assistance of one-person for physical assistance with bed mobility, transfers, locomotion, dressing, toilet use, and limited physical assist of one staff member for personal hygiene. On 11/05/15 at 11:40 a.m., Resident #4 stated there have been times the call lights were on for more than 2 to 3 hours. Resident #4 reported he/she used a clock on the wall, to determine call light response times. Resident #4 stated he/she has had to wait for the call light to be answered for an hour on a daily basis with no specific time during the day or night. Resident #4 reported he/she would be incontinent of urine and occasionally of bowel and knows when this occurred. The resident stated he/she would activate the call light for staff assistance for incontinent cares. The resident would activate the call light for needing assistance with incontinence cares. The resident stated he/she would sit or lie in a soiled brief for up to 3 hours. The resident stated most nights he/she will go from 11:00 p.m. until the next morning when therapy comes into his/her room before she/he receives incontinent cares. Resident #4 stated the facility does not have enough staff available. An interview with Resident #4 on 11/6/15 at 9:40 a.m. identified he/she put the call light on at 8:30 a.m. for assistance and the staff did not respond to the call light until around 9:30 a.m. Resident #4 stated last night he/she had the call light on (activated) for assistance to go to the toilet to have a bowel movement. The resident stated she/he started to go in his/her brief and attempted to hold it for two hours before the staff answered the call light. On 11/5/15 at 11:40 a.m., the resident ' s family member stated he/she was present on occasions when the resident had to wait for up to 3 hours for the call light to be answered and to get the assistance the resident requested. The resident's family member stated he/she went to the Administrator and reported this, but it still continues. Review of the facility's Alarm Response Report dated 10/07/15 to 11/05/15 revealed the response time for the resident's call light to be answered ranged from 17 minutes to 2 hours and 22 minutes to be answered on 56 occasions. Observations on 11/6/15 at 9:15 a.m. revealed call lights going off. Resident's #4's call light was activated at 8:31 a.m. and has not been responded to. Staff B, nurse, standing at nurses' station by computer call light system and she/he looking at a sale add for candy. Staff B noted surveyor observing the call light system on the computer that is approximately 2 feet away from Staff B and Staff B then came over to look at the call lights on the computer. Staff B wrote down some room numbers that were sounding off at the 100 hallway and left and walked down the 200 hallway. Staff B returned and stated to the surveyor that she could not locate the rooms. The surveyor asked Staff B about the other hall and Staff B proceeded down the 100 hall way. Staff B returned a few minutes later and stated he/she answered Resident #4's room and the resident needed assistance and Staff B reported she/he told Certified Nurse Aide (CNA) staff the resident needed help. Observation at the time revealed Resident #4's call light turned off at 9:20 a.m. Review of the residents' council minutes dated 10/26/15 included concerns with the call lights. Interview on 11/5/15 at 2:57 p.m., Staff C, CNA, stated the resident's call lights are not getting answered within 15 minutes and causes residents' to wet them self or get their shower as scheduled, or a delay in getting their requested pain medication. Staff C indicated this is due to not having enough staff. Interview on 11/6/15 at 9:25 a.m., Staff A, nurse, indicated that they have worked here for a few months now and really does not understand the call light system. Staff A stated she did just answer Resident's #4 call light and the resident did need assistance and she told the CNA's and they are going to go assist the resident. Interview on 11/6/15 at 9:50 a.m., Staff B, CNA, stated sufficient staffing has been an issue lately. Staff B stated the resident's call lights go off longer than 15 minutes due to no having enough staff. Staff B stated he/she did just get done completing cares on Resident #4 and could not get to the resident sooner due to feeding assist in the dining room. Interview on 11/6/15, the Administrator stated he does not have a policy/procedure for staff on answering call lights or the call light system. The Administrator stated he is not aware of call lights going unanswered for longer than 15 minutes. The Administrator stated the facility just started having agency staff coming in to assist.

Based on record review, resident and staff interviews, the facility failed to ensure the intervention(s) were followed to provide adequate supervision to prevent falls resulting in major injuries for two of four residents (Resident #1 & #2). The facility reported a census of 49 residents. Finding include: 1. According the MDS (Minimum data set) assessment tool with a reference date of 06/18/14, Resident #2 had [DIAGNOSES REDACTED]., seizure disorder or epilepsy, depression, and post -traumatic stress disorder. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 4 out of 15. The MDS identified Resident #2 required extensive assistance of one staff member to physically assist with transfers, toilet use, dressing and personal hygiene and physically assist of one staff member for bed mobility and locomotion. The MDS indicated the resident balance during transitions and walking not steady, and resident able to stabilize with staff assistance and surface to surface transfer did not occur. The MDS documented the resident normally used a walker for mobility. The MDS documented the resident had one fall since prior assessment being completed resulting in no injury. Review of the facility Fall Risk assessment dated [DATE] indicated a total assessment score of 17. A total score of 10 or above represents high risk. The Care Plan with an initiated date of 03/23/14 listed a Focus of resident at risk falls due to Parkinsonism, impaired vision, impaired balance, history of seizure disorder and psychotropic medication use. The Care Plan listed approaches that directed staff to: 1. Resident is to have pressure alarm to bed and in recliner (and wheel chair if used). 2. Staff makes sure resident's call light is within reach and to encourage the resident to use it for assistant as needed. 3. Staff encouraged resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. 4. Staff makes sure the resident is wearing appropriate footwear when transferring, ambulating or mobilizing in wheel chair. 5. Staff members follow fall protocol. 6. Staff ensure resident has a safe environment with floors free from spills and/clutter, adequate, glare-free light: a working and reachable call light, side rails as ordered, handrails on walls, and personal items within reach. 8. Staff provides activities that minimize the potential for falls while providing diversion and distractions. 9. Staff may use bedside commode at night to eliminate the resident's attempts to ambulate the distance to the bathroom. 10. Physical therapy evaluates and treats as ordered and as needed. 11. 5/3/14 staff educates resident on hygiene needs and the risk of setting self on floor. Review of the facility's Fall Investigation Report 2, dated 6/26/14 at 12:20 a.m., indicated the staff heard a bump and found the resident on the floor of his/her room with visible dislocation of right wrist. The report indicated the resident had bare feet at time of fall, no alarm in place and no assistive device (wheel chair/walker) in use at time of fall. Staff assessed the resident and notified the physician and family and resident was transferred to the emergency room for further evaluation and treatment. Review of the Nurse's Notes dated 6/26/14 at 12:20 a.m. revealed the resident found on the floor of his/her room by staff. The nurse assessed the resident and noted distortion of the resident's right wrist. The nurse contacted the physician's Nurse Practitioner and orders received to have the resident transferred to the emergency room for further evaluation and treatment. Review of the resident's hospital visit summary dated 6/26/14 revealed the resident presented to the emergency department following a fall at the facility. The resident appears to have an isolated injury to the right distal forearm/wrist. X-rays have been obtained that reveal the resident to have a comminuted distal radius and ulnar fractures. Orthopedics was consulted, resident given pain medication, and procedure of closed reduction of fractures and splint applied. Orders given for the resident to follow-up with Orthopaedic. Review of the Nurse's Notes dated 6/26/14 at 1:30 p.m. revealed the resident returned from the hospital via ambulance at 11:00 a.m. The resident has a fracture to the right wrist and it is splinted. Staff performed a circulatory assessment to the resident's right upper extremity and is noted to be good. Review of the facility's Verification Of Investigation with occurrence date of 6/26/14 at 12:20 a.m. indicated CNA's Staff F and G heard the resident fall and call for help. Upon entering the room the resident was on the floor of his/her room between the bathroom door and the doorway of the room. Charge Nurse, Staff E was summoned to the resident's room, assessment done and resident noted to have deformity to right wrist, resident noted to be barefoot. The resident was sent to the emergency room and found to have a right closed distal ulnar and radial fracture. The fracture was reduced in the emergency room and splinted, and resident tolerated well. The facility documented immediate resident protection initiated included resident being sent to the emergency room and resident will be supervised while toileting and staff education provided on resident safety. The Investigation report indicated the resident was left unattended on the toilet, prior to the fall, with no safety interventions in place and the resident fell while attempting to self-transfer from toilet. CNA Staff A assisted the resident to the toilet right before midnight and left the resident unattended to assist another resident back to bed. Staff A stated she/he reported to oncoming staff that the resident was on the toilet when Staff A and Staff C, CNA, left the facility at 12:00 midnight, as it is the end of their shift and the 3rd shift CNA's staff were there. Staff C, CNA, reported that Staff A, CNA, was informed that she/he had assisted the resident onto the toilet shortly before midnight and prior to the incoming shift coming in and Staff A left the facility around 12:00 midnight, as the resident remained in the bathroom. Staff A reported at the time she/he had been tending to another resident and did not have any interaction with the resident during this incident. An interview on 8/1/14 at 11:33 a.m. and review of statement dated 6/26/14, Staff A, CNA. Staff A stated she assisted the resident to the bathroom shortly before midnight on 6/25/14. Staff A stated the resident had a night gown on and bare feet when Staff A transferred the resident onto the toilet, and removed the resident's incontinent brief and placed the resident's walker in the room, out of reach of the resident, and did not place an alarm on the resident. Staff A stated she/he is aware the resident is a fall risk and requires alarms at all times as the resident will attempt to self-transfer. Staff A reported he/she then left the resident unattended in the bathroom to assist another resident back to bed. Staff A stated she/he knew not to leave a fall risk resident that has alarms unattended in the bathroom, but felt she/he never received training regarding this when she/he was hired a month ago. Staff A, indicated after assisting the other resident she/he went to the nurses station, without checking on Resident #2 who is still in the bathroom, and reported to the nurse Staff E and CNA Staff F that resident #2 is on the toilet. Staff A stated while he/she informed the staff the resident is on the toilet, CNA Staff C who was Staff A's coworker on the shift went and removed the gait belt from the resident, who is sitting on the toilet, and both Staff A and Staff C left the facility at midnight. An interview on 7/31/14 at 2:31 p.m., and review of the facility interview dated 6/25/14, Staff C, CNA. Staff C stated that she and CNA Staff A were staying over on 2nd shift until the 3rd shift staff arrived. Staff C stated that Staff A assisted the resident to the toilet around 11:30 p.m. and left the resident unattended and Staff C stated she/he doing cares on another resident at the time. Staff C reported that Staff A can confirm that Staff A did inform nurse Staff E that the resident is on the toilet. Staff C stated that a resident should never be left unattended on the toilet that was a fall risk. Staff C stated she/he did not have any interaction with the resident during this incident and left with Staff A shortly after midnight after giving report to the oncoming shift. An interview on 7/31/14 at 3:39 p.m. and 8/8/14 at 3:50 p.m., and review the facility Witness Report dated 6/26/14. Staff E, RN (Registered Nurse). Staff E stated Resident #2 was left unattended on the toilet and that it should never happened as the resident is a fall risk and makes frequent attempts to get up on his/her own and alarms are always to in place for the resident. Staff E stated the resident does not use call light and is occasionally incontinent of stool and wears incontinent briefs. Staff E states that CNA Staff A informed her/him that the resident is on the toilet when oncoming shift came in. Staff E assumed that CNA Staff C to be with the resident and had assisted the resident back to bed. Staff E indicated he/she never followed-up with staff that and assumed the resident to be in bed when CNA Staff A and C left the facility, but indicated she/should have. Staff E reported she/he was called to the resident's room at 12:20 a.m. by staff and found the resident on the floor between the bathroom door and hall door. Staff E stated the resident had no shoes on, the resident's walker not within reach of the resident, the floor dry, no call light on or alarm sounding, Staff E does not recall if resident had brief pulled up but Foley catheter in place. Staff E indicated the resident had taken approximately 5 to 6 steps before falling due to the distance he/she fell from the toilet. Staff E stated he/she assessed the resident and noted the resident's right wrist deformity. Staff notified the resident's physician and the resident sent to the emergency room via ambulance. Review of Staff F, CNA, Witness Report dated 6/26/14 at 1:45 a.m. Staff F reported he/she came into work at midnight on 6/25/14. Staff F indicated that CNA Staff A and C worked the 3rd shift and never received report from the off going shift. Staff F stated she/he and Staff G headed down the south hall were Resident #2 is located and heard a scream and seen the resident on the floor. Staff F stated the nurse was summoned and the resident sent out to the hospital. Review of Staff G, CNA, Witness Report dated 6/26/14 at 1:30 a.m. Staff G reported she worked 6 p.m. to midnight on 6/25/14 and then went to the floor at 12:05 a.m. Staff G reported when she/he got to the floor she saw CNA Staff A and C, the off going CNA's, filling out time card adjustments with nurse Staff Eat the nurses station and then both left the facility. Staff G stated she/he or coworker received any report from the off going CNA's before they left the facility. Staff G stated that he/she and Staff F were not aware that the resident to be on the toilet until they were heading up south hall around 12:20 a.m. and heard the resident fall and yell for help. Staff G reported that she/he and Staff F entered the resident's room and found him lying on the floor between the bathroom door and the room door. Staff G summoned for the nurse and the resident sent out to the hospital. Interview on 7/31/14 at 1:32 p.m., the DON (Director of Nursing) stated the staff should have never left the resident unattended on the toilet, as it is against the facility policy (no written policy could be produced). The DON stated staff are trained not to leave a fall risk resident unattended on the toilet. The DON indicated staff was at fault for the resident's fall and that CNA A received a written disciplinary action for leaving the resident unattended. 2. According the MDS (Minimum data set) assessment tool with a reference date of 07/2/14, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory problems and modified cognitive skills for daily decision making. The MDS noted Resident #1 required extensive assistance of one staff members to physically assist with bed mobility, transfers, ambulation, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident balance during transitions and walking not steady, and resident able to stabilize with staff assistance. The MDS documented the resident normally used a wheelchair for mobility. The MDS documented the resident had two falls since admission and one fall since admission with a major injury. Review of the facility Fall Risk assessment dated [DATE] indicated a total assessment score of 17. A total score of 10 or above represents high risk. The Care Plan with an initiated date of 06/28/14 listed a Focus of resident at risk falls and history of falls. The Care Plan listed approaches that directed staff to: 1. Resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; working and reachable call light, the bed to be in low position with a fall mat; handrails on walls, and personal items within reach. 2. Resident requires a pressure alarm to his/her bed and chair and ensure the device is in place and working every shift. 3. Staff encourage resident to participate in activities that promote exercises, physical activity for strengthening and improved mobility. 4. Staff insures the resident wears appropriate footwear when transferring, ambulating or mobilizing in wheel chair. 5. Staff follows fall protocol. 6. Physical therapy requested to evaluate and treat as ordered and needed. 7. Resident uses a low bed with a fall mat and no side-rails at this time. 8. Resident #1 ambulates while holding hands with one staff member. Resident does not use other devices at this time. Review of the facility's Fall Investigation Report 2, dated 7/1/14 at 7:15 p.m., indicated the resident fell in his/her room sustained a skin tear and a raised hematoma to the head. Staff assessed the resident and notified the physician and family the resident was then transferred to the emergency room for further evaluation and treatment. Review of the Facility's Verification OF Investigation dated 7/1/14 at 7:15 p.m. revealed investigation findings that a CNA assisted the resident to room at 6:00 p.m. Two family members came in to visit and sat on the bed with the resident, resident sitting up on edge of bed with family member at each side of resident. At 7:00 p.m. when a CNA entered room to assist another resident one family member remained with Resident #1. Family member did not notify staff upon departing the facility. At 7:15 p.m. staff received notification by the resident's roommate the resident was on the floor. Resident #1 found sitting in front of his/her nightstand. Bed in low position. Resident had clothes and shoes on. Floor carpeted and dry. Staff documented no objects or obstruction in the resident's path. Resident #1 did not say why she/he attempted to get up. Resident #1 with history of impulsive movements/transfers. Review of the Nurse's Notes dated 7/1/14 at 7:15 p.m. reveled nurse called to the resident room due to resident had fall and staff found resident on the floor. Staff noted resident #1 ' s head laceration was bleeding. Neurological checks performed, resident alert and orientated to name and time, tongue is midline, grips equal, eyes reactive to light. Resident #1 denies pain and bleeding stopped with pressure applied. The nurse contacted the physician's Nurse Practitioner and orders received to observe resident and report any neurological changes. Staff notified resident's family. Staff continued to monitor the resident and at 2:00 a.m. on 7/2/14 staff noted a change in the resident's condition and staff contacted the resident's Nurse Practitioner and orders received to send the resident to the emergency room for further evaluation and treatment. Staff notified family of the transfer. Interview on 7/31/14 at 2:31 p.m. with Staff C, CNA. Staff C stated he/she walked the resident from the dining room to the resident's room around 6-6:30p.m., and sat him/her on the bed to assist the resident in getting ready for bed. Staff C stated the resident's two sons came into room and sat on each side of the resident on the bed. Staff C stated he/she did not put the mat on the floor or activate the bed pressure alarm before leaving the room. Staff C stated she did not inform the sons of the resident's fall safety interventions that are to be in place nor did Staff C asked the sons to let staff know when they leave the resident. Staff C stated he/she left the resident's room and informed Staff B, CMA (certified medication aid), that the resident is in the room visiting his/her sons; did not tell Staff B that resident did not have alarm on or that fall mat not on floor. Staff C stated he/she clocked out and went to lunch. Staff C stated he/she then standing by the nurses station when she/he heard Staff B yell out for help. Staff C indicated she/he should have activated the resident's bed alarm, place mat down, and informed family to let her know when they leave the resident. Staff C stated the resident dressed and had shoes on when he/she left the room. Interview on 7/31/14 at 2:04 p.m. with Staff B, CMA, revealed he/she came back from supper break at 6:40 p.m. Staff B stated he/she assisted a resident to bed and when Staff B came out of that resident's room Staff B observed Resident #1's roommate in hall. Staff B stated the roommate told him/her that resident #1 was on the floor, sitting with legs out front and back against dresser by bed. Staff B stated no alarm sounding. Staff B stated she summoned for the nurse and Staff D, RN and Staff E, RN responded. Staff B stated she/he does not recall Staff C telling her/him that resident did not have alarm on or fall mat in place, just assumed they were in place when Staff C left the unit. Staff B indicated he/she did not inform the family members to let staff know when family departure the facility. Staff B indicated prior to resident's fall one family member left and the other remained in the resident's room but Staff B did not see the other family member leave. Staff B stated staff members usually inform family/visitors to let staff know when they leave so staff can ensure safety interventions are in place for the residents. Interview on 7/31/14 at 3:00 p.m. with Staff D, RN. Staff D reported around 6:30 p.m. on 7/1/14 he/she was at the nurse ' s station when she heard staff yell out for help. Staff D stated he/she headed to the resident's room and on the way summoned Staff E, RN to come. Staff D stated the resident was sitting on floor with legs out front and back against the dresser by the bed. Staff D indicated he/she does not recall the resident's floor mat in place or not, no alarm sounded. Staff D stated he/she assessed the resident and then Staff E took over. Staff D stated the resident is to have a pressure alarm in place at all times while sitting or in bed and a fall mat by bed. Staff D stated that staff members receive direction to ensure that all safety interventions are in place even when family/visitors are with a resident and to educate the family member on the safety interventions. Interview on 7/31/14 at 2:00 p.m., the DON (Director of Nursing) stated resident #1 ' s fall to be a freak accident. CNA staff C had the resident sitting on the bed and Staff C was standing next to resident and was going to get the resident ready for bed when two of the resident's sons from out of state entered the room and sat on each side of the resident on the bed. The DON stated Staff C did not put the pressure alarm or fall mat in place and Staff C left the resident's room and Staff C did not inform the family members of the safety interventions or for them to inform staff when they departed the facility The DON stated the resident passed away on 7/3/14 in the hospital

Based on record review, interviews with staff and laboratory personnel and review of faciltiy policy/procedures, the facility failed obtain and monitor laboratory tests related to anticoagulant medication usage for 1 of 4 residents reviewed (Resident #13) and failed to provide non- pharmacological interventions before administering antianxiety and antidepressant medications for 3 of 7 residents reviewed (Resident #3,#5, #7), failed to document responses to the administered medication for 3 of 7 residents reviewed (Resident #3,5, 7) and failed to provide rational for the lack of a gradual dose reduction of antidepressants for 1 of 7 residents reviewed. (Resident #7). The facility identified a census of 51 residents. Findings include: 1. Resident #13 had an admitted documented on the facility face sheet as 7/10/13. A University of Iowa Hospitals and Clinics visit summary dated 7/15/13 documented the resident's physician documented [DIAGNOSES REDACTED].#13's initial admission evaluation by the physician. Information documented under the history section of the physician's visit summary revealed the resident also had an admission to the facility following a small bowel obstruction which required surgery. An abdominal wound healing with the help of a Wound-Vac was required. The documentation reflected [MEDICATION NAME], ([MEDICATION NAME]) an anticoagulation medication as satisfactory but a still bit unstable. Documentation revealed the resident's physician as planning on seeing the resident again on 8/12/13. Review of the physician's orders [REDACTED].) (In combination, physician's use the PT and INR blood tests to monitor the effectiveness of [MEDICATION NAME] therapy by determining how quickly the person's blood will make clots.) The resident's plan of care dated 7/23/13 documented a focus (problem) of the resident receiving anticoagulant therapy ([MEDICATION NAME]) related to a post- surgical procedure for a small bowel obstruction. The interventions directed staff to perform the following: a. Labs as ordered. Report abnormal lab results to the MD (physician). b. Inspect skin daily with cares. Report abnormalities to the nurse. c. Administer anticoagulants per physician's order [REDACTED]. Avoid use of aspirin or NSAIDS (nonsteroidal anti-[MEDICAL CONDITION] drugs). d. Monitor/document/report to MD as needed signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. e. Antidote is Vitamin K. Have on hand for emergencies. Review of a LabCorp laboratory lab sheet dated 7/12/13 revealed an INR result of 3.8 High (normal reference range 0.8-1.2) and a [MEDICATION NAME] Time of 39.0 High . Documentation on the laboratory report revealed the physician was notified of the abnormal results on 7/12/13 with the physician giving the order to hold the resident's [MEDICATION NAME] medication on 7/12/13 and to restart 2 milligrams [MEDICATION NAME] daily except 1 milligram on Monday - Wednesday- Friday with a re-check of the PT/INR in 1 week as verified by Staff F, LPN on 10/15/13 at 10:45 a.m. Review of the clinical record revealed no laboratory work of PT/INR was completed for the resident on 7/19/13 and no lab work completed on a weekly basis as ordered by the physician with initial admission. A University of Iowa Hospitals and Clinics visit summary dated 8/12/13 revealed the resident's physician visited on that date. Under the history section, the physician documented: Of note, [MEDICATION NAME] times have not been obtained weekly. The last determination was 7/12/13 just before the last visit when the INR was 3.8 and [MEDICATION NAME] was reduced. Under the impression section: the physician documented: Regular monitoring of [MEDICATION NAME] anticoagulation is important. Need for weekly [MEDICATION NAME] in accordance with the admission order was reasserted to staff. Under PLAN the physician documented: [MEDICATION NAME] ASAP (as soon as possible) was requested with starting of weekly [MEDICATION NAME] on the lab day to commence. Less frequent monitoring once anticoagulation is stable. Review of a physician's orders [REDACTED]. 1. [MEDICATION NAME] ASAP 2. Weekly [MEDICATION NAME] (dx (diagnosis) [MEDICATION NAME] anticoagulation On 8/12/13 a PT/INR result revealed the INR to be at a critical level of greater than 10.0. Notification of the physician took place on 8/12/13 and the following orders from the physician directed staff to: 1. DC (discontinue) [MEDICATION NAME] 2. Give Vitamin K 5 milligrams by mouth ([MEDICATION NAME]) Now from (Emergency Kit) (Vitamin K reverses the effect of blood thinning) 3. Repeat PT/INR on Friday and report to Dr. An interview with a Lab Corp representative on 10/15/13 at 1:00 p.m. revealed verification that the only lab requisitions requested by the facility for a PT/INR came dated for 7/12/13 and 8/12/13. During an interview on 10/15/13 at 1:45 p.m. the facility Director of Nursing (DON) reported 10 nurses as in-serviced about laboratory procedures related to the error of missed PT/INR lab testing for Resident #13. That date of in-servicing with review of facility documentation took place on 8/13/13. The DON stated the resident's physician discovered the resident's PT/INR's as not completed when he visited the resident on 8/12/13 with missed PT/INR lab work not completed for 7/19, 7/26, 8/2 and 8/9/13. The DON stated the previous system in place for obtaining lab work consisted of the lab order being obtained and the order noted which consisted of a lab requisition form written for the lab (laboratory) and then putting this form into the lab book and writing on the lab calendar the date of the needed lab. The DON stated there was no system for checks and balances and the physician ordered weekly PT/INR's for Resident #13 as not noted and not completed. The interview continued with the reported process of the revised PT/INR System consisting of the following: 1. Any lab orders that come in have the resident's name put on the lab calendar along with the lab to be drawn. The lab calendar is a black leather binder at the nurse ' s station. 2. The charge nurse on the day shift on Thursday is responsible to check the lab requisitions and the lab calendar and to make sure they match up. That nurse checks the box on the lab calendar and initials this when they confirm this has been completed. 3. The overnight nurse does the same thing for a second check. 4. On the medication sheet (MAR) there is written PT/INR on the scheduled day the physician orders [REDACTED]. The DON indicated there are 3 sets of eyes on the requisitions and on the calendar. 5. Staff H, registered nurse, goes through the resident charts every Thursday to make sure all the lab work is documented completely. If Staff H, RN is absent, then the DON stated she would do this. The DON stated she and Staff H, RN are working very closely on this. Additionally with further interview on 10/15/13 at 11:20 a.m. the DON stated the facility has in place a double noting system which consists of the following: 6. When a new order is received for a resident, the nurse red lines the it (puts a red tag on the spine of the resident's chart and puts a red tag on the order in the resident's chart to denote a new order has come in). The 3rd shift nurse is responsible for double noting of orders. The DON stated if the lab draw would be scheduled to occur on a holiday the lab would send out a memo as to what day the lab would be drawn. The lab sends and/or calls laboratory results to the facility and it is the facility's responsibility to notify the physician of the results unless the lab has specifically written on the lab form that they have notified the physician of the results. The DON stated it is the responsibility of the charge nurse to make the physician aware of the results of the lab. Review of the Verification of Investigation form with an occurrence date of 8/12/13, provided information reflecting the order for the resident ' s weekly PT/INR did not get transcribed onto the lab calendar and requisition form. On 10/16/13 at 11:00 a.m. Staff H, registered nurse was interviewed and stated they (staff) are able to explain the new system that is now in place for the noting and monitoring of new laboratory orders. Staff H stated she helps check on the orders on Thursdays and double checks the lab orders. Staff H stated if she is gone then the DON would do this and vice-versa. On 10/16/13 at 3:30 p.m. Staff I, licensed practical nurse was interviewed and stated she was able to articulate and demonstrate the process in place for noting and monitoring of laboratory orders. On 10/16/13 at 4:10 p.m. Staff F, licensed practical nurse was interviewed and stated she rarely takes a physician's orders [REDACTED]. Staff F, LPN articulated the process now in place when asked to do so for the surveyor. On 10/16/13 at 4:40 p.m. E, registered nurse, was interviewed and stated as a nurse, she is responsible for the error of missing the physician ordered lab work for Resident #13 but felt she was not solely responsible. Staff E stated she wrote down the initial order for the resident's PT/INR on 7/12/13 on the laboratory calendar and wrote out the required requisition form but did not continue to put it on the laboratory calendar. Staff E stated she noted the admission orders [REDACTED]. In the presence of 2 surveyors, Staff E was able to verify the process and understood the process now in place for the facility related to physician's orders [REDACTED]. On 10/17/13 at 7:45 a.m. Staff G, registered nurse was interviewed and had the ability to articulate and demonstrate the process for the noting and monitoring laboratory orders. When reviewing the new facility procedures, Staff G, stated this new procedure has more safe guards in it than the previous noting system. On 10/17/13 at 10:10 a.m. Staff J, Registered Nurse was interviewed and was able to articulate the process now in place related to noting of physician's orders [REDACTED]. Staff J stated he does not remember the old process that was in place but the process in place now is very lengthy and precise now. On 10/15/13 at 11:15 a.m. the Director of Nursing was interviewed and stated Resident #13 was discharged to home on 8/13/13 with family. The Director of Nursing stated an appointment was made with a nurse practitioner to see the resident on Thursday or Friday of that week for follow up care. The Director of Nursing stated the facility had informed the family member of necessary repeat lab work on 8/16/13. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By 8/13/2013, the facilty had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The facility created a PT/INR Monitoring System policy and provided an in-service to nursing personnel. As of 10/17/13 exit conference, the faciltiy continued to need to: .Continue to in-service all nursing personnel of the new PT/INR Monitoring System policy, .Monitor nursing staff to ensure compliance with the PT/INR Monitoring System policy. 2. The Care Plan for Resident #5 identified a focus with behaviors. Resident #5 frequently calls out (help or hello, etc.) when becomes agitated or anxious. The listed interventions directed facility staff in part to: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. c. Minimize potential for disruptive behaviors by offering tasks which divert attentions such as offering snacks, drinks, etc. A Care Plan goal was identified as: Resident will have no evidence of behavior problems by review date. Review of the admission physician order [REDACTED]. May take 1/2 tab -1 tab (0.25 milligrams - 0.5 milligrams) by mouth every 4 hours PRN (as needed) for anxiety. Review of a October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The behavior monitoring flow sheet was reviewed. The MAR indicated [REDACTED]. The monthly behavior monitoring flow sheet revealed no response as to the outcome of the resident's anxiety after administration of the medication. Continued review of the October 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The monthly behavior monitoring flow sheet revealed no response as to the outcome of the resident's anxiety after the administration of the medication. On 10/17/13 at 3:10 p.m. the Director of Nursing was interviewed and verified the lack of needed documentation for the non- pharmacological interventions utilized before the administration of the anti-anxiety medication on 10/11 and 10/15/13 and the need for resident response documentation to the administered medication. 3. Resident #7 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A consultant pharmacist note dated 6/27/13 documented the resident as taking both of the medications for symptoms of depression and a requirement for an annual dose reduction to ensure lowest effective dose or the discontinuation of medications unless contraindicated. The note proceeded to reflect: please consider stopping the low [MEDICATION NAME] dose at this time. If a reduction cannot be attempted at this time, please include a short note to explain. Review of the record revealed on 7/2/13, the advanced registered nurse practitioner (ARNP) responded the medication to remain. On 10/16/13 the Director of Nursing received notification from the surveyor that no clinical contraindication with rational provided from the physician could be found in the clinical record for the medications of [MEDICATION NAME] and [MEDICATION NAME]. At that time the Director of Nurses stated she would get that from the ARNP. On 10/17/13 at 1:15 p.m. the Director of Nursing handed the surveyor an updated but undated sentence on the pharmacy recommendation report that the resident ' s behaviors remain poor with decreased mood. 4. The MDS with a reference date of 10/02/13, documented Resident #3 had severely impaired daily decision making skills. The MDS revealed in the last seven days the resident had taken antipsychotics, antianxiety, and antidepressant medications. The Resident Care Plan documented a focus area for the resident as disruptive behavior when the resident would repeatedly yell out "help" even when staff were sitting right beside the resident giving one to one attention, and the resident had a history of [REDACTED]. The Resident Care Plan directed staff to provide the following interventions, assess and anticipate resident needs such as food, thirst, toileting needs, comfort level, body positioning, and pain. The Care Plan directed staff to document observed behaviors by the resident and attempted interventions in the behavior log, and call the resident's spouse to talk with the resident for attempts to calm the resident. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Record revealed the order Trazadone 50 milligrams by mouth every six hours PRN (as needed). Upon review of the October 2013 Nurse ' s Notes and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was a lack of documentation as to the effectiveness of the PRN Trazadone for four out of six times it had been given. Review of the Residents Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Record revealed the order Trazadone 50 milligrams by mouth every six hours PRN. Upon review of the September 2013 nurses notes, medication record dated 9/13, and the behavior logs for September the documentation lacked nonpharmicological intervention attempts six out of six times prior to the administration of PRN Trazadone, and lacked documentation as to the effectiveness of the PRN Trazadone for two out of six times it had been given. Review of the Residents Medication Record dated 8/13 documented the resident received Trazadone 50 milligrams eleven times. The Medication Record revealed the order Trazadone 50 milligrams by mouth every six hour PRN. Upon review of the August 2013 nurses notes, medication record dated 8/13, and the behavior logs for August the documentation lacked nonpharmicological intervention attempts for four out of eleven times prior to administration of PRN Trazadone, and lacked documentation as to the effectiveness of the PRN Trazadone for three out of the eleven times it had been given. During an interview on 10/17/13 at 11:55 a.m. Staff K, registered nurse reported if a resident had displayed behaviors or anxiety, the staff would at least try a couple different things prior to giving the resident a PRN medication. For example: decrease stimulation, redirect the resident, offer toileting or food, let the resident vent his/her feelings, offer position change, and might even take the resident to the low stimulus unit.

The following deficiency relates to complaint -I and complaint -C: Based on observation, record review, staff interviews and policy/procedure review, the facility failed to protect Resident #1 from a hazard when a staff person released a whirlpool seat belt and failed to adequately supervise the resident by turning away from the resident. Resident #1 attempted to stand and slipped out of the chair which resulted in a fractured hip and fractured cervical vertebrae #1 and cervical vertebrae #2. Staff found Resident #2 on the bathroom floor. The resident had removed the shirt which had the tab alarm. The bed alarm did not sound and had not been turned on by staff. The facility reported a census of 50 residents. The sample consisted of 5 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 1/28/12. The assessment reflected Resident #1 had a BIMS (Brief Interview for Mental Status) score of 7. A score of 7 indicated the resident had an impairment of short and long-term memory and moderately impaired for cognitive skills for daily decision making. Resident #1 displayed no adverse behavioral symptoms. Resident #1 required extensive assistance with physical assistance of two staff with transfers, bed mobility, dressing, toilet use, personal hygiene and bathing. The assessment indicated Resident #1 was not stable when moving from a seated to standing position, moving on and off a toilet and moving from surface to surface, but able to stabilize without human assistance. Resident #1 had [DIAGNOSES REDACTED]. The Care Plan identified a problem with self care deficit which required supervision and cueing due to cognitive and memory problems and a risk for fall with approaches including: a. Transfers with assist of two staff or more as needed. b. Geri chair for locomotion propelled by staff. c. Body alarm at all times. d. Pressure alarm when in bed. e. Assure environment is free of wet spots and clutter. f. If not wearing shoes make sure resident is wearing non slip slippers prior to transfer or ambulation. A Fall Risk Evaluation dated 1/27/12 indicated Resident #1 with a score of 14. The total score of 10 or above represented high risk. In an interview on 5/8/12 at 3:00 p.m. Staff I stated Resident #1's condition declined in November 2010 and on 1/24/11 he/she was referred to hospice. Resident #1 had been independently mobile and now required a wheelchair for mobility and a stand lift for transfers. On 2/4/11 a geriatric chair was introduced due to Resident #1 having difficulty maintaining his/her posture. The geriatric chair was effective and became a permanent assistive device for the resident ' s comfort and positioning. On 4/30/12 at 2:50 p.m., Staff O (Certified Nursing Assistant) was interviewed and stated on 4/20/12 at 7:30 p.m. she had just finished giving Resident #1 a whirlpool bath. Resident #1 was in the whirlpool chair and pulled onto the carrier where Staff O was assisting with drying Resident #1. Resident #1 asked Staff O to remove the safety belt. Staff O released the belt and as she made a half turn to grab another towel, Resident #1 attempted to stand on the tile floor, slipped and fell on to his/her right side on the floor. Staff O stated when Resident #1 requested the belt be removed, she did so because she did not want Resident #1 to become combative. Staff O stated Resident #1 has a history of combativeness and behaviors and she was trying to avoid those behaviors. Staff O indicated Resident #1 was being very nice and cooperative at the time and she did not see a problem. Staff O also felt by not releasing the safety belt upon request it would be a restraint. In a second interview on 5/8/12 at 11:00 a.m. Staff O stated Resident #1 was transferred from his/her geriatric chair into the whirlpool chair with assist of another staff. The safety belt was applied and the geriatric chair moved to the side. Staff O proceeded to give Resident #1 a whirlpool bath. Following the bath, Resident #1 was given a towel to dry off and he/she stated, "Get this thing off of me", referring to the safety belt. Staff O took the belt off and continued to dry off Resident #1. Staff O made a half turn to grab a towel off the sink and as she did she heard the carrier rattle and saw Resident #1 pushing him/her up from the chair in an attempt to stand. Resident #1 immediately slipped and fell landing on his her right side. Staff O immediately went to the whirlpool room door and called for help. In an interview on 5/8/12 at 4:06 p.m. by phone, Staff P (Licensed Practical Nurse) stated he was called to the whirlpool room and informed Resident #1 had fallen. Upon entering the room Resident #1 was sitting on his/her buttocks, leaning to the right, totally naked. Resident #1 was complaining of right hip pain, but resistive to allowing Staff P an opportunity to assess him/her. Resident #1 was stating, "no, no, I want to get up". Resident #1 was lifted from the floor with assist of three staff and a gait belt, placed in a geri chair and taken to his/her room and transferred into bed. Resident #1 was then cooperative with allowing Staff P to assess him/her. The physician was notified and Resident #1 was sent to the emergency room . Radiology report dated 4/20/12 indicated Resident #1 with a mildly displaced right subcapital femoral fracture (hip). Moderate right posterior subluxation of C1 and C2 with no central spinal canal stenosis (narrowing). A moderate compression deformity at T3 which is age indeterminate. On 4/30/12 at 2:40 p.m. Staff K (Certified Nursing Assistant) was interviewed and stated the safety strap on the whirlpool chair is not to be released until staff are prepared to transfer the resident into another chair. Staff K stated she would not have felt safe to release Resident #1's safety strap. Observation on 5/2/12 at 3:20 p.m. revealed Staff F give a resident a whirlpool bath. The resident was transferred into the whirlpool chair and the safety strap appropriately secured. Following the whirlpool the resident was pulled onto the carrier and the resident began drying him/herself off. Staff F assisted and after placing the resident's shirt on, Staff F released the safety strap and proceeded drying the lower extremities. On two occasions Staff F walked around the privacy curtain to obtain supplies, leaving the resident unattended. In an interview on 5/2/12 at 3:40 p.m. Staff F stated the whirlpool seat belt was to remain on the resident until the resident was ready to be transferred. Staff F asked why the resident he just gave a whirlpool to had the safety strap released prior to being prepared for transfer. Staff F indicated he usually doesn't release the belt but felt comfortable with that resident (independently mobile). Staff F went on to say Resident #1 was difficult because he/she does not like the belt on him/her and can become combative. Staff F indicated he has released Resident #1's belt prior to preparing to transfer. In an interview on 5/2/12 at 3:45 p.m. Staff I (Director of Nursing) stated Staff O failed to follow facility policy when she unstrapped the safety belt on Resident #1 before he/she was prepared to be transferred and before a second staff was present to assist with that transfer. When asked, Staff I was unable to clarify in facility policy where it specifically addresses removal of the safety strap following a whirlpool. Staff I insisted the standard had been discussed in staff in-services. Review of the Policy and Procedure for Whirlpool Bathing (not dated) directed staff to unlatch the seatbelt to transfer and did not direct staff to unlatch and obtain supplies. On 5/8/12 at 11:35 a.m. Staff Q (indicated she has [AGE] years experience and has only been at the current facility 4 weeks). Staff Q stated upon hire she was instructed to leave the belt on until the bath was finished and staff was ready to transfer. Staff Q stated she has been asked by residents to remove the belt prior to being prepared for transfer and she has told the residents the belt is for their safety and can't be removed. Staff Q stated she has not had an opportunity to bath Resident #1, but knows he/she can become combative when doing cares and will kick, scratch, bite and yell. Staff Q stated when she needs assistance in the whirlpool room, she uses the call light. In an interview on 5/8/12 at 12:00 p.m. Staff C (Certified Nursing Assistant) indicated the belt on the whirlpool chair is not to be released until the resident is ready to be transferred. Staff C indicated if the resident is a two person assist, the second person must be available. If the resident is a one person assist, she would place on a gait belt prior to releasing the whirlpool belt and if the resident is independent, she releases the belt if they request. Staff C indicated she has given Resident #1 a bath and Resident #1 has become combative. Resident #1 has requested the belt be removed and depending on Resident #1's mood, Staff C has removed it prior to Resident #1 being prepared for transfer. In an interview on 5/8/12 at 12:25 p.m. Staff D (Certified Nursing Assistant) indicated the whirlpool safety belt should not be removed until the resident is ready to be transferred. Staff D indicated she has given Resident #1 a bath and Resident #1 has never asked her to remove the belt. In an interview on 5/8/12 at 3:30 p.m. Staff M (Certified Nursing Assistant) indicated following a whirlpool bath, she would assist the resident with drying their upper body first, then dress the upper body and proceed with drying off and dressing the lower body. Staff M would then release the safety belt, apply a gait belt and transfer the resident. If the resident was a two person assist, Staff M would turn on a call light and wait for assistance before transferring the resident. Staff M indicated she had not received any training from the facility regarding the whirlpool and safety belt use. Staff M knew what to do from past work experience. On 5/8/12 at 3:45 p.m. Staff R (Certified Nursing Assistant) was interviewed and stated the whirlpool chair belt is to be attached throughout the whirlpool and only removed after the whirlpool and when the resident is ready to be transferred. Staff R stated Resident #1 has had some behaviors when taking a bath, but has never asked Staff R to remove the belt. On 5/8/12 at 4:00 p.m. Staff B (Certified Nursing Assistant) was interviewed and stated the whirlpool belt stays on the resident until the resident has been partially clothed. Once the shoes have been put on and the resident is ready for transfer, the gait belt is put on and the belt removed. Staff B indicated she learned this standard in school. Staff B indicated she did not receive any training from the facility. 2. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 1/28/12 which indicated the resident had a BIMS score of 3. This score reflected the resident had an impaired short and long-term memory deficits and severely impaired cognitive skills for daily decision making. Resident #2 displayed no adverse behavioral symptoms. Resident #2 required extensive assistance with physical assistance of two staff with transfers, bed mobility, dressing, toilet use, personal hygiene and bathing. The balance assessment reflected Resident #2 as not stable when moving from a seated to standing position, moving on and off a toilet and moving from surface to surface and only able to stabilize human assistance. Resident #2's [DIAGNOSES REDACTED]. Resident #2's plan of care indicated the resident at high risk for fall and directed the staff that the resident required a pressure alarm when in bed or chair. The Nurse's Notes dated 4/16/12 at 3:25 a.m. written by Staff P indicated a CNA called Staff P to Resident #2's room to find the resident lying naked on the bathroom floor. Resident #2 was assessed and denied any pain or discomfort. Staff P noted Resident #2 had removed his/her clothes which attached the tab alarm. The pressure alarm was on the bed but the alarm was not turned on. Neither alarm system sounded. Witness Report written by Staff S on 4/16/12 indicated at 3:25 a.m. Staff S was near the front desk when she heard a commotion. Upon investigating, Staff S found Resident #2 sitting in the bathroom entryway naked. Resident #2 indicated he/she was not in pain. A small scrape was noted on his/her lower left side. Staff S indicated she last saw Resident #2 in bed at around 3:15 a.m. Employee Disciplinary Action forms indicated Staff S and Staff T were both given written warnings for failing to assure Resident #2's pressure alarm was turned on.