Every finding on record at Signature Healthcare of Greeneville

Based on facility policy review, medical record review, observation, and interviews, the facility failed to administer a continuous enteral feeding (liquid nutrition provided by a tube inserted into the abdomen) as ordered by the physician for 1 resident (Resident #61) of 1 resident reviewed for continuous enteral feedings.The findings include:Review of the facility's policy titled, Gastrostomy Feeding [enteral feeding] Guidelines, dated 2/7/2023, revealed .Verify the correct formula .Review of the facility's policy titled, Physicians Orders, dated 1/30/2026, revealed .It is the standard of this facility that physician orders are followed .Licensed Nurses .are expected to follow physician's orders .Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Dysphagia, Functional Quadriplegia, Gastrostomy Status (a tube inserted into the abdomen for the administration of feeding), and Unspecified Severe Protein-Calorie Malnutrition. Review of a comprehensive care plan for Resident #61 dated 4/30/2024 and revised on 3/17/2026, revealed .need for use of a feeding tube .Administer tube feeding formula .as ordered .Review of a weight for Resident #61 dated 3/5/2026, revealed the resident weighed 88.9 pounds.Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], for Resident #61 revealed .Feeding tube [enteral feeding] .Review of a physician's order for Resident #61 dated 3/13/2026, revealed .Osmolite 1.5 [artificial nutrition tube feeding formula] .Milliliter Per Hour .25 .Review of a weight for Resident #61 dated 3/16/2026, revealed the resident weighed 90.6 pounds. During an observation and interview on 3/16/2026 at 3:11 PM, with Registered Nurse (RN) B in Resident #61's room revealed Resident #61 had enteral feeding Osmolite 1.2 infusing at 45 ml/hr. RN B stated the resident had a physician's order for Osmolite 1.5 at 25 ml/hr. RN B confirmed Resident #61 had the wrong formula and rate infusing. During an interview on 3/18/2026 at 10:55 AM, Licensed Practical Nurse (LPN) C stated she had prepared and initiated the administration of the new bottle of Osmolite 1.2 enteral feeding at 45 ml/hr for Resident #61 on 3/16/2026 at 5:00 AM (observation was approximately 10 hours after the incorrect tube feeding was initiated). During an interview on 3/18/2026 at 3:17 PM, the Director of Nursing (DON) confirmed the facility failed to follow physician's orders related to tube feeding formula and rate for Resident #61.

Based on facility policy review, observations, and interviews, the facility failed to offer hand hygiene assistance to 4 residents (Residents #120, #122, #111, and #11) prior to meals of 4 residents observed during meal service on 1 of 5 units observed for meal tray distribution. The findings include: Review of the facility's policy titled, Assistance with Meals, revised 5/5/2025, revealed .Facility staff will assist residents with setup and meal preparations as needed to include offering resident to wash their hands prior to meal with washcloth, hand sanitizer or provided toilette . Review of the medical record revealed Resident #120 was admitted to the facility on [DATE] with diagnoses including Spinal Stenosis, Unspecified Lack of Coordination, Chronic Kidney Disease, and Other Recurrent Depressive Disorders. Review of the Brief Interview for Mental Status (BIMS) assessment for Resident #120 dated 3/13/2026, revealed the resident scored a 15 which indicated the resident was cognitively intact. Review of the care plan for Resident #120 dated 3/16/2026, revealed .ADLs [Activities of Daily Living] Functional Status/Rehabilitation Potential .dressing and grooming assist x [times] 2 .During an observation on 3/16/2026 at 12:10 PM, Certified Nursing Assistant (CNA) A delivered the lunch meal tray to Resident #120. CNA A assisted Resident #120 to set up the meal tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #122 was admitted to the facility on [DATE] with diagnoses including Fracture of the Left Femur and Chronic Respiratory Failure. Review of the BIMS assessment for Resident #122 dated 3/10/2026, revealed the resident scored a 15 which indicated the resident was cognitively intact. Review of the care plan for Resident #122 dated 3/12/2026, revealed .ADLs Functional Status .dressing and grooming assist x1 . During an observation on 3/16/2026 at12:13 PM, CNA A delivered the lunch meal tray to Resident #122. CNA A set up the meal tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure and Depression. Review of the BIMS assessment for Resident #111 dated 3/5/2026, revealed the resident scored a 13 which indicated the resident was cognitively intact. Review of the care plan for Resident #111 dated 3/12/2026, revealed .ADLs Functional Status .Dressing and Grooming assist x1 . During an observation on 3/16/2026 at 12:15 PM, CNA A delivered the lunch meal tray to Resident #111. CNA A set up the resident's lunch tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Depression, Paraplegia, Muscle Weakness, and Abnormalities of Gait and Mobility. Review of the admission MDS assessment dated [DATE], revealed Resident #11 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Resident #11 required substantial/maximal assistance for personal hygiene. Review of the care plan for Resident #11 dated 2/26/2026, revealed .self care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL cares . During an observation on 3/16/2026 at 12:16 PM, CNA A delivered the lunch meal tray to Resident #11. CNA A exited the room without offering hand hygiene assistance to the resident. During an interview on 3/16/2026 at 12:20 PM, CNA A confirmed residents were to be offered hand hygiene assistance prior to meals with sanitizing wipes. The sanitizing wipes were available on the meal cart. CNA A confirmed she had not offered hand hygiene assistance to residents today and stated .I didn't today . During an interview on 3/16/2026 at 12:30 PM, the Director of Nursing (DON) confirmed staff were to offer hand hygiene assistance to all residents prior to meals with hand sanitizer if the resident is in the dining room and by hand sanitizing wipes when the tray was delivered to the resident's room via the meal cart.

Based on facility policy review, medical record review, facility investigation documentation review, police report review, observation, and interview, the facility failed to protect the residents' right to be free from physical abuse from another resident for 10 residents (Residents #23, #11, #14, #8, #1, #5, #26, #27, #25, and #36) of 37 residents reviewed for abuse. The facility's failure to protect the residents' right to be free from abuse resulted in actual HARM for Resident #23, #11, and #14. On [DATE], Resident #23 sustained a bruise and laceration to the forehead when Resident #13 threw a plastic bowl and hit Resident #23 on the right side of the forehead. On [DATE], Resident #11 sustained a scratch on the left lower jaw when Resident #12 hit Resident #11 on her left lower jaw. On [DATE], Resident #14 sustained a bite and significant bruising to the left forearm when Resident #15 bit Resident #14 on the to the left forearm. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised on [DATE], revealed .It is the organizations intention to prevent the occurrence of abuse .and to assure that all alleged violations of federal or State laws which involved abuse .are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .the Facility Administrator, or his or her designee, will conduct a reasonable investigation of each such alleged violation .Abuse .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Physical abuse .Includes, but is not limited to, hitting, slapping, pinching, kicking .or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonable related to the appropriate provision of ordered care and services .Allegation of Abuse .Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse .is occurring, has occurred, or plausibly might have occurred .Prevention .Establishing a safe environment that supports, to the extent possible, a resident's safety .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict .Investigation Guidelines .The Facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute 'allegations of abuse,' .the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident .The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation and will implement corrective action consistent with the investigation findings and take steps to eliminate any ongoing danger to the resident or residents .Protection .If a suspected perpetrator is anyone other than a Stakeholder, the Facility Administrator or designee, will immediately take all appropriate measures to secure the safety and well-being of the affected resident or residents . Review of the facility policy titled Abuse, Neglect and Misappropriation of Property, revised [DATE], revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Physical abuse Includes, but is not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonably related to the appropriate provision of ordered care and services .Prevention .Establishing a safe environment that supports, to the extent possible, a resident's safety .Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur .Investigation Guidelines .The Facility Administrator will investigate all allegation, reports, grievance, and incidents that potentially could constitute allegations of abuse .The Facility Administrator may delegate some or all of the investigation as appropriate, but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident . 1. Review of the medical records and facility investigation documentation revealed a resident to resident altercation occurred between Resident #23 and Resident #13 on [DATE]. The incident of resident to resident abuse resulted in actual HARM to Resident #23 who sustained a laceration and bruise when Resident #13 threw a plastic bowl and hit Resident #23 in the forehead. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Dementia with Other Behavioral Disturbance, Generalized Anxiety Disorder (GAD), and Major Depressive Disorder. The resident expired on [DATE]. Review of the weekly skin assessment for Resident #23 dated [DATE], revealed the resident had no skin impairment. Review of the Nursing Progress Notes for Resident #23 dated [DATE] at 8:56 PM, revealed the resident had been involved in an altercation with another resident (Resident #13).Staff heard verbal confrontation [argument] from room [Resident #13 and Resident #23's room] and entered immediately. Staff observed [Resident #23] sitting in her w/c [wheelchair] and a small superficial laceration [small cut] to [Resident #23] forehead. A bowl was observed on floor next to w/c and watermelon pieces on [Resident #23's] lap. [Resident #23] states roommate had thrown a bowl at her. Residents were immediately seperated [separated] and head to toe assessment was complete. No other sign of injury noted. Laceration was cleansed and covered with bandaide [bandaid]. [Resident #23] denies any pain at this time. [ Resident #23] unable to recall details r/t [related to] dx [diagnosis] of dementia. Resident [23] moved to [another room] at this time for separation [separation]. Resident [#23] pleasant mood at this time sitting in w/c at nurses [nurse's] station and no emotional distress or concerns observed . Review of a police report dated [DATE] at 8:13 PM, revealed officers were dispatched to the facility where the Director of Nursing (DON) reported there had been an altercation between 2 residents. The victim (Resident #23) and the suspect (Resident #13) could not remember what had happened. Continued review revealed Resident #23 had told a nurse that Resident #13 had .thrown a fruit cup at her striking her in the head, causing a small cut . Review of a Certified Nursing Assistant (CNA) Skin Care Assessment Sheet for Resident #23 dated [DATE], revealed the resident had a laceration on the left side of her forehead. Review of the Nurse Practitioner (NP) Note for Resident #23 dated [DATE], revealed the resident had .sustained a laceration to her left forehead .after her roommate threw a plastic bowl from dietary at her. The area was dressed with Steri-Strips [strips of tape put across a minor cut] .She has profound Dementia and has no recollection of what happened last evening .Today she has bruising [on forehead] . Review of the Social Services Progress Notes for Resident #23 dated [DATE] and [DATE], revealed the resident did not display any signs of anger, depression, or anxiety. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident had not exhibited aggressive behaviors toward herself or others. Review of the NP Psychiatric Evaluation for Resident #23 dated [DATE], revealed the resident had been involved in an altercation with her roommate (Resident #13).Resident #23 was unable to recall details no recall of altercation. No signs or symptoms of worsening depression, known worsening anxiety, agitation no noted related distress resident is pleasant cooperative denies being fearful . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses included Dementia with Other Behavioral Disturbance, Generalized Anxiety Disorder (GAD), and Major Depressive Disorder (MDD). The resident expired on [DATE]. Review of a quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. The resident had not exhibited aggressive behaviors toward other residents. Review of the Nursing Progress Notes for Resident #13 dated [DATE] at 8:44 PM, revealed .[Resident #23] noted to be involved in a resident to resident altercation. Resident's seperated [separated] immediately .[Resident #13] was placed on 1:1 [1 staff assigned to Resident #13 for monitoring] supervison [supervision]. [Resident #13] head to toe assessment complete and no s/s [signs or symptoms] of any injury or concern noted . Review of a comprehensive care plan for Resident #13 dated [DATE], revealed .Behavioral .Resident demonstrates inappropriate behaviors including increased agitation. History of resident to resident altercation and throwing objects at roommate .Assist resident .away from other residents as needed .Determine the cause for inappropriate behavior and refer to a provider for intervention .Encourage participation in structured activities as appropriate .Observe triggers of inappropriate behaviors and alter environment as needed .Observe for unmet needs such as .companionship . Review of the Social Services Progress Notes for Resident #13 dated [DATE], revealed the resident stated .she was doing fine and was relieved her roommate was not in there w/ [with] her now. [Resident #13] stated she's had a lot of emotions lately that have built up and her roommate tends to [NAME] at her about things. Resident stated she did throw the newspaper and the bowl but never intended on the bowl making contact w/roommate. Resident stated she was very sorry about that and expressed remorse over the incident .[Resident #13] did not display any anger, depression or anxiety. No behaviors noted at this time . Review of the Social Services Progress Notes for Resident #13 dated [DATE], revealed the resident did not display anger, depression, or anxiety. Review of the Psychiatric Evaluation for Resident #13 dated [DATE], revealed the resident was involved in an altercation with her roommate. Continued review revealed the resident had no evidence of increased anxiety, agitation, or worsening depression. Resident #13 was being treated for a Urinary Tract Infection. Review of the facility's investigation documentation dated [DATE] at 6:52 PM, revealed .On this date [[DATE]], [Resident #13] and current roommate [Resident #23] began to argue [in the resident's room] and [Resident #13] allegedly threw a plastic bowl, hitting roommate in the head .resulted in a small superficial laceration to [Resident #23's] forehead .Resident [Resident #13] stated she became frustrated with roommate repetitively asking her for the newspaper . The residents were immediately separated. Resident #23 was placed on 1:1 supervision for 24 hours, then every 30 minute checks until she was moved to a private room on [DATE]. Resident #13 was moved to another room on [DATE] for 48 hours, then returned to her original room on [DATE], after Resident #23 had been moved to a private room. Continued review revealed the incident occurred in Resident #13's and Resident #23's room. Review of the witness statement by CNA R dated [DATE], revealed CNA R heard Resident #13 tell Resident #23 to shut up followed by something hitting the floor. CNA R entered the residents' room (Resident #13 and Resident #23) and observed a cup on the floor and blood .running down [Resident #23's] face .[Resident #13] kept saying she didn't do it . Review of the witness statement by Licensed Practical Nurse (LPN) U dated [DATE], revealed a CNA informed her that Resident #13 had thrown a cup at Resident #23's head and Resident #23's head was bleeding. LPN U entered the resident's room and .Resident #23 had blood coming down her face w/ a laceration to the left side of her forehead .When I [LPN U] asked [Resident #23] what had happened she stated 'She [Resident #13] hit me w/ her cup'. I observed watermelon on [Resident #23's] cheek & [and] pants. When [Resident #13] was asked what happened [Resident #13] stated 'She was being mean & if I really wanted to hurt her I would of threw the book at her .it's all about [Resident #23]' and [Resident #13] started to laugh . Review of the witness statement by CNA V dated [DATE], revealed CNA V .heard [Resident #13] yell at [Resident #23] shut up shut up and immediately after [Resident #23] cried out she hit me with a cup I [CNA V] went in [Resident #23] was bleeding [Resident #13] was laying in bed missing her fruit bowl off her tray .[Resident #13] was talking meanly and smiling and laughing about hitting [Resident #23] with a cup [Resident #23] also had watermelon all over her . During a telephone interview on [DATE] at 5:09 PM, CNA R stated .I could hear Resident #13 yelling shut up to Resident #23 .heard noise and heard [Resident #23] crying .I saw the cup on the ground .Resident #23's face was slowly being covered with blood .the blood was coming from her forehead above her eyebrow . During an interview on [DATE] at 10:48 AM, the Social Services Director stated Resident #23 had a small bruise on her forehead, but the resident stated she was not experiencing pain. Continued interview revealed the resident exhibited no signs of anger, distress, or anxiety. During an interview on [DATE] at 11:45 AM, the NP confirmed Resident #23 sustained a laceration to her left forehead from a plastic food bowl thrown by Resident #13. Continued interview revealed Resident #23 had a bruise and mild hematoma (blood under skin) on [DATE]. The NP stated Resident #23 had no psychosocial effects from the altercation which occurred on [DATE]. During an interview on [DATE] at 2:15 PM, the Administrator, in presence of the DON and Registered Nurse (RN) E, stated LPN U notified him Resident #13 had thrown a plastic bowl, hitting Resident #23 on the head after an argument on [DATE]. The Administrator confirmed Resident #23 sustained a laceration and bruising during the altercation and confirmed the facility's investigation substantiated abuse because the altercation resulted in an injury for Resident #23. 2. Review of the medical records and facility investigation documentation revealed a resident to resident altercation occurred between Resident #1 and Resident #12 on [DATE]. The incident of resident to resident abuse resulted in actual HARM to Resident #11 who sustained a bruise and abrasion on her left jaw when Resident #12 hit her in the face. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Muscle Weakness, Difficulty Walking, and GAD. Review of an admission MDS assessment dated [DATE], revealed Resident #11 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. The resident wandered but had not exhibited other behaviors. Review of the Nursing Progress Notes for Resident #11 dated [DATE] at 5:03 PM, revealed .[Resident #11] noted to be walking the hallway at approximately 1:20 pm [PM] Nurse was in hallway and observed [Resident #11] walking by another elder [Resident #12] and as nurse turned she observed other elder [Resident #12] appear as if something had happened. Nurse immediately intervened and separated the resident's [residents]. Head to toe assessment complete. [Resident #11] noted to have a small scratch to her left cheek .[Resident #11] did not appear to have any fear, anxiety, nor was she tearful . Review of the skin assessment document for Resident #11 dated [DATE], revealed the resident had a small scratch on her left lower jaw. Review of the PSYCHOSOCIAL/BEHAVIOR care plan for Resident #11 dated [DATE], revealed .the resident was monitored for increased need for psychosocial support and psychosocial support provided . Review of the Social Services Progress Notes for Resident #11 dated [DATE] at 5:49 PM, revealed the resident did not display signs of or voice fear, anger, depression or anxiety. Review of the NP Notes for Resident #11 dated [DATE], revealed .On [DATE] patient [Resident #11] was ambulating in hall when another female resident [Resident #12] made contact with an open hand gesture and made contact with patients [Resident #11] lower jaw .Immediately after the occurrence staff noted a small area circular to ovoid [egg shape] in appearance to [Resident #11's] left jawline with tiny open area and minimal bleeding . The resident showed no behavioral changes. Review of the Psychiatric Evaluation for Resident #11 dated [DATE], revealed the resident was involved in a resident-to-resident altercation. Resident #11 was hit by another resident (Resident #12). The resident was alert and calm; was not tearful or crying during the evaluation. The resident denied anxiety, agitation, and feeling depressed. Review of the Social Services Progress Notes for Resident #11 dated [DATE] and [DATE], revealed the resident did not display signs of or voice fear, anger, depression, or anxiety. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Depression, and GAD. Resident #12 expired on [DATE]. Review of the comprehensive care plan for Resident #12 dated [DATE] and updated on [DATE], revealed .Behavioral Res [Resident] has a dx [diagnosis] of Depression, Impulsiveness, GAD, & [and] Dementia with behaviors and is at risk for experiencing behaviors, Pacing, Periods of restlessness, & Verbal aggression/Physical Aggression .Resident sometimes calms when she has her baby doll .Encourage and assist to sensory room as tolerated by resident when noted to have increased agitation .Administer and monitor the effectiveness and side effects of medications .Anticipate care needs and provide them before the resident becomes overly stressed .Intervene as needed to protect the rights and safety of others; approach in calm manner, divert attention, remove from situation and take to another location as needed .Invite and encourage activity programs consistent with resident's interests . Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 had severe cognitive impairment. The resident exhibited physical and verbal aggression toward others, rejected care, and wandered. Continued review revealed a BIMS assessment was not completed due to Resident #12's severe cognitive impairment. Review of the Nursing Progress Notes for Resident #12 dated [DATE], revealed .[Resident #12] noted to be walking the hallway at approximately 1:20 pm [PM] Nurse was in hallway and observed [Resident #12] walking by another elder [Resident #11] and as nurse turned she observed other elder [Resident #12] appear as if something had happened. Nurse immediately intervened and separated the resident's [residents]. Head to toe assessment complete. No injury noted to this resident [Resident #12]. Later observed during assessments that this resident [Resident #12] had hit another female elder [Resident #11] in the face causing a small scratch to her left cheek. Review of the skin assessment document for Resident #12 dated [DATE], revealed the resident had no skin impairment. Review of Nursing Progress Notes for Resident #12 dated [DATE] at 4:25 PM, revealed the resident was placed on 1:1 supervision (1 staff assigned to Resident #12 for monitoring) for 24 hours immediately following the incident. The resident remained on 1:1 supervision until she was sent to the emergency room (ER) for a psychiatric evaluation on [DATE] at 4:00 PM. Review of Nursing Progress Notes for Resident #12 dated [DATE] at 6:32 PM, revealed the resident returned to the facility from the ER with 1:1 supervision to continue until the resident was evaluated by the Psychiatric NP. Review of the PSYCHOSOCIAL/BEHAVIOR care plan for Resident #12 dated [DATE] revealed the resident had increased monitoring and supervision with psychosocial support provided. Review of the Psychiatric Evaluation for Resident #12 dated [DATE] at 2:12 PM, revealed the resident had been involved in a .resident to resident altercation where [Resident #12] had hit another resident on the face causing a small scratch, this resident [Resident #12] noted to be agitated . Resident #12 was calm and cooperative during the evaluation. Review of the Nursing Progress Notes for Resident #12 dated [DATE] at 3:47 PM, revealed 1:1 supervision continued for the resident.We continue to monitor her very closely for any mood or behavioral changes . Review of the medical record revealed Resident #12 remained in 1:1 monitoring until [DATE]. Resident #12 did not exhibit any further aggressive or hostile behaviors and 1:1 monitoring was discontinued on [DATE]. Review of the facility's investigation documentation dated [DATE] at 1:20 PM, revealed Resident #11 told RN G that Resident #12 .had swatted at her [Resident #11's] face making contact . The residents were immediately separated.[Resident #11] does have small scratch to left cheek . Continued review revealed .The allegation is verified as evidenced by small scratch on left side of [Resident #11's] face and witnessed by nurse. Resident #12 had a prior history of verbal aggression but had not had issues of physical aggression. Resident #12 was placed on 1:1 observation . Review of the witness statement by RN G dated [DATE], revealed Resident #11 told RN G that Resident #12 hit her and touched the left side of her face.upon observation [Resident #11] had small amount of blood where she had been scratched on face . During observation and interview on [DATE] at 3:35 PM, Resident #11 was observed seated in a recliner in her room visiting with her son. She was smiling and exhibited no behaviors. When asked if there had been any problems with other residents, Resident #11's son stated something had happened in the hall, but it had been a while, and it was just a misunderstanding. He stated there had been no further issues. During an interview on [DATE] at 2:54 PM, RN G stated Resident #12 walk by and slapped at Resident #11 from the back. Resident #12 had a scratch on her cheek. During a telephone interview on [DATE] at 9:55 AM, CNA D stated Resident #11 and Resident #12 were walking in the hall, when 1 of the residents, who she thought was Resident #11 said Resident #12 had hit her. CNA D stated Resident #11 had a .very tiny spot on her face . During an interview on [DATE] at 11:45 AM, the NP stated Resident #11 had a small circular bruise measuring approximately 1.75 centimeters (cm) x 0.75 cm .with a little abrasion . on her left jaw. The NP confirmed Resident #11's injury occurred during the resident-to-resident altercation on [DATE]. During an interview on [DATE] at 2:15 PM, the Administrator, in the presence of the DON and RN E, stated RN G notified him of a physical altercation between Resident #11 and Resident #12 on [DATE] at 1:20 PM. Resident #11 had told RN G that Resident #12 had swatted at her face making contact. The Administrator stated Resident #11 had a small scratch to the left side of her face. The Administrator stated video surveillance footage was reviewed and revealed Resident #12 .reached and made contact with [Resident #11] . Continued interview revealed the allegation was verified due to Resident #11 having a small scratch on the left side of her face. The Administrator stated .It was a willful act . The Administrator confirmed the altercation was substantiated as abuse because Resident #11 had an area on her face. Video footage was no longer available for surveyor review. 3. Review of the medical records revealed a resident to resident altercation occurred between Resident #14 and Resident #15 on [DATE]. The incident of resident to resident abuse resulted in actual HARM to Resident #14 who sustained bruising to his/her left forearm when Resident #15 bit him/her on the arm. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, Pain, and Depressive Disorder. Review of the admission MDS assessment dated [DATE], revealed Resident #14 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Nurse's Progress Notes for Resident #14 dated [DATE], revealed Resident #15 entered Resident #14's room. When Resident #14 attempted to assist Resident #15 out of the room, Resident #15 grabbed Resident 14's left arm and bit the resident. Resident #14 was placed on every 15-minute checks for safety. Review of the Nurse's Progress Notes for Resident #14 dated [DATE], revealed the resident was assessed by the Nurse Practitioner (NP) and found significant bruising to the left forearm from the bite the resident received from Resident #15. Review of the comprehensive care plan for Resident #14 dated [DATE], revealed a new problem .Psychosocial Well-Being . Resident at risk for psychosocial related stress following resident to resident altercation .[interventions] .Discuss coping strategies with resident and/or family as needed .encourage family/friends to remain involved .Observe resident for the need for psychological/psychiatric services .Psychosocial support from staff .Social services to be available as needed . Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses including Diabetes Type II, MDD, Transient Ischemic Attack (small strokes), and Chronic Pain. Review of the annual MDS assessment dated [DATE], revealed Resident #15 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #15 had no behaviors during the assessment period. Review of the Nurse's Notes for Resident #15 dated [DATE], revealed the resident entered another resident's room (Resident #14). When Resident #14 was trying to show Resident #15 the way out, Resident #15 grabbed Resident #14's left arm and bit it. Resident #15 was placed on 15 minutes checks and monitored for additional physical aggression towards the other residents. Review of the Nurse's Notes for Resident #15 dated [DATE], revealed the NP assessed the resident. The NP note revealed the resident had no recollection of the incident on [DATE]. Review of comprehensive care plan for Resident #15 dated [DATE], revealed Problem .Behavioral Resident demonstrates inappropriate behaviors including: physical aggression towards other residents .Approach .1 on 1 staff supervision .Assist resident to away from other residents as needed .Determine the cause for inappropriate behavior and refer to physician for intervention .Encourage participation in structured activities as appropriate .Monitor for Psychosocial disturbance related to 1:1 incident .Observe for triggers of inappropriate behavior and alter environment as needed .Observe for unmet needs such as for toileting, rest, food, fluids, companionship . Review of Police Report Incident documentation dated [DATE], revealed Officer .responded a Simple Assault .On arrival, I [officer] spoke to .[DON] . The DON stated Resident #14 and Resident #15 had gotten into an altercation where Resident #15 had bitten Resident #14 .no charges were being filed . During an interview on [DATE] at 9:30 AM the Administrator stated the bite from Resident #15 to Resident #14 was abuse and the resident was harmed during the altercation. During an interview on [DATE] at 11:40 AM the NP verified Resident #14 sustained a bite on the left forearm that resulted in significant bruising, and Resident #14 was harmed by Resident #15. 4. Review of the medical records and facility investigation documentation revealed a resident to resident altercation occurred between Resident #8 and Resident #1 on [DATE]. Review of the medical record revealed Resident #8 was admitted to the facility [DATE] with diagnoses including Multiple Sclerosis, Depression, Anxiety, Insomnia and Neuropathy. Review of an admission MDS assessment dated [DATE], revealed Resident #8 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. The resident had not exhibited behaviors toward others. Review of the Nursing Progress Notes for Resident #8 dated [DATE] at 7:45 AM, revealed the resident had been involved in a resident-to resident altercation with Resident #1. Resident #8 was sitting in front of the nurse's station when Resident #1 yelled out shut up to Resident #8.[Resident #8] was hit open handed on left side of face/ forehead . The residents were immediately separated. Head to toe assessments were performed for both residents with no injuries noted. Review of the comprehensive care plan for Resident #8 dated [DATE], revealed .Psychosocial Well-Being At risk for decline in psychosocial well being related to resident to resident altercation .Approach .Activities of choice .Encourage social engagement activities of resident choice .Increased psychosocial support as needed .Observe and report to physician any changes in mood, behavior, cognition, and level of functioning caused by situational stressor(s) .Observe for psychosocial changes .Reinforce appropriate expression of feelings . Review of Social Services Progress Notes for Resident #8 dated [DATE] and [DATE] at 6:41 PM, revealed the resident did not display signs of anxiety, depression, anger, or hostility. Review of Social Services Progress Notes for Resident #8 dated [DATE] at 5:24 PM, revealed the resident did not display signs of anxiety, depression, anger, or hostility. During an observation on [DATE] at 3:31 PM, Resident #8 was observed in the main dining room where he had been participating in an activity. The resident was talkative, stated everything was going good, and no behaviors were noted. During an observation on [DATE] at 7:53 AM, revealed Resident #8 was in the day room eating breakfast and watching television with no behaviors noted. During an observation and interview on [DATE] at 7:55 AM, Resident #1 was seated in a chair in the dining room on the secured unit, drinking coffee.When asked if he had had any problems with other residents he stated .no, not that I know [TRUNCATED]

Based on facility policy review, medical record review, facility investigation review, personnel file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $600.00 was taken from 1 resident (Resident #34) of 8 sampled residents reviewed for misappropriation. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised on 10/17/2022, revealed .It is the organizations intention to prevent the occurrence of abuse, neglect and misappropriation of property .and to assure that all alleged violations of federal or state laws .are investigated and reported immediately . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Functional Quadriplegia, Hypertension, Type 2 Diabetes Mellitus, and Heart Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility investigation documentation dated 11/15/2022, revealed while the facility's Administrator was in Resident #34's room, the resident told the Administrator he needed help setting up a sting operation. The resident stated Certified Nursing Assistant (CNA) Z had taken money from him totaling $600.00 and he had a video of her doing so. The CNA was contacted by the facility on 11/15/2022 and was immediately placed on suspension. Continued review showed the video footage was no longer available for surveyor review. Review of the personnel file for CNA Z revealed the facility terminated CNA Z on 11/18/2022 for violation of company policy. Review of a State of Tennessee Licensure/ Certification report pulled 6/4/2024 revealed CNA Z's License Current Status as being Revoked. Review of a Resident lost, stolen, or damaged replacement form revealed a check was issued to Resident #34 in the amount of $600.00. During an interview on 6/5/2024 at 3:11 PM, the Administrator confirmed the facility substantiated the allegation of misappropriation on Resident #34. The Administrator stated the $600.00 was reimbursed to Resident #34. The Administrator further confirmed the facility failed to protect Resident #34 against misappropriation of property.

Based on facility policy review, medical record review, review of facility investigation documentation, police report review, and interviews the facility failed to report allegations of abuse to the State Agency for 6 residents (Resident #1, #8, #5, #6, #7, and #36) and failed to report an allegation of misappropriation of property for 1 resident (Resident #34) of 37 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised on 10/17/2022, revealed .It is the organizations intention to prevent the occurrence of abuse .and to assure that all alleged violations of federal or State laws which involved abuse .are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .the Facility Administrator, or his or her designee, will conduct a reasonable investigation of each such alleged violation .The Facility Administrator is responsible for reporting all investigations' results to applicable State agencies .Abuse .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Physical abuse .Includes, but is not limited to, hitting, slapping, pinching, kicking .or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonable related to the appropriate provision of ordered care and services .Allegation of Abuse .Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse .is occurring, has occurred, or plausibly might have occurred .All alleged violations involving abuse .are reported immediately , but no later than 2 hours after the allegation is made .all allegations and incidents of abuse .will be reported 'immediately,' .Reporting Guidelines .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Review of the facility policy titled Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made .all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately, .Prevention .Establishing a safe environment that supports, to the extent possible, a resident's safety .Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur .Investigation Guidelines .The Facility Administrator will investigate all allegation, reports, grievance, and incidents that potentially could constitute allegations of abuse .The Facility Administrator may delegate some or all of the investigation as appropriate, but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident .Reporting Guidelines .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . 1.The facility failed to report an allegation of resident-to-resident abuse that occurred between Resident #1 and Resident #8 on 2/26/2024 to the State Survey Agency. Review of the medical record revealed Resident #1 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses including Right Femur Fracture, Metabolic Encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), Acute Respiratory Disease, Reduced Mobility, Vascular Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident had not exhibited behaviors toward others. Review of the Nursing Progress Notes for Resident #1 dated 2/26/2024 at 8:55 AM, revealed Resident #1 had a resident-to-resident altercation with another male resident (Resident #8) that was sitting beside him in front of the nurse's station.Nursing reports [Resident #1] was just sitting in w/c [wheelchair] and all of sudden yelled out 'shut up' to [Resident #8] sitting beside him, then he [Resident #1] proceeded to swing open handed and hit .[Resident #8] . on left side of face/forehead . The residents were immediately separated. Head to toe assessment revealed neither Resident #1 nor Resident #8 had injuries. Review of the medical record revealed Resident #8 was admitted to the facility 1/21/2024 with diagnoses including Multiple Sclerosis, Depression, Anxiety, and Neuropathy. Review of an admission MDS assessment dated [DATE], revealed Resident #8 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. The resident had not exhibited behaviors toward others. Review of a police report dated 2/26/2024, revealed .On February 26th at approximately 0600 [6:00 AM], [Resident #1] smacked [Resident #8] unprovoked while at the nurses' station . Review of the Nursing Progress Notes for Resident #8 dated 2/26/2024 at 7:45 AM, revealed the resident had been involved in a resident-to resident altercation with another male resident [Resident #1]. Resident #8 was sitting in front of the nurse's station when another male resident [Resident #1] yelled out shut up to Resident #8. Resident #8 was hit open handed on left side of face/ forehead. The residents were immediately separated. Head to toe assessments were performed for both residents with no injuries noted. Review of the facility's event report documentation dated 2/26/2024 at 8:55 AM, revealed .Resident [#1] noted to have a resident to resident altercation with another male resident that was sitting beside him early am [morning] .in front of nurse's station .Nursing reports resident was just sitting in w/c and all of sudden yelled out shut up to resident sitting beside him, then he proceeded to swing open handed and hit other resident [Resident #8] on left side of face/forehead. Nursing immediately separated residents .Head to toe assessment was complete per nurse who reports no injury . There was no evidence to show the State Agency was notified of the resident-to-resident altercation. Review of the witness statement by LPN W dated 2/26/2024, revealed LPN W .heard commotion behind me when I turned around [Resident #1] was telling [Resident #8] to shut up and then he swung at [Resident #8] hitting him open handed in the face. At that point they both started swinging at each other just bumping hands . The residents were separated. Review of the witness statement by LPN U dated 2/26/2024, revealed LPN U .was at NSG [nursing] station [and] heard [Resident #1] yell out 'shut up' .reach over and hit [Resident #8] on left side of head/face . The residents were separated. During an interview on 6/3/2024 at 12:38 PM, the Director of Nursing (DON) stated the facility did not report the resident-to-resident altercation between Resident #1 and Resident #8 which occurred on 2/26/2024 to the State Agency. The DON stated the corporate office advised the facility to not report the allegation of abuse to the State Agency because there were no injuries to either resident. During an interview on 6/6/2024 at 8:45 AM, with the DON, Registered Nurse (RN) E (DON at the time of the incident), and the Administrator, the Administrator stated he was made aware of the incident between Resident #1 and Resident #8 around 5:00 AM or 6:00 AM on the morning of the event (2/26/2024) by LPN W. The Administrator stated the incident was reported to Adult Protective Services (APS), the Ombudsman, and the Police Department. Continued interview revealed the incident was discussed with the facility's regional team and it was determined the incident did not meet the definition of abuse. RN E stated the video surveillance footage revealed Resident #1 and Resident #8 were sitting side by side in front of the Long-Term Care Unit nurse's station. Resident #8 was talking with a nurse.[Resident #1] told him [Resident #8] to shut up and [Resident #1] .hit [Resident #8] back handed on the side of [Resident #8's] head .There was contact . During further interview the Administrator stated .There was a willful intent but there was no physical harm, mental anguish, or pain . The Administrator stated based on the facility's interpretation of the changes in regulations related to reporting abuse in 10/2022, guidance by the corporate office and Tennessee Health Care Association (THCA), allegations of resident-to resident abuse were not reported to the State Agency unless there was physical harm, mental anguish, or pain. The Administrator stated the facility stopped reporting resident-to-resident altercations which did not have physical injury, mental anguish, or pain in 2024. The Administrator acknowledge the facility's process for reporting allegations of abuse had been inconsistent. The Administrator confirmed the allegation of resident-to-resident abuse for Residents #1 and #8 had not been reported to the State Agency. 45837 2. The facility failed to report an allegation of resident to resident abuse that occurred between Resident #5 and #6 on 4/11/2024 to the State Survey Agency. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Generalized Anxiety Disorder (GAD), and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 2 on the BIMS assessment, which indicated severe cognitive impairment, and exhibited inattention. The resident had physical behavioral symptoms noted. Review of the Nurse's Progress Notes for Resident #5 dated 4/11/2024, revealed the Assistant Director of Nursing (ADON) documented at approximately 5:35 PM, Resident #5 was in dining area propelling self in wheelchair. Resident #5 was yelling out sporadically and Resident #6 showed physical aggression towards Resident #5. Residents #5 and #6 were immediately separated and no injuries were noted. Review of the Nurse Practitioner (NP) Progress Notes for Resident #5 dated 4/12/2024, revealed Resident #5 who has profound and progressive Dementia resided on the secured and was in the common area last evening. Resident #5 was near Resident #6 and threw an empty tissue box toward him. Resident #6 who has profoundly cognitive impairment reacted by standing to his feet and attempting to pick Resident #5 up out of her wheelchair. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Muscle Weakness and Depressive Disorders. Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored an 8 on the BIMS assessment, which indicated moderate cognitive impairment. The resident had disorganized thinking and no behaviors. Review of a Police Department Incident Report dated 4/11/2024, revealed an officer arrived at 6:00 PM for a simple assault call. The ADON called to report Resident #6 had assaulted Resident #5. Resident #6 picked Resident #5 up out of her chair. Review of an APS report dated 4/11/2024, revealed a report was filed about the resident to resident altercation between Residents #5 and #6 at 6:54 PM. There was no evidence in the facility documentation a report was made to the state agency to notify of the resident to resident altercation. During an interview on 6/4/2024 at 4:09 PM, the ADON stated she provided care for Residents #5 and #6 at the time of the incident. She stated she was in the dining area when Resident #5 was in her wheelchair and propelled past Resident #6, and he suddenly grabbed her and picked her up out of her wheelchair. Staff notified police, NP, Resident #6's son and EMS (Emergency Medical Services), and obtained an order to send Resident #6 to the emergency room (ER) for acute behavioral disturbance. Further interview revealed no injuries were noted to Resident #5 or Resident #6. During an interview on 6/4/2024 at 5:30 PM, the Administrator stated he was notified about the incident between Residents #5 and Resident #6 on 4/11/2024 at about 5:45 PM. The Administrator stated the incident was not reportable to the state agency because there was no injury or psychosocial harm to either resident. The Administrator confirmed the incident was a willful act when Resident #6 got up, went to Resident #5 and picked her up out of a wheelchair. The Administrator stated .it was a resident-to-resident altercation, not abuse, because there was no injury . 3. The facility failed to report an allegation of resident to resident abuse that occurred between Resident #1 and #6 on 4/27/2024 to the State Survey Agency Review of the Nurse's Progress Notes for Resident #1 dated 4/27/2024 at 8:19 PM revealed .Notified by staff that at approximately 6:10 PM [Resident #1] was propelling in wheelchair by room [Resident #6's room] .[Resident #6] who was walking behind his wheelchair then hit him [Resident #1] open handed on the left side of his face .no injuries noted .will continue to monitor . Review of a Nurse's Progress Note for Resident #6 dated 4/27/2024 at 8:23 PM, revealed at approximately 6:10 PM Resident #6 was walking outside of his room behind Resident #1 in a wheelchair. Resident#6 suddenly hit Resident #1 across the left side of the face with an open hand and the residents were immediately separated. Resident #6 was placed on 1 on 1 observation. A NP order was received to send Resident #6 for a psychiatric evaluation, and notifications were made to the police, APS, Ombudsman, and the resident's son. Review of a witness statement dated 4/27/2024, revealed LPN BB documented Resident #6 hit Resident #1 open handed and from behind, in the face. Review of Police Department Incident Report dated 4/27/2024, revealed a Police Officer responded to a Simple Assault. Resident #6 stated that a friend had struck him and after talking with the facility staff, it was found that Resident #6 had struck Resident #1. Resident #6 admitted to the Police Officer he remembered striking Resident #1. Review of the facility's incident documentation revealed no evidence that a report was made to the state agency regarding the resident to resident altercation between Resident #1 and Resident #6. During a telephone interview on 6/5/2024 at 8:16 PM, CNA AA stated on 4/27/2024 at about 6:00 PM, Resident #1 was in a wheelchair at the door of Resident #6's room. The CNA stated Resident #6 came up behind Resident #1 and hit him open handed on the left side of the head around the ear and cheek. During an interview on 6/6/2024 at 8:45 AM, with the DON, RN E and the Administrator, the Administrator stated he was made aware of a resident-to-resident altercation on 4/27/2024 at 6:10 PM, and he came to the facility. The Administrator stated the residents were separated immediately and video evidence was reviewed as part of the investigation. The video evidence revealed that Resident #1 had waved as he passed #6's room, and Resident #6 made contact with Resident #1 from behind with an open-handed slap to side of head, and the staff saw it on camera. The Administrator reported the altercation to APS, Ombudsman, police, MD, and Psych NP, but did not report the resident-to-resident altercation to the state agency because .there was no injury, pain or psychosocial harm .I did not believe I should report it to the state .I did follow my policy . 27405 4. The facility failed to report an allegation of resident-to-resident abuse that occurred between Resident #7 and #36 on 3/2024 to the State Survey Agency. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Abnormalities of Gait and Mobility, Anemia, and Adult Failure to Thrive. Review of the Nurse's Progress Notes for Resident #7 dated 3/20/2024, revealed during the lunch in the main dining area, Resident #7 was observed by staff punching Resident #36 in the shoulder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #7 scored an 8 on the BIMS assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Need for Assistance with Personal Care, Dementia, and Heart Failure. Review of a quarterly MDS assessment dated [DATE], revealed Resident #36 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Review of the Nurse's Progress Notes for Resident #36 dated 3/20/2024, revealed during the lunch in the main dining area, Resident #6 was engaged in a verbal altercation with Resident #7 which led to Resident #7 punching Resident #36 in the left shoulder. No injuries were noted. Review of a Police Department Incident Report dated 3/20/2024, revealed on 3/20/2024 at 12:58 PM, Police Officers responded to a simple assault between two residents. The document revealed Resident #7 and Resident #36 were at the lunch table when Resident #7 struck Resident #36. There were no injuries to either party. Review of a skin assessment for Resident #36 completed on 3/20/2024, revealed no injuries. Review of a Psychiatric NP note dated 3/20/2024, for Resident #36 revealed the resident was evaluated due to reports of an altercation with another resident. Resident #26 was noted in a scuffle but the details were unclear. During an interview on 6/5/2024 at 10:22 AM, the Speech Language Pathologist (SLP) stated she could hear arguing when the incident happened on 3/20/2024 and observed Resident #7 make contact with Resident #36. Continued interview revealed it was not a hard hit as neither resident had much upper body strength, but contact was made. During an interview on 6/5/2024 at 10:24 AM, CNA I stated she heard arguing on 3/20/2024 and observed Resident #7 hit Resident #36 in the arm. During an interview on 6/6/2024 at 8:44 AM, the Administrator confirmed physical contact occurred when Resident #7 struck Resident #36. Continued interview with the Administrator stated he had been made aware of the incident between Resident #7 and Resident #36 and had reported to APS, the Ombudsman, and the Police Department. Continued interview revealed the incident was discussed with the facility's regional team and it did not meet the definition of abuse because no physical harm, mental anguish, or pain was determined so the incident was not reported to the State Agency. 5. The facility failed to timely report an allegation of misappropriation of Resident #34's funds by a staff member to the State Survey Agency. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Functional Quadriplegia, Hypertension, Type 2 Diabetes Mellitus, and Heart Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #34 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a facility investigation dated 11/15/2022 revealed, while the facility Administrator was in Resident #34's room, the resident stated he needed help setting up a sting operation. The resident stated CNA Z had taken money from him totaling $600.00 and he had a video of her doing so. The facility investigation revealed the Staff Development Coordinator (SDC) who had been previously the residents floor nurse had knowledge of the incident prior to Resident #34 reporting to the Administrator. The CNA was contacted on 11/15/2022 and immediately placed on suspension. The video footage was no longer available for review. Review of the personnel file for CNA Z revealed the facility terminated CNA Z on 11/18/2022 for violation of company policy. Review of the personnel file for the SDC revealed the facility terminated the SDC on 11/23/2022 for violation of company policy. Review of a State of Tennessee Licensure/ Certification report pulled 6/4/2024 revealed CNA Z License Current Status as Revoked. During an interview on 6/5/2024 at 12:37 PM the SDC stated she was a floor nurse when first was approached by Resident #34 about the possibility of someone stealing from him. The SDC stated she did not remember an exact date but it was sometime around the end of 2021 or start of 2022 when the resident mentioned the theft to her. The SDC stated the resident was informed he should report it to the Administrator. The SDC stated Resident #34 told the SDC .he doesn't have any proof yet and wasn't going to make any accusations until he knew for sure . Continued interview revealed the SDC was approached again by the resident who declined reporting the theft until he had sufficient proof. Further interview confirmed the SDC failed to report the allegations of misappropriation (date(s) unknown) to the acting Administrator or to anyone else, until the allegations were brought to her attention by the current Administrator after 11/15/2022. During an interview on 6/5/2024 at 3:11 PM, the Administrator stated he was in Resident #34's room on 11/15/2022 when the resident showed him a video of CNA Z taking money out of his nightstand and placing in her pocket. Continued interview revealed the resident stated he had not authorized the CNA to retrieve money from his nightstand. The Administrator stated he immediately began investigation when the information was presented to him. The Administrator stated the SDC had knowledge of the alleged theft prior to 11/15/2022. Further interview revealed CNA Z and the SDC were terminated with legal charges brought against CNA Z by Resident #34. The facility substantiated the allegation of misappropriation of property and the $600.00 which was stolen, was reimbursed to Resident #34. Further interview confirmed the facility failed to report the misappropriation of property timely for Resident #34 since the SDC had knowledge (exact date unknown)of the alleged theft prior to 11/15/2022.

Based on review of the facility policy, observations, and interviews, the facility failed to provide a clean and homelike environment in 1 resident's (Resident #64) room of 6 resident rooms observed. The findings include: Review of the facility policy titled, Resident Rights revised 8/16/2018, showed .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of the facility policy titled, Maintenance dated 1/2005, showed .The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times .Maintaining the building in good repair and free from hazards . Resident #64 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia with Behavioral Disturbance, Unspecified [CONDITION(S)], Unspecified Hearing Loss, and History of falling. Record review of Resident #64's quarterly Minimum Data Set assessment dated [DATE] showed a brief interview of mental status of 00, which indicated the resident had severe cognitive impairment. Resident #64 had moderate difficulty with hearing, impaired vision, and required assitance of 1 staff member for activities of daily living, transfer, ambulation, dressing, and toileting. Review of facility documentation titled, Maintenance Requests showed, an entry was logged 8/12/2022, for room 170 [Resident #64's room], .Ceiling debris came down by bathroom . The area was documented as fixed on 8/14/2022. During an observation on 8/22/2022 at 11:35 AM, in Resident #64's room #170, the ceiling at the bathroom entrance had a yellowing discoloration with a basketball sized spot where popcorn texture was absent. During an observation on 8/23/2022 at 9:35 AM, in Resident #64's room #170, the ceiling at the bathroom entrance had a yellowing discoloration with a basketball sized spot where popcorn texture was absent. Inside the yellow discoloration were multiple dark discolored areas. The wall paper behind Resident #64's bed had peeled from the floor to the top of the headboard. During an interview on 8/23/2022 at 1:55 PM, Registered Nurse (RN) #1 stated the process of reporting facility related repairs was to enter the item in the maintenance log and notify maintenance there was something to be repaired. During an interview and observation on 8/23/2022 at 2:12 PM, the Regional Maintenance Director (RMD) stated the process of reporting facility related repairs was to enter the item in the maintenance log and notify maintenance of the needed repair. Further interview revealed items to be repaired in the facility were prioritized by severity. The RMD confirmed Resident #64's room (Room #170) was in disrepair. During an interview and observation on 8/23/2022 at 3:03 PM, with the Director of Nursing (DON) in Resident #64's room #170. The DON stated .the room was in better condition than where [Resident #64's] came from, but would probably bother another resident if they were to live in the room . The DON confirmed Resident 64's room was not in a homelike condition.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a care plan addressing hospice care and management for 1 resident (Resident #48) of 20 residents reviewed for care plans. The findings include: Review of a facility policy titled Hospice Program dated 5/2018, showed .plan of care will be developed and shall include directives for managing pain and other uncomfortable symptoms . Review of a facility policy titled Comprehensive Care Plans, dated 4/2021, showed .A person-centered Comprehensive Care Plan .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #48 was cognitively intact and received hospice services. Review of a comprehensive care plan initiated on 6/20/2022 showed a care plan had not been developed for hospice care services and management for Resident #48. During an interview on 8/22/2022 at 11:10 AM, Resident #48 stated she received hospice care. During an interview on 8/24/2022 at 10:44 AM, the MDS Coordinator reviewed Resident #48's care plan and confirmed a care plan had not been developed for the hospice care and management.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were stored and administered safely for 1 resident (Resident #86) of 6 residents reviewed for medication administration, which had the potential to cause an accident, when a nurse left Resident #86's medication at the bedside unattended. The findings include: Review of facility's policy titled, Administering Medications, revised 4/2019 showed, Medications are administered in a safe .manner .as prescribed .Only person licensed .administer and document the administration of medications may do so .Residents may self-administer .medications only if the Attending Physician .has determined .capacity to do so safely . Resident #86 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Chronic Pain Syndrome, and Polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #86 was cognitively intact and had no swallowing difficulties. Review of current physician's orders showed, .[MEDICATION(S)] sodium [a medicine for constipation] .100 milligrams [mg] .Twice A Day .[MEDICATION(S)] (vitamin D3) [a nutritional supplement] .2,000 units .Once A Day .Acid reducer (famotidine) .20 mg .Once A Day . During an observation on 8/22/2022 at 11:08 AM, Resident #86 was in bed with a medication cup containing 4 pills sitting on the overbed table unsupervised by licensed staff. The resident stated Licensed Practical Nurse (LPN) #1 usually stayed in the room until the medications were taken. During an observation and interview on 8/22/2022 at 11:10 AM, LPN #1 observed a medication cup containing 4 pills on the overbed table in Resident #86's room. LPN #1 stated the medications were [MEDICATION(S)] and vitamins, and they were left at the bedside while LPN #1 was returning other medications to the medication drawer and forgot to come back. LPN #1 stated usually medications were taken by the resident before the nurse left the room. LPN #1 confirmed the medication should not have been left in the resident's room unattended. Review of the medical record showed a medication self-administration assessment had not been completed for Resident #86. During an interview on 8/23/2022 at 12:32 PM, the Director of Nursing (DON) stated the expectation was for nurses to stay at bedside until medications were taken by a resident, and Resident #86 had not been assessed for medication self-administration. The DON confirmed the medication should have been taken by the resident before LPN #1 exited the resident's room.

Based on facility policy, medical record review, facility investigation, interviews and observations the facility failed to provide adequate supervision for 1 of 5 residents (Resident #1) reviewed for the risk of elopement. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) was identified related to the facility's failure to provide adequate supervision resulting in Resident #1 exited the building through a malfunctioning egress door, crossed a moderately trafficked 2-lane roadway and walked to a gas station that was 945 feet away from the facility. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The Administrator, Director of Nursing (DON) and Regional Nurse Consultant were notified of the Immediate Jeopardy (IJ) on 9/12/2020 at 12:50 PM in the conference room. The facility was cited Immediate Jeopardy for F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective from 8/22/2020 through 9/3/2020. The IJ was removed on 9/3/2020. The facility's corrective action plan, which removed the immediacy of the jeopardy was reviewed and corrective actions were validated onsite by the surveyors on 9/12/2020. The findings include: Review of the facility's policy titled, Safety and Supervision of Resident dated 5/30/2018, showed .Staff shall make routine resident checks to help maintain resident safety and well-being. Resident safety, supervision .to prevent accidents .Facility-oriented approach to safety addresses risks for groups of residents .Routine resident checks by nursing staff involve entering the residents room and/or identifying the resident elsewhere on the unit .Safety risks and environmental hazards are identified on an ongoing basis .Resident-oriented approach to safety addresses safety and accident hazards for individual residents . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] to the secure unit with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had severe cognitive impairment, required supervision with ambulation and did not exhibit wandering behaviors during the 7-day look back period. Review of the quarterly MDS assessment dated [DATE], showed Resident #1 had severe cognitive impairment, required supervision with ambulation and did not exhibit wandering behaviors during the 7-day look back period. Review of Resident #1's Comprehensive Care Plan dated 7/30/2020 showed .at risk for elopement .Goal .resident will remain safely within the (facility) environment .Approach .Complete elopement observation on admission, quarterly .Ensure resident is residing in the correct level of care: Locked behavior unit (secure unit) for elopement & wandering .Increase involvement in activities .Review for recent changes in bed/room moves (reevaluate resident for care needs if moved from current location in the facility) . Review of the quarterly Elopement Risk Evaluations dated 7/22/2019, 11/3/2019, 1/20/2020, 4/11/2020 and 7/14/2020 showed Resident #1 was at risk for elopement due to cognitive impairment, independently mobile, poor decision-making skills, demonstrated exit-seeking behavior, decreased safety awareness and had the ability to exit the facility. Review of a Nurse's Note written by Registered Nurse (RN) #2 dated 8/1/2020 showed Resident #1 .is exit seeking . Review of a Nurse's Note written by Licensed Practical Nurse (LPN) #1 dated 8/13/2020 showed .wandering in and out of patients rooms . Review of a Nurse's Note written by LPN #4 dated 8/21/2020 showed Resident #1 tested positive for COVID-19 and transferred to the COVID unit. During a telephone interview on 9/10/2020 at 2:02 PM, RN #1 stated she worked on the COVID unit on 8/22/2020 from 6:00 AM - 6:00 PM and was made aware Resident #1 had been transferred from the secure unit on 8/21/2020 to the COVID unit. RN#1 reported the resident walked the hallway, wandered in and out of resident rooms and required redirection at times. During a telephone interview on 9/10/2020 at 3:10 PM, RN #2 stated she worked on the secure unit on a routine basis and was familiar with Resident #1. RN #2 also stated the resident would frequently wander on the secure unit and staff were aware of Resident #1's wandering behaviors and need for redirection. During a telephone interview on 9/11/2020 at 11:17 AM, Certified Nursing Assistant (CNA) #3 stated she worked on the secure unit from 6:00 AM - 6:00 PM. CNA #3 also stated the resident would wander in and out of other resident rooms and walked in the hallway on the secure unit. Review of the facility's investigation dated 8/22/2020, showed Resident #1 pushed on an egress door at the end of the hallway on the COVID unit at 4:41 PM. The door was not locked, the alarm did not sound and the resident exited the facility, crossed a 2-lane roadway and walked to a nearby gas station. During an interview conducted on 9/10/2020 at 11:45 AM, LPN #1 stated she worked on the COVID unit when Resident #1 eloped from the facility. LPN #1 also stated that during shift change report on the morning of 8/22/2020, she was notified that Resident #1 was transferred from the secure unit the night before and had wandering behaviors. LPN #1 stated she was familiar with Resident #1 because she provided care for her in the past on the secure unit. LPN #1 confirmed on 8/22/2020 Resident #1 was walking in the hallway, was frequently redirected due to wandering in and out of resident rooms, the CNAs engaged the resident with different types of activities, but Resident #1 became easily distracted throughout the shift. LPN #1 stated the last time she observed Resident #1 inside the facility was at approximately 4:30 PM when she administered medication to the resident. During an interview on 9/11/2020 at 8:30 AM, the gas station employee who was working on 8/22/2020 stated Resident #1 was escorted into the store by a customer at approximately 5:30 PM. The resident appeared to be confused and the employee notified the police. During a telephone interview on 9/10/2020 at 2:24 PM, LPN #2 reported she worked as the House Supervisor on 8/22/2020. She stated that at approximately 5:45 PM, she received a call from the local police dispatch reporting a possible resident elopement. LPN #2 stated she initiated a Code Green (a facility procedure for a missing resident) to ensure all residents were accounted for and safe in the facility. During a telephone interview on 9/10/2020 at 2:31 PM, CNA #1 reported she provided care for Resident #1 on the secure unit and was aware of Resident #1's wandering behaviors. CNA #1 confirmed she worked on 8/22/2020 from 6:00 AM - 6:00 PM on the COVID unit. CNA #1 stated she received report on Resident #1 from LPN #1 at the beginning of her shift and had been informed the resident was at risk for elopement. CNA #1 stated on 8/22/2020, Resident #1 was walking in the hallway, wandering into other resident rooms and stood at the nurse's station talking with staff. CNA #1 also stated the resident had to be redirected throughout the shift and was given multiple activities to engage her such as word search, coloring, watch different television programs and folding laundry. CNA #1 and CNA #2 were completing resident rounds (caring for other residents) and finished at approximately 5:15 PM, they noticed Resident #1 was not in the hallway. CNA #1 and CNA #2 started checking other resident rooms and overheard a Code Green called over the intercom. On 8/22/2020 at approximately 5:45 PM, CNA #1 and CNA #2 were informed by LPN #1 the resident had been located at a gas station near the facility. CNA #1 stated she and CNA #2 went to the gas station and escorted the resident back to the facility. During an interview on 9/10/2020 at 2:57 PM, CNA #2 confirmed she worked on 8/22/2020 from 6:00 AM - 6:00 PM on the COVID unit. CNA #2 stated she received report for Resident #1 from LPN #1 at the beginning of her shift and had been informed the resident was at risk of elopement. CNA #2 stated she was aware the resident had a history of [REDACTED].#1. CNA #2 reported during her shift on 8/22/2020, she spent extra time talking and walking with the resident, attempting to engage the resident in multiple activities and the resident had to be redirected multiple times. CNA #2 stated she last observed the resident at approximately 4:30 PM at the nurse's station. CNA #2 and CNA #1 were completing resident rounds and finished at approximately 5:15 PM, they noticed Resident #1 was not in the hallway. CNA #2 and CNA #1 started checking other resident rooms and heard a Code Green called over the intercom. CNA #2 confirmed she and CNA #1 went to the gas station and escorted the resident back to the facility at approximately 6:15 PM on 8/22/2020. Interview with LPN #1 on 9/10/2020 at 11:45 AM, stated she inspected the COVID unit on 8/22/2020 at approximately 6:00 PM to determine how Resident #1 exited the facility. She observed the egress door on the COVID unit was not locked and the alarm did not sound when the door was opened. LPN #1 stated she notified the Maintenance Assistant of the door not functioning properly and he arrived at the facility approximately 30 minutes later (6:30 PM). During continued interview with LPN #1 confirmed upon Resident #1's return to the facility on [DATE] at 6:15 PM she completed a head to toe assessment with no injuries observed. LPN #1 stated Resident #1 was placed with 1 on 1 supervision after returning to the facility and remained with 1 on 1 supervision throughout the night shift (6:00 PM - 6:00 AM). LPN #1 also stated the Resident #1 was placed on 15-minute checks beginning on 8/23/2020 at 6:00 AM and remained on 15-minute checks. On 8/25/2020 the secure unit was designated as an additional COVID unit and Resident #1 was transferred back to the secure unit. During an interview on 9/10/2020 at 12:10 PM, the Maintenance Assistant stated he was notified by LPN #1 on 8/22/2020 at approximately 6:00 PM, a resident exited the building through the egress door on the COVID unit, the door would not lock and the alarm would not sound when the door was opened. The Maintenance Assistant also stated he removed the cover from the timer box and discovered a loose wire. He fixed the wire, the lock functioned properly, but the alarm would not sound. The Maintenance Assistant stated the doors were checked for proper functioning Monday (M) through Friday (F) but not on weekends (Saturday 8/22/2020 the doors were not checked for proper functioning). The facility had a camera system in place, the Maintenance Assistant reviewed footage from 8/22/2020 and Resident #1 was observed walking back and forth from her room to the nurse's station and followed LPN #1 while she passed out medications. LPN #1 entered a resident's room and Resident #1 went to the egress door, opened it and walked out the egress door at 4:41PM. During an observation on 9/11/2020 at 3:30PM, Resident #1 was ambulating in her room on the secure unit with no distress or exit-seeking behaviors noted. Observation on 9/11/2020 at 4:00 PM of the 2-lane roadway Resident #1 crossed to the gas station, showed a caution sign that read Slow Hidden Entrance. The hidden entrance was the road which led to the facility. Observation of the gas station parking lot showed that one side of the parking lot had access to the 2-lane roadway and the other side had access to a 4-lane heavily trafficked divided highway. During an interview on 9/12/2020 at 11:20 AM, the DON confirmed Resident #1 exited the facility on 8/22/2020, walked up the hill and crossed a 2-lane roadway to the gas station which placed the resident at risk for injury. During an interview on 9/12/2020 at 11:40 AM, the Administrator confirmed the egress door located at the end of the COVID unit malfunctioned on 8/22/2020 and Resident #1 left the facility unsupervised to an unsafe environment. The facility's corrective actions were validated onsite by the surveyors on 9/12/2020. The corrective action plan included the following: A. On 8/23/2020 - 8/24/2020, the DON and designee reassessed all residents for the risk of elopement, updated the care plans if necessary and the elopement books (a book containing photos and identifying information for residents at risk for elopement). Review of the census and documentation of elopement risk assessments dated 8/23/2020 - 8/24/2020 confirmed all residents were reassessed for the risk of elopement. Review of the list of residents identified as being at risk for elopement and observations by the surveyor confirmed the elopement books located on all 3 hallways and in the front office contained the identifying information for all residents at risk for elopement. B. On 8/23/2020, the Administrator reviewed all resident Nurse's Notes for the past 30 days (7/22/2020 - 8/22/2020) for documentation of wandering or exit seeking behaviors for all residents. During an interview on 9/12/2020 at 11:40 AM, the Administrator confirmed she had reviewed all the Nurse's Notes and there were no new residents identified for wandering or exit-seeking behaviors. C. On 8/23/2020, the DON or designee began reviewing the accident reports, 24-hour report and Nurse's Notes daily X (for) 2 weeks, then will review M-F X 3 months to monitor for new wandering behaviors by any resident. Observation of the audit log check list for review of accidents/24-hour report/Nurse's Notes and interview on 9/12/2020 at 11:20 AM, the DON confirmed interventions had been implemented and were ongoing. D. On 8/23/2020 - 8/28/2020, the facility Administrator and/or the DON began reeducation for all facility staff on policies and procedures for Abuse/Elopement, Missing Resident, Safety and Supervision of (a) Resident and Care Plans. Review of the facilities in-service records, employee list and employee test results confirmed 100% of facility staff received reeducation. Staff interviews conducted on 9/9/2020 - 9/12/2020 with 3 CNA's: 2 working day shift (6:00AM - 6:00PM) 1 working night shift (6:00 PM - 6:00 AM), 2 LPN's working day shift (6:00 AM - 6:00 PM), 2 RN's: 1 working day shift (6:00AM - 6:00PM), 1 working night shift (6:00 PM - 6:00 AM), Maintenance Director and Maintenance Assistant confirmed they were aware of the policy and procedures to follow when a resident is missing. E. On 8/22/2020 the Maintenance Assistant notified the Administrator of the malfunctioning alarm. The Administrator and the Maintenance Assistant decided to place a magnetic tab alarm (a pull string that attaches magnetically to the alarm box, if separated the alarm will sound) on the door. He attached the alarm box to the door frame above the door, the string clip was attached to the door with Velcro and if the door was opened the string tab would pull the magnet off of the alarm box and the alarm would sound. The facility initiated daily checks of all egress doors on 8/23/2020. Review of the door check logs confirmed all doors were being checked daily from 8/23/2020 - 9/12/2020. Observations on 9/10/2020 and 9/11/2020 by the surveyors confirmed all egress doors were locked and had functioning alarms. Interviews conducted on 9/9/2020 - 9/12/2020, with 3 CNA's: 2 working day shift (6:00AM - 6:00PM) 1 working night shift (6:00 PM - 6:00 AM), 2 LPN's working day shift (6:00 AM - 6:00 PM), 2 RN's: 1 working day shift (6:00AM - 6:00PM), 1 working night shift (6:00 PM - 6:00 AM), Maintenance Director and Maintenance Assistant confirmed they were aware of the policy and procedures to follow when a resident is missing and revealed no reported concerns related to the doors malfunctioning prior to the elopement of Resident #1 on 8/22/2020. F. On 8/25/2020 the facility implemented weekly Code Green Drills. Review of the in-service sign in sheets dated 8/25/2020 and 9/4/2020 confirmed the drills were being conducted and staff interviews confirmed participation and understanding of the drills. During an interview on 9/11/2020 at 11:00 AM, the Maintenance Director confirmed the Code Green Drills were being conducted on both shifts. On 9/12/2020 at 11:40 AM the Administrator stated the facility would continue to conduct the drills weekly X 4 weeks, monthly X 2 months and quarterly thereafter. G. On 8/25/2020 a Quality Assurance (QA) meeting was held and the QA committee agreed to meet weekly X 4 weeks then monthly to ensure sustained compliance with the interventions implemented. The surveyor reviewed 2 QA meeting sign-in sheets dated 8/25/2020 and 9/4/2020. During an interview on 9/12/2020 at 11:45 AM, the Administrator confirmed the QA meetings were continuing to be held to monitor, re-evaluate, and oversee the implementation and effectiveness of the Plan of Correction. H. On 9/7/2020 the facility implemented a continued education schedule for random testing of employees to complete the elopement test. If the employee does not make 100% on the test the employee will be re-educated and must re-test until 100% is obtained. The schedule for random testing showed the following: 1. 3 employees per shift M-F X 3 weeks 2. 2 employees per shift M-F X 1 week 3. 1 employee per shift M-F X 1 week 4. 1 employee per week M-F X 4 weeks 5. 1 employee every other week M-F X 4 weeks I. Review of the audit tool of employees tested and elopement test results by the surveyor and interview on 9/12/2020 at 11:20 AM, the DON confirmed the facility had implemented the scheduled testing and is ongoing.

Based on medical record review and interview, the facility failed to make a referral to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR) after newly identified serious mental disorders were diagnosed for 2 residents (#48, #86) of 8 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Continued review revealed [DIAGNOSES REDACTED]. Medical record review of the most recent PASARR Level I assessment dated [DATE] revealed Resident #48 had no [DIAGNOSES REDACTED]. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Initial Diagnostic Interview dated 5/7/19 revealed .seeing the patient .major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] . Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed Resident #86 had diagnoses of Non-Alzheimer's Dementia, Anxiety, Depression, and [MEDICAL CONDITION] with Delusions. Medical record review of the most recent PASARR Level I assessment dated [DATE] revealed Resident #86 had no mental health [DIAGNOSES REDACTED]. Interview with the Minimum Data Set Coordinator on 9/5/19 at 11:58 AM, in the conference room, confirmed Residents #48 and #86 were not referred to the state-designated authority for a PASARR Level 2 screen after the residents were newly diagnosed with [REDACTED].

Based on review of the facility policy, medical record review and interview, the facility failed to develop a comprehensive care plan for the [DIAGNOSES REDACTED].#86) of 23 residents reviewed for care plans. The findings include: Review of the facility policy Comprehensive Care Plans last revised 7/19/18, revealed .revised as information about the resident and the resident's condition change . Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Initial Diagnostic Interview dated 5/7/19 revealed .seeing the patient .major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #86 had [DIAGNOSES REDACTED]. Medical record review of Resident #86's Comprehensive Care Plan, revised 8/5/19, revealed the plan of care did not include individualized goals and interventions for the treatment and management for the [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on 9/5/19 at 11:58 AM, in the conference room, confirmed the facility failed to develop a comprehensive care plan to address Major [MEDICAL CONDITION] and [MEDICAL CONDITION] with Delusions for Resident #86.

Based on facility policy review, facility investigation review, medical record review, and interview the facility failed to revise a Comprehensive Care Plan for 2 residents (#48, #61) and failed to revise a Certified Nurse Aide (CNA) plan of care for 1 Resident (#61) of 7 residents reviewed for falls of 49 sampled residents. The findings include: Review of the facility's policy, Falls, with a revision date of 8/16/18 revealed .If a fall occurs the following actions will be taken .Update care plan . Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation for Resident #48 dated 5/22/18 revealed .Resident getting up out of bed, unable to lift him properly, this nurse assisted resident to floor . Medical record review of Resident #48's Comprehensive Care Plan revealed .at risk for fall related injury . Continued review revealed no revision to reflect a new fall intervention on 5/22/18. Interview with the Staff Development Coordinator on 8/22/18 at 8:00 AM, in the conference room, confirmed the facility failed to initiate a new intervention after Resident #48's fall on 5/22/18. Interview with the Assistant Director of Nursing on 8/22/18 at 3:34 PM, at the Bridge Nurse's Station, confirmed the facility had no documented evidence a new intervention had been initiated after Resident #48's fall on 5/22/18. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Investigation for Resident #61 dated 7/20/18 revealed .RESIDENT WAS STANDING IN THE HALL WAY AND SUDDENLY LOST HER BALANCE AND fell .RESIDENT WAS FOUND ON LEFT SIDE OF BODY .No injuries .Fall Interventions Post Fall .Encourage rest periods . Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #61 had moderate cognitive impairment, and required extensive assistance of two or more persons for transfers, bed mobility, and toilet use. Medical record review of Resident #61's Comprehensive Care Plan the care plan had not been revised to include encourage rest periods after a fall on 7/20/18. Medical record review of a CNA plan of care for Resident #61 revealed no revision to include encourage rest periods after a fall on 7/20/18. Interview with the Director of Nursing (DON) on 8/23/18 at 4:40 PM, in the conference room, confirmed Resident #61's Comprehensive Care Plan and CNA plan of care had not been revised to include encourage rest periods after a fall on 7/20/18.

Based on medical record review, observation, and interview, the facility failed to follow a physician's order for 1 Resident (#77) of 49 residents sampled. The findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment and received tube feedings. Medical record review of a Physician's Progress Note dated 8/13/18 revealed . Continue enteral nutrition (tube feeding). Keep head of the bed elevated greater than 45 degrees while in bed . Medical record review of a Physician's Order dated 8/13/18 revealed .HOB (head of bed) elevated at least 45 (degrees) while resident in bed . Observation of Resident #77 on 8/22/18 at 5:56 PM, in the resident's room, revealed the resident was lying in the bed with the head of bed not elevated and the tube feeding being infused. Interview and observation of Resident #77 with the Administrator on 8/22/18 at 5:58 PM, in the resident's room, confirmed the head of bed was not elevated and the tube feeding was being infused. Interview and observation of Resident #77 with the Director of Nursing (DON) on 8/22/18 at 6:00 PM, in the resident's room, confirmed the head of the bed was not elevated and the tube feeding was being infused. The DON confirmed the head of bed needed to be elevated. Interview with the DON on 8/23/18 at 8:34 AM, at the nurse's station, confirmed the facility failed to follow a physician's order to keep the head of the bed elevated for Resident #77.

Based on facility policy review, medical record review, and interview the facility failed to offer the influenza and pneumococcal immunization for 1 Resident (#89) of 5 residents reviewed for immunizations. The findings include: Review of the facility policy Influenza, Prevention and Control of Seasonal revised 8/2014 revealed .The Infection Preventionist will promote and administer seasonal influenza vaccine .Unless contraindicated, all residents .will be offered the vaccine . Review of the facility policy Pneumococcal Vaccine revised 8/2016 revealed .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #89 had not been offered the influenza and pneumococcal vaccinations after admission to the facility. Interview with the Director of Nursing on 8/23/18 at 6:37 PM, in the conference room, confirmed the facility failed to offer Resident #89 the influenza and pneumococcal vaccinations after admission to the facility.

Based on medical record review, observation, and interview, the facility failed to provide pain management for 1 Resident (#297) of 49 residents sampled. The findings include: Medical record review revealed Resident #297 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (a pain medicine) 10/325mg (milligrams) tab (tablet) (1) po (by mouth) q (every) 6 hours prn (as needed) pain . Medical record review of the Baseline Care Plan dated 8/19/18 revealed the resident had pain to the right foot with approaches including to administer pain medications. Medical record review of the Controlled Drug Record dated 8/19/18 revealed the resident received the first dose of pain medication on 8/20/18 at 12:00 AM. Interview with Resident #297 on 8/20/18 at 10:08 AM, in the resident's room, confirmed the resident had requested pain medication on 8/19/18 at approximately 9:00 PM, and the resident stated it was 4 hours before the medication was administered. Further interview confirmed the resident was upset it .took so long . to get the pain medication after it had been requested. Telephone interview with Licensed Practical Nurse (LPN) #1 on 8/23/18 at 2:52 PM, confirmed the resident had complained of pain and requested pain medication at 10:00 PM on 8/19/18 but the pharmacy had not delivered the medication at that time. Further interview confirmed the medication was available in the facility's emergency medication box. Continued interview confirmed the LPN had not obtained the pain medication from the emergency medication box for the resident at the time the medication had been requested. Further interview confirmed the medication was not administered until the resident's medication supply arrived from the pharmacy at 12:00 AM. Interview with the Staff Development Coordinator (SDC) on 8/23/18 at 3:30 PM, in the conference room, confirmed the resident was admitted to the facility on [DATE] at approximately 1:00 PM. Further interview confirmed the resident (#297) requested pain medication at 10:00 PM on 8/19/18 but had not received the pain medication until 12:00 AM on 8/20/18. Continued interview confirmed the facility failed to provide pain management for the resident.

Based on facility policy review, review of facility investigations, medical record review, observation, and interview the facility failed to provide supervision to prevent accidents for 1 resident (#42) using an air mattress; failed to investigate a fall for 1 resident (#44); and, failed to initiate a new fall intervention for 1 resident (#48) with a history of falls of 7 residents reviewed for falls of 49 residents sampled. The findings include: Review of the facility policy, Falls, revised 8/16/18 revealed .If a fall occurs the following actions will be taken .Begin investigation . Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be conducted due to Resident #42 being rarely or never understood. Further review revealed Resident #42 was totally dependent of two or more person physical assist for bed mobility and transfers. Medical record review of Resident #42's Comprehensive Care Plan dated 2/12/18, revised 3/7/18 revealed, .LAL (low air loss) mattress - wt (weight) 111.6 lbs (pounds) - check settings every shift . Medical record review of Resident #42's Certified Nurse Aide (CNA) plan of care revealed, .assist of two .non-ambulatory . Medical record review of Resident #42's Physician's Order Sheet dated 3/1/18 to 3/31/18 revealed, .Low air loss mattress to be set for weight 111 lbs (pounds). Check settings every shift . Medical record review of the Nursing assessment dated [DATE] at 7:11 AM revealed, .Category: Fall .Date and Time: 5/3/18 4:45 AM .Observed laying on right side on floor between bed and wall. Redness noted to right side from eyebrow to above ear .X-ray ordered for right side of skull, right shoulder & (and) elbow, and right hip . Medical record review of the Physician's Telephone Order dated 5/3/18 revealed, .send to .ER (emergency room ) for eval (evaluation) (and) tx (treat) . Review of the facility investigation dated 5/3/18 revealed, .Describe what equipment was involved and how: Low air loss mattress was set on 180 pounds and bolsters at the top of the mattress was not secured .Document the implemented interventions: Educated staff to ensure low air loss mattress is on proper setting of 111 pounds every shift and bolsters are properly secured to bed every shift . Interview with the Licensed Practical Nurse (LPN) Unit Manager on 8/23/18 at 8:05 AM, at the Lilac/Rose Nurse's Station, revealed the nurses were responsible for checking the setting on the low air mattress at the time of the incident. Interview with the Staff Development Coordinator (SDC) on 8/23/18 at 8:35 AM, in the SDC's office, confirmed checking the bolsters should be done every time they go in the room. Further interview confirmed the air mattress was on the incorrect setting, and the bolster applied incorrectly. Telephone interview with CNA #1 on 8/23/18 at 5:58 PM, in the conference room, revealed .the things that hold the sides of the bed on were floppy . Further interview revealed she had provided care to the resident, and placed her on her side. The next time she went into the room, she (Resident #42) was on the floor. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated [DATE] revealed the resident was cognitively intact and required extensive assist of two plus person physical assist with transfers. Review of a nursing progress note dated 7/23/18 revealed .at approximately 12:15 the CNA .assist with transfer to BSC (bedside commode) .turned around facing away from resident briefly .the resident yelled out that she was falling .CNA grabbed the resident and slowly eased the resident to the floor . Interview with Resident #44 on 8/23/18 at 8:55 AM, in her room, revealed she had a fall at the end of July. Further interview revealed Resident #44 had been transferred by 1 CNA and a 2 person transfer was required due to a left leg fracture and non-weight bearing status. Telephone interview with CNA #1 on 8/23/18 at 5:18 PM, confirmed she had assisted Resident #44 on 7/23/18 to the side of her bed, to a standing position. Further interview confirmed the resident started to slide and she eased the resident to the floor. Continued interview confirmed she was not aware the resident required 2 person assist for transfers. Interview with the Director of Nursing (DON) on 8/23/18 at 6:40 PM, in the conference room, confirmed the facility had failed to investigate the fall for Resident #44. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE] revealed Resident #48 had severe cognitive impairment and required extensive assist of 2 persons with transfers. Medical record review revealed of Resident #48's Comprehensive Care Plan dated 1/26/18 revealed .at risk for fall related injury .Pressure alarm to bed . Review of a Physician's Recapitulation order sheet signed 5/16/18 revealed .Order Date .11/29/2017 .**TREATMENT/PR[NAME]EDURE** PRESSURE ALARM TO BED . Review of an investigation for Resident #48 dated 5/22/18 revealed .Resident getting up out of bed, unable to lift him properly, this nurse assisted resident to floor .Resident with bed alarm, not functioning, Placed new batteries in bed alarm. Fall Intervention Post Fall: Pressure sensor alarms . Interview with the SDC on 8/22/18 at 8:00 AM, in the conference room, confirmed the facility failed to initiate a new intervention after Resident #48's fall on 5/22/18. Interview with the Assistant Director of Nursing on 8/22/18 at 3:34 PM, at the Bridge Nurse's Station, revealed Resident #48's care plan dated 1/26/18 had the pressure alarm to bed intervention already in place prior to the fall on 5/22/18, and the facility had failed to initiate a new intervention after Resident #48's fall on 5/22/18.

Based on medical record review, observation, and interview, the facility failed to implement interventions on the comprehensive care plan for 2 residents (#42, #85) and failed to develop a comprehensive care plan for transfer assistance for 1 resident (#44) of 7 residents reviewed for falls of 49 residents sampled. The findings include: Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be conducted due to Resident #42 being rarely or never understood. Further review revealed Resident #42 was totally dependent of two or more person physical assist for bed mobility and transfers. Medical record review of Resident #42's comprehensive care plan dated 2/12/18, revised 3/7/18 revealed, .LAL (low air loss) mattress - wt (weight) 111.6 lbs (pounds) - check settings every shift . Medical record review of the Nursing assessment dated [DATE] at 7:11 AM revealed, .Category: Fall .Date and Time: 5/3/18 4:45 AM .Observed laying on right side on floor between bed and wall. Redness noted to right side from eyebrow to above ear .X-ray ordered for right side of skull, right shoulder & (and) elbow, and right hip . Review of the facility investigation dated 5/3/18 revealed, .Describe what equipment was involved and how: Low air loss mattress was set on 180 pounds and bolsters at the top of the mattress was not secured .Document the implemented interventions: Educated staff to ensure low air loss mattress is on proper setting of 111 pounds every shift and bolsters are properly secured to bed every shift . Interview with the Licensed Practical Nurse (LPN) Unit Manager on 8/23/18 at 8:05 AM, at the Lilac/Rose Nurse's Station, revealed the nurses were responsible for checking the setting on the low air mattress at the time of the incident. Interview with the Staff Development Coordinator (SDC) on 8/23/18 at 8:35 AM, in the SDC's office, confirmed the facility failed to adjust the air mattress setting according to the resident's weight listed on the care plan. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of the comprehensive care plan dated 1/29/18 revealed the resident was at risk for falls with a history of falls with fracture. Further review revealed the resident required the use of .1/4 side rails times 2 . Medical record review of a physician's orders [REDACTED]. Observation of Resident #85 on 8/20/18 at 4:33 PM, in the resident's room, revealed the resident lying in the bed with one side rail up on the bathroom side of bed and no side rail up on the window side of the bed. Observation of Resident #85 on 8/22/18 at 10:38 AM, in the resident's room, revealed the resident lying in the bed with one side rail up on the bathroom side of the bed, no side rail was on the window side of the bed, and a side rail was lying in the floor by the window. Interview with the MDS Coordinator on 8/22/18 at 10:51 AM, in the MDS office, confirmed the resident is care planned for the use of a 1/4 side rail on both sides of the bed. Continued interview and observation, in the resident's room, confirmed a side rail was lying in the floor by the window and no side rail was on the window side of the resident's bed. Interview with the Administrator on 8/22/18 at 11:57 AM, in the conference room, confirmed the side rail was broken. Further interview confirmed the resident should have been placed in another bed for safety until the rail was repaired. Interview with the Administrator on 8/23/18 at 1:07 PM, in the conference room, confirmed no maintenance work order had been submitted for the repair of the broken side rail and the side rail had been broken for an undetermined amount of time. Further interview confirmed the facility failed to implement the care plan for the use of side rails for Resident #85. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #44's comprehensive care plan dated 7/18/18 revealed the resident's care plan did not include interventions for transfer assistance. Review of an admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact and required extensive assist of two plus person physical assistance with transfers. Further review revealed the resident was at risk for falls and would be addressed in the care plan. Interview with Resident #44 on 8/23/18 at 8:55 AM, in her room, revealed she had a fall at the end of July. Further interview revealed Resident #44 had been transferred by 1 Certified Nurse Aide (CNA) and a 2 person transfer was required due to a left leg fracture and a non-weight bearing status. Telephone interview with CNA #1 on 8/23/18 at 5:18 PM, confirmed she had assisted Resident #44 on 7/23/18 to the side of her bed, to a standing position. Further interview confirmed the resident started to slide and she eased the resident to the floor. Continued interview confirmed she was not aware the resident required 2 person assist for transfers. Interview with the Director of Nursing (DON) on 8/23/18 at 6:40 PM, in the conference room, confirmed the resident required two persons to assist with transfers.

Based on review of the Emergency Transfer from Facility forms and interview, the facility failed to send the Ombudsman a notice of transfer or discharges for the months of April, May, and (MONTH) of (YEAR) for a total of 45 of 45 residents reviewed for emergency transfers. The findings include: Review of the Emergency Transfer from Facility forms dated 4/1/18 to 6/30/18 revealed 45 residents had emergency discharges from 4/1/18 - 6/30/18. Telephone interview with the Volunteer Assistant Ombudsman confirmed the Ombudsman had not been notified of acute emergency transfers from 4/1/18 to 6/30/18. Interview with the Business Office Manager on 8/22/18 at 10:03 AM, in the Business Office, confirmed emergency transfers from the facility reports had not been sent to the ombudsman from 4/1/18 to 6/30/18.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure allegations of abuse were reported timely to the Administrator and to the State Survey Agency for 1 residents (#7) of 11 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation or Property, last reviewed 11/16/17 revealed .It is (company) policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #7 scored a 0 (severely cognitive impaired) on the BIMS. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #6 scored a 4 (severely cognitive impaired) on the BIMS. Medical record review revealed on 4/28/18 at approximately 5:30 PM Resident #6 was hallucinating, got up from her supper tray, and proceeded to look for a dead man lying in the hall. Continued review revealed Resident #6 picked up another resident's supper tray that was on a table in the hall and headed toward the table with it. Further review revealed the resident was close to 2 other resident's heads so a nurse grabbed onto the tray to prevent Resident #7 from hitting the other resident's with it. Continued review revealed Resident #6 was very upset, begun to yell, and then let go of the tray and punched the nurse. Further review revealed the nurse stepped back and Resident #6 then punched Resident #7 in the head. Interview with the Administrator and the interim Director of Nursing (DON) on 5/16/18 at 10:00 AM, in the Admissions Office, revealed the facility discovered the alleged incident on 5/6/18 (8 days later) while doing a medical record review. Continued interview confirmed the facility staff failed to report the incident timely to the Administrator and to the State Survey Agency and failed to follow facility policy.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure 3 residents (#5, #7, and #8) were free from abuse of 11 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation or Property, last reviewed 11/16/17, revealed .It is (company) policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Abuse includes physical abuse, mental abuse, verbal abuse and sexual abuse .For purposes of this policy, willful means non-accidental, or not reasonably related to the appropriate provision of ordered care and services .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored a 8 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Medical record review of a psychiatric consult dated 4/17/18 revealed Resident #5 with behaviors including yelling out, verbal aggression towards staff, and reports of physical aggression at times. Review of a facility investigation dated 4/24/18 revealed administration received a report of an allegation of verbal abuse by Licensed Practical Nurse (LPN) #4 directed toward Resident #5. Continued review revealed LPN #4 was sitting at the nurse's desk and Resident #5 was sitting nearby in her wheelchair and was yelling. Further review revealed the resident was attempting to stand, which made her chair alarm go off and LPN #4 stood up, point at the resident, and told her to sit down and shut up. Continued review revealed the resident told LPN #4 You go to hell and LPN #4 replied you first. Further review revealed LPN #4 stated .I hate that woman .I'm tired of the yelling all the time . Continued review of a witness statement from Registered Nurse (RN) #4 revealed RN #4 overheard LPN #4 tell Resident #5 loudly to sit down and shut up. Further review of the witness statement revealed the resident told LPN #4 to go to hell, LPN then #4 told the resident to go first and LPN #4 stated I hate you I hate you you're a hateful old woman. Continued review of a written statement from LPN #4 revealed .Resident (#5) was screaming 'help' per usual and standing up against lap buddy which caused the w/c (wheelchair) to alarm. I said 'sit down' .I'm going to say I told you so when you flip that w/c over because I already told you what could happen .(Resident #5) said 'you go to hell, G .D .you' .She continued screaming and again I said 'sit down and stop it' .looked at (another nurse) and said 'I hate that woman' . Further review revealed LPN #4 was terminated on 5/2/18 due to substantiated verbal abuse. Interview with the Administrator on 5/15/18 at 5:00 PM, in the Admissions Office, confirmed LPN #4 partially admitted the allegation but stated she meant to say she hated the resident's behavior not the resident. Telephone interview with Registered Nurse (RN) #4 on 5/15/18 at 5:45 PM revealed she was at the nurses' station and overheard LPN #4 .being very rude and nasty .(RN #4) was flabbergasted . Continued interview revealed .(LPN #4) yelled at (Resident #5) to 'shut up' .(the resident) then told the nurse to .'go to hell' .(LPN #4) replied ' .you first' .(LPN #4) then stated 3 times ' .I hate her (Resident #5)' . Interview with the interim Director of Nursing (DON) on 5/16/18 at 8:10 AM, in the Admissions Office, revealed she felt it was best to terminate LPN #4. Continued interview revealed LPN#4 denied the allegation at first and then admitted to telling the resident to stop yelling. Telephone interview with LPN #4 on 5/16/18 at 9:10 AM revealed around 6:00 PM she was sitting at the nurses' station and several residents were sitting in front of the nurses' desk, including Resident #5. Continued interview revealed .(Resident #5) was yelling and attempting to stand up in her wheelchair .(LPN #4) asked the resident to please stop and (the resident) cursed and told her (LPN #4) to shut up .listened to the yelling about 30 minutes and (LPN#4) was getting nervous with all the screaming .kept telling the resident to sit down . Further interview revealed LPN #4 .'hated the woman's (Resident #5) behavior' . Interview with the Administrator and the interim DON on 5/16/18 at 9:55 AM, in the Admissions Office, confirmed LPN #4 was terminated for verbal abuse of Resident #5 and confirmed the facility failed to protect Resident #5 from verbal abuse. Telephone interview with RN #5 on 5/17/18 at 3:30 PM revealed Resident #5 was screaming and .one point (LPN #4) stood up pointing at (Resident #5) to sit down and shut up .(Resident #5) then said to (LPN #4) to go to hell .(LPN#4) said you go first .(LPN #4) then sat down and said I hate that woman . Telephone interview with LPN #5 on 5/18/18 at 6:00 PM revealed Resident #5 was yelling and told LPN #4 .you go to hell .(LPN #4) replied you go to hell first . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #7 scored a 0 (severely cognitive impaired) on the BIMS. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #6 scored a 4 (severely cognitive impaired) on the BIMS. Continued review revealed the resident was independent with ambulation with wheelchair use and required assistance of 1 for Activities of Daily Living (ADLs). Medical record review revealed on 4/28/18 at approximately 5:30 PM Resident #6 was hallucinating, got up from her supper tray, and proceeded to look for a dead man lying in the hall. Continued review revealed Resident #6 picked up another resident's supper tray that was on a table in the hall and headed toward the table with it. Further review revealed the resident was close to 2 other resident's heads so a nurse grabbed onto the tray to prevent Resident #7 from hitting the other resident's with it. Continued review revealed Resident #6 was very upset, begun to yell, and then let go of the tray and punched the nurse. Further review revealed the nurse stepped back and Resident #6 then punched Resident #7 in the head. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #8 scored a 0 (severely cognitive impaired) on the BIMS. Review of a facility investigation dated 5/6/18 at 7:30 PM revealed a nurse observed Resident #6 standup from her wheelchair with her oxygen intact and stretch the oxygen tubing a short distance from her chair to where she was standing. Continued review revealed Resident #8 walked up the hall, raised the tubing so she could walk beneath the tubing, turned around, and then started to walk underneath the tubing again. Further review revealed Resident #6 stated .I am tired of you getting into my business . then shoved Resident #8 causing her to fall to the floor. Continued review revealed the residents were separated and both assessed for any injury, with no injuries noted. Interview with Certified Nursing Assistant (CNA) #3 on 5/16/18 at 9:30 AM, in the behavior unit, Resident #8 was walking under the oxygen tubing of Resident #6, which was pulling the oxygen tubing. Further interview revealed Resident #6 told Resident #8 to get away but Resident #6 walked under the oxygen tubing again and Resident #6 pushed Resident #8 to the floor. Continued interview revealed Resident #8 gets .hyper .(Resident #6) doesn't want people to get close to her .(Resident #8) had not gone under the oxygen tubing before but sometimes will do things for attention . Interview with the Administrator and interim DON on 5/16/18 at 11:30 AM, in the Admissions Office, confirmed the facility failed to protect Resident #7 and Resident #8 from a resident to resident altercation with Resident #6.

Based on medical record review, review of a facility investigation, review of Stakeholder Suspension forms, and interview, the facility failed to ensure adequate supervision and assistance was provided during toileting and transfer, resulting in a laceration of the lateral side of the left lower extremity requiring twenty-one sutures (Harm), for one resident (#7) of five residents reviewed for injuries of unknown origin. The findings included: Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital History and Physical dated December 17, 2014, revealed the resident was prescribed Xarelto (anticoagulation therapy due to Atrial Fibrillation). Medical record review of a Fall Risk assessment dated [DATE], revealed the resident scored a twenty (10 or greater high risk). Medical record review of the initial Minimum Data Set (MDS) dated [DATE], revealed a 03/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of two for toileting and transfer. Medical record review of the Care Plan dated December 26, 2014, revealed, "assist with toileting as needed." Review of the facility investigation dated January 11, 2015, at 7:15 p.m., revealed a skin tear/laceration measuring 15 cm (centimeters) long x 2 cm wide with active bleeding was assessed on the residents left lower extremity to the left lateral side after being transferred during toileting by one Certified Nursing Assistant (CNA #5). Continued review revealed the resident was examined by the emergency room (ER) physician and the wound was cleaned, sutured (21) and bandaged by the ER staff. Further review of the facility investigation revealed two CNA's were suspended with additional education required. Continued review revealed "Assistant (CNA #5) answered...call light...when walked into the room (resident) was in a semi-standing position on the toilet and (CNA #5) finished helping (resident) in chair...3+ pitting edema so a small amount of pressure could have caused the tear...unclear if the assistant knew or caused the injury..." Review of Stakeholder Suspension Forms for CNA #4 and CNA #5 revealed CNA #4 had been assigned to mentor (train/oversee) CNA #5. Continued review of the Stakeholder Suspension Forms revealed both CNA #4 and CNA #5 were suspended from work for one day each and re-educated on the mentorship/supervision to be provided. Interview with CNA #4 (present during the incident) on March 3, 2015, at 9:10 a.m., in Room 220, revealed two CNAs (#4, #5) placed the resident on the commode. Continued interview revealed the CNAs instructed the severely cognitively impaired resident to turn the call light on when finished and left the resident in the bathroom unattended to put another resident to bed. Telephone interview with CNA #5 on March 3, 2015, at 10:54 a.m., revealed CNA #5 observed Resident #7's bathroom call light on and asked CNA #4 if the resident was likely to fall with a response of "maybe." CNA #5 went into Resident #7's bathroom and found the resident in the process of standing up with pants at knee length. Further interview revealed the resident turned trying to go to the wheelchair (outside the doorway) at which time the CNA removed the resident's pants, cleaned the resident and put a brief on the resident. Continued interview revealed the resident continued to try to get up and CNA #5 assisted the resident to the wheelchair (one person assist), turned the wheelchair to lock the wheels and noticed blood on the CNA's pants. Continued interview revealed CNA #5 observed a small amount of blood on the bathroom wall and blood on the resident's left sock, at which time the "skin tear" was discovered. Interview with the Special Projects Director of Nursing on March 3, 2015, at 1:40 p.m., in room 220, confirmed Resident #7 was left in the bathroom unattended; transferred to the wheelchair with one staff assist; had been assessed as requiring extensive assistance of two for transfer and toileting; and sustained a laceration of the left lower extremity (Harm) as a result of a transfer by one CNA. C/O #

Based on medical record review and interview, the facility failed to use the results of the assessment to develop, review, and revise the resident's comprehensive care plan related to the amount of assistance required for toileting resulting in Harm for one resident (#7) of twelve residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE] with a readmitted [DATE] and [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set (MDS) dated [DATE], (following readmitted [DATE])revealed a 03 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of two for toileting. Medical record review of the Care Plan dated December 26, 2014, revealed the resident was care planned for assist with toileting as needed. Review of the facility investigation dated January 11, 2015, at 7:15 p.m., revealed a skin tear/laceration measuring 15 cm (centimeters) long x (by) 2 cm wide with active bleeding was assessed on the resident's left lower extremity to the left lateral side after being transferred during toileting by one Certified Nursing Assistant (CNA #5). Further review of the facility investigation revealed "Assistant (CNA #5) answered...call light...when walked in room (resident) was in a semi-standing position on the toilet and (CNA #5) finished helping (resident) in chair..." Continued review revealed the resident was examined by theemsrgency room (ER) physician and the wound was cleaned, sutured (21) and bandaged by the ER staff. Interview with CNA #4 (present during the incident) on March 3, 2015, at 9:10 a.m., in room [ROOM NUMBER], revealed two CNAs (#4, #5) placed the resident on the commode. Continued interview revealed the CNAs instructed the severely cognitively impaired resident to turn the call light on when finished and left the resident in the bathroom unattended to put another resident to bed. Telephone interview with CNA #5 on March 3, 2015, at 10:54 a.m., revealed CNA #5 observed Resident #7's bathroom call light on and asked CNA #4 if the resident was likely to fall with a response of "maybe." CNA #5 went into Resident #7's bathroom and found the resident in the process of standing up with pants at knee length. Further interview revealed the resident turned trying to go to the wheelchair (outside the doorway) at which time the CNA removed the resident's pants, cleaned the resident and put a brief on the resident. Continued interview revealed the resident continued to try to get up and CNA #5 assisted the resident to the wheelchair (one person assist), turned the wheelchair to lock the wheels and noticed blood on the CNA's pants. Continued interview revealed CNA #5 observed a small amount of blood on the bathroom wall and blood on the resident's left sock, at which time the "skin tear" was discovered. Interview with the MDS Coordinator on March 3, 2015, at 1:10 p.m., in the MDS office, confirmed the Care Plan did not include the amount of assistance required for toileting (extensve assistance of two staff). Interview with the Special Projects Director of Nursing on March 3, 2015, at 1:40 p.m., in room [ROOM NUMBER] confirmed the resident had a BIMS score of 03 and would expect staff to follow the care plan. Further interview confirmed the facility failed to adequately address the level of assistance required for toileting in the care plan. C/O #

Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to ensure a safe transfer for one resident (#23), failed to ensure proper positioning to prevent a fall for one resident (#171), and failed to ensure a safety device was functional and a chair was in the locked position for one resident (#136) of forty-one residents reviewed. The facility's failure resulted in actual harm to resident (#23) who sustained a fractured tibia and fibula. The findings included: Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored a fifteen on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making and required extensive assistance of two persons with transfers and did not walk. Medical record review of the Fall Risk Evaluation dated December 7, 2012, revealed the resident was at risk for falls. Medical record review of the Interdisciplinary Progress Notes (IDT) dated April 16, 2013, at 3:25 p.m., revealed "...PTA (Physical Therapy Assistant) came to desk at this time stating that...when transferred resident to w/c (wheelchair) to go to therapy gym (resident) started sliding off the edge of...w/c...stated (PTA) eased (resident) to the floor to prevent injury to resident and...self. 6 staff members and the PTA went to room to place full body lift pad under resident. assessed for injury's at that time, no injurys noted. Resident moving all extremities without difficulty. Lift used to get resident back into bed..." Medical record review of an IDT note dated April 17, 2013, at 3:15 p.m., revealed "Resident ret. (returned) to facility via EMS (emergency medical services) from dialysis. c/o (complains of) left ankle pain. This nurse assessed res. from head to toe r/t (related to) c/o left ankle pain et s/p (status [REDACTED]. has (decreased) mvmt (movement); pedal pulse present but weak. (L) outer leg noted to have 10 small pin-point circular scabbed areas. PRN (as needed) pain med given also @ (at) this time...Spoke with Dr...et...advised to order an x-ray of (L) foot et ankle..." Medical record review of an x-ray of the left ankle dated April 17, 2013, revealed "...Impression: Acute fractures of the distal tibia and fibula..." Review of the facility's investigation of the fall dated April 16, 2013, revealed the resident was non-ambulatory and required maximum assistance of two persons or a mechanical lift for transfers. Continued review of the investigation revealed "...What caused this injury/incident? Res (resident) was sliding from w/c & (and) PTA tried to re-position unassisted. Was unable & res was lowered to the floor by PT...Could this injury/incident have been prevented? Yes...If yes how? Had more assistance with transfers..." Review of a statement dated April 16, 2013, prepared by CNA #11 revealed "...After the resident was returned to bed...The resident complained of pain in...left ankle..." Review of an undated statement for the fall on April 16, 2013, prepared by CNA #12 revealed "...When I walked in the room I observed the resident sitting up in front of...wheelchair in the floor...right foot was under the head of...roommates bed, left foot was in front of bed. Neither foot was trapped. The resident then complained of pain in...foot..." Review of a statement dated April 18, 2013, for the fall on April 16, 2013, prepared by Registered Nurse #5 revealed "At 12:45pm Thursday the 18th day of April, I spoke with (resident #23) concerning...left leg, ankle, and foot. (Resident) was lying in bed with...left leg elevated on a pillow. Ace wrap in place to left ankle. (Resident) stated that when...went to the floor, on 4-16-13, 'my leg was under me. The therapist straigten my leg out, then it got stuck under the table and was turned.' (Resident) denied that anything out of the ordinary happened during the transfer with EMS or while at dialysis. During my visit with (resident)...voiced that...left knee was also hurting. I provided...nurse with this information as well as (resident) appeared to be in pain and needed something for pain..." Review of an interview conducted by the Director of Nursing on April 18, 2013, with the EMS personnel who transported the resident to dialysis on April 17, 2013, revealed "...when arrived at facility on 4-17-13 (resident) stated that...leg hurt...asked (resident) if...felt like...needed to go to the ER (emergency room ) and (resident) said no that...wanted to go for...dialysis treatment..." Continued review of the interview revealed the resident's nurse was notified of the resident's complaints of pain, and the nurse reported the resident had received pain medication, and while the resident was at dialysis the physician would be notified to obtain orders for testing. Review of an interview conducted by the Director of Nursing on April 19, 2013, with the nurse from the dialysis center who had treated the resident on April 17, 2013, revealed the resident had reported pain in the left ankle during the dialysis treatment on April 17, 2013. Medical record review of a Physical Therapy Recertification and Updated Plan of treatment for [REDACTED]. pivot...Pt safer to transfer with use of full body lift..." Observation and interview on May 21, 2013, at 2:00 p.m., with the resident, revealed the resident lying on the bed, watching television with spouse, with the left lower extremity elevated on a pillow. Interview with the resident at this time revealed when the PTA came to the resident's room on April 16, 2013, the resident had told the PTA was unable to stand. Interview with the resident's spouse at this time revealed the resident required a two person assist for transfers. Interview on May 21, 2013, at 9:50 a.m., with the DON, in the conference room, revealed at the time of the resident's fall on April 16, 2013, there was only one person in the resident's room and the person was a Physical Therapy Assistant (PTA). Continued interview confirmed the resident required two person assistance with transfers. Interview on May 21, 2013, at 10:00 a.m., with the Registered Physical Therapist (RPT), in the conference room, confirmed the resident required two person assistance with transfers for safety reasons. Interview on May 21, 2013, at 10:05 a.m., with the PTA, in the conference room revealed, on April 16, 2013, had assisted the resident to stand and pivot to the wheelchair, unassisted, and was obtaining leg rests for the wheelchair when the resident began to slide out of the wheelchair. Continued interview revealed the resident "slouched" when seated in the wheelchair, was a large person and the PTA was unable to stop the resident from sliding from the wheelchair to the floor. Interview on May 21, 2013, at 11:05 a.m., with the Rehab Services Manager, in the Administrator's office, with the Administrator present, revealed the resident was a "bariatric" resident. Continued interview revealed the resident had been transferred by therapy with one person assist prior to April 16, 2013, however, confirmed the resident needed two persons in attendance to ensure safe transfers. Resident # 171 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set assessment dated [DATE], revealed the resident was minimally responsive and completely dependent on staff for transfers, positioning, and all activities of daily living. Review of a facility investigation dated May 1, 2013, revealed the resident experienced a fall, from the bed at 7:40 a.m. on that date. The investigation revealed the completely dependent resident had been positioned too close to the edge of the bed by staff. The resident's bed had a pressure reducing air mattress (inflates and deflates cyclically to interrupt potential pressure areas, for immobile patients). When the air mattress inflated, the improperly positioned resident was forced out of bed, onto the floor. The Licensed Practical Nurse (LPN) on duty at the time of the fall, documented the only injury sustained, due to the fall, was an abrasion to the right forehead that measured 2 centimeters(cm) X 2 cm. Observation on May 19, 2013 at 10:30a.m., revealed the resident lying in bed, unresponsive to verbal stimuli. The resident had a capped tracheostomy cannula intact and oxygen being delivered by nasal cannula. The resident had a percutaneous gastrostomy tube to provide nourishment (continuous tube feedings) and an indwelling urinary catheter with a privacy bag at the bedside. The resident was resting quietly. Observation on May 20, 2013, at 9:00 a.m., revealed the resident slightly more alert and responsive to external stimuli, sitting in a reclining chair with eyes open, as two Certified Nursing Assistants (CNAs) provided routine morning care for the resident. Interview with CNA #1 and CNA #2, on May 20, 2013, at 9:04 a.m., at the resident's bedside, confirmed the May 1, 2013 fall occurred as documented in the investigation. Both CNA's had just come on duty and responded to the resident's room, immediately following the un-witnessed fall. Interview with the Assistant Director of Nursing (ADON) on May 20, 2013, at 2:20 p.m., at the 200 hall nurse's station, confirmed the ADON also responded to the fall the morning of May 1, 2013. The ADON confirmed the events occurred as documented in the facility investigation, and the facility staff failed to position the resident properly on the air mattress to prevent a fall. Interview with the Director of Nursing (DON) on May 21, 2013, at 10:30 a.m. in the DON office, confirmed the investigation was complete and accurate. Continued interview confirmed an un-witnessed fall occurred on May 1, 2013, at 7:40 a.m., in resident #171's room, due to the resident being improperly positioned, on the air mattress, by staff. Resident #136 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had severe cognitive impairment, required extensive assistance for all activities of daily living and required a trunk restraint. Medical record review of the physician's orders [REDACTED]. Medical record review of the Interdisciplinary Progress Notes dated August 4, 2012, at 12:00 a.m., revealed...observed res. (resident) sliding OOB (out of bed)...no injury noted at this time... Medical record review of the Interdisciplinary Progress Notes dated August 7, 2012, revealed a late entry note for the August 6, 2012 IDT (Interdisciplinary Team) meeting held in reference to resident's fall on August 4, 2012. Continued review of the Interdisciplinary Progress Notes revealed "...bed alarm did not sound...nurse checked bed alarm...straightened out...had been tangled...and alarm worked..." Medical record review of the Interim Plan of Care dated July 30, 2012, revealed a handwritten intervention, "When res. (resident) placed in bed ensure alarm is working." Medical record review of the Interdisciplinary Progress Notes dated January 9, 2013, revealed on January 8, 2013 at 1645 "...resident sitting (tilted back) in Broda chair...raised forward...tipping self out of w/c (wheelchair)...fall on (L) left side on floor...Resident with Broda chair to be locked at all x's (times)...Staff to be educated in ensuring res (resident) Broda chair in locked position at all x's (times) and reclined..." Medical record review of the Comprehensive Care Plan dated January 8, 2013, revealed, "...ensure w/c (wheelchair) locked at all times and Broda chair reclined...staff educated on locking w/c..." Interview with the Assistant Director of Nursing on May 21, 2013, at 11:00 a.m. and 1:45 p.m., in the conference room, confirmed the safety device (bed alarm) was not functioning properly at the time of the fall on August 4, 2012. Further interview confirmed the Broda chair "was not locked" at the time of the fall on January 8, 2013. The resident experienced no injury. C/O #

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to ensure safety devices used to alert staff of unassisted transfers were working to prevent falls resulting in a fracture of the hip (Harm) for one resident (#11) of twenty-six residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored 4 out of 15 on the BIMS (brief interview for mental status), (0-7 is severe cognitive impaired), was one person assist for transfers, and walk in room. Medical record review of a Fall Risk Evaluation dated April 21, 2011, revealed a score of 16 (total score of 10 or higher is at risk). Medical record review of the Nurse's Notes dated August 29, 2010 thru November 11, 2010, revealed the resident had experienced several falls from the bed with no injuries. Medical record review of the care plan dated November 12, 2010, revealed the resident sustain a fall from the wheelchair with no injury and a chair alarm was placed on November 14, 2011, to alert staff of any unassisted transfers. Medical record review of a Fall/Change in Functional Status, dated April 21, 2011, revealed "...res (resident) attempted to toilet self per report from staff...res observed lying on r (right) side on floor in bathroom on main hallway...shoes on...brief & pants wet, pants pulled down to directly below brief...chair alarm in place and on but not sounding...res states...was standing in front of mirror when...lost...balance falling to R (right) landing on R hip and R arm..." Review of the facility's investigation dated April 21, 2011, revealed staff member in activities reported turning alarm off. Medical record review of a nurse's note dated April 21, 2011, at 5:00 p.m., revealed "..Transferred to EMS (emergency medical services) stretcher..." Medical record review of a nurse's note dated April 21, 2011, at 7:45 p.m. revealed "...Received call from (named) hospital ER (emergency room )...res. (resident) admitted to hosptial with R femoral neck fx (fracture)...Surgery scheduled for sometime tomorrow..." Medical record review of the hospital x-ray report dated April 21, 2011, revealed "...Displaced, angulated right femoral neck fracture..." Medical record review the resident was in the hospital from April 21 thru April 27, 2011, and was readmitted to teh facility. Observation on September 20, 2011, at 8:00 a.m., revealed the resident was sitting in a wheelchair in the hallway with chair alarm on and working. Observation on September 20, 2011, at 1:00 p.m., revealed the resident lying in bed with bed alarm in place. Medical record review of the care plan undate on July 18, 2011, revealed the care plan did not address the fall or no intervention put in place. Interview with the MDS (Minimum Data Set) Coordinator on September 20, 2011, at 4:20 p.m., in the MDS office, confirmed the facility failed to develop any new interventions on the care plan to prevent any further unassisted transfers or falls. Interview with ADON #1 (Assistant Director of Nursing) and the Restorative Nurse on September 20, 2011, at 11:45 a.m., in the restorative office, confirmed the chair alarm was not turned on at the time to alert staff of unassisted transfers resulting in a fall and fracture of the right hip (Harm).