Every finding on record at Rim Country Health & Retirement Community

Based on clinical record review, staff interviews, facility investigation, and policies and procedures, the facility failed to update and revise the care plan after a fall for one of the three sampled residents (#1). The deficient practice could result in further falls and injuries to residents.Findings Include:Resident #1 was initially admitted on [DATE] and re-admitted on [DATE], with a diagnosis that included type 2 diabetes mellitus with hyperglycemia, anemia in chronic kidney disease, chronic kidney disease stage 3, age-related osteoporosis without current pathological fracture, alcoholic cirrhosis of the liver, hypertension, major depressive disorder, gastro-esophageal reflux disease, wedge compression fracture of T11-T12 vertebra, and hepatic.An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS further documented that the resident did not have any falls.An admission fall risk tool assessment dated [DATE], revealed a score of 2, indicating the resident is at low risk for falls. The fall assessment also revealed that the resident did not have any history of falls within the last six months, and the resident was taking medication such as Antihypertensives and psychotropic medications. A care plan initiated on September 17, 2025, through September 31, 2025, documented a focus area for Resident #1, being a Moderate risk for falls related to psychoactive drugs. Interventions included anticipating and meeting needs whenever possible, calling the light within easy reach, and encouraging its use when assistance is needed; having a prompt response to all requests for assistance; and educating and providing safety reminders on what to do if a fall occurs. An admission fall risk tool assessment dated [DATE], revealed a score of 2, indicating the resident is at low risk. The fall assessment also revealed that the resident did not have any history of falls within the last six months, and the resident was taking medication such as Antihypertensives. Gait analysis revealed that the patient exhibits loss of balance while standing and uses an assistive device. A Five-day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating the resident had moderate cognitive impairment. The MDS further documented that the resident did not have any falls within two to six months.A nurse's note dated December 3, 2025, at 2:52 PM revealed that therapy alerted the nurse that Resident #1 was on the floor. Resident #1 was kneeling and leaning against the bed, the Resident #1 stated that she was trying to ambulate to the bathroom and slipped, and stated that she did not fall. The resident #1 was assessed, and no injuries were noted. Then the Resident #1 was assisted to bed with a two-person assist, and vitals were taken and were within normal limits. Resident #1 was educated to use the call light when needing assistance, and all of the personal items were within reach, safety precautions in place, the bed was placed in the lowest position, and the call light was within reach. Resident #1's family was notified along with the Medical Doctor (MD) and the Director of Nursing (DON). A facility internal incident report dated December 03, 2025, had an incident description documenting that the nurse was alerted by therapy that Resident #1 was on the floor. When she entered the room, Resident #1 was kneeling, leaning against the bed. Resident #1 stated that she was trying to ambulate to go to the bathroom, and then she slipped and stated that she did not fall. Immediate action included that the Resident #1 was assessed for injuries, but none were noted, assisted back to bed with the help of two staff members, vital signs were within normal limits, and education was provided to the resident to use call lights when needing assistance. The document further revealed that all the personal items were within reach, safety precautions were in place, such as the bed in the lowest position and the call light within reach. MD, family, and DON were made aware of the incident. The resident was not sent to the hospital when the incident occurred. The resident was oriented to person, place, and time. Pre-disposing physical factors included gait imbalance, and predisposing situation factors included ambulating without assistance, the resident attempting to toilet self/ or go to the toilet, or the resident attempting to get out of bed. A fall risk tool assessment was completed on December 03, 2025, which revealed a fall score of seven, indicating the Resident #1 was at moderate risk for falls. The reason for the assessment request revealed the resident had a recent fall. Resident #1 has a history of falls 1-2 times. The resident is using antihypertensive medication, has occasional incontinence, and has no gait analysis. A care plan initiated on December 04, 2025, had a documented focus area for Resident #1 being at risk for falls related to deconditioning, and unawareness of safety needs. Interventions included anticipating and meeting Resident #1's needs whenever possible, ensuring the call light is within easy reach, and encouraging the Resident #1 to use it for assistance as needed, prompting response to all requests for assistance as able, and following facility fall protocol at all times. Neurological Assessments (Neuro Checks) dated December 04, 2025, were completed, and no concerns were found for eyes, verbal response, motor response, extremity movements, and eye signs. A nursing progress note dated December 05, 2025, at 5:58 PM revealed that Resident #1 was observed to be lying on the floor in a supine position near the side of the bed. Resident #1 stated that she was getting up to leave. Resident #1 was assessed for injuries, but no injuries were found. Then Resident #1 was assisted back to bed with the help of two staff members. Resident #1's vitals were within normal limits. Resident #1 was able to move all extremities, with a full range of motion, and denied any pain. Resident #1 was educated to use the call light when needing assistance. Safety precautions were in place, such as the bed in the lowest position, call light, and personal items within reach. MD, family, and DON notified. Neuro checks were implemented. A facility internal incident report dated December 05, 2025, had an incident description documenting immediate action taken, the same as the nurse's note dated December 05, 2025, at 5:58 PM. Resident #1 was not taken to the hospital. The resident's mental status at the time of the incident was that of Resident #1, who was oriented to person, and no injuries were observed post-incident. Pre-disposing physiological factors included the resident being confused. The predisposing situation factors included Resident #1 ambulating without assistance and attempting to get out of bed. A fall risk tool assessment was completed on December 05, 2025, which revealed a fall score of nine, indicating the Resident #1 was at moderate risk for falls. The reason for the assessment request revealed the resident had a recent fall. Resident #1 has a history of falls 1-2 times. The resident is using antihypertensive medication and has occasional incontinence. Gait analysis included Resident #1, who required hands-on assistance to move from place to place and a decrease in muscle coordination. A care plan initiated on December 04, 2025, had a documented focus area for Resident #1 being at risk for falls related to deconditioning, and unawareness of safety needs revealed no evidence of update, revision, or interventions implemented after the fall occurred on December 05, 2025, for Resident #1.Neurological Assessments (Neuro Checks) dated December 05, 2025, were completed, and no concerns were found for eyes, verbal response, motor response, extremity movements, and eye signs.A nurse's note dated December 06, 2025, at 02:16 AM indicated that Resident #1 was observed lying supine on the floor. Resident #1 had slurred and broken speech when she was asked what happened; her pupils were not reacting at first, then the right side became sluggish. The vital signs indicated a blood pressure of 95/54, a heart rate of 48, a temperature of 97.3, and an oxygen saturation of 82%. There was a possible head injury; the Nurse Practitioner was made aware, and orders were made for Resident #1 to be sent out to the hospital. The on-call staff was called. Another nurse's note dated December 06, 2025, 05:29 AM revealed Resident #1 was lying supine on the floor next to her bed, with a possible head impact. When Resident #1 was asked what happened, Resident #1's speech was slurred and broken. The resident had a full range of motion to all extremities without stating pain. Resident #1 pupils were fixed, and later her right pupil became sluggish, and the left pupil was reactive upon transport. Resident #1 was not able to state that she had a head impact. Initial Fall vitals 95/54, Heart rate 45, Temperature 97.0, SaO2 (Arterial Oxygen Saturation) at 80%. At 02:00 AM, the second nurse was called as a witness and for help. At 02:05 AM, performed range of motion test, and Resident #1 stated no pain while moving, no signs of bruising or abrasion. The resident was helped back into her wheelchair and was taken to the nursing station for continuous observation while communicating with the provider at 02:10 AM. The provider gave orders to be sent out. At 2:15 a.m., transport was contacted and gave the facility the estimated arrival time of 2:50 a.m. Resident #1's vitals were stable while waiting for the vehicle to warm up. The resident left the building at 03:10 AM, and a report was given to the medical center. A facility internal incident report dated December 06, 2025, had an incident description documenting immediate action taken, the same as the nurse's note dated December 06, 2025, at 5:02 AM. Resident #1's mental status was only oriented to person, and no injuries were observed post-incident. Predisposing situational factors were that Resident #1 was ambulating without assistance. A care plan initiated on December 04, 2025, had a documented focus area for Resident #1 being at risk for falls related to deconditioning, and unawareness of safety needs revealed no evidence of update, revision, or interventions implemented after the fall occurred on December 06, 2025, for Resident #1, since the resident went to the hospital, and did not return. A call attempt was made on March 19, 2026, at 1:49 PM to a Licensed Practical Nurse (Staff #2) who made an incident report for Resident #1 for December 03, 2025, and December 05, 2025, but was unsuccessful. An interview was conducted on May 19, 2026, at 1:56 PM with a Certified Nursing Assistant (CNA/staff #3), who stated that the facility's process for an unwitnessed fall is to first get a charge nurse and not to move the resident until the nurse has assessed them for any injuries. She stated that then they would do vitals for the resident who fell. Then the CNA stated that, depending on the situation, sometimes residents are sent to the hospital. She stated that residents who are at risk for fall preventive measures taken, such as call lights being within reach of the resident, being toileted frequently, and the bed being in a low position. She stated that whenever a resident falls, new interventions are placed for the resident. She stated that if new interventions are not in place, the resident has a risk of falling again. Further, she stated that she had not worked with Resident #1. An interview was conducted on May 19, 2026, at 2:20 PM with a Registered Nurse (RN/ Staff #4), who stated that the facility's process for unwitnessed fall is to assess the resident for any injuries, find out how the fall occurred, discuss it in the fall huddle, fill out a form for the incident, do risk management on the computer, notify family, physician, case manager, and notify any appropriate parties. She also stated that we do post-adverse event and neuro checks. RN also stated that multiple preventive measures are taken for residents who are at risk for falls, such as the resident having a fall bracelet, a falling leaf outside of the door, education resident on asking for assistance when it is needed. Further, she stated that when a resident has fallen, new interventions are placed for the resident; if no new interventions are placed, then the resident will continue to fall. RN further stated that she has not worked with Resident #1. An interview was conducted on May 19, 2026, at 2:36 PM with a Director of Nursing (DON/Staff #5), who stated that the expectation of staff members when a resident falls is that nurse staff will first assess the resident head to toe, question the resident, assess the resident's vitals, incident report, complete progress note, notify family, doctor, and manager on duty. She stated that then the care plan is updated and new interventions are placed for the resident after a fall by the MDS (Minimum Data Set) Coordinator, and a meeting is conducted with the manager the day after the fall, where they discuss the fall. She stated that no new interventions were placed for the resident #1 after December 05, 2026. Then she stated that the MDS coordinator stated that all the interventions were placed on December 04, 2026, after the resident had fallen on December 03, 2026. Further, the DON stated that if no new interventions are placed for the resident and the care plan is not updated, then the resident will be at risk of falling again.An interview was conducted on May 19, 2026, at 3:14 PM with MDS coordinator (Staff #6), who stated that her role is to complete all the MDS for residents, follow all falls for residents and their fall care plans. She further stated that when a resident has fallen, the following morning, they do an Interdisciplinary Team meeting where they discuss the resident's fall and interventions they can use for the resident's fall situation and personalize the care plan for the resident. She stated that she updated the residents' care plans whenever they have a fall, and every fall has new interventions placed in the care plan. She stated that if the care plan is not updated after the resident has fallen and no new interventions are not placed, then it can pose a risk for the resident having another fall and causing injuries. She stated that she put all the interventions in December 04, 2025, instead of separately for the fall that occurred on December 03, 2025, for Resident #1. She further stated that she should have put more interventions and updated the fall care plan for the resident for the fall that occurred on December 05, 2026. She further stated that the care plan was not being updated, and the fall care plan for the interventions did not meet her or the facility's expectations. A Policy titled Resident Falls and Risk Assessment was revised on March 26, 2024, revealing that staff will determine what equipment and interventions are needed to keep the resident as safe as possible, and safety interventions will be included in the resident's Care Plan and discussed at Care Plan meetings.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#34) was free from abuse by another resident (#50). The deficient practice could result in residents being physically and emotionally harmed. Findings Include:-Regarding Resident #50 Resident #50 was readmitted to the facility on [DATE], with diagnoses that included suicidal ideations, displaced fracture of the right lower leg, effusion of the right ankle, chronic pain syndrome, anxiety disorder, muscle weakness, hypertension, seizures, type 1 diabetes, major depressive disorder, insomnia, and spastic hemiplegia affecting the left nondominant side.A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. A care plan initiated on December 10, 2025, revealed a focus on the resident getting easily agitated when other residents' behaviors disrupted her normal routine related to impulse control, with an intervention to guide her away when she and intervene before her agitation escalates and engage calmly in conversation.A progress note dated December 10, 2025, at 10:15 a.m. revealed that a report was submitted on 12/10/2025 to Adult Protective Services (APS) for an altercation on 12/9/2025, and that the ombudsman and police department had been notified.A progress note dated December 10, 2025, at 12:47 p.m. revealed that at approximately 4:45 p.m., the nurse was notified of an altercation in the dining room. The note further revealed that upon observation, the victim was shouting expletives in the dining area, and the perpetrator was seated at a nearby dining table at the time of the incident. The progress note revealed that the perpetrator stood and placed both hands on the victim's shoulder while yelling at the victim, and the victim attempted to move away from the perpetrator. The note further revealed that during the victim's movement, the perpetrator's arm moved upward and made contact with the victim's nose before the victim positioned themselves further away from the perpetrator. -Regarding Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses that included cutaneous abscess of the neck, severe sepsis, generalized anxiety disorder, hypothyroidism, insomnia, major depressive disorder, dementia, and urinary tract infection. A Quarterly Minimum Data Set (MDS) dated [DATE], revealed that a Brief Interview for Mental Status (BIMS) could not be conducted because the resident was rarely or never understood. The MDS also revealed that the resident exhibited physical, verbal, and other behavioral symptoms for 1-3 days, and she had hallucinations and delusions. A care plan focus initiated on December 10, 2025, revealed that the resident would reminisce about her parents, and her behaviors might escalate and disrupt other residents, with interventions to monitor episodes to determine the underlying cause and document behaviors. A progress note dated December 9, 2025, at 4:18 p.m. revealed that the resident was yelling and tossing furniture in the hallway in the afternoon while repeatedly saying, I want my mom. The note further revealed that staff stayed with the resident, redirected her, and kept her under close watch for safety.A progress note dated December 10, 2025, at 10:12 a.m. revealed that a report was submitted on 12/10/2025 to Adult Protective Services (APS) for an altercation on 12/9/2025, and that the ombudsman and police department had been notified.A progress note dated December 10, 2025, at 12:52 p.m. revealed that at approximately 4:45 p.m., the nurse was notified of an altercation in the dining room. The note further revealed that upon observation, the victim was shouting expletives in the dining area, and the perpetrator was seated at a nearby dining table at the time of the incident. The progress note revealed that the perpetrator stood and placed both hands on the victim's shoulder while yelling at the victim, and the victim attempted to move away from the perpetrator. The note further revealed that during the victim's movement, the perpetrator's arm moved upward and made contact with the victim's nose before the victim positioned themselves further away from the perpetrator.A telephonic interview was attempted on December 30, 2025, at 11:34 a.m. with Resident #34's responsible party, and there was no response.An interview was conducted on December 30, 2025, at 11:44 a.m. with Resident #50, who stated that she could not remember if she had been involved in any altercations recently due to her memory loss, but she could recall knowing who Resident #34 was.A telephonic interview was conducted on December 30, 2025, at 12:21 p.m. with the facility psychiatrist (Psychiatrist/Staff#29), who stated that he could recall an altercation being reported to him regarding residents #34 and #50. The psychiatrist further stated that he met with the residents on December 15, 2025, but he did not speak with them about the incident so as not to agitate them. The psychiatrist stated that neither of the residents brought the altercation up in their session, but that Resident #50 would be the one who could recall the incident between the two residents. An interview was conducted on December 30, 2025, at 1:07 p.m. with a Certified Nursing Assistant (CNA/Staff#61) who stated that a resident-to-resident altercation would be defined as a resident saying something to emotionally hurt another resident, or if they physically harmed them. The CNA stated that there was a woman on the locked unit who liked to hit people, and she identified her as Resident #50. The CNA further stated that there was recently an altercation between Resident #50 and another resident, and she was directed to watch the residents closely. The CNA also stated that the resident has not had any issues since the altercation. An interview was conducted on December 30, 2025, at 1:27 p.m. with a Licensed Practical Nurse (LPN/Staff#89) who stated that a resident-to-resident physical altercation would be defined as residents hitting or swinging at each other, and her process if one were to occur would be to immediately separate the residents, check them for injuries, and report to the Director of Nursing (DON) or Administrator immediately, but within 2 hours. The LPN stated that there was an altercation earlier in the month that she did not observe, but it was reported to her, and she took action immediately. The LPN stated that she was in the middle of two new admissions when the CNAs told her that they had to separate two residents in the dining room because Resident #50 was grabbing Resident #34's shoulders and neck area, and that Resident #50's arm flung up and made contact with Resident #34's nose. The LPN stated that the CNAs described that Resident #50 stood up out of her wheelchair because Resident #34 was talking to herself, and Resident #50 went behind Resident #34 to grab and shake her shoulders because she was agitated. The LPN stated that they assessed both of the residents and determined there were no injuries, and they redirected and calmed the residents down within 30 minutes of the altercation. The LPN further stated that the residents did not have any prior issues as far as she knew, and this was a one-time incident. An interview was conducted on December 30, 2025, at 1:51 p.m. with a CNA, Staff #10, who stated that there was a recent altercation between two residents, but she did not observe the incident. The CNA stated that Residents #34 and #50 were involved in the altercation, and that another CNA, Staff #28, yelled for her to go to the dining room to assist the two residents. The CNA stated that when she looked through the windows of the dining room, she saw Resident #50 standing and holding the arms of her wheelchair, and by the time she got there, they were already standing apart from one another. The CNA stated that Staff #28 was not in the dining room when she got there because he was at the nurses' station reporting it to Staff #89. The CNA further stated that Staff #28 was the witness to the incident, and he reported that Resident #50 grabbed Resident #34's shoulders.A telephonic interview was conducted on December 30, 2025, at 2:32 p.m. with a CNA, Staff #28, who stated that a resident-to-resident altercation would be defined as verbal or physical abuse from patient to patient, like putting hands on each other or screaming and yelling. The CNA stated that if he were to observe a resident-to-resident altercation, his process would be to remove the patients, calm the situation, and notify the nurse and DON right away. The CNA stated that there was a resident-to-resident altercation 2-3 weeks prior involving Residents #50 and #34. The CNA further stated that he was moving residents to, or from, the dining room when he saw through the window that Resident #50 was standing up behind Resident #34 and was grabbing her by the neck and choking her. The CNA stated that he immediately got involved with another CNA, and they informed the DON right away after separating the residents. The CNA stated that Resident #50 was irritated with Resident #34, and she put her hands on her. The CNA stated that they did not know that Resident #50 wheeled herself into the dining room, and there were no staff in the dining room at that time. The CNA stated that from as far away as he was, it appeared Resident #50 was choking Resident #34, but he did not think she had the strength to do it. The CNA also stated that Resident #50 hit Resident #34's nose in the altercation, and the nurse assessed both of the residents because Resident #34 was bleeding from her nose. The CNA stated that moving forward, they decided that there would always be someone in the dining room to make sure residents did not wander in alone. An interview was conducted on December 30, 2025, at 2:58 p.m. with the Administrator (Administrator/Staff#73), who stated that they had a resident-to-resident altercation between Residents #50 and #34. The administrator stated that the nurse was giving medications, the staff were trying to get residents to the dining room, and a CNA was talking to a family member when Resident #50 came up behind Resident #34 and grabbed her on the neck and shoulders. The administrator further stated that Resident #50's forearm hit Resident #34's face, and there were no injuries noted on either of the residents. The administrator stated and motioned that the altercation described to him by the CNA appeared to resemble a headlock, and Staff #28 witnessed the altercation from the nurses' station outside the dining room, called for help, and they separated the residents. The administrator stated that they concluded that the altercation was verified because it was witnessed and did happen, they did a medication review with the psychiatrist following the incident, and have seen some differences in the resident's behavior. An interview was conducted on December 30, 2025, at 3:29 p.m. with the Director of Nursing (DON/Staff#56), who stated that there was a resident-to-resident altercation between Resident #34 and Resident #50 in the dining room. The DON stated that, according to staff, Staff #28 was bringing someone back into the dining room when he saw Resident #50 standing up behind Resident #34 with her hands on Resident #34's neck and shoulders before he yelled to Staff #10 to run in to help. The DON stated that the investigation was substantiated because the resident was observed putting her hands on another resident. A review of a policy titled, Summary of Resident Rights, had a review date of February 5, 2024, and revealed that residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, any physical or chemical restraint not required to treat resident symptoms, verbal, mental, sexual, or physical abuse.A review of a policy titled, Resident Abuse and Neglect, had a review date of August 2, 2024, and revealed that the facility was committed to the physical, mental, social, and emotional well-being of the resident and had developed a zero-tolerance policy related to resident abuse. The policy further revealed that any incident or suspected incident of resident abuse would be reported promptly to the appropriate agencies and individuals, the Director of Nursing and Administrator. The policy also revealed that it would not tolerate abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to complete notifications involving abuse for two residents (# 15 and #23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse. The resident #15 was admitted on [DATE] for a planned respite stay while a patient with Arizona Care Hospice, and discharged to his home on 7/8/2025 with diagnoses that included: atherosclerotic heart disease and vascular dementia. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed completion of only section A. A review of the hospice admission packet revealed that the resident was admitted to the facility from Arizona Care Hospice for a respite stay while home health services were established. Additional diagnoses in the admission packet included: aortic aneurysm, weakness, falls and weight loss. The resident had elected a Do Not Resuscitate (DNR) status. The level 1 Preadmission Screening and Resident Review (PASRR) revealed that the resident had a terminal illness and secondary diagnosis of dementia, but no identified serious mental illness, intellectual disability or substance abuse. A review of hospice summary notes included in the care plan revealed that the patient was referred to hospice care for significant cognitive decline, progressive functional dependence, and poor prognosis. The care plan revealed that the patient was alert and oriented to self and place, but not time or situation. The resident had intermittent periods of restlessness and agitation especially in the late afternoon and evening. The resident woke frequently during the night and wandered, and experienced frequent falls and episodes of lightheadedness where he needed assistance getting into bed. The note revealed that the last fall resulted in a skin tear to the left wrist and that the resident refused to use assistive devices for ambulation. A review of a fall risk assessment completed on July 3, 2025/3/2025 at 07:06 A.M. revealed a score of 15 indicating the resident was a moderate risk for falls. A review of resident progress notes dated July 3, 2025 through July 8, 2025 revealed that the resident exhibited exit seeking, wandering, verbal behaviors and inappropriate toileting behaviors requiring orders for additional benzodiazepine and antipsychotic medications that were ordered on July 5, 2025. Staff reported that the resident continued these behaviors and was becoming more difficult to redirect, but there was no evidence that the resident eloped from the facility. The allegation that the resident wandered into another resident's room and entered her bed was confirmed by staff interviews, however, there was some discrepancy noted as to who held responsibility to initiate notifications of the resident's change in condition.An interview with Licensed Practical Nurse, (LPN), (Staff #81), was conducted on 7/23/2025 at 11:54 AM. The LPN stated that the facility provides training on caring for residents with dementia and related behaviors. Staff #81 stated that knowing the residents and their baseline behaviors is one of the best ways to minimize wandering or other disruptions on the unit. The LPN further stated, Knowing the patients is 90% of the job. The LPN stated that if he encountered a resident trying to leave the secured unit or who was demonstrating other disruptive behaviors, he would remove them from the situation, try to redirect them using conversation, a snack, or a walk, and if the behaviors persisted, he would check the orders to see if medications were available to administer to decrease the behaviors. Staff #81 stated that he recalled a respite patient who was on the unit who exhibited a number of behaviors including exit seeking, and while the resident set off door alarms, he did not exit the building. An interview with Certified Nursing Assistant, (CNA), Staff #3) was conducted on 7/23/2025 at 12:22PM. The CNA confirmed that some residents are exit seeking, but staff is able to get to them in time to redirect them back to their room or another activity. The CNA stated that no resident has been able to get out of the unit during her shift. An interview with Certified Nursing Assistant, (CNA), (Staff #53) was conducted on 7/23/2025 at 12:30 PM. The CNA stated that staff become aware of resident behaviors through a review of the Kardex and through staff report. Staff #53 stated that staff receive extensive training from the Behavioral Health Team about dementia and that. The unit is staffed sufficiently to manage resident care. The CNA reported that she recalled a recent resident who was on the unit for respite care who walked into another resident's room and required redirection by staff. The CNA stated that if a resident was wandering or disruptive, she would notify the nurse. An interview with the Director of Nursing, (DON), (Staff #52), was conducted on 7/23/25 at 1:26 PM. The DON stated that an incident whenever there was an unusual occurrence such as a fall, an actual elopement, or a new skin condition, or serious resident to staff behaviors. Upon recalling the specific incident, the DON stated that residents can wander into other resident's rooms as the facility cannot shut the doors in order to ensure monitoring by staff. The DON stated that if a resident entered another resident's room, the staff would guide them out. When asked what she would do if a resident entered a room and laid down on the bed, the DON stated that she would evaluate the situation. The DON stated that she recalled the situation that initiated the allegation and determined there were no adverse effects since both residents were fully clothed, there appeared to have been no touching between the residents, and that staff noticed the situation in less than three minutes and responded immediately to escort the resident out of the other's room. The DON further stated that Resident #23 had significant visual impairment, was legally blind, did not realize the other resident had entered her room or bed, and neither resident had incurred an injury. The DON stated that she attempted to reach LPN (Staff #16) to provide mentoring and instruction on how to document the incident. An interview with Certified Nursing Assistant, (CNA), (Staff #3) was conducted on 7/23/2025 at 12:30 PM. The CNA stated that staff become aware of resident behaviors through a review of the Kardex and through shift staff report. Staff #3 stated that staff receive extensive training from the Behavioral Health Team about dementia. The CNA stated that the unit is staffed sufficiently to manage resident care. The CNA reported that she recalled a recent resident who was on the unit for respite care who walked into another resident's room and required redirection by staff. The CNA stated that if a resident was wandering or disruptive, she would notify the nurse. The CNA stated that the risk of elopement from the facility could be that the resident could fall, be hit by a car, get lost or be stranded. An interview with Licensed Practical Nurse (LPN), (Staff #16), was conducted on 7/23/2025 at 2:31 PM. The LPN stated that she recalled the incident concerning the respite patient (Resident #15) and the situation when he was found in bed with a female resident. Staff #16 stated that the event occurred at the end of the shift while she was working with her back to the unit in the nurses' station facilitating the report with the oncoming shift LPN (Staff #15). The CNA advised both nurses that she needed help with a resident. Both LPNs followed the CNA into resident #23's room where they observed resident #15 lying in bed with resident #23. The LPN stated that resident #23 was lying closest to the wall and had a blanket wrapped around her. Resident #15 was observed lying on top of the bedding, but was not beneath the blanket. Both residents were assessed for injury and resident #23 was noted to be oriented only to self, was awake and calling resident #15 by her former spouse's name. She observed that resident #23 did not appear did not appear to be upset or afraid. Resident #15 began yelling when removed from the female resident's bed but calmed down quickly when redirected to his room by Staff #15. The LPN stated that neither resident was injured during the incident. Staff #16 stated that she immediately notified the DON of the event as resident #15 was a respite patient and she was not sure of the necessary next steps since resident #15 was not a regular resident of the facility. The LPN stated that the DON asked if she would be comfortable saving the note she had drafted for later review and discussion. The LPN stated that the DON (Staff #52) advised her that she would notify the respite resident's spouse. The LPN stated that she did not notify resident #23's representative of the incident as she reported off to Staff #15, the day shift, LPN, who offered to conduct notifications. The LPN stated that the lack of notification to the resident's representatives did not meet her expectations as she is aware that the event should have been handled differently, and that she now knows how important it is to communicate with resident's families. The LPN stated that it is important that everyone knows what is going with patient and that this was a failure to communicate. Staff #16 acknowledged that the experience was a learning point for her. A telephone interview with Licensed Practical Nurse, (LPN), (Staff #15) was conducted on 7/23/2025 at 2:51 P.M. The LPN stated that he recalled the event when resident #15 was found in bed with resident #23 who thought it was her husband. The LPN stated that neither resident was injured and believed that resident #23 was facing the wall when the situation was identified. When asked about the facility's process for notifying family members of incidents that occurred at the facility, he stated that since it happened during shift-change, whomever wrote up the report also would have made notifications. Staff #15 stated that if no report was written, the DON would have conducted the notifications. The LPN stated that if he had documented the incident, he would have indicated who he notified in the progress note. The LPN stated that the lack of notification would not meet his expectation as the family could be pretty upset if they were not notified within 24-48 hours. A follow-up interview was conducted with Director of Nursing (DON), (Staff # 52) on 7/23/2025 at 3:18 PM. The DON reviewed the record and confirmed that there was no indication that notification of either resident's families regarding the incident occurred. The DON further stated that this did not meet her expectation as notifications of incidents are to take place in a timely manner. Staff #52 further stated that she would be providing education on timely notification to staff at monthly staff meetings. The DON identified the risk related to lack of notification would be a lack of trust in the facility to give proper care. A review of the Accidents, Incidents and Supervision policy, reviewed on 7/22/2024 revealed that the facility is committed to providing an environment as free from accidents and hazards as possible for all residents and ensuring that each resident will receive the supervision and interventions needed to promote such an environment. The policy further revealed that the Director of Nursing, Administrator, and or designee will be notified immediately if a resident or other individual creates a risk to others.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to develop and implement policies and procedures for the documentation and reporting of alleged violations involving abuse for one resident (#23). The deficient practice resulted in allegations of abuse not being reported, not investigated and residents not protected from further abuse.Findings include:The resident was admitted on [DATE] for a planned respite stay while a patient with Arizona Care Hospice, and discharged to his home on 7/8/2025 with diagnoses that included: atherosclerotic heart disease and vascular dementia. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed completion of only section A.A review of the hospice admission packet revealed that the resident was admitted to the facility from Arizona Care Hospice for a respite stay while home health services were established. Additional diagnoses in the admission packet included: aortic aneurysm, weakness, falls and weight loss. The resident had elected a Do Not Resuscitate (DNR) status. The level 1 Preadmission Screening and Resident Review (PASRR) revealed that the resident had a terminal illness and secondary diagnosis of dementia, but no identified serious mental illness, intellectual disability or substance abuse. A review of hospice summary notes included in the care plan revealed that the patient was referred to hospice care for significant cognitive decline, progressive functional dependence, and poor prognosis. The care plan revealed that the patient was alert and oriented to self and place, but not time or situation. The resident had intermittent periods of restlessness and agitation especially in the late afternoon and evening. The resident woke frequently during the night and wandered, and experienced frequent falls and episodes of lightheadedness where he needed assistance getting into bed. The note revealed that the last fall resulted in a skin tear to the left wrist and that the resident refused to use assistive devices for ambulation. A review of a fall risk assessment completed on July 3, 2025/3/2025 at 07:06 A.M. revealed a score of 15 indicating the resident was a moderate risk for falls. The admission care plan dated 7/1/2025 revealed that the resident was incontinent of bowel and bladder and had a history of falls. The care plan further revealed that the resident had lost approximately 40 pounds in the past year, 5 pounds in the past week and was cachexic. A review of resident progress notes dated July 3, 2025 through July 8, 2025 revealed that the resident exhibited exit seeking, wandering, verbal behaviors and inappropriate toileting behaviors requiring orders for additional benzodiazepine and antipsychotic medications that were ordered on July 5, 2025.Staff reported that the resident continued these behaviors and was becoming more difficult to redirect, however, there was no evidence that the resident eloped from the facility. The allegation that the resident wandered into another resident's room and entered her bed was confirmed by staff interviews, however, the electronic health record revealed no documentation of the incident. Further, there was a discrepancy noted as to who held responsibility to document the resident's behaviors and change in condition.An interview with Licensed Practical Nurse, (LPN), (Staff #81), was conducted on 7/23/2025 at 11:54 AM. The LPN stated that the facility provides training on caring for residents with dementia and related behaviors. Staff #81 stated that knowing the residents and their baseline behaviors is one of the best ways to minimize wandering or other disruptions on the unit. The LPN further stated, Knowing the patients is 90% of the job. The LPN stated that if he encountered a resident trying to leave the secured unit or who was demonstrating other disruptive behaviors, he would remove them from the situation, try to redirect them using conversation, a snack, or a walk, and if the behaviors persisted, he would check the orders to see if medications were available to administer to decrease the behaviors. Staff #81 stated that he recalled a respite patient who was on the unit who exhibited a number of behaviors including exit seeking, and while the resident set off door alarms, he did not exit the building. The LPN stated that documentation of resident care is the responsibility of the nurse providing the care. An interview with Certified Nursing Assistant, (CNA), (Staff #53) was conducted on 7/23/2025 at12:30 PM. The CNA stated that staff become aware of resident behaviors through a review of the Kardex and through staff report. Staff #53 stated that staff receive extensive training from the Behavioral Health Team about dementia and that. The unit is staffed sufficiently to manage resident care. The CNA reported that she recalled a recent resident who was on the unit for respite care who walked into another resident's room and required redirection by staff. The CNA stated that if a resident was wandering or disruptive, she would notify the nurse. An interview with the Director of Nursing, (DON), (Staff #52), was conducted on 7/23/25 at 1:26 PM. The DON stated that an incident whenever there was an unusual occurrence such as a fall, an actual elopement, or a new skin condition, or serious resident to staff behaviors. Upon recalling the specific incident, the DON stated that residents can wander into other resident's rooms as the facility cannot shut the doors in order to ensure monitoring by staff. The DON stated that if a resident entered another resident's room, the staff would guide them out. When asked what she would do if a resident entered a room and laid down on the bed, the DON stated that she would evaluate the situation. The DON stated that she recalled the situation that initiated the allegation and determined there were no adverse effects since both residents were fully clothed, there appeared to have been no touching between the residents, and that staff noticed the situation in less than three minutes and responded immediately to escort the resident out of the other's room. The DON further stated that Resident #23 had significant visual impairment, was legally blind, did not realize the other resident had entered her room or bed, and neither resident had incurred an injury. The DON stated that she attempted to reach LPN (Staff #16) to provide follow up mentoring and instruction on how to document the incident. An interview with Certified Nursing Assistant, (CNA), (Staff #3) was conducted on 7/23/2025 at12:30 PM. The CNA stated that staff become aware of resident behaviors through a review of the Kardex and through shift staff report. Staff #3 stated that staff receive extensive training from the Behavioral Health Team about dementia. The CNA stated that the unit is staff sufficiently to manage resident care. The CNA reported that she recalled a recent resident who was on the unit for respite care who walked into another resident's room and required redirection by staff. The CNA stated that if a resident was wandering or disruptive, she would notify the nurse. An interview with Licensed Practical Nurse (LPN), (Staff #16), was conducted on 7/23/2025 at 2:31 PM. The LPN stated that she recalled the incident concerning the respite patient (Resident #15) and the situation when he was found in bed with a female resident. Staff #16 stated that the event occurred at the end of the shift while she was working with her back to the unit in the nurses' station facilitating the report with the oncoming shift LPN (Staff #15). The CNA advised both nurses that she needed help with a resident. Both LPNs followed the CNA into resident #23's room where they observed resident #15 lying in bed with resident #23. The LPN stated that resident #23 was lying closest to the wall and had a blanket wrapped around her. Resident #15 was observed lying on top of the bedding, but was not beneath the blanket. Both residents were assessed for injury and resident #23 was noted to be oriented only to self, was awake and calling resident #15 by her former spouse's name. She observed that resident #23 did not appear did not appear to be upset or afraid. Resident #15 began yelling when removed from the female resident's bed but calmed down quickly when redirected to his room by Staff #15. The LPN stated that neither resident was injured during the incident. Staff #16 stated that she immediately notified the DON of the event as resident #15 was a respite patient and she was not sure of the necessary next steps since resident #15 was not a regular resident of the facility. The LPN stated that the DON asked if she would be comfortable saving the note she had drafted for later review and discussion. The LPN stated that the DON (Staff #52) advised her that she would notify the respite resident's spouse. The LPN stated that she did not notify resident #23's representative of the incident as she reported off to Staff #15, the day shift, LPN, who offered to conduct notifications. The LPN stated that she did not complete documentation of the incident as she planned to work with the DON to complete documenting the events when she returned to work. The LPN stated that when she returned to work, she learned that resident #15 had been discharged and removed from the electronic health record and that she was unable to access the record to add nursing notes regarding the incident. The LPN stated that the lack of documentation did not meet her expectations as she is aware that the event should have been handled differently, and that she now knows how important it is to document patient care. The LPN stated that it is important that everyone knows what is going on, or happening with the care of the patient and this was a failure to communicate.An interview with Licensed Practical Nurse, (LPN), (Staff #81), was conducted on 7/23/2025 at 11:54 AM. The LPN stated that the facility provides training on caring for residents with dementia and related behaviors. Staff #81 stated that knowing the residents and their baseline behaviors is one of the best ways to minimize wandering or other disruptions on the unit. The LPN further stated, Knowing the patients is 90% of the job. The LPN stated that if he encountered a resident trying to leave the secured unit or who was demonstrating other disruptive behaviors, he would remove them from the situation, try to redirect them using conversation, a snack, or a walk, and if the behaviors persisted, he would check the orders to see if medications were available to administer to decrease the behaviors. Staff #81 stated that he recalled a respite patient who was on the unit who exhibited a number of behaviors including exit seeking, and while the resident set off door alarms, he did not exit the building. The LPN stated that documentation of resident care is the responsibility of the nurse providing the care. An interview with Certified Nursing Assistant, (CNA), (Staff #53) was conducted on 7/23/2025 at12:30 PM. The CNA stated that staff become aware of resident behaviors through a review of the Kardex and through staff report. Staff #53 stated that staff receive extensive training from the Behavioral Health Team about dementia and that. The unit is staffed sufficiently to manage resident care. The CNA reported that she recalled a recent resident who was on the unit for respite care who walked into another resident's room and required redirection by staff. The CNA stated that if a resident was wandering or disruptive, she would notify the nurse. An interview with the Director of Nursing, (DON), (Staff #52), was conducted on 7/23/25 at 1:26 PM. The DON stated that an incident whenever there was an unusual occurrence such as a fall, an actual elopement, or a new skin condition, or serious resident to staff behaviors. Upon recalling the specific incident, the DON stated that residents can wander into other resident's rooms as the facility cannot shut the doors in order to ensure monitoring by staff. The DON stated that if a resident entered another resident's room, the staff would guide them out. When asked what she would do if a resident entered a room and laid down on the bed, the DON stated that she would evaluate the situation. The DON stated that she recalled the situation that initiated the allegation and determined there were no adverse effects since both residents were fully clothed, there appeared to have been no touching between the residents, and that staff noticed the situation in less than three minutes and responded immediately to escort the resident out of the other's room. The DON further stated that Resident #23 had significant visual impairment, was legally blind, did not realize the other resident had entered her room or bed, and neither resident had incurred an injury. The DON stated that she attempted to reach LPN (Staff #16) to provide follow up mentoring and instruction on how to document the incident. An interview with Certified Nursing Assistant, (CNA), (Staff #3) was conducted on 7/23/2025 at12:30 PM. The CNA stated that staff become aware of resident behaviors through a review of the Kardex and through shift staff report. Staff #3 stated that staff receive extensive training from the Behavioral Health Team about dementia. The CNA stated that the unit is staff sufficiently to manage resident care. The CNA reported that she recalled a recent resident who was on the unit for respite care who walked into another resident's room and required redirection by staff. The CNA stated that if a resident was wandering or disruptive, she would notify the nurse. An interview with Licensed Practical Nurse (LPN), (Staff #16), was conducted on 7/23/2025 at 2:31 PM. The LPN stated that she recalled the incident concerning the respite patient (Resident #15) and the situation when he was found in bed with a female resident. Staff #16 stated that the event occurred at the end of the shift while she was working with her back to the unit in the nurses' station facilitating the report with the oncoming shift LPN (Staff #15). The CNA advised both nurses that she needed help with a resident. Both LPNs followed the CNA into resident #23's room where they observed resident #15 lying in bed with resident #23. The LPN stated that resident #23 was lying closest to the wall and had a blanket wrapped around her. Resident #15 was observed lying on top of the bedding, but was not beneath the blanket. Both residents were assessed for injury and resident #23 was noted to be oriented only to self, was awake and calling resident #15 by her former spouse's name. She observed that resident #23 did not appear did not appear to be upset or afraid. Resident #15 began yelling when removed from the female resident's bed but calmed down quickly when redirected to his room by Staff #15. The LPN stated that neither resident was injured during the incident. Staff #16 stated that she immediately notified the DON of the event as resident #15 was a respite patient and she was not sure of the necessary next steps since resident #15 was not a regular resident of the facility. The LPN stated that the DON asked if she would be comfortable saving the note she had drafted for later review and discussion. The LPN stated that the DON (Staff #52) advised her that she would notify the respite resident's spouse. The LPN stated that she did not notify resident #23's representative of the incident as she reported off to Staff #15, the day shift, LPN, who offered to conduct notifications. The LPN stated that she did not complete documentation of the incident as she planned to work with the DON to complete documenting the events when she returned to work. The LPN stated that when she returned to work, she learned that resident #15 had been discharged and removed from the electronic health record and that she was unable to access the record to add nursing notes regarding the incident. The LPN stated that he was aware that the night LPN had or planned to speak with the DON about the incident. The LPN stated that if he had documented the incident, he would have indicated who he notified in the progress note. The LPN stated that the lack of documentation would not meet his expectation as there would be no record of the event if it was not charted. An interview was conducted with Director of Nursing (DON), (Staff # 52) on 7/23/2025 at 3:18 PM. The DON reviewed the record and confirmed that there was no indication that documentation of the incident was recorded in either resident's electronic health record. The DON stated that the day shift staff should have documented the event and that staff will be written up for the lack of completing documentation. The DON further stated that this did not meet her expectation because, if it wasn't charted, it wasn't done. A request to review the facility documentation policy revealed that the facility had none. This attestation was confirmed by the Administrator (Staff #79) on 7/23/2025 at 3:40 PM.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#6) to be free from abuse by another resident (#4). The deficient practice could lead to ongoing abuse leading to harm of residents. -Findings include: Resident #4 was admitted to the facility with an original admission date of September 11, 2021, with diagnoses that included dementia, weakness, acute cerebrovascular insufficiency and anxiety disorder. A review of the minimum data set (MDS) dated [DATE] for Resident #4 revealed severe impaired cognition. Resident #6 was admitted on [DATE] with diagnoses that included senile degeneration of brain, Alzheimer's disease and chronic kidney disease. A review of the minimum data set (MDS) dated [DATE] for Resident #6 revealed a brief interview of mental status (BIMS) of 02, indicating severe cognitive impairment. A review of progress notes in Resident #6's electronic health record (EHR), shows a progress note from February 19, 2024 1:53 p.m. revealed that Certified Nursing Assistant (CNA) Staff #3 heard Resident #6 yelling at Resident #4 to stop hitting the side of the wheel chair and turned around and began hitting Resident #4 on the arms and cussing at her. Both residents were separated. An interview was conducted on June 3, 2025 at 12:41 p.m. with Certified Nursing Assistant (CNA) Staff #3 who stated he saw Resident #6 hit Resident #4 and they were separated. Resident #4 was sitting in her long chair and Resident #6 got upset and then hit Resident #4. They were immediately separated. This happened in front of the nursing station. A report was made by Licensed Practical Nurse (LPN) Staff #4. An interview was conducted on June 3, 2025 at 1:13 p.m. with Registered Nurse (RN) Staff #2 and revealed that when you see any type of abuse, you report it to the manager on duty, then to the administrator and do a state report right away. Does not recall incident. An interview was conducted on June 3, 2025 at 1:40 p.m. with Director of Nursing (DON) Staff #1 revealed that abuse training is done multiple times a year. Both ladies were by the nurses station. Resident #4 is very touchy and reached out to Resident #6 and Resident #6 smacked Resident #4's hand. Staff #3 broke it up after three smacks. Resident #4 has now passed (unable to interview Resident #4). Review of the policy Resident Abuse and Neglect Updated/Revised February 9, 2024 revealed that Rim Country Health has developed a zero tolerance policy related to resident abuse. Physical abuse is defined as hitting, slapping, pinching, kicking, etc.

Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure two residents (#20 and #22) were not physically abused in a resident to resident altercation. The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Regarding Resident #20: Resident #20 was readmitted to the facility November 18, 2024, with diagnoses that included anxiety disorder, insomnia, flaccid hemiplegia affecting left side, dysphagia, difficulty in walking, dysarthria, and acquired absence of left leg below the knee. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A care plan initiated November 21, 2024, revealed Resident #20 has the potential to demonstrate physical behaviors like striking out at staff or fell ow residents due to poor impulse control and dementia, with interventions to analyze key times, places, circumstances, triggers, and what de-escalates behavior and document, monitor frequently and document any behaviors in a behavior progress note, and attempt to intervene when able. A Behavior note dated February 16, 2025, revealed a nurse observed that Resident #20 quickly propelled his wheelchair into the dining area and toward another resident and aggressively struck her drink off the table with significant force while shouting. The residents were separated. A Behavior note dated March 12, 2025, revealed the Resident #20 was on an outdoor porch during a smoking session and began pushing the furniture around. Resident #20 got behind another resident and grabbed a piece of the brief on the resident in front if him and raised the piece of brief above his head. Staff intervened and Resident #20 lowered his hand back to his side. A Behavior note dated March 29, 2025, revealed Resident #20 was in his wheelchair and another resident was in front of him in the hallway. Resident #20 stated to the other resident to get out of the way. Staff stated to Resident #20 that the other resident was not in the way. Resident #20 turned around very angry and pushed a table which fell to the floor. Staff accompanied the resident to his room. An Incident Note dated April 9, 2025, revealed Resident #20 had an altercation with another resident. Incident was witnessed by certified nursing assistants (CNAs) who stated that the other resident was trying to get to an empty chair and Resident #20 was in the way. CNAs state that the other resident punched out at Mr. [NAME] and ended up losing his balance and falling to the floor. Resident #20 swung at the other resident and grabbed/pulled the other resident's leg. Then, the CNAs intervened and separated the two residents. -Regarding Resident #22: Resident #22 was readmitted to the facility on [DATE], with diagnoses that included altered mental status, cognitive communication deficit, atrial fibrillation, chronic kidney disease, and rhabdomyolysis. An MDS assessment had not been completed due to the resident's newly admitted status. There was no evidence that a BIMS assessment had been completed. A care plan initiated April 8, 2025, indicated for behavior management, with interventions that included encourage participation in self-calming behaviors such as breathing exercises, meditation, or guided imagery, ensure the safety of the resident and others, and establish boundaries and limits with the resident. A Behavior note dated April 8, 2025, revealed Resident #22 was wandering the halls throughout the shift, and made several attempts to get off the unit. A Behavior note dated April 9, 2025, revealed the resident was exit-seeking, resisting personal care, and very agitated with nursing staff. Staff performing frequent checks on the resident. A Behavior note dated April 9, 2025, revealed the resident continues to roam hallways, making several attempts to get off the unit. An Incident Note dated April 9, 2025, revealed Resident #22 became upset that another resident was in his way when he wanted to sit in an empty chair. Resident #22 told the other resident to move and struck out at him and fell to the floor. The other resident punched back. Resident #22 then tried to kick the other resident and had his leg grabbed and pulled. At this point the CNAs who witnessed the altercation separated the two residents and called for the nurse. A witness statement from a CNA (Staff #41), dated April 9, 2025, revealed that at 5:00 PM, Resident #20 and Resident #22 had an altercation in front of the nurse's station. Resident #22 wanted to sit in an empty chair, and Resident #20 was sitting in his wheelchair between Resident #22 and the empty chair. Resident #22 demanded that Resident #20 move so he can sit in the chair. Resident #20 did not move. Resident #22 then punched at Resident #20 but did not connect, lost his balance, and fell to the floor. Resident #20 punched Resident #22 on the upper right arm. Resident #22 then kicked Resident #20 in the stomach, and Resident #20 grabbed his leg. CNAs (Staff #41 and Staff #55) intervened and separated the residents. The nurse (Staff #33) was called to assist. A witness statement from a CNA (Staff #55), dated April 9, 2025, revealed that Resident #20 and Resident #22 had an altercation in front of the nurse's station. Resident #22 wanted to sit in an empty chair and said Resident #20 was in the way. Resident #22 told Resident #20 to move and punched him back. Resident #22 kicked at Resident #20, and Resident #20 pulled Resident #22's leg. CNAs (Staff #41 and Staff #55) intervened, separated the residents, and called the nurse. An observation was conducted on April 17, 2025, at 11:06 AM, of Resident #22. The resident was observed to have bruising to the back of his left hand and scabs on the base of the middle finger of his left hand. An interview was conducted with a Licensed Practical Nurse (LPN / Staff #33) on April 17, 2025, at 10:40 AM. Staff #33 stated that he did not witness the event, and that he was not on the unit at that time. When he returned, the CNAs had separated the two residents, and Resident #22 had a couple skin tears on the left hand. Staff #33 stated he notified the physician and the resident's families, and nursing supervisor. An interview was conducted with a CNA (Staff #41) on April 17, 2025, at 10:53 AM. Staff #41 stated it was around 5:00 PM, and Staff #41 was sitting at the nurse's station desk. Staff #41 stated that in front of the nurse's station, Resident #22 stated for Resident #20 to move out of his way so he could sit in a chair. Resident #22 got upset because Resident #20 did not move, and then punched at Resident #20 and fell . Resident #22 was sitting in a wheelchair and punched Resident #22 on his shoulder. Resident #22 then kicked Resident #20 forcefully in the stomach, and Resident #20 then grabbed the foot of Resident #22. Then, Staff #41 stated that she and Staff #55 separated the two residents. On April 17, 2025, at 11:04 AM, an interview was conducted with Resident #20 who did not recall the incident. On April 17, 2025, at 11:06 AM, an interview was conducted with Resident #22 who could not recall the incident. An interview was conducted on April 17, 2025, at 11:09 AM, with a CNA (Staff #55) who stated it was around 4:00 PM when she was at the nurse's station and she observed the altercation between Residents #20 and #22. Staff #55 stated that the facility was short-staffed the day of the incident, that normally there are two CNAs on the right side of the unit, and one CNA on the left side, but that day there was only one CNA. Staff #55 stated that Resident #22 struck at Resident #22 with a fist and kicked Resident #20, and Resident #20 held the leg of Resident #22. Staff #55 stated she called the nurse on the radio, and the residents were kept separated. Staff #55 stated that the nurse put a bandage on Resident #22's knee abrasion. On April 17, 2025, at 11:40 PM, an interview was conducted with the Director of Nursing (DON / Staff #90), who stated to prevent abuse in the facility, staff develop personalized care plans for residents, that staff are made aware of what is going on with residents and act proactively to remove residents from escalating situations. The DON stated that abuse is absolutely not tolerated in the facility, and that examples of abuse could be a resident physically or verbally striking out at another resident. The DON stated the facility prevents abuse by performing frequent checks on residents, and by MDS nurses creating accurate care plans. The DON stated that the impact to residents if abuse occurs could be physical or psychosocial harm. The interview continued and the DON stated her understanding of the incident was that Resident #22 demanded that Resident #20 move, and that Resident #20 did not move quickly enough. Resident #22 swung and fell on his side. Resident #20 did lean forward and punch Resident #22 in the right upper arm. Resident #22 kicked out and contacted Resident #20 in the stomach. Resident #20 held onto Resident #22's leg. The DON stated that Resident #22 sustained a skin tear on the middle finger of his left hand, and that afterward the residents were kept separated. Review of the facility policy titled Resident Abuse and Neglect, updated August 2, 2024, revealed the facility is committed to the physical, mental, social and emotional wellbeing of the resident and has thus developed a zero-tolerance policy related to resident abuse. Any incident or suspected incident of resident abuse or un-witnessed injury that cannot be explained will be reported promptly to the appropriate agencies and individuals, Director of Nursing and Administrator. The facility will not tolerate abuse by anyone including but not limited to staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It is the responsibility of the facility to identify any resident whose personal history puts them at risk for abusive behavior and to develop intervention strategies to prevent occurrence, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis.

Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for two residents (#20 and #22) regarding assessment following an incident of abuse. The deficient practice could result in care team members not being adequately informed regarding the status of residents and lead to missed or delayed care. Findings Include: -Regarding Resident #20: Resident #20 was readmitted to the facility November 18, 2024, with diagnoses that included anxiety disorder, insomnia, flaccid hemiplegia affecting left side, dysphagia, difficulty in walking, dysarthria, and acquired absence of left leg below the knee. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. An Incident Note dated April 9, 2025, revealed Resident #20 had an altercation with another resident. Incident was witnessed by certified nursing assistants (CNAs) who stated that the other resident was trying to get to an empty chair and Resident #20 was in the way. CNAs state that the other resident punched out at Mr. [NAME] and ended up losing his balance and falling to the floor. Resident #20 swung at the other resident and grabbed/pulled the other resident's leg. Then, the CNAs intervened and separated the two residents. The clinical record was reviewed and there was no evidence of documentation of a head to toe assessment, or any injuries sustained, for Resident #20 following the incident. -Regarding Resident #22: Resident #22 was readmitted to the facility on [DATE], with diagnoses that included altered mental status, cognitive communication deficit, atrial fibrillation, chronic kidney disease, and rhabdomyolysis. An MDS assessment had not been completed due to the resident's newly admitted status. An Incident Note dated April 9, 2025, revealed Resident #22 became upset that another resident was in his way when he wanted to sit in an empty chair. Resident #22 told the other resident to move and struck out at him and fell to the floor. The other resident punched back. Resident #22 then tried to kick the other resident and had his leg grabbed and pulled. At this point the CNAs who witnessed the altercation separated the two residents and called for the nurse. The clinical record was reviewed and there was no evidence of documentation of a head to toe assessment, or any injuries sustained, for Resident #22 following the incident. A witness statement from a CNA (Staff #41), dated April 9, 2025, revealed that at 5:00 PM, Resident #20 and Resident #22 had an altercation in front of the nurse's station. Resident #22 wanted to sit in an empty chair, and Resident #20 was sitting in his wheelchair between Resident #22 and the empty chair. Resident #22 demanded that Resident #20 move so he can sit in the chair. Resident #20 did not move. Resident #22 then punched at Resident #20 but did not connect, lost his balance, and fell to the floor. Resident #20 punched Resident #22 on the upper right arm. Resident #22 then kicked Resident #20 in the stomach, and Resident #20 grabbed his leg. CNAs (Staff #41 and Staff #55) intervened and separated the residents. The nurse (Staff #33) was called to assist. A witness statement from a CNA (Staff #55), dated April 9, 2025, revealed that Resident #20 and Resident #22 had an altercation in front of the nurse's station. Resident #22 wanted to sit in an empty chair and said Resident #20 was in the way. Resident #22 told Resident #20 to move and punched him back. Resident #22 kicked at Resident #20, and Resident #20 pulled Resident #22's leg. CNAs (Staff #41 and Staff #55) intervened, separated the residents, and called the nurse. An observation was conducted on April 17, 2025, at 11:06 AM, of Resident #22. The resident was observed to have bruising to the back of his left hand and scabs on the base of the middle finger of his left hand. An interview was conducted with a Licensed Practical Nurse (LPN / Staff #33) on April 17, 2025, at 10:40 AM. Staff #33 stated that he did not witness the event, and that he was not on the unit at that time. When he returned to the unit, the CNAs had separated the two residents, and Resident #22 had a couple skin tears on the left hand. Staff #33 stated he notified the physician and the resident's families, and nursing supervisor of the incident. Staff #33 stated he assessed the residents following the incident, but could not remember if he had documented it in the clinical record. An interview was conducted on April 17, 2025, at 11:09 AM with a CNA (Staff #55) who stated it was around 4:00 PM when she was at the nurse's station and she observed the altercation between Residents #20 and #22. Staff #55 stated that Resident #22 struck at Resident #22 with a fist and kicked Resident #20, and Resident #20 held the leg of Resident #22. Staff #55 stated she called the nurse on the radio, and the residents were kept separated. Staff #55 stated that the nurse put a bandage on Resident #22's knee abrasion. On April 17, 2025, at 11:40 PM, an interview was conducted with the Director of Nursing (DON / Staff #90), who stated her understanding of the incident was that Resident #22 demanded that Resident #20 move, and that Resident #20 did not move quickly enough. Resident #22 swung and fell on his side. Resident #20 did lean forward and punch Resident #22 in the right upper arm. Resident #22 kicked out and contacted Resident #20 in the stomach. Resident #20 held onto Resident #22's leg. The DON stated that Resident #22 sustained a skin tear on the middle finger of his left hand, and that she was not aware of any other injuries. The clinical record was reviewed, and the DON stated there was no documentation in the progress notes or assessment lists or anywhere in the medical record of either resident that indicated an assessment of the residents was completed following the incident, or any injuries sustained. The DON stated that this would not meet her expectation and that it would not be adequate for the medical record. A formal request was made on April 17, 2025, to the facility for the policy on documentation in the clinical record, and the DON signed a statement that the facility had no policy. Review of federal regulation S483.70(h), revealed the facility must maintain medical records, in accordance with accepted professional standards and practices, on each resident that are complete, accurately documented, readily accessible, and systematically organized.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of one sampled residents (#5) was safe to self-adminster medication. The deficient practice could result in a medication overdose. Resident #5 was initially admitted on [DATE], with a diagnoses of bipolar disorder, shortness of breath, and major depressive disorder. Review of the clinical record revealed no evidence of a medication self-administration order for: Floonase Propionate 50 MCG/ACT suspension [NAME] Ellipta Aerosol Power 100-25 MCG Review of the clinical record revealed no evidence of a medication self-administration assessment. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A Care Plan dated January 20, 2025 revealed no indication of a focus for medication self-administration. An observation was conducted on February 25, 2025 at approximately 1:38 P.M. of the resident ' s room.Two medications were observed not in a lock box and were on the resident's bed . The medications included Floonase Propionate 50 MCG/ACT, and [NAME] Ellipate Aerosol Power 100-25 MCG. An interview was conducted on February 25, 2025 at 1:41 P.M. with Licensed Practical Nurse (LPN/ Staff #156) in the resident ' s (#5) room. The LPN stated that the resident has an order to have the medication at bed side. The LPN looked at both of the medication labels and placed it back onto the resident ' s bed for both . A clinical record review was conducted on February 25, 2025 at 2:07 P.M. with (LPN/staff #156 ) who stated that she was unable to find a record of medication self-administration assessment. She further stated that she will contact the provider about the medication self-administration assessment. An interview was conducted on February 26, 2025 at 1:20 P.M. with Director of Nursing (DON/Staff #320) who stated she had reviewed the clinical record for resident #5 and was unable to find an assessment of medication for self-administration. She further stated that she will contact the provider to get the medication self-administration assessment document. A further interview was conducted on February 27, 2025 at 12:09 P.M. with (DON/staff #320) who stated that in their facility policy, if the resident wants to self-administer medication, the interdisciplinary team (IDT) in conjunction with the provider would assess the resident ' s ability to safely self-administer medications.The DON further stated that the assessment had been completed but was unable to provide any evidence of a medication self-administration assessment. She further stated the risk would be that there would be no paperwork to back up the proof that an assessment was done for medications self-administration. Review of the policy titled Self-Administration of Medication revision dated August 1, 2023 noted the resident has the right to self-administer their own medication provided that the IDT has determines that the resident can safely perform this task. The policy further stipulates that residents who self-administer medications must keep the medications in a lock box to which the resident and nurse have a key. Review of the policy entitled Medication Administration revised dated August 4, 2023 noted that no medication will be left unattended at bedside.

Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications were administered according to provider orders for one resident (#30). This deficient practice could result in side effects leading to negative resident outcomes. Findings Include: Resident #30 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, anxiety disorder, and gastro-esophageal reflux. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was not conducted because residents is rarely or never understood.The staff assessment of cognitive patterns for this resident revealed that the resident has both short and long term memory problems and his daily decision making skills are noted as severely impaired. A physician order dated November 29, 2024 revealed Midodrine HCL tablet 10 MG (milligrams) to be given by mouth every 6 hours as needed for low blood pressure, systolic BP less than 90. Review of the Medication Administration Record (MAR) for December 2024 through February 2025 revealed that medications were administered outside of physician ordered parameters on: December 2024: 8, 15, 17, 22, 31 January 2025: 21 February 2025: 6, 18 An interview was conducted on February 27, 2025 at 10:15 A.M. with Licensed Practical Nurse ( LPN/Staff #39) who stated that the best way to give all medication is to check the resident ' s blood pressure prior to giving medication.The LPN stated that when medication is given outside of the parameter, staff would need to make a report and contact the provider because this is a medication error. He further stated that the consequence of this would be that the resident ' s blood pressure would spike. A clinical record review was conducted on February 27, 2025 AM at 10:21 A.M. with (LPN/Staff #39).The LPN stated that the orders for the midodrine say to give when blood pressure is less than systolic of 90. He stated that on February 6, 2025 the resident blood pressure was (119/59) and (104/49) , and on the 18th of February 2025 the resident blood pressure was (120/61). He further stated that the medication was not given within parameters and this could lead to resident blood pressure to spike. (LPN/Staff #39) stated that December 15, 2024 resident blood pressure was (97/45) and (103/65) , December 17, 2024 resident blood pressure was (110/60) and December 31 resident blood pressure was (92/58). He further stated that the medication should not have been given. An clinical record review was conducted on February 27, 2025 at 11:13 A.M. with Director of Nursing (DON/Staff #320) who stated that on February 6, 2025 the blood pressure was (119/59) and went down to (104/49). The DON called the Licensed Practical Nurse who documented the blood pressure on February 18, 2025. The LPN(Staff #17) called back the DON to state why the medication was given that day. The LPN/(Staff#17) stated via phone interview that the resident ' s daughter had requested the medication to be given. The DON stated that on February 21, 2025 there were no progress notes regarding the blood pressure and that the reason why blood pressure was not documented on that date is because the Certified Nurse Assistant(CNA) charted it on paper before the nursing staff then documented in the resident ' s chart. She further stated that on February 22, 2025 the nurse documented the blood pressure (95/49) that was taken on February 21, 2025 into the system. The DON stated that this medication was given outside parameters. A further clinical record review was conducted on February 27, 2025 at 11:50 A.M. with (DON/Staff #320) who stated that the review of the Medication Admission Record (MAR) for December 31, 2024 blood pressure was (92/58), December 17th, 2024 blood pressure was (110/60), December 15th, 2024 (97/45) and (103/65). She stated that for December 15th, 2024 one of those blood pressures could be manual done and the other one was done mechanical. She further stated that based on what was reviewed this did not follow physician ' s orders. The DON stated that she would expect a progress note if the family requested medication to be given outside of the parameters. She stated that she expects that staff to document pre and post blood pressure. The DON stated that the risk of this medication being given outside of parameters would increase blood pressure. She further stated that the risk of not documenting correctly for the blood pressure would cause the provider not to realize that the medication is not given within parameters. Review of the facility policy titled Medication Administration/MAR reviewed or revised and reviewed dated August 4, 2023 the nursing staff will document the date, time, drug,dose, route and site on the EMAR as well as resident response if indicated.

Based on observations, staff interviews, and policy review, the facility failed to ensure kitchenware were following professional standards of practice. The deficient practice could result in residents becoming ill. Findings include: On February 26, 2025 at 10:52 a.m., a brief kitchen inspection was conducted with the Dietary Director (DD/staff #321) and the Register Dietician (RD/staff #400). Both the DD and RD stated that a low temperature dishwashing machine is used which runs at 120 degrees Fahrenheit (F). In addition, Staff #400 stated that they use sanitizer/chlorine for the dishwashing machine. At this time, Staff #400 conducted a test strip to determine the dishwasher sanitation, and stated that the strip was about 100 ppm. An interview was conducted on February 26, 2025 at 12:40 p.m., with the RD (staff #400) who stated that the chlorine range of 200 ppm was beyond the set limits for sanitation in the dishwasher machine. He then stated that the deviation on chlorine could be related to the QUAT test strips were used instead of chlorine test strip for dishwasher by kitchen staff. The RD further stated that the risk of running dish machine with too much chlorine could be utensils getting too much chemicals which is hazards to residents health. He also stated that he conducted in-service training with all kitchen staff today regarding the deviation in chlorine and proper documentation of chlorine range on log form titled Food Temperature/Sanitation Record. An interview was conducted on February 26, 2025 at 02:07 p.m., with the DD (staff #321) who stated that the dishwasher machine generally run by the kitchen aids and she guess a low temperature dishwashing machine is used which runs at 120 degrees Fahrenheit (F). She then stated that chlorine tests on dish machine was conducted by every shift and are documented on log form titled Food Temperature/Sanitation Record, and she reviews the log weekly. The DD then reviewed the document titled Food Temperature/ Sanitation Record Log form from January through February, 2025, and stated that as far as sanitation chlorine range for dishwasher machine was above 50ppm then we are good as per manufacturer instructions. The DD then stated that the only risk could be excess chlorine chemical in dish machine is going into utensils which would take out coating from silverwares which prevents rust. On February 26, 2025, surveyor received the requested documents for the dish machine temperature and sanitization log for the months of January through February, 2025. The document titled, Food Temperature/ Sanitation Record Log revealed for breakfast, lunch and dinner sanitation column has daily logged as 200 parts per million (ppm) from January through February, 2025. On February 27, 2025, at 9:34 a.m., the administrator (staff # 300) stated that sanitation log form has documentation error and dishwasher machine is not running at 200 ppm but at 100 ppm. He also stated that the staff were taught incorrectly and told to write that range by previous kitchen director even if machine is showing 50-100 ppm. We also educated our staff now and did in-service training as plan of correction. An interview was conducted on February 28, 2025 at 08:28 a.m., with a dietary aide (staff # 122) who stated that dishes are cleaned after every meal, using chlorine as a sanitizer and document sanitation/chlorine range on the log form titled Food Temperature/Sanitation Record. He then stated that the dishwasher machine was showing error of 200 ppm, every time he tested but he never notified anyone. He further, stated that the log forms were generally reviewed by with the dietary director (staff #321). He also stated that the DD and the RD informed all kitchen staff that the sanitation chemical was too high and provided staff with the training on how to test temperature and sanitation on dishwasher machine couple days ago. Review of the manufacturer's instructions for low dishwashing machine titled, American Dish Service Installation Instructions, indicated not to exceed 50 parts-per-million (PPM) free or available chlorine, using higher than 50 ppm will be dependent on local health requirements. Review of facility's policy titled, Recording of Dishmachine Temperature, August 29, 2023 revealed The concentration of the sanitary solution during the rinse cycle is 50-100 ppm with Chlorine sanitizer. This is used on low temperature dishmachines. Assure that test strips are within the Use-By date and not outdated.

Based on clinical record review, staff and caregiver interviews, and policy and procedures, the facility failed to ensure medications were securely stored in accordance with professional standards for one resident (#10). The deficient practice resulted in resident hospitalization . Findings include: Resident #10 was admitted on [DATE], with diagnoses of essential hypertension, adult failure to thrive, atherosclerotic heart disease, anxiety disorder, and major depressive disorder. The nursing note dated February 6, 2025 at 8:00 a.m. revealed that the resident was found unresponsive and unknown medications were found with resident. Per the documentation, the resident was sent to the local emergency department (ED) for further evaluation. Further review of the clinical record revealed no additional documentation regarding this incident. During an initial interview with the Director of Nursing (staff #124) conducted on February 11, 2025 at approximately 2:55 p.m., the DON stated that the resident was admitted to the facility on [DATE] at approximately 8:00 p.m.; and, was later found unresponsive with empty medication bottles with the resident on February 6, 2025 at approximately 6:10 a.m. The DON further stated that the resident's family reported giving the box of resident's medications to the nurse; and that, the resident's family had seen the registered nurse (RN/staff #19) put the bottles of medications in the medication cart. The DON also said that the other medications of the resident were destroyed. An interview was conducted on February 12, 2025 at approximately 9:45 am with a licensed practical nurse (LPN/staff #48) who stated that he arrived for his shift that day at approximately 6:00 a.m. and received a report from previous nurse (RN/staff #19) who was concerned about a small turquoise box of medications that were missing that belonged to the resident; and that, the medications were not immediately located or secured. The LPN stated he was then asked by a certified nursing assistant (CNA/staff #31) to come to the room of resident #10. He stated that he found resident #10 unresponsive, had a labored breathing and had a very low BP (blood pressure). The LPN said that the resident also had a blue box between her legs with medication bottles in it and one of the medication bottles was clonazepam (anti-anxiety) was opened and laying on top. The LPN stated he attempted to arouse the resident using a sternal rub with no response from the resident and then called the nurse manager and 911. Further, he stated that when the resident's bedding was pulled back in preparation for paramedics, there were three (3) additional empty medication bottles found on the resident's bed. He stated that one bottle was for Isosorbide (vasodilator), second bottle was for Plavix (platelet inhibitor) and he could not recall what the third bottle was for. He stated that the paramedics arrived and began treatment of the resident and he gave the empty medication bottles to the paramedics; and that, the resident was then taken to the local hospital. The LPN said that he then took the blue box to the medication room and locked it in that room. However, he does not know where the box was now or what happened to it after he locked it in the medication room; and, he did not see the box again. He stated that he was not aware of any additional keys to the medication room. The LPN stated that later in the shift that day (February 6, 2025) a hospital physician from the metro area called and asked about the events that led to the incident; and that, the hospital physician was not from the local hospital that the resident was taken to. The LPN stated that the hospital physician told him that the resident was admitted at the hospital in the metro area; and that, the resident was intubated in the hospital and was nonresponsive. Further, the LPN stated that the DON also asked him questions about the incident. During an interview with the CNA (staff #31) conducted on February 12, 2025 at 10:39 a.m., the CNA stated that he arrived for work around 6:00 a.m. that day; and, he taking vital signs. The CNA stated that he entered the room of resident #10 who was still and did not wake up so he attempted again to wake up the resident but the resident did not. He stated that he then called out for the LPN (staff #48). The CNA stated that the resident's BP was very low; and, there was a blue box between the resident's legs with an empty bottle on top. The CNA stated that the LPN (staff #48) took a picture of the box and then left the room to call 911. He stated that while waiting for the LPN to return he continued to try to awaken the resident with no response. The CNA also said that when the LPN returned and acknowledged that 911 was coming, he and the LPN pulled the blanket back and found three more open, empty medication bottles. He stated that when the paramedics arrived and began treating the resident he had no further involvement. The CNA further stated that no one had asked him any questions regarding this incident prior to this interview. A phone interview with the resident representative (RR) was conducted on February 12, 2025 at approximately 11:12 a.m. The RR stated that she was the resident's primary caregiver at home; and, she was in charge of the resident's medications at home and the resident did not have access to medications at home. She also said that on the day of the resident's admission at the facility, she had a blue box containing the resident's medications that she gave to an RN (staff#19) whom she identified by name. The RR said that she saw the RN take the box and placed it in a room where they keep medications; and that, there were no medications in resident's room. She further stated that at around 4:30 a.m. or 5:00 a.m., the RN (staff #19) called her to ask if she had taken home the box of resident's medications; and that, she told the RN (staff #19) that she gave it to the RN. The RR also said that between 6:30 a.m. and 7:00 a.m., the LPN (staff #48) called her and told her of the incident. She stated that the resident had been transferred from the local hospital to a larger hospital in the metro area; and that, the resident remained intubated and unresponsive. In another interview with the DON (staff #124) conducted on February 12, 2025 at approximately 11:35 a.m., the DON stated that the resident representative (RR) told her that the resident may have been suicidal. The DON further stated that the RN (staff #19) called the RR prior to the end of the RN's shift in an effort to reconcile medications. The DON retracted her prior statement that all the resident's medications were destroyed; and it was and error. The DON said that all of the resident's medications were sent with resident to the hospital. On February 12, 2025 at approximately 11:40 a.m., the DON initiated a telephone communication with the hospital case manager involved in the admission of the resident to the facility. The DON stated that the case worker told her that the resident representative (RR) told the case worker that the resident was behavioral; and that, that after the incident on February 5, 2025 the RR informed the case worker that the resident may have been suicidal. Multiple attempts were made to conduct a phone interview with the RN (staff #19) on February 12, 2025 but was unsuccessful. The RN did not answer and/or return the call. In an interview with another RN (staff #65) working in the facility conducted on February 12, 2025 at 1:05 p.m., the RN stated that if a family brought in medications for a resident, she would reconcile those medications and notify the physician. The RN stated that if she was unable to reconcile the medications at the time they were delivered or given to her she would lock them in the medication cart until she was able to reconcile them because she would be responsible for the medications. She further stated that even in an emergency she would secure the medications. During another interview with the DON (staff # 124) conducted on February 12, 2025 at approximately 1:10 p.m., the DON stated the expectation was that the nurse would secure medications in the medication cart or in the medication room until the nurse were able to complete a reconciliation. She stated that medications should never be left in a resident's room. Regarding the incident, the DON stated that according to the report from the resident's RR, the RN (staff #19) acted appropriately by securing the box of resident's medications in the medication cart/room. However, the DON was unable to say where the box of medications went after the LPN (staff #48) secured it in the medication room. She stated that the LPN (staff #48) took pictures of the box and sent the pictures to her but these pictures were immediately deleted from the LPN's and DON's phone because these were HIPAA (Health Insurance Portability and Accountability Act) violation. The facility policy on Security of Medications with revision date of March 25, 2022 included that the facility will ensure the security of all medications in the facility to maintain resident and staff safety. Nursing will ensure that all medications are secured at all times. Nurses must ensure that the medication cart is securely locked at all times when not in nurses view. Only licensed staff will have access to any area that medications are stored.

Based on documentation, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#21) did not abuse another resident (#32). The deficient practice could result in residents being physically and/or emotionally injured. Findings include: -Resident #32 was admitted on [DATE] with diagnosis that included unspecified dementia with unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance, schizoaffective disorder, Alzheimer's disease and anxiety. A review of the annual MDS (minimum data set) dated December 6, 2024 revealed a BIMS (brief interview of mental status) score of 01, indicating severe cognitive impairment. The MDS further revealed no noted potential indicators of psychosis, but did note physical behaviors 1-3 days and wandering 4-6 days within a week. The care plan revealed that resident #32 uses psychotropic medications for behavior management, schizoaffective disorder, anxiety and dementia with behaviors. Furthermore, the care plan indicated that resident #32 was a wanderer, at risk for impaired thought processes and has the potential to be unable to avoid a physical confrontation with a fell ow resident due to dementia. -Resident #21 was admitted on [DATE] with diagnosis that included senile degeneration of the brain, Alzheimer's disease, dementia of unspecified severity with psychotic disturbance and other mixed anxiety disorder. A review of the quarterly MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. The MDS further revealed that the resident had no noted potential indicators of psychosis and that verbal behaviors were present 1-3 days per week. A review of the physician orders revealed that the resident was prescribed lorazepam (Psychotropic medication) and quetiapine fumarate (Psychotropic medication). The care plan for resident #21 revealed that the resident uses psychotropic medications, is at risk for impaired thought processes, has the potential to demonstrate verbally abusive behaviors and has demonstrated the physical behavior of slapping another resident (noted posted incident). A review of the progress notes dated December 12, 2024 at 1:52 P.M. revealed that a nurse was standing at the nurse's station when she heard yelling from the dining room. It was noted that a resident who was sitting in front of the nurse's station stated that that lady just slapped that man across the face. It was noted that the nurse ran over to separate the residents and asked the resident if she had slapped the gentleman, to which it was noted that she replied I did slap him but don't ask me why I can't remember. No injuries were noted in the progress notes. Review of the electronic health record revealed no evidence of prior physical resident to resident altercations. A review of the facility 5-day investigation revealed that on December 11, 2024 at 8:35 P.M. resident #21 was in the dining room in the secured behavioral unit with fell ow resident #32. It was noted that resident #32 was propelling his wheelchair past resident #21 and bumped into her when she struck resident #32 with a open hand to his left cheek. It was noted that the residents were separated and that no injuries were observed. It was noted that resident #24 had witnessed the incident and that staff #13 had separated the residents. The report further revealed that resident #21 did state that she hit resident #32 but could not recall why. An interview was attempted with resident #32 on December 26, 2024 at 12:32; however, the resident refused to answer any questions. An interview was conducted with the Human Resource Director staff #20 on December 26, 2024 at 12:36 P.M. as the director of nursing, administrator were not available and the facility did not have an assistant director of nursing. Staff #20 stated that the expectation is for resident to resident altercations not to happen and that effective interventions suited to the resident are expected to be carried out. She stated that staff had recently gone through behavioral health training, identifying triggers, which was extremely beneficial. Two trainings had been conducted on the 18th of November 2024 and the other on the 12th of December, 2024. She stated that the risk with resident to resident altercations is not protecting the resident from being abused, injury, getting hurt, fear and not understanding why it had happened. She stated that she was aware of the incident and that it had occurred during the evening meal when the altercation occurred but she had not been involved in the investigation. She further stated that the facilities 5-day investigation did not address the absence of staff in the pine dining room, but stated that it should have been addressed. An interview was conducted with LPN (staff #21) on December 26, 2024 at 2:02 P.M. Staff #21 stated that staff receive ongoing training for behavioral health related concerns. He stated that when an incident occurs, residents are separated and assessed for injuries right away and then the formal reporting process starts. He stated that in the dining room area there should always be staff present. He stated, that during meal times, if staff is not present the residents could also be at risk for choking or other injuries. He stated that he was not aware of any resident to resident altercations on his unit. An interview was conducted with resident #24 on December 26, 2024 at 3:15 P.M. Resident #24 stated that she observed resident #21 slap resident #24. The resident, per MDS dated [DATE], is noted to have a BIMS score of 13, indicating that she is cognitively intact. She stated that they were just talking to each other and then resident #21 slapped resident #32 for no reason. She stated that the incident had occurred in the dining room. She stated that 3 staff were present on the unit and felt that enough staff were there but that the incident had just happened so fast. She stated that she did not observe any injuries on resident #32, but that resident #21 had a history of being aggressive. A review of the policy entitled Resident Abuse and Neglect with a review date of August 2, 2024 revealed that the facility has a zero-tolerance policy related to resident abuse and that abuse will not be tolerated by anyone including other residents. The policy further defines physical abuse as hitting, slapping, pinching, kicking, etc.

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #2 was free from abuse from resident #1. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider when the resident appears to be a danger to others. There was no evidence that this focus area was in the resident's care plan prior to November 11, 2024. A nurse's note, dated November 11, 2024, revealed a late entry note. The note indicated that at 8:50 AM a Certified Nursing Assistant (CNA) called for help and the nurse was informed that resident #1 had punched another resident in the head twice behind the right ear. The note also indicated that both residents were in their wheelchair and were then separated. A review of a hospital's health and progress notes revealed resident #1 was taken to the emergency room due to his aggression towards another resident and for a possible urinary tract infection. The note also indicated resident #2 stated he was forced to leave and to put it frankly there was a bitch walking up and down the hallway that was waking me up. Regarding Resident #2: Resident #2 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, trochanteric bursitis in the right hip, anxiety disorder, and difficulty walking. Review of the quarterly MDS assessment, dated October 27, 2024, revealed a BIMS score of 03 which indicated the resident was cognitively impaired. A care plan, last revised on October 23, 3034, revealed resident #2's risk of having impaired thought processes. Interventions included keeping the resident's routine consistent and reporting any changes related to cognitive function to the provider. A nurse's note, created on November 15, 2024 but effective on November 11, 2024, indicated a full head to toe assessment was completed after the incident; there were no injuries noted and vital signs were within normal limits. An interview was conducted with resident #1 on November 20, 2024 at 9:58 AM. Resident #1 explained that he was upset that resident #2 had hit him on his back and then he had gotten upset and hit her. He was not able to identify who resident #2 was. An interview was conducted with a Registered Nurse (RN/staff #65) on November 20, 2024 at 10:24 AM. Staff #65 confirmed that she was working on the 11th and did not witness the actual abuse but had heard staff #49 yelling for help at the end of the hall. Staff #49 had then told staff #65 that resident #1 had punch resident #2 on the left side of the head two times. Staff #65 indicated that she completed a full assessment on both residents, who were both in a wheelchair, and there were no visible injuries. She also indicated that resident #1 was assigned a 1 on 1 sitter for the rest of her shift. An interview was conducted with CNA/staff #49 on November 20, 2024 at 10:53 AM. Staff #49 confirmed she was working on November 11, 2024 and had witnessed the altercation between resident #1 and resident #2. Staff #49 explained she was in the hallway and both residents were at the end of the same hallway with resident #1 facing towards staff #49 and resident #2 was facing away from staff #49. She heard resident #2 voice out stop it and so staff #49 ran down the hall while yelling out for help from other staff members. She then heard resident #1 say get the fuck away from me, as resident #2's hand was up trying to block herself from resident #1's hand while she said ow. Staff indicated she had seen resident #1 hit resident #2 on the left side of the head near her ear. Staff #49 then pulled resident #2's wheelchair away from resident #1 while the other two staff members redirected resident #1. Staff #49 indicated that it was the first time she had seen resident #1 have a physical outburst as he usually will have verbal outburst. An interview was conducted with Resident #2 on November 20, 2024 at 11:09 AM. Resident #2 was not able to recall being hit by resident #1 and indicated that she currently felt safe at the facility. An interview was conducted on November 20, 2024 at 12:47 PM with the Director of Nursing (DON/staff #44). Staff #44 indicated that she had received a phone call from the facility explaining that resident #1 had hit resident #2 on the left side of her head, behind the ear, twice. Staff #44 indicated that after the incident took place, she informed resident #1 that the facility had zero tolerance for violence and had him meet with a psychiatrist via telehealth. After that appointment, the provider had determined resident #1 was a danger to himself and others so he ordered resident #1 to be sent to the hospital. When asked what the risks were related to allowing residents to abuse other residents, staff #44 stated that the facility would not be able to stay open if they were not able to protect their residents. Staff #44 indicated that resident #1 was supposed to be in the facility for 2 weeks as their family planned to move him out of state to be closer to them, however that has not yet happened. Review of the facility policy titled, Resident Abuse and Neglect indicated that abuse is defined as willful infliction of injury, and physical abuse is defined as hitting, slapping .

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1's care plan was updated to accurately reflect the resident's care. The deficient practice could result in residents not getting the appropriate care they need. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of acquired absence of left leg below the knee, dementia, and aphasia. A nurses' note, dated October 18, 2024 at 5:34 AM indicated resident #1 had raised his hand toward the nurse when the nurse refused to leave his morning medications on his table. No physical contact was made. A nurses' note dated, October 30, 2024 at 6:30 PM, revealed resident #1 had punched a Certified Nursing Assistant (CNA), on the front of the upper thigh, who was attempting to redirect him out of another resident's room. The note indicated the punch resulted in a large bruise which was 6 centimeters round on the CNA's thigh. A nurse's note, dated November 11, 2024, revealed a late entry note. The note indicated that at 8:50 AM resident #1 had punched another resident in the head. The care plan was revised on November 11, 2024 included that the resident has potential for physical behaviors towards staff and other residents due to poor impulse control. Interventions included addressing the resident's trigger of loud noises, intervening and redirecting when inappropriate behaviors are observed and notifying the provider when the resident appears to be a danger to others. There was no evidence that this focus area was in the resident's care plan prior to November 11, 2024. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated the resident was moderately cognitively impaired. A care plan note, dated November 22, 2024 at 9:00 AM indicated the resident's care plan was updated to reflect the recent physical behavior. An interview was conducted with resident #1 on November 20, 2024 at 9:58 AM. Resident #1 explained that he was upset that another resident had hit him on his back and then he had gotten upset and hit her. An interview was conducted on November 20, 2024 at 12:47 PM with the Director of Nursing (DON/staff #44). Staff #44 explained that resident #1 had hit and struck another resident on the side of the head, twice. She indicated that after the incident she spoke with the resident about the facility's zero tolerance for violence. Staff #44 had also explained that prior to the resident-to-resident altercation, resident #1 had hit one of her CNAs so hard that she couldn't walk that day. Staff #44 explained that the facility had accepted the resident knowing he had a history of physical behaviors at his previous placement because the plan was for the resident to be onsite for two weeks. After two weeks, the resident's daughter had planned to move the resident closer to her. However, the transfer did not happen as planned. Staff #44 indicated that care plans are updated by the facility's MDS coordinator (staff #37) and then she (staff #44) then signs off on them. Staff #44 indicated that she took full responsibility for the care plan not being updated after the resident-to-staff altercation took place and that I thought it was crazy we didn't have anything in the care plan about the physical behaviors prior, because the resident had a history of physical behaviors at the other facilities prior to coming here. Staff #44 indicated that the risk of not having care plans updated then abuse would not be noted as potential abuse. An interview was conducted with staff #37 on November 20, 2024 at 1:13 PM. Staff #37 confirmed that she is responsible for updating resident care plans. When asked what would be considered a change in a resident's condition, staff #37 indicated that resident falls, new skin conditions, and incidents would be some examples. Staff #37 indicated that she does update care plans after a resident to resident altercation however, she does not after a resident to staff altercation. Staff #37 indicated that she probably should have. She confirmed that she did update resident #1's care plan after his recent resident to resident altercation. When asked what would be the risk(s) to the residents if their care plan was not updated to include physical behaviors, she indicated that the risk would be that the incident could happen without anyone realizing what was going on with the resident. A review of the facility's policy titled, Change of Condition defines it as a decline or improvement in a resident's mental, psychosocial . functioning which requires a change in the resident's comprehensive plan of care. A review of the facility's policy titled, Care Plans and Care Plan Meetings indicates that care plans are updated as scheduled or as needed.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#9) were free from physical abuse resulting in injury by other residents (resident #23). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #9 was admitted to the facility on [DATE], with diagnosis that include Dementia, Psychotic disturbances, anxiety, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had mild cognitive impairment. A behavioral care plan revised April 7, 2023 revealed the resident is at risk for impaired thought processes related to vascular dementia, with a noted intervention of keeping the resident's routine consistent in order to decrease confusion when able. However, review of the care plan revealed no care plan measures addressing verbal or physical aggression showed by the resident. -Resident #23 was admitted to the facility on [DATE] with diagnoses that include Paranoid personality disorder, and other schizoaffective disorders, and a history of lobotomy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 which indicated the resident had moderate cognitive impairment. A behavioral care-plan initiated May 1, 2012, revealed the resident is at risk for mood swings and behaviors related to a history of a lobotomy as evidenced by verbally abusive behaviors, with noted interventions of when the resident becomes agitated, intervene before agitation escalates, and guide the resident away from sources of distress. Review of information received from the SA complaint tracking system revealed that on October 1, 2024, a complaint was received that revealed on October 1, 2024 at 6:25 p.m. on the secured memory and behavioral unit there was a resident to resident altercation after the evening meal in the dining room between resident #9 and resident #23. It further revealed that resident #23 grabbed resident #9 by her right arm when resident #9 was attempting to pass resident #23 to leave the dining room. Resident #9 then turned around and smacked resident #23 in her face with an open left hand. It continues that staff verbally intervened while approaching the residents asking them to separate. Resident #9 then pushed resident #23 causing resident #23 to lose her balance falling backwards and hitting the back of her head on the floor. Resident #23 was later sent to the ER for diagnostics. A review of progress notes for resident #23 revealed no documentation related to the above incident. A review of progress notes for resident #9 dated October 2, 2024 at 3:01 a.m. revealed that resident #9 returned from the ER after having a CT of the head and cervical spine, and that the resident's daughter was present with the resident at the hospital. An interview was conducted with a Licensed Practical Nurse (LPN/staff #58) on October 8, 2024 at 4:25 p.m. The LPN stated that resident #23 is behavioral, pleasant most of the time but has had incidents in the past of violent actions. The LPN noted that there have been multiple instances of resident to resident interactions with resident #23. The LPN stated that the above incident was witnessed by staff #42, as they were watching the residents at the time. The LPN further stated that after the incident resident #23 had an abrasion, a contusion, and a skin tear to the right wrist. resident #9 was complained that her head was hurting. The LPN concluded that resident #9 also gets into resident to resident incidents, and her mood fluctuates a lot. An interview was conducted with a Certified Nursing Assistant (CNA/staff #74) on October 8, 2024. The CNA revealed that resident #23 has moments where she says she is in pain and can be aggressive. The CNA stated that because we have sundowners, we have to keep on top of the patients. The CNA further revealed that resident #9 will not let you get away with hitting her, that she jumped out of her wheelchair to get at each other. The CNA also stated that resident #23 has had a few incidents in the past, and concluded that when asked what could have been done to prevent this incident, the CNA stated that her answer to preventing incidents would be to have more staff. An interview with the Director of Nursing (DON/staff #80) was conducted on October 8, 2024 at 5:39 p.m. The DON stated that that her expectations are that staff notify her immediately when an incident happens, and that they have statements to her by the next morning. The DON also stated that when dealing with incidents of resident to resident they are proactive and react appropriately, and that her expectation is that care plan is updated following an incident. However, no care plan updates were noted for resident #9, or resident #23 in relation to this incident at the time of this review. A review of facility policy titled ''Resident abuse and neglect revised August 2, 2024 revealed that Rim country health is committed to the physical, mental, social, and emotional well-being of the resident, and thus has developed a zero-tolerance policy related to resident abuse. Rim country health will not tolerate abuse by anyone, including but not limited to staff, other residents, or other individuals.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#50) to be free from physical abuse by another resident (resident #99). The deficient practice could result in resident not protected from further abuse. Findings include: -Resident #50 was admitted on [DATE], with diagnoses of depression, hypertension, constipation, weakness, anxiety, and bursitis. A behavioral care-plan initiated February 10, 2023 revealed the resident was at risk for confusion. The goal was to maintain the resident's current level of cognitive function. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had severe cognitive impairment. The progress note dated August 25, 2024 revealed that the nurse heard resident #99 said I just shit my pants in an upset manner from inside of her room. Per the documentation, within seconds at approximately 11:10 p.m., resident #50 opened the door and wheeled herself out of the room into the hall; and that, resident #50 was bleeding from a half dollar sized hematoma to the middle of her forehead. It also included that the nurse immediately wheeled resident #50 to the nurse's station for treatment; and that, resident #50 reported that her roommate (#99) hit her. -Resident #99 was admitted on [DATE] with diagnoses of chronic pain syndrome, anxiety, hypertension, diabetes mellitus type 2, and depression. A behavioral care plan with revision date of March 13, 2023 revealed the resident showed behaviors such as being very needy and repetitive with staff, demanding and swearing at times. The goal was that the resident's behaviors will be managed through staff monitoring. Interventions included to monitor the resident for triggers which lead to aggressive behaviors and remove the resident before the resident's behavior escalates. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 which indicated the resident had mild cognitive impairment. The facility investigation included that on August 25, 2024 at 9:15 p.m. a registry licensed practical nurse (LPN) reported that resident #99 hit resident #50 while both residents were in their room. The report included that resident #50 was bleeding from a half-dollar sized contusion to the center of her forehead; and, had wheeled herself out of the room to the unit LPN that was directly across from the resident's room. Per the documentation resident #50 was assessed and had her wound taken cared of; and, resident #50 reported that her roommate (#99) hit her, did not know why she was hit and did not know if she was hit openhanded or closed fist by resident #99. The report also included that resident #99 reported that she just woke up, was knocking things over, did not really know what happened but she hit resident #50 with her hand. Per the report, resident #99 did not remember whether she made a fist or not and did not remember what happened. The report concluded that resident #99 admitted to striking out at resident #50 while angry. An interview was conducted with resident #99 on September 9, 2024 at 5:44 p.m. Resident #99 stated resident #50 used to be her roommate; and that, she hit resident #50. An interview with the Director of Nursing (DON/staff #15) was conducted on September 9, 2024 at 6:05 p.m. The DON stated that resident #99 hit resident #50; but, she did not feel that it was the intent of resident #99 to do it maliciously. The DON further stated that resident #99 was upset that she messed in her pants and took it out on resident #50. The facility policy on Resident Abuse and Neglect with revision date of August 22, 2024 revealed that the facility is committed to the physical, mental, social, and emotional well-being of the resident, and thus has developed a zero-tolerance policy related to resident abuse. The policy also included that the facility will not tolerate abuse by anyone, including but not limited to staff, other residents, or other individuals.

Based on record review, interviews, facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure one resident (#10) was free from abuse from a staff member. The deficient practice could lead to further abuse of residents. Findings include: Resident #10 was admitted to the facility on [DATE] with a diagnoses of congestive heart failure, edema, paroxysmal atrial fibrillation and chronic respiratory failure with hypercapnia. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating that resident #10 was cognitively intact. Review of the intake information submitted by the facility to the SA complaint tracking system on June 14, 2024 revealed that the ADON was advised by a RN (registered nurse/staff #3) of an incident with resident #10. The information included that after resident (#10) said he was not going to take the cup of medication until he saw his doctor the resident handed the cup back to the RN and as the RN turned to exit the room the resident grabbed the cup of medication and made a fist and a motion towards the RN. The information noted that the RN (staff #3) reacted by grabbing the resident's right wrist causing a skin tear. An interview was conducted June 18, 2024 at 1:40 p.m. with resident #10. The resident stated he used to take ten pills a day, including vitamins, prophylactic medication, an antibiotic and a heart medication. He said he did not like taking all ten pills at once and after speaking with his physician some of those pills were no longer necessary. Regarding the incident, resident #10 stated that an RN (staff #3) handed him a cup of pills but he told the RN that he was only going to take the heart medication and any other medications he absolutely needed. The resident explained that the RN took the cup from him and said that she was tired of going through this with him every day and that the RN said she was just going to say that he had refused his medications. Resident #10 said that he grabbed the cup back from the nurse and put it in his other hand to put on the table. The resident said that the RN then reached over him and grabbed his arm and then his wrist trying to grab the cup back. Resident #10 stated that the RN was very inappropriate and that his skin tore in those places (referring to where he was grabbed). The resident said that the RN came back in his room later to address his arm but he told her to get out of his room and to not come back. He said he has not seen the RN since. The resident stated that he may not be able to get out of his bed but he knew what happened. An interview was conducted on June 18, 2024 at 2:10 p.m., with the ADON (Assistant Director of Nursing/staff #7). The ADON stated that on the morning of June 14, 2024 at approximately 07:30 a.m. she received notification of the incident from staff #3. The ADON stated she then sent the RN (staff #3) home and got the Social Worker involved and began the investigation. An interview was conducted on June 18, 2024 at 2:21 PM with a CNA (Certified Nurse Assistant/staff #12). The CNA stated as she was getting residents ready for breakfast, resident #10 had his call light on. The CNA added that when she entered resident #10's room he told her that he was attacked. The CNA said she made sure the resident was alright. Then the CNA said she asked who attacked him and the resident named staff #3 and showed two skin tears, one was on the right upper arm, the other was midway, and another on the left hand. The CNA stated that the skin tears looked like it just happened because they were open and bleeding. The CNA said that she went to staff #3 because she was the nurse she reports to and told her that the resident was saying he was attached and he had skin tears. The CNA said that the nurse (staff #3) said that she had a hard time giving him his medicine and she did try to take the medications from him. The CNA also said she did not think she should report what the resident was claiming but the CNA did tell the nurse (staff #3) about the skin tears. The CNA stated that the nurse (staff #3) said to her, oh my gosh, I'm going to check on him and try to clean up the tears. Further, the CNA said it was hard because the resident had stated that the nurse attacked him but yet the nurse was who she was supposed to report to. The facilities policy on Resident Abuse and Neglect, dated February 9, 2024, states Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also defines physical abuse as hitting, slapping, pinching, kicking, etc.

Based on clinical record review, staff interviews, facility documentation, policy and procedures, and the State Survey Agency database, the facility failed to develop and implement their policy on abuse reporting and investigation for one resident #67. The deficient practice could result in abuse continuing and not being prevented. Findings include: - Resident #67 was admitted to the facility on [DATE] with diagnoses that included visual disturbance, schizoaffective disorder, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, and aphasia. Resident #67 was discharged home on December 4, 2023. The resident's Brief Interview for Mental Status (BIMS) score was 14 on May 25, 2023 and August 19, 2023, indicated that she was cognitively intact. A review of resident #67's clinical records revealed a progress note dated June 3, 2023 at 1:46 PM, the Nurse Practitioner (NP/staff #85) included that the patient suffered from anxiety and post-traumatic stress disorder (PTSD) after sexual abuse as a child and that nursing reported concerns for drug seeking behaviors. The progress note on June 13, 2023 at 3:06 PM, written by the Social Service Director (SSD/staff #45), stated that resident #67's post-traumatic event was from her daughter feeding her food with drugs in it and caused her to overdose so she refused to attend family functions in fear that her daughter would be there. There were no progress notes dated June 29 or 30, 2023 related to the psychosocial abuse allegations nor that resident #67's psycho-social outcome had been assessed. -Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, and post-traumatic stress disorder. Resident #66 was transferred/discharged on [DATE]. Resident #66's BIMS score was 15 on April 7, 2023 which indicated that he was cognitively intact. A progress note dated June 30, 2023 at 12:30 PM, that the resident was discharged from the facility and transported to the emergency room . The resident was alert and oriented and vital signs were normal. The resident was observed propelling his wheelchair. The discharge plan of care was completed. There was no progress note dated for June 29, 2023 or any other progress notes dated June 30, 2023 indicating why the resident was discharged . The care plan dated July 3, 2023 revealed a care plan initiated on April 7, 2023, indicated that the resident used antidepressant medication related to depression. Interventions included: attempt non-pharmacological interventions prior to administering medication, give medications ordered by physician, monitor/document/report to the physician signs or symptoms of depression, and to provide a quiet, relaxing environment. A review of the facility's investigative documentation revealed that on June 29, 2023 at 5:15 PM, resident #67 reported the allegation of mental abuse to the Assistant Director of Nursing/Case Manager (ADON/Staff #84, no longer employed). Resident #67 reported that she was fearful of her boyfriend resident #66. She stated that he was very controlling, went through her personal items, was easily angered, and she felt that he would have physically harmed her if she wasn't in the facility. Resident #67 stated that she would have to move out to get away from him. On June 30, 2023 at 12:18 p.m., the DON wrote that she interviewed resident #67 regarding her psycho-social abuse claims against resident #66. The DON documented that the resident reported that she had been feeling that way about resident #66 for a couple of months. Resident #67 had also reported that she was unable to have a private conversation with her daughter without resident #66 being present. Further review of the facility's investigative report revealed that documentation that the DON had interviewed resident #67 but was unable to interview resident #66 due to he had already been transferred/discharged from the facility and was unreachable by phone. The report also documented that three people had been interviewed and denied seeing or hearing resident #66 be verbally abusive. The report did not document whether the three individuals were residents or staff, the date, time, or by whom the interview took place. The investigation did not include interviews with staff that worked that unit nor resident #67's family member. Email documentation provided by the facility revealed the State Agency received the report of the alleged abuse on June 30, 2023 at 4:48 PM. (approximately one day after facility was made aware of the allegation of abuse). During an interview with the Director of Nursing (DON/staff #62), the DON stated that the resident #67 reported the allegation to the ADON on June 29, 2023 at 5:15PM, but that the ADON did not report the allegation to her until the following morning on June 30, 2023. The DON stated that the allegation was not reported within two hours due to there was no injury and that it just needed to be reported within 24 hours. The DON also stated that she needed to initiate an investigation prior to submitting the report. The DON further stated that if a resident reported psychosocial or mental abuse concerns that she would get with the social worker and get a referral to a behavior health agency for counseling. The DON stated that the Minimum Data Set (MDS) nurse was responsible for updating/revising care plans post abuse allegations. The DON stated that a new MDS nurse had just started and was still in training. Review of the facility's policy titled Resident Abuse and Neglect updated/reviewed on August 1, 2023, included mental abuse as a type of abuse and that the Administrator would be alerted for every potential abuse incident. The DON or designee was responsible for overseeing the investigation and for assuring the process was followed. The policy stated that all alleged violations involving abuse would be reported to the proper agencies within the regulatory guidelines after the allegation is made. The policy does not specify the time frame for reporting allegations of abuse. The policy stated the facility was responsible to identify residents who are at risk for abusive behavior and develop interventions to prevent occurrences, monitor for changes that would trigger abuse behavior, and reassess the interventions for appropriateness. The facility was to assess, care plan, and monitor residents with needs or behaviors that may lead to conflict. The facility was to investigate all potential abuse incidents by interviewing staff, resident witnesses, and all involved parties. The facility was to review and revise care plans for residents in all suspected situations of abuse. The residents were to be assessed and the results of the assessment documented in the resident's clinical record. Agencies and required contacts included the health department, nursing board if applicable, ombudsman, adult protective services, police if applicable, family/responsible party/legal representative/case manager, and physician. The resident's psychosocial outcome in relation to the incident was to be assessed and documented in the resident's clinical record.

Based on review of the clinical record, facility documentation, review of the State Agency database, staff interviews, and review of policy and procedure, the facility failed to ensure two allegations of abuse were thoroughly investigated and prevent further potential abuse and take appropriate corrective action for two residents. The deficient practice could lead allegations of abuse not being investigated and abuse occurring in the facility. Findings Include: Regarding resident #67 and resident #66 -Resident #67 was admitted to the facility on [DATE] with diagnoses that included visual disturbance, schizoaffective disorder, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, and aphasia. Resident #67 was discharged home on [DATE]. -Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, and post-traumatic stress disorder. Resident #66 was transferred/discharged on [DATE]. Review of the clinical record for resident #66 and #67 revealed no documentation showing that any measures were taken to prevent resident #67 from contacting resident #66 to prevent the potential for further abuse from [DATE] at 5:15 PM when the allegation was reported until the following day when resident #67 was transferred/discharged on [DATE] at 12:30 PM. Review of the SA database revealed that the facility failed to submit a completed and thorough investigation of the allegation to the SA. A review of the facility's investigative documentation revealed that on [DATE] at 5:15 PM, resident #67 reported the allegation of mental abuse by resident #66 to the Assistant Director of Nursing/Case Manager (ADON/Staff #84). Resident #67 reported that she was fearful of her boyfriend resident #66. She stated that he was very controlling, went through her personal items, was easily angered, and she felt that he would have physically harmed her if she wasn't in the facility. Resident #67 stated that she would have to move out to get away from him. A report was received by the State Agency (SA) on [DATE] that indicated that a resident-to-resident abuse allegation occurred between residents #67 and #66. A review of the facility's investigative documentation revealed that on [DATE] at 12:18 PM, the DON wrote that she interviewed resident #67 regarding her psycho-social abuse claims against resident #66. The DON documented that the resident reported that she had been feeling that way about resident #66 for a couple of months. Resident #67 had also reported that she was unable to have a private conversation with her daughter without resident #66 being present. The report included the names of three individuals that denied hearing or seeing resident #66 being abusive but did not indicate if they were staff or residents. The facility's investigative report stated that the investigation was completed on [DATE]; however, it was documented that a meeting had taken place on [DATE] involving both residents and facility staff where staff observed resident #66 reaction to resident #67 and were concerned. The facility investigative report revealed that the report contained inconsistent and conflicting information regarding the residents as compared to what was documents on resident #67 and #66's clinical records and that a thorough investigation that included witness interviews of residents, family members, and staff were not conducted. Further review of the facility's investigative report revealed documentation that the DON had interviewed resident #67 but was unable to interview resident #66 because the resident had already been transferred/discharged from the facility and was unreachable by phone on [DATE]. The investigation, also, did not include interviews or statements from staff that worked that unit nor resident #67's family member nor resident #66. The facility was unable to substantiate the allegation due to lack of evidence. During an interview with the Director of Nursing (DON/staff #62) conducted on [DATE] at 4:00 PM, the DON stated that she needed to initiate an investigation prior to submitting the (allegation) report. The DON also stated that the meeting did not occur on [DATE] but actually took place on [DATE] and was an error. The DON stated that staff #84 was no longer employed by the facility. Regarding resident #38 and resident #68 -Resident #38 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, paranoid personality disorder, muscle weakness, dysphagia, epilepsy, depressive disorder, and anxiety disorder. Review of the medication administration record revealed that resident had been taking Risperdal 1 mg by mouth twice daily for schizoaffective disorder since [DATE] Review of resident #38's clinical records revealed a Brief Interview for Mental Status (BIMS) score of 10 on [DATE], which indicated moderate cognitive impairment. A progress note dated [DATE] at 1:00 PM, stated that another resident had grabbed onto resident #38's jacket and wouldn't let go, so staff #8 stepped in between the two residents to separate them when they began arguing and then resident #38 swung and hit the other resident in the face at the bridge of his nose. Resident #38 was assessed to have no injuries. A progress note dated [DATE] at 9:21 AM, revealed the Psychiatrist/staff #80 reviewed the resident's chart for the quarterly review of behavioral health interventions. The psychiatrist documented the resident was stable and there was no indication for need of change in medications or other care interventions. A progress note dated [DATE] at 5:48 AM, revealed that NP/staff #85 spoke with the psychiatrist/staff #80 regarding the resident's behaviors and increased the dosage of Risperidone to 2 mg by mouth two times daily. A progress note dated [DATE] at 6:35 AM, revealed that NP/staff #85 saw resident #38 and that nursing staff had reported the resident's behaviors had improved following the dosage increase of Risperidone. The clinical record revealed no interventions implemented to prevent resident #38 from having further access to resident #68 or preventing resident #38 from abusing other residents. The care plan dated [DATE], revealed the resident had the potential to demonstrate physical behaviors since [DATE] with no changes in interventions since [DATE]. There were no changes/updates following the resident's behavior of hitting another resident. -Resident #68 was admitted to the facility on [DATE] with diagnoses that included dementia unspecified severity without behavioral disturbance, adult failure to thrive, and schizoaffective disorder. Resident #68 deceased on [DATE]. Review of resident #68's clinical records revealed a BIMS score of 13 on [DATE] which indicated cognitively intactness. A progress note dated [DATE] at 1:44 PM, stated the resident was confused and disoriented. A progress note dated [DATE] at 1:00 PM, stated that resident #68 had grabbed another resident's jacket and the other resident was yelling for resident #68 to let go of her jacket when staff #8 stepped in between the two residents to separate them. The progress note further stated that the other resident then swung an open hand over staff #8's shoulder and hit resident #68 on the bridge of his nose. Resident #68's face was assessed with no injuries and resident #68 denied pain. The care plan dated [DATE], revealed that the resident had impaired thought processes related to dementia; used psychotropic medications of Seroquel and Haloperidol related to behavior management;was at risk for communication problems related to not always understanding what is said; and, was appropriate to live in the secured unit and that it helped him feel safe. Interventions that included that staff were to anticipate and meet the resident's needs, staff were to be conscious of the resident's position when in groups, activities, and the dining room to promote proper communication, and to monitor the effectiveness of communication strategies; staff were to anticipate and meet his needs as much as possible, attempt to identify the stimulus that triggered his distress, attempt to keep the unit as low stimulus as possible, and provide adequate supervision. The were no updates or revisions to the care plan following the resident to resident altercation on [DATE]. A review of the facility investigative documentation revealed that housekeeper/staff #8 witnessed residents #38 and #68 in the dining room arguing and stepped in between them on [DATE] at 1:00PM. Resident #38 had been yelling at other residents when resident #68 became startled and grabbed onto resident #38's jacket. The two residents began yelling at each other because resident #38 wanted resident #68 to let go of her jacket. Staff #8, then, stepped in between the two residents to separate them. While staff #8 stood between the two residents resident #38 swung her arm over the staff #8, hitting resident #68 in the face at the bridge of his nose. Resident #68 went to his room while resident #38 remained in the dining room. Resident #38 admitted that she swung at another resident but was unable to recall the incident and resident #68 was also unable to recall the incident due to cognitive impairment. The Director of Nursing (DON/staff #62) documented that both residents were interviewed. There is no documentation of the interviews or when they occurred. Resident #68 was assessed to have no signs of increased anxiety, fear, or psycho-social distress. Both residents remained in the same secured behavioral/memory unit. There were no witness statements. The facility investigative documentation stated that resident #68 went to his room and that resident #38 remained in the dining/common area. The facility investigative report, also, stated that both residents remained in the same secured behavioral/memory unit. Regarding resident #38 and resident #36 -Resident #38 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, paranoid personality disorder, muscle weakness, dysphagia, epilepsy, depressive disorder, and anxiety disorder. Review of the clinical record revealed resident #38 had a Brief Interview for Mental Status (BIMS) score of 10 on [DATE], which indicated moderate cognitive impairment. A progress note dated [DATE] at 9:21 AM, revealed the Psychiatrist/staff #80 reviewed the resident's chart for the quarterly review of behavioral health interventions. The psychiatrist documented the resident was stable and there was no indication for need of change in medications or other care interventions. A progress notes dated [DATE] at 12:00 AM and [DATE] at 1:51 AM, and [DATE] at 4:13 PM, stated that the resident was yelling at other residents to stop staring at her. A progress note dated [DATE] at 5:48 AM, revealed that NP/staff #85 spoke with the psychiatrist/staff #80 regarding the resident's behaviors and increased the dosage of Risperidone to 2 mg by mouth two times daily. A progress note dated [DATE] at 6:35 AM, revealed that NP/staff #85 saw resident #38 and that nursing staff had reported the resident's behaviors had improved following the dosage increase of Risperidone. The care plan dated [DATE], revealed the resident had the potential to demonstrate physical behaviors since [DATE] with no changes in interventions since [DATE]. There were no changes/updates following the resident's behavior of kicking another resident or that resident #38 believed other residents were staring at her. The clinical record revealed no interventions were put into place to prevent resident #38 from having further access to resident #36 or preventing resident #38 from abusing other residents. -Resident #36 was admitted to the facility on [DATE] with diagnoses that included aphasia following nonromantic Intradermal hemorrhage, weakness, dementia unspecified severity without behavior disturbance, insomnia, cerebral infarction, syncope and collapse, major depressive disorder, mixed anxiety disorder, and dysphagia. Review of the clinical record revealed that the resident had a BIMS score of 13 on [DATE], which indicated cognitively intact. A progress note dated [DATE] at 11:59 PM, revealed the resident was sitting in his wheelchair at the nurses' station when another resident yelled at him to stop looking at me. Resident did not respond to the other resident. The other resident then kicked him in his foot and then went to her room. The resident denied pain, and was evaluated to have no signs of injury, increased anxiety or psychosocial distress noted. The care plan dated [DATE], revealed that a care plan and interventions had not been developed following the resident-resident altercation in [DATE] to prevent further abuse. Review of the facility investigative documentation provided onsite on [DATE], revealed a witness statement written by a certified nursing assistant (CNA/staff #83). The CNA wrote that she witnessed resident #38 kick resident #36 in the foot purposefully on [DATE] at 7:25 PM. The CNA wrote that resident #38 said have him (resident #36) stop staring at her (resident #38). Resident #38 was directed to go to her room. The final investigative report also revealed that following the incident, resident #38 felt angry toward resident #36 but was unable to recall the incident due to cognitive impairment. The facility's investigative documentation included that CNA/staff #83 reported the resident-to-resident incident to nurses/staff #86 and #2. There was no witness statement from either nurse. An interviews with staff #83 and #2 were unable to be conducted due to they were no longer employed by the facility. During an interview with the Director of Nursing (DON/staff #62) conducted on [DATE] at 4:00 PM, the DON stated that following resident-resident abuse altercations or allegations, care plans and interventions are developed/updated the next morning after morning meeting. The DON stated that the Minimum Data Set (MDS) nurse was responsible for updating/revising care plans and that a behavior care plan would be done regarding individual interventions to prevent further abuse. The DON stated that a new MDS nurse just started working for the facility and is still in training. The DON stated the facility did not have any additional documentation regarding the investigation of resident #38 or #68 on [DATE]. Review of the facility's policy titled Resident Abuse and Neglect updated/reviewed on [DATE], included that the facility was responsible to identify residents whose personal history put them at risk for abusive behavior and develop intervention strategies to prevent occurrence, monitor for changes that would trigger abusive behavior, and reassess interventions on a regular basis. The facility was to assess, care plan, and monitor residents with needs and/or behaviors that might lead to conflict. In all suspected situations of abuse, neglect, mistreatment, or misappropriation of property, the resident's care plan was to be reviewed and revised as needed to provide care and treatment needed. The facility was to assure that residents were protected from harm during the investigation and that the individual reporting the incident was protected from any retribution or retaliation. The DON or designee was responsible for overseeing the investigation and for assuring the process was followed. The facility was to investigate all potential abuse incidents by interviewing staff, resident witnesses, and all involved parties. The results of each investigation were to be forwarded to the appropriate agencies according to state law within 5 days of the online report.

Based on clinical record review, staff interviews, facility documentation, and facility policies and procedures, the facility failed to allow one resident the right to exercise his rights without coercion or interference or coercion from the facility and to be supported by the facility in the exercise of his rights. The deficient practice could result in other residents not being able to exercise their rights. Findings include: -Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, chronic obstructive pulmonary disease, muscle weakness, congestive heart failure, major depressive disorder, hypothyroidism, hypertension, and post traumatic stress disorder. A progress note dated June 30, 2023 at 12:30 PM. The progress note stated that resident #66 was discharged from the facility at 12:30 PM and transported to the emergency room accompanied by staff. The progress note also stated that the resident was alert and oriented, vital signs were stable, and that he was propelling himself in his wheelchair. The progress note also stated that the discharge plan of care and post discharge plan of care were completed and that the documents and medication list would be faxed to the receiving facility. No reason for discharge was documented in the progress notes. The care plan dated July 3, 2023 revealed the resident had a behavior problem and made false allegations toward staff members. The care plan did not show that it had been updates regarding the behavior or concerns of resident #66 toward resident #67 as indicated by the staff during the meeting on June 20, 2023. -Resident #67 was admitted to the facility on [DATE] and discharged home on December 4, 2023. Resident #67's diagnoses included cardiac arrhythmia, cluster headache, visual disturbance, schizoaffective disorder, morbid obesity, bipolar disorder depressed severe with psychotic features, generalized anxiety disorder, chronic pain, major depressive disorder, hypothyroid, chronic obstructive pulmonary disease, shortness of breath, insomnia, hypertension, diabetes, congestive heart failure, repeated falls, difficulty walking, muscle weakness, and aphasia. Review of resident #67's clinical records revealed there were no progress notes dated for June 29 or 30, 2023. The care plan dated September 25, 2023 included that the resident received psychoactive medication therapy related to diagnoses of depression, anxiety, the inability to get restful sleep, bipolar, and manifested by behaviors of self-isolation and withdrawal, intractable sadness, and agitation. It also included that the resident had a problem of coping psychotic disorder related to fear of being poisoned as exacerbated by verbalization of feeling fear and reports of apprehension; and, had the potential for mood or behavioral changes due to a mandated change to social events and visiting policies. The care plan did not show that it had been updated regarding the behavior or concerns that resident. Review of the facility investigative documentation revealed on June 29, 2023 at 5:15 PM, resident #67 reported to the Assistant Director of Nursing (ADON/staff #84) that she was fearful of her boyfriend, resident #66. She stated that he was controlling, went through her personal belongings, and was easily angered. She felt that if she wasn't in the facility that he would have harmed her. She also stated to the ADON that she would have to move out to get away from resident #66. Further review of the facility's final investigative documentation also revealed that a meeting took place on June 20, 2023 (July 20, 2023 was an error per the DON), that included the DON, staff #84, staff #45, resident #66, resident #67 and other other residents. The documentation stated that the staff members noticed that resident #66 gritted his teeth and showed anger immediately when resident #67 spoke. After the meeting, the staff members agreed that the relationship between residents #66 and #67 would need to be watched closely. On June 30, 2023 at 11:18 AM, the DON interviewed resident #67 who stated she had felt that resident #66 had been treating her that way for a couple of months. During this interview, resident #67 stated that resident #66 was very controlling and would get mad if she didn't do what he wanted. He would give dirty looks, grit his teeth, and his jaw would be tight. Resident #67 stated that resident #66 wanted to get a place together but resident #67 didn't want to. Resident #67 also stated that resident #66 wanted to get a joint bank account and resident #67 didn't want to. Resident #67 stated that resident #66 would go through her personal property and dresser drawers. Resident #67 stated that resident #66 had also talked to resident #67's family member and had gotten her to agree that he could move in with resident #67 if she left. Resident #67 stated the only way to stop it was for one of them to leave. Resident #67 stated she felt he would become physically abusive if they were not in a facility being watched. On July 4, 2023 at 1:30 PM, the DON had interviewed residents #17, #54, and #44 and all denied seeing or hearing resident #66 be verbally abusive. During an interview with the Director of Nursing (DON/staff #62) conducted on December 13, 2023 at 4:00 PM, the DON stated that she was not notified of the allegation until the following morning on June 30, 2023 and that staff #84 was no longer employed. The DON stated that she then contacted resident #66's case managers at the veterans administration who agreed that resident #66 needed to be placed in another facility. The DON stated she transferred/discharged resident #66 to the emergency room until placement at another facility could be found at the direction of the case managers and that she did not need to contact the physician or obtain an order from the physician for the transfer/discharge. The DON stated that resident #66 was discharged from the facility based on the allegation from resident #67 against resident #66. The DON stated there was no order received from the physician to transfer or discharge for resident #66. The DON stated she notified resident #66 on the morning of June 30, 2023 of the allegation of mental abuse toward another resident and resident #66 stated he did not know who would would say that about him. The DON, further, stated that on June 30, 2023, at the time resident #66 was to be transported to the emergency room , he became angry and verbally refused to go willingly, so the police were notified. The DON stated that the police arrived and advised resident #66 that he needed to cooperate and go the emergency room as instructed. The resident then complied and was transported to the emergency room . Review of the facility policy titled Summary of Resident Rights updated/reviewed on October 3, 2023, revealed that the facility was to protect and promote the rights of each resident. The resident had the right to exercise their rights as a resident. The resident had the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his rights. Except in medical emergencies, the facility was to consult with the resident and notify the resident's physician and legal representative for decisions to transfer or discharge a resident from the facility. The resident also had the right to voice grievances without discrimination or reprisal and the facility was to promptly resolve the grievances including those concerns regarding the resident's stay. The facility was also to ensure that all alleged violations involving abuse were to be reported immediately to the Administrator or DON and all other officials/agencies in accordance with state law. Review of the facility policy titled Resident Transfer or Discharge updated/reviewed on March 28, 2023, revealed residents would not be transferred unless the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met in the facility, or the safety of the individuals in the facility were endangered due to the clinical or behavioral status of the resident, or the health of individuals in the facility were endangered. The policy also stated that if the resident exercised their right to appeal a transfer or discharge notice, he or she would not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. If the resident was transferred or discharged despite the pending appeal, the danger that failure to transfer or discharge would pose, would be documented.

Based on record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure that one resident (#1) was provided basic life support including CPR (cardio-pulmonary resuscitation) in accordance the resident's advance directives. The deficient practice resulted in actual harm to the resident and has the potential to result in advance directives not being followed for additional residents. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included falls, chronic obstructive pulmonary disease with exacerbation, cognitive communication deficit, emphysema, and senile degeneration of brain. Review of a form titled Rim Country Skilled Nursing and Rehabilitation Advanced Directive Information Acknowledgement dated [DATE], included a statement that the facility had provided her with a written copy of the facility's policy regarding advanced directives, had been given written materials regarding her right to accept or refuse medical treatment, and had been informed of her right to execute advanced directives. The form included a check mark next to the statement that she had executed an advanced directive. The form was signed by her guardian. Review of a form titled Rim Country Skilled Nursing and Rehabilitation Advanced Directive Statement dated [DATE], include multiple advance directive options, and was marked with an X for a section that read Yes, Cardiopulmonary Resuscitation (CPR). The form was signed by the resident's guardian, and witnessed by a staff member. A base line care plan dated [DATE], revealed that the resident's advanced directives/code included cardiopulmonary, intravenous infusion, resuscitation, tube feeding and IV infusion. It revealed an initial admission goal as respite, to return home with family. Review of the clinical record revealed no evidence of physician orders for Advanced Directive. A clinical noted dated [DATE] at 15:49 by Staff #44, included that all paperwork was reviewed with the Power of Attorney (POA), and the resident was full code. A clinical note dated [DATE] at 9:51 by Staff #100 included a Certified Nursing Assistant (CNA) was in to feed the resident and requested this nurse assess resident. Upon entering resident room resident sitting up and had a small amount of vomit with phlegm on her gown. Her lungs are congested throughout. Phone call placed to hospice and will be sending a nurse to see resident. Resident was not fed this morning as this was when resident was found to have phlegm on her gown. Review of the clinical record revealed no nurse assessments or notes regarding the resident status between 9:51 AM and 12:13 PM. A clinical note dated [DATE] at 12:13 PM by a Registered Nurse (RN/staff #100) included the time of death at 10:26 AM, family notified by Hospice nurse, provider, and the Director of Nursing notified. Review of the clinical record for [DATE] did not reveal any documented evidence that CPR had been provided, or that 911 had been called for immediate transport to the hospital, or the provider had been notified. Review of a hospice fax cover sheet dated [DATE], revealed that they had no DNR on file. An interview was conducted on February 3, 2023 at 11:41 AM with a Registered Nurse (RN/staff #100) via telephone, who stated that she remembered the resident. She stated that she had been informed by the CNA that the resident had vomited, and she helped to clean up the resident and repositioned her. She also stated that she had checked on the resident and her breathing had slowed down and would not open her eyes. The nurse stated that she called hospice, but she was not certain if they arrived at the facility prior to the resident passing. She stated that in a form she had been given, it stated that the resident was DNR. However, she was not sure if she looked at the advanced directives form in the clinical record. She stated that if the advanced directive stated that the resident wanted CPR she would have started it at that time. She further stated that if the resident was full code, she would have notified the provider and the administrator and awaited orders, and started CPR. An interview with a CNA (Staff # 101) was conducted on February 3, 2023 at 11:42 AM via telephone. He stated that he was familiar with the resident. He stated that the resident was aspirating and struggling to breath and the nurse did not help him. He stated that he placed oxygen on the resident, informed the nurse and the manager on duty. He further stated that the resident was at the facility for a short respite stay, and was also on hospice. He stated that the hospice nurse did not come into the facility on [DATE] to assess the resident due to her change of condition. He stated that the nurse said the resident was a DNR because she was on hospice, but he did not see her review the chart. He stated that after the resident passed he found that the resident record stated the resident was full code. He also stated that it was a horrible death. He stated that he did not observe the nurse performing any assessments or vitals during the change of condition, she only looked at the resident. He stated that his major concern was that the resident was struggling to breath and had a decrease in oxygen saturations. An interview was conducted on February 3, 2023 at 1:18 PM with the previous Director of Nursing (DON/RN/staff #102) via telephone, stated that she was not aware of the concerns regarding the resident's death until a policeman came to the facility. She further stated that she had not been notified by the CNA or the nursing regarding any concerns of Resident #1's care/treatment on [DATE]. An interview was conducted on February 3, 2023 at 9:34 AM with a Licensed Practical Nurse (LPN/staff #103), who stated that for a change of condition, or decline with a hospice patient that had a full code advanced directive, leadership should be notified regarding the resident's status. An interview was conducted on February 2, 2023 at 9:45 AM with a CNA (staff #31). She stated that when a resident is declining (change of condition), and a full code, CPR would be administered immediately until paramedics arrive. An interview was conducted on February 3, 2023 at 9:53 AM with an LPN (staff #42), who stated that the facility policy related to advance directives, includes reviewing the form with the resident or POA on admission. She stated that if the resident is full code there should be physician order in the clinical record. The LPN also stated that according to standard nursing practice, when a hospice resident is declining/change of condition, hospice and the provider should be notified, and it should be documented in the medical record. She stated that she would expect to see a full set of vitals, and nursing assessments/monitoring until hospice arrived, and document it should be documented in the clinical record. She reviewed Resident #1's clinical record and stated that the resident was having respiratory issues and was full code, so she should have been sent out to the emergency room . She reviewed the advanced directive in the clinical record, dated [DATE], and stated that the resident was full code. Further interview was conducted on February 2, 2023 at 1:35 PM with a CNA (staff #31), who stated that when a resident is full code the physician should be notified regarding a change of condition. She further stated that when a resident is declining and the nurse is not responding the CNA should notify another nurse or the DON and report the concerns. An interview was conducted on February 3, 2023 at 1:57 Pm with the facility Administrator (staff #43), who stated that the nurse caring for the resident on February 17, 2021 was under the idea that the resident was DNR. She reviewed the clinical record and stated that the resident was full code. An interview was conducted on February 2, 2023 at 2:09 PM with the DON (staff # ), who stated that she had reviewed Resident #1's clinical record and stated that she would have expected that the hospice nurse would have been contacted a second time, if she did not come quickly to assess the resident. She stated that her expectation is to honor the residents advanced directives. She further stated that she expected that resident #1 would have received CPR, and should have been moved to a higher level of care. The DON also stated the risk of not following the advance directives could result in possible premature death. Review of the facility policy titled, Advanced Directives, revealed that all staff will comply with the resident directives.

Based on record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure that one resident (#1) received treatment and care in accordance with professional standards of practice regarding implementation of basic life support including CPR (cardio-pulmonary resuscitation) in accordance the resident's advance directives. The deficient practice resulted in actual harm to the resident by their physical needs not being met in resident advance directives not being followed. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included falls, chronic obstructive pulmonary disease with exacerbation, cognitive communication deficit, emphysema, and senile degeneration of brain. Review of a form titled Rim Country Skilled Nursing and Rehabilitation Advanced Directive Statement dated [DATE], include multiple advance directive options, and was marked with an X for a section that read Yes, Cardiopulmonary Resuscitation (CPR). The form was signed by the resident's guardian, and witnessed by a staff member. A base line care plan dated [DATE], revealed that the resident's advanced directives/code included cardiopulmonary, intravenous infusion, resuscitation, tube feeding and IV infusion. It revealed an initial admission goal as respite, to return home with family. A clinical noted dated [DATE] at 15:49 by Staff #44, included that all paperwork was reviewed with the Power of Attorney (POA), and the resident was full code. A clinical note dated [DATE] at 9:51 by Staff #100 included a Certified Nursing Assistant (CNA) was in to feed the resident and requested this nurse assess resident. Upon entering resident room resident sitting up and had a small amount of vomit with phlegm on her gown. Her lungs are congested throughout. Phone call placed to hospice and will be sending a nurse to see resident. Resident was not fed this morning as this was when resident was found to have phlegm on her gown. Review of the clinical record revealed no evidence of change of condition assessments or notes regarding the resident's status between 9:51 AM and 12:13 PM on [DATE]. A clinical note dated [DATE] at 12:13 PM by a Registered Nurse (RN/staff #100) included the time of death at 10:26 AM, family notified by Hospice nurse, provider, and the Director of Nursing notified. Review of the clinical record for [DATE] did not reveal any documented evidence that CPR had been provided, or that 911 had been called for immediate transport to the hospital, or the provider had been notified. Review of the clinical record revealed an alert note dated [DATE] at 3:42 by CNA (staff #101), that included at 8:15 I brought breakfast and noticed she was gurgling and spitting up phlegm, so I notified the nurse immediately, oxygen saturation at 88. Another alert note dated [DATE] at 3:46 by CNA (staff #101), included at 8:30 oxygen saturation was 77, nurse notified. Nurse said to keep an eye on her, I put on oxygen mask and oxygen saturation continues to decline. 9:30 saturation at 66, nurse notified, 10:06 notified nurse resident took last step. An interview was conducted with the facility administrator (staff # 43), on February 3, 2023 at 10:15 AM. She stated that the previous Director of Nursing (DON) had started an investigation regarding resident #1's death. She reviewed the DON's notes and stated that no formal investigation had been initiated, or submitted to the State Agency, but there were notes regarding her inquiry into the incident that included: -staff #100 stated that she found a document that stated the resident was DNR (do not resuscitate), but she did not know where she saw the form. -Two other nursing staff were talking about sending the resident out of the facility related to her code status. -A Nursing Assistant (CNA/staff #101) stated that the resident was gagging/struggling to breath, and he tried to get an RN to send her out, but the RN did not assess the resident. -Hospice Nurse on call stated that the RN had declined a visit by the hospice nurse. -[NAME] Nurse notified the facility regarding an investigation they were conducting regarding the resident's death. - Review of a hospice fax cover sheet dated [DATE], revealed that they had no DNR on file. An interview was conducted on February 3, 2023 at 9:34 AM with a Licensed Practical Nurse (LPN/staff #103), who stated that for a change of condition, or decline with a hospice patient that had a full code advanced directive, leadership should be notified regarding the resident's status. He further stated that nursing should conduct assessments regarding the resident's status. An interview was conducted on February 3, 2023 at 9:45 AM with a CNA (staff #31). She stated that when a resident is declining (change of condition), and a full code, CPR would be administered immediately until paramedics arrive. She also stated that nursing should assess and monitor all residents that have had a change of condition. An interview was conducted on February 3, 2023 at 9:53 AM with an LPN (staff #42), who stated that the facility policy related to advance directives, includes reviewing the form with the resident or POA on admission. She stated that if the resident is full code there should be physician order in the clinical record. The LPN also stated that according to standard nursing practice, when a hospice resident is declining/change of condition, hospice and the provider should be notified, and it should be documented in the medical record. She stated that she would expect to see a full set of vitals, and nursing assessments/monitoring until hospice arrived, and document it should be documented in the clinical record. She reviewed Resident #1's clinical record and stated that the resident was having respiratory issues and was full code, so she would have expected documentation of vitals, assessments, and the resident should have been sent out to the emergency room . She reviewed the advanced directive in the clinical record, dated [DATE], and stated that the resident was full code. An interview was conducted on February 3, 2023 at 11:41 AM with a Registered Nurse (RN/staff #100) via telephone, who stated that she remembered the resident. She also stated that the resident did have a change of condition, and that she did not notify the provider. She further stated that with a change of condition the resident's oxygen status, respirations and pain should be assessed/monitored every 15 minutes, and documented in the clinical record. The RN stated that if she had assessed the resident it would have been documented in the progress notes, but she did not remember if she did complete assessments related to the resident's change of condition. She stated that she had checked on the resident and her breathing had slowed down and would not open her eyes. She also stated that she was not sure if she looked at the advanced directives form in the clinical record. She stated that if the advanced directive stated that the resident wanted CPR she would have started it at that time. An interview with a CNA (Staff # 101) was conducted on February 3, 2023 at 11:42 AM via telephone. He stated that he was familiar with the resident. He stated that he was concerned about the resident's care and documented it in an alert note. He stated that the resident was aspirating and struggling to breath and the nurse did not help him. He stated that he placed oxygen on the resident, informed the nurse and the manager on duty. He further stated that the resident was at the facility for a short respite stay, and was also on hospice. He stated that the hospice nurse did not come into the facility on [DATE] to assess the resident due to her change of condition. He stated that the nurse said the resident was a DNR because she was on hospice, but he did not see her review the chart. He stated that after the resident passed he found that the resident record that stated the resident was full code. He also stated that it was a horrible death. He stated that he did not observe the nurse performing any assessments or vitals during the change of condition, she only looked at the resident. He stated that his major concern was that the resident was struggling to breath and had a decrease in oxygen saturations. An interview was conducted on February 3, 2023 at 1:18 PM with the previous Director of Nursing (DON/RN/staff #102) via telephone, stated that she was not aware of the concerns regarding the resident's death until a policeman came to the facility. She further stated that she had not been notified by the CNA or the nursing regarding any concerns of Resident #1's care/treatment on [DATE]. Further interview was conducted on February 3, 2023 at 1:25 PM with LPN (staff #42), who stated that when a resident has a change of condition nursing assessments should be documented in the clinical record. She further stated that if assessments were not completed it would be considered neglect. Further interview was conducted on February 2, 2023 at 1:35 PM with a CNA (staff #31), who stated that when a resident is full code the physician should be notified regarding a change of condition. She further stated that when a resident is declining and the nurse is not responding the CNA should notify another nurse or the DON and report the concerns. The CNA stated that when a resident is declining and the nurse id not responding another nurse or manager should be notified immediately. An interview was conducted on February 3, 2023 at 1:57 PM with the facility Administrator (staff #43), who stated that the nurse caring for the resident on February 17, 2021 was under the idea that the resident was DNR. She reviewed the clinical record and stated that the resident was full code. An interview was conducted on February 2, 2023 at 2:09 PM with the DON (staff #44), who stated that she had reviewed Resident #1's clinical record and stated that she would have expected that the hospice nurse would have been contacted a second time, if she did not come quickly to assess the resident. She stated that her expectation regarding changes of condition, would be to assess the resident's vitals, status and document in the medical record. She stated that she did not see nursing documentation in Resident #1's medical record regarding the change of condition related to a decline. She also stated that she would have expected that the provider would have been notified regarding the decline, if the nurse did not want hospice attending the resident. She reviewed the CNA Alert Notes, and stated that she expected the CNA to notify another nurse regarding his concerns, and if the nurse did not respond to contact a manager on duty. She stated that the risk of resident harm and potential death could result from negligent nursing, regarding the nurse not assessing frequently after a change of condition and decline in well-being. Review of the facility policy titled, Quality of Care and Services, revealed that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical well-being. Professional standards of quality means services that are provided according to accepted standards of clinical practice. Staff shall notify physicians as appropriate and show evidence of discussions regarding acute medical problems. Residents with acute conditions who require intensive monitoring and hospital level treatments will be promptly transferred to a higher level of care according to physician orders. There shall be evidence of assessment and care planning sufficient to meet the needs of newly admitted residents. Direct caregiver staff should have an understanding of the expected outcomes of the care they provide and understand the relationship of these expected outcomes to the care provided.

Based on clinical record review, resident and staff interviews and hospital and facility documentation, the facility failed to ensure one resident (#63) was transferred in a safe manner. The deficient practice resulted in a fall with major injury. Findings include: Resident #63 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated (MONTH) 8, 2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS included the resident required extensive assistance of one for transfers, and had not fallen since admission. The care area for falls had triggered and would be addressed in the care plan. Review of the accident potential care plan dated (MONTH) 1, 2019 revealed a goal that the resident would comply with safety precautions. An intervention included the resident required the assistance of two people with a gait belt for transfers. Review of the Certified Nursing Assistant (CNA) documentation regarding support provided for transfers (excluding transfers on and off the toilet) revealed that 5 of 14 entries included the resident received one person physical assistance from (MONTH) 1-8, 2019. Review of the CNA documentation regarding support provided for toileting assistance including transfers on and off the toilet revealed that 16 of 16 entries included the resident received one person physical assistance between (MONTH) 1-8, 2019. One of the entries was by CNA (staff #129) who had documented that the resident received one person physical assistance with toileting on (MONTH) 8. According to a nurses note dated (MONTH) 8, 2019 at 11:30 a.m., the nurse was called to resident #63's room regarding a fall in the bathroom. Per the note, the resident was agitated and complaining of pain in her legs and knees and the paramedics were called and the resident was transferred to the hospital to rule out a fracture. Review of the hospital x-ray report dated (MONTH) 8, 2019 at 12:07 p.m., revealed the left knee bones were diffusely osteopenic, and the presence of an oblique impacted [MEDICAL CONDITION] aspect of the femur, with overlap of the fracture components. Review of the hospital physician's history and physical exam dated (MONTH) 8, 2019 at 4:16 p.m. revealed the resident presented to the emergency room with left leg and hip pain, after loosing her balance while being assisted to the toilet. The documentation included the resident had stated that she was caught by a staff member, but landed on both knees. The report further included that the x-ray showed an impacted distal femur fracture on the left. The resident had received [MEDICATION NAME] in the emergency department with relief of her pain and that upon arrival to the medical/surgical floor, resident #63 was having excruciating pain. Review of the addendum to the hospital history and physical dated (MONTH) 8, 2019 at 5:56 p.m., revealed the resident was being assisted to the bathroom when the CNA lost her grip and the resident fell to the floor. Review of the facility's investigative report revealed that on (MONTH) 8, 2019 at approximately 11 a.m., a CNA (resident #129) transferred resident #63 by herself to the toilet. The resident started to slide off the toilet and the CNA slid the resident to the ground. Upon the charge nurse's assessment, the resident had an abnormality to her left leg, 911 was called and the resident was transferred to the hospital. Per the report, a hospital xray confirmed that the resident had a left femur fracture. The facility's report also included a written statement from the CNA (staff #129) who stated that she put the resident on the toilet by herself. She reported the resident called her back to take her off and the resident stood up, then when she started pulling up her brief, her legs were giving up and she tried to pull her back on the toilet. She stated the resident sat on the edge, but then started to slide off so she put her down to the floor slowly. Review of the personnel file for staff #129 revealed the CNA completed training on transfers, including two person transfers with a return demonstration on (MONTH) 10, 2019. The file also contained a statement from staff #129 that she knew she should have gotten someone else in regard to the transfer of resident #63. Per the documentation, staff #129 was placed on suspension on (MONTH) 8, 2019 due to transferring the resident alone when the resident was care planned for two person assistance with transfers, which resulted in a major injury. The file also contained a hand-written resignation by staff #129 dated (MONTH) 15, 2019. During an interview with resident #63 conducted on (MONTH) 18, 2019 at 1:52 p.m., the resident stated that she had fallen and broke her leg in two places, when she was transferred to the toilet by a CN[NAME] The resident stated that the CNA did the transfer alone and there should have been two CNA's to assist with transfers. She also stated the CNA had transferred her alone many times and she had told the CNA that she needed two people for transfers. During an interview with a CNA (staff #72) on (MONTH) 19, 2019 at 2:05 p.m., staff #72 said that she knew resident #63's care needs well. She said when resident #63 was admitted to the facility she required only one person assistance with transfers, but after the resident sustained [REDACTED]. She also stated that resident #63 now requires a mechanical lift and two person assistance, because of the broken leg and it is facility policy to use two people when transferring a resident using a mechanical lift. She said that to her knowledge, the resident has not refused two person assistance with transfers. During an interview with a Licensed Practical Nurse (LPN/staff #42) conducted on (MONTH) 19, 2019 at 2:10 p.m., staff #42 stated she was not present on the day the resident fell but she was aware that the resident fell while being transferred in the bathroom by one CNA, and she was aware that the resident's care plan called for two person assistance with transfers at that time. She stated now the resident's care plan requires transfers with a mechanical lift. In an interview with the Director of Nursing (DON/staff #125) conducted on (MONTH) 19, 2019 at 2:15 p.m., the DON stated that the CNA's receive care plan information from the nurses and the Kardex, which displays the interventions required of the CN[NAME] The DON showed that the two person transfer intervention was on resident #63's Kardex beginning on (MONTH) 1, 2019. The DON stated that all CNA's are instructed to access the Kardex when they are in orientation. During an interview with the Assistant Director of Nursing (ADON/staff #69) conducted on (MONTH) 21, 2019 at 12:25 p.m., staff #69 stated that she monitors staff and provides oversight in order to assure care and services are implemented based on the care plan and resident's needs by making rounds throughout the day and by random chart audits. She stated the incident with resident #63 was not reported to her. She said that she was coming out of a meeting and the paramedics were entering resident #63's room. She stated that she found out what happened and called the DON immediately. She said the CNA did not say why she did the transfer alone and she was aware that the other nurses would help if a CNA was not available. During the survey, multiple telephone attempts were made to reach staff #129 including leaving voicemails, with no return call.

Based on clinical record review, staff interviews, hospital medical records, and facility policy, the facility failed to ensure one resident (#164) received adequate supervision to prevent a fall with injury. Findings include: Resident #164 was initially admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment Tool dated April 20, 2016, revealed the resident had a history of [REDACTED]. This assessment also included that the resident losses balance while standing, and requires hands on assistance to move from place to place. The fall risk score was 18, which indicated the resident was at high risk for falls. Review of the care plan initiated April 20, 2016, revealed a problem related to accident potential due to dementia, disorientation/confusion, history of falls, new environment, and poor safety awareness. The goals included for the resident to be free from major injury and to comply with safety precautions. Interventions included Do not leave unattended in the shower room even if I am Independent with shower. An ADL care plan initiated on April 20, 2016, revealed the resident required assistance with ADLs related to dementia with behaviors. Interventions included to assist the resident with ambulation, transfers, bathing, and hygiene as needed. The admission Minimum Data Set (MDS) assessment dated [DATE], included a Basic Interview for Mental Status (BIMS), the resident's score was 7, which indicated the resident had severe cognitive impairment. Review of the functional assessment section revealed the resident required one person physical assistance and physical help with bathing. The Care Area Assessment from the same MDS revealed Falls triggered for care planning. Review of the progress note dated April 28, 2016 at 12:34 p.m., revealed the resident had an unwitnessed fall in the shower. The note indicated the Certified Nursing Assistant (CNA/staff #62) turned away and heard a thud then turned back and saw the resident on the floor with his head bleeding. This note also included that the resident's family and physician were notified and 9-1-1 was called. Review of the facility's fall investigation revealed the resident had a gait imbalance, impaired memory, and was confused. This investigation also revealed that staff #62 was with the resident in the shower room, she had turned away to clean feces off the floor and heard a thud. Review of the hospital medical records dated April 28, 2016, revealed the resident fell in the shower and sustained a 3 x 3 centimeter (cm) abrasion with bleeding to the occipital area of the head. In an interview conducted on June 30, 2016 at 11:20 a.m., staff #62 stated she was with resident #164 for his shower. Staff #62 stated the resident required supervision, but she had to clean feces off the floor so another CNA (staff #18) came to the shower room to stay with the resident. Staff #62 stated that staff #18 left the shower room before she returned. Staff #62 stated she was out side of the shower room when she heard the thump. Staff #62 stated when she entered the shower room she found the resident on the floor. She also stated there was a lot of blood from the resident's head and 9-1-1 was called. In an interview conducted with the Director of Nursing (DON/staff #31) on June 29, 2016 at 11:35 a.m., staff #31 stated the resident did fall and was sent to the hospital. She also stated the resident was independent with showers on the care plan, but that residents are not to be left alone in the shower room. Review of the facility policy titled Resident Falls and Risk Assessment revealed one of the primary risks for injury to the elderly is due to falls and the facility is committed to timely and appropriate assessment of resident risk and corresponding interventions to prevent such injury. Review of the facility policy titled Accidents/Incidents and Supervision indicated the facility will provide a safe and secure environment that is as free from accidents and hazards as possible and ensure every resident receives the supervision and interventions needed to accomplish this.

Based on closed clinical record review, facility documentation, hospital records, staff interview and facility policy, the facility failed to ensure that one resident (#5) was not administered another resident's medications, which subsequently resulted in the resident requiring emergency treatment and hospitalization . Findings include: Resident #5 was admitted on [DATE], was discharged to the hospital on December 10, 2015, and readmitted on [DATE], with [DIAGNOSES REDACTED]. A nursing note dated December 10, 2015, included that at approximately 10:45 a.m., this resident was accidentally administered another resident's (a resident with a similar name) medications. The medications included the following: -[MEDICATION NAME]-anti-[MEDICAL CONDITION]. -[MEDICATION NAME]-anti-convulsant. -[MEDICATION NAME]-anti-psychotic. -[MEDICATION NAME]-anti-hyperglycemic. -[MEDICATION NAME]-anti-psychotic. -[MEDICATION NAME]-anti-hypertensive. -[MEDICATION NAME]-anti-psychotic The nursing note also included, The resident was unresponsive when the nurse noticed the error and went back in the residents room approximately 20 min later. According to the documentation, oxygen was administered, 911 was called and the resident was transferred to the emergency room . Another nursing note also dated December 10, 2015, included that the resident was admitted to the hospital because of altered mental status and a [DIAGNOSES REDACTED]. The facility's report of the incident included that a RN (registered nurse/staff #119) had administered another resident's medications to resident #5. Review of resident's medication orders revealed that resident #5 had not been prescribed any of the above medications that had been administered in error. The emergency room report dated December 10, 2015, included that the resident experienced an unintentional drug overdose, lethargy, and had developed [DIAGNOSES REDACTED], which was treated with intravenous fluid to maintain his blood sugar levels. A review of the hospital history and physical dated December 10, 2015, revealed that the resident presented to the emergency room after an accidental ingestion of [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME]. The assessment included that the resident presented with acute kidney injury, urinary tract infection, and toxic metabolic [MEDICAL CONDITION]. The hospital discharge summary dated December 12, 2015, included: Discharge Diagnoses: [REDACTED]. Toxic metabolic [MEDICAL CONDITION] secondary to medication administration error and urinary tract infection. An interview was conducted on June 28, 2016 at 2:47 p.m., with the Director of Nursing (staff #31). Staff #31 stated that following this incident, she spoke with the staff #119 who reported the following: -Staff #119 prepared resident #5's medications and then went to his room to administer them, however, he was sleeping. So the RN put his name on the medication cup, with the medications in it, and placed it in the medication cart drawer. -Staff #119 then proceeded to prepare another resident's medications and went to his room to administer them, however, the resident was in the shower. The RN put his name on the medication cup, with the mediations in it, and placed it in medication cart drawer. -When resident #5 woke up, staff #119 went to his room to administer the medications that she had prepared earlier. -When the second resident finished his shower, approximately 15 minutes later, staff #119 went to administer his medications and realized at that time that she had actually administered the wrong medications to resident #5. Staff #31 stated that at the time of this medication error, it would have been, Standard practice, to put a resident's name on a medication cup, with the medications in it, and store it in the medication cart, if the medications were unable to be administered when they were prepared. Staff #31 also stated that since this medication error occurred, the facility changed their policy and that it was no longer acceptable to store prepared medications in the medication cart and later administer them. Staff #31 stated that it was now facility policy to discard those prepared medications, if a resident was unavailable at the time they were prepared. A facility policy dated April 24, 2012, and titled, Medication Administration, included the following: -A physician's orders [REDACTED]. -Nursing staff will observe the 6 Rights (right drug, right dose, right route, right time, right resident, right documentation) when administering medication. No medication should be given without first checking the MAR (Medication Administration Record) and then checking the resident's identifiers such as: name, armband, and picture. An updated policy dated January 13, 2016, and also titled, Medication Administration, now included the following: -It is good practice to check your resident first to ensure that they are ready to receive their medication, but if for whatever reason, the resident is unable to take the medication that has been prepared for them such as (sleeping, showers, off the unit), the nurse will destroy the medication as per facility policy. You may not leave the medication in the cart, when the resident is ready and able to take their medication, you must prepare their medications utilizing the 6 rights. Another facility policy titled, Medication Error Reporting, included the following: Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety.

Based on a review of the clinical records, observations, staff interviews, and a review of facility policies, the facility failed to assess and monitor multiple skin conditions for three residents (#'s 205, 53 and 204). The sample size was 3. Findings include: -Resident 205 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a care plan that the resident had been identified to be at risk for skin breakdown. A nursing note dated October 10, 2014, included that during a shower a CNA (Certified Nursing Assistant) found that the resident's left lower back was swollen, hard, and painful to the touch. According to the documentation, the physician was notified, ice was applied, pain medication was administered, and the resident would continue to be monitored. However, a review of the clinical record revealed no documented evidence that the resident left lower back had continued to be monitored or assessed. A review of the October 2014, TARs (Treatment Administration Records) and nursing note entries also revealed no documented evidence that ice was offered or applied after October 11, through October 22, 2014, when the resident was transferred to the hospital. A physician's progress note dated October 18, 2014, did not include any documentation regarding the swollen, hard, and painful area on the resident's left lower back. The only documentation regarding the resident's skin condition was that it was dry. A nursing note dated October 21, 2014, now included that the resident complained of having Unbearable, pain to left side of her back and that she cried when it was touched. The documentation did not include that the physician had been notified. Although a facsimile was sent to the physician on October 21, 2014, concerning the resident's lethargy, poor appetite, and refusal to get out of bed, it did not address the status of the resident's left lower back. At this time, laboratory blood studies were orders. According to the nursing note dated October 22, 2014, the resident now had labored breathing, difficulty swallowing, abnormal vital signs, and severe lower back pain. Per the documentation, the physician was notified and an order was obtained to send the resident to the hospital. From the time of onset on October 10, 2014, to the time of discharge to the hospital on October 22, 2014, the only documentation regarding the painful, hard, swollen area on the resident's left lower back were on October 10, and 11, 2014, and then not again until October 21, 2014, which was the day before the resident was discharged to the hospital. The resident was discharged to the hospital on October 22, 2014, due to labored breathing, abnormal vital signs, difficulty swallowing, mouth sores, and back pain. A review of the hospital documentation revealed that the resident arrived in septic shock, and was diagnosed with [REDACTED]. The treatment plan was for debridement and drainage of the abscess to the left flank area. Per the documentation, the resident was taken to the operating room where 2 Liters of purulence drainage was evacuated. An interview was conducted on April 15, 2015, with the DON (Director of Nursing). Following a review of the clinical record she stated that an on-going assessment and monitoring of the resident's left lower back issue had not been provided. At this time, the DON stated that the occurrence of a hard, and swollen area on the resident's left lower back would have been a change of condition, which therefore, would have required the licensed staff to assess and document the resident's condition every shift for at least three days, and notify the resident's physician, accordingly. -Resident #53 was admitted [DATE], with [DIAGNOSES REDACTED]. A weekly skin assessment dated [DATE], included documentation that the resident had a bruise on her upper arm due to an altercation on April 5, 2015, with another resident. However, a review of the resident's shower records dated April 8, 12, and 15, 2015, revealed no documentation regarding any bruised or discolored areas. During an initial resident observation conducted on April 20, 2015, the resident was observed to have a small purplish colored area on the top of her right hand, that appeared to be a bruise, which was approximately a half dollar size. A second resident observation was conducted on April 15, 2015. Although the resident was not able to state how the bruises occurred, she spontaneously pulled up her left arm sweater sleeve and exposed multiple areas of deep purple on her arm. The resident then pulled up the sweater sleeve on her right arm, and again, exposed multiple areas of deep purple. A continued review of the clinical record revealed no documentation regarding the discolored/bruised areas. An interview was conducted on April 16, 2015, with the CNA (Certified Nursing Assistant) assigned to care for the resident. She stated that she had been assigned to care for the resident all week, and that she had seen the bruises on the resident's arms but had not reported it to the licensed staff on duty because she thought that it already had been reported. A second interview was conducted with the LPN (Licensed Practical Nurse,) who stated that the resident had a fall a few days ago (per the clinical record documentation the last fall occurred on March 30, 2015), and thought that the bruised area on the resident's arms were from the fall. The LPN then stated that the bruised areas also could be the result of the resident grabbing at things as she was escorted in her wheelchair. The LPN further stated that if the clinical record did not include documentation that the resident's bruised arms were a result of the last fall, an unusual occurrence report would need to be initiated, and the bruised areas monitored and assessed. Another interview was conducted on April 15, 2015, with the DON (Director of Nursing), who stated that the bruises should have been monitored and that they could be considered an injury of unknown origin and should be investigated. -Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the secured behavioral unit. Per a nursing note dated December 2, 2014, the resident was noted to have a large purple bruise to the right upper forearm and right elbow. The bruise was measured at 17 centimeters (cm) long and 21 cm wide. Also documented was that the bruising wrapped around the right forearm from the anterior view around the lateral forearm to the posterior view. In a review of the clinical record, and specifically skin assessments and nursing notes, there was no evidence that the staff consistently assessed and monitored the bruising. Multiple interviews were conducted with the Director of Nursing (DON) on April 14 and 15, 2015. She stated that skin issues, such as bruising, needed to be monitored by the licensed staff to ensure that healing was taking place and that there were no other problems. She further stated that the bruising would have been a change of condition and that would require licensed staff to assess and document every shift and notify the physician. A facility policy titled, Resident Abuse and Neglect, included, The facility will identify events, such as suspicious bruising or patterns and trends that may constitute abuse and determine the direction of the investigation. A facility policy titled, Resident Care and Services, included, Change of condition of the resident requires notification of the Physician and monitoring every shift for 72 hours or longer if necessary; this monitoring will be documented in the resident medical record.

Based on clinical record review, staff interviews, and review of facility documentation, policies, personnel file, and hospital records, the facility failed to ensure one resident (#156) was free from neglect that resulted in actual harm and subsequent hospitalization for treatment of [REDACTED]. Findings include: Resident #156 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented to person, place, and date/time. The resident was aphasic (unable to verbally speak) and utilized a communication board to communicate with others. Per the resident's plan of care for April 2012, the resident required the assistance of two staff members for transfers. A nursing note dated April 4, 2012 at 10:32 a.m. documented a summary of events that had occurred earlier that morning: The nurse was asked to come and assess the resident due to her complaints of pain to the left side of her body and not letting anyone touch her or get her out of bed. The resident was lying on her right side in bed. The nurse palpitated the left side of the resident's body and the resident tensed up in pain. The resident is unable to communicate verbally and uses a communication board to communicate. The Restorative Nursing Assistant (RNA) staff stated that the resident reported her left leg is hurting the most. The resident was asked to use the communication board to communicate. The resident typed out,"The person that got me up (this morning) did not lock my brakes and were (sic) not able to get me back up in the chair. I do not want to get anyone in trouble. Left leg twisted behind me and I was laid on floor. The nurse asked further 'yes' or 'no' questions and the resident able to answer yes by nodding that the night Certified Nursing Assistant (CNA) tried to transfer the resident on her own and dropped her to the floor. The resident nodded yes when asked if the night nurse or CNA picked her up off the floor and put her back into bed. The physician was notified and the resident transferred to the emergency room . A review of the hospital records dated April 4, 2012, revealed documentation of a fractured femur with subsequent hospitalization . The facility's investigative report included the following details: -Per a written statement by the CNA, (identified as staff #1) who had been assigned to provide care to resident #156 on April 4, 2012, she acknowledged that she had transferred the resident independently from the bed to the wheelchair and that the resident had been on the floor following this transfer. Additionally, the resident was then transferred from the floor to the bed. The statement did not include the time the tranfer occurred. -A written statement dated April 4, 2012 by the Licensed Practical Nurse (LPN) who was assigned to provide care to resident #156 on April 4, included that when she entered the resident's room around 5:30 a.m., the resident was lying on her right side in bed. The resident communicated and staff #1 concurred that the resident was complaining of pain to her left leg. The LPN completed a visual examination and did not note any redness, swelling, or bruising. Also documented was that staff #1 did not report to the LPN about the transfer and the resident ending up on the floor. Tylenol was administered and the resident was taken to the dining room per her request. Documentation further included that during breakfast the resident continued to complain of pain and then communicated to staff that earlier in the morning she had sustained a fall, when staff #1 dropped her to the floor while transferring her without assistance from the bed to the wheelchair. -A written statement dated April 4, 2012 by the Director of Nursing (DON) included that she was aware that resident #156 required two person assistance for transfers and that staff #1 had attempted to transfer the resident without assistance. It further included that staff #1 stated the resident ultimately was on the floor, as a result of an unsafe transfer from the bed to the wheelchair. The statement also documented that staff #1 knowingly failed to follow the care plan for resident #156 which led to an injury. Staff #1 was then terminated from employment. Attempts to contact staff #1 via telephone were not successful. A review of the personnel file revealed that training had been provided related to safe transfers and that staff #1 displayed competency in this area. An interview was conducted on December 3, 2012, with the LPN who had been assigned to provide care to resident #156 on April 4, 2012. She stated she entered the resident's room on April 4, at approximately 5:30 a.m. per usual. As she entered the room the resident was sitting on the side of her bed and motioned that her left leg hurt. After a visual examination was completed the resident was transferred to the wheelchair as she had requested. She stated that staff #1 did not report the resident had been on the floor earlier that morning. An interview was conducted with the DON on December 3, 2012. She stated that resident #156 had a care plan in place which documented the requirement of two staff assistance for transfers. She said that staff #1 transferred the resident without assistance and did not lock the brakes of the wheelchair causing an unsafe transfer and the resident subsequently was on the floor. She said that staff #1 failed to report to licensed staff that the resident had been on the floor. She further stated that this incident led to the resident's transfer to the emergency room and subsequent hospitalization for treatment of [REDACTED]. A facility policy related to neglect included the definition of neglect to be a failure to provide goods and services necessary to avoid physical harm.

Based on clinical record reviews, staff interviews, and facility and hospital documentation, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one resident (#156), by failing to ensure staff reported a fall with injury, which resulted in a delay of evaluation and treatment and failed to ensure one resident (#57) had consistent monitoring and documentation of post-[MEDICAL TREATMENT] status. The sample size for the significant change assessment was one and the [MEDICAL TREATMENT] assessment sample was one. Findings include: -Resident #156 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented to person, place, and date/time. The resident was aphasic (unable to verbally speak) and utilized a communication board to communicate with others. The resident required the assistance of two staff for transfers. Per facility documentation, administrative staff determined that a Certified Nursing Assistant (CNA) identified as staff #1, had knowingly transferred resident #156 without assistance on April 4, 2012, that resulted in a fall. Staff #1 did not immediately report this fall to licensed staff and therefore the resident remained in pain and emergency treatment was delayed due to the omission of the reporting of the fall. Specific information is as follows: At approximately 5:30 a.m. on April 4, 2012, staff #1 acknowledged in a written statement that she had attempted to transfer resident #156 without assistance. During this unsafe transfer from the bed to the wheelchair, the resident ended up on the floor and was then transferred from the floor back to the bed. Facility investigative documentation revealed that staff #1 did not immediately report the incident to licensed staff. A written statement dated April 4, 2012, by the Licensed Practical Nurse (LPN) documented that as she entered the resident's room at approximately 5:30 a.m. on April 4, 2012, the resident was lying on her right side in the bed. The resident communicated and staff #1 concurred, that the resident was complaining of pain in her left leg and that it "was hurting." The LPN completed a visual examination and did not note any redness, swelling, or bruising or any injury. Also documented was that staff #1 did not report to the LPN at that time about the fall which had occurred. Tylenol was administered and the resident was taken to the dining room per her request. Additional documentation from restorative nursing staff revealed the resident was taken to the dining room as she requested on the morning of April 4, 2012. Around 8:30 a.m. during breakfast, the resident complained of severe left leg pain again and "Hollered and moaned and kept pointing to her left leg". The resident only finished half of her breakfast and continued to moan in pain. She was returned to her room and then communicated to the staff that she she sustained a fall earlier in the morning when staff #1 dropped her to the floor while transferring her without assistance from the bed to the wheelchair. Per the resident's statement on the morning of April 4, 2012, staff #1 attempted to transfer her from the bed to the wheelchair without assistance and dropped her to the floor, and then put her back to bed. It further included that the "person who got me up this morning (identified as staff #1) did not lock my brakes and were (sic) not able to get me back up in the chair. Left leg twisted behind me and I was laid on the floor." Per a nursing note entry dated April 4, 2012, a Registered Nurse (RN) had now been informed that the resident had communicated that she had been dropped to the floor earlier in the morning by staff #1 and remained in pain. The physician was notified and the resident was transferred to the emergency room and subsequently admitted to the hospital for treatment of [REDACTED]. Review of the facility investigative report related to this incident revealed that staff #1 knowingly failed to report to licensed staff an incident in which resident #156 was injured following a fall. A review of the hospital records dated April 4, 2012, documented that the resident was dropped when getting up from the wheelchair earlier this morning and the left leg was bent behind the resident. The resident was assessed to be in pain with pain identified in the left upper and lower leg and left knee. Attempts to contact staff #1 via telephone were not successful. An interview was conducted with the LPN who had been assigned to provide care to resident #156 on April 4, 2012. She stated that staff #1 did not immediately inform her that the resident had sustained a fall as a result of an unsafe transfer from the bed to the wheelchair earlier in the morning. An interview was conducted with the Director of Nursing (DON) on December 3, 2012. She stated that staff #1 failed to immediately report a fall for resident #156 that occurred on April 4, 2012. Stated this failure to inform was inconsistent with facility policy and the resident's level of pain and subsequent treatment was delayed because of failure to report. A facility policy related to accidents/incidents and supervision included that all accidents and injuries must be reported immediately to licensed staff. A policy related to falls and risk assessment included that any resident that has a fall or is assisted to the floor by the staff will be assessed by the nurse before being assisted up to determine if there is an injury. -Resident #57 was admitted [DATE], with current [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's order dated September 11, 2011, for the resident to receive [MEDICAL TREATMENT] treatments on Monday, Wednesday, and Friday, at an off-site [MEDICAL TREATMENT] center. A review of the resident's care plans revealed documentation of a care plan for [MEDICAL TREATMENT] that documented that staff would obtain vital signs and weight per the [MEDICAL TREATMENT] protocol and report significant changes in pulse, respirations, and blood pressure, immediately to the resident's physician. Further review of the resident's clinical record revealed nurses' notes and assessments that inconsistently documented the resident's post-[MEDICAL TREATMENT] status. On November 29, 2012, an interview was conducted with the Licensed Practical Nurse (LPN) who was providing cares to the resident. The LPN stated she had worked with the resident on days when the resident had gone to [MEDICAL TREATMENT] treatments. The LPN stated when the resident returned from [MEDICAL TREATMENT] treatments, the nurse was to assess and document the resident's vital signs, to include blood pressure, respirations, heart rate, pulse and shunt site. The LPN stated that the assessment was to be documented in nurses' notes in the resident's clinical record and that she did not always assess and document when the resident came back from [MEDICAL TREATMENT]. A review of the facility policy/protocol for [MEDICAL TREATMENT] revealed documentation that upon return from [MEDICAL TREATMENT], the resident would have their vital signs checked and access site observed for bleeding. The policy further documented that the assessment information would be recorded in the resident's medical record and if there were any complications, the resident's physician would be notified, immediately.