Every finding on record at Peabody Retirement Community

Based on interview and record review, the facility failed to ensure hospital discharge orders were accurately transcribed to ensure continuation of treatment for 2 of 3 residents reviewed for new admissions. (Resident B and Resident D)Findings include:1.Resident B's clinical record was reviewed on 6/29/26 at 9:29 a.m. Diagnoses included essential (primary) hypertension, anxiety disorder, depression, and bipolar II disorder.A behavioral health care office note, dated 2/4/26, indicated Resident B's medications included bupropion (antidepressant) 200 milligram (mg) every morning and at noon, and divalproex (anticonvulsant/mood stabilizer) 500 mg in the morning and 1000 mg at bedtime. He was discharged from the hospital to the facility on 3/11/26. Discharge orders included bupropion 450 mg daily, divalproex sodium 500 mg daily, divalproex sodium 250 mg twice daily, and divalproex sodium 1000 mg at bedtime. The March 2026 Medication Administration Record (MAR) indicated divalproex sodium 500 mg at bedtime and divalproex sodium 250 mg twice daily.The clinical record lacked an order for bupropion 450 mg daily, divalproex sodium 500 mg daily, and divalproex sodium 1000 mg at bedtime.A nurse practitioner note, dated 3/12/26 at 12:14 p.m., indicated that he was seen as a new admission and his medications were reviewed.A nurses note, dated 4/17/26 at 5:48 p.m., indicated the resident expressed concerns about a higher dose of divalproex while at another facility and asked if the nurse practitioner needed to change his order. The psychiatric nurse practitioner and the facility nurse practitioner were notified regarding the situation. Multiple times throughout the day, he inquired about a dosage change. Before supper, he became angry that the nurse practitioner had not replied.A nurses note, dated 4/17/26 at 7:05 p.m. indicated a new order was received for divalproex sodium 750 mg twice daily and to monitor for targeted behaviors related to psychotropic medication therapy including quick-to-anger or agitation, mood swings, and verbal aggression.A nurses note, dated 4/18/26 at 10:54 a.m., indicated a new order was verified by the psychiatric nurse practitioner for divalproex sodium 500 mg daily and 1000 mg at bedtime.A nurses note, dated 4/22/26 at 6:00 p.m., indicated he was observed coming out of the dining room and indicated that his meal order was wrong again and he was upset. He became increasingly agitated due to receiving insulin and needing to eat. An aide stepped toward him indicating that he would get the correct meal and bring it to his room. Resident B raised his cane into the air but did not swing or strike with it demonstrating restraint. He indicated that the aide stepped too close to him and thought that it might be aggressive. The aide stepped back and indicated that he was trying to help and went to get the resident's tray. Later, Resident B apologized to staff members for his behavior.A nurses note, dated 4/24/26 at 12:50 a.m., indicated he was very adamant that he would continue to be on his best behavior as he wanted to be able to move to assisted living.A nurses note, dated 4/28/26 at 12:25 a.m., indicated he was very adamant that he would continue to be on his best behavior as he wanted to be able to move to assisted living.A nurse practitioner note, dated 5/6/26 at 9:48 a.m., indicated he was seen for increased behaviors. He reported significant frustration and agitation related to disruptions in his daily routine. He described being upset about food service issues in the dining room, stating he was told he was to be served within 15 minutes per his meal ticket but this has not been occurring. He mentioned that he had received psychiatric care through a local behavioral care office for many years. He described feeling burnt out and physically fed up. He presented with increased behavioral issues and reported significant frustration with facility routines, dietary services, and interactions with staff. A urine dipstick would be obtained to rule out urinary tract infection as a cause of increased behaviors and obtain a follow up with the local behavioral health care office.A behavior note, dated 5/6/26 at 1:45 p.m., indicated he became upset at breakfast when he requested a food item. Staff went to retrieve the item, and he began yelling at staff. A CNA intervened trying to de-escalate the situation. He became more angry and balled up his fist and made threats at the CNA. He left dining room demanding his food be brought to him in his room and for the food to be warm. He was provided a room tray with new food and drinks. He continued to raise his voice and be demanding.A nurses note, dated 5/6/26 at 6:27 p.m., indicated at 8:00 a.m. he was asked if his blood sugar could be obtained. He indicated that his blood sugar needed to be taken first then his food needed to be ready. It was indicated that the nurse would get his blood sugar and would give the insulin before breakfast. He asked if the kitchen was ready and the nurse indicated the they were not sure. He yelled that the nurse was supposed to take care of him and do their d--n job. The nurse educated him to speak respectfully to people and to stop yelling.A nurses note, dated 5/6/26 at 6:38 p.m., indicated at 12:00 p.m., he was yelling in dining room, and observed balling up his fist and threatening to hit a caregiver who was standing in front of a peer resident. He walked out of dining room, to his room and slammed the door. When he was asked what had happened he held his hand up and indicated that he was not talking to anyone until he called his POA.A social service note, dated 5/7/26 at 10:57 a.m., indicated the local behavioral health care office was contacted. An appointment was scheduled for the next day.A local behavioral health care office visit note, dated 5/8/26, indicated order was placed for divalproex blood level to assess current therapeutic range, given recent medication administration inconsistencies. Once laboratory results were available, the resident's medication regimen would be reviewed and adjusted as necessary to ensure therapeutic divalproex levels were achieved and maintained. His bupropion dosage was adjusted to 150 mg twice daily, rather than resuming previous 200 mg twice daily, to safely titrate dose after a period of discontinuation. He was to maintain the divalproex at 500 mg in the morning and 1000 mg at bedtime. An explicit instruction was placed that no changes to his prescribed medications were to be made without prior consultation with the psychiatrist. A current printed list of medications and orders were provided for the facility staff to ensure accurate administration and prevent unauthorized changes. The resident was stable until medications were changed, medications to be restarted at appropriate doses. No changes of any medications were to be made without discussing with the nurse practitioner first.A nurses note, dated 5/27/26 at 5:40 p.m., indicated he was observed yelling and leaving the dining room, indicated that he didn't was his f-king food and a stupid b-ch told him that he had to wait his turn. He angrily walked to his room. A room tray was provided he was slightly calmer but still very upset, he indicated that he went back to his room so he didn't do anything stupid.A behavior note, dated 5/29/26 at 4:54 a.m., indicated he was heard yelling from his room at approximately 11:00 p.m. Upon entering his room, he was in his bathroom with no clothes on yelling and wanting to know where his shower chair was as he preferred a taller shower chair. It was explained that the shower chairs were limited and one at the appropriate height would be found for him. He slammed bathroom door closed and indicated that it was f--king [NAME]-t and why the other person didn't get their own f-king chair. A shower chair was located, he showered, and apologized to staff for yelling.A behavior note, dated 5/30/26 at 3:15 a.m., indicated he was heard screaming I want to talk to the f-king nurse right now! He entered the nurses station and indicated that it was f-king [NAME]-t that they had lost three pairs of his shorts, he wanted them back and described what they looked like. It was explained to him that the staff could not attempt to locate the shorts due to the hour of the night. He left the nurses' station and within a few minutes, he returned with a pair of shorts indicating that was what the missing shorts looked like. He was asked to leave the nurses station, and he drew back both fists and thrusted his body towards the staff member and yelled Come on! He was asked again to leave the nurse's station and he indicated that he was calling his POA. He was reminded the time of night, and he yelled I don't give a f-k! and went to his room and slammed his door shut, opened the door and slammed the door again.A nurses note, dated 6/8/26 at 4:01 a.m., indicated no behaviors were noted or reported, although, during a conversation with medication administration, he indicated that he had been good the last few days but could put his fist through a glass and not think anything of it. The conversation subject was changed and retired to his room. A social service note, dated 6/19/26 at 3:23 p.m., indicated he spoke about touring another facility, and that no one had given him a clear answer if he was accepted for the facility's assisted living. He was told that he was not accepted and his POA was aware and that was the reason he toured the other facility. The resident expressed frustration and confusion due to the fact that other residents had behaviors and yelled out, and he wanted to know what the difference was. He was told that due to his younger age, physical attributes, his verbal and physical threats were not comparable to the elder community at the facility. He verbalized understanding and thanked writer for explaining it to him in such a way he was able to understand.During an interview, on 6/29/26 at 11:56 a.m., Resident B indicated he had not been given his divalproex correctly nor received his bupropion, causing him to have withdrawal symptoms, which created issues. He was denied the opportunity to move to the facility's assisted living and started looking elsewhere for a place to live. He felt that he was being punished for the facility's mistake with his medication. The facility told his POA that there was a typo and that they could not get ahold of the behavioral office about his medications. This mistake made him feel mad, he was upset, made him use F word, which was not normal for him. He recently had an issue with a nurse and he blew up at the nurse. He got upset like normal people but did not have outbursts like he had been due to not receiving his medication correctly.During an interview, on 6/30/26 at 9:33 a.m. RN 24 indicated that she had completed Resident B's admission to the facility. She normally entered the orders from the hospital into the electronic health record and anything that didn't make sense, she clarified with the nurse practitioner, and a second nurse verified the orders. The nurse manager used to verify the new admission orders, but now the nurse on the next shift verified the orders. The divalproex, bupropion, and the insulin orders were higher dosages and she spoke to the nurse practitioner about the insulin orders but did not document the conversation in the clinical record. She could not recall the nurse practitioners' name nor the nurse who completed the verification on Resident B's medication orders.2. Resident D's clinical record was reviewed on 6/29/26 at 2:51 p.m. Diagnoses included essential (primary) hypertension, chronic kidney disease, Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, and presence of cardiac pacemaker.Behavioral hospital discharge orders dated 4/22/26 included amlodipine besylate (treat blood pressure) 5 mg daily hold for systolic blood pressure below 100 and heart rate below 60, carvedilol (treat blood pressure) 12.5 mg twice daily and Vitamin D (supplement) 1000 units/25 mcg (micrograms) two tablets daily.The April 2026 MAR indicated amlodipine besylate 5 mg daily, Vitamin D 1000 unit daily, and carvedilol 12.5 mg twice daily, give with food and hold for systolic blood pressure below 100 and pulse below 60.The MAR lacked blood pressure and heart rate perimeters for amlodipine besylate and Vitamin D 1000 units/25 mcg two tablets daily order.The resident's clinical record lacked daily or twice daily blood pressure and heart rate monitoring documentation.During an interview, on 6/30/26 at 10:13 a.m., Nurse Practitioner 7 indicated that she did not complete Resident B or Resident D's admission. She would normally compare the resident's discharge orders from the hospital to what the nurse entered into the computer. She was not a psychiatric nurse practitioner and did not change psychiatric medications, she left that up to the local behavioral health care office. Resident B was very agitated and had explosive behaviors.During an interview, on 6/30/26 at 10:56 a.m., the DON indicated the nurses would use the hospital discharge paperwork and transcribe the medications and new orders. If there were questions, the nurse should reach out to the provider and the second nurse reviews the discharge orders and the medications. The Administrator indicated that the divalproex orders were on multiple lines on the discharge orders, which caused confusion. The bupropion was on a single line but was not entered. The medication was a very high dose, and later clarification was received from the local behavioral health care office. A notice was entered into the nurse practitioner book for them to review the orders and it got missed. Resident B was denied admission to the facility's assisted living due to behaviors. The incorrect doses of medication could have initially caused Resident B's behaviors, but the medications had now had time to reach the therapeutic levels and he continued to have behaviors.During an interview, on 6/30/26 at 12:16 p.m., the DON indicated the nurses should have converted the units by dividing the units by 40 to get micrograms for the resident's Vitamin D. A Vitamin D level had been drawn shortly after admission and would be redrawn on 7/1/26.During an interview, on 6/30/26 at 1:16 p.m. the DON indicated that Resident D's blood pressure or heart rate was not documented.During an interview, on 6/30/26 2:30 p.m., Unit Manager 33 indicated she assisted with Resident D's admission and entered some of his orders into the electronic health records. She was unable to recall who the admitting nurse was, but during the admission process, if the resident was admitted during day shift, the next shift would either finish the admission process or verify the orders.A current facility policy, revised 10/2010, titled Reconciliation of Medications on Admission, provided by the DON, on 6/30/26 at 12:46 p.m., indicated the following: .Preparation 1. Gather the information needed to reconcile the medication list: Discharge summary from referring facility.General Guidelines.2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process.This citation relates to Intake 3041952.

Based on record review and interview, the facility failed to complete a required Preadmission Screening and Record Review (PASRR) Level I screening assessment to determine if a Level II assessment was required when a resident received a new major mental illness diagnosis for 3 of 3 residents reviewed for PASRR (Resident 2, Resident 6, and Resident 160). Findings include: 1. Resident 160's clinical record was reviewed on 5/14/26 at 12:37 p.m. Diagnoses included psychotic disorder with delusions due to known physiological condition, depression, anxiety, and mood disorder due to known physiological condition with depressive features. Resident 160's clinical record indicated mood disorder was added as diagnosis 4/3/24 and the psychotic disorder diagnosis was added 4/1/25. A PASARR level I screening, dated 10/10/19, indicated Resident 160 had a diagnosis of depression/depressive disorder and took the medication escitalopram (antidepressant). The record lacked any additional Level I screenings. A physician's order, dated 4/2/25 and discontinued 4/17/25, indicated to administer lurasidone (an antipsychotic medication) 20 milligrams (mg), by mouth, one time a day related to psychotic disorder. A physician's order, dated 4/18/25 and discontinued 8/5/25, indicated to administer lurasidone (an antipsychotic medication) 20 mg, by mouth, one time a day related to psychotic disorder. Targeted behaviors for this antipsychotic use was mood disturbances, irritability, self-isolating, and noncompliance. A current physician's order, dated 4/15/26, indicated to administer divalproex (an anticonvulsant medication used as a mood stabilizer) 250 mg, by mouth, twice daily related to mood disorder. Targeted behaviors for this anticonvulsant use was mood disturbances, irritability, self-isolating, and noncompliance. The clinical record indicated Resident 160 had taken divalproex since 4/3/24 for a mood disorder. A current physician's order, dated 4/30/26, indicated to administer hydroxyzine (antihistamine medication used to treat anxiety) 25 mg, by mouth, once daily at bedtime, for anxiousness. Monitor for drowsiness, slurred speech, dizziness, nausea, aggression, and impulse behavior. An annual Minimum Data Set (MDS) assessment, dated 4/2/25, indicated Resident 160 was cognitively intact and had a psychotic disorder. A quarterly MDS assessment, dated 7/3/25, indicated Resident 160 was cognitively intact, had a psychotic disorder, and received an antipsychotic on a routine basis. An annual MDS assessment, dated 3/31/26, indicated Resident 160 was cognitively intact, had a psychotic disorder, and received an anticonvulsant and antidepressant. A current careplan, dated 11/23/24, indicated Resident 160 received an anticonvulsant medication related to a mood disorder. Interventions included the following: administer anticonvulsant medications as ordered by physician and monitor for side effects and effectiveness (11/23/24), monitor for adverse effects and vital signs per order/policy, and report any changes to the prescriber (11/23/24), monitor for suicidal thoughts or actions and offer to talk to a doctor or counselor if needed (11/23/24), and monitor for targeted behaviors such mood disturbances, irritability, self-isolating, and noncompliance with effective interventions of validation, offer psych services, and provide reassurance (4/14/26). A current careplan, dated 4/17/26, indicated Resident 160 had a mood problem related to the resident may report not having interest in doing things, depression, difficulty sleeping, tired, appetite has started come back, and feeling bad about self. Interventions included the following: administer medications as ordered, monitor, and document any side effects and effectiveness (4/17/26), provide the resident with a program of activities that is meaningful and of interest, encourage and provide opportunities for exercise and physical activity (4/17/26), assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these (4/17/26), behavioral health consults as needed (psycho-geriatric team, psychiatrist)(4/17/26), monitor, record, and report to MD any risk for harming others, increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, and possession of weapons or objects that could be used as weapons (4/17/26). A provider's progress note, dated 8/5/25 at 9:39 a.m., indicated Resident 160 was prescribed Latuda 20mg daily for a psychotic disorder. The medication was ineffective for symptom management. Psychotropic medications taken was Viibryd (antidepressant) 20 mg daily, Depakote 250 mg twice a day, Latuda 20 mg daily, and hydroxyzine 25 mg every eight hours. A provider's progress note, dated 11/18/25 at 4:12 p.m., indicated Resident 160 was currently prescribed Viibryd and Depakote for a mood stabilizer. He was on adjunct therapy with an antipsychotic, which did not benefit his symptoms. He would benefit from ongoing cognitive-based psychotherapy from a psychologist. During an interview, on 5/15/26 at 11:42 a.m., SSD 5 indicated a follow up PASRR screening was to be done if a resident had a new mental health diagnosis. She confirmed Resident 160's clinical record indicated he had a psychotic and mood disorder diagnoses. The resident's insurance case manager was to be notified when he received the psychotic disorder diagnosis. She was unsure if the case manager was notified. A new PASRR screening would be completed if needed after the case manager reviewed the information. During an interview, on 5/15/26 at 1:50 p.m., the DON indicated she spoke with the psychiatric nurse practitioner and he gave Resident 160 a psychotic disorder diagnosis in error. She entered an order to remove the diagnosis on 5/15/26. The mood disorder diagnosis was to remain. During an interview, on 5/15/26 at 2:39 p.m., the DON indicated Resident 160 did not have a follow up PASSRR screening completed after a mental diagnosis was given and an antipsychotic medication was initiated due to the resident consistently displayed mood disorder symptoms rather than psychotic symptoms. The resident was not primarily being treated for a psychotic disorder. Latuda was initiated as an adjunctive medication when the medication Wellbutrin (an antidepressant) was not effective. Prior to the initiation of Latuda, the resident had an increase in his behavioral symptoms as a result of having had pneumonia. A psychotic disorder, as a result of a medical condition, did not indicate a PASRR screening was to be completed. The facility did not automatically send notifications for PASRR screenings to be completed. The interdisciplinary team determined if a notification of a level I screening was to be sent or not. If the screening was not going to change the outcome of the previous screening they did not have to send in the notification, even with a new psychiatric diagnosis. 2. Resident 2's clinical record was reviewed on 5/14/26 at 10:05 a.m. Diagnoses included senile degeneration of the brain (2/3/26), depression (9/8/23), unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) (9/11/23), anxiety disorder (9/24/25), delusional disorder (9/2/25), and other sexual disorders (5/27/25). Current physician orders included lorazepam (anti-anxiety) 0.5 mg by mouth every four hours as needed for anxiety/restlessness. Targeted behaviors for anxiety included wandering into other residents' rooms, increased scratching, tiredness, decreased appetite, restlessness, yelling out for help continuously, unable to get adequate sleep due to yelling out throughout the night (3/24/26), and risperidone (antipsychotic) 0.5 mg by mouth two times a day related to delusional disorders. Targeted behaviors included increased agitation and anxiety, and excessive yelling out (11/18/25). A Significant Change Minimum Data Set (MDS) assessment, dated 2/6/26, indicated the following conditions/care areas were triggered: cognitive loss/dementia, urinary incontinence, psychotropic drug use, falls, nutritional status, pressure wound(s), dental care, pain, and anxiety, depression, and psychotic disorder (other than schizophrenia). A preadmission Level I PASRR Outcome document, completed on 9/7/23, indicated a Level II was not required. Rationale: .There is no evidence of a PASRR condition of an intellectual/developmental or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. During an interview with SSD 5, on 5/14/26 at 10:43 a.m., she indicated a new Level 1 PASRR screening should be performed when a resident was diagnosed with and new mental health disorder (e.g., major depressive disorder, schizophrenia). In Resident 2's case, because he already had a diagnosis of dementia, any new mental health diagnoses would be cancelled out and because of that, she had not submitted a new Level 1 screening. Technically, he should have had a new Level 1 screening. 3. Resident 6's clinical record was reviewed on 5/14/26 at 9:32 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, which was present upon admission to the facility. Current medications included risperidone 0.5 milligrams (mg) three times a day related to bipolar disorder (3/24/26). A 1/23/24, preadmission Level I PASRR Outcome document, submitted on 1/22/24 by the facility, indicated a Level II was not required. Rationale: .There is no evidence of a PASRR condition of an intellectual/developmental or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. During an interview, on 5/18/26 at 2:40 p.m., the Director of Nursing (DON) indicated the PASRR was completed prior to the resident's admission to the facility. The resident was admitted with a diagnosis of bipolar disorder. She was unable to locate a PASRR completed after the 1/23/24 PASRR. She notified the Social Services Designee (SSD) 5. During an interview, on 5/18/26 at 2:50 p.m., SSD 5 indicated she was continuing to look to see if a more recent PASRR Level I had been completed for the resident. She had access to the electronic site which contained PASRR submissions. During an interview, on 5/18/26 at 4:13 p.m., the DON indicated SSD 5 submitted a new PASARR Level I with the bipolar disorder for the resident today (5/18/26) as a PASARR had not been submitted since 1/22/24. She indicated the facility utilized the Maximus Provider Manual for the facility policy regarding PASRR assessments. The Maximus IN [Indiana] LCAR [Level of Care Assessment Representative] Provider Manual, provided by the Administrator on 5/18/26 at 12:35 p.m., indicated the following: .Submitting Level I for Mental Status Change If a nursing facility resident's behavioral or mental status significantly changes, the nursing facility must submit a new Level I to report the change through the PASRR process. This applies to people who have a known Level II condition and to people with a previous negative Level I. Nursing facilities must submit mental status change referrals within 14 days of the significant change event. Examples of a mental status change event include: A new mental health diagnosis that is not listed on previous Level I or Level II.

Based on observation, record review, and interview, the facility failed to identify targeted behaviors and individualized interventions to clinically support the use of an antipsychotic medication for 2 of 2 residents reviewed for chemical restraints. (Residents 2 and 3) 1.During an observation on 5/12/26 at 10:02 a.m., Resident 2 was asleep in his wheelchair and the television was on. On 5/14/26 at 11:18 a.m., Resident 2 was sitting in his wheelchair in his room talking with a visitor. He laughed intermittently and waved to staff passing by. On 5/18/26 at 10:45 a.m., Resident 2 was up and dressed, sitting in his wheelchair in the living area, watching television. He was quiet and slept intermittently. Resident 2's clinical record was reviewed on 5/14/26 at 10:05 a.m. Diagnoses included senile degeneration of the brain (2/3/26), depression (9/8/23), unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) (9/11/23), anxiety disorder (9/24/25), delusional disorder (9/2/25), and other sexual disorders (5/27/25). Current physician orders included lorazepam (anti-anxiety) 0.5 mg by mouth every four hours as needed for anxiety/restlessness. Targeted behaviors for anxiety included wandering into other residents' rooms, increased scratching, tiredness, decreased appetite, restlessness, yelling out for help continuously, unable to get adequate sleep due to yelling out throughout the night (3/24/26). Risperidone (antipsychotic) 0.5 mg give by mouth two times a day related to delusional disorders. Targeted behaviors included increased agitation and anxiety, and excessive yelling out (11/18/25). An annual Minimum Data Set (MDS) assessment, dated 9/18/25, indicated Resident 2 exhibited no delusions or hallucinations. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds – this type of behavior occurred daily. Those behaviors significantly disrupted care or the resident's living environment. A quarterly MDS assessment, dated 12/19/25, indicated Resident 2 exhibited no delusions, hallucinations, or behaviors. A quarterly MDS assessment, dated 1/6/26, indicated Resident 2 exhibited no delusions, hallucinations, or behaviors. A Significant Change Minimum Data Set (MDS) assessment, dated 2/6/26, indicated the following conditions/care areas were triggered: cognitive loss/dementia, urinary incontinence, psychotropic drug use, falls, nutritional status, pressure wound(s), dental care, pain, and anxiety, depression, and psychotic disorder (other than schizophrenia). A quarterly MDS assessment, dated 3/25/26, indicated Resident 2 exhibited no delusions, hallucinations, or behaviors. A current care plan, initiated 9/12/23, indicated Resident 2 was at risk for pain related to general pain/discomfort, gout, angina pectoris, vitamin D deficiency, hypertension, GERD, and depression. Interventions included administering medications as ordered, anticipating the resident's need for pain relief and responding immediately to any complaint of pain, evaluating the effectiveness of pain interventions, reviewing for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, identifying, recording, and treating the resident's existing conditions which may increase pain, monitoring/documenting probable cause of each pain episode, removing/limiting causes where possible, monitoring/documenting side effects of pain medication, observing for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (emotional discomfort), nausea, vomiting, dizziness, and falls, monitoring/recording pain characteristics every shift and as needed, monitoring/recording/reporting to nurse any signs or symptoms of non-verbal pain (vocalizations like grunting, moaning, yelling out, silence), and mood/behavior changes (irritability, restlessness, aggressiveness). A current care plan, initiated 12/18/23 and revised on 4/9/26, indicated Resident 2 had a behavior problem and might state that he has thoughts of being better off dead related to dementia (denies any plans of self-harm). The resident might wander into his old room and other residents' rooms, had a tendency to make animal noises and yell out marching commands like Hut, 2, 3, 4 and Beep!, Here, Polly [NAME], come here!, Help me!, Help me find my wife!, and Have mercy on me! He might make inappropriate sexual comments to staff about taking their clothes off. He had no signs or symptoms of distress. He might yell out for help or make animal noises in the common area and/or his room but denied needing assistance. He might beg family and staff to take him home. Interventions included administering medications as ordered, monitoring/documenting side effects and effectiveness (5/30/25), anticipating and meeting the resident's needs, assisting the resident toa quiet, calm space/room, providing reassurance and validating his feelings (4/9/26), providing opportunities for positive interactions/attention, stopping and talking with him when passing by (12/18/23), praising any indication of his progress/improvement in behavior, and providing a program of activities of interest to the resident. A current care plan, initiated 9/18/23 and revised on 1/19/24, indicated Resident 2 had impaired cognitive function/dementia or impaired thought processes. Interventions included asking yes/no questions to determine his needs, communicating with the resident/family/caregivers regarding his capabilities and needs, and cueing, reorienting, and supervising as needed. A current care plan, initiated 9/18/23 and revised on 8/19/25, indicated Resident 2 used an antidepressant medication related to depression. Interventions included administering antidepressant medications as ordered, monitoring/documenting side effects and effectiveness every shift, educating the resident/family/caregivers about risks, benefits, and side effect and/or toxic symptoms, monitoring/documenting/reporting, as needed, adverse reactions to antidepressant therapy, changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living ability, continence, no voiding, constipation, fecal impaction, diarrhea, gain changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyes. Targeting behaviors for depression included constant worry, repetitive verbalization, and yelling out. Effective interventions were offering tv/music, visitors, or walking with the resident. A current care plan, initiated 4/25/24 and revised 8/13/25, indicated Resident 2 used anti-anxiety medications related to anxiety. Interventions included administering anti-anxiety medications as ordered, monitoring for side effects and effectiveness every shift, and monitoring the resident for safety. The resident was taking anti-anxiety medications which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looked like dementia and increased the risk of falls, broken hips, and legs. Targeted behaviors for anxiety included wandering into other residents' rooms, increased scratching, tiredness, decreased appetite, restlessness, yelling out for help continuously, and lack of sleep due to yelling out throughout the nights. Effective interventions included medications as needed, redirection, walking with the resident around the facility or outdoors when weather permitted, reassurance, and television/radio. A current care plan, initiated 9/5/25, indicated Resident 2 used psychotropic medications related to behavior management. Interventions included administering psychotropic medications as ordered, monitoring for side effects and effectiveness every shift, monitoring/documenting/reporting, as needed, any adverse reactions of psychotropic medications (unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person, and monitoring/recording occurrences of target behavior symptoms and documenting per facility protocol. Targeted behaviors for antipsychotic use included increased agitation/anxiety, and excessive yelling out. Effective interventions included television/music, family visits, and offering the resident a nap after lunch. A risk management note, dated 7/10/25 at 10:14 p.m., indicated the IDT met to review Resident 2's behavior of continuously yelling out throughout the shift (Beep! and making sounds like an owl.) Multiple attempts to redirect were not always successful. The resident was reoriented to time/situation, would quiet for a minute, then repeat the outbursts. A behavior note, dated 7/14/25 at 5:57 p.m., indicated the resident repeated phrases spoken to him. He was pleasantly confused and had several visitors. He enjoyed having someone to talk to but would repeat what the other person said to him. A behavior note, dated 7/14/25 at 11:31 p.m., indicated the resident yelled loudly Help me! during medication pass. When asked what he needed, he replied Nothing, I just like to yell it!. The resident was educated about the importance of using his call light to make his needs known. He demonstrated the ability to use the call light and verbalized he understood the instruction. He continued to yell Help! while staff was still in the room. A risk management note, dated 7/24/25 at 9:22 p.m., indicated the IDT met to review Resident 2's behavior of yelling out. The resident would repeat phrases spoken to him, or other comments like Have mercy on me!, Help me, Lord, Beep! Beep!, or Whoo! Whoo! The resident stated he just liked to yell those things. He was noted in the common area giggling and yelling out I'm going do it! Here it goes! You hear that fart? That was a good one! He propelled his wheelchair saying Beep! Beep! I'm coming through! Interventions such as redirection, reorienting to time/situation, snacks, television, drinks, 1:1 with staff, a quiet environment, were successful for a time. After a short period, he would resume yelling out. The 1:1 was very successful, resulting in the resident calming. A psychiatric progress note, dated 7/29/25 at 5:10 p.m., indicated a follow-up visit for a recent medication change. Oral hydroxyprogesterone (hormone) was previously discontinued due to increased symptoms of yelling out, which might be an underlying side effect of the medication. The resident was seen for follow-up on continued sexually inappropriate behaviors. He was making inappropriate and rude sexual comments to the nursing staff. That behavior was ongoing. He also displayed a worsening cognitive deficit. The plan was to resume the medroxyprogesterone acetate (hormone) injections every two weeks. Changes since the last visit included the resident saying Whoo! repeatedly during the night. He told staff he was an owl. Staff were unable to redirect the resident and when they left the room, he would start the Whoo! again. He was later heard yelling Help!. When staff offered to help, the resident denied any need. Staff were able to redirect the resident each time, but he would resume yelling when staff left the room. Once Resident 2 was up for the day and taken to the common area, he was calm and quiet. No hallucinations or delusions were reported by staff. A psychiatric progress note, dated 8/5/25 at 10:53 a.m., indicated Resident 2 had occasional inappropriate verbalizations. Overall, his advancing cognitive deficit was consistent with dementia. Staff were to continue to redirect the resident. There were no signs or symptoms of hallucinations or delusions. A risk management note, dated 8/7/25 at 10:01 p.m., indicated the Interdisciplinary Team (IDT) met to review Resident 2's behavior for the risk reference period of 7/31/25 through 8/6/25. The resident showed signs of socially inappropriate/disruptive behavior, and repetitive verbalizations. These were tendencies for Resident 2. Music and television were not successful. The resident had a recent medication change and was prescribed medroxyprogesterone acetate injections every 14 days. Care plans were updated and staff would continue to follow and support as needed. A psychiatric progress note, dated 8/12/25 at 1:18 p.m., indicated the psychiatric nurse practitioner followed up with Resident 2 for increased symptoms of restlessness and anxiety. He had increased yelling out, especially at night. The symptoms had been ongoing for a week or two. Resident 2 had previously been started on medroxyprogesterone which appeared to help with his sexually inappropriate behaviors. A short-term trial of alprazolam was started and would be monitored for effectiveness and side effects. Resident 2 denied delusions, hallucinations, paranoia, anxiety, and depression. No obvious signs of hallucinations or delusions were reported by staff. Current psychiatric diagnoses included depression, and the resident was not receiving any psychotropic medications at that time. A behavior note, dated 8/24/25 at 5:55 a.m., indicated the resident was yelling loudly Help me, God help me! When asked what he needed, Resident 2 laughed and said Nothing. A behavior note, dated 8/24/25 at 5:32 p.m., indicated the resident started yelling, Help me! Help me! Nursing staff asked resident what he needed help with, and resident stated, I don't know. Nursing staff tried to redirect the resident, but he continued to call out. A behavior note, dated 8/29/25 at 12:01 a.m., indicated Resident 2 yelled Help me, help me! When asked what was wrong, he did not respond, just started to yell the same thing again. The behavior continued for a few hours, and he could not be redirected. A behavior note, dated 8/29/25 at 5:08 p.m., indicated Resident 2 yelled Help me! most of that shift. He slept minimally throughout the night and did not rest during the day. He continued to yell out even when his son was present in the room. Pharmacological and non-pharmacological interventions were ineffective. A behavior note, dated 9/2/25 at 5:37 p.m., indicated Resident 2 was taken to the common area where he began to yell out Help! Someone, help me! Staff asked what he needed but the resident was unable to answer, shrugged his shoulders, and as soon as staff walked away, he began to yell out again. He was redirected and offered a snack. Interventions were effective but short lived. The resident was given a PRN (as needed) alprazolam with positive effect, slept for 20 minutes, and afterwards was pleasant and participated in activities. A behavior note, dated 9/15/25, indicated Resident 2 was calling out help me during that shift. Staff reassured the resident, but he continued to yell out repeatedly. He was left alone with the door cracked to ensure safety. He did quiet down but had several occurrences of yelling out help me, even with family sitting at his bedside. A psychosocial note, dated 10/14/25 at 12:56 p.m., indicated Resident 2 appeared confused and repeated the same statements. After some time, he became anxious and said Help me. He was easily redirected. The social worker offered support and companionship and would continue to build a relationship with the resident. The resident did not exhibit hallucinations, delusions, mood changes, depression, or anxiety. A psychiatric note, dated 10/28/25 at 11:33 a.m., indicated Resident 2 was visited for a routine psychiatric follow-up. The resident was previously started on risperidone with a dose increase due to ongoing symptoms of agitation and yelling out. He was also started back on PRN (as needed) alprazolam for 14 days. He was very confused and had cognitively declined. The resident was unable to answer most of the psychiatric NP's question. He had noted behavior(s) of yelling Help me! He responded well to therapy with risperidone with a reduction in his symptoms. The plan included continuation of PRN alprazolam. The resident denied delusions, hallucinations, paranoia, anxiety, and depression. Staff did not report hallucinations or delusions. For depression, risperidone 0.5 mg was continued and for sexually inappropriate behavior(s), medroxyprogesterone acetate injections was continued. The NP would consider adding a mood stabilizer for continued symptoms of anxiety and yelling out. A progress note, dated 11/15/25 at 8:10 a.m., indicated an aide alerted the nurse about the need for an assessment of Resident 2. The left side of his face was drooping, and he had weakness in his left hand and foot. He was able to respond to questions clearly. He was sent to the emergency room for evaluation and treatment. A progress note, dated 11/15/25 at 2:53 p.m., indicated the hospital called and reported the resident was being admitted with a diagnosis of stroke. A progress note, dated 11/22/25 at 1:00 a.m., indicated Resident 2 was alert and able to recognize staff names and/or faces. No delirium was exhibited. He exhibited verbal behavior symptoms and had no symptoms of depression. A progress note, dated 12/2/25 at 4:19 a.m., indicated Resident 2 was able to recognize staff names and/or faces, was oriented to self, unable to recall a situation that occurred less than 5 minutes prior, was exhibiting verbal behavior symptoms of yelling out Help me! at times. He did not display any distress. He was pleasant and cooperative with care. A risk management note, dated 1/4/26 at 11:37 p.m., indicated the IDT met to review the resident behaviors. Resident 2 continued to yell out Help me! When staff asked the resident if he had pain, he replied yes and acetaminophen was given, with positive results of pain relief. A psychiatric progress note, dated 1/6/26 at 9:56 a.m., indicated the resident was being evaluated for a possible GDR of risperidone 0.5 mg twice daily for underlying delusional disorder. He continued to have ongoing restlessness, anxiety, yelling out, and was sometimes difficult to redirect. After reviewing the patient's current medication therapy as well as recent mood and behavior, along with a review of nursing documentation and pharmacy recommendations, a GDR would be contraindicated. A reduction in Resident 2's antipsychotic medication would likely result in increased symptoms of unstable mood, restlessness, anxiety, and/or insomnia. His mood and behavior would be closely monitored. The resident denied delusions, hallucinations, paranoia, anxiety, and depression. His mood was noted to be calm, he made good eye contact, his appetite was good, his judgement was fair, his attention span was good, and he had no obvious or reported signs of hallucinations or delusions. A Gradual Dose Reduction (GDR) Request and Risk versus Benefit Statement, dated 1/6/26 and provided by the DON on 5/18/26 at 10:12 a.m., indicated risperidone 0.5 mg by mouth twice a day was due for a gradual dose reduction. No prior reductions were attempted. The behaviors indicated were increased agitation and anxiety and excessive yelling out. The provider's response indicated Resident 2 was not a candidate for a dose reduction at that time because a GDR attempt would likely result in persistent distress or worsening symptoms. A psychiatric progress note, dated 1/13/26 at 1:45 p.m., indicated Resident 2 was very confused and cognitively declined. He had periods of intermittent anxiety. He would continue risperidone 0.5 mg twice a day as ordered. There were no reports of hallucinations or delusions. A progress note, dated 4/22/26 at 3:02 a.m., indicated lorazepam 0.5 mg was given, as needed, for anxiety/restlessness. Targeted behaviors for anxiety included wandering into other residents' rooms, increased scratching, tiredness, decreased appetite, restlessness, yelling out for help continuously, or unable to get adequate sleep due to yelling out through the night. The prn administration of the medications was documented as effective. Resident was resting in bed with eyes closed. No distress was noted. The clinical record lacked documentation of non-pharmacological interventions attempted prior to administering lorazepam. A progress note, dated 4/26/26 at 6:39 p.m., indicated lorazepam 0.5 mg was given. Targeted behaviors included wandering into other residents' rooms, increased scratching, tiredness, decreased appetite, restlessness, yelling out for help continuously, unable to get adequate sleep due to yelling out through the night. The resident had signs and symptoms of restlessness. The clinical record lacked documentation of non-pharmacological interventions attempted prior to administering lorazepam. A progress note, dated 4/29/2026 at 6:31 p.m., indicated lorazepam 0.5 mg was given. Targeted behaviors included wandering into other residents' rooms, increased scratching, tiredness, decreased appetite, restlessness, yelling out for help continuously, unable to get adequate sleep due to yelling out through the night. The resident had signs and symptoms of restlessness. The clinical record lacked documentation of non-pharmacological interventions attempted prior to administering lorazepam. A document titled Behavior Monitoring and Interventions, between the dates of 4/19/26 and 5/16/26, indicated Resident 2 did not exhibit any behaviors on 24 out of the 25 days monitored. During an interview with Psychiatric NP 16, on 5/18/26 at 9:48 a.m., he indicated Resident 2 was treated with risperidone for agitation and screaming out all night, which were typical dementia behaviors. The resident did not sleep well and was observed reaching for things that were not there or looking for something on the floor. No GDRs had been attempted because the resident had only been on the antipsychotic medication since September 2025. Staff told the NP the resident slept better but continued with confusion and yelling out. The NP had previously tried alprazolam for the resident. During an interview with CNA 17 on 5/18/26 at 10:13 a.m., she indicated she had never observed Resident 2 exhibiting any kind of behaviors. During an interview with CNA 18 on 5/18/26 at 10:29 a.m., she indicated Resident 2 could sometimes say inappropriate, sexual comments. She had not observed other behaviors. She had never observed the resident hallucinating or having delusions. During an interview with LPN 9 on 5/18/26 at 10:43 a.m., she indicated Resident 2's behaviors could be sexually inappropriate comments, although not often. He received prn alprazolam. He yelled out a lot, and she thought that was due to his dementia. He was easily redirected. During an interview with the DON on 5/18/26 at 1:35 p.m., she indicated she reviewed Resident 2's behaviors but would have to go back through all of her morning meeting notes to see if the resident exhibited hallucinations or delusions. Resident 2 woke his neighbors up with his constant yelling. He would not tell staff what he wanted. It was hard to know if he was having hallucinations or delusions at those times. There was a combination of medications that brought the resident rest/peace. His behaviors decreased. He was provided a calm, quiet space, participated in talk therapy, and could be redirected when he wandered into other residents' rooms. During an interview with Social Services 23 on 5/18/26 at 3:34 p.m., she indicated Resident 2 had a lot of yelling and sleep disturbance in June, July, August, and September of 2025. There were multiple complaints from neighbors not being able to sleep. Resident 2's inability to sleep was disturbing others. He would yell out repeatedly, some cute, little statements. The majority of his statements were help me and God help me. When staff went to his room, he would say he did not need anything. When staff turned to leave, he would start with the repetitive statements again. 2. Resident 3's clinical record was reviewed on 5/13/26 at 2:13 p.m. Diagnoses included delusional disorders, major depressive disorder, bipolar disorder, and post post-traumatic stress disorder. Current orders included Seroquel (antipsychotic) 25 milligram (mg) at bedtime, Viibryd (antidepressant) 40 mg daily, nortriptyline (antidepressant) 10mg daily, and trazodone (antidepressant, insomnia) 50 mg at bedtime. A 10/23/25, quarterly, Minimum Date Set (MDS) assessment indicated Resident 3 was not experiencing any hallucinations or delusions during the assessment period. Resident 3 had non-Alzheimer's dementia. A 1/23/26, quarterly, MDS assessment indicated Resident 3 was not experiencing any hallucinations or delusions during assessment period. Resident 3 had non-Alzheimer's dementia. A Psychiatric Nurse Practitioner (NP) progress note, dated 12/9/25, indicated Resident 3 was not experiencing any hallucinations, delusions, or paranoia. A progress note, dated 12/30/25, indicated Resident 3 was not having any hallucinations or delusions at that time. An electronic mail (e-mail) communication between Social Services and the Psychiatric Nurse Practitioner, dated 12/30/25 at 5:40 p.m., indicated Resident 3's representative wanted her evaluated for face picking and excessive itching. The representative felt these symptoms were due to a mental issue. The representative took Resident 3 to a local grocery store, where Resident 3 wanted lice shampoo because she felt she had lice for the past three weeks. The clinical record lacked documentation of identification and tracking of behaviors, hallucinations, delusions, or paranoia. A Psychiatric Nurse Practitioner progress note, dated 1/6/26, indicated Resident 3 had increased symptoms of hallucinations and paranoid delusions. She had some reported visual hallucinations over the prior several weeks, including seeing bugs in her room. Seroquel 25 mg at bedtime was prescribed. The clinical record lacked documentation of identification and tracking of behaviors, hallucinations, delusions, or paranoia. A Psychiatric Nurse Practitioner progress note, dated 1/20/26, indicated Resident 3 was started on Seroquel for underlying anxiety and depression related to bipolar disorder, including increased psychosis and hallucinations. The clinical record lacked documentation of identification and tracking of behaviors, hallucinations, delusions, or paranoia. A Psychologist progress note, dated 4/29/26, indicated he believed Resident 3's behaviors were related to her early traumatic brain injury and requested the diagnosis of dementia be removed from Resident 3's medical record. Resident 3's diagnosis of dementia was removed 4/29/26. A Psychiatric Nurse Practitioner progress note, dated 5/5/26 at 1:12 p.m., indicated Resident 3 was being evaluated for a possible dose reduction of Seroquel. Resident 3 was prescribed Seroquel 25mg at bedtime for delusional/bipolar disorder. She continued to experience ongoing symptoms of insomnia, mood dysregulation, anxiety and depression. The medication was beneficial for managing her chronic symptoms. A reduction in this patient's psychotropic medication would likely result in increased symptoms of unstable mood, restlessness, anxiety and or insomnia. A 5/5/26 Gradual Dose Reduction (GDR) risk versus benefit statement indicated Resident 3's behavioral indications included irritability, memory problems, highs and lows. The Psychiatric Nurse Practitioner indicated Resident 3 was not a candidate for a dose reduction at this time, as the benefits of treatment outweigh the associated risks for the following risks: A GDR attempt would likely result in persistent distress or worsening symptoms, and the following functional impairments were unchecked. During an interview, on 5/13/26 at 3:15 p.m., CNA 11 indicated Resident 3 had episodes of confusion and forgetfulness. She had an episode where she felt someone was looking at her. Behaviors were charted under point of care documentation. During an interview, on 5/13/26 at 3:23 p.m., LPN 12 indicated that any behaviors would have been documented under the resident's progress notes. During an interview, on 5/13/26 at 6:03 p.m., CNA 13 indicated she could not recall any behaviors for Resident 3. During an interview, on 5/13/26 at 6:38 p.m., LPN 4 indicated the only behavior Resident 3 had occurred when Resident 3 ripped off a blood pressure cuff when it was too tight on her arm. She was told Resident 3 had previously given out personal information on the internet but could not recall any other behaviors. During an interview, on 5/14/26 at 11:40 a.m., the DON indicated Resident 3 did not have any documented behaviors, other than the email correspondence between the social worker and the Psychiatric Nurse Practitioner. During an interview, on 5/15/26 at 11:20 a.m., the Psychiatric Nurse Practitioner indicated Resident 3 had reported to him that she was seeing people in her room at night and people were looking in her window. Some of her delusions over the past few years included pursuing relationships with famous people. The social worker reached out to him around the holiday requesting her to be assessed. He indicated nursing staff typically document any behaviors, hallucinations or delusions. Resident 3 had been stable since he started her on Seroquel. Before that, she had experienced episodes of paranoid delusions. He based his assessment and the need for Seroquel on what the social worker reported and on Resident 3's history. Resident 3 had a history of bipolar disorder and intermittent psychosis. A current facility policy, dated 7/2022, titled Psychotropic Medication Use, provided by the DON, on 5/15/26 at 4:35 p.m., indicated the following: .Resident Evaluations: 3. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: a. other causes for symptoms (including symptoms that mimic a psychiatric disorder) have been ruled out; b. signs and symptoms are clinically significant enough to warrant medication therapy A current facility policy, titled Identifying Involuntary Seclusion and Unauthorized Restraints, provided by the DON on 5/18/26 at 10:32 AM., indicated the following: .4) Behavioral issues that arise among residents are managed according to strategies documented in the care plan and approved by the interdisciplinary team. Unauthorized Chemical Restraints: 1) Residents are free from the use of any chemical restraint not required to treat their medical condition. 2) Chemical restraint is defined as any drug that is used for discipline or staff convenience and not required to treat medical symptoms. 3) Convenience is defined as the result of any action that has the effect of alternative residents' behaviors such that the resident requires a lesser amount of effort of care and is not in the residents best interest. 4) Psychotropic medications are not administered to residents with psychological or behavioral symptoms, without documented indication for use, and without assessing potential underlying causes for distressed behavior, including a) pain and b) delirium, c) adverse consequences of current medications.5) If psy

Based on observation and interview, the facility failed to ensure insulin pen needles were primed prior to administration according to manufacturer's instructions and professional standards to ensure the full dosage was received for 1 of 14 residents reviewed for medication administration. (Resident 17)Findings include:On 5/13/26 at 6:58 p.m., during a medication administration observation, LPN 4 administered 32 units of insulin glargine (long acting insulin) to Resident 17. LPN 4 did not prime the pen needle before administration. Upon completion of administration, LPN 4 indicated she did not prime insulin pen needles before administration.On 5/14/26 at 12:39 p.m., the DON indicated staff should prime the insulin pen before administration.Resident 17's clinical record was reviewed on 5/14/26 at 10:44 a.m. Diagnoses included diabetes mellitus and a physician order for insulin glargine inject 32 units at bedtime.A facility document, titled Insulin Injections, provided by the Infection Control Nurse, on 9/25/23 at 11:35 a.m., indicated the following under the heading Administering Insulin .6) Inject the insulin: Let go of the skin pinch before you inject the insulin. Push the plunger with your thumb at a moderate, steady pace until the insulin is fully injected. If using a syringe, keep the needle in the skin for 5 seconds. If using a pen, keep the needle in the skin for 10 seconds. Insulin Pens from the Centers for Disease Control and Prevention (CDC) website at https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections was accessed on 5/19/26 at 9:01 a.m., guidance included: .6. Prime the insulin pen. Priming means removing air bubbles from the needle. It ensures that the needle is open and working. You must prime the pen before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears.Basaglar (insulin glargine) Insulin Pen Instructions for use, retrieved from https://uspl.lilly.com/basaglar/basaglar.html#ug0 was accessed on 5/19/26 at 9:05 a.m., indicated the following: .Priming your Pen: Prime before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6. To prime your Pen, turn the Dose Knob to select 2 units. Step 7. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps. Small air bubbles are normal and will not affect your dose.410 Indiana Administrative Code (IAC) 16.2-3.1-48(c)(1)

A. Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident to prevent repeated falls for 1 of 4 residents reviewed for falls (Resident 45).B. Based on interview, observation, and record review, the facility failed to provide safe bed mobility assistance for a dependent resident which resulted in the resident being rolled out of the bed and onto the floor by staff for 1 of 4 residents reviewed for falls (Resident 7). Findings include: A1. During an observation, on 5/11/26 at 12:16 p.m., Resident 45 sat in a wheelchair in the dining room at a table. His face was bruised on the right side of his face, around his eye. On 5/12/26 at 10:20 a.m., Resident 45 attempted to stand on his own three times. CNA 14 attempted to assist the resident to a wheelchair. She was unable to complete the transfer on her own and asked CNA 15 to assist her with the resident's transfer. Once the resident was transferred, he immediately stood up again and was unwilling to sit down. CNA 14 asked him if he needed to use the restroom. He nodded, and then sat down in the wheelchair. Resident 45's clinical record was reviewed on 5/13/26 at 9:29 a.m. Diagnoses included traumatic subdural hemorrhage without loss of consciousness (1/26/26), traumatic subdural hemorrhage without loss of consciousness status unknown (5/4/26), fracture of orbital floor right side (5/4/26),maxillary fracture, unspecified side (5/4/26), aphasia (1/29/26), cognitive communication deficit (1/29/26), dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, metabolic encephalopathy, unsteadiness on feet, and muscle weakness (generalized). Orders included furosemide (diuretic) 20 milligrams (mg) daily for edema (4/7/26), sertraline (antidepressant) 100 mg daily (3/25/26), and lorazepam (antianxiety) 0.5 mg twice a day, metoprolol tartrate (for blood pressure) 37.5 mg twice a day – hold for systolic blood pressure less than 110, heart rate less than 60 (started 4/17/26 and discontinued 5/4/26), cyclobenzaprine (muscle relaxant) 10 mg three times a day for left shoulder pain (4/8/26), hydralazine (for blood pressure) 10 mg three times a day – hold for systolic blood pressure less than 110, heart rate less than 60 (3/31/26), hydrocodone acetaminophen (opioid pain reliever) 7.5/325 mg three times a day for pain (1/23/2026), morphine sulfate (opioid pain reliever) 20 mg/mL (milliliters) – give 0.25 mL two times a day for pain, and nonslip strips to floor at exiting side of bed, in front of recliner, in front of toilet, and in front of bathroom sink. Verify placement and replace If missing or peeling (4/20/26). An admission Minimum Data Set (MDS) assessment, dated 1/30/26, indicated the resident was moderately cognitively impaired. He demonstrated verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others for one to three days during the seven-day assessment period. The behaviors put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, significantly interfered with the resident's participation in activities or social interactions, and significantly disrupted care or living environment. He rejected care for 1 to 3 days of the assessment period. He required supervision/cueing assistance with toileting hygiene. He required supervision/touching assistance with transfers and walking 10 to 50 feet. He was occasionally incontinent of bladder. He indicated he had occasional pain rated 6 of 10 on a 0 to 10 scale. The pain rarely or not at all affected sleep, day-to-day activities, and therapy activities. He had a fall in the last month prior to admission. He had two or more falls with no injury since admission. He received speech and physical therapy. A current care plan, initiated 1/26/26 and revised 5/7/26, indicated the resident was at risk for fall/injury related to a recent decline with weakness due to subdural hemorrhage, right orbital fracture, maxillary sinus fracture, impaired mobility, impaired cognition with dementia diagnoses, atrial fibrillation, hypertension, hypothyroidism, chronic kidney disease, hypomagnesemia, anemia, cardiac medications, pain at time with narcotic use, psychotropic medication use, history of falls, aphasia, history of liver cirrhosis, diuretic use, and anticonvulsant use. A progress note, dated 4/13/26 at 1:00 p.m., indicated the resident told staff he had fallen. A supraorbital ridge of the right eyebrow and a bruise to the resident's left elbow was found. The resident indicated he had gotten up from bed to use the restroom and fell to the floor. He did not want to bother anyone and ask for help because he was embarrassed. He got himself up and continued to the restroom. He tripped causing the fall. The bedside table was near where the resident fell. The bedside table was moved to the wall near the resident's recliner out of the resident's pathway from bed to chair to restroom with the resident's permission. Nonskid strips were placed in front of the bed. Skin repair cream was applied to the resident's right eyebrow and left elbow. A care plan intervention, initiated 4/14/26, included relocating the bedside table to the wall near the recliner, with the resident's permission. A care plan intervention, initiated 4/16/26 and revised on 4/30/26, included the placement of nonslip strips at the bedside, by the toilet, in front of the sink and the recliner. A progress note, dated 4/29/26 at 10:45 a.m., indicated the resident was found seated on the bathroom floor. His eyeglasses were lying beside him with the frames bent and blood noted on them. The resident had a 3.3 centimeter (cm) laceration above the right eye, a 1 cm laceration to the lower lip, and active nasal bleeding. Pressure was applied to the nose and right eyebrow until bleeding slowed or stopped. An abrasion measuring 4.2 cm length by 0.1 cm width by 0.1 cm depth with no drainage was observed on the right elbow. The resident stated he had fallen but was unable to describe the cause. He was not using his walker and had his shoes on at the time of the fall. Vital signs included blood pressure of 130/73 and pulse of 60. Pupils were sluggish bilaterally; however, hand grips were strong and equal bilaterally, and he demonstrated full range of motion in all extremities. He reported a headache but denied neck pain. The resident was assisted to a standing position with extensive assistance from three staff members and transferred to his recliner. His facial wounds were cleansed, and pressure was reapplied to the nose and right eyebrow, with moderate drainage noted. A progress note, dated 4/29/26 at 12:00 p.m., indicated the resident was transferred to the hospital for further evaluation and treatment. An IDT (interdisciplinary team) progress note, dated 4/30/26 at 4:47 p.m., indicated the team met to review the resident's fall in his room on 4/29/26. An IDT progress note, dated 4/30/26 at 4:48 p.m., indicated the immediate intervention for the resident's fall was the pressure applied to the resident's nose and eyebrow until the bleeding slowed/stopped. The face was cleansed with moderate amount of drainage that continue. The clinician was notified and gave an order to send the resident to the hospital for evaluation and treatment. The resident was sent via emergency medical services (EMS) with EMS staff escort to the hospital. The IDT would review and reassess intervention upon the resident's return to the facility. A CT (computed tomography) scan of the head, on 4/29/26 at 1:16 p.m., indicated the following: a right frontal subdural hematoma (collection of blood) measuring 5 mm (millimeters) in thickness, was mildly increased from a 1/22/26 scan, a right frontal scalp contusion with soft tissue swelling, and right maxillary sinus disease. A CT scan of the face, on 4/29/26 at 1:18 p.m., indicated the following: acute fractures of the anterior and posterior walls of the right maxillary sinus, nondepressed fracture of the right orbital floor, and a prominent hematoma in the right periorbital soft tissues. A hospital Trauma History and Physical, dated 4/29/26, indicated the resident was found to have 5 mm right subdural intracranial hemorrhage as well as a right orbital floor fracture and maxillary sinus fractures. A repeat CT (computed tomography) scan of the brain approximately six hours after the initial scan showed a slightly increased right subdural intracranial hemorrhage at 6 mm thickness. A progress note, dated 5/4/26 at 4:54 p.m., indicated the resident returned to the facility from the hospital. He answered questions appropriately but was notably confused. He was unsteady and required assistance from two staff members. Bruising remained to the right side of his face. Fifteen-minute monitoring was initiated. A progress note, dated 5/6/26 at 6:50 p.m., indicated the resident had exited the dining room using his rolling walker and wearing nonskid socks less than 15 minutes prior to being found seated on the floor in front of his room. The resident stated he was 'trying to configure with everything here,' gesturing toward his walker and the closed door to his room. Two staff members assisted him to a standing position and transferred him to his recliner. No injuries were observed. Staff encouraged the resident to use his pendant to request assistance prior to ambulating. A care plan intervention, initiated on 5/6/26, indicated the resident was to be checked every 15 minutes. An IDT progress note, dated 5/7/26 at 8:35 a.m., indicated the team met to review the resident's fall in the common area. The immediate interventions included providing standby assistance with ambulation and continued 15-minute checks. Care plan interventions, initiated on 5/7/26, included standby assistance with ambulation and a therapy evaluation for the appropriate durable medical equipment for ambulation. A progress note, dated 5/9/26 at 12:10 p.m., indicated the resident was seated in the dining room. He stood up, turned, and attempted to take a step, lost his balance, then fell to the floor. He landed on his left side. No injuries were observed. He required extensive assistance of two staff members for transfer to his wheelchair. A care plan intervention, initiated on 5/9/26, indicated the resident was to sit with staff during meals, and staff was to encourage the resident to stay in the common area as he allowed. A progress note, dated 5/10/26 at 3:30 p.m., indicated the resident was observed on his knees in front of his wheelchair in the common area. He was assisted back to his chair and to the restroom. The resident returned to the common area with staff assistance. A cushion and a non-slip pad was placed in his wheelchair. No new injuries were observed. A progress note, dated 5/10/26 at 7:15 p.m., indicated the resident was in the common area and stood up partially from his wheelchair. He then sat down on the floor and rolled onto his side. No new injuries were observed. A progress note, dated 5/11/26 at 4:44 a.m., indicated during 15-minute checks, the resident was found in different locations in his room. He moved from his wheelchair to his recliner to his bed. A progress note, dated 5/11/26 at 9:20 a.m., indicated the resident was observed by housekeeping staff falling in the common area. The resident was found seated on the floor on his buttocks with his legs positioned in a near–cross legged manner. Blood was noted on the top of his right sock over the great toe, and upon removal of his sock a skin tear was observed on the right foot. A provider progress note, dated 5/11/26 at 11:30 a.m., indicated the resident was seen for a follow up to a witnessed fall. The resident had experienced a significant decline in mentation and increased confusion since his hospitalization. The recommended plan was to continue physical and occupational therapy and reassess for potential hospice referral. A care plan intervention, initiated on 5/11/26, indicated a cushion and non-slip pad was to be placed in the resident's wheelchair. A progress note, dated 5/12/26 at 2:44 p.m., indicated the resident was admitted to hospice care. An IDT progress note, dated 5/12/26 at 5:09 p.m., indicated the team met to review the resident's fall. The immediate intervention was to place the resident on one-on-one monitoring until further notice. During an observation, on 5/13/26 at 12:06 p.m., the resident sat in his recliner with his eyes closed. CNA 6 sat in a chair near the resident and indicated she was providing one on one supervision for the resident. During an observation, on 5/14/26 at 3:28 p.m., the resident, with his eyes closed, sat in his recliner with his feet elevated in his room. During an observation, on 5/15/26 at 9:28 a.m., the resident sat in his recliner in his room with legs curled up on the seat of the recliner on their right side. His eyes tracked the television. A progress note, dated 5/15/26 at 10:20 a.m., indicated the resident was lying on the floor in front of his restroom. He lay on his left side with his left arm under his body and his legs were extended. He was lifted to a sitting position, then to a standing position. No injuries were observed. He was transferred from sitting in his recliner to sitting in a high-backed reclining wheelchair and taken to the activity area. During an interview, on 5/18/26 at 9:58 a.m., CNA 24 indicated the resident had previously been placed on one on one supervision to reduce fall risk. Although he was no longer on one on one supervision at the time of the interview, he remained on 15 minute safety checks, which were documented on a log at the nurse's station. She stated that when the resident became restless or began moving around, she toileted him as needed. She also attempted to keep him in the common area to allow for closer observation. The resident wore a pendant around his neck to request assistance. When in bed, the bed was kept in the lowest position with a fall mat placed beside it. All interventions were documented in the Kardex within the electronic medical record (EMR). During an interview, on 5/18/26 at 10:02 a.m., CNA 25 indicated the resident had recently begun using a high-backed reclining chair as a fall prevention measure. To further reduce fall risk, she brought the resident to the common area to participate in activities. He enjoyed watching television. She indicated the resident frequently monitored staff presence and appeared aware of when staff were not in view, at which point he would attempt to stand. She indicated that all fall prevention interventions were listed in the Kardex within the EMR. During an interview on 5/18/26 at 10:09 a.m., RN 26 indicated the resident remained on 15 minute safety checks. To reduce his fall risk, his bed was kept in the lowest position with a fall mat placed beside it when he was in bed. When he sat in a chair, his walker was positioned in front of him to ensure that, if he attempted to stand, he could access it safely. She indicated she closely monitored him and, when he permitted, staff kept him in the common area and engaged him in activities. He had been moved to the assist dining area following a fall in the dining room. Although he was able to feed himself, he occasionally attempted to rise and ambulate without assistance. Staff attempted to keep him within view, engaged him in activities, and provided routine toileting. She indicated he appeared very anxious when he first returned from the hospital. She thought he knew he was changing and declining. He had recently been admitted to hospice services. During an interview, on 5/18/26 at 2:21 p.m., Unit Manager 3 indicated, to reduce the resident's fall risk, staff encouraged him to come to the common area and participate in activities. Following each fall, staff closely assessed his room for potential fall hazards. His bed was required to remain in the lowest position with a fall mat placed beside it when he was in bed. Fifteen minute safety checks were initiated whenever the resident was in his room. She reported that the resident had been provided a call pendant and educated on its use; however, according to the call log report, he had not used it. He often waited until staff were out of sight before attempting to get up. The resident was placed on one to one supervision for several days as a fall prevention measure. Therapy evaluated his walker to determine whether alternative equipment was needed. Although therapy services were initiated, the therapist reported significant difficulty engaging the resident in participation. The resident received one on one supervision from 5/11/26 through 5/14/26. He had recently been placed on hospice services, with hospice staff visiting at least twice weekly. Attempts were made to obtain hospice volunteers to sit with him, but availability was limited. During an interview, on 5/18/26 at 2:26 p.m., the Director of Nursing (DON) indicated, to reduce the resident's fall risk, staff attempted to provide standby assistance, encouraged his participation in therapy with the goal of strengthening, and implemented environmental safety measures including positioning the bedside table against the wall and placing nonskid strips on the floor near the recliner, toilet, sink, and bed. The resident experienced additional falls following his 4/29/26 hospital stays, specifically on 5/6/26, 5/9/26, 5/10/26, 5/11/26, and 5/15/26. One to one supervision was initiated for several days after the fall on 5/11/26. The resident continued with 15-minute safety checks. A current facility policy, revised 3/2018, titled Falls – Clinical Protocol, provided by the Administrator on 5/18/26 at 4:20 p.m., indicated the following: .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. B1. During an interview, on 5/11/26 at 4:32 p.m., Resident 7 indicated she fell off the bed when staff pulled her too fast while removing the bedpan. The left side of the bed was observed to be against the wall. Resident 7's clinical record was reviewed on 5/13/26 at 11:40 a.m. Diagnoses included cerebral palsy, contractures to the left elbow, left hand, and right hand, muscle wasting and atrophy to lower leg, and stiffness of knee and ankle. An annual Minimum Data Set (MDS) assessment, dated 4/10/126, indicated Resident 7 was cognitively intact. Her functional range of motion was impaired on both sides of her upper extremities and her lower extremities. She was dependent for all her care, including bed mobility and toileting hygiene, except for eating in which she needed setup or clean up assistance. She was not able to stand or walk due to her medical condition or safety concerns. She used a motorized wheelchair. She had sustained one fall without injury since the prior MDS assessment. A current care plan, revised 1/19/26, indicated Resident 7 was at risk for falls related to limited mobility due to cerebral palsy, chronic pain, and contractures to bilateral hands and her left elbow. Interventions included the following: be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (8/31/20), the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, and personal items within reach. (8/31/20), therapy to evaluate and treat as ordered and PRN (revised 4/6/21), and anticipate and meet the resident's needs (8/31/20). A current care plan, revised 4/4/25, indicated Resident 7 had an activity of daily living self-care performance deficit related to disease processes of cerebral palsy, contractures to bilateral hands and elbow, and a new diagnosis of dysphagia. Interventions included the following: the resident is non ambulatory and has an electric wheelchair (5/3/21), staff to assist as needed with bed mobility (5/3/21), staff to assist as needed with toilet use (5/3/21), staff to assist as needed with transfers (5/3/21), provide skin care as scheduled for contractures to bilateral hands and elbow (8/31/20), staff to assist as needed with personal hygiene (5/3/21), and encourage the resident to participate to the fullest extent possible with each interaction (8/31/20). A nurses note, dated 3/22/26 at 8:10 p.m., indicated Resident 7 was rolled out of bed onto the floor while being assisted by staff. The resident was on her belly and the left side of her face rested on the floor. An assessment for injuries was completed. No injury was noted. A late entry interdisciplinary team (IDT) note, dated 3/23/26 at 2:15 p.m., entered on 3/26/26 at 2:15 p.m., indicated the IDT reviewed a recent event where Resident 7 was lowered to the floor from her bed during a transfer. The resident was safely lowered to the floor by staff. A latent injury was later noted. The IDT determined the level of assistance for bed mobility was not sufficient given the resident's history of cerebral palsy, contractures, overall limited mobility, and increased risks due to anticoagulation use. An updated intervention was implemented for two-person assistance for all bed mobility to ensure safety and prevent recurrence. Staff was to be re-educated on proper transfer technique, and addition assistance was to be requested as needed. A provider's progress note, dated 3/24/26 at 2:38 p.m., indicated Resident 7 had cerebral palsy, was wheelchair bound, and used a mechanical lift for transfers. Resident 7 was seen for chin and lip bruising. The resident indicated she had a witnessed fall with staff during an assisted transfer. No damage was observed to her teeth, mouth pain, or difficulty swallowing. A chin bruise, noted 3/22/26, measured 5.5 cm long x 4 cm wide, dark purple/black in color, and no hematoma. A lip bruise, noted 3/22/26, measured 0.8 cm long x 4 cm wide, presented as a dark purple bruise, and no hematoma. During an interview, on 5/13/26 at 4:20 p.m., the left side of Resident 7's bed was against the wall. Assist rails were not present on the bed. Resident 7 indicated one staff member was present at the time of her fall. The staff member had rolled her quickly onto her right side which caused her to face the staff member. The staff member held onto her with one hand while she attempted to reach over her to hold the bed pan with the other hand. She was rolled too fast and she rolled off the bed. The bed was at a relatively higher height and she fell hard against the floor. She hit her head on the floor. She was not lowered to the floor. She thought she just about got knocked out from hitting her head so hard. It was normal to have one staff member assist her with personal care. During an interview, on 5/15/26 at 4:44 p.m., LPN 21 indicated she was unable to recall much about Resident 7's fall, including what staff member was involved. She believed there was only one staff member present at the time of the incident and the staff member rolled the resident towards themselves rather than the wall. The staff member tried to stop the fall but Resident 7 fell between the staff member and the bed. They finished dressing the resident on the floor before getting her up. During an interview, on 5/18/26 at 3:14 p.m., CNA 19 indicated Resident 7 was dependent for all care and a mechanical lift was used for transfers. The resident preferred to use the toilet rather than a bedpan. After the fall, staff was instructed that two staff members were needed to provide care to Resident 7. During an interview, on 5/18/26 at 4:37 p.m., QMA 20 indicated she was not present at the time of Resident 7's fall. She was informed of the fall by CNA 22. When she entered the room, the resident was on her belly. She assisted the nurse and obtained the resident's vital signs. Resident 7 was dependent for care and it was routine for one staff member to assist the resident with her care. During an interview, on 5/18/26 at 4:50 p.m., CNA 22 indicated Resident 7 preferred to eliminate her bowels and bladder while sitting on the toilet, however Resident 7's mechanical lift pad was soiled and the resident was placed on a bedpan. The left side of Resident 7's bed was against the wall. After Resident 7 indicated she was ready to be taken off the bedpan, she rolled Resident 7 onto her right side. Resident 7 was facing CNA 22 and the bed pan was behind the resident towards the wall. The momentum of rolling Resident 7 towards her, caused the resident to bump into her, which caused her upper body to go backwards away from the resident. Resident 7 rolled out of the bed and briefly landed on CNA 22's knees prior to falling to the floor. Resident 7 complained of chin pain after the incident. She should have rolled Resident 7 towards the wall to ensure safety and easier removal of the bedpan. During an interview, on 5/18/26 at 4:58p.m., the DON indicated Resident 7 was rolled out of her bed onto the floor. She had laid on the floor on her belly, with her face resting on the floor. Initially no injuries were noted. Resident 7 indicated she turned too fast. No poor technique was used at the time of the incident and Resident 7 needed more assistance. Resident 7 had strong core movement and had more ability in her right upper extremity to assist with bed mobility, so she needed rolled to the right. Typically, a resident would be rolled the opposite way of the bedpan. She was unsure if Resident 7 had an assist rail on her bed to aide in turning. Resident 7 needed two person assistance with tasks. A facility policy, revised 2/2018, titled Bedpan/Urinal, Offering/Removing, provided by the Administrator on 5/18/26 at 5:16 p.m., indicated the following: .Steps in the Procedure .Assistance with a Bedpan: 10. If the resident is unable to lift his or her buttocks to get on or off the bedpan turn the resident on his or her side with the back facing you .18 .If the resident was rolled onto the bedpan it may require two (2) assistance to remove the bedpan and clean the resident Summon assistance as necessary 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation and interview, the facility failed to prepare and distribute food in a safe and sanitary manner. This deficient practice has the potential to affect 46 of 46 residents who receive meals from the Transitional Care Unit and Tulip Place kitchenette. Finding includes: During a meal service observation on 4/4/25 at 11:30 a.m., Dietary [NAME] 8 donned gloves and utilized utensils to scoop food items onto plates, warmed up a cooked hamburger on the griddle, picked up the mustard container with his gloved hands, and applied mustard to the hamburger. While wearing the same gloves, Dietary [NAME] 8 removed an egg roll from inside a warmer and placed it onto a resident's plate. He prepared four more resident's plates dipping up the stir fry and rice with utensils and placing the egg rolls on the plates with his gloved hands. He doffed his gloves, washed his hands with soap and water, and donned new gloves. Dietary [NAME] 8 used his gloved hand to place a plate on the serving board. He used the same gloved hand to remove an egg roll from inside the warmer and placed it on a plate. Using the same gloves, he walked to the freezer, opened the freezer door, reached inside, and retrieved frozen chicken tenders with his gloved hands. He walked back to the fryer and placed the frozen chicken tenders he was holding in his gloved hands into the fryer. During a meal service observation on 4/4/25 at 11:47 a.m., Dietary [NAME] 8 was wearing gloves. He opened the steam oven top and placed a piece of cheese onto a cooking hamburger patty. Wearing the same gloves, he retrieved a plate, placed an egg roll onto the plate, and then opened the plastic wrapping of a package of buns. He removed one bun from the package. On the bottom portion of the bun, he placed a piece of lettuce picked up the ketchup container adding ketchup to the sandwich. He checked the temperature of the items in the fryer nearby with a thermometer. Using the same gloves, he lifted the fryer basket and dumped out the chicken tenders onto a plate. He opened the warming oven and retrieved gravy. He placed a bun on top of the hamburger sandwich. He removed his gloves and washed his hands with soap and water. He removed his gloves and washed his hands with soap and water. He went to the freezer and removed a box of egg rolls, which he placed on a table. He donned new gloves and opened the microwave. Wearing the same gloves, he took the temperature of the soup, placed the bowl back into the microwave and reset the time. He cleaned the thermometer, used a spatula and flipped the egg on the griddle. He opened a loaf of bread, removed two slices with his soiled gloves, then picked up the mayonnaise container and added mayonnaise. Dietary [NAME] 8 removed the soup from the microwave with his gloved hands. He placed the egg onto the bread with a spatula and with his gloved hands picked up slice of tomato and the top piece of bread to complete the sandwich. He retrieved two egg rolls with the same gloved hands from the box on the table and placed them into two different fryer baskets. He removed his gloves and washed his hands with soap and water. He donned a new pair of gloves. The Dietary Manager arrived and handed Dietary [NAME] 8 tongs to use when serving the egg rolls. During an observation on 4/4/25 at 12:13 p.m., Dietary [NAME] 8 utilized the tongs to serve the egg rolls. Using gloves, he removed a peanut butter and jelly sandwich from a refrigerator and placed it on a plate. He opened a package of hot dog buns and removed a bun with the same gloved hands. He then picked up the mustard container, added the mustard to the bun, and utilized the tongs to place the hot dog onto the bun. He removed a hamburger bun from the bag using the same gloves. Next, he retrieved a cheese sandwich from the refrigerator with his gloved hands and placed it on the griddle. He opened another can of soup with his gloved hands and placed it into the microwave. Dietary [NAME] 8 removed a hamburger bun from the package with his gloved hands and placed on a plate. During an interview on 4/4/25 at 12:45 p.m., Dietary [NAME] 8 indicated he would change his gloves if he touched something that was not food safe. He was permitted to touch all the ready-to-eat items with his gloves. If the handles in the kitchen were clean, he touched them with his gloves too. During an interview on 4/4/25 at 12:47 p.m., the Dietary Manager indicated the staff were not supposed to touch food items with gloved hands unless the gloves were clean. The staff needed to change their gloves to touch other items. She instructed her staff to utilize tongs when serving meals and not wear gloves. A current facility policy, revised 7/2014, titled Preventing Foodborne Illness - Food Handling, provided by the DON on 4/7/25 at 3:45 p.m., indicated the following: .Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized 3.1-21(i)(3)

A. Based on observation, interview and record review, the facility failed to utilize infection prevention and control practices for residents in droplet precautions for 6 of 9 residents reviewed for infection control. (Residents 369, 15, 109, 147, 29, and 153). This deficiency had the potential to affect 38 of 38 residents with orders for droplet precautions. B. Based on observation and interview, the facility failed to ensure infection prevention and control practices were followed during dining services for 3 of 8 residents observed in the Evergreen Park Unit dining room. (Residents 75, 76, and 94) Findings include: A1. On 4/3/25 at 10:23 a.m., Resident 109's room had a Droplet Precautions sign posted by the door. CNA 20 exited Resident 109's room, leaving the door open. No hand hygiene was performed upon exiting the room. CNA 20 walked to another area of the unit and retrieved a mechanical lift. CNA 20 re-entered Resident 109's room and closed the door. Upon exiting the room, CNA 20 carried a bag of trash to the appropriate trash receptacle. Resident 109 was seated in a wheelchair beside the bed. CNA 20 washed their hands with soap and water. The CNA returned to the resident's room, retrieved the mechanical lift, and walked to another area of the unit. CNA 20 was not wearing eye covering during any part of the observation. Resident 109's clinical record was reviewed on 4/9/25 at 1:36 p.m. Diagnoses included unspecified dementia, coronary artery disease, and type 2 diabetes mellitus. A current physician's order, dated 3/25/29, indicated droplet precautions, every shift, related to viral syndrome such as coughing and wheezing. A 2/28/25, Quarterly Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Resident 109 was dependent on staff for bed mobility and transfers. A2. During an observation, on 4/3/25 at 2:37 p.m., Resident 15's room had a Droplet Precautions sign posted by the door, noticeable before entry. QMA 11 answered the call light for Resident 15, leaving the door open. QMA 11 entered the resident's room, stood at the resident's bedside and spoke with them for several minutes. QMA 11 exited Resident 15's room. No hand hygiene was performed. QMA 11 was not wearing eye covering during the observation. Resident 15's clinical record was reviewed on 4/9/25 at 1:37 p.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, and morbid obesity. A current physician's order, dated 3/25/29, indicated droplet precautions, every shift, related to Influenza A diagnosis. A 1/22/25, Quarterly MDS assessment indicated the resident was cognitively intact. Resident 15 required substantial assistance from staff for bed mobility and transfers. An isolation precaution care plan, initiated 3/31/25, indicated Resident 15 required droplet isolation for seven (7) days related to a diagnosis of Influenza A. Interventions included all good and services brought to resident's room, droplet precautions as ordered, and resident to remain in private room to prevent spread. A3. During an observation, on 4/7/25 at 1:04 p.m., Resident 369's room had a Droplet Precautions sign posted by the door. CNA 21 answered the call light for Resident 369. CNA 21 entered the resident's room and closed the door. CNA 21 was not wearing eye covering during the observation. No hand hygiene was performed upon exiting the room. Resident 369's room had a Droplet Precautions sign posted by the door. During an interview, at the time of the observation, CNA 21 indicated since the Personal Protective Equipment (PPE) was not visible at the resident's doorway, she went into the room anyway. If the PPE isn't easily noticeable, she would talk to the nurse manager to get help finding it. CNA 21 indicated she should have done this before she entered the resident's room. During an observation, on 4/7/25 at 1:22 p.m., Resident 369's room had a Droplet Precautions sign posted by the door. Dietary Aide 22 entered Resident 369's room. Dietary Aide 22 stood at the resident's bedside and spoke with them for several minutes. No hand hygiene was completed upon exiting the room. Dietary aide 22 was not wearing eye covering during the observation. During an interview, at the time of the observation, Dietary Aide 22 indicated the Droplet Isolation sign at the doorway meant staff needed to wear gowns and gloves to prevent the spread of infections when they were working closely with the resident. Since she had talked with the resident, she had not needed to wear any PPE while in the resident's room. Resident 369's clinical record was reviewed on 4/7/25 at 12:55 p.m. Diagnoses included type 2 diabetes mellitus, morbid obesity, and unspecified cirrhosis of the liver. A current physician's order, dated 3/31/25, indicated droplet isolation related to cough, shortness of breath, and respiratory flu symptoms until 4/8/25. A care plan, initiated on 3/30/25, indicated Resident 369 required droplet isolation related to signs and symptoms of Influenza A for 7 days. Interventions included to encourage good oral intake, give medications as ordered for fever and pain, and monitor, document, and report signs of dehydration. A 3/13/25, Admission MDS indicated the resident was moderately cognitively impaired. Resident 369 required substantial assistance from staff for bed mobility. He was dependent on staff for transfers. 45122 A4. During an observation, on 4/4/25 at 9:42 a.m., signage on Resident 147's room indicated the following: DROPLET PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry . The signage had a picture of a person wearing a face shield and a person wearing goggles with an or between the pictures. CNA 6 donned a gown, gloves, and placed an N95 mask over her surgical mask. She entered the room and spoke with the resident. She removed her personal protective equipment (PPE) prior to exiting the room. She sanitized her hands and applied a clean surgical mask. During an interview, on 4/4/25 at 9:45 a.m., CNA 6 indicated she was supposed to fully apply PPE to enter the resident's room. The facility training had indicated she did not need a face shield for Resident 147 nor Resident 29. Resident 147's clinical record was reviewed on 4/4/25 at 10:39 a.m. Diagnoses included chronic obstructive pulmonary disease and bronchitis. A current physician's order, dated 3/31/25, indicated the resident was to remain in droplet precautions isolation due to a diagnosis of bronchitis until the symptoms resolved or resident was fever free for 48 hours without intervention. A quarterly Minimum Data Set (MDS) assessment, dated 1/8/25, indicated the resident was severely cognitively impaired. He required substantial/maximal assistance with oral hygiene, toileting, showering/bathing, upper/lower body dressing, personal hygiene, moving from sitting to lying, moving from lying to sitting, and transfers. He was dependent on the staff for putting on/taking off footwear. A5. During an observation, on 4/4/25 at 9:48 a.m., a droplet precautions sign was on Resident 29's door. QMA 7 sanitized her hands, donned a gown, gloves, and placed an N95 mask over her surgical mask. She removed her eyeglasses and entered the resident's room. She delivered medications to the resident. She removed her PPE and exited the room, leaving her surgical mask on. She put on her glasses. During an interview on 4/4/25 at 9:51 a.m., QMA 7 indicated she was not required to wear the N95 mask, but she did so because she wanted to have extra protection against the respiratory infections. The facility did not require face shields/ eye protection for the droplet rooms, which included Resident 29 and Resident 147. During an interview on 4/4/25 at 9:57 a.m., QMA 7 indicated she should have worn a face shield into the residents' rooms with droplet precautions. Resident 29's clinical record was reviewed on 4/7/25 at 10:59 a.m. Diagnoses included unspecified asthma, chronic obstructive pulmonary disease, dependence on supplemental oxygen, pneumonia, acute respiratory failure with hypoxia, and shortness of breath. Physician's orders included prednisone 40 milligrams (mg) daily for increased cough for five days (3/31/25), amoxicillin 500 mg (antibiotic) two times a day for pneumonia (4/1/25), and azithromycin (antibiotic) 500 mg for one day (started 3/31/25 and discontinued 3/31/25), azithromycin 250 mg daily for four days (4/1/25), oxygen at two to three liters per minute via nasal cannula (3/31/25), and the resident was to remain on droplet precautions until symptom resolution or was fever free without intervention (started 3/31/25, discontinued 4/4/25). An admission MDS, dated [DATE], indicated the resident was cognitively intact. She required partial/moderate assistance with toileting hygiene, showering/bathing, upper body dressing, and ambulating 10 feet. She required substantial/maximal assistance with lower body dressing, putting on/taking off footwear, rolling in bed, moving from sitting to lying, moving from lying to sitting, moving from sitting to standing, bed to chair/chair to bed transfers, and toilet transfers. During an interview on 4/8/25 at 5:07 p.m., the Infection Preventionist indicated eye protection was required to enter rooms with droplet precautions. The staff were expected to read and follow the isolation signage on the doors. 42685 A6. During an observation on 4/2/25 at 4:52 p.m., CNA 15 approached Resident 153's room, where a droplet isolation sign was in place at the door. The droplet isolation sign indicated everyone was required to perform hand hygiene before entering and when leaving the room. A face shield or goggles was required. The face protection was required to be removed prior to exiting the room. She donned a gown and gloves, and entered the resident's room. CNA 15 already had a surgical mask in place when she approached the resident's room. The mask was not changed when she entered the room and delivered a cup of water to the resident. She wore regular eyeglasses. Eye protection was not worn during the observation. CNA 15 doffed her gown and gloves and exited the room at 4:54 p.m., without removing her surgical mask. She continued to deliver water to random residents' rooms on the Cedar Ridge Unit. Resident 153's clinical record was reviewed on 4/4/25 at 10:52 a.m. Diagnoses included influenza due to identified novel Influenza A virus with other respiratory manifestations. A physician's order, from 3/27/25 to 4/3/25, indicated the resident was required to remain on droplet precautions isolation due to a diagnosis of Influenza A. An isolation precaution care plan, initiated 3/27/25 and discontinued on 4/4/25, indicated the resident required droplet isolation for seven days related to a diagnosis of Influenza A. Interventions included droplet precautions as ordered (3/28/25). During an interview on 4/4/25 at 1:17 p.m., CNA 25 indicated staff were required to don a gown, gloves, surgical mask, and a face shield prior to the entrance of residents' rooms on droplet precautions. During an interview on 4/7/25 at 1:41 p.m., CNA 15 indicated staff were required to don a gown, gloves, face mask, and a face shield prior to the entrance of residents' rooms on droplet precautions. She had not donned a face shield during the observation on 4/2/25 when she delivered ice water to Resident 153. Face shields were readily available and the droplet signs indicated goggles or a face shield was required. During an interview on 4/7/25 at 2:36 p.m., the Infection Preventionist (IP) indicated the staff were required to wear a surgical face mask and a face shield or goggles for residents requiring droplet precautions. If the staff were at risk for high contact with the resident, their surroundings, or bodily fluids, they were expected to wear a gown and gloves. During an interview on 4/8/25 at 11:23 a.m., the IP (Infection Preventionist) indicated the facility followed the Center for Disease Control (CDC) guidelines for droplet precautions. A current facility policy, dated 2001 and titled Isolation - Categories of Transmission-Based Precautions, provided by the DON on 4/7/25 at 9:25 a.m., indicated the following: .Policy Statement . Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . Policy Interpretation and Implementation . 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precautions(s), instructions for use of PPE . Droplet Precautions . 4. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions 51985 B1. During a continuous observation on 4/2/25 from 11:35 a.m. to 12:20 p.m., CNA 10 was assisting Resident 75 with his meal. The CNA rested her elbows on the dining room table and used her left index finger to rub her nose. She picked up the resident's fork and assisted him with his meal. She palmed over the top of Resident 75's drinking cup with her right hand and assisted the resident with a drink. She turned to her left and used the same hand to palm the top of Resident 94's bowl. She obtained a spoonful of food, brought it up to her lips, and blew on the food. She indicated that the food was hot and placed the spoonful of food into Resident 94's mouth. The CNA palmed the top of Resident 94's cup and gave the resident a drink. She wiped Resident 94's mouth with a napkin. She turned back to Resident 75 and offered the resident a bite of food. She indicated to Resident 75 the food was not hot because she had blown on it. Resident 75 took a bite of the food. She picked up Resident 94's unused fork, reached across the table, and used the fork to move the remaining food around on Resident 76's plate. She sat the fork down back in front of Resident 94. She stood up and left the table. She approached the kitchenette in the dining room and requested dietary staff to get Resident 76 more onion rings. She retrieved a clean cup, walked over to the refrigerator, and used her hands to open the refrigerator door. She balanced the cup on the refrigerator door and put her finger inside the rim of the cup. She poured milk into the cup. She picked up the previously used fork in front of Resident 94 and used it to offer Resident 75 his dessert. She assisted Resident 75 with his meal. She palmed the top of Resident 75's cup and assisted the resident with a drink. CNA 10 did not perform hand hygiene throughout the observation. During an interview on 4/8/25 at 12:20 p.m., CNA 24 indicated plates, bowls, and cups were handled from the bottom and the tops of bowls and cups were not touched. Hand hygiene was to be done frequently when in the dining room. Hand hygiene was to be performed after personal clothing, face, and hair was touched. Food was never touched bare handed. Utensils were not shared among residents. During an interview on 4/9/25 at 11:09 a.m., the Infection Preventionist indicated staff had been encouraged to carry their own hand sanitizer when they assisted in the dining room. Hand hygiene was to be performed often during individual dining assistance and between multiple residents. Hand hygiene was to be performed when personal clothing, face, or hair were touched. Utensils, cups, or plates were not to be shared among residents. Food was to be cooled naturally, and a replacement plate item obtained if it was too hot and not cooled down timely. Food was not to be touched with bare hands and was not to have been blown on to cool it off. Tableware was to be handled from the underside and the top rim or lip area of cups, and bowls were not to be touched. A current facility policy, revised on March 2022 and provided by the DON on 4/9/25 at 10:00 a.m., titled Assistance with Meals, indicated the following: .All Residents: 3. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling 3.1-18(a) 3.1-18(b)(2) 3.1-18(l)

Based on observation, record review, and interview, the facility failed to promote resident dignity by failing to provide prompt care for bowel incontinence for 1 of 1 resident reviewed for dignity. (Resident 71) Finding includes: Confidential interviews were conducted during the course of the survey. During the confidential interview, the interviewee indicated Resident 71 had been assisted into a wheelchair and out of his room that day. The resident indicated he had been having a bowel movement as he left the room. He was not permitted to return to his room because his room was being sprayed for pests. The room had been sprayed about an hour ago. The resident had been in the common area since he had left his room. The staff members were aware the resident was soiled, but did not know what to do and did not know how to help him get changed as they were not permitted to return to the resident's room due to the exterminator's spray. During an interview on 4/7/25 at 2:36 p.m., Resident 71 indicated his room had been treated today for pests, and he had to stay out of his room. He was very incontinent. He had an incontinent episode as soon as he left his room. He was sitting in feces, and no one knew what to do to help him since his room was unavailable. On 4/7/25 at 2:41 p.m., Resident 71 sat in a wheelchair in the common area of the unit with a mechanical lift net under him. He indicated he still needed to be assisted with incontinence care. During the interview, QMA 11 in the hall near the common area, and CNA 12 was documenting on a kiosk a short distance away from the resident. During an interview on 4/7/25 at 2:43 p.m., QMA 11 indicated Resident 71's room was being cleaned, and an exterminator had sprayed in his room. She was uncertain where she should take the resident to be given incontinence care as there were no empty rooms on the unit. She was going to find the supervisor and ask what she should do. During an interview on 4/7/25 at 2:44 p.m., CNA 12 indicated she thought Resident 71's room had been sprayed about an hour ago. She did not know what she was supposed to do since there was not anywhere to take the resident for incontinence care or toileting. During an interview on 4/7/25 at 2:58 p.m., Unit Manager 4 indicated the resident had recently had Clostridioides difficile (an infection of bowel causing severe diarrhea) and had an issue with pests in his room. He could now go back to his room because it had been over two hours since his room had been sprayed. The staff should have taken the resident to an empty room or notified her (Unit Manager 4) so she could have directed them where the resident could go for toileting needs. During an observation on 4/7/25 at 3:00 p.m., CNA 12 indicated to Resident 71 that she needed to make his bed first, then she would assist him with changing his pants. The resident remained in the common area, seated in a wheelchair. On 4/7/25 at 3:04 p.m., CNA 12 assisted the resident to his room. During an observation on 4/7/25 at 3:12 p.m., QMA 11 and CNA 12 lowered the resident into his bed using the mechanical lift. The resident had feces on and between his buttocks, extending from his scrotum up to a bandage on his sacral/coccyx area. During an interview on 4/7/25 at 4:13 p.m., the DON indicated she would expect incontinence care to be provided immediately for a resident known to have been incontinent. When the resident's room was sprayed, the plan had been for the resident to be taken to an empty room or taken to a private room in the therapy room. Resident 71's clinical record was reviewed on 4/8/25 at 9:56 a.m. Diagnoses included depression, bipolar disorder, paraplegia, and enterocolitis (inflammation of both the small and large intestines) due to Clostridium difficile (also known as Clostridioides difficile) not specified as recurrent. Current physician's orders included bupropion (antidepressant) extended release 200 milligrams (mg) daily, fluoxetine (antidepressant) 20 mg daily, trazodone (antidepressant) 75 mg daily, and quetiapine fumarate (antidepressant) 50 mg daily. An admission Minimum Data Set (MDS) assessment, dated 2/27/25, indicated the resident was cognitively intact. The resident felt down/depressed/hopeless for two to six days of the 14-day assessment period. He was dependent on staff for toileting, bathing, dressing of his lower body, chair to bed/bed to chair transfers, and tub/shower transfers. He required substantial/maximal assistance with rolling from left to right in bed and moving from sitting to lying position. The resident was always incontinent of bowel. During an interview on 4/8/25 at 3:45 p.m., RN 16 indicated a resident who was incontinent of bowel or bladder should be provided incontinence care right away. During an interview on 4/8/25 at 4:53 p.m., Unit Manager 4 indicated a resident should not be left sitting in a soiled incontinence brief. A current facility policy, revised 2/2021, titled Dignity, provided by the DON on 4/8/25 at 8:56 a.m., indicated the following: .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; for example: . promptly responding to a resident's request for toileting assistance 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure residents who self-administered medications were assessed for safety for 2 of 2 residents reviewed for medication self-administration. (Residents 31 and 14) Findings include: 1. During an interview on 4/2/25 at 3:09 p.m., a medication cup sat on Resident 31's bedside table. She indicated the cup contained applesauce and her medications. A large, red-colored pill and white colored pills were observed in the cup. The resident indicated the pills had to dissolve in the applesauce before she could swallow them. Staff left the medications with her because the pills took a long time to dissolve. Resident 31's clinical record was reviewed on 4/8/25 at 4:19 p.m. Diagnoses included atrial fibrillation, major depressive disorder, anxiety disorder, heart failure, and acute kidney failure. Current physician's orders included levothyroxine sodium 75 micrograms (mcg) (thyroid medication), one tablet in the evening, gabapentin 100 mg (seizure or nerve pain medication), two capsules twice a day, mechanical soft diet, no salt added, thin consistency, no bacon, sausage, hot dogs, or ham, and an 1800 milliliter (mL) fluid restriction. The clinical record lacked a physician's order for self-administration of medications. A Medication Self-Administration Safety Screen, dated 2/27/25 at 6:35 p.m., indicated Resident 31 was able to correctly read the label and/or identify each medication, required assistance to identify what condition each medication treated, the time/frequency medications were to be administered, and to open the medication packages or containers. The Interdisciplinary Team (IDT) review summary indicated medications were to be administered by nursing staff. The resident was not safe to self-administer medications. A quarterly Minimum Data Set (MDS) assessment, dated 2/28/25, indicated the resident was moderately cognitively impaired, had no difficulty swallowing, and received a mechanically altered diet. The clinical record lacked a care plan for medication self-administration. During an interview on 4/8/24 at 3:41 p.m., QMA 25 indicated Resident 31 preferred her medications to sit in applesauce until dissolved. The resident did not want the medications crushed before adding to the applesauce. Some days, the resident would refuse to take the medications until they dissolved. QMA 25's practice was to return the medication cup containing the applesauce and floated medications to the medication cart, where she would put the cup in the drawer under the resident's name. After the medications were dissolved, she would take them back to Resident 31. She never left medications in the room with the resident. During an interview on 4/8/25 at 3:48 p.m., RN 26 indicated the resident would sometimes try to take the medications without dissolving them in applesauce. The medications should not be left with the resident. RN 26 would occasionally dissolve the medications in applesauce before taking them to Resident 31. The resident's Self-Administration Assessment Safety Screen indicated staff needed to be present for medication administration. 2. During an observation on 4/3/25 at 9:52 a.m., QMA 27 indicated another staff member reported medication on the floor in Resident 14's room. QMA 27 went to the resident's room, picked up a medication cup from the bedside table, picked up pills from the floor, and put the pills in the medication cup. Resident 14 requested the pills but the QMA told her the pills had been on the floor and she could not have them. The QMA removed the pills and cup from the room. During an interview, immediately following the observation, QMA 27 indicated medications should not be left in resident rooms. She was unsure if the resident dropped the pills. The resident received 11 pills in the morning. The medication cup contained two white pills. Resident 14's clinical record was reviewed on 4/9/25 at 9:46 a.m. Diagnoses included heart failure, anemia, overactive bladder, and osteoarthritis. Current physician's orders included aspirin 81 mg delayed release, give one tablet by mouth daily for heart health, cetirizine 10 mg, give one tablet daily for allergies, furosemide 40 mg, give one tablet daily for pulmonary edema, gabapentin 100 mg, give one capsule by mouth one time a day for neuropathy, glucosamine-chondroitin 750-600 mg, give one tablet by mouth daily, linaclotide 72 mcg, give in the morning for constipation, potassium 20 milliequivalents (mEq), give in the morning for hypokalemia (low potassium), primidone 50 mg, give three tablets daily for benign familial tremor, vitamin D3 1000 units, give two capsules daily for osteoporosis, guaifenesin 600 mg, give every morning and at bedtime for ongoing productive cough for ten days, and hydrocodone-acetaminophen 5-325, give one tablet three times a day for chronic pain. A quarterly MDS assessment, dated 2/18/25, indicated the resident was moderately cognitively impaired, had no difficulty swallowing, and received a regular diet. A current care plan, initiated on 11/14/24, indicated the resident was at risk for pain related to a pressure area on her buttocks, polymyalgia rheumatica (an inflammatory condition), osteoarthritis, and chronic pain. Interventions included administration of analgesia according to physician's order, evaluate the effectiveness of pain interventions, identify, record, and treat the resident's conditions which might increase pain or discomfort. A current care plan, initiated 2/23/25, indicated the resident was on pain medication. Interventions included administration of analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift. The clinical record lacked a care plan for medication self-administration. The clinical record lacked a Medication Self-Administration Safety Screen. A current facility policy, titled Administering Medications, provided by the Director of Nursing (DON) on 4/8/25 at 4:26 p.m., indicated the following: Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation indicated the following: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely 3.1-11(a)

Based on interview and record review, the facility failed to monitor bowel movements and initiate the facility's bowel protocol for a resident with constipation for 1 of 1 resident reviewed for constipation. (Resident 40) Finding includes: During an interview on 4/7/25 at 1:57 p.m., Resident 40 indicated her bowels moved that day, but it was very hard. It had been about three days since her bowels last moved. She hoped the constipation was getting better. Resident 40's clinical record was reviewed on 4/7/25 at 4:34 p.m. Diagnoses included Parkinson's disease, constipation, generalized anxiety disorder, unspecified dementia, iron deficiency anemia, and difficulty walking. A current physician's order included bisacodyl rectal suppository 10 mg insert one suppository rectally as needed for constipation daily, An admission Minimum Data Set (MDS) assessment, dated 12/16/24, indicated the resident was moderately cognitively impaired, used a manual wheelchair, required set-up assistance for eating, toileting, and oral hygiene. She could walk 10 feet with supervision. The resident was always continent of bowel. A current care plan, initiated on 12/10/24, indicated the resident was at risk for bladder and bowel incontinence related to dementia and pain. Interventions included encourage fluids during the day to promote a prompted voiding response, monitor and document intake and output according to facility policy, and establish voiding patterns. A current care plan, initiated on 12/10/24, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to her diagnoses of Parkinson's disease, a history of falls, degenerative disc disease, arthritis, scoliosis, and dementia. The intervention was to toilet the resident as needed. A current care plan, dated 12/10/24, indicated the resident had a diagnosis of constipation. Interventions included follow the facility bowel protocol for bowel management, monitor/document/report, as needed, signs and symptoms of complications related to constipation, a change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow heart rate), abdominal distension, vomiting, small loose stools, fecal smearing, bowel sounds, diaphoresis (sweating), abdominal tenderness, guarding, rigidity, or fecal compaction. During an interview with CNA 19 on 4/8/25 at 12:14 p.m., she indicated Resident 40 required limited assistance for toileting and assistance with personal hygiene after a bowel movement. The resident had experienced constipation for some time. CNA 19 thought the resident's constipation had improved. The resident's medication helped with the constipation. Any problems with constipation or diarrhea were to be charted in the resident's electronic health record and reported to the nurse. She reported Resident 40's constipation concerns to RN 16 approximately three weeks ago. During an interview with RN 16 on 4/8/25 at 12:23 p.m., she indicated the staff told her about Resident 40's constipation but could not recall when. Nurses were able look up the residents' bowel patterns in the electronic health record. Staff could also report concerns directly to the nurses. If a resident had no bowel movements for three days, nursing could request an order for prune juice, magnesium hydroxide (laxative), polyethylene glycol 3350 (laxative), or senna (laxative/stool softener). All nurses should monitor for bowel concerns during their shift. They should run a bowel report, then follow the bowel protocol. Resident 40 had a diagnosis of dementia and might not remember to tell staff she was constipated. RN 16 could not locate documentation to indicate the resident received anything for constipation between 3/10/25 and 4/8/25. If the constipation was not documented in the clinical record, staff would not know whether the bowel protocol was utilized for the resident since 3/10/25. The last time the bowel protocol was utilized for Resident 40 was December 2024. The resident should have received bowel protocol interventions between 3/10/25 and 4/8/25, especially since the resident had no bowel movements for more than three days. A bowel elimination record, dated 3/10/25 through 4/7/25 and provided by RN 16 on 4/8/25 at 12:46 p.m., indicated the resident did not have any bowel movements between 3/16/25 through 3/18/25, and 3/24/25 through 3/31/25. During an interview with Unit Manager 3 on 4/8/25 at 3:36 p.m., she indicated CNA staff should chart bowel movements every shift, whether the resident had a bowel movement or not. The nurses, every shift, should have monitored when a resident did not have a bowel movement in a 72-hour period or more. When the 72 hours (or more) had passed, the bowel protocol should have been followed, sooner if the constipation had been reported to nursing. Failure to follow the bowel protocol increased the risk for impaction or bowel perforation. A current facility policy, dated 12/2009, titled Monitoring of Bowel Movements, provided by the DON on 4/8/25 at 2:49 p.m., indicated the following: It is the policy of (the facility) to monitor bowel function of all residents routinely and as needed for signs of constipation .2. All BM's will be documented in the kiosk or on paper in the resident medical record every shift. 3. A Bowel Movement (BM) report will be run nightly on the 6:00 p.m. to 6:00 a.m. shift from the kiosk that will reflect the previous 72 hours bowel activity. 4. The BM report will be audited for each resident to identify any resident who has had either no BM or a small BM within the previous 72 hours for further intervention. 5. Any resident identified as having no BM or only one small BM within the previous 72 hours will have a complete assessment including but not limited to palpation of abdomen, auscultation of bowel sounds, and any signs or symptoms of discomfort noted and documented. After assessment completed the resident will be offered prune juice or PRN (as needed) medication as ordered 3.1-37(a)(2)(C)

A. Based on observation, record review, and interview, the facility failed to implement interventions to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 71) B. Based on observation, record review, and interview, the facility failed to utilize infection prevention and control strategies to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 153) Findings include: A.1. Confidential interviews were conducted during the course of the survey. During the confidential interview, the interviewee indicated Resident 71 had been assisted into a wheelchair and out of his room that day. The resident indicated he had been having a bowel movement as he left the room. He was not permitted to return to his room because his room was being sprayed for pests. The room had been sprayed about an hour ago. The resident had been in the common area since he had left his room. The staff members were aware the resident was soiled, but did not know what to do and did not know how to help him get changed as they were not permitted to return to the resident's room due to the exterminator's spray. During an interview on 4/7/25 at 2:36 p.m., Resident 71 indicated his room had been treated today for pests, and he had to stay out of his room. He was very incontinent. He had an incontinent episode as soon as he left his room. He was sitting in feces, and no one knew what to do to help him since his room was unavailable. On 4/7/25 at 2:41 p.m., Resident 71 sat in a wheelchair in the common area of the unit with a mechanical lift net under him. He indicated he still needed to be assisted with incontinence care. During the interview, QMA 11 in the hall near the common area, and CNA 12 was documenting on a kiosk a short distance away from the resident. During an interview on 4/7/25 at 2:43 p.m., QMA 11 indicated Resident 71's room was being cleaned, and an exterminator had sprayed in his room. She was uncertain where she should take the resident to be given incontinence care as there were no empty rooms on the unit. She was going to find the supervisor and ask what she should do. During an interview on 4/7/25 at 2:44 p.m., CNA 12 indicated she thought Resident 71's room had been sprayed about an hour ago. She did not know what she was supposed to do since there was not anywhere to take the resident for incontinence care or toileting. During an interview on 4/7/25 at 2:58 p.m., Unit Manager 4 indicated the resident had recently had Clostridioides difficile (an infection of bowel causing severe diarrhea) and had an issue with pests in his room. He could now go back to his room because it had been over two hours since his room had been sprayed. The staff should have taken the resident to an empty room or notified her (Unit Manager 4) so she could have directed them where the resident could go for toileting needs. During an observation on 4/7/25 at 3:00 p.m., CNA 12 indicated to Resident 71 that she needed to make his bed first, then she would assist him with changing his pants. The resident remained in the common area, seated in a wheelchair. On 4/7/25 at 3:04 p.m., CNA 12 assisted the resident to his room. During an observation on 4/7/25 at 3:12 p.m., QMA 11 and CNA 12 lowered the resident into his bed using the mechanical lift. The resident had feces on and between his buttocks, extending from his scrotum up to a bandage on his sacral/coccyx area. The resident's inner buttocks were reddened. During an observation on 4/7/25 at 3:54 p.m., LPN 13 removed the soiled dressing from the resident's sacral/coccyx area. LPN 13 cleaned the feces from the pressure injury and the surrounding area. The skin surrounding the pressure injury was reddened. The pressure injury was slightly smaller than the size of a dime. The depth was approximately the diameter of a triple A battery. LPN 13 packed the wound with the Dakin's moistened gauze and applied a bandage to the pressure injury. During an interview on 4/7/25 at 4:13 p.m., the DON indicated she expected incontinence care to be provided immediately for a resident known to have been incontinent. When the resident's room was sprayed, the plan had been for the resident to be taken to an empty room or taken to a private room in the therapy department. He was only supposed to be out of the room for two hours. Resident 71's clinical record was reviewed on 4/8/25 at 9:56 a.m. Diagnoses included paraplegia, and enterocolitis (inflammation of both the small and large intestines) due to Clostridium difficile (also known as Clostridioides difficile) not specified as recurrent. A current physician's order included cleanse the sacrum with mild soap and water, pat dry, skin prep peri wound, apply 1/4 strength Dakin's solution (wound treatment) to dampened gauze cotton roll, and cover with abdominal gauze bandage and paper tape daily for wound care and as needed. An admission Minimum Data Set (MDS) assessment, dated 2/27/25, indicated the resident was cognitively intact. He was dependent on staff for toileting, bathing, dressing of his lower body, chair to bed/bed to chair transfers, and tub/shower transfers. He required substantial/maximal assistance with rolling from left to right in bed and moving from sitting to lying position. The resident was always incontinent of bowel. He was at risk for pressure ulcers. He had one unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer, present on admission, with the wound bed covered by slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (dead or devitalized tissue that is hard or soft in texture). Skin interventions included a pressure reducing device for his chair and bed. A care plan problem indicated the resident was at risk for skin impairment related to paraplegic, new suprapubic catheter, multiple wounds, C-diff in isolation, anticoagulant and aspirin regimen was initiated and revised on 2/19/25. An intervention was to provide incontinence care after each incontinent episode. A weekly wound assessment, dated 4/2/25 at 2:26 p.m., indicated the resident had a stage 3 (full-thickness skin loss where subcutaneous fat is visible, but bone, tendon, or muscle is not exposed) pressure injury measuring 1.5 centimeters (cm) long by 1.5 cm wide by 1 cm deep and had 0.5 cm of undermining (the tissue under the wound edges becomes eroded or separated, creating a pocket or a shelf beneath the skin at the wound's edge). The pressure injury had a small amount of serosanguineous (mixture of clear, watery fluid and blood) drainage. The overall impression of the visible tissue was that the pressure injury was unchanged since the prior week. A weekly wound assessment, dated 4/8/25 at 10:30 a.m., indicated the resident had a stage 3 pressure injury measuring 1.5 centimeters (cm) long by 1.5 cm wide by 1 cm deep and had 0.5 cm of undermining around entire wound edge. A new tunnel (channel underneath the skin surface) measuring 1.5 cm was at the top of the pressure injury. The pressure injury had a moderate amount of purulent drainage. The overall impression of the visible tissue was that the pressure injury was worsened since the prior week. During an interview on 4/8/25 at 4:13 p.m., RN 16 indicated a resident who was incontinent of bowel or bladder should be provided incontinence care right away. Sitting in feces could increase the risk of infection to a pressure injury. During an interview on 4/8/25 at 4:53 p.m., Unit Manager 4 indicated a resident should not be left sitting in a soiled incontinence brief and could have an increased risk of infection for a resident with a pressure injury. A current facility policy, revised 4/2020 and titled Prevention of Pressure Injuries, provided by the DON on 4/8/25 at 2:49 p.m., indicated the following: .Skin Care .Clean promptly after episodes of incontinence 42685 B1. During an observation on 4/3/25 at 12:02 p.m., Resident 153 was seated in a wheelchair in his room. The outline of a dressing was observed on the resident's right heel under his sock. The resident indicated he had a hole in his right heel with a dressing over it. There was no pressure relief intervention observed under the resident's feet. A green pressure relief boot was observed on the floor near the foot of the bed. Resident 153's clinical record was reviewed on 4/4/25 at 10:52 a.m. Diagnoses included a fracture of an unspecified part of the neck of the right femur, subsequent encounter for closed fracture with routine healing. A current physician's order, dated 3/25/25, indicated to cleanse the right heel every day shift for wound care with mild soap and water, pat dry, apply calcium alginate (wound dressing) to the wound bed, and cover with a foam dressing. A provider notification was required for adverse changes. A quarterly Minimum Data Set (MDS) assessment, dated 2/11/25, indicated the resident was cognitively intact. He required partial assistance from staff for lower body dressing and transfers. He required substantial assistance to don and doff footwear. The resident was at risk for pressure ulcers. He had one unstageable pressure ulcer, present on admission, with the wound bed covered by slough or eschar. Skin interventions included a pressure-reducing device for his bed and pressure ulcer care. A current care plan, initiated 11/1/24, indicated the resident was at risk for skin impairment related to a recent fall with a right hip fracture with surgical repair and a right heel wound. Interventions included pressure-relieving boots placed on the resident's feet as he allowed (11/6/25) and medications provided as ordered (11/1/24). A current care plan, initiated 11/5/24, indicated the resident had an unstageable pressure injury to his right heel upon admission. Interventions included wound measurement weekly (11/5/24) and administer the wound treatment as ordered (11/5/24). An admission nurse's note, dated 10/31/24 at 2:23 p.m., indicated the resident had a wound to his right heel measuring 5.0 centimeters (cm) by 5.5 cm. No depth or type of wound was included. A weekly wound assessment, dated 11/5/24, indicated the resident had an unstageable pressure ulcer to the right heel, present on admission. The wound measured 3.5 cm in length by 6 cm in width. The depth was unknown. During a wound observation on 4/4/25 from 1:56 p.m. to 2:14 p.m., RN 23 entered the resident's room and donned a gown and gloves. RN 23 did not perform hand hygiene. She placed the wound care supplies directly against the overbed table without a barrier or cleaning it. The resident had a soft open-toed shoe on his right foot that was removed by RN 23 with both gloved hands as she touched the sole of the shoe. With the same gloves, she removed the dressing to the resident's right heel, dated 4/2/25, which contained a small amount of yellow with blood tinged drainage on the dressing. The wound was open around the edges with a large, scabbed area to the center of the wound. RN 23 doffed the gloves, performed hand hygiene, and donned clean gloves. She opened a package from the overbed table, then turned on the faucet and placed soap and water on the gauze. She then used it to cleanse the wound and discarded the gauze. She doffed her gloves, performed hand hygiene, and donned clean gloves. She picked up another gauze package from the overbed table with her gloved hands, opened it, and used it to pat the wound dry. She measured the right heel wound at 2.5 cm length by 3.7 cm width. x 0.1 cm depth on the medial side of the right heel. RN 23 confirmed the date on the previous dressing was two days ago and indicated the depth of the wound could not be determined due to the scab. She applied the calcium alginate and foam dressing retrieved from the overbed table. During an interview on 4/4/25 at 2:16 p.m., RN 23 indicated she had not used a barrier on the overbed table or cleaned it prior to placing wound supplies directly against it. She had not performed hand hygiene after she removed the resident's shoe and prior to the beginning of the wound care observation. These practices were a potential opportunity for contamination of the resident's pressure injury site. During an interview on 4/8/25 at 3:20 p.m., Clinical Nurse Specialist 17 indicated it was not appropriate infection control practice when wound supplies were placed on a surface that had not been cleaned or had a clean barrier. The supplies should not have been opened from a dirty surface and used for wound care. This was a risk for wound contamination. A current facility policy, dated 2001, titled Dressings, Dry/Clean, provided by the DON on 4/7/25 at 9:25 a.m., indicated the following: Purpose . The purpose of this procedure is to provide guidelines for the application of dry, clean dressings . Equipment and Supplies . The following equipment and supplies will be necessary when performing this procedure. 1. Clean dressing(s) . 5. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure . 1. Clean the beside stand. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached .4. Position resident and adjust clothing to provide access to affected area. 5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and remove soiled dressing . 11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. Put on clean gloves . 15. Cleanse the wound with ordered cleanser 3.1-40(a)(2)

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. Finding includes: 1. Review of the Summary Statement of Deficiencies, for the facility's last annual Recertification and State Licensure Survey completed on 5/1/24, indicated the facility failed to provide monitoring of a pressure injury and failed to develop and implement interventions to promote the healing of pressure injuries. The plan of correction indicated, .the DON or designee, will audit four (4) resident's dressing changes one (1) time a week for four (4) weeks then one (1) time a month for five (5) months for potential infection related to contamination for example, glove use and hand hygiene - Before handling clean or soiled dressings, gauze pads, - After handling used dressings, contaminated equipment, - After contact with objects in the immediate vicinity of the resident. Results of these audits will be forwarded to QAPI. Any negative findings will add an additional month of auditing until 100% compliance is achieved Repeat concerns regarding failure to develop and implement interventions to promote the healing of pressure injuries were cited during the April 7, 2025, survey as follows: Based on observation, record review, and interview, the facility failed to implement interventions to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 71) 2. Review of the Summary Statement of Deficiencies, for the facility's last annual Recertification and State Licensure Survey completed on 5/1/24, indicated the facility failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care. The plan of correction indicated, .The Director of Nursing (DON) or designee, will audit all residents with pressure wounds for interventions, assessments, quality of dressing changes and healing one (1) time a week for four (4) weeks then one (1) time a month for five (5) months. Results of these audits will be forwarded to QAPI. Any negative findings will add an additional month of auditing until 100% compliance is achieved Repeated concerns regarding failure to utilize infection prevention and control strategies to prevent contamination of wounds during wound care were cited April 7, 2025, survey as follows: Based on observation, record review, and interview, the facility failed to utilize infection prevention and control strategies to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 153) During an interview, on 4/9/25 at 12:17 p.m., the Administrator and DON indicated the QAPI meetings happened no less than quarterly, and sometimes on a monthly basis. The QAPI meeting covered previously identified areas of concern and specific set areas based on the facilities calendar. The previously cited concerns would be reviewed through the timeframe listed on the Plan of Correction (POC). The DON indicated she had started a Performance Improvement Plan (PIP) related to pressure ulcers after the previous survey, but was unable to locate the appropriate supportive documentation. An undated, current facility policy, titled, Quality Assurance and Performance Improvement (QAPI) Plan, provided by the Administrator shortly after entrance conference on 4/2/25, indicated the following: .The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and interact with our residents, team members, and other care partners so that we may realize our mission and to be the premier provider of Residential, Skilled Long Term, and Short-Term Rehabilitation services in the area .The QAPI plan will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The QAPI plan will ensure care and services delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement is achieved and sustained . Cross reference F686. 3.1-52(b)(2)

Based on record review and interview, the facility failed to prevent staff-to-resident verbal abuse of a dependent resident (Resident D) and neglect of a resident (Resident E) from a staff member, CNA 1, for 2 of 3 residents reviewed for abuse. The deficient practice was corrected on [DATE], prior to the date of the survey, and was therefore past noncompliance. Findings include: 1. The clinical record for Resident D was reviewed on [DATE] at 10:57 a.m. Diagnoses included dysphagia, cerebral infarction, and glaucoma. The most recent significant change Minimum Data Set (MDS) assessment, dated [DATE], was reviewed on [DATE] at 10:57 a.m. The MDS indicated Resident D had severe cognitive impairment and was dependent on staff for all activities of daily living. In a written statement, dated [DATE], CNA 2 indicated while getting Resident D ready for bed, Resident C indicated CNA 2 had told Resident D to Shut up, You don't need to talk right now. CNA 1 also told the resident that she would give her permission to talk. During an interview on [DATE] at 12:57 p.m., Resident C indicated on the morning of [DATE], CNA 1 had been verbally abusive to Resident C when she came to provide morning care. Resident D indicated CNA 1 told Resident C to shut up; you don't need to talk right now, and I will give you permission to talk. Resident D did not report the incident to the facility until [DATE]. The resident reported the incident to CNA 2. Neither CNA 1 nor CNA 2 were available for interview during the survey. 2. The clinical record for Resident E was reviewed on [DATE] at 11:10 a.m. Diagnoses included intertrochanteric fracture of the right femur, chronic obstructive pulmonary disease, and atrial fibrillation. The most recent quarterly MDS assessment, dated [DATE], was reviewed on [DATE] at 11:10 a.m. The MDS indicated Resident E was cognitively intact. The resident was impaired in the lower extremity on one side and required moderate assistance for showering and dressing. Review of a written statement, dated [DATE], indicated CNA 2 indicated while providing care to the resident, Resident E asked for a shower. The resident indicated CNA 1 had told the resident they were too tired to provide a shower. CNA 2 provided the resident with a shower. During an interview on [DATE] at 1:48 p.m., the DON provided the facility investigation regarding the incident. The facility reported CNA 1 to their agency and the appropriate state agency. The DON indicated CNA 1 was no longer allowed to work in the facility. During an interview on [DATE] at 4:46 p.m., the DON indicated resident rights were revived during Resident Council meetings. The DON provided a copy of the resident rights reviewed that indicated the following: Freedom from Restraint and Abuse You have the right to: Be free from verbal, physical, sexual, and mental abuse; corporal punishment; neglect; and involuntary seclusion. This deficient practice was corrected by [DATE] after the facility implemented a systemic plan that included the following actions: assessment of all residents for psychosocial harm, corrective action for the CNA involved in abuse allegation, in-servicing re-education to staff related to resident abuse and neglect, and audits of residents for neglect concerns were completed. This citation relates to Complaint IN00444013. 3XXX,d+[DATE](b)

Based on observation, interview, and record review, the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. This deficient practice resulted in the resident eloping from the facility and being unaccounted for overnight for 1 of 3 residents reviewed for elopements. (Resident B) The Immediate Jeopardy began on 5/23/24 when the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. The resident eloped from the facility on 5/23/24 at 10:34 p.m. and being unaccounted for overnight until 5/24/24 at 7:09 a.m. when he was found in a local park approximately one-half mile from the facility. The resident complained of being cold and had been incontinent of bowel when he was located by a staff member. The Administrator was notified of the Immediate Jeopardy at 4:59 p.m. on 6/5/24. The Immediate Jeopardy was removed, and the deficient practice corrected on 5/24/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: Resident B's clinical record was reviewed on 6/5/24 at 10:19 a.m. Diagnoses included metabolic encephalopathy, repeated falls, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, delirium due to known physiological condition, post-traumatic stress disorder, difficulty in walking, weakness, other lack of coordination, and need for assistance at home and no other household member able to render care. Physician's orders included relocate him to a secured unit now (5/24/24), admit to a secured unit (6/4/24), Prozac (treat depression) 10 mg (milligram) daily, apixaban (treat atrial fibrillation) 5 mg twice daily, and metoprolol succinate (treat high blood pressure) 50 mg daily. An admission Minimum Data Set (MDS) assessment, dated 5/23/24, indicated he was moderately cognitively impaired. He required extensive assistance from one staff member for bed mobility and toileting. He required limited assistance from one staff member for transfers. He was frequently incontinent of bowel and bladder. An elopement risk assessment, dated 5/17/24, indicated he was at risk for elopement and an elopement care plan was initiated. The care plan indicated he was at risk for elopement related to impaired cognition/safety awareness. His goal was he would remain safe through the next review. His interventions included distracting him from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, etc., offer resident the restroom, and redirect him to areas appropriate for him. An elopement risk assessment, dated 5/19/24, indicated he was at risk for elopement and an elopement care plan was initiated. The care plan indicated he was at risk for elopement related to impaired cognition/safety awareness. His goal was he would remain safe through the next review. His interventions included distracting him from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, etc., offering him the restroom, and redirect him to areas appropriate for him. He had a current care plan for elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended (5/24/24). His goal was to not leave the facility unattended through the review (5/24/24). His interventions included distracting him from wandering by offering pleasant diversions, structured activities, food, conversation, television, books he preferred (5/24/24), identify a pattern of wandering: Is wandering purposeful, aimless, or escapist? Is he looking for something? Does it indicate the need for more exercise? Intervene as appropriate (5/24/24), monitor for fatigue and weight loss (5/24/24), he resided on secure unit due to wandering and confusion (5/24/24). He had a current care plan for having a behavior problem related to his desire to return to his home. He tended to exit seek and linger by the exit doors to his current neighborhood. He may speak about returning to his home where his wife was waiting on him. (His wife had passed.) (5/31/24). His interventions included administering medications as ordered. Monitor/document for side effects and effectiveness (5/31/24), anticipate and meet his needs (5/31/24), caregivers to provided opportunity for positive interaction, and attention. Stop and talk with him as passing by (5/31/24), if reasonable, discuss his behavior, explain/reinforce why the behavior was inappropriate and/or unacceptable to him (5/31/24), intervene as necessary to protect the rights and safety of others, approach/speak to him in a calm manner, divert attention and remove him from the situation and take him to an alternate location as needed (5/31/24), offer one on one activity, conversation of interest, snack and/or beverage (5/31/24), praise him for any indication of his progress/improvement in his behavior (5/31/24), provide a program of activities that is of interest and accommodates his status (5/31/24). Review of nurses' notes indicated the following: A late entry nurse note, dated 5/24/24 at 6:10 a.m. and created on 5/24/24 at 8:10 p.m., indicated CNA 7 reported that Resident B was not in his room during a.m. rounds. Staff immediately initiated unit sweep and were unable to locate him. The phone tree was initiated per facility protocol. The sweep was widened to facility and grounds. The 911 dispatch was called, and the local police department was notified. Staff located him at 7:05 a.m. in a cabin shelter at a local park, approximately one-half mile from the facility. Resident B came willingly with staff back to the facility. Once he was back on the unit, a head-to-toe assessment was performed. There were no injuries noted. He did not report emotional distress and apologized for worrying everyone. He reported he had left to find two churches. He was relocated to a secured unit. An observation of the video footage, on 6/5/24 at 3:19 p.m., with the DON and the Administrator present indicated the following: On 5/23/24 at 10:29 p.m., Resident B was seen exiting his room without his walker. He was wearing a pullover sweatshirt, pants and tennis shoes. He ambulated from his room to the double doors of the Rehab Unit. He pushed the door open on the right and exited the unit at 10:30 p.m. At 10:31 p.m., he ambulated down the hall from the Rehab Unit through the rotunda towards the Assisted Living area. He was out of the camera view at 10:33 p.m. At 10:34 p.m., he ambulated to the Assisted Living door (door 8) and exited the facility. On 5/24/24 at 6:09 a.m., CNA 7 was observed entering Resident B's room, then the CNA exited the room and walked towards the nurses station. On 5/24/24 at 7:09 a.m., Resident B was in the foyer at the rotunda accompanied by Floor Technician 34 and Maintenance Employee 25. Resident B was assisted into a wheelchair and was escorted to the Rehab Unit. During an interview at the time of the video observation, the DON indicated she had watched the video, and during the time of Resident B being out of the facility CNA 6, who was responsible for him, did not enter his room the entire night and his door remained partially open. The CNA did enter the room next to Resident B's room. It was the facility's expectation that staff completed walking rounds at shift change. Review of the website www.wunderground.com for historical weather, indicated on 5/23/24 at 10:54 p.m. the temperature was 70 degrees Fahrenheit. On 5/24/24 at 12:54 a.m., it was 67 degrees Fahrenheit. On 5/24/24 at 6:54 a.m., it was 58 degrees Fahrenheit. During an interview with LPN 16 and with Nurse Manager 52 present, on 6/5/24 at 11:21 a.m., LPN 16 indicated she arrived to work at 6:00 a.m. on 5/24/24. CNA 7 completed resident rounds at 6:10 a.m. and Resident B was not in his room. She started the phone chain per facility protocol. They looked through the Rehab Unit and the whole building was looking for him. The grounds employees and the nursing aides were outside looking for him. The resident was found by Maintenance Employee 34 and Floor Technician 24 at a local park in a little log cabin just after 7:00 a.m. Resident B was driven back to the facility and escorted in a wheelchair back to the unit and kept apologizing to her for leaving. The resident didn't seem to have any emotional distress and he said he was trying to find two churches. The son indicated to her that he had worked in a grocery store between two churches. Nurse Manager 52 indicated Resident B left through the double doors of the unit, passed the main entrance (door 9), straight to the Assisted Living door (door 8) and left the building at 10:30 p.m. on 5/23/24. An Agency Nurse was on duty that night and CNA 6 was assigned to him. CNA 6 had not checked on the resident during the night and her reasoning was that he was independent, and he didn't want her in his room. LPN 16 indicated Resident B was supposed to ambulate with a walker but didn't have the walker with him. She last saw him around 9:30 p.m. on 5/23/24, he was ambulating in the hallway, and she reminded him to use his walker and he told her that he was stretching his legs. She had left the facility around 11:30 p.m., on 5/23/24. During an interview with CNA 7, on 6/5/24 at 1:22 p.m., she indicated she gave CNA 6 report at 6:00 p.m. on 5/23/24 and told her that Resident B had some confusion towards the end of her shift. She had asked him to go to supper and he declined and told her that he had not eaten breakfast or lunch, which he had, because she took him to the dining room. On 5/24/24 at 6:00 a.m., she came to work, and she normally did walking rounds with the other aide during shift change, but they didn't that day. CNA 6 told her Resident B didn't like her. The resident shut the door in her face and wouldn't let her do his care. CNA 7 went to Resident B's room and noticed he was gone, so she checked a couple of other resident's rooms, whose doors were open, thinking he went in the wrong room. Then she went to the nurses station and reported him missing to the nurse. They checked every single room, the closets, and under the beds. Some staff went outside and checked around the building. She stayed in the Rehab Unit and when he returned, he was cold to touch, and he had been incontinent of bowel. He was wearing a pair of black dry-fit pants and a sweatshirt with a t-shirt underneath it. He also had shoes and socks on. She didn't know he was at risk for elopement. During an interview with Agency Nurse 15, on 6/5/24 at 1:53 p.m., she indicated it was her first time working at the facility and did not know any of the residents. It was not reported to her that he was an elopement risk. He toileted himself, so she didn't have to check on him every two hours to make sure he was clean. She thought she saw him before midnight on 5/23/24. During an interview with Maintenance Employee 25, on 6/5/24 at 2:03 p.m., he indicated he was told there was a missing resident on the day Resident B was found to be missing. He drove the facility's complex first, the nearby cemetery and then the nearby recreation area. He drove through the local park and as he was driving back out onto the street he looked right, then left. Something white caught his eye in the children's cabin at the park. He and Floor Technician 34 had walked up to the cabin at the same time. The floor technician called the facility to tell them that Resident B was located. Maintenance Employee 25 went to the cabin and put his head in the door and asked Resident B his name and if he was alright. He was shivering and indicated he was cold. Resident B took his hand and assisted him into his truck, turned the heat on for him, and drove him back to the facility. Resident B indicated to him he was visiting the church and something about his son. Resident B was dressed in a sweatshirt, pants, and tennis shoes. They brought him back to the facility and escorted him in a wheelchair to the Rehab Unit. During an interview with CNA 6, on 6/5/24 at 2:47 p.m., she indicated she couldn't remember what time she had seen Resident B in his room on 5/23/24. She had only passed ice water to the residents who asked for it. She didn't believe she checked on him that night because he was usually okay. He had shut the door on her and she didn't see him the rest of the night. He toileted himself and she assumed he was continent. She had completed walking rounds with CNA 7 on the evening of 5/23/24 or the morning of 5/24/24 and she didn't remember CNA 7 saying Resident B was confused at the end of CNA 7's shift on 5/23/24. Normally she would check on the residents and open the door. She didn't know why she didn't check on him. She thought she had a lot in on her mind that day. She still felt terrible about it. On 6/6/24 at 8:58 a.m., CNA 6's employee file was reviewed and indicated the following: A form titled, Resident Services Coordinator Department Specific Orientation, dated 4/19/24 and initialed by CNA 6, indicated the following: .26. Before leaving for the day do walking rounds and give detailed report on all residents to your replacement . A form titled, Position Description, dated and signed by CNA 6 on 3/29/24, indicated the following: .Principal duties .2. Monitor residents throughout the day without interfering with their privacy . During an interview with the Administrator, on 6/7/24 at 1:41 p.m., she indicated it was a standard of care to check on the residents every two hours or more frequently if needed, it depended on the resident. A current facility policy, titled Safety and Supervision of Residents, provided by the DON, on 6/6/24 at 9:40 a.m., indicated the following: .Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities A current facility policy, titled Wandering and Elopements, provided by the DON, on 6/6/24 at 9:42 a.m., indicated the following: .1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. The Past Noncompliance Immediate Jeopardy began on 5/23/24. Immediate Jeopardy was removed and corrected by 5/24/24 after the facility inserviced all staff on two-hour care checks, on systemic change of identifying residents who were an elopement, the elopement and abuse/neglect policies. Colored background name plates for residents who are at risk for elopement, ribbons on electronic health records noted for those residents who are an elopement risk and documentation for safety checks for residents who were at risk for elopement and resided on an unsecured unit were implemented. Audits were to be conducted to ensure elopement assessments were completed with new admissions and appropriate interventions were in place weekly for six months. This citation relates to Complaint IN00435415. 3.1-45(a)(2)

Based on interviews and record review, the facility failed to report accurate information regarding an elopement for 1 of 1 facility reported incidents reviewed for elopement (Resident B). Findings include: A Facility Reported Incident indicated the following: The actual or identified date and time of the incident was 5/23/24 at 9:30 p.m. Resident B was admitted to the facility on [DATE] for rehab services. Upon admission he was identified as moderately cognitively impaired, and he was an elopement risk. A discussion with the family regarding his risk for elopement resulted in the family declining a need for his placement on a secured unit. On 5/24/24 at 6:10 a.m., CNA 7 went into Resident B's room to check on him, discovered he was not in his room, and she alerted LPN 16. Resident B was located outside of the facility and returned without incident. The clinician and the family were notified and in agreement to relocate Resident B to a room within a secured unit. There was no physical, mental or emotional injury observed. The follow up report added on 5/28/24, indicated he continued to adjust well to his new unit. His family remained supportive to his plan of care. There was no latent physical injury or emotional distress observed. A late entry nurse note, dated 5/24/24 at 6:10 a.m. and created on 5/24/24 at 8:10 p.m., indicated CNA 7 reported that Resident B was not in his room during a.m. rounds. Staff immediately initiated unit sweep and were unable to locate him. The phone tree was initiated per facility protocol. The sweep was widened to facility and grounds. The 911 dispatch was called, and the local police department was notified. Staff located him at 7:05 a.m. in a cabin shelter at a local park, approximately one-half mile from the facility. Resident B came willingly with staff back to the facility. Once he was back on the unit, a head-to-toe assessment was performed. There were no injuries noted. He did not report emotional distress and apologized for worrying everyone. He reported he had left to find two churches. He was relocated to a secured unit. An observation of the video footage, on 6/5/24 at 3:19 p.m., with the DON and the Administrator present indicated the following: On 5/23/24 at 10:29 p.m., Resident B was seen exiting his room without his walker. He was wearing a pullover sweatshirt, pants and tennis shoes. He ambulated from his room to the double doors of the Rehab Unit. He pushed the door open on the right and exited the unit at 10:30 p.m. At 10:31 p.m., he ambulated down the hall from the Rehab Unit through the rotunda towards the Assisted Living area. He was out of the camera view at 10:33 p.m. At 10:34 p.m., he ambulated to the Assisted Living door (door 8) and exited the facility. On 5/24/24 at 6:09 a.m., CNA 7 was observed entering Resident B's room, then the CNA exited the room and walked towards the nurses station. On 5/24/24 at 7:09 a.m., Resident B was in the foyer at the rotunda accompanied by Floor Technician 34 and Maintenance Employee 25. Resident B was assisted into a wheelchair and was escorted to the Rehab Unit. During an interview with Resident B's family member, on 6/5/24 at 12:35 p.m., it was indicated Resident B had not had problems leaving his home unattended. The facility had not asked the family about admitting Resident B to a secured unit and they had not declined for him to be admitted to a secured unit prior to him being admited to the rehab unit, but they knew eventually he would be going to a memory care unit somewhere. During an interview with the DON and with the Administrator present, on 6/7/24 at 1:58 p.m., the DON indicated she didn't normally complete the Facility Reported Incidents, when she reported the elopement, she didn't have all the information yet and she knew it just needed it reported to the state agency. The Administrator indicated the facility reported incident wasn't intentionally meant to be misleading. A policy was requested during the interview for reporting and the Administrator indicated they normally followed the guidance for reporting. This citation relates to Complaint IN00435415. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to follow physician orders regarding blood glucose monitoring, insulin administration, and elastic wraps (for swelling) for 2 of 26 residents reviewed for following physician orders. (Residents 90 and 82) Findings include: 1. Resident 90's clinical record was reviewed on 4/26/24 at 3:34 p.m. Diagnoses included type 2 diabetes mellitus and hypothyroidism. A current physician order, dated 3/28/24, indicated metformin (diabetes medication) 1000 milligrams (mg), give 1 tablet by mouth twice a day. A physician order, dated 6/18/23, included check blood sugar two times daily. The order was discontinued on 4/22/24. A physician order, dated 7/1/23, included Novolog Flexpen (insulin for diabetes) 100 units/milliliters, inject subcutaneously every morning and at bedtime per sliding scale: if blood glucose is 150 - 200 = 2 units, 201 - 250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351 - 400 = 10 units. The order was discontinued on 4/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 3/1/24, indicated the resident was cognitively intact and received insulin seven out of seven days during the assessment period. A Nurse's Note, dated 3/1/24 at 2:33 p.m., indicated new orders were received to monitor and chart if the resident's blood glucose was less than 100 mg/dL at night and to chart if the night insulin was held. A current care plan, dated 3/8/24, indicated the resident had diabetes mellitus. Interventions included to administer diabetes medication as ordered by the physician (3/8/24), and obtain fasting blood sugar as ordered by the physician (3/8/24). Review of the Medication Administration Record (MAR) for March and April 2024 indicated the following information: The resident's blood sugar was not obtained as ordered on 3/10/24 in the evening. On 3/15/24, the resident's blood sugar in the evening was 211 mg/dL. Novolog was not administered according to the physician-ordered sliding scale. The resident's blood sugar was not obtained as ordered in the evenings on 4/7/24 and 4/15/24. The clinical record lacked documentation indicating the resident refused the blood glucose monitoring, medication, or was out of the facility. Review of the Leave of Absence Logs from 1/1/24 to 4/30/24 indicated the resident was not on leave of absence during the above mentioned dates and times. During an interview on 4/30/24 at 10:13 a.m., QMA 18 indicated blood glucose testing was completed by QMAs, charted in the clinical record, and reported to the nurse on duty for administration of the insulin. Physician orders must be completed as ordered. During an interview on 4/30/24 at 11:51 a.m., LPN 3 reviewed the resident's Medication Administration record and indicated the resident's clinical record lacked blood glucose monitoring according to the physician orders on the above mentioned dates in March and April. It should have been documented in the resident's clinical record on the MAR or nurse's notes if the resident refused or was out of the building. On 3/15/24, the resident's evening blood sugar was 211 mg/dL, and the resident should have received 4 units of Novolog, but did not. If the blood sugars were obtained or insulin was administered, it could not be verified since it was not charted. During an interview on 5/1/24 at 8:58 a.m., the DON indicated the resident's physician orders for blood glucose monitoring and sliding scale insulin should have been followed. During an interview on 5/1/24 at 9:55 a.m., the DON indicated staff would not have a way to know how much sliding scale insulin to administer when blood glucose testing was not obtained. 48146 2. During an observation, on 4/24/24 at 12:20 p.m., Resident 82 was lying in bed without pants. His bilateral lower legs had a dark discoloration from his ankles to mid-calf. During an observation and interview, on 4/25/24 at 9:30 a.m., Resident 82 was lying in bed without pants, His bilateral lower legs had a purplish discoloration from his ankles to mid calf. Resident 82 indicated he was concerned about his legs since he had poor circulation and the daily wraps for this legs were not being completed by the staff. During an observation, on 4/25/24 at 11:24 a.m., Resident 82 was seated in a wheelchair, playing cards with another resident. Resident 82's bilateral lower legs had a purplish discoloration from his ankles to mid calf. His legs were not wrapped. During an observation and interview, on 4/26/24 at 10:05 a.m., Resident 82 was lying in bed. His bilateral lower legs had a purplish discoloration from his ankles to mid calf and were not wrapped. Resident 82 indicated he spoke with the night nurse about his leg wraps and was advised the order was for the day shift to complete. During an observation and interview, on 4/29/24 at 9:51 a.m., Resident 82 was lying in bed. His bilateral lower legs had a purplish discoloration from his ankles to mid calf. His legs were not wrapped. He indicated his legs hurt and when his legs were wrapped, the compression from the wraps helped. He was able to get his legs wrapped on Sunday, but not on Saturday. He was supposed to have therapy today, but planned to ask if the time could be adjusted since his legs hurt this morning. During an observation and interview, on 4/29/24 at 2:38 p.m., Resident 82 was lying in bed with an elastic bandage wrapped around his bilateral lower legs from his ankle to his calf. Resident 82 indicated the mild compression was helpful in pain relief. During an observation and interview, on 4/30/24 at 9:55 a.m., Resident 82 was lying in bed. His bilateral lower legs had a purplish discoloration from his ankles to mid calf. His legs were not wrapped. Resident 82 indicated he his legs hurt today and he was waiting on the staff to come apply his leg wraps. During an observation on 4/30/24 at 10:58 a.m., Resident 82 was lying in bed without pants on. His bilateral lower legs had a purplish discoloration from his ankles to mid calf and were not wrapped. Resident 82's clinical record was reviewed on 4/26/24 at 1:49 p.m. Diagnoses included morbid (severe) obesity due to excess calories, diabetes mellitus, type 2, unspecified gout, and chronic peripheral venous insufficiency. Current physicians orders, dated 7/4/23, indicated to apply Ace Wraps (elastic bandages) to both legs after washing and applying petroleum jelly to treat every morning for edema, and remove the wraps in the evening. A current care plan, initiated 10/16/20, indicated Resident 82 was at risk for impaired skin integrity related to venous insufficiency, diabetes mellitus, obesity, and history of pressure areas. The interventions included: Evaluate skin for areas of blanching or redness (10/16/20), evaluate skin for redness or excoriation (10/16/20), provide skin care per facility guidelines and PRN as needed (10/16/20). A review of the electronic treatment administration record, for the dates of 4/24/24 through 4/30/24, indicated Resident 82's legs were wrapped as ordered on the following days: 4/24/24, 4/25/24, 4/27/24, 4/28/24, and 4/29/24. The record lacked documentation for 4/26/24. During an interview, on 4/30/24 at 2:11 p.m., LPN 12 indicated the resident liked to do things on his own time frame. He would sometimes refuse care and refusals were documented in the electronic medical record. During an interview, on 4/30/24 at 2:19 p.m., QMA 10 indicated Resident 82 had good days and bad days and required some encouragement to allow staff to complete care. If the resident refused medications, the QMA would notify the registered nurse and document the refusal in the electronic medical record. During an interview, on 4/30/24 at 2:44 p.m., Unit Manager 11 indicated Resident 82 refused treatments based on his mood or who the staff member was providing the care. Refusals should be documented in the electronic medical record and treatments should be completed prior to checking the tasks off in the treatment record. A current facility policy, revised 12/31/23, titled Physician Orders, provided by the DON, on 4/30/24 at 9:56 a.m., indicated the following: . Implementation of Orders. The facility is responsible for the carrying out of physician orders as written. The order may be carried out by the staff member who is legally permitted to carry out such order . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide monitoring of a pressure injury (Resident 5) and failed to develop and implement interventions to promote the healing of pressure injuries (Residents 5 and 120). for 2 of 3 residents reviewed for pressure injuries. Findings include: 1. During an observation, on 4/26/24 at 10:00 a.m., Resident 5 sat in her wheelchair in her room and wore non-skid shoes on both feet. During an observation, on 4/26/24 at 2:19 p.m., the resident sat in her wheelchair in the activity area and wore non-skid shoes on both feet. Resident 5's clinical record was reviewed on 4/25/24 at 4:24 p.m. Diagnoses included type 2 diabetes mellitus without complications, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, chronic kidney disease stage 3, pressure of left heel unstageable, and need for assistance with personal care. Current physician's orders included, but were not limited to the following: inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness every night shift (initiated 4/21/23) and treatment: left heel: cleanse with normal saline (NS) and gauze, pat dry, paint with povidone iodine. Notify NP of any adverse reactions every day shift for wound care. No shoe to left foot. (initiated 1/31/24). A hospital wound assessment for 9/20/23 at 10:56 a.m. indicated the resident had a type 3 skin tear (entire wound bed exposed) to the left posterior heel with total flap loss. The wound bed was moist with slough (dead cells generally yellow/white) present. The wound measurements were 1.8 cm (centimeters) long by 1 cm wide and was dressed with a bordered foam dressing. A hospital wound assessment for 9/21/23 at 3:23 p.m. indicated the resident had a type 3 skin tear to the left posterior heel with total flap loss. The wound bed was moist with slough present and was dressed with a bordered foam dressing. A facility Nurses Note, dated 9/21/23 at 10:59 p.m., indicated the resident arrived from the hospital at 7:20 p.m. An Admission/Readmission/Quarterly Nursing Evaluation, dated 9/21/23 at 11:36 p.m., indicated Resident 5 returned from the hospital. An unstageable left heel pressure area was listed under the pressure injury assessment section and lacked measurements. The Notable changes to skin integrity documented in complete sentences section included pressure area to left heel and lacked measurements for the area. A significant change Minimum Data Set (MDS) assessment, completed on 9/28/23, indicated Resident 5 was severely cognitively impaired, was dependent on staff for lower body dressing and putting on/taking off footwear, and required substantial/maximal assistance to roll left and right in bed. She was at risk for developing a pressure injury and did not have a pressure injury. The clinical record lacked wound descriptions, wound measurements, and treatment orders for the wound identified upon readmission to the facility on [DATE], from 9/22/23 through 10/18/23. A current care plan indicated Resident 5 had a pressure wound (unstageable) to the left heel (initiated on 10/9/23 and revised on 1/23/24). The interventions included measure area weekly (10/9/23), administer treatment as ordered (10/9/23), and monitor for change in condition and infection until healed. Notify MD/NP as needed (10/9/23). A Nurses Note, dated 10/19/23 at 9:31 a.m., indicated the staff had reported to the nurse the resident had an area to the left heel. The area was purple/red in color, tender to touch, and not open. The measurements were documented as 2.5 x 2 x 5 x < [less than] 0.2 cm (centimeters). A Nurses Note, dated 10/19/23 at 5:28 p.m., indicated the area to the left heel was a deep tissue injury (DTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) and measured 2.5 cm by 2.5 cm by less than 0.2 cm. The area was tender to touch and had no drainage. The resident's family member indicated the area to the heel was present in the hospital in September. A Nurses Note, dated 10/23/23 at 1:11 a.m., indicated the resident had a pressure injury. The area was reddish-brown in color and soft to touch with firm edges. A Provider Note, dated 10/23/23 at 11:37 p.m., by the Wound NP, indicated the resident had an unstageable left heel pressure injury that measured 2.0 cm by 3.0 cm, with a necrotic (dark, dead tissue), firmly adherent wound bed. A Provider Note, dated 11/14/23 at 12:52 p.m., by the Wound NP for date of service on 11/6/23, indicated the pressure injury to the left heel was a stage 3 (full thickness loss of skin) pressure injury. The measurements were 1.5 cm long by 1.7 cm wide by 0.1 cm deep. Orders were written to apply calcium alginate and silicone bordered foam every 3 days and as needed, use an offloading boot except to transfer, and no left shoe to be worn. A Provider Note, dated 12/19/23 at 11:52 a.m., by the Wound NP, indicated the left heel pressure injury was a stage 3 and measured 0.7 cm long by 0.5 cm wide by 0.1 cm. The wound bed was 100 percent slough with no drainage. A Provider Note, dated 1/9/24 at 11:51 a.m., by the Wound NP, indicated the left heel pressure injury was unstageable and measured 1.5 cm long by 2.0 cm wide by 0.1 cm deep and was 100 percent scabbed. A Wound Assessment, dated 2/13/24 at 3:45 p.m., indicated the left heel pressure injury measured 1.0 cm long by 1.5 cm wide with no depth. A quarterly MDS assessment, completed on 2/26/24, indicated Resident 5 was severely cognitively impaired, was dependent on staff for lower body dressing, putting on/taking off footwear, and rolling from right to left in bed. She was at risk for developing a pressure injury and had an unstageable wound due to coverage of slough and/or eschar pressure injury that was present upon admission or reentry. A Wound Assessment, dated 4/9/24 at 9:39 a.m., indicated the left heel pressure injury measured 1 cm long by 1.5 cm wide. The wound bed was 100 percent callus. The area under the callus was soft. A Nurses Note, dated 4/9/24 at 2:45 p.m., indicated the resident's left heel callus was mechanically debrided without pain or injury. A Wound Assessment, dated 4/23/24 at 10:29 a.m., indicated the resident's left heel pressure injury measured 0.3 cm long by 0.5 cm wide with no depth. The wound bed was 100 percent callus. During a wound treatment observation, on 4/26/24 at 3:34 p.m., LPN 12 cleansed the resident's left heel with normal saline. The pressure area was a pea-sized, brownish-white callus area on the posterior left heel. Povidone iodine was applied to the left heel and permitted to dry. After the feet were washed, rinsed, and dried socks and shoes were applied. During an observation, on 4/29/24 at 9:48 a.m., the resident sat in a wheelchair in the common area near the activity area and wore non-skid shoes on both feet. During an observation, on 4/30/24 at 10:06 a.m., the resident sat in a wheelchair in the common area and wore non-skid shoes on both feet. During an interview, on 4/30/24 at 10:26 a.m., CNA 9 indicated Resident 5 wore offloading boots while in bed and shoes during the day. The CNA utilized the Kardex on the computer to know what interventions were needed for the residents. During an interview, on 4/30/24 at 11:22 a.m., QMA 10 indicated the area to Resident 5's heel started hurting and had opened, but the QMA was uncertain when it occurred. The resident wore her pressure relieving boots in bed and her shoes when up. A Kardex report for Resident 5, provided by Unit Manager 11 on 4/30/24 at 11:26 a.m., indicated Resident 5's care interventions included a pressure reducing mattress. The Kardex lacked directions for no shoe to the left foot. During an interview, on 4/30/24 at 11:27 a.m., Unit Manager 11 indicated pressure wounds were measured one time a week by the wound team. During an interview, on 5/1/24 at 10:28 a.m., the DON indicated Resident 5 came to the facility after her hospital stay with a pressure injury. The hospital had indicated the resident had a stage 3 skin tear on her left heel and was identified by the hospital on 9/15/24. The hospital said it was healed. She did not believe it was a healed skin tear. She had contacted the Wound NP and discussed the area to the resident's left heel with her. The Wound NP had told her to monitor it. During an interview, on 5/1/24 at 10:34 a.m., the DON indicated the resident did not have any ordered treatments from the hospital upon admission to the facility. The facility believed it started in the hospital. If it was a pressure injury in the hospital, then it was not going to heal, so it was captured on the admission assessment. It was red, but it was closed. It looked like a healed wound. On 10/19/23, the area started to develop dark tissue around it. The damage was already there and began to surface. It took a couple of years for the tissue to be completely healed with a deep tissue injury. The weekly skin assessments would not have documented anything about the area to the left heel because they only addressed new things or changes. During an interview, on 5/1/24 at 11:06 a.m., the Wound NP indicated she had spoken to the facility about the resident's left heel area upon return from the hospital. The NP did not believe the area was a skin tear, but was a pressure related injury. The NP had told the facility they needed to watch it closely, as it may have looked healed, but was highly likely to open. In October of 2023, another wound nurse began looking at it every week. The Wound NP was uncertain about the no left shoe order, as another wound nurse on the team was currently providing care for the resident. During an interview, on 5/1/24 at 11:27 a.m., the DON indicated Resident 5's skin concern could have been a healed skin tear and was red tissue, which could have been either. The area had discoloration. They were monitoring red tissue. The DON was unaware that the current treatment order indicated no left shoe. The nurse should have been monitoring for this when the order was signed off. During an interview, on 5/1/24 at 2:44 p.m., RN 14 indicated she had completed the admission assessment on 9/21/24 for the resident's return to the facility. The nurse was unable to recall details about the resident's skin condition. Whatever she documented is what she saw. If the area was not open, she would not have not gotten measurements. An article titled, Evolution of Deep Tissue Pressure Injury, dated 1/8/21, retrieved on 5/2/24 from the National Pressure Injury Advisory Panel (NPIAP) website at https://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htm, indicated the following: .The process leading to deep tissue injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotic . 48146 2. During an observation, on 4/25/24 at 11:06 a.m., Resident 120 was seated in his recliner with his legs elevated. He had a dressing to his left heel and wore non-slip socks. During an observation, on 4/26/24 at 9:56 a.m., Resident 120 was fully dressed. He was seated in his recliner with non slip socks to bilateral feet. During an observation, on 4/29/24 at 10:08 a.m., Resident 120 was seated in his recliner with non slip socks on his bilateral feet. A pair of pressure relief boots were on the top of the dresser. Two handwritten signs were taped to the dresser doors in his room and indicated the following: Wear pressure relief boots to bed. Left boot at all times. During a catheter care observation, on 4/29/24 at 2:27 p.m., QMA 23 and CNA 24 indicated Resident 120 did not have his offloading boot on his left foot. His left foot dressing was dated 4/28/24. During an observation, on 4/30/24 at 12:08 p.m., Resident 120 was seated in the dining room. He wore non-slip socks to his bilateral feet. He was not wearing an offloading boot to his left foot. Resident 120's clinical record was reviewed on 4/26/24 at 9:28 a.m. Diagnosis included adult failure to thrive, unspecified protein-calorie malnutrition, and pressure ulcer of unspecified heel. A current physician's order, dated 4/2/24, indicated to cleanse the left heel with normal saline and gauze, pat dry, apply skin prep to periwound, use Medihoney (a wound gel to promote healing) and foam dressing daily and as needed, every night for wound care. A current physician's order, dated 1/30/24, indicated off loading boot to left foot at all times, except for showers and morning or night care. A review of the April 2024 treatment administration record, on 4/30/24 at 2:29 p.m., indicated the treatment as completed and the off loading boot was in place daily. No refusals were documented. A care plan, initiated on 3/3/23, indicated the resident had an unstageable to his left inner heel present on 3/3/23. Resident 120 had protein calorie malnutrition, history of wounds, slow healing, adult failure to thrive, required assistance with bed mobility, and had cardiovascular issues. Interventions included administer treatment as order, heel boots while in bed, and offloading boot to left foot. A wound note, dated 3/26/24, indicated the left heel was originally categorized at deep tissue injury and had a history of stage 3 pressure ulcer. The wound measurements were a width of 0.3 cm by length of 0.3 cm and was scabbed over. A wound note, dated 4/2/24, indicated the left heel was originally categorized at deep tissue injury and had a history of stage 3 pressure ulcer. The wound measurements were a width 0.3 cm by length of 0.3 cm and depth of 0.2 cm. A wound note, dated 4/23/24, indicated the left heel wound was originally categorized at deep tissue injury and Resident 120 had a history of stage 3 pressure ulcer (Full-thickness skin loss). Measurements were width of 0.3 centimeters (cm) by length of 0.3 cm and depth of 0.1 cm. The wound was currently unchanged. The previous wound notes on 4/16/24 and 4/9/24 indicated the same information. A progress note, dated 4/26/27 at 3:27 a.m., indicated the resident refused to wear the left heel boot. A provider note, dated 4/16/24 at 10:50 a.m., indicated the resident had multiple underlying medical co-morbidities and need for assistance with activities of daily living. He had history of a left heel pressure sore for several months. Wound care continued to follow for the left heel pressure ulcer. During a wound observation and interview, on 4/29/24 at 4:07 p.m., Unit Manager 11 indicated Resident 120's wound used to cover the entire heel. The resident did not like to wear the left heel boot and would kick it off. The activity staff had documented this in the electronic medical record. The Unit Manager could not provide documentation to confirm the resident kicked off or removed the left heel boot. During an interview, on 4/30/24 at 2:44 p.m., Unit Manager 11 indicated the check off done by the activities and certified nursing aide (CNA) staff did not have an area to document when the resident would kick off the boot after it was applied. The staff had to amend the charting or add additional documentation later. A current facility policy, revised 4/18, titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, provided by the DON on 4/30/24 at 4:22 p.m., indicated the following: .Treatment/Management. 1. The physician will order pertinent treatments, including pressure reduction surfaces or devices 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to develop and implement a system of individualized behavior monitoring and management that provided information for assessment to develop individualized interventions to prevent recurrence of behavior expressions for 1 of 4 residents reviewed for dementia services (Resident 85). Findings include: During an observation on 4/24/24 at 12:27 p.m., Resident 85 was seated in a wheelchair in the lounge area. He was calm. During an observation on 4/25/24 from 9:51 a.m. to 10:00 a.m., the resident was seated a chair in the lounge attending a remembering activity. He was calm. During an observation on 4/30/24 at 11:04 a.m., the resident was seated in a wheelchair in the lounge. His eyes were closed and his chin was to his chest. During an observation on 4/30/24 at 2:50 p.m., the resident was seated in a wheelchair in the lounge. His eyes were closed and his chin was to his chest. Resident 85's clinical record was reviewed on 4/30/24 at 9:55 a.m. Current diagnoses included unspecified dementia without behavioral disturbances, Parkinson's disease, delusional disorder, and major depressive disorder recurrent. The resident had a current (originated 2/16/23) physician's order to reside on a locked dementia care unit. The resident also had a current (originated 2/1/21) order for Nuplazid 34 mg- take 1 tablet daily (an atypical anti-psychotic medication used to treat Parkinson's disease with related delusions or hallucinations.) A 2/27/24 late entry Providers Note indicated the behavioral management committee had meet to discuss a gradual dose reduction of Nuplazid. The resident was deemed not to be a candidate for dose reduction because the staff reported the resident continues to have episodes of delusions and hallucination. Review of Resident 85's progress notes indicated no documented Behavioral Notes since 1/11/24, when he resisted personal care. There were no documented Social Services Notes since 12/8/2020. There were no documented Psychosocial Notes since 1/21/22. The progress notes for 4/29/24 through 2/1/24 lacked notes regarding displayed behaviors, the location of the event, what activity or action proceeded the behavioral event, and which staff were present when the behavioral event occurred. A 3/18/24, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired, and had displayed no delusions or hallucinations during the assessment period. Resident 85 had a current care plan problem/need, which originated 9/8/20 and was revised 11/7/22, regarding the use of an antipsychotic medication in relationship to delusions and hallucinations related to Parkinson's disease. An approach to this problem was monitoring/record occurrence of target behaviors symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The resident had a current care plan problem/need, which originated 12/15/20, regarding making inappropriate comments towards staff. An approach to this problem/need was to monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes. The Behavior Monitoring and Intervention Report for February 2024, prior to the decision to consider Nuplazid based on behaviors, indicated the following: A 2/2/24 at 11:19 p.m. entry contained check marks in the columns of grabbing others, hitting others, pushing others, physically aggressive towards others, accusing of others, express frustration/anger at others, threatening others, agitated, anxious/restless, delusions, hallucinations, insomnia/not sleeping, and refused care. Additional checkmarks indicated he was redirected, removed from situation, and provided a calm environment, reapproach, and one to one support with worsened behaviors. The clinical record lacked documentation regarding where the event occurred, what event proceeded or precipitated the behavior, what staff were present, if any other residents were present, what aggression was displayed, who he grabbed, hit and or pushed, environmental considerations (such as temperature, noise, or lighting), a narrative description of what behavioral symptom the resident displayed, what resident specific interventions were attempted, what type of care was refused, and/or how long the behavior was exhibited. A 2/3/24 at 11:13 p.m. entry contained check marks in the columns pushing others, physically aggressive towards others, expressed frustration/anger at others, agitated, anxious/restless, delusions, hallucinations, and refusing care. Additional checkmarks indicated he was redirected, removed from situation, and provided a calm environment with unchanged behaviors. The clinical record lacked documentation regarding where the event occurred, what event proceeded or precipitated the behavior, what staff were present, if any other residents were present, what aggression was displayed, who he pushed, environmental considerations (such as temperature, noise, or lighting), a narrative description of what behavioral symptom the resident displayed, what resident specific interventions were attempted, what type of care was refused, and/or how long the behavior was exhibited. A 2/8/24 at 11:41 p.m. entry contained a check mark in the column for [undefined] delusions. Additional checkmarks indicated he provided a calm environment, offered meaningful activities, and reapproached with unchanged behaviors. The clinical record lacked documentation where the event occurred, what event proceeded or precipitated the behavior, what staff were present, if any other residents were present, environmental considerations (such as temperature, noise, or lighting), a narrative description of what behavioral symptom the resident displayed, what resident specific interventions were attempted, and/or how long the behavior was exhibited. A 2/19/24 at 2:02 p.m. entry contained check marks in the columns for agitated and [undefined] delusions. Additional checkmarks indicated he was redirected and removed from the situation with improved behaviors. The clinical record lacked documentation of where the event occurred, what event proceeded or precipitated the behavior, what staff were present, if any other residents were present, environmental considerations (such as temperature, noise, or lighting), a narrative description of what behavioral symptom the resident displayed, what resident specific interventions were attempted, and/or how long the behavior was exhibited. A 2/22/24 at 12:01 a.m. entry contained check marks in the columns of [undefined] delusions, hallucinations, and insomnia. Additional checkmarks indicated he was provided a calm environment, offered meaningful activities, was reapproached, and toileted without any changes in behavior. The clinical record lacked documentation where the event occurred, what event proceeded or precipitated the behavior, what staff were present, if any other residents were present, environmental considerations (such as temperature, noise, or lighting), a narrative description of what behavioral symptom the resident displayed, what resident specific interventions were attempted, and/or how long the behavior was exhibited. A 2/26/24 at 11:24 p.m. entry contained check marks in the columns for agitated, anxious/restless, [undefined] delusions, elopement/exit seeking, [undefined] hallucinations, insomnia/not sleeping, and refusing care. Additional checkmarks indicated he was provided redirected, removed from the situation, and provided a calm environment all without a change in behaviors. The clinical record lacked documentation of where the event occurred, what event proceeded or precipitated the behavior, what staff were present, if any other residents were present, environmental considerations (such as temperature, noise, or lighting), a narrative description of what behavioral symptom the resident displayed, what resident specific interventions were attempted, what care was refused, and/or how long the behavior was exhibited. During a 4/30/24 at 2:32 p.m. interview, the DON indicated The Behavior Monitoring and Intervention Report which contained checkmarks without additional narrative information was where behaviors were to be documented. The facility documented behaviors by exception only and if they were they resident's norm, they didn't require additional documentation. Only behaviors which were a danger to the resident and/or others needed greater detail. There was no other documentation to provide regarding the behaviors Resident 85 displayed in February prior to the behavior management team's determination to continue the antipsychotic medication, due to delusions and hallucinations. During an interview on 4/30/24 at 2:52 p.m., QMA 4 indicated they were familiar with Resident 85, who had displayed behaviors when having vivid dreams. When this happened, he reached for objects that were not present. Staff should always approach Resident 85 carefully if he was sleeping. The resident had not been displaying hallucinations or delusions. During an interview on 4/30/24 at 2:54 p.m., Activity Assistant 5 indicated they were familiar with Resident 85. The Activity Assistant had never witnessed the resident have delusions or hallucination. If she did, she would inform the nurse. During an interview on 4/30/24 at 2 :56 p.m., CNA 6 indicated they were familiar with Resident 85. The only behavior the resident displayed was reaching for objects that weren't there. Resident's usual behaviors were displayed in the clinical record. If a resident displayed a behavior that was new for that resident, staff filled out a form. If a behavior was dangerous, the nurse should be informed. During an interview on 4/30/24 at 2:58 p.m., LPN 7 indicated they were familiar with Resident 85. The resident some times reached for items that were not there. Resident 85 did not seem distressed by these objects. CNAs informed the nurse if a resident displayed a behavior that was concerning. Review of a current, November 2016, facility policy titled, Behavior Management, Prevention and Documentation, provided by the Administrator on 4/30/24 at 3:10 p.m., indicated the following: .It is the policy of [NAME] Retirement Community to identify mood and behavior symptoms that negatively affect residents, staff, or visitors. Mood and Behavior symptoms will be investigated to provide, or make referral to, appropriate interventions that prevent, contain, or manage such behaviors 3.1-37(a)

Based on observation and interview, the facility failed to ensure medications were labeled with resident identifiers and directions for 2 of 5 medication carts reviewed. (Rehabilitation Cart 1 and Rehabilitation Cart 2) Findings include: 1. During an observation on 4/29/24 at 9:30 a.m., accompanied by QMA 20, the Rehabilitation Unit Medication Cart 2 contained an opened and unlabeled bottle of morphine sulfate oral solution (to treat pain) 100 milligram (mg)/5 Milliliters (ml), in the narcotic drawer. The bottle lacked identifiers and directions. During an interview, at the time of observation, QMA 20 indicated the opened bottle of morphine sulfate oral solution lacked a label or resident identification. She was uncertain why it was not labeled. All medications required labels regardless of where the medications came from. Medication labels were required to include the following: resident identifiers, drug name, drug dose, route of administration, and directions for use. She had not administered the medication, but was aware to whom the medication belonged to since she received the information in report. During an interview on 4/29/24 at 10:07 a.m., QMA 20 indicated she should have noticed the morphine bottle was not labeled when she did her controlled medication count at the beginning of her shift. 2. During an observation on 4/29/24 at 9:49 a.m., accompanied by QMA 20, the Rehabilitation Unit Medication Cart 1 contained the following opened and unlabeled medication bottles, without resident identifiers or directions for use: One orange bottle with a white lid contained the word aspirin hand written on the lid, One bottle of [NAME] pain reliever/caffeine 500 mg caplets, One bottle of COQ 10 (supplement) 200 mg softgels, One bottle of Turmeric Curcumin (supplement) capsules, One bottle of acetaminophen 250 mg capsules, One bottle of Tylenol arthritis pain extended release 650 mg capsules, One bottle of headache relief acetaminophen 250 mg capsules, One bottle of stool softener plus stimulant laxative 50 mg/8.6 mg capsules, One bottle of simethicone (gas relief) 125 mg bottle, and One bottle of apple cider vinegar (supplement) 450 mg capsules. During an interview, at the time of observation, QMA 20 indicated all of the bottles lacked resident identifiers and directions for use. The bottles should have been labeled immediately upon receipt. During an interview on 4/29/24 at 9:50 a.m., LPN 3 indicated she could not be certain to whom the medication bottles belonged to, since they were unlabeled in the medication carts. During an interview on 4/29/24 at 10:07 a.m., LPN 16 indicated all medications should have been labeled with resident identifiers, medication dosage, directions for use, and should have been labeled upon receipt before they were placed in the medication carts. Rehabilitation Medication Cart 1 contained medications for 10 residents. Rehabilitation Medication Cart 2 contained medications for 9 residents. A current facility policy, revised April 2019, titled Labeling of Medication Containers, provided by the DON on 4/30/24 at 11:14 a.m., indicated the following: . All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations 3.1-25(j) 3.1-25(k)

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care for 2 of 3 residents reviewed for skin conditions. (Residents 154 and 467) Findings include: 1. Resident 154's clinical record was reviewed on 4/26/24 at 10:57 a.m. Diagnosis included necrotic pancreatitis, generalized muscle weakness, and need for assistance with personal care. A current physician order, dated 4/9/24, indicated to cleanse the resident's abdominal wound from gastrostomy tube removal with normal saline and gauze, pat dry, and apply skin preparation every night. A current physician order, dated 4/23/24, indicated to provide a treatment to the abdominal wounds daily, as needed every night shift, and as needed for soilage and dislodgement. Cleanse the abdominal wounds with normal saline and gauze, pat dry, apply skin prep to periwound, and apply foam. A current physician order, dated 4/24/24, included Keflex (antibiotic) 500 mg capsule, give one capsule by mouth two times a day for seven days related to a wound infection. Review of the resident's admission Minimum Data Set assessment, dated 2/28/24, indicated the resident had moderate cognitive impairment and required substantial/maximal assistance from staff for bathing, personal hygiene, and rolling left and right. The resident had frequent urinary and bowel incontinence. Skin conditions included surgical wounds. Skin interventions included a pressure reducing device for the resident's bed and surgical wound care. The resident received antibiotic treatment for 7 out of 7 days during the assessment. A care plan, dated 2/22/24, indicated the resident was at risk for infection related to a surgical incision to the left side of abdomen from a tube placement present on admission and later removed. Interventions included the following: monitor site for signs and symptoms of infection such as redness, warmth, or drainage (2/22/24) and provide treatment per physician orders (2/22/24). A wound assessment, dated 4/23/24, indicated the left abdominal surgical incision was 0.3 centimeters (cm) length, 0.2 centimeters width, worsening, dehiscence x 2, purulent drainage noted, and suspected chronic infection. A wound assessment, dated 4/23/24, indicated the right abdominal surgical incision was 0.5 cm length, 0.3 cm width, worsening, dehiscence x 2, purulent drainage noted, and suspected chronic infection. During a wound care observation on 4/29/24 at 2:31 p.m., LPN 3 brought an overbed table (overbed table 2) to the resident's room from the nursing office with a bag of wound supplies, a marker, and a canister of disinfectant wipes. She used alcohol based hand rub (ABHR) upon entering the residents room, moved the resident's uncleaned overbed table (overbed table 3) away from the resident bedside and placed the black marker and disinfectant canister over onto the resident's uncleaned overbed table 3, without a barrier. Gloves were donned prior to disinfecting overbed table 2 when it was brought into the room for use during the wound care. Gloves were doffed, hand hygiene performed, gloves were donned, and wound supplies were placed unopened on overbed table 2. LPN 3 used both gloved hands to move overbed table 3 further out of the way. Without doffing her gloves or using hand hygiene, the foam dressing on the right side of the abdomen and a foam dressing on the left side of the abdomen were both removed and had a small amount of serousanguineous drainage noted the length of each open wound on the dressings. LPN 3 doffed the gloves, performed hand hygiene, donned clean gloves, opened a 4x4 gauze, saturated the gauze with wound wash, and cleansed the right abdominal surgical incision with her right gloved hand, opened another 4x4 gauze, saturated the gauze with wound wash, and cleansed the left abdominal surgical incision with her right gloved hand. Gloves were then doffed, hand hygiene performed, gloves donned, gauze pads opened, and both left and right abdominal incisions were patted dry with separate clean gauze pads. Without changing gloves or performing hand hygiene, the marker was pickup up from the surface of (uncleaned) overbed table 3 with the right gloved hand, the lid removed with the left hand, and dates written on both of the foam dressings. Without changing gloves and hand hygiene, the nurse picked up and opened the skin preparation for the wound treatment and used her right gloved hand to apply skin preparation to the right abdominal incision. Without changing gloves or performing hand hygiene, she opened another skin preparation and used her right gloved hand to apply skin preparation to the left abdominal incision. The dated foam dressings were then applied to each of the abdominal incisions with her gloved hands. Gloves were doffed, hand hygiene was performed, and disinfectant wipes were moved to overbed table 2 with the black marker and bag of wound supplies. During an interview on 4/30/24 at 11:37 a.m., LPN 3 indicated during the resident's wound care observation on 4/29/24, the contaminated marker should not have been handled with gloved hands, then continue wound care with skin preparation without changing gloves and performing hand hygiene. This caused a risk for potential infection related to contamination. 2. Resident 467's clinical record was reviewed on 4/26/24 at 10:06 a.m. Diagnoses included, unspecified fracture of thoracic 11 and thoracic 12 vertebra, subsequent encounter for fracture with routine healing, fusion of spine thoracic region, fusion of spine lumbar region, and obstructive and reflux uropathy. A current physician order dated, 4/17/24, indicated to provide back treatment every day shift. Cleanse the back with soap and water, pat dry, apply povidone iodine, and leave open to air. Review of the resident's admission Minimum Data Set assessment, dated 4/17/24, indicated the resident was cognitively intact and required substantial/maximal assistance from staff for toileting, bathing, dressing, and rolling left and right. An indwelling catheter was required and the resident had surgical wounds. A current care plan, dated 4/15/24, indicated the resident was at risk for skin impairment related to a ground level fall resulting in a lumbar 1 vertebra and thoracic 11 compression fracture. The resident admitted with multiple surgical incisions. Interventions included medications as ordered. During a wound observation on 4/29/24 at 2:09 p.m., LPN 16 and LPN 3 performed hand hygiene upon entering Resident 467's room. LPN 16 and LPN 3 each donned gloves. After the overbed table was disinfected by LPN 16, her gloves were doffed and hand hygiene was completed. LPN 16 then donned clean gloves and set up wound supplies on the table. LPN 3 walked to the left side of the resident's bed to assist the resident onto his left side. With gloved hands, LPN 16 picked up the bed controller with her left gloved hand and used her right gloved hand to lower the head of the resident's bed to aide the resident in turning. Without changing gloves or performing hand hygiene, LPN 16 picked up the 4x4 gauze package and opened it with her right gloved hand. Without changing gloves or using hand hygiene, she saturated the gauze and used her right gloved hand to cleanse the 4 incisions on the right side of the spine. She used her right hand to pick up another saturated gauze and cleansed the incisions on the left side of the spine. A new gauze was not used for each incision. LPN 16's gloves were doffed after cleansing the incisions and hand hygiene was performed prior to donning clean gloves. Another package of 4x4 gauze was opened and the incisions were dried. LPN 16's gloves were doffed and hand hygiene performed prior to donning clean gloves. She opened the iodine sticks and applied iodine to the 8 incisions, and allowed it to dry before LPN 3 assisted the resident back onto his back. During an interview on 4/30/24 at 11:37 a.m., LPN 3 indicated she assisted LPN 16 during the resident's wound care treatment on 4/29/24. LPN 16 should not have used her gloved hands to touch the bed controller and continue with wound care cleansing prior to changing her gloves and performing hand hygiene. The was a risk for potential infection from contamination. During an interview on 4/30/24 at 5:02 p.m., the DON indicated hand hygiene was required prior to continuation with wound care when a contaminated surface was touched during a wound care treatment. A current facility policy, revised August 2019, titled Handwashing/Hand Hygiene, provided by the DON on 4/30/24 at 4:18 p.m., indicated the following: Policy Statement .This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62 % alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .g. Before handling clean or soiled dressings, gauze pads, etc . k. After handling used dressings, contaminated equipment, etc . l. After contact with objects .in the immediate vicinity of the resident 3.1-18(a) 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure services for effective supervision were provided to ensure a pencil sharpener was not left unattended and within the reach of a cognitively impaired resident with dementia for 1 of 3 residents reviewed for dementia care. This deficient practice resulted in Resident B ingesting the sharpener blade and required hospitalization for surgical removal. Findings include: On 4/16/24 at 11:10 a.m., Resident B was observed in A wheelchair at a table in the common area, with a staff member sitting next to her. On 4/18/24 at 12:07 p.m., Resident B was observed in a wheelchair with her head down and her eyes closed, in the dining room. A staff member was assisting another resident at the same table. Resident B's clinical record was reviewed on 4/16/24 at 10:47 a.m. Diagnoses included, but were not limited to, Alzheimer's disease with early onset, dementia in other disease classified elsewhere, moderate, with agitation, psychotic disorder with delusions due to known physiological condition, and unspecified mood (affective) disorder. A 3/14/24, significant change Minimum Data Set (MDS) assessment, indicated the resident was rarely/never understood. There were no behaviors exhibited. Extensive assistance of two staff members was required for bed mobility, transfers, and toilet use. Extensive assistance of one staff member was required for eating. The current physician's orders included, but were not limited to, divalproex sodium (mood stabilizer) 250 mg twice daily, citalopram hydrobromide (treat depression) 20 mg daily, and olanzapine (treat mental disorders) 2.5 mg daily. A nurses note, dated 4/3/24 at 10:13 a.m., indicated Resident B was coloring in the common area during activities programming when a CNA noticed the resident was chewing on something. The CNA called for the nurse to assist. The resident had placed a small pencil sharpener in her mouth and was chewing on it. Using the finger sweep method, the nurse was able to effectively remove the majority of the plastic fragments from the resident's mouth, along with a small screw that held the sharpener blade in place. A moist oral swab was used to remove smaller fragments. The resident was not asked to swish and spit due to her baseline chronic confusion. The sharpener blade was unaccounted for after the oral cavity had been cleared of foreign objects. Staff searched the resident's clothing, pockets, wheelchair, and the floor within her vicinity. The blade was not found. The Nurse Practitioner (NP) was called, and new orders were given for a STAT (immediately) chest x-ray and a Kidneys, Ureter and Bladder (KUB) x-ray. The resident drank a cup of apple juice without difficulty and denied pain when swallowing or gastrointestinal upset. She had no signs of bleeding from her mouth. The NP assessed her and advised staff to continue to monitor pending x-rays. Her vital signs were obtained. A call was placed for the estimated time of arrival for the mobile x-ray, and they indicated it would be several hours before they could arrive at the facility. The unit manager and the Administrator decided she should be seen in the ER to prevent unnecessary complications. Emergency Medical Services were called and she left the facility at 12:15 p.m. A 4/3/24 physician's order indicated may send to the emergency room (ER) for evaluation and treatment for the ingestion of a foreign object. A hospital X-ray report, completed on 4/3/24 at 1:57 p.m., indicated there was an area of metallic density that measured 2.3 centimeters projected into the left upper quadrant of the stomach and a concern for a foreign body was identified. The radiology report for the findings from an upper GI endoscopy (exam completed with a tube with a camera on it, inserted into the mouth and throat, then through the stomach and upper intestine) performed on 4/3/24 at 5:03 p.m., indicated a new diagnosis of esophagitis (irritation of the esophagus) with no bleeding was received. The entire examined stomach and small intestine was normal. Removal of the blade from the pencil sharpener was accomplished with a retrieval net, from the lower portion of stomach. A nurses note, dated 4/3/24 at 11:00 p.m., indicated the resident returned from the hospital. The resident had general anesthesia for the procedure to remove the razor blade from the pencil sharpener. The hospital nurse reported the resident had small cuts in her upper airway and the back of her throat, and her esophagus was okay with no cuts found. She was suctioned with minimum bleeding. The resident could resume her ordered diet as tolerated. No new orders were received. The resident was to be monitored for bleeding. The resident was alert to self, with word salad (unorganized speech) when talking. An assessment did not display signs of pain or discomfort. A plan of care for of unintentional self-injury, related to eating small non-edible objects, with a created date of 4/17/24, indicated the plan was initiated on 4/4/24 with interventions for staff to monitor Resident B while in the area to ensure that small non-edible objects were not placed within her reach, she would be offered items of appropriate size and comparable recreational value, and staff would frequently inspect area where she was and remove any small nonedible objects from her reach. During an interview with the DON, on 4/16/24 at 1:43 p.m., she indicated the facility had on 4/3/24, determined the item in Resident B's mouth looked like a pencil sharpener. The NP was notified, and the facility called for x-ray. The resident was sent out to be evaluated at the ER and providers were able to see a piece of metal. Hospital staff retrieved what appeared to be a blade. When the NP assessed her, there was no injury. The resident returned from the hospital with no new orders and no limitations and did not recall the incident. The facility decided to sweep the area and make the environment as safe as possible. No one at the facility had seen the pencil sharpener prior to the incident, and the facility didn't feel like it was the facility's pencil sharpener. The facility sent out a notice to families on what not to bring in to ensure it didn't happen again. The facility was completing ongoing audits and did a sweep on all the units. There was one other sharpener found on another unit the same day. There was video footage, but the DON did not feel like much could be viewed. During an interview with CNA 8, on 4/16/24 at 1:52 p.m., she indicated Resident B was sitting at a table in the common area with Agency CNA 11 when CNA 8 had left to take her break. Upon return to the unit, CNA 8 noticed Resident B was crunching on a green plastic object in her mouth and went to get the nurse, who was in the nurses station charting on the computer. The nurse put on gloves and got little green pieces of plastic and the screw from the resident's mouth. The CNA realized it was a pencil sharpener, but she and the nurse couldn't locate the blade. They took the resident to her room, took her clothes off, checked the wheelchair, and then sent her to the ER because the only thing missing was the blade. Activities staff normally sat out the box with colored pencils for the resident. The CNA had seen the pencil sharpener before, and it must had been buried in the box with the colored pencils. The resident must have pulled it out and put it in her mouth. The pencil sharpener was not normally in the colored pencil box. Agency CNA 11 was not sitting with the resident when she returned to the unit from break. Resident B was a fall risk and they tried to keep her busy and within sight. During an interview with CNA 4, on 4/17/24 at 9:48 a.m., she indicated she was not working the day Resident B swallowed the pencil sharpener blade, but she had purchased some pencil sharpeners a long time ago and they were stored in a toolbox in the nurse's station. She had not seen any left out. She threw the pencil sharpeners away that were in the nurse's station after Resident B had ingested one. Sometimes they sat with Resident B or watched her from a distance. Usually if she had pencils, the activities aide or someone was with her. The CNA had never seen Resident B put anything in her mouth like that. During an interview with LPN 21, on 4/17/24 at 10:00 a.m., she indicated she was in the nurse's station charting, when CNA 8 came to her and told her Resident B was chewing on something. The nurse put gloves on and did a finger sweep. CNA 8 recognized what she was chewing on, and it was a hippo-shaped pencil sharpener. There was a similar hippo-shaped pencil sharpener located in the medication cart. The nurse and CNA pulled out a bigger piece of the head of the hippo, some smaller pieces, and the screw, but could not locate blade of the pencil sharpener. The nurse used a mouth swab to clean out the resident's mouth. There was no bleeding. Resident B denied throat pain. The nurse called the NP, who gave the okay to offer drinks, and ordered an x-ray and a KUB. The nurse and CNA had the resident drink apple juice. The NP assessed the resident and she was sent to the hospital. The hospital retrieved the blade and she came back to the facility around 11:00 p.m. that night. Resident B was not known to put things in her mouth. Activities staff had an electric pencil sharpener for the colored pencils. Resident B normally sat and colored with activities, but she was in the common area this day by herself, and the box of colored pencils was next to her. During the interview, LPN 21 retrieved a hippo-shaped pencil sharpener from the top drawer of the medication cart. The body of the pencil sharpener had an open back with a metal blade and a screw holding the blade to the plastic. LPN 21 indicated the pencil sharpener Resident B chewed up was just like this one, except for the color. During the interview, LPN 21 reviewed her handwritten statement completed on 4/3/24. The statement indicated what happened during the incident, and the last line of the statement read Did not see this item before, written in a different handwriting, and a lighter shade of ink. LPN 21 indicated she did not write that statement. Observation of video footage, with the DON present on 4/17/24 at 2:04 p.m., indicated CNA 8 propelled Resident B to a table in the common area on 4/3/24 at 8:38 a.m. CNA 8 placed paper and a clear shoe box on the table in front of Resident B and walked away, leaving her alone at the table. At 9:17 a.m., an unidentified staff member approached Resident B, adjusted an unidentified item within the resident's reach on the table, and walked away. At 9:18 a.m., CNA 8 was near the table where Resident B was seated, picking up an unidentified item from the floor. Agency CNA 11 sat down across the table from Resident B, then got up and walked away at 9:20 a.m., leaving Resident B alone at the table. At 9:39 a.m., Resident B used her right hand to pick up an item (not able to fully visualize item due to the quality of the camera footage) off the table and place it in her mouth. At 10:04 a.m., CNA 8 walked by the common area, paused, and walked up to Resident B. She walked away, retrieved gloves, and spoke to the nurse at the nurse's station. CNA 8 looked through the pencil box, then began looking through the resident's clothing and beside her in the wheelchair. The nurse and CNA stood the resident up and checked the wheelchair and sat her back down. The nurse began using a flashlight looking into Resident B's mouth. At 10:11 a.m., the nurse was on the phone and CNA 8 looked through the pencil box again and walked out of sight of the camera. During an interview with Activity Assistant 15, on 4/18/24 at 12:17 p.m., she indicated she didn't put anything in front of Resident B if she couldn't watch her. Years back, the facility may have had manual sharpeners on the unit. The Activity Assistant had been taught not to leave anything sharp out. The facility had an electric sharpener to sharpen colored pencils. The Activity Assistant had no idea Resident B had put something in her mouth that day. The Activity Assistant was involved in an activity at the fireplace across from the common area where Resident B was sitting at the table. The activity group had anywhere from 12 to 15 residents that day, and the Activity Assistant was totally tuned in to the group. A current facility policy, revised 12/2007, titled Safety and Supervision of Residents, provided by the Administrator on 4/18/24 at 2:55 p.m., indicated the following: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Systems Approach to safety .2. Resident supervision is a core component .The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment This citation relates to Complaint IN00431817. 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide appropriate interventions related to dementia behavioral care for 1 of 3 residents reviewed for behaviors (Resident B). This deficient practice resulted in an altercation with staff, the police were called, and the resident was placed in handcuffs. Using the reasonable person concept, it is likely that this would lead to humiliation, chronic or recurrent fear, and anxiety. Findings include: On 4/25/23 at 10:00 a.m., Resident B was sitting quietly in a facility chair in the common area with other residents during an activity. He had dark purple discoloration to his bilateral upper extremities, from his hands and the length of his forearms. Resident B's clinical record was reviewed on 4/25/23 at 9:45 a.m. Diagnoses included mild cognitive impairment of uncertain or unknown etiology, chronic migraine without aura, not intractable, without status migrainosus, Alzheimer's disease, adult failure to thrive, and restlessness and agitation. His current orders included ibuprofen (pain reliever) 400 mg twice daily (10/5/22), divalproex sodium (anticonvulsant) 250 mg daily (2/13/23), lorazepam (treat anxiety) 1 mg (milligram) every eight hours as needed (only for agitation episodes) (4/23/23), psychiatric provider to evaluate and treat (4/25/23), and apply skin repair lotion to discoloration bilateral arms and hands every shift until resolved, and monitor discolorations to left forearm, right forearm, and right and left posterior hands - report to physician any complications (4/26/23). A quarterly MDS (Minimum Data Set) assessment, dated 3/23/23, indicated he was severely cognitively impaired. He had other behavioral symptoms not directed towards others one to three days during the assessment period. He wandered one to three days during the assessment period. He needed supervision for bed mobility, transfers, walking in his room and corridor and locomotion on and off the unit. A Trauma Informed Care Screening PTSD (Post-Traumatic Stress Disorder) test, dated 9/15/22, indicated he did not have any known previous trauma. He had a current behavior care plan for removing the headboard from his bed, and he became agitated with staff when they attempted to re-attach it. He threw his clothes around the room, and was agitated about needing to help his brother. He banged the door into the wall and put a hole in the wall. He hoarded items in his room including silverware, bottles of hand sanitizer, and he may become resistive or become agitated when staff cleaned his room. He banged his head against the wall, he had no bruising or marks, and he was able to be redirected (11/8/22). His interventions were anticipate and meet his needs (11/8/22), caregivers to provide opportunity for positive interaction, attention, stop and talk with him as you were passing by (11/8/22), explain all procedures to him before starting, and allow him time to adjust to changes (11/8/22). If reasonable, discuss his behavior, explain/reinforce why his behavior was inappropriate and/or unacceptable (11/8/22). His POA was agreeable to staff removing hoarded items from his room as needed (2/13/23). He preferred not to have a headboard on his bed (11/8/22). Validate his feelings of anger/frustration (12/12/22), and one on one conversation to redirect him (12/12/22). A behavior note, dated 4/23/23 at 5:36 a.m., indicated he was in and out of a female resident's room after supper. He was difficult to re-direct with several attempts made by staff. He was re-directed to his room multiple times, and each time he would state the room was not his. He sat in the common area for a few hours and finally returned to his room without incident. No further issues were noted. A behavior note, dated 4/23/23 at 3:31 p.m., indicated he was pleasant with staff upon rising. He was friendly and joking per his normal. He went to the dining room for lunch. It was reported to the nurse he refused to leave the dining room. She approached him in an attempt to assist him from the dining room. He continuously repeated to himself while he held his head in his hands and scratched his head repeatedly. She offered to take him to his room and administer headache medication if needed. He stated he didn't need any headache medicine. The nurse again was notified he would not leave the dining room. He was the only resident who remained in the dining room at that time. The dementia unit dining room doors were to always remain locked once meals were completed. He continued to refuse to leave the dining room. He doubled his fist and threatened to hit the nurse. The other staff went to the opposite side of him as he began to lift the dining room chair to hurt the nurse. The nurse and the CNA placed their arms under his arms to assist him to stand and he fought the entire time. He attempted to bite the nurse and the other staff member. As they walked with him, he fought and pulled away. At this point, he threw the nurse onto the table as he continually pushed against her. She was able to get to a standing point and again he threw his body weight against her onto the dining room table. He shoved her into the wall multiple times, pinched her, and attempted to bite her. She told the aide to bring her the phone and call 911. The aide handed the phone to the nurse and indicated she didn't know how to call the police. The nurse made the call and attempted to speak with dispatch as she tried to avoid being bitten and pinched. The resident realized the nurse was speaking with 911 so he acted like he was fainting. Staff ensured his safety and kept him upright. He again became combative and very aggressive with the nurse and the CNA. A nurse from another unit arrived to provide assistance, if needed. The police arrived and staff assisted with holding him so police could handcuff him. Another officer arrived on scene and Resident B kicked the officer in the groin. The nurse left to print paperwork for the officers. When the nurse returned, Resident B was in a wheelchair. The nurse remained with the officers at the rotunda until EMS arrived. He was placed on gurney and taken to a local hospital. The incident was reported to the unit manager, administrator, and social service. A nurses note, dated 4/23/23 at 9:00 p.m., indicated the resident returned to the facility. He was in a good mood and joked around with a male EMT while he was assisted to his room. A new order was received for lorazepam one tablet every eight hours for anxiety (agitation episodes only). After the EMTs left the unit, he came to the common area and attempted to go into a female resident's room. He was re-directed away from the resident's door and asked him if he was tired. He stated that he supposed he was. He was assisted back to his room and he asked about his children. He was told his children had not been at the facility, but he would be notified if they were seen. He yelled they were at the facility and he was being lied to. He was reassured the nurse had been at the facility since 6:00 p.m. and may had missed them. He apologized and stated he appreciated the service that was given to him, and he didn't want to be nasty, but he would if he needed to be. A female resident walked up the nurse and he rudely asked her what she was looking at and to get away from him because the situation was none of her concern. The female resident walked away with no further altercation. A 4/24/23, weekly vital signs/skin observation tool indicated his vitals were taken and no skin issues were noted. A psychosocial note, dated 4/24/23 at 4:25 p.m., indicated he wandered the unit and was conversational with staff and visitors. He appeared to have no lasting effect and did not remember incident from the previous day. A social service note, dated 4/25/23 at 11:17 a.m., indicated the daughter shared that she believed her father had some PTSD. A trauma informed screening would be conducted. A risk management note, dated 4/25/23 at 12:19 p.m., indicated the interdisciplinary team met to review his behaviors during the reference period of 4/18/23 to 4/24/2. He became extremely physical and verbally aggressive with staff and agitated. Interventions included calling police and going to the emergency room . He returned with a new order of lorazepam. His care plan was appropriate. He would continue to be followed and assisted as needed. A 4/26/23, revised care plan, initiated on 4/25/23, indicated he had latent discolorations to his right forearm, left forearm, and post right and left hands related to altercation with staff and police/handcuffs. His interventions included administer skin repair as directed (4/25/23), assess for pain (4/25/23), follow skin at risk care plan (4/25/23) and notify physician of worsening condition (4/25/23). His behavior care plan was revised, on 4/25/23, and indicated he may not want to leave an area when requested, give him plenty of time. His intervention was to allow him to exit areas in his own time and provide a safe environment (4/25/23). A nurses note, dated 4/26/23 at 12:18 a.m., indicated he was pleasant with staff and other residents. After supper, he visited in the common area with other residents, and he smiled and laughed. He joked with the nurse when medications were administered. He denied pain or discomfort. He had latent discolorations noted to his bilateral forearms related to his recent altercation with staff and police/handcuffs. He had dark purple discoloration to his right forearm that measured 20 cm (centimeters) x 9 cm with no swelling and his skin was intact, it joined up to his right posterior hand with discoloration that measured 10 cm x 8 cm. He had purple discoloration to his left forearm that measured 13 cm x 8 cm with no swelling and his skin was intact. His left post hand had purple discoloration and measured 12 cm x 7 cm with no swelling observed and his skin was intact. He was able to move his bilateral arms without difficulty. The security video footage for the Willow Way dining room, from 4/23/23, was reviewed on 4/24/23 at 3:15 p.m. The video was without sound and time. The approximate time was observed from a clock visible in the kitchen area in the video footage. The video footage indicated the following: At 12:12 p.m., Resident B ambulated into the dining room and sat in a chair at a table, his back was towards the camera. At 12:48 p.m., there was a female resident sitting at another table in the dining room. CNA 6 talked with Resident B and touched him on the arm. He rubbed his face with open hands and rubbed the back of his head. CNA 6 sat down across from him at the table and talked to him and the dietary aide that was cleaning up the dining room. At 12:50 p.m., he continued to rub his head. CNA 6 got up and went to his left side then stood away from him to his left. The female resident was still at the other table. At 12:54 p.m., CNA 6 walked to the [NAME] doors. LPN 26 entered the dining room and talked with the female resident at the other table. She then walked to Resident B's left side and placed her hand on his back and appeared to be talking with him. She stopped talking to him and stood at his left side with her hand on the back of his chair and slightly leaned over his left shoulder as she talked to him, then pushed his chair back from the table. He continued to rub his head. The female resident continued to sit at the other table. At 12:57 p.m., LPN 26 continued to stand to his left side slightly behind him as she talked with CNA 6 who was standing in front of him. The female resident continued to sit at the other table. At 12:58 p.m., LPN 26 placed her hands in front of him as if to indicate for him to take her hands, then she placed her hands on his knees as she spoke to him. LPN 26 spoke to CNA 6 and CNA 6 moved the dietary cleaning cart out of the walkway. She walked towards Resident B to his right side, between him and the table where he sat, and LPN 26 was on his left. At 1:00 p.m., Resident B slightly pushed his chair back and stood up. He walked forward, away from the exit door from the Willow Way unit, and was faced towards the camera. LPN 26 moved in front of him and when he moved, she moved and placed her arms out to her side to block him from walking the opposite direction from the exit doorway. CNA 6 walked up to the right side of him. At 1:01 p.m., the female resident left the dining room. At 1:02 p.m., LPN 26 took the resident's right arm, and he turned around with his back towards the camera. CNA 6 was on the left side of him, and LPN 26 was in front of him. They were struggling with him and their arms were interlocked with his arms as they struggled to hang onto him. CNA 17 entered the dining room and appeared to talk to him while CNA 6 and LPN 26 struggled with him. He moved his body from side to side with his legs spread apart. CNA 17 left the dining room. As he moved side to side, he pushed LPN 26 to where her buttocks landed on top of the table he had been sitting at. CNA 17 brought LPN 26 the phone. CNA 17 bent down and appeared to speak to him as they struggled with him and continued to have their arms in his. He broke free from CNA 6's arm and LPN 26 remained sitting on the table. He started to walk forward, and CNA 6 held onto him with both her hands and stood to the left behind him. LPN 26 was blocked by the [NAME] door from the camera view. CNA 6 held his left arm while CNA 17 was at eye level with him and appeared to be going through his pockets. As CNA 17 left the dining room, the resident turned to where CNA 6 was on his left, and LPN 26 was on his right up against the wall, holding onto him. He appeared to be kicking at them. A dietary aide in the area had her hands out in front of her and moved them in a downward motion, as if to indicate to calm down. At 1:10 p.m., police officers entered the dining room, held the resident's legs, and handcuffed his hands in front of his body. They sat him in a dining room chair with his back towards the camera. The policeman to his right placed his left hand on Resident B's right shoulder and the other policeman stood in front of him. They stood him up and walked him out of the dining room, then brought him back into the dining room. CNA 6 brought a wheelchair in the dining room and they placed him in the wheelchair and pushed him out of the dining room at 1:15 p.m. During an interview with the DON, on 4/25/23 at 10:22 a.m., she indicated there was a physical altercation with Resident B, a CNA and a nurse. The police tried to restrain him. He continued to kick at them, and they took him to the hospital. He was returned to the facility. The dietary staff was cleaning the dining room, and the resident was putting his hands on his head as if he may of had an actual headache. He had no real behaviors before or after the incident. He had been easily redirected the morning of the incident. They tried to handle the situation gingerly, but he was physically hitting the staff and had the nurse pinned up to the table. He had silverware in his pocket. He had her arm in his and she couldn't break free. EMTs were called, but the police arrived first. No one grabbed him until the police came. The CNA was able to get the silverware from him. The police put him in an arm move to sit him down into the chair and held that position as they handcuffed him. The Unit Manger had indicated she was on call that day, and was told the basically the same thing. He was fine in the morning and was easily redirectable. They were cleaning in the dining room and asked if he was ready to go and he lost it on them and became physically aggressive. They called 911 and EMTs took him to the hospital, where an evaluation was done. They sent him back because he was not aggressive while he was at the hospital. During an interview with Social Service 12, on 4/25/23 at 10:45 a.m., she indicated Resident B was a veteran with behaviors. He had banged his head on the wall; it was care planned. He had taken a sliding bathroom door, bent it, and removed it from the tract. He was not normally aggressive towards anyone, nor threatened anyone. He did not receive psychiatric services. The VA (Veterans Affairs) would not pay for services in the facility and the facility's provider was not in their network. The VA offered psychiatric services, but they didn't want to take him there because he was an elopement risk, and his family felt they would not be able to get him back into the facility. She thought he may have gone to a VA appointment last week. On 4/24/23, he walked around and talked to people like a normal dementia resident. During an interview, on 4/25/23 at 11:13 a.m., LPN 26 indicated Resident B's morning was great on 4/23/23. He was talkative with staff and left the dining room per his usual. Lunch was served later than usual, between 12:45 p.m. and 1:00 p.m. The facility policy was the dining room doors were to be locked, as the unit next door was under construction. The doors must be locked on their side to keep the residents safe. She approached him and he was rubbing his head. He suffered from migraines, and she offered him migraine medication, per his migraine protocol. He became more and more agitated and verbally threatening. He said if you don't leave me alone, I'm going to hurt you. When he stood up, he was going to pick up the chair and she put her foot on the chair. He was going to leave the dining room and he was going to walk past her to go to the other side. She walked side to side to keep him from going the other direction. She was on his left side and the aide on his right. Then she was pushed up against the table, and he pressed up against her. Her arm was locked in his arm as they walked and turned, and she was up against the wall and he kept pushing and pushing. Her back hurt as a result. He had escalated so much with no redirection or calming. He stomped at her feet as she was up against the wall. He tried to bite her while she was on the phone with the 911 dispatch. The police arrived and approached him, and he started to fight. The officer had his hand on Resident B's shoulder and reached around to hand cuff him. Normally Resident B needed prompts to come to the dining room for meals and he would bring himself out to the dining room. This was a new behavior, she had never seen him act like this before. She felt for everyone's safety, it was necessary to remove him from the dining room. She didn't know if reapproaching him would have made a difference. She felt he was familiar with her, and would approach her to call his family. During an interview with CNA 17, on 4/25/23 at 2:32 p.m., she indicated the resident was fine at lunch. After lunch, he was always the last one out. He sometimes got irritated when asked to leave the dining room. She was walking another resident from the dining room when she heard someone screaming for her. She walked into the dining room, and she asked Resident B what was wrong and if she could fix it. She had never seen him that mad, but she would be mad too if someone was holding both of her arms. They were trained not to hold anyone down, as it would put him into a fight or flight mode. They were taught that in dementia training. LPN 26 had one of his arms and CNA 6 had his other. She was not sure what got them to this point. He collected silverware, and if you tried to get the silverware from him, he got upset. She would normally let him take the silverware back to his room and then go back to his room and collect it later. She wished she was in the dining room before all this happened. Normally, you could coax him to leave or leave him and reapproach him later, and she would watch him through the window. He didn't usually get mad. He would sit in the dining room for a minute, and then she would wave him on. When he showed any sign of irritation, she would leave him and come back later. He kept screaming he had a migraine during the incident, and she felt they made things worse by holding his arms. He was not normally aggressive. It was totally different with a military man, you don't know about his past and what he had been through. He was trying to get away from staff. The police took him and handcuffed him. The officer grabbed his shoulder and the resident started to cry. The police officer told him don't cry now. It was really hard to watch. During an interview with CNA 6, on 4/25/23 at 2:46 p.m., she indicated the resident had been in a good mood until after lunch, when he lingered to come out of the dining room. LPN 26 came in and thought she could talk to him and walk him to his room. He was absolutely not having it, and he screamed and doubled up his fist. He tried to pick up the chair with his left hand and she put her leg on it. He just went off, and pushed her into the table. He was hitting, pinching, and kicking. LPN 26 called the police. They took silverware from his pockets and went to sit him in the chair. Police used a pressure point on his shoulder because he kicked the policeman in the groin. He was normally kind of aggressive, but not to the point of hitting. She didn't push him, if she tried to get him out of a room, he would yell at her. A staff member had said Resident B was going to use the silverware on someone, but didn't report it. They couldn't have left him in the dining room, the dietary people couldn't of handled him. When he was first approached, he indicated he was not ready, and she sat down across the table from him for a while and talked to him. Then the nurse came in. He was already mad and got up from the chair and doubled his fist. He was fine until she asked him to leave the dining room. He had complained of a headache before it started. LPN 26 asked him if he needed medicine, and he said he didn't need anything. He complained of headaches all of the time. When he was asked to leave the dining room, he was probably going to collect more silverware. He tried to pocket silverware on his way out of the dining room. When the police handcuffed him, she took the silverware from his pockets. Other residents collected silverware, too. One resident collected silverware on her way out of the dining room and put the silverware in her room. The other resident put the silverware in her purse. CNA 6 was very upset about the incident. She knew he would probably blow one day. She heard he may have planned to use the silverware as a weapon. During an observation of the dining room between the Willow Way unit and the Evergreen Park Unit, on 4/26/23 at 8:58 a.m., the following was observed: a dining area on the side of the Willow Way unit, a dining area on the Evergreen Park side, and another dining area in the middle of them. The dining rooms were open, but separated by half walls with windows. There was a walkway between the kitchen area and the dining rooms allowing free access from one dining room to the next dining room. The double doors to enter Evergreen Park were locked,with a handle with a turn style lock on the right-side door. During an interview with Agency QMA, on 4/26/23 at 9:08 a.m., she indicated she had not seen Resident B have behaviors. Sometimes, he didn't want to come out of his room, because he was tired or he had a headache. She had not seen him be aggressive. When he had a headache, he would put his head down. Both noise and talking bothered him. He had chronic migraines. He was usually one of the last residents to come out of the dining room, and he liked to steal the silverware. He just took them back to his room, and if you tried to take them from him, he would get upset. They just went in and took it from his room later. A lot of residents would take silverware from the dining room. If he didn't want to leave the dining room and was eating, they stood there or would come back if he was just sitting in there. If he tried to go to the other side, they stayed in there with him. If you pushed his chair back or touched him, it would just make him mad. She walked beside him but didn't touch him, he was not a touchy person. There was a note in the dining room to indicate the doors were not to be opened until they were ready to serve meals so the residents didn't go in there. During an interview with QMA 29, on 4/26/23 at 9:52 a.m., she indicated Resident B was normally in a happy mood, and not aggressive with her. He refused to shower for her. He liked to sleep most of the day. He was good if he stayed in his routine. Once he got upset then he would get really upset. He became upset if disrupted from what he wanted to do. He needed more encouragement to redirect him. She did not touch him or pull on his arm, as it would upset him. He normally was the last one to leave the dining room, and most of the time he would go out on his own. If he was just sitting there, she encouraged him with an activity to come out of the dining room. During an interview with Dietary Aide 15, 4/26/23 at 10:11 a.m., she indicated she was not working the day of the incident and she was shocked that it happened. Resident B was nice. He was usually one of the last residents to leave the dining room, and they would let him sit. He would eventually leave. She had not seen him be aggressive. During an interview with Housekeeper 4, on 4/26/23 at 10:15 a.m., she indicated Resident B was nice talk to. She talked to him about how he used to fly airplanes and the weather. They made small talk. He was a nice gentleman. She had not seen him be aggressive. Review of a document tilted Communication and Alzheimer's, Communication in the middle stage, (2023) was retrieved on 4/26/23 from the Alzheimer's Association website (www.alz.org/help-support/caregiving/daily-care/communications). The document indicated the following: .The tips for successful communication included engage the person in one-on-one conversation in a quiet space that has minimal distractions, speak slowly and clearly, maintain eye contact. It shows you care about what he or she is saying, give the person plenty of time to respond so he or she can think about what to say . be patient and offer reassurance. It may encourage the person to explain his or her thoughts . avoid arguing. If the person says something you don't agree with, let it be A current, undated, facility policy tilted Dementia - Clinical Protocol, provided by the DON, on 4/26/23 at 2:55 p.m., indicated the following: .Assessment and Recognition .4. The IDT will review the past and current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications and functional impairments. a. Using several sources, including the resident (if appropriate), family and information form prior records, the following information will be collected and documented in the resident's record: 1. Life experiences .5. Mood and behavior patterns, including how the resident typically expresses physical, emotional and psychosocial needs including distress The deficient practice was corrected by April 24, 2023, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, audits, and education related to the facility's dementia care protocol. This Federal tag relates to complaint IN00407085. 3.1-37(a)

Based on interview and record review, the facility failed to prevent physical abuse of a resident when a contracted staff member (LPN 1) grabbed her wrist in an attempt to remove her from an area for 1 of 6 residents reviewed for abuse (Resident B). Findings include: An Indiana Department of Health (IDOH) reportable was provided by the Administrator on 7/18/22 at 11:05 a.m. The report indicated on 7/10/22 at 7:25 p.m., CNA 2 observed LPN 1 pushing Resident B and observed LPN 1 having her arms wrapped around the resident and forcibly pushing her through the common area and telling her she needed to go to her room. Review of the facility investigation indicated the following: a. A computer progress note, dated 7/10/22 at 8:32 p.m., LPN 1 indicated she attempted to get Resident B to take her medications. The resident was extremely anxious about another resident standing to close, so the other resident was redirected. At that point, Resident B threw her pills into the trash and began acting out. She was asked to leave the nurses station, sit down or go to her room. She continued to work and opened the top drawer of the medication cart and the resident grabbed all the diabetic finger-sticks and threw them onto the floor. She was finished with current medication administration and attempted to crowd her back to her room. The resident became combative and aggressive, then an aide came to help and she stepped away from the situation. The aide redirected her back to her room. b. A written statement by CNA 2 indicated on 7/10/22, she was standing outside the soiled utility room when she heard voices coming from the common area. She went to see what was going on and saw LPN 1 forcefully pushing and grabbing Resident B. LPN 1 was telling the resident she needed to go to her room. The resident was yelling why are you doing this to me, you're hurting me, ow [sic] you cut me, she cut me. CNA 2 asked what was going on and LPN 1 indicated the resident knocked items off the medication cart and she needed to go to her room. CNA 2 offered to take her to her room and the resident agreed to go with her. While walking back to her room, the resident was upset and told her she was scared and afraid someone was going to lock her up and kill her. The resident indicated she was cut, but only a scratch was noted. c. A statement provided by QMA 3 indicated she heard LPN 1 talking in a stern voice to get away from her and indicated she was bothering her. Resident B was asking LPN 1 why she was mad at her and LPN 1 indicated to the resident she was being disrespectful. Later in the evening, she was taking Resident B to her room and she was very upset. She kept showing her arm where the nurse had a hold of her. The resident indicated it hurt and a small bruise her right arm. She kept saying to not let that woman hurt her again and to not let her kill her. d. The 5-day follow up indicated LPN 1 was suspended and placed on a do not return list. The nursing agency was contacted and informed of the incident. The agency indicated they would also take disciplinary action following the investigation. The Director of Nursing (DON) assessed the resident for injuries and was noted to have some discoloration on her right hand that measured 1.5 cm x 1.5 cm. The family and Nurse Practitioner (NP) were notified of the incident. On 7/18/22 at 2:25 p.m. with the Administrator, the video surveillance was viewed for 7/10/22. At 7:11 p.m., Resident B and LPN 1 were observed at the medication cart. The nurse and resident continued to stand near each other, then LPN 1 opened the medication cart and turned to throw something away and the resident reached into the drawer, grabbed the finger sticks and dropped them onto the floor. The nurse quickly grabbed her right wrist, turned her around and the resident was leaning back attempting to not be moved. The resident grabbed the handrails and the nurse appeared to be attempting to remove her hands from the handrail. She was behind the resident, bumping her in an attempt to move her along, the resident was still holding and then let go of the handrails. The nurse was still holding the resident as the resident was moving around. LPN 1 was seen to be holding her wrist then had her hands on the resident's back. CNA 2 comes into view and LPN 1 leaves the area. The clinical record for Resident B was reviewed on 7/18/22 at 9:15 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/28/22, indicated the resident had moderate cognitive impairment. During the assessment period, she had 12-14 days of having little interest in doing things, 12-14 days of feeling depressed and 7-11 days of difficulty falling asleep. She required set-up help for mobility and was able to ambulate per self. A care plan, dated 2/22/22, indicated the resident had the potential to be physically aggressive and had poor impulse control. Behaviors included throwing water, ripping paper and foam cups. Interventions included, but were not limited to, redirect to room and provide one on one visits. Another care plan, dated 4/13/22, indicated the resident had delusions and hallucinations related to dementia. Interventions included, but were not limited to, reassure resident of safety, validate feelings and offer rosary for prayers. A social service progress note, dated 7/11/22 at 12:18 p.m., indicated the resident was assessed following the incident. The resident was unable to recall any event with any staff member, but repeatedly asked for her family to visit. A NP note, dated 7/11/22 at 5:55 p.m., indicated the resident was evaluated following the 7/10/22 incident. The resident indicated she was having a great day so far and was very pleasant. A skin assessment, dated 7/12/22 at 12:38 p.m., indicated a new bruise to the back of her left hand that measured 1.5 cm x 1.5 cm. An Interdisciplinary Team (IDT) note, dated 7/15/22 at 3:08 p.m., behaviors were reviewed that included refusing medications, excessive worrying, throwing items, exit seeking and crying. The NP was to follow up for the increased behaviors. During an interview with the Administrator on 7/18/22 at 12:29 p.m., she indicated the cameras were reviewed and that was why she was not allowed to return. She was bothered by what she saw on the cameras. CNA 2 called immediately and the contracted agency was contacted. During a telephone interview on 7/18/22 at 12:37 p.m., LPN 1 indicated she was in the middle of medication administration. The resident always stood with whoever was at the med cart. The resident was bothered by another resident so when she removed that resident, Resident B freaked out. She had asked her several times to leave and then she grabbed the finger sticks and threw them on the floor. She dealt with the situation in the wrong manner. She was a little more aggressive than she should have been, but the goal was to just remove her from the situation. She remained in the building for about 1 hour until the nurse manager came to relieve her. She knew she messed up when she let go of her wrist and at that time, the CNA took over. Staff has been asking the NP for awhile to adjust her medications. During an interview on 7/18/22 at 2:42 p.m., the Administrator indicated the Unit Manager clocked in at 8:15 p.m. and LPN 1 left at 8:37 p.m. She received the initial call at 7:52 p.m. She indicated the Unit Manager sat with her at the nurses station while she completed her documentation. During a telephone interview 7/19/22 at 2:03 p.m., CNA 2 indicated she was at the soiled utility room washing her hand when she heard raised voices. She went out and saw LPN 1 had the resident in front of the nurses station and was kind of pushing her towards her room. The nurse kept telling the resident to go to her room. She asked the nurse what happened and she said the resident knocked stuff off the med cart. The resident was acting scared and asked why she was being mean and hurting her. LPN 1 had a hold of the resident in a couple different areas since she was trying to get loose. She took her to her room and she calmed down. She then told the other aide she was leaving the unit to call and report the incident. She did not speak to the nurse after she reported it and the nurse remained in the office with the Unit Manger who came in to relieve her. Review of timecard for LPN 1, she arrived to work on 7/10/22 at 5:55 a.m. and left at 8:37 p.m. Review of the timecard for Nurse Manager 4, she arrived to work on 7/10/22 at 8:15 p.m. and left at 10:15 p.m. Review of LPN 1's education courses, she completed the following: a. Dementia training: 6-hours on 1/27/22. b. Abuse: Child, Elder, Intimate Partner on 1/27/22. c. Patient Rights on 1/27/22. A current policy, titled Abuse Prevention Program, was provided by the Director of Nursing on 7/18/22 at 8:52 a.m. The policy indicated the following: It is the policy of this community to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .d. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. .III. Preventing Resident Abuse - Establishing a Resident Sensitive Environment .V. Protection of Residents: The community will take steps to prevent mistreatment while the investigation is underway. .Employees .who have been accused of abuse, neglect, or mistreatment will be immediately suspended until the results of the investigation have been reviewed by the administrator or designee. This Federal tag relates to Complaint IN 095. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to provide supervision and immediate individualized interventions to prevent falls. This deficient practice resulted in 4 of 8 residents reviewed for falls sustaining fractures (Residents 79, 179, 125, and 18). The immediate jeopardy began on 1/24/22, when Resident 79 fell and sustained a right femur fracture and immediate interventions to prevent falls were not put into place, resulting in additional falls. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. Findings include: 1. On 3/8/22 at 2:16 p.m., Resident 79 was seated in her wheelchair at a table in the unit common area. Activity Aide 31 was seated next to her. On 3/8/22 at 2:30 p.m., she was saying she wanted to get up; Activity Aide 31 was encouraging her to sit still. On 3/9/22 at 9:14 a.m., she was sitting up on the side of her bed, with her feet on the floor. CNA 34 entered the room and asked if she was ready to get up for the day. On 3/9/22 at 9:33 a.m., she was up walking alone in her darkened room, partially dressed, standing near her armoire. She then walked to her recliner chair, sat down, and began putting on socks. During an interview, on 3/9/22 at 9:35 a.m., LPN 51 indicated staff tried to keep her from being up by herself. At 9:42 a.m., she was assisted to the common area via wheelchair. On 3/9/22 at 10:43 a.m., she was up walking away from the activity group in the common area. LPN 51 went to assist her and asked her to sit in a chair near the fireplace sitting area. On 3/9/22 at 1:10 p.m., she was seated at a table in the common area with a baby doll during a small group activity. On 3/10/22 at 8:51 a.m., she was seated in her wheelchair in the common area with her head in her hands. On 3/10/22 at 9:20 a.m., she remained in her wheelchair near an activity group, holding her head up with her fingers in her eyes. On 3/10/22 at 11:18 a.m., the resident's wheelchair sat in the common area, with the cushion tilted forward. There was no anti-slip mat observed in the seat. CNA 52 assisted the resident from a chair into her wheelchair for lunch in the dining room. On 3/10/22 at 3:06 p.m., the resident left her wheelchair in the common area and began walking. CNA 53 assisted her to a chair in the lounge area near the fireplace. The CNA walked away and then the resident got up and walked to a chair across the lounge area and sat down with two other residents. On 3/11/22 at 8:35 a.m., she was up walking around the unit with CNA 39, looking for her family member. On 3/11/22 at 9:32 a.m., she was up walking toward the medication carts. LPN 37 assisted her back to her wheelchair near a small group of residents and walked away. On 3/14/22 at 9:59 a.m., she was in bed, laying facing the wall. Her bed was elevated to approximately knee height. During an interview, at the time of the observation, CNA 52 indicated the bed was at knee height, but there were no current interventions for the resident's bed to be kept low. On 3/15/22 at 9:36 a.m., she was seated in a recliner in the common area, asleep, with a pillow on her lap. Resident 79's clinical record was reviewed on 3/8/22 at 9:50 a.m. Diagnoses included, but were not limited to, (1/27/22) fracture of unspecified part of neck of right femur, major depressive disorder, [CONDITION(S)] (TIA), restlessness and agitation, psychotic disorder with delusions, dysphagia, unsteadiness on feet, age-related physical debility, and Alzheimer's disease. She had current physician orders for, but not limited to, [MEDICATION(S)] (anti-depressant) 50 mg daily, [MEDICATION(S)] (anti-depressant) 25 mg at HS for [CONDITION(S)] and neuropathic pain secondary to hip fracture, [MEDICATION(S)] (opiate pain medication) 50 mg every six hours as needed for pain, acetaminophen (analgesic) 325 mg two tablets three times daily, [MEDICATION(S)] (anti-psychotic) 25 mg 0.5 tablet (12.5 mg) at bedtime, and [MEDICATION(S)] (anti-anxiety) 1 mg twice daily. A 12/17/21, annual, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired and required supervision for ADLs and mobility. A 1/31/22, 5 day, MDS assessment indicated she was severely cognitively impaired and required extensive assistance for ADLs and supervision for mobility. She had a current, 2/10/22, care plan problem of confusion/distress as evidenced by calling her family members and them asking about her husband, wanting to go home, stating husband has given her money, and being unable to find her husband. She had a current, 3/4/22, care plan problem of risk for falls related to confusion, wandering, and behaviors. She had impaired safety awareness and attempted to transfer and ambulate without assistance. She had a walker, but at times would not use it, stating she did not need it. Interventions included, but were not limited to, the following: a. anti- rollbacks to wheelchair (1/28/22) b. encourage to sit in common area if awake during high risk walking rounds (1/28/22) c. hipsters to be worn at all times (1/31/22) d. be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. (2/2/22) e. anti-slip mat to wheelchair (2/7/22) f. keep footrest to recliner down while resident is sitting in recliner (2/7/22) g. remove exercise equipment from across the nook area (2/7/22) h. encourage to sit in common area while awake, offer activity and/or conversation (2/14/22) i. staff to get resident up and ready for breakfast between 6-7 am and assist to common area. (2/17/22) j. keep bed at appropriate height (2/18/22) k. staff to encourage resident to wear glasses appropriately (2/22/22) l. non-skid strips in and out of bathroom doorway (2/23/22) m. high risk walking rounds-if awake during rounds, encourage to sit in common area. If awake during sleep hours, offer/assist to toilet (2/24/22) n. offer/encourage to rest in recliner in common area (2/24/22) o. obtain urinalysis sample (3/4/22) p. assist to common area when finished eating meals (3/8/22) q. assist to toilet before and after meals (3/8/22) Review of progress notes and assessments indicated the following: On 1/11/21, she was started on [MEDICATION(S)] 5 mg at bedtime and a one time dose of 15 mg. On 1/13/22, a Nurse Practitioner note indicated she had a shuffling gait; the resident didn't realize she was walking any differently. On 1/18/22, the facility's secured unit and it's residents were moved to another area of the facility. On 1/20/22, a Nurse Practitioner note indicated an acute visit, per staff request, for an aggressive episode towards another resident, throwing belongings out the window, and continued delusions. She was started on [MEDICATION(S)] 12.5 mg daily. Review of a 1/24/22 at 6:30 p.m. fall risk assessment indicated score of 6, low fall risk. On 1/24/22 at 11:01 p.m., the resident was standing next to another resident in the common area, when she turned around and then fell on the ground, landing on her right hip. She was unable to move her right leg and complained of severe pain when attempting to sit up. She was sent to the emergency department for evaluation. A 1/25/22 Interdisciplinary Team (IDT) note indicated therapy was to evaluate her when returned from the hospital. On 1/27/22 at 3:40 p.m., she returned from the hospital following a surgical repair of a right hip fracture. On 1/27/22 at 8:23 p.m., she was found sitting on her bottom in front of the fireplace, with her legs bent at the knee and feet flat on floor. Staff were to continue high risk walking rounds. Staff was in the back cluster of the unit, and the resident had been seen in the common area talking with another resident 5 minutes before the fall. No immediate intervention was implemented to prevent further falls. On 1/27/22 at 10:08 p.m., she was found lying on her right side in front of her room, facing the hallway. She stated she was just going for a walk and fell . She had a 2-centimeter (cm) bruise to her right shoulder and swelling to her right outer hip area and appeared inwardly rotated. She was transferred to the Emergency Department for evaluation. She returned to the facility on [DATE] at 2:40 a.m. and was to be placed on 1:1 supervision. A 1/28/22 IDT note indicated she was currently using a wheelchair and an intervention would be added for an anti-rollback device to her wheelchair. A 1/28/22 IDT note indicated she had dementia and poor safety awareness and continued to attempt to walk. An intervention was added to encourage her to be in the commons area if awake during walking rounds. Review of a 1/28/22 Nurse Practitioner note indicated she had fallen twice since return to the facility and was now unable to ambulate and had an obvious deformity to her right hip. Staff report she fell out of bed and onto her right side. She had a large abrasion and hematoma to her right shoulder and redness and swelling to her right hip. A progress note dated 1/28/22 at 2:41 p.m. indicated she had an unwitnessed fall requiring a further evaluation. No new fractures were identified, and the resident was expected to return to the facility. On 1/28/22, new orders were received to discontinue the [MEDICATION(S)], wean the [MEDICATION(S)], and start [MEDICATION(S)] for mood, sleep, and neuropathic pain secondary to falls and hip fracture. On 1/29/22 at 7:20 a.m., she had an unwitnessed fall in the common area. She had last been seen 15 minutes prior, sitting in a chair in the common area. Resident stated she got tripped up on her own feet and was lying on her left side, with her right leg at an awkward angle, bent inward; she complained of pain when moved. She was transferred to the emergency department for evaluation. No interventions were implemented upon her return to the facility on [DATE]. A 1/31/21 IDT note indicated she had experienced increased anxiety and was unable to understand she couldn't get up on her own. An intervention was added to wear hipsters at all times. A 2/1/22 IDT note indicated a review of staff monitoring of the fall interventions from 1/24/22, 1/27/22, 1/27/22, and 1/29/22. The IDT found the interventions remained effective and continued to follow care plan. On 2/2/22 at 11:25 p.m., she was found sitting on her bed with an abrasion to her right lower arm posteriorly, measuring 1.1 cm long x 4.9 cm wide. She was unable to state what had occurred. On 2/3/22 at 2:55 p.m., she was in the common area, near the fireplace, visiting with another resident, when staff heard the other resident asking her to wait for help as she slid out of her wheelchair and onto the floor. No injuries were noted. No immediate intervention was implemented to prevent further falls. On 2/4/22 at 12:10 p.m., she was propelling herself in the common area, stood up to ambulate and fell backwards, hitting her head on exercise equipment. She was conscious but moaning and wanting to hold the back of her head; her pupils were dilated. A laceration of at least 4 cm in length and unknown depth was noted to the back of her head. She was transferred to the emergency department for evaluation. On 2/4/22 at 5:10 p.m., report was received from the hospital of the resident having six sutures to her head and a possible compression fracture. She was to be transferred back to the facility. Review of a 2/4/22 Emergency Department visit summary indicated diagnoses of compression fracture, closed head injury, and stitches. No immediate intervention was implemented to prevent further falls. On 2/5/22 at 7:55 p.m., she was observed sitting in front of her recliner. She stated she was going walking and was unable to remember to not get up on her own. She was assisted into her wheelchair and to bed. There was no immediate intervention implemented to prevent further falls. A 2/7/22 IDT note indicated an anti-slip mat would be placed on her wheelchair seat due to the her having slid from her wheelchair on 2/3/22. A 2/7/22 IDT note indicated the unit's exercise equipment would be removed due to her striking her head on it on 2/4/22. A 2/7/22 IDT note indicated an intervention was added to ensure the footrest was down on her recliner when she was sitting in it. A 2/11/22 IDT note indicated a review of staff monitoring of the fall interventions from 2/2/22, 2/3/22, 2/4/22, and 2/5/22. The IDT found the interventions remained effective and continue to follow care plan. On 2/12/22 at 4:24 p.m., a yell then a thud was heard in the hallway off the side of the nurses station. The resident was found on the floor, laying on her back, crying. She complained of pain, but no injury was noted. No immediate intervention was implemented to prevent further falls. On 2/13/22 at 4:09 p.m., the nurse was informed the resident was on the floor again, and went to the unit to assess her. An x-ray of her hip was ordered. No immediate intervention was implemented to prevent further falls. A 2/14/22 IDT note indicated she was not injured in the 2/13/22 fall. An intervention was added to encourage her to stay in the common area when awake and offer her a snack. On 2/14/22 at 8:04 p.m. staff heard an oomph and turned and found the resident sitting in the middle of the hallway in front of her wheelchair. No injuries were noted. She was kept in staff's line of sight. A 2/15/22 IDT note indicated an intervention was added to keep her walker within reach at all times. On 2/16/22 at 7:00 a.m., she came out of her room earlier in the morning, tearful, and stated I woke up to use the bathroom and just broke my self all up. She had been in bed sleeping approximately 15 minutes prior. She had a 2 cm linear skin tear under her chin and complained of a headache. High risk walking rounds continued due to high fall risk. No immediate intervention was implemented to prevent further falls. A 2/16/22 IDT note indicated a review of staff's monitoring of the fall on 2/12/22 intervention. The IDT found the intervention remained effective and continued to follow the care plan. A 2/17/22 IDT note indicated she had been going to the bathroom on 2/16/22 broke herself all up. She had a laceration to her chin. A new intervention was added to assist her with getting up in the morning between 6:00 and 7:00 a.m., then to the common area. On 2/18/22 at 1:37 a.m., she was heard by staff, calling out for help, and was found sitting on the floor at the end of her bed. She stated she was trying to get up to use the bathroom. The bed was in the lowest position. No injuries were noted. She was assisted to the bathroom. No immediate intervention was implemented to prevent further falls. A 2/18/22 IDT note indicated an intervention was added to keep bed at an appropriate height. The appropriate bed height was not defined by the facility. On 2/19/22 at 7:24 p.m., she was seen in front of the chair on one knee, halfway into getting up. She claimed she did not fall she just sat down; other residents in the area said she sat too far forward on the chair and slipped out and down to ground. She was assisted to her room and then was resting. No immediate intervention was implemented to prevent further falls. A 2/21/22 IDT note indicated she had missed the chair on 2/19/22 and fell to her left side, due to not wearing her glasses appropriately. A new intervention was added to encourage her to wear her eye glasses appropriately. On 2/23/22 at 12:42 a.m., she was found lying on her back on the floor in her room at the bathroom entrance. She had a light red 2 cm long x 2 cm wide abrasion to her left buttock. She complained of back pain and had no visible injuries noted. She was assisted to the bathroom, then back to bed. No immediate intervention was implemented to prevent further falls. A 2/23/22 IDT note indicated she had lost her balance while ambulating, causing her last fall. An intervention was added for non-skid strips to the floor in front of her bathroom and inside of her bathroom. On 2/23/22 at 11:06 a.m., she was found laying on the floor, on her left side, in front of the recliner in her room. She was assisted to her wheelchair and transported to the bathroom for ADL care. She denied any pain or discomfort and no new injury was noted. No immediate intervention was implemented to prevent further falls. On 2/24/22 at 1:35 a.m., she was found sitting in front of her wheelchair beside her bed. She said she was on the way to the bathroom and she slipped. She grimaced slightly when she stood and then took off walking on her own. She was assisted to the bathroom. No pain indicators were noted. No immediate intervention was implemented to prevent further falls. A 2/24/22 IDT note indicated on 2/23/22, she had attempted to transfer by herself and lost balance. An intervention was added to offer her to rest in recliner in common area during day. A 2/24/22 IDT note indicated an intervention was added to offer to assist to toilet if awake during high-risk walking rounds. A 2/25/22 IDT note indicated a review of staff's monitoring of the fall interventions from 2/14/22, 2/16/22, 2/18/22, 2/19/22. The IDT found the interventions remained effective and continued to follow the care plan. A 3/1/22 IDT note indicated a review of staff's monitoring of the fall interventions from 2/22/22, 2/23/22, and 2/24/22. The IDT found the interventions remained effective and continued to follow the care plan. On 3/3/22 at 3:05 p.m., she was sitting in the common area during an activity. When the activity staff went to attend to another resident, Resident 79 got up and fell beside her wheelchair. No injury was noted. No immediate intervention was implemented to prevent further falls. On 3/3/22 at 7:51 p.m., she was found on the floor in the common area with her wheelchair behind her. No injuries were noted. The nurse observed her wheelchair and the cushion seemed to be slanted, with the anti-rollback system was pushing it up into the chair, causing the cushion to slant forward. A maintenance request was made for the cushion to be evaluated. A 3/4/22 IDT note indicated an intervention of risk versus benefit, and she continued to be a fall risk related to her dementia and poor safety awareness. A 3/4/22 IDT note indicated the resident had been experiencing increased urinary frequency and a urinalysis order would be requested of the Nurse Practitioner. On 3/6/22 at 5:16 p.m., she was found on her knees in front of her wheelchair in the common area. Staff had reported leaving her to sit in a chair while they assisted another resident. When they returned 10 minutes later, she was on the floor. No injuries were noted. No immediate intervention was implemented to prevent further falls. On 3/7/22 at 6:45 p.m., staff was assisting another resident out of the dining room, and observed Resident 79 walking, while holding on to the tray line rails. She went down and sat on her buttocks and then laid back on the floor. Her wheelchair was still sitting at the table where she had been seated. No injuries were noted and she was assisted back into her wheelchair. The nightshift QMA was to keep the resident close while passing medications to prevent repeated fall. A 3/8/22 IDT note indicated a new intervention of toileting before and after meals. A 3/8/22 IDT note indicated a new intervention of assist out of dining room after finished eating. Review of a 3/10/22 Nurse Practitioner note indicated she was seen at 9:05 a.m. due to a fall earlier in the morning and hitting her head on a filing cabinet. She complained of a headache right after the fall but denied one at the time of the exam. A 3/10/22 at 5:04 p.m. progress note indicated the nurse had been at the medication cart and the resident was inside the nurses station, organizing her purse, when she lost balance and fell backward, hitting her head against the filing cabinet. Pain medication was administered for head pain. No immediate intervention was implemented to prevent further falls. A 3/11/22 IDT note indicated a new intervention to wear tennis shoes when awake. On 3/12/22 at 5:03 p.m., she had a witnessed fall in the commons area, landing on her right side. She had been wandering the unit all day, had been difficult to redirect, and continued to walk without assistance. On 3/13/22 at 5:13 p.m., another resident reported the resident was falling and by the time staff got there, she had fallen again. She sustained a nickel-sized bruise on her left elbow. No immediate intervention was implemented to prevent further falls. On 3/14/22 at 5:52 a.m., staff heard a crash and found the resident on the floor on her right side with her head facing the front of a neighboring room. She had a 1 cm long x 1 cm wide abrasion to her right elbow and a light, 2 cm x 2 cm bruise above her right eyebrow. No immediate intervention was implemented to prevent further falls. A 3/14/22 IDT note indicated a review of her 3/12/22 fall. An intervention was added to ask her family to remove her slippers from her room. A 3/14/22 IDT note indicated she had recently been started on an antibiotic for a [CONDITION(S)] and an intervention was added to encourage her to wear a gait belt at all times when awake. A 3/14/22 IDT review of her 3/14/22 fall indicated an intervention was added to assess her feet and toenails. On 3/14/22 at 2:00 p.m., she was found laying on her left side in front of her wheelchair in the hallway near her room. She was assisted back into the wheelchair and to an area with an activity group. High-risk walking rounds were to continue and a new order was received for an antibiotic for a [CONDITION(S)]. No immediate intervention was implemented to prevent further falls. On 3/14/22 at 3:30 p.m., her family was asked if her slippers could be removed from her room. On 3/15/22 at 5:12 a.m., she was found on her floor, up against a wall. She was unable to verbalize how she had fallen. She had a 1.5 cm long x 1.5 cm wide skin tear to her right forearm. An elastic wrap was applied to her arm for stability until an x-ray was completed due to pain in her right wrist. She frequently forgot to ask for staff assistance, as she had dementia and was tearful and stated she was trying to leave. No immediate intervention was implemented to prevent further falls. A 3/15/22 IDT note indicated a review of her 3/14/22 fall when she stood up and fell slowly. A review of her psychoactive medications would be requested. A 3/15/22 IDT note indicated a review of her 3/15/22 fall. A request would be made for genetic testing for medication effectiveness. A 3/15/22 at 11:36 a.m. progress note indicated she had sustained an ulna (lower arm bone) fracture and was to be transferred to the orthopedic urgent care facility. A 3/15/22 Nurse Practitioner note indicated she had sustained a fracture to her distal ulna and would likely need a hard cast placed. On 3/15/22 at 7:13 p.m., the facility had been unable to transport her to the orthopedic facility due to a staff shortage. Transportation was set up for the next day at 8:00 a.m. During an interview, on 3/11/22 at 10:22 a.m., CNA 30 indicated she did not know where fall interventions were located but could go ask. She was not sure what Resident 79's specific interventions were, but knew she fell a lot. During an interview, on 3/11/22 at 10:40 a.m., the DON indicated all fall information and investigations were noted in the clinical record. During an interview, on 3/11/22 at 1:22 p.m., RN 33 indicated following a resident fall, she would be expected to develop and add an appropriate intervention to the resident's plan of care. During an interview, on 3/14/22 at 9:59 a.m., CNA 52 indicated the nurses would post any new fall interventions at the nurses station. They attempted to keep Resident 79 in a chair and to keep her busy and in activities. She was frustrated she couldn't walk. During an interview, on 3/14/22 at 12:12 p.m., the DON indicated the resident got up frequently, even if someone was standing right next to her. The DON would expect the nurses to implement immediate interventions to prevent further falls, but it does not always get done. The IDT looked at fall specifics afterward and placed interventions as well. The interventions were added to the care plan and at times, added to the kiosk to have the CNAs look at them. They try to keep her within sight. They have discussed her falls with the Nurse Practitioner and asked to have her medications adjusted; her family thought it may be related to anxiety. 2. On 3/9/22 at 9:07 a.m., Resident 179 was in bed, being assisted with breakfast. Resident 179's clinical record was reviewed on 3/9/22 at 1:55 p.m. Diagnoses included, but were not limited to, fracture of left upper end of humerus, hypertensive heart disease, and COVID-19. She had a current, 2/25/22 care plan for risk for falls. Interventions included, but were not limited to, non-skid strips on floor (3/8/22). A 2/25/22 admission assessment indicated she was independent with ADLs and mobility. A 2/28/22 Nurse Practitioner note indicated she had [CONDITION(S)] pneumonia and a slight increase in cough and malaise. A 3/5/22 at 11:45 a.m. progress note indicated she was found at 7:15 a.m., sitting on the floor, scared and crying. She indicated she had fallen and couldn't get back up. She did have a disfigured left shoulder area, and was transferred to the emergency department. She remained on the floor until EMS arrived and helped get her off the floor. There was no immediate intervention implemented to prevent further falls. Review of a 3/6/22 Nurse Practitioner note indicated she a left humerus fracture and had been sent to the emergency department due to a head injury and use of [MEDICATION(S)] (a blood thinner). Review of a 3/7/22 Nurse Practitioner note indicated her pain was poorly controlled. A new order was placed for [MEDICATION(S)] patch (opioid pain medication). A 3/8/22 IDT note indicated non-skid strips would be placed on the floor beside her bed due to having loss of balance when she fell . During an interview, on 3/7/22 at 10:21 a.m., LPN 30 indicated Resident 179 had not been doing well due to a recent decline and recent fall. She had required total assistance since her decline. 3. On 3/8/22 at 2:05 p.m., Resident 125's door was closed. On 3/9/22 at 9:13 a.m. her door was slightly ajar, unable to see resident from the doorway. On 3/11/22 at 2:08 p.m., Resident 125 was lying on her back in bed, her bed was at thigh height, fall mat in place. Her overbed table was on top of the floor mat and over the resident's lap, her head was elevated. On 3/15/22 at 9:55 a.m. she was in her wheelchair at a table in the common area. Resident 125's clinical record was reviewed on 3/8/22 at 3:05 p.m. Diagnoses included, but were not limited to, hypertensive heart disease with heart failure, age-related [CONDITION(S)] without current pathological fracture, generalized anxiety disorder, weakness, altered mental status, repeated falls, dizziness and giddiness, cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, unspecified lower leg, unsteadiness on feet, need for assistance with personal care, muscle weakness (generalized), difficulty in walking, not elsewhere classified, encounter for other orthopedic aftercare, displaced intertrochanteric fracture of right femur, and subsequent encounter for closed fracture with routine healing, Her orders included, but were not limited to, [MEDICATION(S)]-acetaminophen (narcotic pain reliever) 5-325 mg (milligram) twice daily, [MEDICATION(S)] (treat depression) 7.5 mg daily, [MEDICATION(S)] (diuretic) 20 mg every other day, [MEDICATION(S)] (treat depression) 20 mg daily, [MEDICATION(S)] (treat anxiety) 10 mg three times daily and high-risk walking rounds. A quarterly MDS (Minimum Data Set), dated 11/21/21, indicated she was severely cognitively impaired. She required limited assistance of one staff member for bed mobility, transfers, walk in room/corridor, locomotion on/off unit. She required extensive assistance of one staff member for dressing, toilet use and personal hygiene. She used a walker and a wheelchair. She was occasionally incontinent of bladder and continent of bowel. She had one fall with injury. A Fall Risk Assessment, dated 11/19/21, indicated she was a low risk for falls. She had a care plan that indicated she was at high risk for fall related to history of falls and she attempted to put herself on the floor to pray initiated on 2/15/21 and revised on 11/26/21. Her goal was she would be free of fall with injury through the review date. Her interventions included, but were not limited to, anti-roll back bars to her wheelchair initiated on 7/27/21, anticipate and meet the resident's needs initiated on 2/15/21, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance initiated on 2/15/21, dycem to recliner and wheelchair initiated on 2/17/21, encourage to keep door open to room initiated on 5/17/21, ensure recliner foot rest are not up initiated on 2/17/21, ensure that she was wearing appropriate footwear (non-skid socks/shoes) when ambulating or mobilizing in wheelchair, initiated on 2/15/21, fall mat beside her bed initiated on 2/15/21, follow facility fall protocol initiated on 2/15/21, gait belt to be used for all transfers initiated on 10/7/21, high risk walking rounds initiated on 2/15/21, keep transfer wheelchair folded up and out of sight initiated 7/27/21, offer prayer visitation services per Catholic Priest initiated on 5/17/21, evaluate and treat per falls initiated on 2/15/21, review information on past falls and attempt to determine cause of falls. Record possible root causes, alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes initiated 2/15/21, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach) initiated on 2/15/21. Her nurses notes and care plan interventions indicated the following: On 12/3/21 at 4:29 a.m., resident called for help at 2:00 a.m., she was lying on her back between her bed and the entrance to her room. She was swaddled in her bed linen and some blood was noted to the linen. She reported that she had rolled from the bed, the low air loss bed was noted to be half deflate, the connection from the foot blow up and mattress had failed. To attempt the use of standard pressure reduction mattress to promote sleep. She had a frequent history of wandering from her bed during the night hours, possibly, her bed caused sleep disturbances. to She stated mild discomfort to left hip during the assessment. She had no signs or symptoms of pain or injury with AROM (Active Range of Motion) or weight bearing. Discomfort was resolved with position change. Her gait was at her baseline when she walked to the restroom post fall. She was noted to be incontinent. Staff reported, she was toileted an hour prior and she was seen resting in bed 15-20 minutes before fall. A 6 cm x 3 cm skin tear was noted to her right [TRUNCATED]

Based on observation, interview, and record review the facility failed to provide adequate supervision and intervention to prevent resident to resident abuse for 4 of 7 residents reviewed for resident to resident abuse. (Resident 117, Resident 93, Resident 107, and Resident 108) This deficiency resulted in Resident 117 grabbing Resident 65 resulting in Resident 117 falling and fracturing her left hand. The immediate jeopardy began on 2/9/22, when Resident 117 grabbed Resident 65 and had a fall that resulted in a left hand fracture. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. Findings include: 1.On 3/08/22 at 2:03 p.m., Resident 117 was observed ambulating independently in the common area, she stopped and stroked another resident's hair. On 3/10/22 at 8:52 a.m., Resident 117 was observed ambulating independently into Resident 93's room. On 3/15/22 at 9:00 a.m., Resident 117 was observed ambulating into another resident's room. There were no facility staff visible. Resident 117's clinical record was reviewed, on 3/10/22 at 3:01 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired. She was never or rarely understood. Inattention or disorganized thinking behaviors were continuously present. Staff assessment of the resident's mood indicated, she was short-tempered or easily annoyed two to six days. Her verbal behavioral symptoms directed toward others occurred one to three days. She required extensive assist of one staff member for walking in room, walking in corridor, and locomotion on unit. No mobility devices were listed. Medication orders included, but were not limited to, [MEDICATION(S)] 5 mg daily and Tylenol 650 mg three times a day. She had a focused care plan, initiated 2/23/22, for resident to resident altercations which indicated, but was not limited to, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings (2/23/22), allow resident to express their emotions/feelings about (2/23/22) , consult with: pastoral care, social services, psych services (2/23/22), encourage participation from resident who depends on others to make own decisions (2/23/22), high risk walking rounds (2/23/22), increase communication between resident/family/caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes(2/23/22), initiate referrals as needed or increase social relationships(2/23/22), monitor/document resident's usual response to problems: Internal how individual makes own changes, external - expects others to control problems or leaves to fate, or luck (2/23/22). A progress note, on 2/9/22 at 7:40 p.m., indicated the resident was ambulating in the hallway. She grabbed the arm of Resident 65. Resident 65 jerked her arm away causing the resident to lose balance and sit on floor. On the way down, she encountered Resident 65's zipper on sweater causing a laceration. An Interdisciplinary Team (IDT) progress note, on 2/10/22 at 9:10 a.m., indicated the resident grazed her left eyebrow on Resident 65's sweater. A progress note, dated 2/11/22 at 2:07 a.m., indicated the resident's left hand was swollen over the knuckle. A progress note, dated 2/12/22 at 2:44 p.m., indicated the left hand was swollen and bruised. The nurse practitioner (NP) ordered X-rays of the left hand. The Xray on 2/13/22 of the left hand with two views indicated an acute oblique fracture at base of the 2nd proximal phalanx. During a confidential interview a staff member indicated she did not have enough help to do what she needed to do. She indicated there were times when she worked when there was only one CNA there for the unit. She indicated she was supposed to keep an eye on Resident 117. During an interview, with RN 43 on 3/10/22 at 12:32 p.m., she indicated high risk walking rounds signified residents were checked every 15 minutes. She indicated the high risk walking rounds were signed off in the treatment administration record one time a shift, not every 15 minutes. During an interview, with LPN 46 on 3/11/22 at 11:00 a.m., she indicated she would give Resident 117 a cookie to distract her. To prevent altercations, she would intervene immediately and remove the residents from the situation. QMA 44 indicated, during an interview on 3/11/22 at 11:18 a.m., she had not worked this unit much, but she asked the other staff at shift change what interventions were needed for the residents. She indicated it was tough to know what the interventions were but would get to know them as she worked the unit more often. During an interview, on 3/14/22 11:11 a.m., CNA 42 indicated the care plans in the kiosk gave the interventions for the residents. She indicated Resident 117 needed directed away from crowded areas. During an interview, on 3/15/22 at 9:19 a.m., CNA 41 indicated they have activities for the residents. She indicated they try to distract the residents as much as they can when the residents were upset. She indicated Resident 117 liked to go into other residents' rooms and the staff try to direct her out. 2. On 3/7/22 at 11:21 a.m., Resident 93 was observed ambulating independently about the unit. On 3/8/22 at 8:25 a.m., Resident 93 was observed sitting at table in the activity/dining area with her head resting on a table and was wearing a helmet. On 3/14/22 at 10:16 a.m., Resident 93 was observed ambulating independently in her room and wearing a helmet. Resident 93's clinical record was reviewed on 3/10/22 at 11:16 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired. The resident was never or rarely understood. The resident never or rarely understands. Inattention or disorganized thinking behaviors were continuously present. The resident required supervision with one staff member assist for walking in her room, the corridor and locomotion on the unit. Her physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A focused care plan for resident to resident altercations included, but was not limited to the following interventions: allow resident to express their emotions/feelings about incident (10/23/21), consult with: pastoral care, social services, psych services (10/23/21), high risk walking rounds (10/23/21), and if resident moving furniture in common area, staff to move furniture back to original (10/25/21). A progress note, dated 3/3/22 at 2:30 p.m., indicated Resident 93 was wandering around in the common area when she came up behind and pinched Resident 108. An IDT note, dated 3/4/22 at 9:20 a.m., indicated during the resident to resident altercation, Resident 93 walked up behind another resident and pinched other resident 108 on back of right upper arm. Residents were immediately separated. RN 43 indicated, during an interview, on 3/14/22 at 10:22 a.m., Resident 93 liked to touch others, the staff try to intervene when necessary. During an interview, on 3/14/22 at 11:11 a.m., CNA 42 indicated the stop signs seem to come up missing. She indicated she thought Resident 108 was supposed to have a stop sign hanging across her doorway but was not certain. During an interview, on 3/15/22 at 9:15 a.m., CNA 42 indicated she tries to keep the residents separated to prevent altercations. She indicated Resident 108 became upset if anyone touched her. Resident 93 upset other residents. 3. On 3/7/22 at 3:56 p.m. Resident 45 was observed sitting in a chair and participating in an activity. On 03/15/22 at 09:35 a.m., Resident 45 was observed lying in her bed turned away from the door covered by a blanket. Resident 45's record was reviewed on 3/14/22 at 3:45 p.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired. Staff assessment of mood indicated the resident was short-tempered, easily annoyed two to six days. A focused care plan on resident to resident altercations included, but was not limited to, the following interventions: consult with pastoral care, social services, psych services, Psych nurse to assess for anxiety (11/8/21) , high risk wandering rounds (2/21/21), social service to look in on resident offer support to resident and family (2/21/21), visits from spiritual leaders and other individuals as identified by resident and family(2/21/21), and when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings(2/21/21). A progress note, dated 10/23/21 at 1:16 a.m., indicated a review of a video showed Resident 45 pushed the chair out from under Resident 93 when Resident 93 went to sit back down in the char that was in front of Resident 45's room door. An IDT note, dated 10/25/21 at 9:13 a.m., indicated Resident 45 also pushed chair into Resident 93. Interventions were separation of residents and placement on high risk walking rounds. A progress note, dated 11/7/21 at 2:30 p.m., indicated Resident 45 was in the main dining area where activities staff were serving ice cream. Resident 93 placed her hand on Resident 45's shoulder. Resident 45 then began yelling at Resident 93 and tried to knock her away by elbowing Resident 93 in the stomach. A progress note for risk management, dated 1/9/21 09:20 a.m., indicated during the resident to resident altercation on 11/7/21, Resident 45 elbowed Resident 93 in the stomach due to Resident 93 touching her. No interventions listed. RN 43 indicated, during an interview, on 3/14/22 at 10:22 a.m., Resident 93 liked to touch others, the staff try to intervene when necessary. During an interview, on 3/15/22 at 9:15 a.m., CNA 42 indicated she tries to keep the residents separated to prevent altercations. Resident 93 upset other people. During an interview, on 3/15/22 at 9:19 a.m., CNA 41 indicated they have activities for the people. She indicated they try to distract the residents as much as they can when the residents were upset. They make sure to distract Resident 93 and redirect her the best they can. 4. On 3/7/22 at 9:41 a.m., Resident 120 was observed sitting on the bed in another resident's room. On 3/10/22 at 9:02 a.m., Resident 120 was observed in another resident's room lying on the bed. On 3/11/22 at 9:30 a.m., Resident 120 was observed ambulating with a rolling walker independently wandering in and out of other resident's rooms. On 3/11/22 at 1:52 p.m., Resident 120 was observed ambulating independently with a rolling walker going in and out of other residents' rooms. Resident 120's record was reviewed on 3/11/22 at 9:48 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment on 8/23/21 indicated the resident was severely cognitively impaired. She demonstrated behavioral symptoms not directed toward others one to three days. An annual MDS assessment, dated 11/23/21, indicated the resident was severely cognitively impaired. Staff assessment of mood indicated resident was short-tempered, easily annoyed seven to eleven days. The resident was identified as having delusions. Physical and verbal behavioral symptoms directed toward others occurred one to three days. According to the MDS, there was not change in behavior or other symptoms since the last assessment (8/23/21). physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A focused care plan on resident to resident altercations included, but were not limited to, the following interventions: allow resident to express their emotions/feelings about incident (10/30/21), consult with: pastoral care, social services, psych services (10/30/21), high risk walking rounds (initiated 1/12/22), when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings (10/30/21). A progress note, dated 10/16/21 at 6:20 a.m., indicated the resident had been up walking through facility since 3 am. The resident ambulated without her walker many times pushing a stationary chair instead. She snarled and swore at staff when chair was replaced with walker. She was seen talking and swearing at an invisible companion. She was not easily redirected. One on one intervention seemed to increase her agitation. A progress note, dated 10/29/21 at 7:09 p.m., indicated resident was in an argumentative and agitated mood. The resident said there were men out there that were going to kill them. The nurse indicated she told resident that security had been notified and the men were no longer there. The resident did not accept the explanation. A progress note, dated 10/30/21 2:14 a.m., indicated resident walked the hall all night. Resident was aggressive toward staff and other residents. She ran her walker into staff and would have acted out on other residents if staff had not intervened with one on one conversation and an ice cream snack. A progress note, dated 10/30/21 at 9:20 a.m., indicated loud voices were heard in the dining room. Per the dining room staff resident pushed her walker into the back of Resident 93's legs. Staff indicated Resident 120 said Resident 93 was crawling on the floor and biting her. An IDT note, dated 11/1/21 at 09:14 a.m., indicated the IDT met to review the resident to resident altercation on 10/30/21. They determined the resident was having delusions as Resident 93 was not on the floor trying to bite Resident 120 when Resident 120 pushed her walker into Resident 93. The interventions for the altercation were the immediate separation of the Resident 120 from others. Resident 120 was placed on one on one supervision until calm and then placed on high risk walking rounds. [MEDICATION(S)] 0.25 mg daily was increased to twice a day after the nurse practitioner (NP) assessed the resident. A progress note, dated 1/4/22 at 9:35 a.m., indicated the resident was ambulating with her walker throughout the unit. She went into other residents' rooms and banged her walker into objects. Staff was able to redirect the resident though redirection was met with resistance. A progress note, dated 1/4/202 2:26 p.m., indicated the resident was lying on another resident's couch. The CNA redirected the resident by saying the people and the police (from the resident's delusion) could come with them. The resident ambulated out of the room and into the common area. The resident yelled at the staff to leave her alone because the police were coming. Staff were unable to redirect her. A progress note, dated 1/5/22 at 10:08 p.m., indicated the resident was wandering in and out of other residents' rooms. The resident was heard yelling at a sleeping resident to get out of the room. Resident 120 was about to strike the sleeping resident and had her hand up above the other resident's head when the staff intervened. Staff was unable to calm the resident with one on one support or a snack. Resident 120 ran her walker into items on the unit, flipped a table in the common area and took items off a shelf to throw at the staff members. The staff monitored the resident from a distance to ensure the resident's safety and to prevent the resident from going into other residents' rooms. Resident120 began to go into another resident's room. The other resident was asleep in a recliner. Resident 120 began to yell Get out of my room. Resident 120 was redirected out of the other resident's room. Psych NP was notified of the resident's behaviors and ordered a one time dose of [MEDICATION(S)] 15 mg to be administered right away. A progress note, dated 11/9/22 at 11:21 a.m., indicated the resident ambulated into another room with her walker and slammed the walker into the inside of the closet. The resident was redirected but cursed at the staff member saying the police will be coming. The resident lied down in her own bed, then 20 minutes later she ambulated into a different room. She attempted to hit the staff member with her walker when the staff member redirected her back to her own room. A progress note, dated 1/9/22 at 12:37 p.m., indicated the resident was agitated and ambulated in and out of other residents' rooms throughout shift. She was verbally and physically aggressive with staff when redirected. A progress note, dated 1/10/22 at 11:33 a.m., indicated the resident was incontinent of urine. A staff member persuaded resident to go back to room to get her pants changed. The resident was toileted and soiled clothing was removed. The resident became upset when staff attempted to assist with putting on of a new brief. The resident pulled out a handful of the staff's hair. The resident was reapproached and pulled staff's hair and struck the staff member three times with fist during the encounter. Staff member left the room, reapproached again and was able to put pants on the resident. The resident was verbally abusive and struck the staff member again. A progress note, dated 1/11/22 at 11:00 p.m., indicated the resident came out of her room yelling that everyone needs to stay away from her because she called the police. She threw items at the staff, attempted to tip over tables, and attempted to enter other residents' rooms. The staff stood in the doorways of other residents' rooms to prevent the resident from entering. Resident 120 hit the staff blocking the doorways and said the residents in the rooms had it coming because that was her room. Staff was unable to redirect or distract resident. Psych NP was notified and ordered [MEDICATION(S)] 2.5 mg intramuscularly immediately. [MEDICATION(S)] was given. The resident was not affected. She continued to require one on one for safety. A progress note, dated 1/12/22 at 12:28 a.m., indicated the resident continued to wander on the unit and attempted to go in other residents' rooms. She stopped yelling and was assisted to bed. She whispered to herself while her eyes were closed. A progress note, dated 1/12/22 at 11:54 a.m., indicated the resident ambulated through the shift going in and out of other residents' rooms. She lied in the other residents' beds and couches. A progress note, dated 1/12/22 at 2:07 pm., indicated Resident 120 went into Resident 107's room and rammed walker into Resident 107's shins causing a bruise to the left lower extremity. A spouse of a different resident witnessed the event and told Resident 120 to leave the room. Resident 120 left Resident 107's room. She walked into the common area and attempted to enter another resident's room. The QMA used the medication cart to block the entrance. RN 43 indicated, during an interview, on 3/14/22 at 10:22 a.m., high risk walking rounds signified they put eyes on every resident. She indicated they try to do this every 15 minutes and do the best they can. She indicated Resident 120 was much easier to redirect than she used to be prior to medication change. During an interview, on 3/14/22 at 11:07 a.m., RN 43 indicated Resident 107 should have a stop sign hanging across doorway. She indicated the stop signs often disappear and are probably in someone's room. She indicated she will find and hang a stop sign across the doorway right away. During an interview, on 3/14/22 at 11:11 a.m., CNA 42 indicated the stop signs seem to come up missing. She indicated she thought Resident 107 was supposed to have stop signs hanging across her doorway but was not certain. During an interview, on 3/15/22 at 9:15 a.m., CNA 42 indicated she tries to keep the residents separated to prevent altercations. Resident 120 became upset if people were in her way. Resident 107 did not like people in her room. During an interview, on 3/15/22 at 9:44 a.m., RN 43 indicated the staff try to keep the residents as occupied as they can. She indicated Resident 120 liked to lie in other residents' beds. During an interview, on 3/15/22 at 9:52 a.m., the Administrator indicated their IDT updated the care plans after resident to resident altercations. She indicated either she or the DON provided immediate interventions for the resident altercations depending on which of them completed the reportable. They have the staff do high risk walking rounds which means walk around unit every 10 to 15 minutes. They have activity programming during the day and some activity programming during the evening and weekends. A current policy, titled Abuse Prevention Program, provided upon entrance to the facility, indicated It is the policy of this community to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion . Physical abuse is defined as hitting, slapping, pinching, kicking, etc.Resident Assessment: As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, or mistreatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The community will take steps to prevent mistreatment while the investigation is underway. Resident who allegedly mistreat another resident will be removed from contact with other resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents . The immediate jeopardy that began on 2/9/2022 was removed on 3/17/22 when the facility reviewed and updated resident care plans, began educating staff on the interventions in place to prevent abuse, and developed intervention sheets, that included interventions related to resident-to-resident altercations and behaviors and updated as needed. The facility developed and implemented staffing strategies to ensure supervision and care of residents at risk of expressing behavioral symptoms. The noncompliance remained at a level of no actual harm with the potential for more than minimal harm as the monitoring and education remained ongoing. 3.1-27(a)

Based on observation, interview and record review, the facility failed to ensure staffing levels were adequate related to falls, abuse prevention, meal timing and call lights for 12 of 46 residents reviewed for staffing, (Residents 179, 125, 18, 93, 117, 65, 108, 14, 86, 91 and Resident B). The immediate jeopardy began on 12/3/21, when the facility failed to ensure staffing levels were adequate to allow supervision of residents to prevent frequent falls resulting in major injury of cognitively impaired residents and resident to resident abuse and altercations. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. Findings include: During a confidential interview, on 3/9/22, Employee 8 indicated the facility had been working short of staff, especially lately, it had been hard to get everything done and be able to spend time talking to any of the residents. During an interview, on 3/9/22 at 3:05 p.m., Resident 38 indicated sometimes it took the staff an hour to answer his call light, he knew it had been an hour because he had two clocks in his room. He had fallen five times and had a whistle to alert staff. During a confidential interview, on 3/11/22, Employee 2 indicated she didn't always have time to look for interventions due to not having enough staff. During an interview, on 3/14/22 at 12:20 p.m., the Scheduler for the Nursing Department indicated ideally she would schedule one CNA per eight bed cluster of residents, had recently tried having two CNAs per unit with an additional float between the two units, this would have been about 9.5 residents per CNA. Tried to do this will all Healthcare units. Tried to schedule one nurse and one QMA per unit, there had been a nurse that called off today so there was only one nurse and one QMA to work that unit. The facility had six different agencies they used to supplement staffing. She did not consider acuity of residents with scheduling. During a confidential interview, on 3/15/22, Employee 10 indicated they had tried to give residents showers but the nurse would have had to watch the floor for them while they were in a resident's room. Cross reference F689. During a confidential interview, on 3/11/22, Employee 4 indicated they didn't have enough staff a lot of the time and the residents aren't able to the time and care they deserved. During a confidential interview, on 3/11/22, Employee 6 indicated they didn't have enough help to what needed to be done. They didn't have enough time to do anything, sometimes they only had one CNA for a whole unit. They had gotten so stressed they cried and had been yelled at for not being able to get everything done. During an interview, on 3/11/22 at 11:18 a.m., QMA 44 indicated they sometimes had enough help to do what needed to be done. During an interview, on 3/14/22 at 12:12 p.m., the DON indicated they had not been able to do 1:1 with residents due to not having the staffing available. Cross reference F600. Cross reference F744 . During an observation of meal service on Cedar Ridge, on 3/9/22 from 9:10 a.m. to 10:04 a.m., residents were sitting in the small dining room across from the nurses' station, a dietary staff member was picking up trays from resident rooms that were finished eating, a covered breakfast tray was sitting on the ledge outside of the Nurses' Station. The meal tray also included a glass of apple juice and a covered breakfast tray sitting on a table in the small dining room across from the Nurses' Station. This tray included a glass of milk and a glass of orange juice. During an interview, on 3/9/22 at 9:19 a.m., CNA 21 had picked up the tray from the ledge and started to place in the open serving rack. She indicated it was Resident 14's breakfast, she was trying figure out what to do next, she needed to get a resident up for breakfast, Resident 14 needed to be assisted with her meal. Immediately after the interview she went into another resident's room to check on her. 3/9/22 at 9:22 a.m., CNA 21 entered Resident 86's room with a mechanical lift, then exited the room. On 3/9/22 at 9:24 a.m., CNA 21 entered room [ROOM NUMBER], a resident exited from the bathroom, CNA 21 assisted her to sit on the side of her bed and prepared her meal tray that was sitting on the over-bed table. She brought out the other resident's meal tray. On 3/9/22 at 9:27 a.m., CNA 21 pulled Resident 14's meal tray out from the open serving rack and sat it on the ledge outside of the Nurses' Station. On 3/9/22 at 9:28 a.m., CNA 21 entered Resident 86's room and closed the door. On 3/9/22 at 9:34 a.m., CNA 21 exited Resident 86's room and let the dietary staff member know to not pick up Resident 14 and Resident 86's meal trays yet, then re-enter the room. On 3/9/22 at 9:42 a.m., CNA 21 exited Resident 86's room with the mechanical lift and re-entered the room. On 3/9/22 at 9:46 a.m., CNA 21 assisted Resident 86 to the dining room, removed the cover, took the plate to the kitchenette and placed it in the microwave, the milk and orange juice remained on the resident's tray. On 3/9/22 at 9:49 a.m., CNA 21 brought Resident 86 a cup of coffee then retrieved the plate from the microwave and took to the resident, cut up the pancakes and poured syrup over them. On 3/9/22 at 9:51 a.m., CNA 21 picked Resident 14's meal tray off the ledge, warmed the food in the microwave, the apple juice remained on the tray, then took the tray to the resident's room. Resident 14's clinical record was reviewed on 3/11/22 at 11:56 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Med Pass (nutritional supplement), 90 ml (milliliters) three times a day for weight loss, the order date was 7/19/21. b. [MEDICATION(S)] (antidepressant), 7.5 mg (milligram), one tablet at bedtime for weight loss, the order date was 7/21/21. c. Regular diet, pureed texture, liquids at pudding consistency. A 3/9/22 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment and required extensive assistance with eating. A current care plan, with a revised date of 1/19/22, indicated she was at risk for potential alteration of her nutrition and/or weight status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She received [MEDICATION(S)] to stimulate her appetitive, her meal intakes were inadequate to meet her nutritional needs and she required supplementation. A review of her weights indicated, on 10/7/21 she weighed 84.7 lbs (pounds) and on 3/1/22 she weighed 78.2 lbs, a 7.67% weight loss. Resident 86's clinical record was reviewed on 3/16/22 at 3:13 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/5/22 quarterly MDS assessment indicated she had severe cognitive impairment and required extensive assistance with eating. A current care plan, with a revised date of 2/18/22, indicated she had the potential for alteration of her nutritional and weight status related to dementia, dysphagia, anxiety and depression. Interventions included, but were not limited to, she needed assistance with eating and drinking, date initiated was 11/6/21. A review of her weights indicated, on 11/2/21 she weighed 159.8 lbs and on 3/1/22 she weighed 153.3 lbs, a 4.07% weight loss. The Facility Assessment, dated 2/21/22 and scheduled to be reviewed with QAA/QAPI on 3/9/22, indicated their staffing plan indicated their general approach was to maintain a PPD (Per Patient Day) of 4.2 based on a budgeted census of 173, staff adjusted accordingly as acuity and census fluctuated, up with increased census/acuity or down with decline in census/acuity. The staff training/education and competencies section indicated to see staff development list. The section for policies and procedures for provision of care indicated the Medical Director reviews with the DON, Pharmacy, QAPI, QAA, and Administration all policies and procedures reviewed and instituted on a quarterly basis. The section identified to describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments did not include a response. A staffing formula included in the Facility Assessment indicated the number of CNA's X 8 hours X 7 days would equal 2,072 hours. A review of the facility's working schedules indicated the following: On 3/6/22, there had been 228 CNA hours worked. On 3/7/22, there had been 252.5 CNA hours worked. On 3/8/22, there had been 212.5 CNA hours worked. On 3/9/22, there had been 277 CNA hours worked. On 3/10/22, there had been 293 CNA hours worked. On 3/11/22, there had been 208.5 CNA hours worked. On 3/12/22, there had been 212.5 CNA hours worked. The total of the above hours was 1,684 hours. The difference between the number indicated on the Facility Assessment and the number from the working schedule indicated 48.5 less hours had been worked. The immediate jeopardy that began on 10/23/21 was removed on 3/17/22 when the facility began education and interventions for staffing, but the noncompliance remained at the lower scope and severity level of actual harm that is not immediate jeopardy because the facility had not completed education with all staff and had not completed monitoring to ensure staff was following the plan. This Federal Tag relates to Complaint IN 468. 3.1-17(a)

Based on observation, interview, and record review the facility failed to provide adequate supervision, failed to implement behavior interventions, and failed to provide adequate dementia care to prevent resident to resident altercations for 4 of 7 cognitively impaired residents reviewed for abuse (Resident 45, Resident 93, Resident 117, and Resident 120) and failed to identify and implement individualized, non-pharmacological interventions for 2 of 10 residents reviewed for dementia care (Resident 1 and Resident 79). The immediate jeopardy began on 10/23/21, when Resident 45 pushed a chair out from under Resident 93. The Administrator and DON were notified of the immediate jeopardy on 3/15/22 at 11:04 a.m. The immediate jeopardy was removed on 3/17/22, but noncompliance remained at the lower scope and severity level of actual harm that is not immediate jeopardy. Findings include: 1. Resident 1's clinical record was reviewed on 3/16/22 at 9:22 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (treat anxiety) 10 mg (milligram) three times daily, trazadone (treat [CONDITION(S)]) 50 mg daily, [MEDICATION(S)] (treat depression) delayed release sprinkle 60 mg daily and [MEDICATION(S)] (treat pain) 300 mg three times daily. She had a previous order from 1/28/22 to 3/12/22 for [MEDICATION(S)] 10 mg at bedtime and 5 mg two times daily. A quarterly MDS (Minimum Data Set), dated 2/26/22, indicated she was severely cognitively impaired. She had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) daily. She had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred daily. She rejected evaluation or care daily and she wandered daily. Her care plans included, but were not limited to the following: She had the potential to be verbally aggressive related to dementia, and poor impulse control. She may yell at staff or other residents, initiated on 5/24/21. Her goal was that she would demonstrate effective coping skills through the review date. Her interventions, initiated on 5/24/21, included administer medications as ordered, monitor/document for side effects and effectiveness, give the resident as many choices as possible about care and activities. She had the potential to be physically aggressive (hitting, slapping, grabbing staff) related to dementia, initiated on 1/21/22. Her goal was that she would not harm self or others through the review date. Her interventions, initiated on 1/21/22 included, but were not limited to, administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document, assess and address for contributing sensory deficits, assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc . 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, give the resident as many choices as possible about care and activities, monitor/document/report PRN (as needed) any sign and symptom of resident posing danger to self and others, psychiatric/psychogeriatric consult as indicated. She used anti-anxiety medication [MEDICATION(S)] related to anxiety disorder, initiated on 6/25/21. Her goal was that she would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Her interventions, initiated on 6/25/21, included, but were not limited to, administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift, educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of [MEDICATION(S)], monitor the resident every shift for safety. She took anti-anxiety medication which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. unexpected side effects: [CONDITION(S)], hostility, rage, aggressive or impulsive behavior, hallucinations. Monitor/record occurrence of targeted behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc .) and document per facility protocol. She was at risk for decline in psychosocial wellbeing related to resident to resident altercations. On 6/5/21, she was hit/scratched by a female peer during a verbal argument. This was an unwitnessed altercation reported by another resident. On 2/23/22, she wandered into other resident's room, staff heard yelling, entered room and found both residents hitting each other. On 3/10/22, she hit another resident with lint roller. Her goal was that she would not have indications of psychosocial well-being problem by/through review date. Her interventions included, but were not limited to, allow resident to express their emotions/feelings about incident, initiated on 6/5/21, encourage her to visit in common area, initiated on 6/7/21, high risk walking rounds, initiated on 6/5/21, psychiatric NP (Nurse Practitioner) to assess for behaviors of wandering, agitation and aggression, when conflict arises initiated on 3/11/22, remove residents to a calm safe environment and allow to vent/share feelings, initiated on 6/5/21. On 2/18/22 at 3:07 p.m., IDT met to review behaviors from 1/24/22 through 2/13/22 of agitation, combative with care, intrusive wandering, took others things, took toilet apart and flooded the bathroom. Immediate interventions were to redirect her to her own room or common area, switch caregivers and re-approach at later time. The psychiatric NP referral with new order to change times of medication administration. The care plan was reviewed and was current. On 2/23/22 at 3:43 p.m., staff heard yelling coming from a resident's room, staff entered room and found she had wandered into another residents room and both residents were hitting each other. Residents were immediately separated and placed on high risk walking rounds. Stop sign placed across other resident's door to deter her from wandering in. The care plan was updated. On 2/24/22 at 9:05 a.m., IDT met to review resident to resident altercation from 2/23/22 in which resident had entered another resident's room, staff heard yelling and upon entry, found residents hitting each other. Residents were immediately separated and Resident 1 was removed from the room. The other resident had abrasions to left forearm . A stop sign was placed across other resident's doorway to deter her from wandering into other's rooms. On 3/1/22 at 3:10 p.m., IDT met to review behaviors from 2/14/22 - 2/20/22 of aggressive with care, intrusive wandering and she took others things. Physical aggression during when redirection attempted. The immediate interventions were to attempt to redirect to common area or own room, approach at later time to retrieve other's belongings, offer snack/drink which are occasionally successful. On 3/7/22 on 4:37 p.m., IDT met to review behaviors from 2/21/22 - 2/27/22 of hitting, punching, spitting, kicking staff, cursing at staff, disrobing in the common area, attempted to urinate on the floor in another resident's room, resident to resident altercation in which resident was in another's room and hit the other resident. The immediate interventions were to separate her from other resident, redirected her to a quiet area and reproached for care. The psychiatric NP notified and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/10/22 at 10:10 p.m., there was yelling that came from a resident's room. Resident 1 was observed hitting another resident in the leg with a lint roller. She was asked to stop hitting the other resident and she replied I hate that b----. She also tried to take the other resident's rolling walker and became very aggressive when the writer tried to stop her from taking it. The writer let her take the walker in order to allow space between the two resident's. The walker was found in the common area. Resident 1 was redirected to her room without incident. On 3/12/22 at 2:49 p.m., a psychiatric provider note, indicated an acute visit per staff request for an incident that took place on 3/10/22. She had hit another resident with a lint roller. The staff reported she had increased restlessness and agitation. The plan was to increase [MEDICATION(S)] to 10 mg three times daily which would help treat anxiety by easing symptoms of restlessness, irritability, and difficult concentrating. Discontinue [MEDICATION(S)] 5 mg twice daily and 10 mg at bedtime and start [MEDICATION(S)] 10 mg three times daily. Staff was to monitor for changes in moods, behaviors, sleep, and appetite. During an interview, on 3/16/22 at 1:43 p.m., the SSD (Social Service Director) indicated she was not sure why the decision was made to increase her [MEDICATION(S)], it was the psychiatric NP. They have GDR (Gradual Dose Reduction) meetings monthly and review [CONDITION(S)] and increased or new behaviors and had not reviewed her yet. The NP came in on a Saturday and saw the resident. The NP would rather increase medication than start a new one, to prevent poly pharmacy. It is ultimately up to the prescriber. 2. On 3/8/22 at 2:16 p.m., Resident 79 was seated in her wheelchair at a table in the unit common area. Activity Aide 31 was seated next to her. On 3/8/22 at 2:30 p.m., she was saying she wanted to get up; Activity Aide 31 was encouraging her to sit still. On 3/9/22 at 10:43 a.m., she was up walking away from the activity group in the common area. LPN 51 went to assist her and asked her to sit in a chair near the fireplace sitting area. On 3/9/22 at 1:10 p.m., she was seated at a table in the common area with a baby doll during a small group activity. On 3/10/22 at 8:51 a.m., she was seated in her wheelchair in the common area with her head in her hands. On 3/10/22 at 9:20 a.m., she remained in her wheelchair near an activity group, holding her head up with her fingers in her eyes. On 3/10/22 at 3:06 p.m., the resident left her wheelchair in the common area and began walking. CNA 53 assisted her to a chair in the lounge area near the fireplace. The CNA walked away and then the resident got up and walked to a chair across the lounge area and sat down with two other residents. On 3/11/22 at 8:35 a.m., she was up walking around the unit with CAN 39, looking for her spouse. On 3/11/22 at 9:32 a.m., she was up walking toward the medication carts. LPN 37 assisted her back to her wheelchair near a small group of residents and walked away. On 3/15/22 at 9:36 a.m., she was seated in a recliner in the common area, asleep, with a pillow on her lap. Resident 79's clinical record was reviewed on 3/8/22 at 9:50 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/17/21, annual, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. She experienced hallucinations and delusions, and had behaviors not directed at herself or other for 1-3 days of the assessment period. They did not interfere with her daily functioning, nor those of other people. A 1/31/22, 5 day, MDS indicated she was severely cognitively impaired. She had no hallucinations or delusions and wandered daily. She had a current, 2/10/22, care plan problem of exhibited behavior of confusion/distress as evidenced by calling her family members and them asking about her husband, wanting to go home, stating her husband has given her money, being unable to find her husband, and wanting to go home. Interventions included call representative, reminisce, remind her that her husband's ashes were in her room. The care plan did not include any additional individualized, targeted interventions to support the resident's confusion or distress. She had a current, 1/26/21 care plan problem of verbal and/or physical aggression towards staff. Interventions included, but were not limited to, medications, assess needs, intervene as needed, guide away from situation, and engage in conversation. She had a current, 1/19/22, care plan problem of elopement risk. Interventions included, but were not limited to, distract with activities the resident prefers such as [left blank], high-risk walking rounds, offer a snack, call her spouse, and redirection. The care plan did not include any additional individualized, targeted interventions to support the resident's wandering and elopement risks. She had a current, 1/21/22, care plan problem of anti-psychotic medication use. Interventions included, but were not limited to, medications, monitor for adverse reactions, and record delusions. The care plan did not define her delusional thoughts, nor did it include any additional individualized, targeted interventions to support her delusional thoughts or hallucinations. She had a current, 6/29/21, care plan for leisure/activity interests. She enjoyed being around animals such as pets, it was not very important to her to do things with groups of people, her favorite activities included TV and to go outside for fresh air, she may enjoy spending time in her room and would be offered 1:1 visits from staff. Review of progress notes indicated the following: On 1/1/22, she was looking for her babies and her husband, and had been up at least 15 times. A snack calmed her for a few minutes. She was opening windows in her room, then saying she didn't open them. She attempted to get her leg over a half-door on the unit, attempting to open a window. Attempts were made to redirect her with conversation but were unsuccessful. She continued on increased [MEDICATION(S)]. She came out of her room repeatedly with no pants on at 11:05 p.m. On 1/2/22, she was looking for her husband and the little boy that was there earlier. She continued to search for a way out of the facility. She calmed after 1:1 and support of staff. On 1/3/22, the Interdisciplinary Team (IDT) met to review behaviors during the period of 12/13-12/26/21 of exit seeking (attempting to open windows, banging on doors demanding to be let out, asking to go home), delusions (looking for children she thinks were in her room, husband waiting for her at home), slamming doors, increased confusion and verbal aggression. Immediate interventions were to redirect to own room, redirect to an activity, offer snacks/drinks, 1:1 conversation/support which is usually successful for short periods. The Psychiatric Nurse Practitioner (NP) assessed her, with a new order for increased [MEDICATION(S)]. Her care plan was reviewed and found to be current. On 1/5/22, a Psychiatric NP note indicated the resident had been experiencing anxiety, wandering, and exit-seeking since January 2021. A 1/5/22 Social Services note indicated her family took the urn containing her spouse's ashes home. On 1/5/22, she had been restless and delusional, and had taken items out of her room and then said she had no idea how they got out here and someone had stolen them. On 1/7/22, she was placed on the facility bowel movement protocol, as she had not had a BM in 72 hours. On 1/10/22, the IDT met to review her behaviors for the week of 12/27 - 1/2/22. She continued with exit-seeking, delusions there were children around, her husband was waiting for her, and tearfulness. Immediate interventions were 1:1 support, snack, and redirection to her room. A 1/11/22 Psychiatric NP note indicated she was seen for paranoid thoughts and starting to speak in word salad. A new order for [MEDICATION(S)] 5 mg at bedtime for anxiety. On 1/11/22, she was looking for her keys, stating her kids were out in the freezing cold and no one cared. 1:1 support was not successful and she began throwing items off of the medication cart. An order was received for a one-time dose of [MEDICATION(S)] 15 mg and the resident accepted the medication on the second attempt of offering it. On 1/13/22, she attempted to climb the half-door and open the windows. She was looking for her husband and her babies. She continued to look for her keys and packing up her personal items. On 1/13/22, the resident was transferred to a different room and nursing unit, when the secured unit was moved within the facility. On 1/16/22, she continued to look for her husband, wandering and exit-seeking. On 1/19/22, she was looking for her grandmother. On 1/20/22, she was seen by the Psychiatric NP per staff request for the altercation with the other resident, throwing belongings out the window, and continued delusions. A new order was received for [MEDICATION(S)] 12.5 mg daily and she was to continue on [MEDICATION(S)] 100 mg daily, [MEDICATION(S)] 1 mg twice daily, and [MEDICATION(S)] 5 mg at bedtime. On 1/21/22, she was placed on the facility bowel movement protocol, as she had not had a BM in 72 hours. On 1/22/22, she continued with packing her belongings and exit-seeking. Redirection continued at times. On 1/24/22, she was placed on the facility bowel movement protocol, as she had not had a BM in 72 hours. On 1/24/22, she tripped on another resident's wheelchair and sustained a hip fracture. On 1/27/22, she returned to the facility at 3:40 p.m., following surgical repair of her hip fracture. She fell twice after her return, with the second fall requiring a transfer to the emergency department. On 1/28/22, she was placed on the facility bowel movement protocol, as she had not had a BM in 72 hours. On 1/28/22, she fell , requiring a transfer to the emergency department. On 1/28/22, a Nurse Practitioner note indicated she continued to exit-seek. On 1/31/22, she was yelling at staff to find her car and her husband. Review of January CNA behavior monitoring indicated her interventions were remove from situation, calm environment, meaningful activity, reapproach, 1:1, food or drink, toilet, and provide comfort such as massage or repositioning. There were no individualized interventions included. A 1/31/22 NP note indicated she had several falls over the weekend. On 2/18/22, the IDT met to review behaviors from 1/24 - 2/13/22 of yelling out, agitation, exit seeking, and refusing care. Immediate interventions were to offer reassurance, redirect to her room and allow time and space for her to calm, which was successful. Her care plan was reviewed and found to be current. On 2/19/22, she had been agitated and yelling out, going in and out of other resident rooms, taking other resident's belongings, yelling, and cursing at staff, stating that she was going to her mom's and continued to exit-seek. Staff was unable to redirect, she refused to sit in her wheelchair and insisted on wandering about the unit. On 3/7/22, she became combative with staff when they attempted to direct her to her room, as she was in the hallway undressed. She calmed when they entered her room. On 3/8/22, she was placed on the facility bowel movement protocol, as she had not had a BM in 72 hours. On 3/11/22, she was found to have a urinary tract infection. During an interview, on 3/11/22 at 9:07 a.m., RN 37 indicated agency staff obtained information about the residents from report and reviewing the clinical record at the start of the shift. During an interview, on 3/11/22 at 10:22 a.m., CNA 39 indicated behaviors were documented in the clinical record with some interventions listed for each resident, but she wasn't sure what Resident 79's specific interventions were. She was very difficult to redirect and calm. During an interview, on 3/11/22 at 1:50 p.m., the Social Services Director (SSD) indicated the resident's spouse had recently passed away and she didn't recall that. Interventions for her were reassurance, 1:1, and try to get her involved in activities and keep her with the group of friends in the common area. She had been started on [MEDICATION(S)] for agitation and aggression and also for delusional thoughts her husband was still here or at the bar drinking, and she had seen some kids running around. Care plans were reviewed with the MDS schedule. During an interview, on 3/14/22 at 9:59 a.m., CNA 52 indicated Resident 79 would become frustrated from wanting to walk. Staff encouraged her to remain seated and to stay busy with activities. During an interview, on 3/15/22 at 10:19 a.m., the SSD indicated medication initiation and adjustments would be up to the Psychiatric NP. The facility sent her an acute list weekly for new or worsening behaviors and had her assess the residents. The resident had been on anxiety medication and an anti-depressant, but they were ineffective, and her behavior was out of control. She was seeing kids running around and thought her husband was at the bar to the point she would grab her purse, wanting to go find him. 3. On 3/7/22 at 11:21 a.m., Resident 117 was observed aimlessly ambulating throughout the unit wearing nonskid socks. 03/8/22 at 8:20 a.m., the resident was observed wandering in and out of other residents' rooms wearing nonskid socks. On 3/8/22 at 2:03 p.m., the resident was observed ambulating independently in the common area, she stopped and stroked another resident's hair. No stuffed animal or doll was in her hands or around the resident. On 3/10/22 at 8:52 a.m., the resident was observed ambulating independently into Resident 93's room. No stuffed animal or doll was in her hands or around the resident. On 3/10/22 at 12:25 p.m., the resident was observed ambulating independently in the hall. No stuffed animal or doll was in her hands or around the resident. On 3/11/22 at 1:38 p.m., the resident was observed ambulating independently in the hall with a soft helmet and nonskid socks on. No stuffed animal or doll was in her hands or around the resident. On 3/14/22 at 10:15 a.m., the resident was observed ambulating independently in hall with a soft helmet and nonskid socks on. No stuffed animal or doll was in her hands or around the resident. On 3/15/22 at 9:00 a.m., the resident was observed ambulating into another resident's room. No facility staff were visible. No stuffed animal or doll was in her hands or around the resident. Resident 117's clinical record was reviewed, on 3/10/22 at 3:01 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired. She never or rarely understood. Staff assessment of the resident's mood indicated, she was short-tempered or easily annoyed two to six days during the assessment period. Her verbal behavioral symptoms directed toward others occurred one to three days during the assessment period. She required extensive assistance of one staff member for walking in her room, walking in the corridor, and locomotion on the unit. No mobility devices were listed. Her medications included, but were not limited to, [MEDICATION(S)] (antidepressant) 5 mg daily and Tylenol (for pain) 650 mg three times a day. She had a focused care plan initiated 2/23/22 for resident to resident altercations which indicated, but was not limited to, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings (2/23/22), allow resident to express their emotions/feelings about incident (2/23/22), consult with: pastoral care, social services, psych services (2/23/22), encourage participation from resident who depends on others to make own decisions (2/23/22), high risk walking rounds (2/23/22), increase communication between resident/family/caregivers about care and living environment(2/23/22): explain all procedures and treatments, medications, results of labs/tests, condition, all changes (2/23/22), initiate referrals as needed or increase social relationships (2/23/22), monitor/document resident's usual response to problems: Internal - how individual makes own changes, external - expects others to control problems or leaves to fate, or luck (2/23/22). She had a care plan for risk for falls related to Alzheimer's initiated on 2/8/21. Interventions included, but were not limited to, anticipate and meet the resident's needs (2/8/22), high risk walking rounds (2/8/22), the resident needs activities that minimize the potential for falls while providing diversion and distraction (2/8/22), and offer doll or stuffed animal to hold while walking (2/10/22). She had a care plan for impaired cognitive function related to dementia initiated on 2/8/21. Interventions included, but were not limited to, cue, supervise, and reorient as needed (2/8/21) and reminisce with the resident using photos of family and friends (2/8/21). A progress note, dated 2/9/22 at 7:40 p.m., indicated the resident ambulated in the hallway. She grabbed the arm of Resident 65. Resident 65 jerked her arm away and caused the resident to lose balance and sit on the floor. On the way down, she encountered Resident 65's sweater zipper which caused a laceration. An Interdisciplinary Team (IDT) progress note, on 2/10/22 at 9:10 a.m., indicated the resident grazed her left eyebrow on Resident 65's sweater. A progress note, dated 2/11/22 at 2:07 a.m., indicated the resident's left hand was swollen over the knuckle. A progress note, dated 2/12/22 at 2:44 p.m., indicated the left hand was swollen and bruised. The nurse practitioner (NP) ordered X-rays of the left hand. The X-ray on 2/13/22 of the left hand with two views indicated an acute oblique fracture at base of the 2nd proximal phalanx (the index finger base where it connects to the left hand). A progress note, on 2/16/21 at 1:42 p.m., indicated the resident wandered in and out of other residents' rooms most of the evening. She sat or stood and randomly screamed. A progress note, on 2/19/22 at 10:57 p.m., indicated the resident wandered in and out of other residents' rooms and placed her hands on other residents causing the other residents to become upset. Staff attempted to intervene and separate the residents. A progress note, on 2/21/22 at 3:32 a.m., indicated the resident wandered in and out of nearly every room. She grabbed other people and angered them. A progress note, on 3/7/22 at 5:58 a.m., indicated the resident wandered in and out of most rooms while she picked up items along the way. She also tried to reach into the staff member's pocket several times. During a confidential interview, (CNA 45 on 3/11/22 at 9:12 a.m.) a staff member indicated she did not have enough help to do what she needed to do. She indicated there were times when she worked when there was only one CNA there for the unit. She indicated she was supposed to keep an eye on the resident. During an interview, with CNA 41 on 3/14/22 at 10:43 a.m., she indicated she regularly worked on the unit. She indicated for interventions it was really knowing everyone and how they reacted to stuff. She indicated someone usually passed on any new interventions for the residents. During an interview, on 3/15/22 at 9:19 a.m., CNA 41 indicated they had activities for the people. She indicated they tried to distract them as much as they can if the residents were getting upset. She indicated the resident liked to go into other residents' rooms, and the staff tried to direct her out. 4. On 3/7/22 at 11:21 a.m., Resident 93 was observed ambulating independently about the unit. On 3/8/22 at 8:25 a.m., the resident was observed sitting at a table in the activity/dining area with her head resting on the table. She was wearing a soft helmet. On 3/10/22 at 8:50 a.m., the resident was observed standing, bent over a table in the activity/dining area wearing a soft helmet and lace up shoes. On 3/14/22 at 10:16 a.m., the resident was observed ambulating independently in her room and wearing a soft helmet. Resident 93's clinical record was reviewed, on 3/10/22 at 11:16 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired. She was never or rarely understood. The resident never or rarely understood others. Continuous presence of disorganized thinking and inattention that did not fluctuate was indicated. The resident required supervision with assistance of one staff member for walking in her room, the corridor and locomotion on the unit. Her physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A focused care plan for resident to resident altercations included, but was not limited to the following interventions: allow resident to express their emotions/feelings about incident (10/23/21), consult with: pastoral care, social services, psych services (10/23/21), high risk walking rounds (10/23/21) and if resident moving furniture in common area, staff to move furniture back to original place (10/25/21). A care plan for elopement risk was initiated on 2/21/21 and revised on 12/2/21. Interventions included, but were not limited to, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident prefers listening to music in common area or her room (2/21/21). Allow resident to walk in secured courtyard with supervision when weather permits (2/21/21). A current care plan for impaired cognitive function/dementia or impaired thought processes related to dementia indicated resident may wander around unit or into others' rooms. Interventions included, but were not limited to cue, reorient, and supervise as needed (2/10/21), high risk walking rounds (2/25/21), and redirect from others' rooms with music, coloring, snack/beverage (2/25/21). A progress note, on 12/18/21 at 4:30 a.m., indicated the reside [TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent development of pressure ulcers for 4 of 6 residents reviewed for pressure ulcers (Resident 12, 125, 57 and 63). This deficient practice resulted in Resident 12 sustained a stage 4 pressure ulcer to her right elbow and a stage 2 to her coccyx. Resident 125 sustained an SDTI (Suspected Deep Tissue Injury) pressure ulcer to her right heel and a stage 2 pressure ulcer to her coccyx. Resident 57 sustained an unstageable pressure ulcer to his left heel. Resident 63 sustained an unstageable pressure ulcer to her coccyx. Findings include: 1. On 3/9/22 at 12:55 p.m., Resident 12's dressing change was observed to her right elbow, with RN 70, she indicated the wound edges were rolled, 25% of the wound had yellow slough in it and the wound was an approximate size of a dime. The wound bed was clean and pink. The resident did not complain of pain. RN 70 indicated there was maceration/shearing to both buttocks and on coccyx and it did not have a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/10/22 at 3:00 p.m., she was lying in bed with the gingerbread pillow under the blanket elevating her right arm. On 3/11/22 at 2:01 p.m., an observation of the resident's wheelchair with CNA 55, her wheelchair had a standard pillow with a pillowcase cover and dycem on the seat of the chair. CNA 55 indicated the dycem was there so the pillow did not slip. Resident 12's clinical record was reviewed on 3/8/22 at 12:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her orders included, but were not limited to, [MEDICATION(S)] solution (treat depression) 60 mg (milligram) by daily, [MEDICATION(S)] (treat [CONDITION(S)] pain) 300 mg daily, [MEDICATION(S)] (treat breast cancer) 2.5 mg daily, [MEDICATION(S)] (appetite stimulant) 7.5 mg daily, vitamin D3 (supplement) 25 mcg (microgram) daily, [MEDICATION(S)] (treat anxiety) twice 10 mg daily, weekly vital signs and skin assessment to be completed first shower day of the week. (Complete weekly vital signs/skin assessment in assessments) every day shift on Mondays, fortified foods three times daily for weight loss and supplement, medpass (supplement) 90 ml (milliliters) three times daily for malnutrition risk, apply skintergrity impregnated gauze after cleansing wound daily for pressure ulcer to right elbow and apply [MEDICATION(S)] to bilateral buttocks every shift for MASD (Moisture-Associated Skin Damage) until resolved. A quarterly MDS (Minimum Data Set), dated 12/6/2, indicated she was severely cognitively impaired. She required extensive assistance of two staff members for bed mobility. She required total assistance of one staff member for transfers and toilet use. She required extensive assistance of one staff member for dressing and personal hygiene. She had an impairment to her bilateral lower extremities. She used a wheelchair. She was always incontinent of bowel and bladder. She was at risk for pressure ulcer development. She did not have a pressure reducing device in place and was not on a turning/repositioning program. Her care plans included, but were not limited to, the following: a. She had a potential for impaired skin integrity related to impaired mobility, medication use, pain and incontinence, She wore a brace. Her goal was that she would be free from skin impairment through the review date. Her interventions included, but were not limited to, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . b. She had a stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.) pressure ulcer to her right elbow 2/2/22, now presenting as a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.). Her goal was her pressure ulcer would show signs of healing and remain free from infection by/through the review date. Her interventions included, but were not limited to, educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . c. She had [CONDITION(S)] of the right elbow related to infection to stage 4 decubitus ulcer of elbow, revised on 2/8/22. Her goal was that she would have no complications resulting from the [CONDITION(S)] through the review date. Interventions included, give antibiotics for infection and mild analgesics to relieve discomfort as prescribed by physician, monitor/document side effects and effectiveness, monitor /document healing of the [CONDITION(S)] and any new or worsening symptoms should be reported to MD (Medical Doctor). d. She had a stage 2 pressure ulcer to her coccyx. Her goal was her pressure ulcer would show signs of healing and remain free from infection by/through review date. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Wound-weekly observation tool for her right elbow indicated the following: a. On 1/27/22 at 12:54 p.m., the unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) pressure ulcer was facility acquired, on 1/17/22, 75% of the tissue was slough (yellow, tan, white, stringy). It measured 1.5 cm x 1.5 cm x 0.3 cm. Infection was suspected and slight redness was noted to the wound edges. She continued on an antibiotic and no changes to the treatment. Her January orders indicated she started [MEDICATION(S)] (antibiotic) 500 mg three times daily for right elbow wound infection for one week and Dakins (treat skin and tissue infections) (full strength) Solution 0.5 % cleanse wound and cover with [MEDICATION(S)] dressing on right elbow twice daily on 1/17/22. b. On 2/2/22 at 8:11 p.m., the unstageable was documented as a stage 4 pressure ulcer. The wound was moist and tendon was visible. Measurements remained the same. The pressure area was red and swollen, the wound edges were rolled. New treatment orders were received to cleanse and apply [MEDICATION(S)] impregnated gauze and cover with foam dressing daily. She continued on an antibiotic. c. On 2/16/22 at 1:19 p.m., the stage 4 pressure area was improving. Wound was moist with tendon visible and measured 0.8 cm x 0.5 cm x 0.2 cm. No changes in treatment and she continued on an antibiotic. d. On 2/23/22 at 3:44 p.m., the pressure ulcer was worsening, epithelial tissue was present (pink), moist. tendon visible, 1.0 cm x 1.0 cm x 0.2 cm. There were no changes in treatment. e. On 3/2/22 at 12:31 p.m., the pressure ulcer was unchanged and the treatment remained the same. f. On 3/9/22 at 6:46 p.m., the pressure ulcer was unchanged and the treatment remained the same. Wound-weekly observation tool for her coccyx indicated the following: a. On 2/16/22 at 1:19 p.m., the stage 2 pressure ulcer to her coccyx was facility acquired, on 2/10/22, it measured 0.2 cm (centimeters) x 0.2 cm x 0.2 cm. The current treatment was to apply [MEDICATION(S)] every shift. Continue current plan of care and dietary was updated. b. On 2/23/22 at 3:44 p.m., there were not changes to the pressure ulcer or treatment. c. On 3/2/22 at 12:31 p.m., there were no changes to the pressure ulcer or treatment. d. On 3/9/22 at 6:46 p.m., there were no changes to the pressure ulcer or treatment. e. On 3/16/22 at 5:10 a.m. there were no changes to the pressure ulcer or treatment. During an interview on 3/10/22 at 11:52 a.m., the DON indicated Resident 12 had COVID then developed the pressure ulcer to her elbow, she had been noted to tuck her elbow in her wheelchair and in bed, they used the gingerbread pillow to try to keep her elbow elevated. She did not have the low loss air mattress when the area developed on her elbow. She currently had a pressure reducing mattress. She had been in bed more, she was incontinent and prone to skin breakdown, she had seen a trend with covid and staying in bed more. Resident 12 was positive for COVID on 11/30/21. During an interview with QMA 71, on 3/10/22 at 3:02 p.m., she indicated Resident 12 had a tendency to tuck her arms in, in her wheelchair and her bed. They monitored the placement of her arm and used the gingerbread shaped pillow in her wheelchair and in bed. She had COVID and was in the COVID unit a while ago and a lot of residents came back with skin issues. 2. On 3/10/22 at 8:53 a.m., Resident 125's dressing change was observed to her right heel with RN 70. It was an unstageable pressure ulcer and observed as a half dollar sized area, she was sleeping and lying on an air mattress with a top sheet, bed pad and a chux under her. RN 70 indicated the estimated width was 9 cm by length of 8 cm with no depth. RN 70 indicated she was going to a wound clinic appointment today. On 3/11/22 at 8:32 a.m., she was observed in bed. On 3/15/22 at 9:55 a.m., she sat in her wheelchair at the table in the common area with a pressure relieving boot on her right foot. On 3/15/22 at 10:41 a.m., an observation of the pressure ulcer to her coccyx with Unit Manager 74, small amount of exudate to the old dressing, stage 2 with granular tissue, no eschar, area was pink and blanchable. Resident 125's clinical record was reviewed on 3/8/22 at 3:05 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, [MEDICATION(S)] (treat depression) 20 mg daily, [MEDICATION(S)] (supplement) 1000 mcg daily, [MEDICATION(S)] (diuretic) 20 mg every other day, [MEDICATION(S)] (depression) 7.5 mg daily, multivitamin daily for wound healing, vitamin D3 125 mcg daily, medpass (nutritional supplement) 120 ml three times daily, [MEDICATION(S)] (treat anxiety) 10 mg three times daily, skin prep to right heel twice daily and apply border foam dressing to sacral ulcer change every three days and PRN (as needed). An annual MDS, dated [DATE], indicated she was moderately cognitively impaired. She required extensive assistance with two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. She had an impairment to one side of her lower extremity. She used a wheelchair. She was always incontinent of bowel and bladder. She had a stage 1 or greater pressure ulcer and was at risk for developing pressure ulcers. She had a stage 2 unhealed pressure ulcer and a surgical wound. She had a pressure reducing device to her chair and bed. She received pressure ulcer care, application of non surgical dressing other than to her feet and applications of ointments/medications other than to her feet. Her care plans included, but were not limited to, the following: a. She had an actual impaired skin integrity related to surgical wound to right hip. Her goal was the wound would be healed by next review. Her intervention included treatments as ordered. b. She had a stage 2 pressure ulcer to her coccyx, initiated on 2/16/22. Her goal was her pressure ulcer would show signs of healing and remain free from infection by/through review date. Her interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly and as needed measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Medical Doctor), educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . c. She had a DTI (Deep Tissue injury) (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) to her right heel, initiated on 2/23/22. Her goal was her DTI would heal without complications through next review. Her interventions included, but were not limited to, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD and weekly skin assessments and PRN (as needed). A Braden scale for predicting pressure sore risk, dated 2/15/22, indicated she was at high risk. A nurses note, dated 2/15/22 at 5:10 p.m., indicated resident's coccyx was assessed and an open area was noted and measured 3 cm x 3 cm x 0.2 cm. There was not drainage present. Surrounding tissue was pink and intact. She denied any pain or discomfort. An order was obtained to apply xeroform to area and cover with dry dressing daily and as needed. On 2/16/22 at 9:20 a.m. IDT met to review the new open area to coccyx. She was noted to have open area to coccyx during care. She had a decline in condition and recent fracture to her hip. She had poor intakes. The intervention was treatment as ordered and low air mattress to bed. Wound-weekly observation tool for her 2/15/22 facility acquired pressure ulcer to her coccyx indicated the following: a. On 2/16/22, she had a new stage 2 pressure ulcer to her coccyx. Preventative measures was a cushion to her wheelchair. There was epithelial tissue present (pink) and the wound measured 3.0 cm x 3.0 cm x 0.2 cm, low air loss mattress to be applied to bed and pressure reducing cushion to wheelchair. Treatment was to apply xeroform and dry dressing daily. She requested to stay in bed throughout the day. b. On 2/23/22, her stage 2 pressure ulcer was improving and measured 1.5 cm x 0.8 cm x 0.2 cm. There were no changes in treatment. Plan of care was in place and interventions remained appropriate. Resident continued to request to stay in bed throughout the day. c. On 3/2/22, her stage 2 pressure ulcer was improving. She had a cushion to her wheelchair and a low air loss mattress on her bed. Her wound measured 2.0 cm x 0.5 cm x 0.2 cm. There were no changes in treatment. Plan of care was in place and interventions remained appropriate. She continued to request to stay in bed throughout the day. d. On 3/9/22, there were no changes to her pressure ulcer or treatment. She continued to request to stay in bed throughout the day. e. On 3/16/22, her stage 2 pressure ulcer was unchanged and measured 0.75 cm x 0.3 cm x 0.2 cm. Plan of care was in place and interventions remained appropriate. Resident continued to request to stay in bed throughout the day. A nurses note, dated 2/23/22 at 4:48 p.m., indicated while doing routine treatment to open areas of coccyx and top of right foot writer noted a DTI to her right heel. Her skin was evaluated. A treatment was put into place and preventative measures put into place. Do we know what they were? This is when the CP and interventions were initiated 2/23/22 and I did not see a treatment on her Feb MAR. Skin prep was started on 3/10/22. On 2/24/22 at 9:42 a.m., IDT met to review new DTI to her right heel that was noted on 2/23/22. The area was noted during care. She continued to have a decline in condition, poor intakes and not getting out of bed. She had been kicking heel boot off. Intervention was to continue to encourage heel boot and turn and reposition every two hours. Wound-weekly observation tool for her 2/23/22 facility acquired DTI pressure ulcer to her right heel indicated the following: a. On 3/2/22, she had a cushion to her wheelchair and low air loss mattress on her bed. The SDTI was new and described with 100 % necrotic tissue present (brown, black, leather, scab-like) and measured 3.0 cm x 4.3 cm. The peri-wound was pink, moist with well defined attached edges. The current treatment plan was apply foam dressing as ordered. The plan of care was in place and the interventions remained appropriate. She continued to request to stay in bed throughout the day. Dietary was updated. b On 3/9/22, her SDTI was unchanged. Plan of care was in place and the interventions remained appropriate. She continued to request to stay in bed throughout the day. Dietary was updated and her appetite was poor. c. On 3/16/22, her SDTI was unchanged. Plan of care was in place and the interventions remained appropriate. She continued to request to stay in bed throughout the day. Dietary was updated and her appetite was poor. During an interview, on 3/10/22 at 11:18 a.m., the DON indicated she had a huge blister on her foot that had popped due to the [CONDITION(S)] she had from her hip fracture, while doing the treatment to the top of her foot, she noticed the area on her heel. She had a heel float boot on at the time of noticing it and an air mattress was in place. She refused to get out of bed. She told the staff she wanted to be left alone. She was not eating well. The interventions were in place because she was in bed more due to the hip fracture. She tested positive for COVID on 12/5/21. 3. On 3/8/22 at 2:02 p.m., Resident 57 was lying on a low loss air mattress, his head of bed was elevated. On 3/9/22 at 1:08 p.m., during a wound observation, with RN 70, of Resident 57's left heel, he indicated his pain was not too bad. The left heel was dry and flaky. There was not an area on the right heel. Resident 57's clinical record was reviewed, on 3/9/22 at 2:44 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His current orders included, but were not limited to, cleanse left heel with soap and water, pat dry then cover with [MEDICATION(S)] dressing daily. Monitor for s/s of infection until healed and notify MD of any changes every day shift., Medpass 90 ml (milliliters) twice daily for wound healing two times daily for wound healing between meals, fortified foods at bedtime for wound healing give fortified cookie and skin prep wipes apply to bilateral heels topically every shift for prevent skin breakdown. A significant change MDS, dated [DATE], indicated he was cognitively intact. He required extensive assistance of two staff members for bed mobility. He required total assistance of two staff members for transfers and toilet use. He required extensive assistance of one staff member for dressing and personal hygiene. He used a wheelchair. He had a life expectancy less than 6 months. He had MASD and a pressure reducing device to bed and chair. He had a care plan for DTI pressure ulcer to his left and right heel related to immobility initiated on 1/26/22. His goal was his pressure ulcer would show signs of healing and remain free from infection by/through review date. His interventions, initiated on 1/26/22, included, but were not limited to, administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden scale for predicting pressure sore risk, dated 1/17/22, indicated he was at moderate risk for developing pressure ulcers. A nurses note, dated 1/22/22 at 7:00 p.m., indicated skin prep was applied to both of his heels and both heels felt hardened. Both heels were black, the left heel measured 4.5 cm x 3 cm, the right heel measured 1 cm x 1.5 cm. He showed no signs of pain, both feet were elevated on pillows, not touching pillows or the bed. He had been wearing boots to both feet. On 1/24/22 at 9:46 a.m., IDT met to review pressure areas to bilateral heels from 1/22/22. Nurse applied skin prep and noted heels to be dark in color. He did have heel boots and low air loss mattress. The intervention was heels to be elevated on pillows when in bed. A Wound-weekly observation tool for his 1/22/22 facility acquired DTI pressure ulcer to his left heel indicated the following: a. On 1/26/22, he had a low air loss mattress. DTI was new, it was a dry area hard tan with burgundy center and measured 4.5 cm x 3 cm. The peri-wound was pale white with [CONDITION(S)] noted to feet, wound edges were intact and irregular. Staff was to use pillows to float heels and not heel boots. The treatment was skin prep every shift. The plan of care updated and interventions in place. b. On 2/2/22, his DTI was unchanged. The plan of care was updated and interventions in place. c. On 2/16/22, the DTI worsened and was an unstageable pressure ulcer. The ulcer was 90 % slough tissue present (yellow, tan, white, stringy) it was moist and measured 4.5 cm x 3.0 cm x 0.1cm. The peri wound was pale white with [CONDITION(S)] was noted to feet. The edges were intact and irregular. No changes in treatment. The wound declined since last assessment. The plan of care was updated and interventions in place. d. On 2/23/22, the unstageable pressure ulcer improved since last assessment. Epithelial tissue was present (pink), slough tissue was present (yellow, tan, white, stringy), the ulcer was moist and measured 3.0 cm x 3.0 cm. The peri wound was pale white with [CONDITION(S)] noted to feet, the edges were intact and irregular. The treatment was changed to cleanse left heel with soap and water, pat dry then cover with [MEDICATION(S)] dressing daily. The plan of care was updated and interventions in place. e. On 3/2/22, the unstageable pressure ulcer improved. 100% tan slough tissue present and the pressure ulcer was moist and measured 1.5 cm x 1.5 cm. The peri-wound appearance did not change. The treatment remained the same. The plan of care was updated and interventions were in place. f. On 3/9/22, the unstageable pressure ulcer improved and measured 1.5 cm x 1.0 cm. The peri-wound was pink, dry and flaky. There were no changes in treatment. The plan of care was updated and interventions were in place. g. On 3/16/22, the unstageable pressure ulcer was unchanged. The plan of care was updated and interventions were in place During an interview, on 3/10/22 at 11:40 a.m., the DON indicated the resident had tested positive for COVID-19 at the end of November, he tested negative at the facility, he was sent to the hospital and tested positive there. He had pressure areas on both heals and was put on hospice due to cancer. He returned from the hospital on 1/3/22. Once he found out he had cancer he has remained in bed a lot. She was not sure how the areas started. He started on hospice on 1/13/22 and the air mattress was delivered on 1/8/22. He had pressure relieving boots on his feet according to a nurses note dated 1/22/22. 4. On 3/10/22 at 12:45 p.m., Resident 63's coccyx pressure ulcer was observed with RN 70. RN 70 indicated she was so contracted as she took the blankets from between her legs. RN 70 indicated her coccyx was unstageable with necrotic, yellow tissue, little epithelial tissue, little tunneling at 10 o'clock, the edges were rolled and looked like a Kennedy ulcer. The resident was grimacing in pain as she completed the treatment. RN 70 indicated she had been given pain medication about an hour prior to the dressing change. Resident 63's clinical record was reviewed on 3/10/22 at 12:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current orders included, but were not limited to, cleanse area to coccyx with soap and water, pat dry, apply calcium alginate to wound bed, apply skin prep to surrounding tissue, cover with adhesive dressing daily, admit to hospice, on 3/4/22, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance of one staff member for bed mobility and dressing. She required total assistance of one staff member for transfer, toilet use and personal hygiene. She had an impairment to her bilateral upper and lower extremities. She was frequently incontinent of bowel and bladder. She was at risk for developing pressure ulcers. She had a pressure reducing device to her chair and bed. Her care plan included, but were not limited to, the following: She had a potential for impaired skin integrity related to decreased oral intakes, PVD (Peripheral Vascular Disease, history of pressure area stage 2, revised on 10/5/21. Her goal was she would be free from skin breakdown through next assessment. Her interventions included, but were not limited to, assist with checking and changing her incontinent brief every two hours and as needed, revised on 4/27/21, evaluate skin integrity, initiated on 8/18/20, low air loss mattress for bed initiated 4/27/21, perform objective pressure ulcer risk tool such as Braden / Norton scale, initiated on 8/18/20, pressure reducing cushion to wheelchair and chair, initiated on 9/3/20, provide skin care per facility guidelines and PRN as needed, initiated on 8/18/20, turn and reposition every two to three hours initiated: 5/19/21. She had a stage 2 pressure ulcer to her sacrum, revised on 2/21/22. Her goal was her pressure ulcer would show signs of healing and remain free from infection. Her interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, initiated on 2/10/22, assess/record/monitor wound healing weekly and as needed, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the MD, revised on 2/15/22, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to ensure her comfort, initiated on 2/10/22, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, initiated on 2/10/22. A Braden scale for predicting pressure sore risk, dated 10/1/21, indicated she was at high risk for developing pressure ulcers. A nurses note, dated 2/10/22 at 10:37 a.m., indicated the CNA asked the writer to assess the coccyx and heel area for notable areas. Writer assessed her coccyx area and found an opened area. Wound bed was red with edges well rounded and approximated, no drainage, painful to touch. New treatment order was noted. Area to left side of great toe was intact, bright red, and blanchable and painful to touch. On 2/11/22 at 9:47 a.m., IDT met to review an open area on her coccyx from 2/10/22. Area noted during care. She was incontinent of bowel and bladder. She continued to be turned and repositioned every two hours. She was currently working with therapy. The intervention was treatment as ordered. A Wound-weekly observation tool for her 2/10/22 facility acquired stage 2 pressure ulcer to her coccyx indicated the following: a. On 2/16/22, a low air loss mattress pressure reducing cushion was in place. The stage 2 pressure ulcer was new. Epithelial tissue present (pink) and measured 0.3 cm x 0.1 cm x 0.1 cm. The peri wound was pink and moist with well-defined edges. Therapy was to assess for a different wheelchair. The current treatment was to cleanse area to coccyx with soap and water, pat dry, apply skin prep to surrounding tissue, cover with adhesive dressing daily. The plan of care was updated. On 2/23/22, the stage 2 pressure ulcer measured 0.3 cm x 0.3 cm x 0.1 cm. There was no change to wound since last assessment and to continue current plan of care. The interventions remained appropriate. On 3/2/22, the stage 2 pressure ulcer was worsening. Epithelial tissue present (pink) and moist, the wound bed top of wound was white and below it appeared to have a blood blister that ruptured. Measurements were 3.0 cm x 3.0 cm x 0.2 cm. The peri-wound was pink and moist. The wound edges were well defined. Continue current plan of care, The interventions remained appropriate. On 3/9/22, the stage 2 had worsened and was considered an unstageable pressure. Epithelial tissue was present (pink), 25 % of white necrotic tissue was present (brown, black, leather, scab-like), there was a foul smell and i

Based on observation, interview, and record review, the facility failed to act upon a significant weight loss and develop personalized interventions for a resident at risk for weight loss (Resident 79). This deficient practice resulted in the resident experiencing a 10% loss of weight in one month with no interventions being put into place. Findings include: On 3/8/22 at 2:30 p.m., Resident 79 was seated at a table with an activity group, and was saying she wanted to get up; Activity Aide 31 was encouraging her to sit still. On 3/9/22 at 10:43 a.m., she was up walking away from the activity group in the common area. LPN 51 went to assist her and asked her to sit in a chair near the fireplace sitting area. On 3/10/22 at 8:51 a.m., she was seated in her wheelchair in the common area with her head in her hands. On 3/10/22 at 9:20 a.m., she remained in her wheelchair near an activity group, holding her head up with her fingers in her eyes. On 3/10/22 at 11:39 a.m., she was seated at a dining table for lunch. She had a cold cut sandwich and French fries. She was taking the sandwich apart and holding the bread in her hand and placing it on the table, the holding it in her hand again. While placing the bread on the table, she spilled her drink onto her plate and onto her lap. At 11:44 a.m., her tablemate alerted the Unit Manager of the spill. The Unit Manager placed the cup upright and left to order a replacement meal. The plate was left at the table and she continued to nibble a French fry. At 11:56 a.m., a new meal was offered to her. On 3/10/22 at 12:40 p.m., she was seated in her wheelchair in the common area. Her plate remained at the dining table, with the sandwich taken apart and a small amount of cold meat gone. Resident 79's clinical record was reviewed on 3/8/22 at 9:50 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She received a mechanical soft diet with thin liquids. A 12/17/21, annual, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. She required supervision with eating and had a weight gain of 5% since her last assessment. A 1/31/22, 5 day, MDS indicated she was severely cognitively impaired. She required supervision with eating and had no weight change. She had a current, 2/10/22, care plan problem of exhibited behavior of confusion/distress as evidenced by calling her family members and them asking about her husband, wanting to go home, stating her husband has given her money, being unable to find her husband, and wanting to go home. She had a current, 2/10/22, care plan problem of risk for potential alteration of nutrition and/or weight status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 1/27/22 progress note indicated she had returned from the hospital following a surgical repair of a hip fracture. Review of weights indicated she had weighed 124 pounds on 2/1/22. On 3/1/22, she weighed 112 pounds, which was a loss of 10%. There was no physician notification of the weight loss, nor were interventions put into place to prevent further weight loss. Review of a 2/2/22 dietary short assessment indicated she received a regular diet with regular texture. A 2/5/22 dietary assessment indicated she received a regular diet, weighed 124 pounds and accepted 51-100% at most meals. Review of a 2/8/22 Occupational Therapy (OT) note indicated she was having increased difficulty with self-feeding. She required verbal cues for task initiation and continuation in a busy environment. On 2/8/22, her diet was downgraded from regular to mechanical soft. Review of meal intakes from 2/9/22 through 3/9/22 indicated the following: She accepted 76-100% of 18 meals. She accepted 51-75% of 15 meals. She accepted 26-50% of 19 meals. She accepted 1-25% of 18 meals. She refused four meals. There was no documentation of replacements being offered or accepted. Review of a 3/4/22 OT discharge summary indicated she demonstrated poor ability to comprehend new information and safety awareness. Review of a 3/14/22 nutrition note indicated she continued to receive a mechanical soft diet with extra gravy on ground meat. She fed herself and her average meal consumption over the past 7 days was 43% and she drank eight ounces of fluid at most meals. She weighed 112 pounds on 3/1/22. Her current weight reflected a significant loss of 8.7% x 1 month, 11.3% x 3 months and 13.4% x 6 months. Her BMI was 18.0 and was below goal range. A variety of supplements had been offered in the past and she had not been accepting of them. A re-weight was requested. During an interview, on 3/11/22 at 10:22 a.m., CNA 53 indicated residents were weighed by the CNAs and the nurses documented the weights in the clinical record. During an interview, on 3/11/22 at 10:40 a.m., the DON indicated the dietary department monitored resident weights. During an interview, on 3/11/22 at 11:22 a.m., Agency RN 37 indicated nurses documented resident weights. The previous weights were visible sometimes. She would request a re-weight if there was a 5% difference or an obvious discrepancy. She would then contact the medical provider and tell the unit manager, so the dietician could be notified. During an interview, on 3/16/22 at 1:19 p.m., Agency LPN 31 indicated the resident could feed herself with cuing. She had needed a little extra help that morning, but usually just needed cuing. During an interview, on 3/16/22 at 1:23 p.m., CNA 53 indicated the resident could feeds herself, but was not a big eater. During an interview, on 3/16/22 at 2:09 p.m., the Certified Dietary Manager indicated monthly weights were completed by the 10th of the month, then the dietician reviewed them on the 10th or 11th and pulled any pertinent reports and reviews. Review of a current facility policy, titled Weight Assessment and Intervention, dated September 2008 and provided by the DON on 3/14/22 at 2:15 p.m., indicated the following: .Any weight change of 5% of more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing .The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falling for a resident with a history falls for 1 of 34 residents reviewed for falls (Resident 50). This deficient practice resulted in Resident 50 falling and sustaining a fracture to her right distal radius. Findings include: During an observation, on 2/05/19 at 4:16 p.m., CNA 72 obtained the resident's vital signs in the common area. On 2/07/19 at 10:54 a.m., the resident sat in a recliner in her room and a staff member was speaking to her. On 2/08/19 at 8:34 a.m., the resident sat in the common area in her wheelchair with ace wrap to her right arm. On 2/11/19 at 2:16 p.m., the resident played bingo in the common area with a red cast to her right arm. The clinical record for Resident 50 was reviewed on 2/07/19 at 11:10 a.m [DIAGNOSES REDACTED]. Medications included, but were not limited to, donepezil [MEDICATION NAME] (dementia) 10 mg (milligram) at bedtime, [MEDICATION NAME] (depression) 5 mg daily, [MEDICATION NAME] (high blood pressure, [MEDICAL CONDITION]) 12.5 mg daily. A quarterly MDS (Minimum Data Set), dated 1/18/19, indicated the resident was severely cognitively impaired, she transferred and toileted with extensive assistance of two staff members, she was always incontinent of bladder and frequently incontinent of bowel. A current care plan indicated the resident was at risk for falls related to limited mobility, dementia, use of hypertension medications and history of falls, right [MEDICAL CONDITION] on 10/15/18 and a right radius fracture on 2/5/19. Interventions included, but were not limited to the following: 1/18/16, a fall assessment quarterly and PRN (as needed), (9/24/18) nursing to make sure slip on shoes are on properly, (10/8/18) ensure there are no throw rugs in bathroom, (10/8/18) non skid strips in front of toilet, (10/12/18) if resident desires to perform household chores make sure she is supervised at all times, (12/21/18) antiroll back attachments to wheelchair, (2/5/19) After toileting resident bring out to common area to prevent resident getting up by self. and (2/6/19) MDS to pattern BM (bowel movement) to adjust toileting schedule if needed. A review of the Morse fall risk assessment indicated the following: On 10/11/18 and 10/16/18, 11/22/18, 12/20/18 and 2/5/18 indicated the resident was at a high risk for fall and to implement high risk fall prevention interventions. A nurses note, dated 10/11/18 at 7:15 p.m., indicated the resident was found laying on her right side on the floor in the dining room, a broom was laying on the floor nearby. Vital signs were obtained and neurological checks were initiated and the resident complained right hip/leg pain. The resident was unable to move her leg voluntarily. An order was obtained to send resident to the emergency room for evaluation. A nurses note, dated 10/11/18 at 11:00 p.m. indicated the hospital was contacted for an update on the resident and was informed that resident is admitted to the hospital for a right [MEDICAL CONDITION]. A review of the Morse fall risk assessment, dated 10/11/2018, the resident was at a high risk for fall and to implement high risk fall prevention interventions. A nurses note, dated 10/12/18 at 9:14 am, indicated the resident had gotten a broom out of nurses station and attempted to sweep without staff present. Resident was sent to the emergency room and staff was to be educated to keep nurses station door closed and broom to be kept in a locked area out of reach of residents. Intervention added to the care plan was to supervise the resident at all times if she desired to perform household chores. A nurses note, dated 10/16/18 9:00 p.m., indicated the resident was readmitted to the facility. A nurses note, dated 10/19/18 at 10:42 a.m., indicated the IDT (Interdisplinary Team) met and discussed fall interventions. The care plan and summary was up to date and was effective. The resident was on another unit and received skilled services for a [MEDICAL CONDITION]. A nurse note, dated 11/21/18 at 4:27 p.m., indicated the resident was sitting in the common area and stood up, her wheelchair was not locked and moved out from under her and she fell . There were no injuries. A nurses note, dated 11/27/18, indicated the resident was found standing beside the sink in the common room, but sat down in her wheelchair when asked. A nurses note, dated 12/20/18 at 7:10 p.m., indicated the resident was found sitting on her buttocks in the bathroom of her room. The wheelchair was backed up by the sink and the clothes hamper had fallen over. Resident thought the chair flew back. There were no injuries. A nurses note, dated 12/21/18 at 9:37 a.m., indicated the IDT met to discuss fall on 12/20/18. The resident attempted to transfer herself to get ready for bed and the wheelchair was locked at time of fall. Interventions added were for staff to toilet before and after meals and as needed when the resident was awake and for staff to assess and make sure resident has the correct wheelchair. A nurses note, dated 2/5/19 at 4:00 p.m., indicated the resident was found lying on her right side with her right arm under her body in the shower with her legs outside of the shower and the wheelchair at her feet. The resident was examined for injuries and was guarding her right wrist, she did not want to move it and complained of pain in her right wrist and it appeared slightly swollen. The resident was unable to grasp with her right hand. The resident had indicated she had taken herself to the bathroom, had a bowel movement, pulled clothes up and removed her brief, lost her balance and fell . The resident was brought out to the common area to be easily observed by staff. An order was received for an xray of the right wrist. A telephone order, dated 2/5/19, indicated the resident had a fall with injury, [DIAGNOSES REDACTED]. A nurse note, dated 2/6/19 at 9:18 a.m., indicated the IDT met to discuss resident fall on 2/5/19 at 4pm, the resident was found lying in the shower on right side, the root cause was self transferring to bathroom, intervention added was a 7 day bowel and bladder assessment and encourage resident to go to the common area when awake. During an interview on 2/13/19 at 2:52 p.m., Nurse Supervisor 76 indicated the resident was in the Memory Care Unit when she fell the first time, the second time was where she lived currently. Before her [MEDICAL CONDITION], the resident was up independently. She was in a wheelchair now and walked with assistance. The resident didn't realize she needed assistance. They had applied antiroll backs to her wheelchair because she had tried to transfer herself before and had applied non slip strips in front of toilet. A current policy, revised 9/2012, titled Falls - Clinical Protocol, provided by the ADON on 2/13/19 at 3:53 p.m. indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3.1-45(a)

Based on interview, and record review, the facility failed to provide adequate supervision and interventions to prevent falls for 1 of 3 residents reviewed for accidents (Resident B). This deficient practice resulted in Resident B sustaining a subdural hematoma and subarachnoid hemorrhage. Findings include: The clinical record for Resident B was reviewed on 10/2/18 at 9:31 a.m. The resident admitted to health care from assisted living on 7/20/18. [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment, dated 8/14/18, indicated the resident was mildly cognitively impaired. She required extensive assistance with bed mobility, transfers, dressing and toilet use with one person assistance. She was not steady with walking and turning around, but was able to stabilize with staff assistance. She used a rolling walker for ambulation. A current care plan initiated 8/17/18 titled, FALLS indicated the resident at risk for falls related to limited mobility, weakness, anxiety and narcotic use. Interventions included, but were not limited to, assist with activities, keep in view as much as possible, remind to use assistive devices and fall committee to review all falls and provide appropriate interventions as indicated. A fall risk assessment, dated 8/26/18, indicated the resident was weak during gait and/or transferring and forgot limitations. She was at a high risk for falls with a score of 55. Review of the nurses notes indicated the following: a. On 8/26/18 at 7:19 a.m., the resident was sitting on the side of her bed. She reported to staff she had fallen earlier, but was unsure of the time. She had a 2 cm x 2 cm hematoma to the back of her head. Neurological checks were initiated. An immediate intervention included to have the resident wear non-skid socks, but the resident refused. She was currently receiving therapy. b. On 9/16/18 at 6:52 p.m., the resident was found on the floor between the recliner and bathroom door at 4:35 p.m. She was assisted to the bathroom and was noted to have foul smelling urine. A urinalysis was ordered. The interventions included a bladder scan and urinalysis. c. On 9/18/18 at 10:52 a.m., during an activity, the resident went down to her knees while holding onto her walker. The fall was witnessed by others in the room. d. On 9/18/18 at 1:29 p.m., the resident was noted on the floor next to her walker during an activity. The activity aide stated the resident was ambulating with her walker and another resident when she heard a loud noise. The resident was noted to have a 4 cm x 3 cm raised lump to the back of her head. The resident was sent to the local hospital. The intervention was to provide emergency care. No additional interventions were added because the resident was transferred to an acute facility. This fall resulted in Resident B sustaining a subdural hematoma and subarachnoid hemorrhage. e. On 9/21/18 at 2:52 a.m., the resident returned from the hospital on [DATE] 7:25 p.m. A new intervention included to keep her door open for increased supervision. f. On 9/25/18 at 8:00 a.m., the resident was found sitting on the floor in the doorway of her room. Resident claimed she had crawled there. g. On 9/26/18 at 9:41 a.m., an Inter-Disciplinary Team (IDT) fall investigation, indicated the resident was not safe to ambulate by herself. The fall mat intervention was removed for fear of tripping. The new intervention included to get the resident up for breakfast, even if she was sleeping for increased supervision. h. 9/26/18 at 6:50 p.m., the resident was found sitting on the floor in another resident's room with her back against the recliner. Resident indicated she was hiding from those men. i. 9/28/18 at 5:56 a.m., the resident was found lying on the floor in her room. The resident thought it was time for breakfast. An immediate intervention was offer to take her to the bathroom and a snack at 5:00 a.m. j. 9/28/18 at 4:27 p.m., the resident was found in the doorway of her room. k. 9/29/18 at 9:26 a.m., the resident was found on the floor beside the low mat with her back against the bed. Review of a time-line of falls, provided by Memory Care Unit Manager 1 on 10/3/18 at 8:31 a.m., indicated the following: a. Fall #1 occurred on 8/2/18 at 4:45 a.m. Interventions included to continue therapy and non-skid socks. b. The second fall was on 9/14/18 at 4:35 p.m. A new intervention for a bladder scan and urinalysis were obtained. She also had a previous care plan, dated 8/17/18, that included to check room for clutter. c. The third fall was on 9/18/18 at 10:30 a.m. After the fall, the activity aide left the resident to go to the other side of the Memory Unit to get the nurse. A visitor stated the resident got herself up off the floor and sat in a chair. d. The fourth fall was on 9/18/18 at 11:00 a.m., while the nurse was calling the family and physician to notify them of the third fall. Interventions included to keep the bed in the lowest position with a mat on the floor and for therapy to evaluate for a helmet. e. The fifth fall was on 9/25/18 at 8:00 a.m. A new intervention included to take the resident to the dining room for breakfast instead of letting her sleep in. f. The sixth fall was on 9/26/18 at 3:45 p.m. The root cause of the fall was related to hallucinations. Interventions included psychogenetic testing. The significant change Minimum Data Set assessment, dated 8/14/18, indicated the resident had hallucinations. g. Fall seven was on 9/28/18 at 5:30 a.m. The immediate intervention was to give her a snack and get her up at 5:00 a.m. h. Fall eight was on 9/28/18 at 1:00 p.m. The immediate intervention was to provide one to one observation for the duration of the shift. i. The ninth fall was on 9/29/18 at 8:30 a.m. A new intervention to offer sugar packets of different types for the resident to sort along with involving in activities. Review of the most recent Resident Service Coordinator (RSC) notes, dated 10/2/18, indicated the resident was encourage to have her door open when she was in her room. Staff was to assist with ambulation and place her in a low bed with a mat on the floor at night. She was to wear hipsters at all times when available and to offer to get her up at 5:00 a.m. and provide a snack and toileting. The RSC notes lacked documentation related to providing the resident with sugar packets to sort. During an interview on 10/2/18 at 2:33 p.m., Memory Care Unit Manager indicated staff were to implement an immediate intervention following a fall. The IDT would then meet and the care plan was updated the following day. The entire chart was a care plan and it would also show up on their Resident Service Coordinator (RSC) notes. The genetic testing may not sound like an intervention. Resident B was to have been wearing hipsters, but had urinated on them so they were being laundered. She will need to order another pair. During an interview 10/3/18 9:00 a.m., LPN 2 indicated on the day of the fall, staff did stay with the resident all the time, but it was not documented. They kept her beside them while they were passing medications and during activities. On 10/3/18 at 9:07 a.m., CNA 3 indicated when the resident fell , she filled out the fall paperwork, but they were not charting one to one following the fall. The resident has not been one to one, but they just kept her with them at all times. A total of 4 aides were here today, two on each side. During an interview 10/3/18 at 10:57 a.m., CNA 4 indicated the resident has been losing her strength and not really using the rolling walker. They just started getting her up at 5:00 a.m. Most of the interventions were new. They did remind her to call and ask for help, but her dementia was progressing. The resident was difficult to keep track of at all times. On 10/3/18 at 12:28 p.m., the Administrator indicated after the fall on 9/28/18, staff were providing one to one with Resident B, but it was not documented. She indicated Unit Manager 1 had made modifications to previous care plans, which erased the previous intervention that were put in place. Review of a current facility policy, revised (MONTH) 2012, titled Fall - Clinical Protocol, which was provided by the Administrator on 10/3/18 at 1:29 p.m., indicated the following: .Monitoring and Follow-up 1. The staff, with the physician's guidance, will follow up on any fall 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons This Federal tag relates to Complaint IN 319 3.1-45(a)(2)

Based on interview and record review, the facility failed to prevent resident to resident abuse for 3 of 7 residents reviewed for abuse (Resident C, D and E) and failed to ensure interventions were in place for the supervision of a resident with a known history of physical contact towards other residents (Resident B). This deficient practice had the potential to affect 40 of 70 cognitively impaired residents who resided on Unit A, B and C. The immediate jeopardy began on 7/9/18 when Resident B entered into a resident's room and inappropriately physically touched him (Resident D). Resident B then approached another resident and touched on his genital area while in public (Resident C). Resident B then approached another resident having his legs and groin area rubbed during an activity (Resident E). The Administrator was notified of the immediate jeopardy on 8/30/18 at 10:52 a.m. Findings include: 1. The clinical record for Resident D was reviewed on 8/29/18 at 1:10 p.m. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 8/20/18, indicated the resident was severely cognitively impaired. He required one person physical assistance when moving on and off the unit. A current health care plan, indicated Resident D had impaired decision making skills secondary to dementia. Interventions included, but were not limited to, observe for signs of frustration and provide assistance as needed. Another health care plan, indicated the resident was deaf and preferred to use a communication board to write on. Interventions included, but were not limited to, watch for non-verbal communication such as crying, gestures and anger. A event report, dated 7/9/18 at 4:30 p.m., indicated Resident in room yelling out help me when CNA Approached (sic) room, another resident was next to (Resident D) with hand on (Resident D's) abdomen. An undated and unsigned statement, indicated On (MONTH) 9th (YEAR) around 4:30 pm, (Resident D) was heard yelling Help. Upon Entry (sic) .rubbing .chest then he placed his hand on (Resident D's) Genitals (sic). (Resident D) continued to yell and staff removed A mood and behavior observation form, dated 7/9/18, indicated at 5:00 p.m., (Resident D) was screaming help I went in his room and (Resident B) was rubbing his hand down (Resident D's) stomach to his penis when I walked in (Resident B) left the room immediately. A progress note, dated 7/9/18 at 6:46 p.m., indicated a Certified Nursing Assistant (CNA) reported she had entered the room an witnessed Resident B's hand on Resident D's abdomen. Resident B left the room. A social service evaluation note, dated 7/9/18, indicated a behavior was reviewed related to Resident D yelling out on 7/9/18. Staff reported the resident had yelled throughout the morning. They attempted to reposition and meet basic needs related to toileting. A mood and behavior observation form, dated 7/18/18 at 7:00 a.m., indicated Resident B was observed making sexual remarks and facial gestures to Resident D. A social service evaluation note, dated 7/18/18, indicated Psych .reviewed increase in (Resident D) yelling out, hallucination, delusion, and agitation with emotional distress observed. NP increased [MEDICATION NAME] (antipsychotic drug) 2. The clinical record for Resident C was reviewed on 8/29/18 at 10:50 a.m. [DIAGNOSES REDACTED]. An admission MDS assessment, dated 7/22/18, indicated the resident had both long and short-term memory loss. He required one person staff assistance to moved off the unit. An undated health care plan, indicated the resident was at risk for changes to his psychosocial welling. The resident was ambulating on Unit B when another male resident extended his hand and initiated quick, light touch below res' (residents) waist Interventions included, but were not limited to, 1:1 visits PRN (as needed) to assess mood/behavior/psychosocial well being Another health care plan, indicated the resident ambulated throughout Unit B and C. Interventions included, but were not limited to, involve resident in a supervised activity. An event report, dated 8/16/18 at 4:25 p.m., indicated a resident came up to Resident C and the other resident reached out and inappropriately touched the front of Resident C's pants. An event report, dated 8/16/18 at 4:25 p.m. indicated a resident came up to Resident C and asked him to go to his room. The other resident then reached out and touched the front of Resident C's pants. A progress note, dated 8/16/18 at 5:27 p.m., indicated the resident had wandered to Unit B's common area and was standing along the railing next to the nurses' station. The resident was asked by another resident to come to his room. Staff informed Resident B that Resident C would not be going to his room. Resident B then reached out and touched the front of Resident C's pants. 3. The clinical record for Resident E was reviewed on 8/29/18 at 10:34 a.m. [DIAGNOSES REDACTED]. A current, undated health care plan, indicated the resident was at risk for impaired communication. Interventions included, but were not limited to, watch for non-verbal communication such as crying, restlessness and anger. Another health care plan, indicated the resident was at risk for psychosocial well-being after receiving physical touch from another resident. Intervention included, but were not limited to, 1:1 visits as needed. A mood and behavior observation form, dated 8/22/18 at 10:45 a.m., indicated Resident B was observed to approach Resident E and rub in a downward motion on each leg. The staff person called his name and the resident then moved his wheelchair to conceal his actions. He then reached for Resident E's groin area. The staff person called his name again and he then went to his room. The resident was told to keep his hands to himself. A progress note, dated 8/22/18 at 4:56 p.m., indicated staff reported Resident E was sitting in the common area when he was approached by another male resident, who extended a touch to his leg. Staff redirected the resident away from Resident E. 4. The clinical record for Resident B was reviewed on 8/29/18 at 9:27 a.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 6/8/18, indicated the resident was cognitively intact. The resident was independent with locomotion on and off the unit and used a wheelchair for ambulation. A current health care plan, dated 6/4/18, indicated the resident had a behavior that included sexual advances, extending inappropriate touch to male residents, being drawn towards cognitively impaired males and approaching other male residents who may be sitting by themselves. Interventions included, but were not limited to, Encourage (Resident B) to a quiet space such as his room if witness (sic) sexual comments/behaviors Redirect the resident to his room for self soothing behavior Offer basic needs Redirect away from other rooms as needed. Another health care plan, dated 8/23/18, indicated the resident was at risk for making unsafe decisions related to dementia and a [DIAGNOSES REDACTED]. Limit choices to reduce confusion. A event report, dated 7/9/18 at 4:30 p.m., indicated Resident in room yelling out help me when CNA Approached (sic) room, another resident was next to (Resident D) with hand on (Resident D's) abdomen. An undated and unsigned statement, indicated On (MONTH) 9th (YEAR) around 4:30 pm, (Resident D) was heard yelling Help. Upon Entry (sic) .rubbing .chest then he placed his hand on (Resident D's) Genitals (sic). (Resident D) continued to yell and staff removed A social service evaluation, dated 7/12/18, indicated staff had reported behavior occurrences on 7/8/18 and 7/9/18. Staff reported Resident B in another resident's room sitting within close proximity and describe resident may have been displaying hand motions of self-stimulation. Resident was dressed and was not self-exposed. He was redirected with ease from room. Second occurrence, resident was found in same resident's room observed to be touching resident abdomen. Resident left the room Behavior interventions reviewed/updated. Resident has not had another behavior occurrence A psychological consult, dated 7/12/18, indicated the resident was seen for a routine follow up per facility request related to resident to resident encounters of sexual nature. The note indicated Attempted to coach nurse & aid re: (reason) his behavior .our job to protect others was their primary responsibility. Their attitude was punitive He is a predator in my professional opinion (Resident B) be moved off this unit. Nursing reported 1 hr (hour) checks. A progress note, dated 7/12/18, indicated Resident B was seen by the Nurse Practitioner (NP) who ordered [MEDICATION NAME] (antidepressant) 20 mg daily. A social service evaluation, dated 7/18/18, indicated .(Resident B) was further recorded to make sexual remarks during this event despite attempted redirection A behavior sheet, dated 8/3/18, indicated Resident B was observed in the common area naked, while rubbing himself and moaning. A social service evaluation, dated 8/6/18, indicated Resident B came out of his room into the common area without clothing on and was heard moaning and touching himself. He was redirected to his room. An event report, dated 8/16/18 at 4:25 p.m., indicated Resident B reached out and inappropriately touched a confused resident's pants in the front. An event report, dated 8/16/18 at 4:25 p.m. indicated a resident came up to another resident and asked to go to his room. The resident then reached out and touched the front of the resident's pants. A mood and behavior observation form, dated 8/22/18 at 10:45 a.m., indicated Resident B was observed to approach Resident E and rub in a downward motion on each leg. The staff person called his name and the resident then moved his wheelchair to conceal his actions. He then reached for Resident E's groin area. The staff person called his name again and he then went to his room. The resident was told to keep his hands to himself. A progress note, dated 8/22/18 at 5:17 p.m., indicated staff reported Resident B was observed leaving a group activity to visit with another male resident. Staff observed Resident B initiating touch to other resident's leg. A new order was received on 8/22/18 to increase [MEDICATION NAME] (antidepressant) to 30 mg daily. The order also included to add Depo-[MEDICATION NAME] (control sexual aggression) 150 mg intramuscular every three months for hypersexuality. During an interview on 8/29/18 at 11:17 a.m., the Social Service Director (SSD) indicated the transition move was more related to Resident B's well-being. After the two occurrences happened, staff had a different opinion of him. The physician felt it would be best to move him to another unit, where he has done better. She indicated his [MEDICATION NAME] was increased and he was started on Depo-[MEDICATION NAME]. The resident could have trouble recalling names, but did score well on a BIMS test. Resident B was transferred to another unit on 7/18/18 at 4:58 p.m. During an interview on 8/29/18 at 3:48 p.m., the SSD indicated she was not sure why Resident B had targeted cognitively impaired resident. She indicated she would not put a cognitively impaired resident in the same room with Resident B. The cubicle he resided on had one male resident who is alert and oriented and the rest were female residents. Confidential interviews for staff were completed. Exact times and dates withheld to maintain anonymity. Employee 1 indicated she felt Resident B was alert and oriented and knew what he was doing. Employee 2 indicated Resident B always wanted to know where the male residents were. The staff was frustrated that nothing was being done to protect the other residents. She felt he was aware of what he was doing because he picked cognitively impaired residents. Employee 3 indicated Resident B had a lot of behaviors and he seemed to target Resident D. She indicated she filled out at least three behavior sheets in one week for Resident B. Employee 4 indicated Resident B had some inappropriate sexual behaviors. She indicated the resident was a predator and did not belong at the facility. Employee 5 indicated Resident B would have a behavior of panting towards Resident C. She indicated Resident C was not able to move himself about the facility and he was deaf. Employee 6 indicated a comment was made that the physician wanted to move Resident B to a different unit because staff were not sensitive to his case. She indicated the resident only targeted confused residents. Employee 7 indicated about six to seven weeks ago, Resident B was found in Resident D's room, masturbating in front of him. He indicated the resident would walk around making a v shape with his two fingers and make a licking motion to other residents. He indicated the resident had several behavior sheets that staff had filled out. Employed 8 indicated she was aware the resident had touched another resident's groin area. He was not on fifteen minute checks, but the staff checked on him. Management was aware of the concerns with Resident B. Review of a current facility policy, dated 2001 and revised (MONTH) (YEAR), titled Abuse Prevention Program, which was provided by the Administrator on 8/29/18 at 9:34 a.m., indicated the following: Our residents have to right to be free from abuse, neglect This includes but not limited to .sexual or physical abuse .As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents Another facility policy, dated 2001 and revised (MONTH) (YEAR), titled Abuse and Neglect - Clinical Protocol, which was provided by the Administrator on 8/29/18 at 9:34 a.m., indicated the following: .3. 'Sexual abuse' is defined at .'non-consensual sexual contact of any type with a resident. Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse ad neglect. Monitoring and Follow-Up 1. The staff .monitor individuals who have been abused at least until their medical condition, mood .thereafter. The Immediate Jeopardy (IJ) that began on 7/9/18 was removed on 8/31/18 when interviews with staff confirmed the facility had begun inservicing staff on abuse and the reporting process and monitoring of Resident B. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced and monitoring was on-going. This Federal tag relates to Complaint IN 299. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure the safe use of rice packs for treating a resident complaints of pain for 1 of 2 residents reviewed for safe use of rice packs in the sample of 4. This failure resulted in Resident A sustaining a second degree burn to the shoulder. (Resident A). Findings included: 1. During the facility tour on 4/25/11 at 11:07 A.M., with the ADON (Assistant Director of Nurses), she indicated Resident A had a sustained a burn from a rice pack in the past 3 to 4 weeks. Resident A's clinical record was reviewed on 4/25/11 at 2:30 P.M. Resident A's [DIAGNOSES REDACTED]. Review of the quarterly MDS (minimum data set) assessment, dated 3/11/11, indicated a score of 8 of 15 for cognitive patterns which indicated Resident A was moderately cognitively impaired. The clinical record lacked any nurses' notes from 3/25/11 until 3/31/11. The clinical notes for Resident A had a note, dated 3/31/2011 at 8:15 A.M., with the following: "Nurse noted 1.8 cm (centimeter) x 2.5 cm blister with [DIAGNOSES REDACTED] surrounding site on resident's R (right) shoulder at 0700 today.... Per RSC (resident service coordinator (a certified nurses' aid)), heated rice bag had been placed on resident's shoulder last night and resident had c/o (complained of) burning so bag was immediately removed. Redness was noted at the site last night, but there was no blister. when (sic) site palpated pt (patient) states, 'it hurts,' could not determine pain level from facial expression due to flat affect, no grimacing. No others s/s (signs/symptoms) of discomfort noted, no s/s infection noted...." Review of the nurse practitioner's progress note, dated 3/31/11, indicated "2o (second degree) burn. Apply Silvadene cream (a treatment for [REDACTED]. May give xtra (extra) dose of Tramadol (a pain medication) prn (an needed) pain." Review of the physician's orders [REDACTED]. Review of the MAR (Medication Administration Record)/TAR (Treatment Admission Record) for March 2011 indicated the lack of documentation of the use of the rice pack. Review of the facility incident report, dated 3/31/11, indicated Resident A had a burn on her right shoulder which was 1.8 cm x 2.5 cm with a blister with [DIAGNOSES REDACTED]. The brief description was "RSC informed nurse that resident has a blister on her (R) shoulder. Per RSC heated rice bag was put on resident's shoulder last night (3/30) and resident had stated that it felt like it was burning. Rice bag was immediately removed, site was red but no blister was present at that time." The report contained a statement made by RSC #1 indicated "On 3/30/11 res. had a rice pack on right shoulder @ lunch. Stated that she thought it had burned her. Res shoulder was just a little red so we took it off. This morning on 3/31/11 while getting the res ready for her shower, I had seen it was blistered and reported it to the nurse." There were phone interviews conducted with the RSC's who had worked on the unit on 3/30/11. The interview with RSC #2 noted "she heated up a rice pack for resident shortly before lunchtime because she was c/o (complaining) of pair to the R shoulder. Stated she heated it up for 3 minutes, securely wrapped it up in a towel and placed it on her R shoulder." Review of the policy for "Moist Heat Application (Rice Packs), dated 5-04, and provided by the Administrator on 4/25/11 at 3:00 P.M., indicated "It is the policy of Peabody Retirement Community to use dry heat to relieve chronic pain and discomfort or in preparation for another treatment such as massage or stretching. Dry heat may be applied by a nurse as a nursing measure or with a physician's orders [REDACTED]. Use microwave in Medication Room only to heat rice packs. Place rice pack in microwave on high for 11/2 - 2 minutes. 2. Knead rick pack to ensure equal distribution of the heat. 3. Place rice pack in towels, using as many as necessary for the comfort of the resident.... 5. Assess skin prior to heat pack application and document assessment on Hot/Cold Pack Application Flow Sheet which will be placed on the TAR.... 8. After 5 minutes, the clinical staff nurse will remove the pack and inspect the skin for redness or blistering. A pinkish hue is normal. 9. At the end of the treatment, the area where the heat was applied will be inspected. The skin assessment and response to treatment will be recorded on the Hot/Cold Pack Application Flow Sheet." During an interview with RSC #2, who was a Restorative CNA, on 4/25/11 at 6:00 P.M., she indicated she had heated the rice pack in the microwave for 2 minutes and had wrapped it in a towel and placed it on Resident A's left shoulder while the resident sat on a couch in the unit's common area. She indicated she had also placed another rice pack on the resident's right groin. She indicated she had done this sometime between breakfast and lunch. She did not tell the nurse on the unit and she could not remember if she had told one of the RSC's. She did not remain on the unit after she had placed the rice packs. She indicated she had placed many rice packs over the 6 years she had worked at the facility. She indicated she had been told how to heat the rice packs by other staff members in the past. During an interview with the Administrator on 4/25/2011 at 5:30 P.M., she indicated the facility had discontinued the use of the rice packs as it was not possible to ensure the temperature of the rice packs. This federal tag relates to complaint IN 382. 3.1-45(a)(1)