Every finding on record at The Blossoms at Eureka Springs Rehab & Nursing Cen

Based on observation, interview, and record review the facility failed to have an accurate system of medication records that enabled periodic, accurate reconciliation and accounting for all controlled medications with prompt identification of loss or potential diversion of controlled substances for three (Resident #1, Resident #2, and Resident #3) of three residents reviewed. The findings include: Resident #1 Review of Resident #1's admission Record revealed the facility admitted the resident with diagnoses which included type 2 diabetes mellitus, anemia, recurrent depressive disorders and schizoaffective disorder, bipolar type. Review of Resident #1's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Review of Resident #1's Care Plan Report initiated on 04/09/2026, revealed Resident #1 was at risk for pain related to back pain. Interventions included give medications as ordered and document the effectiveness or ineffectiveness of medication. Review of Resident #1's Order Summary Report revealed Resident #1 had an order dated 04/16/2026 and discontinued 05/13/2026, for a narcotic pain medication give one tablet by mouth every eight hours as needed for pain. Review of the 200 Hall Narcotic Sign Out Book in comparison to Resident #1's electronic Medication Administration Record (eMAR) for May 2026, revealed Licensed Practical Nurse (LPN) #1 signed out one narcotic pain medication on 05/09/2026 at 1:10 PM, that was not documented as given to the resident on the eMAR. Review of Resident #1's Progress Notes revealed a progress note was not present for the date and time the resident's narcotic medication was signed out. During an interview on 05/18/2026 at 3:15 PM, Resident #1 reported having chronic pain for 20 years. Resident #1 indicated the as needed oral pain medication did not work. Resident #1 indicated two topical pain medications prescribed for pain did not work and were usually refused. Resident #1 indicated only one specific medication for pain would work to manage the resident's pain. Resident #2 Review of Resident 2's admission Record revealed the facility admitted the resident with diagnoses which included chronic pain syndrome, major depressive disorder recurrent severe with psychotic symptoms, schizophrenia, bipolar disorder, and anxiety disorder. Review of Resident #2's admission MDS with an ARD of 03/12/2026, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Review of Resident #2's Care Plan Report initiated on 03/10/2026, revealed Resident #2 was at risk for pain. Interventions included, give medications as ordered, observed/document for side effects of pain medication, and observe/document the effectiveness or ineffectiveness of medication. Review of Resident #2's Order Summary Report, revealed the resident had an order, dated 04/01/2026, for an anti-anxiety medication instructing staff to give one tablet by mouth every eight hours as needed for anxiety. Review of the 200 Hall Narcotic Sign Out Book from 04/14/2026 to 04/30/2026 in comparison to Resident # 2's eMAR for April 2026, revealed LPN #1 signed out a narcotic anti-anxiety medication eight times that were not documented as given to the resident on the eMAR. The dates and times for those medications were as follows: 04/14/2026 signed out on page 30 at 8:35 AM, administration record was not found on eMAR. 04/15/2026 signed out on page 30 at 6:00 AM, administration record was not found on eMAR. 04/16/2026 signed out on page 30 at 6:00 AM, administration record was not found on eMAR. 04/21/2026 signed out on page 30 at 8:00 AM, administration record was not found on eMAR. 04/23/2026 signed out on page 30 at 8:00 AM, administration record was not found on eMAR. 04/29/2026 signed out on page 30 at 9:20 AM, administration record was not found on eMAR. 04/30/2026 signed out on page 30 at 7:31 AM, administration record was not found on eMAR. Review of Resident #2's Progress Notes revealed a progress note was not present for the dates and times the resident's narcotic medication was signed out. Resident #3 Review of Resident 3's admission Record revealed the facility admitted the resident with diagnoses which included cerebral infarction, diabetes mellitus, parkinsonism, schizoaffective disorder, acquired absence of left leg below knee, anxiety disorder, bipolar disorder, and major depressive disorder recurrent severe with psychotic symptoms. Review of Resident #3's quarterly MDS with an ARD of 03/13/2026, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Review of Resident #3's Care Plan Report initiated on 06/25/2025, revealed Resident #3 was at an increased risk for alteration in pain/discomfort. Interventions included administer analgesic medications as ordered per plan of care and notify MD if medication is ineffective or resident has adverse reaction. Review of Resident #3's Order Summary Report revealed the resident had an order dated 03/31/2026, for a narcotic pain medication give one tablet by mouth every four hours as needed for pain. Review of 200 Hall Narcotic Sign Out Book from 04/13/2026 to 05/14/2026 in comparison to Resident #3's eMAR March 2026 to May 2026, revealed LPN #1 signed out narcotic pain medication 48 times that were not documented as given to the resident on the eMAR. The dates and times for those medications were as follows: 04/13/2026 signed out on page 28 at 12:27 PM, administration record was not found on eMAR. 04/13/2026 signed out on page 28 at 5:08 PM, administration record was not found on eMAR. 04/14/2026 signed out on page 28 at 5:07 PM, administration record was not found on eMAR. 04/15/2026 signed out on page 28 at 8:48 AM, administration record was not found on eMAR. 04/15/2026 signed out on page 28 at 12:00 PM, administration record was not found on eMAR. 04/16/2026 signed out on page 28 at 8:40 AM, administration record was not found on eMAR. 04/16/2026 signed out on page 28 at 12:00 PM, administration record was not found on eMAR. 04/16/2026 signed out on page 28 at 5:54 PM, administration record was not found on eMAR. 04/20/2026 signed out on page 28 at 8:00 AM, administration record was not found on eMAR. 04/20/2026 signed out on page 28 at 12:01 PM, administration record was not found on eMAR. 04/20/2026 signed out on page 28 at 5:30 PM, administration record was not found on eMAR. 04/21/2026 signed out on page 28 at 8:17AM, administration record was not found on eMAR. 04/21/2026 signed out on page 28 at 5:33 PM, administration record was not found on eMAR. 04/21/2026 signed out on page 28 at 12:30 PM, administration record was not found on eMAR. 04/22/2026 signed out on page 28 at 8:00 AM, administration record was not found on eMAR. 04/22/2026 signed out on page 28 at 12:30 PM, administration record was not found on eMAR. 04/22/2026 signed out on page 28 at 5:40 PM, administration record was not found on eMAR. 04/23/2026 signed out on page 28 at 7:56 AM, administration record was not found on eMAR. 04/23/2026 signed out on page 45 at 12:30 PM, administration record was not found on eMAR. 04/23/2026 signed out on page 45 at 5:20 PM, administration record was not found on eMAR. 04/27/2026 signed out on page 45 at 12:01 PM, administration record was not found on eMAR. 04/27/2026 signed out on page 45 at 5:28 PM, administration record was not found on eMAR. 04/28/2026 signed out on page 45 at 8:10 AM, administration record was not found on eMAR. 04/29/2026 signed out on page 45 at 7:59 AM, administration record was not found on eMAR. 04/29/2026 signed out on page 45 at 12:14 PM, administration record was not found on eMAR. 04/29/2026 signed out on page 45 at 5:44 PM, administration record was not found on eMAR. 04/30/2026 signed out on page 45 at 12:10 PM, administration record was not found on eMAR. 04/30/2026 signed out on page 45 at 8:00 AM, administration record was not found on eMAR. 04/30/2026 signed out on page 45 at 5:00 PM, administration record was not found on eMAR. 05/04/2026 signed out on page 45 at 12:00 PM, administration record was not found on eMAR. 05/04/2026 signed out on page 45 at 5:30 PM, administration record was not found on eMAR. 05/05/2026 signed out on page 45 at 8:20 AM, administration record was not found on eMAR. 05/05/2026 signed out on page 45 at 12:26 PM, administration record was not found on eMAR. 05/05/2026 signed out on page 45 at 5:30 PM, administration record was not found on eMAR. 05/08/2026 signed out on page 57 at 12:00 PM, administration record was not found on eMAR. 05/08/2026 signed out on page 57 at 5:24 PM, administration record was not found on eMAR. 05/09/2026 signed out on page 57 at 8:00 AM, administration record was not found on eMAR. 05/09/2026 signed out on page 57 at 12:30 PM, administration record was not found on eMAR. 05/09/2026 signed out on page 57 at 5:36 PM, administration record was not found on eMAR. 05/10/2026 signed out on page 57 at 8:00 AM, administration record was not found on eMAR. 05/10/2026 signed out on page 57 at 12:40, PM administration record was not found on eMAR. 05/10/2026 signed out on page 57 at 5:50 PM, administration record was not found on eMAR. 05/13/2026 signed out on page 57 at 8:02 AM, administration record was not found on eMAR. 05/13/2026 signed out on page 57 at 12:00 PM, administration record was not found on eMAR. 05/13/2026 signed out on page 57 at 5:20 PM, administration record was not found on eMAR. 05/14/2026 signed out on page 57 at 8:10 AM, administration record was not found on eMAR. 05/14/2026 signed out on page 57 at 12:40 PM, administration record was not found on eMAR. Review of Resident #3's Progress Notes revealed a progress note was not present for the dates and times the resident's narcotic pain medication was signed out. During an interview on 05/18/2026 at 6:49 PM, LPN #1 reported he began work at the facility in September of 2025. He indicated he was put with another nurse on the medication cart for a couple of days for orientation to learn the order of facility operations. LPN #1 indicated he encouraged Resident #1 to take the prescribed as needed oral narcotic pain medication on 05/09/2026 because the resident was trying to go to the hospital for a specific pain medication before trying the pain medications that were already prescribed for the resident. During an interview on 05/19/2026 at 12:23 PM, Human Resources (HR)/Licensed Practical Nurse (LPN) indicated a nurse administering a narcotic pain medication should enter a progress note noting the resident's pain level. She indicated the nurse should also document the medication as given in the MAR and sign the medication out of the narcotic sign out book. During an interview on 05/19/2026 at 6:15 PM, LPN #2 reported she had noticed at times a narcotic pain medication would not be documented in a resident's MAR but was signed out of the narcotic sign out book. LPN #2 indicated this was reported to the Director of Nursing (DON) several times. During an interview on 05/21/2026 at 8:34 AM, LPN #4 indicated when a nurse gave a narcotic medication the nurse should sign the medication out of the narcotic sign out book, administer the medication, mark the medication as administered in the MAR, and then follow up in the MAR on the effectiveness of the medication. LPN #4 reported if there was a check mark, time, and initials in the MAR box, that would indicate the medication was given. LPN #4 indicated if the MAR box was left blank, she would only know if a narcotic medication was given if she saw it in the narc book signed as given, and that could cause a med error. During an interview on 05/20/2026 at 11:15 AM, the DON indicated when a nurse administered a narcotic pain medication that nurse should sign the medication out of the narcotic sign out book, administer the medication to the resident and mark the medication as administered in the MAR. She indicated if the box on the MAR was blank that would mean the medication was not given. She reported that if the box on the MAR was blank, she would expect to see a progress note explaining why the medication was held or refused. She stated, there isn't a way to know if the narcotic that got signed out was given if it isn't documented as given. The DON reported she had not received any complaints from staff nor residents regarding how LPN #1 administered medications. During a phone interview on 05/22/2026 at 10:33 AM, the Medical Director indicated when a resident's narcotic medication was signed out of the narcotic sign out book, he expected documentation of the narcotic medication being administered to be in the resident's medical record. He further indicated he expected to see documentation of which nurse gave the medication as well as the date and time the narcotic was administered. Review of a facility policy titled Medication Administration with a reviewed date of 11/25/24, revealed the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next resident's medications. The policy also indicated, if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on observation, interviews, and record review, it was determined the facility failed to ensure staff performed hand hygiene while providing incontinent care for 1 (Resident #48) of 1 sampled resident reviewed for incontinent care; failed to properly clean a glucometer after use for 1 (Resident #49) of 1 sampled resident reviewed for glucometer use; and failed to ensure staff implemented infection control practices while performing wound care for 1 (Resident #219) of 1 sampled resident reviewed for wound care. The findings are: 1. A review of Resident #48's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2025, indicated the resident was dependent on staff for toileting hygiene. a. A review of Resident #48 ' s Care Plan revealed an intervention, dated 07/31/2024, to provide incontinent care and change Resident #48 ' s brief every two hours and as needed due to incontinence. b. During an observation on 05/28/2025 at 3:50 PM, Certified Nurse Assistant (CNA) #1 and CNA #2 provided incontinent care for Resident #48. During the incontinent care, CNA #1 was not seen performing hand hygiene at any time before, during, or after incontinent care, or before exiting the resident ' s room. c. During an interview on 05/28/2025 at 4:24 PM, CNA #1 indicated hand hygiene should have been performed before, during, and after incontinence care. She verified she did not perform hand hygiene at any time during incontinent care for Resident #48. d. During an interview on 05/29/2025, the Director of Nursing (DON) reported the facility did not have a handwashing policy, or an incontinent care policy. 2. A review of Resident # 49's Order Summary revealed an order, dated 10/01/2024, to perform capillary blood glucose (CBG) checks before meals and at bedtime. a. During an observation and interview on 05/29/2025 at 5:27 AM, Licensed Practical Nurse (LPN) #3 performed a CBG check on Resident #49 using a glucometer. LPN #3 placed the used glucometer back into the medication cart, without cleaning or disinfecting the glucometer. LPN #3 was asked if the glucometer had been cleaned after use, and verified she did not clean the glucometer before placing it back into the medication cart. LPN #3 stated there is a potential for contamination of the medication cart by not cleaning the glucometer. b. A review of an Assure Prism Glucometer Instruction Manual provided by the Director of Nursing (DON) on 05/29/2025 indicated to minimize the risk of transmission of blood borne pathogen, the cleaning and disinfection procedure should be performed as recommended. The Cleaning and Disinfecting section indicated The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The manual further indicated The meter should be cleaned and disinfected after use on each patient. 3. A review of Resident #219's Order Summary indicated an order, dated 05/26/2025, to clean surgical incision to pubis with wound cleanser, to pack the incision with gauze, and cover with a dressing daily. a. During an observation on 05/28/2025 at 1:27 PM, while providing wound care, the Wound Care Nurse was wearing gloves while applying wound cleanser onto dry gauze, cleansed around Resident #219 ' s perineal wound, then using the same gauze, wiped inside the open incision. The Wound Care Nurse did not remove his dirty gloves, or sanitize his hands, before touching all clean bandages in the resident's bandage bin, to obtain a dressing to apply over the packed wound. He used bandage scissors he removed from his scrubs pocket, without cleansing the scissors, on the abdominal pad he placed over the packed wound. After using the scissors, he returned the uncleansed scissors to his scrubs pocket. b. During an interview with the Wound Care Nurse on 05/28/2025 at 1:27 PM, he indicated it was important to avoid touching an open wound with used gauze, due to the potential for contamination, infection, and/or worsening of the wound. He reported bandage scissors should be cleaned, before and after use, during wound care, and before placing back into scrub pocket. The Wound Care Nurse verified he did not cleanse the scissors, before or after use, and he did use contaminated gloves to search through clean dressing supplies. c. During an interview on 05/29/2025, the DON reported the facility did not have a wound care policy.

Based on observation, interviews, and facility policy review, the facility failed to ensure the ice machine was clean and sanitary to avoid contamination of the ice provided to residents in 1 of 1 ice machines. The findings include: During an observation and interview on 05/29/2025 at 9:00 AM, Dietary Manager (DM) #4 was asked to wipe the inside of the ice machine with a white paper towel. A pink and brown discoloration was transferred to the paper towel. DM #4 wiped the bottom of the ice guard, with a different white paper towel, and the surveyor observed pink discoloration transfer to the paper towel. DM #4 wiped the wall on the side above the ice with a new white paper towel. A brown discoloration transferred onto the paper towel. DM #4 was asked to describe the substance and stated it was, dirt. During an interview on 05/29/2024 at 9:05 AM, DM #4 revealed that the ice machine was sanitized monthly, and as needed, by the Maintenance Director. She revealed that the machine was taken apart every three months, ice was dumped and thoroughly cleaned by the Maintenance Director. During an interview with Maintenance Assistant (MA) #5 on 05/29/2025 at 9:14 AM, MA # 5 reported that the ice machine was cleaned the week before by the Maintenance Director, and there should not have been any discoloration observed during the observation. He reported that the ice machine was scheduled to be cleaned monthly by the Maintenance Director.

Based on observation, interview and record review the facility failed to ensure that an insulin pen was primed according to manufacturer recommendations prior to administration for 1 (resident #14) of 1 case mix who had physician's orders for an insulin pen. The findings are: Resident #14 ' s Physician's Orders were reviewed and read in part, resident had a diagnosis of type 2 diabetes mellitus and an order for (Insulin degludec) FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML [milliliter] Inject 42 unit subcutaneously two times a day for diabetes. ( Insulin degludec is a long-acting type of insulin that works slowly, over about 24 hours.) On 12/31/2024 at 7:22 PM, medication pass was observed with Licensed Practical Nurse (LPN) #1. After attaching the needle cap to the insulin pen, LPN #1 dialed up 2 units to prime the needle and depressed the plunger with the needle pointed downward before administering the 42-unit dose to Resident #14. On 12/31/24 at 7:42 PM, LPN #1 was asked to describe the purpose of priming the needle. LPN #1 stated the pen was primed to remove the air from the needle. LPN #1 was asked if the pen should be primed with the needle pointed down. LPN #1 responded yes. LPN #1 was asked if the air would be better removed if the needle was pointed up for the air to be removed from the pen. LPN responded that yes it probably would. LPN #1 was asked if removing the air was to ensure the resident received the appropriate insulin dose and LPN #1 responded yes, I should have held it point up. On 01/01/2025 at 8:40 AM, the Director of Nursing (DON) was asked to provide education for the nursing staff, if available, for the insulin pen. The DON stated no insulin pen education had been provided that she was aware of since May 2024, and any education that was provided from the sister facility would have been lost to the tornado damage. A package insert for the (brand name) insulin pen was requested at that time. On 01/01/2025 at 10:32 AM, a package insert for insulin degludec pen was provided by DON. The insert was reviewed and read in part, in order to prime the pen, dial up 2 units and hold the pen with the needle pointing up, tap the top of the pen gently to let air bubbles rise to the top. While holding the pen needle point up, press and hold the plunger until the dose counter showed zero. On 01/01/2025 at 10:32, the DON was asked if the facility expected manufacturer guidelines to be followed when it instructed to prime the insulin pen with the pen needle point up, she responded yes, the pen should have been primed needle point up.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to maintain limited access to special care residents in 2 of 2 units reviewed for resident comfort and safety. Findings include: A review of a facility policy titled, Resident Rights, revised on 11/01/2022, indicated residents have a right to live in a safe and environment. A review of a facility policy titled, Special Care Unit, revised on 02/15/2022, indicated the facility would maintain a safe environment for residents who were an elopement risk, at risk due to cognitive impairment, and/or occurrences of behavior symptoms. The Interdisciplinary Team (IDT) reviewed appropriate placement for residents quarterly. A review of the document titled, Consent for Admission to Special Care Unit, dated 02/2022, indicated the Special Care Unit provides a quieter living environment for those whose physical, mental, and/or psychosocial diagnoses require protection from external stressors to promote enhanced function and improved quality of life by decreasing anxiety and agitation. The Special Care Unit is maintained by locked doors to support these residents' enhanced environment which allows for reduction in psychiatric medications. During an interview and observation on 08/28/2024 at 8:27 AM, Maintenance Worker (MW) #1 was seen leaving the 300 Hall Special Care Unit and monitoring the door close. The sign posted on the door stated, Please use other door the magnet is tricky. MW #1 stated he was unaware of the sign on the door. The Director of Nursing (DON) approached and put the code in the keypad. Both doors were pushed open and allowed to shut, waited two minutes, the alarm blared, and the doors could be pushed open. The DON and MW #1 both attempted to instruct this surveyor how to use only one door so it would lock. During a second attempt, the code was entered into the keypad and both doors were pushed open. The doors were allowed to close without interference and the magnetic click on the door was heard engaging. Attempted to open the right door only and it was not secured, and the door was opened. No alarm sounded with the second attempt. During a concurrent observation and interview on 08/28/2024 at 8:38 AM, all 300 Hall residents were ambulating in the hallway directly inside the secure doors. Certified Nursing Assistant (CNA) #2 stated the tricky sign was on the 300 Hall secure doors on 08/20/2024 at 8:40 AM when CNA #2 arrived at work. During a concurrent observation and interview on 08/28/2024 at 8:48 AM, the 500 Hall Special Care Unit secure doors were found to have one door not closed and was not secure. Nursing Assistant (NA) #5 stated the secure doors had been broken for about a week. During an interview on 08/28/2024 at 9:10 AM, MW #1 stated technicians had been called and would be out tomorrow to fix the 300 Hall secure doors. During a phone interview on 08/28/2024 at 2:03 PM, the Ombudsman reported secured unit doors propped open with a chair to one of the Special Care Units and at the other Special Care Unit two unidentified staff holding secure doors shut, due to non-functioning secure doors, while exit seeking residents were exhibiting aggressive behavior. During an interview on 08/29/2024 at 10:52 AM, the Maintenance Director stated the issues with the 300 Hall Special Care Unit door was the hinge on the top of the left door when entering. It was an old door and too heavy for the current hinge which was bending under the weight. The Maintenance Director stated he planned to install a heavier hinge to allow the magnetic lock to engage. During a concurrent observation and interview on 08/29/2024 at 12:40 PM, CNA #4 entered the code to the 300 Hall Special Care Unit secure doors, three people walked through the doors and the doors were allowed to shut without interference. Both doors shut completely without issue. The sound of the magnetic click was heard engaging and the light over the doors turned red to indicate they were locked. The doors were able to be pushed open. CNA #4 stated the door did not lock and was not secure. During an interview on 08/29/2024 at 12:52 PM, the Administrator stated the doors were locked, but not locking. The Administrator stated no knowledge that a hinge was needed. The Administrator stated the unit was secure and stated the surveyors seemed to be the only ones having issues. Administration was informed it was CNA #4 who entered the code.

Based on record review, facility document review and interviews, it was determined the facility failed to report alleged abuse for 4 (Resident #6, #7, #8, and #10) residents of 4 resident reviewed for abuse. Findings include: A review of a facility policy titled, Policies and Procedures, with a subject of Abuse, Neglect, and Exploitation, with a reviewed date of 07/2023, specified Reporting: .All complaints, concerns, or suspicions of abuse should be immediately reported to the Administrator .3. The facility will report all alleged violations involving .abuse to the Office of Long-Term Care .shall be reported immediately, but not later than 2 hours after forming the suspicion .or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. A review of the Admission Record indicated the facility admitted Resident #6 on 05/26/2024 with diagnoses that included vascular dementia, depression, and anxiety. The quarterly Minimum Data Set [MDS], with an Assessment Reference Date [ARD] of 08/19/2024 revealed Resident #6 had a Brief Interview for Mental Status [BIMS] score of 3, which indicated resident had severe cognitive impairment. Resident #6 was independent with toileting and required setup or clean up assistance with eating, oral hygiene, showering, dressing, and personal hygiene. Resident #6 was independent with ambulation and did not require an assistive device. A review of a Care Plan, with an initiation date of 05/30/2024, revealed Resident #6 had a history of self-harm and self-mutilation ideation related to severe mental illness. Interventions included a stop sign placed across the room door to deter wandering and uninvited residents out of the room; conduct random room safety checks and personal wellness checks, and behavior monitoring. A review of the Incident Note, dated 07/23/2024 at 5:55 PM, revealed Resident #6 became upset when another resident entered Resident #6's room and attempted to lay down on the bed. Aggressor was placed 1:1 supervision [one-on-one meaning one staff member was assigned to aggressor for observation]. Local Police Department was notified. A review of the Admission Record, indicated the facility admitted Resident #7 on 05/28/2024 with diagnoses that included a brain disorder caused by a chemical imbalance in the blood, Alzheimer's Disease, and anxiety disorder. A review of the admission MDS, with an ARD of 06/02/2024, revealed Resident #7 had a BIMS score of 2, which indicated Resident #7 had severe cognitive impairment. Resident #7 required supervision with eating; partial to moderate assistance with oral hygiene and dressing; substantial to maximum assistance with personal hygiene and was dependent on staff for toileting and showering; and required partial to moderate assistance from sitting to lying, lying to sitting, and sitting to standing, and utilizes a manual wheelchair for ambulation. A review of the Incident Note, dated 07/23/2024 at 5:48 PM, revealed Resident #7 entered another resident's room attempting lay in another resident's bed, the resident became upset and hit Resident #7 in the arm. Resident #7 in turn, hit the other resident in the arm. Notification was made to the local Police Department, APRN[Advance Practice Registered Nurse] , and resident representative. A review of the Incident Note, dated 07/25/2024 at 11:10 AM, revealed an investigation was conducted and showed staff heard a resident yell out and upon arrival to Resident #6's room, Resident #7 was getting into Resident #6's bed, and Resident #6 hit Resident #7 in the arm and Resident #7 hit Resident #6 back in the arm. A review of the local Police Department Offense/Incident Report, dated 07/23/2024 at 5:30 PM, revealed the type of incident as an Information Report. The report revealed Licensed Practical Nurse (LPN) #7 contacted the police department to report an altercation involving Resident #6 and the progress notes from the nurses were attached to the report. The attached report indicated it was privileged and confidential. The report revealed physical aggression initiated, listed impulsive as a predisposing factor. The incident was described as Resident #6 sitting in his room when another resident entered and attempted to lay on the bed. Resident #6 hit the other resident on the arm and Resident #6 was struck back in their arm. No visible marks present. Notification was made to the Administrator, Police Department, Family, Physician, and Director of Nursing (DON). The report was completed by LPN #10. The attached incident note dated 07/25/2024 at 11:25 AM, revealed Resident #6 was placed 1:1 supervision for safety and a stop was placed across Resident #6's door, wife and APRN MD [Medical Director] were notified. During an interview on 08/29/2024 at 5:58 PM, the DON stated she was notified and was familiar with the Resident-to-Resident incident involving Resident #6 and Resident #7 on 07/23/2024. The DON notified the Administrator via social communication at 09:40 AM. The incident did occur, and an incident number was requested. No facility report was done, and the Office of Long-Term Care was not notified. A review of an Incident Note, dated 08/19/2024 at 9:35 AM, revealed Resident #7 was placed 1:1 supervision for safety, after staff reported hearing screams and observed Resident #7 trying to us the call light to choke a resident and kneeing the other resident in the chest Notification was made to local Police Department, POA (Power of Attorney), DON, Administrator and physician. Police incident number issued was issued A review of the Admission Record, indicated Resident #8 was admitted on [DATE] with diagnoses that included age related macular degeneration, bipolar disorder, anxiety disorder, traumatic brain injury, alcohol-induced persisting dementia, somnolence [excessive sleepiness with known causes that included anxiety, medication, depression or stress], altered mental status and delusional disorders. The significant change MDS, with an ARD of 08/04/2024, revealed Resident #8 had a BIMS score of 2 which indicated the resident had severe cognitive impairment. Resident #8 had a Mood score of 1 which indicated resident had little interest or pleasure in doing things 2-6 days. Behaviors toward others occurred 1 to 3 days a week and included physical and verbal symptoms. Resident #8 required assistance eating and was dependent on staff for oral hygiene, toileting dressing, and personal hygiene and required supervision walking and moderate assistance sitting, standing from seated position, and transfers from chair to bed and bed to chair, and use an assistive device for ambulation was not indicated. A review of SBAR [Situation Background Appearance Review and Notify] Communication Form, dated 08/19/2024, indicated Resident #8's change in condition was skin wound, other change in condition: receiver of physical aggression. Notification of the primary care was listed as 9:35 AM with recommendation to monitor. A review of Resident #8's Progress Notes New type Incident Note dated 08/19/2024 at 9:35 AM revealed, the Certified Nursing Assistant [CNA] heard screaming and observed another resident with their knee in Resident #8's chest while trying to choke Resident #8 with a call light. Resident #8's body audit revealed an abrasion on the bridge of the nose. The aggressor was placed on 1:1 for safety. Eureka Springs police department, the POA, DON, Administrator and MD were notified. An Incident Note, dated 08/21/2024 at 07:03 AM indicated Resident #8 had not been sleeping at night, staff reported screaming and upon investigation found a resident trying to use the call light to choke [Resident #8's first name] while kneeing [Resident #8 gender pronoun] in the chest. Staff separated residents before resident could get cord completely around [Resident #8] neck to choke [Resident #8 gender identity]. During an interview on 08/29/2024 at 12:20 PM, LPN #7 stated Resident #8 was watching television [TV] and visiting with Resident #11 when Resident #7 attempted to choke Resident #8. Resident #7 lifted their leg to Resident #8's chest and began hitting Resident #8 with their knee. The CNA was sent to report to the DON. Resident #7 was placed 1:1, and the doctor was notified. Resident #7 remained 1:1 until they were sent to behavioral health. Resident #8 usually did not show emotion and there were no signs or symptoms of pain. During an interview on 08/29/2024 at 5:58 PM, the DON stated she was notified of the incident on 08/19/2024 involving Resident #7 and Resident #8 and that Resident #8 had an abrasion on their nose from the incident, and indicated the bridge of the nose, the DON placed their right index finger on upper part of the nose between their eyes. A review of the local Police Department Offense/Incident Report,, dated 08/19/2024 at 9:58 AM, and an incident type listed as Battery-3rd. The report indicated the incident occurred on 08/19/2024 at facility. The victim is listed as Resident #8, and the suspect is listed as Resident #7. The Offense/Incident Narrative indicated the office spoke with the DON who revealed two residents were involved in an altercation with no injuries and requested the incident be documented, and that both had issues to where they did not fully understand what they were doing. Resident #8 entered Resident #7's room to watch television and Resident #8 became angry and attempted to choke Resident #7 with a cord and was unsuccessful. Resident #8 also kneed Resident #7 in the chest a couple of times. A review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses that included blood clot formation in the brain after injury, loss of brain function caused by toxins in the blood due to liver damage, and anxiety. The admission MDS with an ARD of 06/02/2024 revealed Resident #10 had a BIMS score of 6, which indicated resident had severe cognitive impairment. Resident #10 Mood score was 1 feeling down, depressed, or hopeless 2-6 days. Resident #10 was independent eating, toileting and oral hygiene; required set up/cleanup assistance with dressing; and required supervision with showering and personal hygiene. Resident #10 was independent with transfers and walking. Resident #10 did not have behaviors. A review of a Behavior Note, dated 08/27/2024 at 12:45 AM revealed, Resident #10 was in another resident's room and was stuck on the left cheekbone causing swelling and hematoma [abnormal collection of blood in the tissues outside of the blood vessel]. A review of the local Police Department Offense/Incident Report, dated 08/27/2024 at 1:24 AM, revealed the complaint and the incident was listed as Battery 3rd. Resident #10 was identified as the victim, and Resident #11 was identified as the suspect. The narrative indicated a CNA heard cursing and went to the room, Resident #11 was angry and began hitting Resident #10 in the chest and face. The CNA left the room to seek a nurse and upon return, Resident #10 had blood in his/her mouth and a black eye. Resident #11 had a scratch to their hand. The police report contained photos of the injuries. During an interview on 08/29/2024 at 3:54 PM, LPN #9 stated they are employed by online staffing platform and was working 6:00 PM to 6:00 AM shift. Resident #10 was wandering all night and went into Resident #11's room, through the bathroom. Resident #10 was confused and had a hematoma on their left cheek when LPN #9 entered room. Notification was made to the DON, who notified the Administrator, the Physician, and Resident #10's responsible party. LPN #9 notified LPN #7 who called to make a police report. During an interview on 08/29/2024 at 5:58 PM, the DON stated they were notified of the incident on 08/27/2024 involving Resident #10 and Resident #11. On 08/29/2024 at 6:37 PM, the Administrator stated residents are not responsible for their actions and the incident was resident to resident and not required to be reported if there were no injuries. The Administrator stated he had never seen anything in the regulations that says they don't have to report based on resident to resident. The Administrator stated the facility had two hours, per the requirement, to report. It was not done, not reported to the state. The Administrator could not recall the incident with Resident #7 and Resident #8. The Administrator stated the incident was not reported to the state, he believes it was serious, and there was intervention by staff and the process was taken care of. Putting an extra report on that to the state was an unnecessary thing. The Administrator stated Resident #10 and Resident #11 incident was not reported and the fact considering the diagnoses and the hematoma on Resident #10's cheek from being struck by Resident #11 was a resident-to-resident altercation and was not reportable. On 08/29/2024 at 6:52 PM, the DON stated there was no report made to the Office of Long-Term Care for the incident involving Resident #7 and Resident #8 or the incident involving Resident #10 and Resident #11. We did all the steps but no, it was not reported.

Based on observations, interviews, record review, facility document review and facility policy review, it was determined the facility failed to identify abuse to ensure a calm, safe and injury free environment for 4 (Resident #6, Resident #7, Resident #8, and R #10) of 4 residents reviewed for abuse. Findings include: A review of a facility policy titled, Policies and Procedures .Abuse, Neglect, and Exploitation, with a reviewed date of 07/2023, indicated, Policy Statement .the resident has the right to be free from .physical .abuse .uses the general term abuse to specify all .Policy Interpretation and Implementation .4. Identify events and occurrences that may constitute .abuse .5. Investigation of all allegations of abuse, neglect, or mistreatment .7. Reporting/Response - assurance that incidents are reported, corrective actions are taken, and preventative measures are put into place .Reporting .1. All personnel must immediately report suspected cases of abuse to the Administrator. In the Administrator's absence, suspected abuse should be reported to the Director of Nursing [DON] and immediate supervisor .3. The facility will report all alleged violations involving .abuse to the Office of Long-Term Care, Family, Police, and MD [Medical Director]. Suspicion of allegation of abuse shall be reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury .Investigation .5. All incidents involving abuse will be analyzed to determine root cause and identify ways to prevent recurrence .Definitions .Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . A review of Resident #6's Consent for Admission to Special Care Unit, indicated risks of residing on the special care may include, incidents of resident-to-resident altercations. Residents may wander into the personal space of others . A review of the Admission Record indicated the facility admitted Resident #6 on 05/26/2024 with diagnoses that included vascular dementia, depression, and anxiety. The quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/19/2024 revealed Resident #6 had a Brief Interview for Mental Status [BIMS] score of 3, which indicated resident had severe cognitive impairment. Resident #6 had a mood score of 1 indicating resident had little interest or pleasure in doing things and scored 1 on feeling down and hopeless 2 to 6 days. Resident #6 did not exhibit behaviors. Resident #6 was independent with toileting and required setup or clean up assistance with eating, oral hygiene, showering, dressing, and personal hygiene. Resident #6 was independent with ambulation and did not require an assistive device. A review of a Care Plan, with an initiation date of 05/30/2024, revealed Resident #6 had a history of self-harm and self-mutilation ideation related to severe mental illness. Interventions included a stop sign placed across the room door to deter wandering and uninvited residents out of the room; conduct random room safety checks and personal wellness checks, and behavior monitoring. A review of a Behavioral assessment dated [DATE], revealed Resident #6's behaviors as cursing, yelling, agitation, and aggression/combativeness. The interdisciplinary team [IDT] recommendation was continuation on Special Care Unit. A review of the Incident Note dated 07/23/2024 at 5:55 PM, revealed Resident #6 became upset when another resident entered Resident #6's room and attempted to lay down on the bed. Aggressor was placed 1:1 [one-on-one meaning one staff member was assigned to aggressor for observation]. Eureka Springs Police Department was notified. A review of the local Police Department Offense/Incident Report, dated 07/23/2024 at 5:30 PM, revealed the type of incident as an Information Report with a complaint number of 24-000344. The report revealed Licensed Practical Nurse [LPN] #7 contacted the police department to report an altercation involving Resident #6 and the progress notes from the nurses were attached to the report. The attached report indicated it was privileged and confidential. The report revealed the incident #1702 Physical Aggression Initiated, listed impulsive as a predisposing factor. The incident was described as Resident #6 sitting in his room when another resident entered and attempted to lay on the bed. Resident #6 hit the other resident on the arm and Resident #6 was struck back in their arm. No visible marks present. Notification was made to the Administrator, Police Department, Family, Physician, and Director of Nursing (DON). The report was completed by LPN #10. The attached incident note dated 07/25/2024 at 11:25 AM, revealed Resident #6 was placed 1:1 supervision for safety and a stop was placed across Resident #6's door, family member and APRN [Advance Practice Registered Nurse]/MD [Medical Director] were notified. Review of Resident #6's progress notes did not reveal the other resident involved in this incident. A review of the Incidents by Incident Type dated 08/28/2024, under the subheading of Physical Aggression Initiated Incidents, revealed Resident #6 listed with the date of 07/23/2024 at 5:00 PM, and under the subheading of Physical Aggression Received Incidents, Resident #7 listed with a date of 07/23/2024 at 5:00 PM. During interview on 08/29/2024 at 1:11 PM, Licensed Practical Nurse (LPN) #10 stated Resident #7 wandered into Resident #6's room and has a history of wandering. The staff intervened in an altercation between the two of them. Resident #7 went in and laid in Resident #6's bed. Staff heard yelling and LPN #10 was notified and intervened to keep it from becoming physical. Staff also notified LPN #7. LPN #10 stated 1:1 is standard intervention for the aggressor, usually for 24 hours, and the DON will follow up to determine if the situation will occur again. During an interview on 08/29/2024 at 5:58 PM, the DON stated she was notified and was familiar with the Resident-to-Resident incident involving Resident #6 and Resident #7 on 07/23/2024. The DON notified the Administrator via a social communication platform at 9:40 AM. The DON described the procedure for staff to follow, stating the nurses call the physician and then they call the family and the police department. The incident did occur, and an incident number was requested. The physician was notified at 9:40 AM, the police department was notified at 9:47 AM, and the responsible party was notified at 10:02 AM. The nurse did the body audit, and the aggressor was placed on one on one. Resident #7 was sent to the geri-psych unit as an intervention. No facility report was done, and the state was not notified. The DON stated the incident did not involve malice because there were no injuries and the resident's BIMS scores were low. The DON believes no notification to the Office of Long-Term Care was necessary because no malice was involved. The DON stated she received the information regarding malice from a CMS in-service on electronic reporting and could not recall when the in-service was attended. A review of the Admission Record, indicated the facility admitted Resident #7 on 05/28/2024 with diagnoses that included a brain disorder caused by a chemical imbalance in the blood, Alzheimer's Disease, and anxiety disorder. A review of the admission MDS, with an ARD of 06/02/2024, revealed Resident #7 had a BIMS score of 2, which indicated Resident #7 had severe cognitive impairment. Resident #7 required supervision with eating; partial to moderate assistance with oral hygiene and dressing; substantial to maximum assistance with personal hygiene and was dependent on staff for toileting and showering; and required partial to moderate assistance from sitting to lying, lying to sitting, and sitting to standing, and utilizes a manual wheelchair for ambulation. A review of the Incident Note dated 07/23/2024 at 5:48 PM, revealed Resident #7 entered another resident's room attempting to lay in another resident's bed, the resident became upset and hit Resident #7 in the arm. Resident #7 in turn, hit the other resident on the arm. Notification was made to the local Police Department, APRN, and resident representative. A review of the eINTERACT SBAR Summary for Providers note, dated 07/23/2024 at 5:49 PM, revealed the situation as an Other change in condition. The primary care provider recommended monitoring. A review of the Incident Note, dated 07/25/2024 at 11:10 AM, revealed an investigation was conducted and showed staff heard a resident yell out and upon arrival to Resident #6's room, Resident #7 was getting into Resident #6's bed, and Resident #6 hit Resident #7 on the arm and Resident #7 hit Resident #6 back on the arm. A review of the Behavior Note, dated 07/25/2024 at 6:45 PM, revealed Resident #7 exhibiting aggressive behaviors toward staff and went for an unnamed Certified Nursing Assistant's [CNA's] hair and throat. Resident #7 placed on 1:1 supervision, notifications made to Assistant Director of Nursing [ADON], and physician. The physician gave order for geri-psych [geriatric psychiatry] transfer. A review of the Behavior Note, dated 07/25/2024 at 9:47 PM, revealed geri-psych did not have a bed available. A review of the Behavior Note, dated 07/27/2024 at 03:50 AM, revealed Resident #7 was aggressive toward staff earlier in the shift. A review of the Behavior Note, dated 07/31/2024 at 07:33 AM, revealed Resident #7 had episodes of agitation related to a failed gradual dose reduction [GDR - reducing the amount of a medication being given to determine the lowest effective dose of the medication]. The medication was not identified. A review of the Nursing Progress Note, dated 08/03/2024 at 6:00 PM, revealed Resident #7 became aggressive with staff and residents and began coming at nurse with a butter knife, and stated, I'm going to cripple you. Resident #7 was kicking and hitting other residents. Residents were not identified in the note. Resident #7's responsible party was notified. A review of the Nursing Progress Note, dated 08/05/2024 at 5:11 AM, revealed the DON was notified of the incident on 08/03/2024 and Resident #7 is scheduled to see psychiatrist on the 9th. A review of the Behavior Note. dated 08/16/2024 at 1:34 PM revealed resident continuing to be aggressive with residents and staff. Resident #7 cannot be redirected. The physician ordered medication for depression to be restarted. A review of an Incident Note, dated 08/19/2024 at 09:35 AM, revealed Resident #7 was placed 1:1 supervision for safety, after staff reported hearing screams and observed Resident #7 trying to us the call light to choke a resident and kneeing the other resident in the chest Notification was made to Eureka Springs Police Department, Power of Attorney [POA], DON, Administrator and physician. Police incident number issued was 24-00416. A review of the local Police Department Offense/Incident Report, complaint number 24-000416, dated 08/19/2024 at 09:58 AM, and an incident type listed as Battery-3rd. The report indicated the incident occurred on 08/19/2024 at The Blossoms Rehab & Nursing Center. The victim is listed as Resident #8, and the suspect is listed as Resident #7. The Offense/Incident Narrative indicated the office spoke with the DON who revealed two residents were involved in an altercation with no injuries and requested the incident be documented, and that both had issues to where they did not fully understand what they were doing. Resident #8 entered Resident #7's room to watch television and Resident #8 became angry and attempted to choke Resident #7 with a cord and was unsuccessful. Resident #8 also kneed Resident #7 in the chest a couple of times. A review of an Incident Note, dated 08/21/2024 at 6:40 AM, revealed Resident #7 had unpredictable behaviors. An unidentified CNA heard screaming and observed Resident #7 using the call light to choke another resident while putting their knee in the other resident's chest. Staff separated the residents immediately before [Resident #7] could get the cord completely around the resident. Resident #7 was sent for a geri-psych consult. A review of the Admission Record indicated Resident #8 was admitted on [DATE] with diagnoses that included age related macular degeneration, bipolar disorder, anxiety disorder, traumatic brain injury, alcohol-induced persisting dementia, somnolence [excessive sleepiness with known causes that included anxiety, medication, depression or stress], altered mental status and delusional disorders. The significant change MDS with an ARD of 08/04/2024 revealed Resident #8 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. Resident #8 had a mood score of 1 which indicated resident had little interest or pleasure in doing things 2-6 days. Behaviors toward others occurred 1 to 3 days a week and included physical and verbal symptoms. Resident #8 required assistance eating and was dependent on staff for oral hygiene, toileting dressing, and personal hygiene and required supervision walking and moderate assistance sitting, standing from seated position, and transfers from chair to bed and bed to chair, and use an assistive device for ambulation was not indicated. A review of SBAR [Situation Background Appearance Review and Notify] Communication Form, dated 08/19/2024, indicated Resident #8's change in condition was skin wound, other change in condition: receiver of physical aggression. Notification of the primary care was listed as 9:35 AM with recommendation to monitor. A review of eINTERACT Change in Condition evaluation V5, dated 08/19/2024 at 09:35 AM, revealed, the change in condition was a skin wound or ulcer and other change in condition listed as receiver of physical aggression on 08/19/2024. The skin evaluation status indicated Resident #8 had an abrasion and the site indicated was on the face, with a description of bridge of nose. Response to evaluation for pain status was listed as Not clinically applicable to the change in condition being reported. Additional pertinent diagnosis was marked as dementia. Notification of resident representative was listed as case worker notified on 08/19/2024 at 09:35. A review of Resident #8's Incident Note dated 08/19/2024 at 09:35 AM revealed, the CNA heard screaming and observed another resident with their knee in Resident #8's chest while trying to choke Resident #8 with a call light. Resident #8's body audit revealed an abrasion on the bridge of the nose. The aggressor was placed on 1:1 supervision for safety. The local police department, the POA, the DON, the Administrator, and MD were notified. A Health Status note, dated 08/20/204 at 3:24 PM, revealed Resident #8 remained on follow up for previous altercation and had no complaints of pain or discomfort. An Incident Note, dated 08/21/2024 at 07:03 AM indicated Resident #8 had not been sleeping at night, staff reported screaming and upon investigation found a resident trying to use the call light to choke [Resident #8's first name] while kneeing [Resident #8 gender pronoun] in the chest. Staff separated residents before resident could get cord completely around [Resident #8] neck to choke [Resident #8 gender identity]. Investigation was conducted and revealed Resident #8 entered another resident's room and was sitting on a roommate's bed watching television [TV]. A small abrasion on the bridge of nose was noted and Resident #8 states does not know where it [the abrasion] came from. During an interview on 08/29/2024 at 12:20 PM, LPN #7 stated Resident #8 was watching TV visiting with Resident #11 when Resident #7 attempted to choke Resident #8. Resident #7 lifted their leg to Resident #8's chest and began hitting Resident #8 with their knee. The CNA was sent to report to the DON. Resident #7 was placed 1:1, and the doctor was notified. Resident #7 remained 1:1 until they were sent to behavioral health. Resident #8 usually did not show emotion and there were no signs or symptoms of pain. During an interview on 08/29/2024 at 5:58 PM, the DON stated they were notified of the incident on 08/19/2024 involving Resident #7 and Resident #8 and Resident #8 had an abrasion on the nose from the incident, and indicated the bridge of the nose, the DON placed the right index finger on upper part of the nose between the eyes. The DON stated CNAs were interviewed and the call light was in front of Resident #8's face, but not touching the body. The DON was asked if the documentation in the EHR [electronic health record] was accurate and stated, The nurse put on the I & A [incident and accident report] what she was told. The DON then demonstrated using hands, palms with fingers curled as if holding an object, facing away from their shoulders, even with their jaw line/chin on either side of their neck. The DON was asked to demonstrate with a charging cord, the DON pulled the cord with the right hand, straight out away from their right shoulder, and began to drape the cord to the opposite side of the body, then let the cord drop along the right side and stated the cord was pulled and still attached to the wall in one of Resident #7's hands and was not close to Resident #8's neck, the rest of it was laying on the bed next to him. A review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses that included blood clot formation in the brain after injury, loss of brain function caused by toxins in the blood due to liver damage, and anxiety. The admission MDS, with an ARD of 06/02/2024, revealed Resident #10 had a BIMS score of 6, which indicated resident had severe cognitive impairment. Resident #10 mood score was 1 feeling down, depressed, or hopeless 2-6 days. Resident #10 was independent eating, toileting and oral hygiene; required set up/cleanup assistance with dressing; and required supervision with showering and personal hygiene. Resident #10 was independent with transfers and walking. Resident #10 did not have behaviors. A review of a Behavior Note, dated 08/27/2024 at 12:45 AM revealed, Resident #10 was in another resident's room and was stuck on the left cheekbone causing swelling and hematoma [abnormal collection of blood in the tissues outside of the blood vessel]. A review of a Health Status, note dated 08/27/2024 at 10:36 AM, indicated Resident #10's cheekbone continues to have swelling and labs were drawn for increased confusion. A review of an Order Note, dated 08/27/2024 at 2:53 PM, indicated Resident #10 had vomiting and received an order for medication to relieve nausea and vomiting to be given every 8 hours. A review of a Health Status, note dated 08/29/2024 at 2:52 PM indicated Resident #10 continues to have confusion and swelling to left cheekbone. A review of the local Police Department Offense/Incident Report, dated 08/27/2024 at 1:24 AM, revealed the complaint number was 24-000439 and the incident was listed as Battery 3rd. Resident #10 was identified as the victim, and Resident #11 was identified as the suspect. The narrative indicated a CNA heard cursing and went to the room, Resident #11 was angry and began hitting Resident 10 in the chest and face. The CNA left the room to seek a nurse and upon return, Resident #10 had blood in his mouth and a black eye. Resident #11 had a scratch to the hand. The police report contained photos of the injuries. During an interview on 08/29/2024 at 3:54 PM, LPN #9 stated they are employed by an online staffing platform and was working 6:00 PM to 6:00 AM shift. Resident #10 was wandering all night and went into Resident #11's room, through the bathroom. Resident #10 was confused and had a hematoma on their left cheek when LPN #9 entered the room. Notification was made to the DON, who notified the Administrator, the Physician, and Resident #10's responsible party. LPN #9 notified LPN #7 who called to make a police report. Both residents were assessed. Resident #11 had previously exhibited behaviors that included throwing things and hitting people. During an interview on 08/29/2024 at 5:58 PM, the DON stated being notified of the incident on 08/27/2024 involving Resident #10 and Resident #11 and that Resident #10 was turned around leaving the bathroom and got into Resident #11's bed. When staff arrived in the room, Resident #11 had already hit Resident #10. Staff removed Resident #10 from the room and did a body audit. Resident #10 had redness or signs of pain. The DON stated the assessment did not show any injuries and no treatment was needed because there was no swelling or bruising to Resident #10's face. The DON stated the vomiting was related to Resident #10's elevated potassium level and when Resident #10 was admitted , the level was over 300. [normal range for potassium in adults is 3.5 to 5.2 mEq/L (milliEquivalent per liter)] The DON did not observe any swelling or bruising when they assessed Resident #10 and states there was no swelling or bruising on reassessment. On 08/29/2024 at 6:30 PM, the DON stopped the interview stating they needed to get a copy of the In-service. On 08/29/2024 at 6:37 PM, the Administrator entered the conference room and stated residents are not responsible for their actions and the incident was resident to resident and not required to be reported if there were no injuries. The Administrator stated he had never seen anything in the regulations that says we don't have to report, and it is based on resident to resident. The Administrator stated he was made aware of the incident involving Resident #6 by the DON and that residents were assessed according to the facility's process. The Administrator stated the facility does all the steps as if it was to be reported to the state and notifications to the physician, police department, and family are made. The Administrator stated it was Always told from surveyors, that resident-to-resident are not responsible for their actions and does not need to be reported. The Administrator stated he could not tell the names of everyone that told him and he could not recall what the regulation says. The Administrator stated the facility had two hours, per the requirement, to report. It was not done, not reported to the state, and stated the reason was [AGE] years ago the person doing the intake at the state said it was not reportable. The Administrator stated it was only major injuries that needed to be reported and stated a major injury, I assume it is a broken bone. The Administrator could not recall the incident with Resident #7 and Resident #8. The Administrator stated the incident was not reported to the state, he believes it was serious, and there was intervention by staff and the process was taken care of. The putting an extra report on that to the state was an unnecessary thing. The Administrator stated Resident #10 and Resident #11 incident was not reported and the fact considering the diagnoses and the hematoma on Resident #10's cheek from being struck by Resident #11 was a resident-to-resident altercation and was not reportable. On 08/29/2024 at 6:52 PM, the DON returned to the conference room to resume the interview. The DON stated there was no report made to the Office of Long-Term Care for the incident involving Resident #7 and Resident #8 or the incident involving Resident #10 and Resident #11. We did all the steps but no, it was not reported. On 08/29/2024 at 7:19 PM, the Nurse Consultant entered the conference room and provided additional information via email to the surveyor. The document was titled, RCF [Residential Care Facility] Incident Reporting, and is not a regulation for a Skilled Nursing or Nursing Facility.

Based on observations, interviews, record review, and facility document review, the facility failed to allow the resident to receive and open their packages for 1 (Resident #12) of 1 resident reviewed for privacy of communication by mail. Findings include: A review of a facility policy titled, Resident Rights, revised on 11/01/2022 and signed by Resident #12 and the facilities representative on 08/24/2023, indicated residents have the right to communicate by mail in privacy. A review of the Admission Record indicated the facility admitted Resident #12 with diagnoses that included major depressive disorder with a single episode, post-traumatic stress disorder, anxiety, and bipolar disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #12's Care Plan, undated, revealed the resident had behavior problems. Interventions included the facility would open her packages related to history of drug abuse. A review of a progress report dated 06/10/2024 at 7:33 AM revealed Resident #12 had received packages in the mail. The Director of Nursing (DON), witnessed by another staff member, opened the packages to inspect the contents. When Resident #12 was informed, Resident #12 became upset about the violation of rights and stated the DON was breaking the law. During an interview on 08/28/2024 at 12:03 PM, Resident #12 reported to this surveyor packages were delivered to the facility and then opened by the DON with the Administrator's approval. Resident #12 felt this was disrespectful and stated it's a dignity issue and illegal. During an interview on 08/29/2024 at 10:45 AM, the Administrator stated they opened all packages addressed to Resident #12 to inspect what items she had ordered. The Administrator reported Resident #12 had a history of ordering unauthorized items for his/her room in the past. During an interview on 08/29/2024 at 11:00 PM, the DON stated she opened all packages addressed to Resident #12. The DON stated all items were added to one of two inventory lists as the packages were opened and inspected. The first list is approved items that were then turned over to the resident. The second list were unapproved items the DON kept locked in the office in a file cabinet accessible by the DON. During a concurrent observation and interview on 08/29/2024 at 12:17 PM, the DON opened three packages addressed to Resident #12. The first package was a box that contained 6 cans of baked beans, the second, a plastic shipping bag, contained a small black box with two blue stoned rings, and the third, a plastic shipping bag, contained a bag of flavored sunflower seeds. The DON stated she was entering all items on Resident #12 inventory list and would then deliver the approved items.

FACILITY Environment 2. On 2/26/2024 at 12:00 PM A brown vinyl loveseat in the main dining room was observed with the vinyl peeling. See photo. 2a. On 2/26/2024 at 12:01 PM The hand rail near the dining room was observed with approximately 1 inch of missing wood. The edges of the missing would are pointed and sharp. 2b. On 2/26/2024 at 12:06 PM A brown vinyl recliner was observed in the dining room with the vinyl peeling and cracking near the headrest. See photo 2c. On 2/2720/24 at 11:40 AM A brown vinyl loveseat in the main dining room was observed with the vinyl peeling. 2d. On 2/07/2024 at 11:40 AM The hand rail near the dining room was observed with approximately 1 inch of missing wood. The edges of the missing would are pointed and sharp. 2e. On 2/27/2024 at 11:40 AM A brown vinyl recliner was observed in the dining room with the vinyl peeling and cracking near the headrest. 2f. On 2/27/2024 at 3:49 PM The Nurse Consultant #1 stated, I called the pest control yesterday, because of this warm weather is causing the flies to get bad, not only here, but at other facilities and the hotel. 2g. Review of the facility Maintenance Request Form dated 11/23/2023 through 2/27/2024, revealed no maintenance request for the handrail near the dining room, window in room [ROOM NUMBER], the recliner and loveseat in the dining room. 2h. A review of a facility policy titled, Resident Rights, 11/1/2022, specified, Resident and employees are routinely made aware of rights or residents. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a safe, clean, homelike environment including but not limited to treatment and supports for daily living safely. 49981 Based on observation, interview, and record review, the facility failed to ensure the residents had a safe, clean, homelike environment for 1 (Resident #6) of 1 sampled residents and in 1 Dining Room and had the potential to affect 29 residents. The findings are: 1. On 2/27/2024 at 10:46 AM, a window in resident 6's room was found to have the screen sitting in the windowsill leaned up against the window. There were 3 strips of tape on the right corner of the window to hold the window in place. a. On 2/27/2024 at 3:45pm the Maintenance Director was shown the window in the resident's room. The Maintenance Director said he/she was unaware of the screen and the tape on the resident's window. The screen was taken to be placed in the appropriate position. 2. On 2/26/2024 at 12:00 PM A brown vinyl loveseat in the main dining room was observed with the vinyl peeling. See photo. a. On 2/26/2024 at 12:01 PM, the handrail near the dining room was observed with 1 inch of missing wood. The edges of the missing wood were pointed and sharp. b. On 2/26/2024 at 12:06 PM, a brown vinyl recliner was observed in the dining room with the vinyl peeling and cracking near the headrest. See photo. c. On 2/2720/24 at 11:40 AM, a brown vinyl loveseat in the main dining room was observed with the vinyl peeling. d. On 2/07/2024 at 11:40 AM, the handrail near the dining room was observed with 1 inch of missing wood. The edges of the missing wood were pointed and sharp. e. On 2/27/2024 at 11:40 AM, a brown vinyl recliner was observed in the dining room with the vinyl peeling and cracking near the headrest. f. Review of the facility Maintenance Request Form dated 11/23/2023 through 2/27/2024, revealed no maintenance request for the handrail near the dining room, window in room [ROOM NUMBER], the recliner and loveseat in the dining room. g. A review of a facility policy titled, Resident Rights, 11/1/2022, specified, Resident and employees are routinely made aware of rights or residents. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a safe, clean, homelike environment including but not limited to treatment and support for daily living safely.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and a humidifier bottle was dated for 2 residents (Resident #22 and #282) of 3 (Residents #11, #22, and #282) sampled residents who required oxygen therapy, to minimize infections. 1a. The Care Plan for Resident #22, dated 01/22/24, list diagnosis as Dementia, Psychotic disturbance, Behavioral disturbance, Mood disorder, Anxiety, and Chronic obstructive pulmonary disease (COPD). 1b. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a BIMS (Brief Interview for Mental Status) of 13 (13 to 15 indicates cognitively intact). 1c. A Physicians order, dated 2/14/24, documented Change Bottle every week on Wednesday and as needed, date tubing and bottle every night shift every Wednesday related to COPD. Continuous oxygen 2-4 Liters at via nasal cannula to maintain [oxygen] saturations above 90%. 1d. On 2/26/24 at 11:23 AM, Resident #22 was receiving oxygen via nasal cannula. There was no evidence that the tubing or humidifier bottle connecting the nasal cannula to the oxygen concentrator had been changed. At 2:07 PM, the oxygen tubing and humidifier bottle had not been changed or labeled as per order. 1e. On 2/27/24 at 08:23 AM, Resident #22 was receiving oxygen via nasal cannula. There was no evidence that the oxygen tubing or bottle had been changed. 1f. On 2/27/24 at 2:35 PM, Resident #22 was receiving oxygen via nasal cannula. The oxygen tubing had been dated 02/26/24. 1g. On 2/27/24 at 3:15 PM, in response to the question, Who is responsible to ensure that the Oxygen tubing is changed and labeled, why is it important to change Oxygen tubing and what could be the outcome of not providing new tubing and a label? Licensed Practical Nurse (LPN) #1 stated, It is the responsibility of the night nurse on a certain day according to the medication profile, and if it is not changed it cause infection. 1h. On 02/29/24 at 11:10 AM, in response to the question, Who is responsible to ensure that the Oxygen tubing is changed and labeled, why is it important to change Oxygen tubing and what could be the outcome of not providing new tubing and a label? The Nurse Consultant stated, It is the responsibility of the night nurse, it is written on the Medication Administration Record (MAR) and if not changed fungus can go in the tubing. 2. Resident #282 had diagnoses of Acute bronchiolitis due to respiratory virus, Pneumonia, and Chronic obstructive pulmonary disease with (acute) exacerbation. The Admissions MDS with an Assessment Reference Date (ARD) of 2/25/25 showed a BIMS of 15 (13-15 points indicates cognitive intactness.) 2A. The Physician's Order Summary dated 2/26/24 showed no order regarding changing and dating oxygen tubing and humidifier bottles. 2B. A Progress noted dated 2/23/24 showed, .resident is a new admit admitted on [DATE] for physical therapy (PT)/occupational therapy (OT) related to Acute bronchiolitis due to respiratory syncytial virus . the resident has bouts of shortness of breath (SOB) . 2C. On 02/26/24 at 01:49 PM, the Surveyor observed no date on the humidifier bottle or tubing and no containment bag in place. 2D. On 02/26/24 at 02:59 PM, the Surveyor observed no date on the humidifier bottle or tubing and no containment bag in place. 2E. On 02/27/24 at 11:10 AM, the Surveyor observed no date on the humidifier bottle or tubing and no containment bag in place. 2F. On 02/28/24 at 10:36 AM, the Surveyor asked LPN #2, When new oxygen tubing and a new humidifier bottle is placed what are the steps you take? LPN #2 stated, You would date them. The Surveyor asked, Is there a date on this tubing? LPN #2 stated, It was dated today; the previous one was not. The Surveyor asked, Should there be a containment bag available? LPN #2 stated, Yes. The Surveyor asked, Was there one? LPN #2 stated, No. 2G. On 02/28/24 at 10:48 AM, the Surveyor asked Nurse Consultant (NC) #1, Was the tubing and humidifier bottle for Resident #282 dated prior to today? NC #1 confirmed the oxygen tubing and humidifier bottle was not dated. 2H. A document provided by the Nurse Consultant on 2/28/24 at 4:43 PM titled, Policies and Procedures Oxygen Administration-Resident Effective date 4/2021 Revised date: 11/25/22 showed, .oxygen tubing will be .labeled with date it was changed . 48808

Based on observation, interview, and record review, the facility failed to ensure residents were provided privacy during bathing to promote resident rights and dignity for Resident #13. a. The Care Plan , dated 12/14/23, list diagnosis as Paraplegia, Spinal stenosis, Muscle wasting and atrophy, Post traumatic stress disorder (PTSD), Major depressive disorder, and Pressure ulcers. b. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/05/23 listed a Brief Interview for Mental Status (BIMS) of 14 (13 to 15 indicates cognitively intact). c. On 02/27/24 at 02:32 PM, Resident #13 was observed leaving the whirlpool room in a wheelchair with a white sheet placed on the front of the resident with the left side of their body exposed during the transfer to their room, traveling from one hall to another hall. d. On 02/27/24 at 2:40 PM, Certified Nursing Aide (CNA) #2 was asked How do you ensure the residents are provided with privacy and dignity after leaving the whirlpool room while being transported to the residents room? CNA #2 responded, Need to make sure that the resident is covered for privacy. In response to the question, Why should the resident be provided privacy? the CNA responded, Because it is their right to be treated with dignity. In response to the question, have you been trained on how to maintain resident's privacy, and dignity after showers or whirlpools? CNA #2 stated, Yes, I have. I knew to cover the resident. e. On 02/27/24 at 3:40 PM, LPN #1 was asked How do you ensure Resident #13 is provided with privacy and dignity after showers and whirlpools while being transported back to their room. The LPN #1 stated, The CNA is aware to cover the resident, and I have told them to be sure and cover their residents completely. f. On 02/29/24 08:30 AM, in response to the question, How do you ensure the resident are provided with privacy and dignity after leaving the whirlpool/shower room while being transported to the residents room? the Director of Nurses (DON) responded, The staff is aware to cover the residents to promote dignity and privacy. The Surveyor asked, Are you aware that Resident #13, had not been completely covered after leaving the Whirlpool on 2/27/24? The DON stated, I will provide in-services. g. The policy titled, Resident Rights (Revised 11/01/22) read in part .Federal and state laws guarantee certain basic right to all residents of this facility. A dignified existence, be treated with respect, kindness, and dignity.

Based on interview and policy review, the facility failed to ensure residents received mail on Saturdays. This failed practice had the potential to affect all sampled residents who receive mail. The findings are: 1. On 02/27/24 at 02:41 PM, the Surveyor asked Residents #3, #12, #26, #27 during Resident Council, When do you receive your mail? Resident # 3 stated, We get mail Monday through Friday. There is nobody working on Saturday to deliver it. The Surveyor asked, Do you receive mail on Saturday? Resident #3 stated, No. 1A. On 02/28/24 at 11:00 AM, the Surveyor asked the Activities Director (AD), How is mail delivered? The AD stated, The Business Office Manager (BOM) receives the mail and goes through it first and then it is given to me to pass out to the residents. The Surveyor asked, What days are mail delivered? The AD stated, Monday through Saturday. The Surveyor asked, Who delivers it on Saturday? The AD stated, Either the BOM or the Administrator, they alternate weekends. 1B. On 02/28/24 at 12:44 PM, the Surveyor asked the Administrator, How do residents receive mail on Saturday? The Administrator stated, We don't have a process right now. The Surveyor asked, Do they receive mail on Saturdays? The Administrator stated, No. 2a. On 2/27/24 at 2:00 PM, one piece of mail for Resident #2 was laying at front nurses' desk in wire basket. 2b. On 2/28/24 at 08:10 AM, one piece of mail for Resident #2 was laying at front nurses' desk in wire basket. 2c. On 2/28/24 at 12:50 PM, one piece of mail for Resident #2 was laying at front nurses' desk in wire basket. 2d. On 2/29/24 at 08:37 AM, one piece of mail for Resident #2 was laying at front nurses' desk in wire basket. 2e. On 2/29/24 at 08:55 AM, the Social Services Director (SSD) stated, The BOM checks the mail and keeps any insurance related mail on the residents. Then they will place remaining mail into this wire basket. I try to check it daily. I admit I was busy yesterday. Surveyor advised that this letter for Resident #2 was observed in this wire basket since 2/27/24. The SSD stated, I will get it to the resident right now. 2f. A document provided by the Nurse Consultant on 2/26/24 at 3:12 PM titled, Policies and Procedures: Resident Rights Effective Date: 4/2021 Revised Date: 11/1/22 showed, .federal and state laws guarantee certain basic rights to all residents of this facility . these rights include .access to .mail .

Based on observation, interview, and record review, the facility failed to ensure the residents had access to their personal funds on nights and weekends, and that the long-term care financial team assumed the responsibility of managing the resident personal funds. The findings included: a. On 1/09/2024, a Grievance Form documented [Resident #9], requesting cash funds for shopping but has not received [the resident ' s] SSI (Supplemental Security Income) check for here. It is still being deposited in (Corporate facility) and has not been transferred here yet. b. On 1/10/2024, a Grievance Form documented, [Resident #20], requesting cash funds for an outing on 01/10/24. Unable to provide due to no way to cash trust funds checks. c. On 01/16/24, a Grievance Form documented, [Resident #3], requested cash funds for an outing on 1/15/24. No way to cash trust fund account. d. On 01/21/24, a Grievance Form documented [Resident #27], requested cash for his personal wants on 01/08/24 but due to no SSI checks we had no funds to give him. On 02/26/24, on 11:47 AM, Resident #13 complained that the facility would not provide transportation to go to the bank. Resident #13 stated, I have been here for months and I cannot access any money, as my bank is in another town. In response to the question on 02/27/24 at 10:47 AM, Was there any transportation available to take the resident to the bank for business? The Social Services/Transport/Activities Director, stated, I was not aware that the resident needed to go to the bank. In an interview on 02/27/2023, at 11:30 AM with the Business Officer Manager (BOM), in response to the question, Was there any transportation available to take the resident to the bank for business? The BOM stated, [The resident ' s] bank was too far away. On 2/27/24 at 10: 47 AM, in an interview with the Social Services/Transport/Activities Director, in response to the question, How do the residents access their personal funds? the Social Services/Transport/Activities Director responded, We had a corporate card and can no longer use the card. They (Administration) used to give me money. I only go shopping for the residents on our VISA card. If I need more money, I go to the Administrator and use his card. The Surveyor asked, can they access their personal funds on weekends and after hours throughout the week? The Social Services/Transport/Activities Director responded, No, they cannot access any personal funds. On 2/27/24 at 11:20 AM, in an interview with Licensed Practical Nurse (LPN) #1 and the Administrator, in response to the question, How do the residents access their personal funds? LPN #1 stated, We have a list and social services goes shopping on Friday, they don't need anything. The Administrator stated, I know that they should have something in place for petty cash but we do not have anything in place. The policy titled, Resident Rights (Revised 11/01/22) read in part .Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: Manage his or her personal funds, or have the facility manage his or her personal funds (if he or she wishes).

Based on observation, interview, and record review, the facility failed to ensure that residents received nail care to minimize the spread of infection for 2 (Residents #11 & #22) of 14 sample mix residents who were dependent on assistance with nail care; the facility failed to ensure 1 (Resident #11) of 7 sample mix residents who are dependent on 2-person assistance received a shower; the facility also failed to ensure oral care for a resident dependent on staff for oral care. This failed practice had the potential to affect one resident (resident #8) of 5 sample of mixed residents. The findings are: 1. The Care Plan for Resident (R) #22, dated 01/11/24, listed diagnosis of Dementia, Psychotic Disturbance, Behavioral Disturbance, Mood Disorder, Anxiety and Chronic Obstructive Pulmonary Disease (COPD), and documented that the resident needs assistance of staff for basic needs including: Dressing, toileting, bathing, grooming, locomotion, etc. a. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/2024 documented a Brief Interview for Mental State (BIMS) of (13-15 indicates cognitively intact). b. On 02/26/24 at 11:39 AM, R #22 ' s fingernails were jagged with broken sharp edges. c. On 02/26/24 at 02:07 PM, R #22 ' s fingernails were jagged with broken sharp edges. d. On 02/27/24 at 9:05 AM, R #22 ' s fingernails were jagged with broken sharp edges. e. On 02/28/24 at 11:11 AM, the Nurse Consultant provided documents titled, Shower/Bath dated 1/18/202 through 1/29/24 and Body/Skin Check dated 01/30/24, 01/24/24, 01/10/24, 02/09/24, 02/15/24, and 02/19/24. There was no documentation of any nail care. In response to the question, Where is nail care documented? the Nurse Consultant stated, I know that we are going to get tagged for nails, I have an aide coming in to do just nails today only. f. On 02/28/24 at 11:25 AM, in response to the question, Who does the nail care, how often are they trimmed, and when is the nail care performed? Licensed Practical Nurse (LPN) #1 stated, The nurses and the Certified Nursing Aides (CNA) do the nail care, during baths, unless the president is a diabetic, usually every week. The Surveyor asked ,Where are the nail care documented? LPN #1 stated, it is documented on the Shower/Bath and Body/Skin Check. In response to the question, Are you aware that [R #22] has long nails, jagged with broken sharp edges? LPN #1, responded, Yes, documented on Body/Skin Checks. 2. A review of an Admission Record indicated the facility admitted R #11 with a diagnosis of Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. a. The Quarterly MDS dated [DATE], revealed R #11 had a BIMS score of 15. The resident was dependent on staff for personal hygiene and showering/bathing. b. R #11's Care Plan, initiated 3/1/2022, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to (r/t) history of left hip fracture and history of cerebral vascular accident (CVA) deficits to left arm and leg. Interventions initiated on 3/1/2022; bathing/showering, requires extensive assistance by (2) staff with bathing/showering 3 times weekly and as necessary; personal hygiene, requires extensive assistance by (1) staff with personal hygiene. c. On 2/26/2024 at 11:29 AM, R #11 ' s toenails on the left foot were yellow and thick. d. On 02/26/24 at 01:53 PM, R #11 ' s toenails on the left foot are yellow and thick. R #11 ' s fingernails on the right hand are long, jagged with a dried black substance under them. R #11 was asked how often they received a shower. R # 11 stated, I got one last week, but not often, they don't have enough help, especially on the weekends. R #11 was asked, Do you have to wait a long time for someone to answer your call light? R #11 stated, Sometimes, sometimes it's over an hour before they come. R #11 was asked if he/she sees the podiatrist and stated, They have come 3 or 4 times and I saw them then. e. On 2/27/2024 at 2:51 PM, R #11 ' s fingernails on the right hand were observed with a dried black substance under the nail. R #11 was asked, Have you received a shower yet? R #11 stated, No. f. On 2/27/2024 at 2:55 PM, CNA #1 was asked, When is nail care done? CNA #1 stated, When we do showers. CNA #1 was asked how often residents receiving showers. CNA #1 stated, At least twice a week, but they haven't had it lately, I've been here for the last week and half, and they aren't being done. CNA #1 was asked where showers were documented. CNA #1 pulled up the shower sheet book and stated, On these shower sheets. CNA #1 verbally confirmed R #11 had not had a shower and there were no shower sheets for R #11. 3. A review of an Admission Record indicated the facility admitted R #8 with diagnoses of Cerebral infarction that included idiopathic normal pressure hydrocephalus, Aphasia, Quadriplegia unspecified, Aphagia, Dry mouth, Contracture of muscle at multiple sites, and Dysphagia. a. The Annual MDS, dated [DATE], revealed Resident #8 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The resident is dependent on staff for all ADLs. b. Resident #8's Care Plan, initiated 1/12/2016, revealed the resident had an ADL self-care performance deficit. He/She is totally dependent on 1-2 staff to anticipate their needs and to perform all ADLs such as transfers, feeding, bathing, mobility, grooming, oral care, and personal hygiene. Interventions included ensure that he/she is neatly groomed including hair, oral care, and clothing. Alternate rest periods with grooming activity as needed. c. Resident #8's Physician Orders, dated 12/2/2022, revealed a nothing by Mouth (NPO) diet. On 11/30/2021, a Physician Order for (Mouthwash) .by mouth every 4 hours as needed for dry mouth. Apply with swab as needed for dry mouth. d. Record review of oral hygiene dated 2/1/24 through 2/28/24: i. Resident was provided oral hygiene one time on 2/1/24. ii. Resident was provided oral hygiene one time on 2/2/24. iii. Resident was provided oral hygiene one time on 2/3/24. iv. Resident was provided oral hygiene one time on 2/4/24. v. No documentation of oral hygiene 2/5/24-2/7/24. vi. Resident was provided oral hygiene one time each day 2/8 - 2/10/24. vii. No documentation of oral hygiene 2/11-2/15/24. viii. Resident was provided oral hygiene one time each day 2/16 - 2/19/24. ix. No documentation on oral hygiene 2/20-2/21/24. x. Resident was provided oral hygiene one time each day 2/22 - 2/25/24. xi. No documentation of oral hygiene 2/26-2/27/24. xii. Resident was provided oral hygiene one time on 2/28/24. e. Record review of toileting hygiene dated 2/1/24 through 2/28/24: i. Resident was provided toileting hygiene one time on 2/1/24. ii. Resident was provided toileting hygiene one time on 2/2/24. iii. Resident was provided toileting hygiene one time on 2/3/24. iv. Resident was provided toileting hygiene one time on 2/4/24. v. No documentation of toileting hygiene 2/5/24-2/7/24. vi. Resident was provided toileting hygiene one time each day 2/8 - 2/10/24. vii. No documentation of toileting hygiene 2/11-2/15/24. viii. Resident was provided toileting hygiene one time each day 2/16 - 2/19/24. ix. No documentation of toileting hygiene 2/20-2/21/24. x. Resident was provided toileting hygiene one time 2/22-2/25/24. xi. No documentation of toileting hygiene 2/26-2/27/24. xii. Resident was provided toileting hygiene one time on 2/28/24. f. On 02/26/24 at 1:33 PM, Resident #8 was in their room with door closed on transmission based precautions. A white, crusty substance was observed above upper lip. A thick film was noted to teeth and upper and lower lips, with a yellow buildup noted on teeth. g. On 02/27/24 at 10:57 AM, R #8 was resting in bed with their eyes closed and mouth open. A thick film noted to teeth and upper and lower lips, with a yellow buildup noted on teeth. White, crusty substance remains above upper lip. h. On 02/28/24 at 09:56 AM, the Surveyor requested CNA #3 to accompany Surveyor to R #8's room. The film remained over teeth and upper and lower lips. CNA #3 was asked what the process is for oral care on this resident. We use lemon glycerin swabs to swab [R #8 ' s] mouth. We do it every two hours when we change [the resident] and whenever else it is needed. The Surveyor asked when last time R #8 was changed. CNA #3 stated, Probably around eight o'clock this morning so the next one should be soon. Oral care by CNA #3 was not provided at this time. i. On 2/28/2024 at 10:15 AM, the Surveyor inquired about oral care for Resident #8. LPN #2 stated, I provide it when I am in here, typically the CNA's provide oral care though. Oral care was not provided by LPN #2 to the resident at this time. j. On 2/28/2024, the Surveyor continued to monitor Resident #8's room until 11:13 AM. No facility staff entered room to provide oral care or check for incontinence. k. On 2/29/2024 at 4:00 PM, LPN #1 was asked when oral care is provided to Resident #8 and stated, [Resident #8] receives [named medicated mouthwash] in the morning every day. The CNAs are supposed to swab [the resident ' s] mouth every time they are in there, too. l. On 2/28/24 at 3:00 PM, the Nurse Consultant stated the facility did not have a policy on ADLs. 48808 49865

Based on observation and interview, the facility failed to ensure that the State Survey Binder was readily available to residents and visitors. This failed practice had the potential to affect all sampled residents who choose to read the State Survey Binder. The findings are: On 02/26/24 at 02:31 PM, the Surveyor did not observe a State Survey Binder readily available to residents and visitors. On 02/26/24 at 02:36 PM, the Surveyor asked the Administrator, Can you show me where the State Survey Binder is located? The Administrator stated, I can't find it. The Administrator confirmed the State Survey Binder was not readily available to residents and visitors. A document provided by the Nurse Consultant on 2/26/24 at 3:12 PM titled, Policies and Procedures: Resident Rights Effective Date: 4/2021 Revised Date: 11/1/22 showed, .federal and state laws guarantee certain basic rights to all residents of this facility . these rights include .the right to .examine survey results .

Based on observation, interview, and record review, the facility failed to ensure the resident received person centered care and services as evidenced by failure to ensure residents with skin injuries receiving treatments in 1 of 1 (Resident #13) sampled residents; the facility also failed to ensure a physician's order was followed for 1 (Resident #282) of 3 sample mixed residents who require a physician's order to receive oxygen. The findings are: 1a. The Care Plan for Resident (R) #13, dated 12/14/23, listed diagnoses of Paraplegia, Spinal stenosis, Muscle wasting and atrophy, Post traumatic stress disorder (PTSD), Major depressive disorder, and Pressure ulcers. 1b. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/05/23 documented a BIMS (Brief Interview for Mental Status) of 14 (13 to 15 indicates cognitively intact). 1c. A physician ' s order for R #13 read Cleanse L (left) heel PU (pressure ulcer) with wound cleanser, apply [named a sterile honey and glycerin dressing] to wound bed, cover with foam heel dressing Q (every) Monday, Wednesday, Friday and prn (as needed) until healed every day. The Treatment Profile does not show that the order was followed on the 9th and 12th of February. 1d. A physician ' s order read to Cleanse stage I pressure ulcer to top right foot with wound cleanser, apply [named a sterile honey and glycerin dressing] to wound bed, cover with 4x4 gauze, wrap with [named gauze] every Mon(day)-Wen(day)-Fri(day) one time a day The Treatment Profile did not show that the order was followed on the 7th, 9th, or 12th of February. 1e. A physician ' s order read to Cleanse stage III pressure ulcer on right ankle with normal saline, apply [named a sterile honey and glycerin dressing] to wound bed, cover with 4x4 gauze and wrap with [named gauze] Mon(day), Wed(day), Fri(day) until healed every day shift The Treatment Profile did not show that the order was followed on the 7th, 9th, 12th, or 23rd of February. 1f. A physician ' s order read to Cleanse stage IV (4) pressure ulcer on Sacrum with wound cleanser, skin prep [perineal] wound area, place [named a sterile honey and glycerin dressing] to wound bed and cover with sacral dressing every Mon(day), Wed(day), and Fri(day) every day shift. The Treatment Profile did not show that the order was followed on the 7th, 9th, 12th, or 23rd of February. 1g. On 2/27/24 at 9:55 AM, Licensed Practical Nurse (LPN) #1 confirmed that the treatments were not done on the treatment administration sheet for the 7th, 9th, 12th, and 23rd of February. The LPN stated, I have been here 90 days, and I am the only floor nurse, and I give medications and treatments. The other staff are agency. The blanks verify that the treatments had not been completed. 1h. On 02/27/24 at 7:30 AM, in response to the question, Why is important to ensure that dressing changes are completed per the Physicians order and are you aware that R #13 had received ordered treatments on the 7th, 9th, 12th, or 23rd of February? the Nurse Consultant stated, It is important to follow the physician orders for skin issues to prevent further problems. I was not aware. 2. R #282 had diagnoses of Acute bronchiolitis due to respiratory virus, Pneumonia, and Chronic obstructive pulmonary disease with (acute) exacerbation. The Admissions MDS with an ARD of 2/25/25 showed a BIMS of 15 (13-15 points indicates cognitively intact) 2A. The Physician's Order Summary dated 2/26/24 did not include an order for oxygen. 2B. A Progress noted dated 2/23/24 showed, .resident is a new admit admitted on [DATE] for physical therapy (PT)/occupational therapy (OT) related to acute bronchiolitis due to respiratory syncytial virus . the resident has bouts of shortness of breath (SOB) . 2C. On 02/26/24 at 01:49 PM, the Surveyor observed the resident with oxygen in place at 2 liters (L). 2D. On 02/26/24 at 02:59 PM, the Surveyor observed resident #282 with oxygen in place at 2L. 2E. On 02/27/24 at 11:10 AM, the Surveyor observed the resident with oxygen in place at 2L. 2F. On 02/28/24 at 10:36 AM, the Surveyor asked LPN #2, When a resident is admitted to the facility whose responsibility is it to receive and input orders? LPN #2 stated, Previously it was the Director of Nursing (DON), but they haven't had a DON in a while, so it was up to the charge nurses and then the Minimum Data Set (MDS) nurse to go through and verify the orders. The Surveyor asked, Should a resident be given oxygen without an order? LPN #2 stated, No. The Surveyor asked, Can you tell me when R #282's oxygen order was initiated? LPN #2 stated, 2/27/24. The Surveyor asked, Can you tell me when the resident was admitted . LPN #2 stated, 2/21/24. 2G. On 02/28/24 at 10:48 AM, the Surveyor asked Nurse Consultant (NC) #1, Who puts the orders in the computer when a resident admits? NC #1 stated, The floor nurse or the MDS nurse. It just depends on who is here and what nurse is on the floor. I did see there was not an oxygen order for [Resident #282] so I added it yesterday. The Surveyor asked, Was there an order for oxygen prior to 2/27/24? NC #1 confirmed there was not an order for oxygen. 2H. A document provided by the Nurse Consultant on 2/28/24 at 4:43 PM titled, Policies and Procedures Oxygen Administration-Resident Effective date 4/2021 Revised date: 11/25/22 showed, .verify that there is a physician's order .review the physician's orders .for oxygen administration . 48808

Surveyor: [NAME], [NAME] Resident #10 Accidents Based on observations, interview, and record review, the facility failed to ensure the environment was as free of potential accident hazards as possible as evidenced by failure to ensure unlabeled medicine cups containing a white cream like substance was contained and not left out in residents rooms; and failed to ensure razors, perineal/body wash, aftershave, shaving cream, and finger/toenail clippers were contained and not left out in residents rooms, to prevent potential accidents for 2 (Resident #10 and #23) of 2 sampled residents. The findings are: 1. The Quarterly Minimum Data Set (MDS), dated , 11/21/2023, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The resident was dependent on staff for personal hygiene and showering/bathing. On 2/26/2024 at 11:13 AM, Resident # 10 was lying in bed. A blue disposable razor, a bottle of perineal/body wash, a pair of fingernail clippers, 2 cans of shaving cream, and 1 bottle of aftershave were observed on Resident #10 ' s nightstand, none of which were contained. On 2/26/2024 at 1:51 PM, Resident # 10 was observed lying in bed. A blue disposable razor, a bottle of perineal wash, a pair of fingernail clippers, 2 cans of shaving cream, and 1 bottle of aftershave were observed on Resident #10 ' s nightstand, none of which were contained. On 2/27/2024 at 2:52 PM, Resident # 10 was observed lying in bed. A pair of nail clippers, a bottle of aftershave, and a bottle of perineal/body wash were observed sitting on the bedside table at the foot of Resident #10 bed and not contained. 2. The MDS dated [DATE], revealed Resident #23 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. The resident was dependent on staff for all activities of daily living (ADL). A review of Resident #23's Physician Orders, for the month of 2/2024, revealed an order, dated 2/7/2024, for cleanse stage 2 pressure ulcer left (L) buttock with wound cleanser, pat dry, apply alginate and cover with foam adhesive dressing Monday-Wednesday-Friday and as needed (prn) soiled/dislodged. On 02/26/24 11:00 AM, a bottle of wound wash was observed on the bedside table in resident room from the doorway. An unlabeled medicine cup containing a cream substance was observed on the nightstand. On 2/27/2024 at 2:55 PM, Certified Nursing Assistant (CNA) #1 was asked, Where are disposable razors and toenail clippers be stored when not in use? CNA #1 stated, The razors in the biohazard container or locked up. CNA #1 was asked, Where is shaving cream, aftershave, and perineal/body wash supposed to be stored when not in use? CNA #1 stated, In central supply. CNA #1 was asked why razors, nail clippers, shaving cream, aftershave and perineal/body wash should be contained when not in use. CNA #1 stated, Because it's a chemical and the residents could drink it, and the razor, they could cut themselves or commit suicide. On 2/27/2024 at 3:09 PM, Licensed Practical Nurse (LPN) #1 was asked where disposable razors and toenail clippers should be stored when not in use. LPN #1 stated, In the supply rooms or the treatment cart locked up. LPN #1 was asked, Where is shaving cream, aftershave, and perineal/body wash supposed to be stored when not in use? LPN #1 stated, In the supply carts in a locked room. LPN #1 was asked why razors, nail clippers, shaving cream, aftershave and perineal/body wash should be contained when not in use. LPN #1 stated, Because it's hazardous to the residents. A facility policy titled, Accidents and Hazards, dated 5/20/2022, specified, The facility strives to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. A document titled, Material Safety Data Sheet Finished Product, dated January 2011, specified, [Brand name] After Shave, potential health effects, eye: contact may cause mild, transient irritation. Some redness and/or stinging my occur. Ingestion: accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea. Explosive Hazard: Flammable Liquid. Explosive mixtures may form with air if large quantities of product are release in unventilated areas. A document titled, Safety Data Sheet, No Rinses Peri Wash, dated 1/25/2021, specified, Eye Contact: May cause temporary eye irritation. Flush eyes with plenty of water. A document titled, Material Safety Data Sheet Finished Product, dated September 2009, specified, [Brand name] Series Shave Foam Sensitive Skin, Eye: Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Inhalation: May cause mild, transient respiratory irritation. Avoid prolonged contact to concentrated vapors. Ingestion: Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea. Accidental ingestion of product may necessitate medical attention. For Household Settings: Pressurized container. Protect from sunlight and do not expose to temperatures exceeding 120 degrees Fahrenheit. Do not place in hot water or near radiators, stoves, or other sources of heat. Keep from extreme cold. A document titled, Safety Data Sheet, [Brand name] Shaving Cream, dated 5/28/2015, specified, Contains gas under pressure, may explode if heated. Eye Contact: Flush eyes with large amounts of water for at least 15 minutes. Skin Contact: Flush with water; if irritation persists, seek medical attention. Ingestion: If swallowed, call a physician immediately. Rinse mouth and throat thoroughly with water.

Based on interview and record review, the facility failed to ensure routine incontinence care was provided for 1 (Resident #2) of 11 sample mix residents dependent on staff for incontinent care. The findings are: A review of an Admission Record indicated the facility admitted Resident (R) #2 with Hemiplegia and hemiparesis following cerebral infarction, Contracture of right hand, and Neuromuscular disorder of bladder. The Annual Minimum Data Set (MDS), dated [DATE], revealed R #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident requires extensive assistance with activities of daily living (ADLs). Review of R #2's Care Plan, updated 07/16/2020, revealed the resident had an ADL self-care performance deficit related to activity intolerance, fatigue, hemiplegia, impaired balance, limited mobility, limited range of motion and stroke. R #2 is dependent on staff for most ADLs. Interventions include extensive assist x1 staff for personal hygiene and oral care. According to the Care Plan, updated 7/22/2022 resident #2 has potential skin impairment related to incontinence, mobility limitations and use of multiple psychoactive and diuretic medications. Interventions include change brief every two hours and as needed, establish voiding patterns, clean peri-area with each incontinence episode, encourage fluids during the day to promote prompted voiding responses, and monitor and document intake and output as per facility policy. On 02/26/24 at 1:30 PM, R #2 reported being wet one evening around 6:00PM. R #2 stated, I told the CNA (Certified Nursing Aide) that my brief was wet. [The CNA] told me I would be changed when our rounds are due, meaning I was changed at 9:00 PM that night. On 2/29/24 at 1:35 PM, CNA #3 was asked, Is R #2 dependent on staff for incontinence care? The CNA stated, Yes. CNA #3 was asked, What is process for checking for incontinence? The CNA stated, Whenever the resident calls us or we round every 2-3 hours to check on them. Of course, it depends on mealtime, too. CNA #3 was asked, If a resident informed you that they were wet and it was not rounding time, what would you do? The CNA stated, I would change [the resident] right then. CNA #3 was asked, What could happen if a resident sits in their wet brief? CNA #3 stated, Their skin can breakdown. On 2/29/24 at 1:45 PM, the Nurse Consultant (NC) was asked, Is R #2 dependent on staff for incontinence care? The NC stated, Yes. The NC was asked, What is process for checking for incontinence? The NC stated, Resident should be checked every 2 hours. This resident can also use the call light and I have answered it before when R #2] was wet. The NC was asked, If resident informed you that he/she was wet and it was not rounding time, what would you do? The NC stated, Resident needs to be changed right then. The NC was asked, What could happen if a resident sits in their wet brief? The NC stated, Resident could have skin breakdown and/or urinary tract infection. Record review of toileting hygiene dated 2/1/24 through 2/28/24 1. Resident was provided toileting hygiene one time on 2/1/24. 2. Resident was provided toileting hygiene twice on 2/2/24. 3. Resident was provided toileting hygiene one time on 2/3/24. 4. Resident was provided toileting hygiene one time on 2/4/24. 5. No documentation of toileting hygiene 2/5/24-2/7/24. 6. Resident was provided toileting hygiene one time each day 2/8 - 2/10/24. 7. No documentation of toileting hygiene 2/11-2/15/24. 8. Resident was provided toileting hygiene one time each day 2/16 - 2/19/24. 9. No documentation of toileting hygiene 2/20-2/21/24. 10. Resident was provided toileting hygiene one time 2/22 - 2/26/24. 11. No documentation of toileting hygiene 2/27/24. 12. Resident was provided toileting hygiene one time on 2/28/24.

Based on observation and interview, and policy review, the facility failed to ensure that the medication cart had locked storage drawers, and that undated and discontinued medications were not stored in the facility medication room. The findings are: 1. On 2/26/24 at 12:30 PM, Licensed Practical Nurse (LPN) #1 was administering medications in the dining room with a lockable medication storage cart. The LPN was observed taking medications out of the cart and walking to residents delivering individual medications. While administering medications to residents the cart was left unlocked and unattended. On 2/26/24 at 12:35 PM, LPN #1 was asked, Why should you lock up the medication cart between giving medications to the residents? LPN #1 stated, Should lock cart so resident cannot open up the cart and take out medication, for safety reasons. 2. On 02/29/24 at 9:41 AM, an opened vial used for residential skin test to help diagnose tuberculosis (TB) infections was not dated in the refrigerator. The Director of Nursing (DON) was asked, Who is responsible for dating the Tuberculin vial, how long can an unopened vial be in the refrigerator, why would you date a vial, and what would be outcome of not dating the vial? The DON responded, The nurse who opens the vial should date it, as it should only be opened for 30 days before discarding, as it might affect the shelf-life. 3. On 02/29/24 at 9:50 AM, a medium plastic tub containing pharmacy bubble pack medications was observed in the medication storage room, with bottles of medications on top. The DON was asked, Are these medications belonging to the residents? The DON responded, I believe this is discontinued medications, I am not sure, let me ask [LPN #1]. At 9:55 AM, LPN#1 was asked, Are these discontinued medications? LPN #1 stated, Yes, the tub is full and the top is the overflow. The Nurse Consultant came into the medication room at 9:57 AM and was asked, What is the process for storing discontinued drugs and should it be in an orderly manner? The Nurse Consultant stated, The nurse will copy the discontinued medications into this book Records of Drugs Destroyed until the pharmacist visits, and this is where it is stored. LPN #1 provided the book, with the last entry dated 10/05/23, and stated, I have been here for 3 months, and I never entered any discontinued medications. 4. The policy titled, Label/Store Drugs and Biologicals (Revised 12/26/22) read in part, .The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used in transport such items shall not be left unattended if open of other side potential available to others . 5. An Admission Record indicated the facility admitted Resident #23 with diagnoses of Parkinson's and Dementia. a. On 02/26/24 11:00 AM, a bottle of wound wash was observed on a bedside table in resident room from the doorway. A medicine cup containing a cream substance was observed on the nightstand. 6. A review of an Admission Record indicated the facility admitted Resident #9 with diagnoses of Kidney failure and Neurogenic bladder. a. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. b. A review of Resident #9's Physician Orders, for the month of 02/2024, revealed an order, dated 8/23/2023, for acetic acid irrigation solution 0.25%, use 60 cubic centimeters (cc) via irrigation, one time a day, for catheter irrigation (this is used to prevent infection due to placement of a catheter into the bladder). c. On 02/26/24 at 11:41 AM, Resident # 9 was lying in bed. An opened, undated, 1000 milliliter bottle of 0.25% Acetic Acid Irrigation solution containing 900 milliliters of clear liquid was observed on the nightstand in resident ' s room. d. On 02/27/2024 at 2:48 PM, Resident # 9 was lying in bed. An opened, undated, 1000 milliliter bottle of 0.25% Acetic Acid Irrigation solution containing 850 milliliters clear liquid, was observed on the nightstand in resident room. 7. A facility policy titled, Label/Store Drugs & Biologicals, dated 12/26/2022, specified, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparations areas in a clean, safe, and sanitary manner. Medication will not be stored in a resident room unless the resident has been approved for self-administration of medication. 48808

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week. This failure had the possibility to affect all 29 residents according to the Midnight Census dated 2/26/24. The findings are: On 03/01/24 at 10:21 AM, the Surveyor reviewed staffing logs for nurse staffing dated 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/24/24 that showed the facility did not have 8 hours of RN coverage. Time sheets dated: 1. 2/15/24: No RN coverage. 2. 2/16/24: No RN coverage. 3. 2/17/24: RN Coverage 6:00 PM to 12:00 AM. 4. 2/18/24: RN Coverage 12:01 AM to 6:05 AM. 5. 2/24/24: RN Coverage 5:54 PM to 12:00 AM. On 03/01/24 at 10:26 AM, the Surveyor asked the Nurse Consultant (NC) #1, Was there 8 hours RN coverage documented for these 5 days? NC #1 confirmed there was no RN coverage.

Complaint # (AR 309) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure the facility's abuse prohibition policies and procedures were implemented, as evidenced by failure to ensure a suspicious injury of unknown origin (reddened area in shape of handprint) was immediately reported to the Administrator and the Office of Long Term Care (OLTC), failure to conduct an investigation of the injury to rule out or confirm whether abuse occurred, and failure to implement any protective measures, such as increased monitoring, to prevent further potential injury or abuse for 1 (Resident #1) of 2 (Residents #1 and 5) case mix residents who were cognitively impaired. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was observed by staff with a hand-shaped reddened area to her thigh, and had the potential to affect 18 residents who were cognitively impaired, according to a list provided by the Administrator on 12/19/18. The Administrator was informed of the immediate jeopardy situation on 12/6/18 at 11:10 a.m The findings are: 1. The facility's Abuse Policy, provided by the Administrator on 12/5/18 at 9:15 AM, documented, .The facility does and will continue to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures . The Shift Supervisor or Charge Nurse is identified as responsible for immediate initiation of the reporting process. 4. The Administrator and Director of Nursing are responsible for investigating and reporting .Identification: 1. Instruct staff . to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and or misappropriation of property such as suspicious bruising of residents . that may indicate abuse, neglect, and/or mistreatment and investigate .Protection: 1. Provide for the immediate safety of residents, upon identification of suspected abuse, neglect, mistreatment .Move resident to another room or unit, Provide 1:1 (one-on-one) monitoring as appropriate, Immediate suspension of suspected employee(s), pending outcome of the of the investigation .Initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interviewable and have information regarding the allegation .Reporting: 1. Notify the shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment .2. Report the incident to the Director of Nurses and Administrator. 3. Notify the local law enforcement immediately. 4. Notify the appropriate State agency(s) as per the State requirement. 5. Notify the legal guardian or responsible family member of the allegation. 6. Notify the Physician . 7. Report to the State authorities a final report as per the State agencies' protocol . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly day Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 9/25/18 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was inattentive, had disorganized thinking and had altered level of consciousness, had not behaviors and was dependent on 2 plus person(s) for all Activities of Daily Living (ADLs). a. The Care Plan dated as revised of 11/26/18 documented, Dependent on staff x (times) 2 person for assist with ADLs - bathing dressing, transfers with Hoyer lift, turning and repositioning, carrot to right hand in after breakfast and out before supper then in during sleeping hours 9pm-6am (9:00 p.m. - 6:00 p.m.) . Skin observed . bruises and report changes to the nurse. Resident has severely impaired cognitive function .(Resident #1) is and has the potential to be physically aggressive (to staff) r/t (related to) Dementia, Poor impulse control. She appears to have more behaviors in the evening and during care .Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) her posing danger to self and others .She tolerates few people at a time. She may reacts to touch by Staff during care . b. A Progress Note dated 11/9/18 at 8:51 a.m. and signed by the Director of Nursing (DON) documented. It was reported to this nurse by LPN (Licensed Practical Nurse) that resident had a redden area on her left thigh which appeared to be finger marks. Upon investigation and reassessment, there were no marks noted. Staff showed this nurse where the marks were, which was consistent of where the resident places her hand on her left thigh. Resident is turned and re-positioned q (every) 2 hours and it is observed that she prefers to tuck her hand between her left thigh and the bed when on her left side. Staff in-serviced on the proper way to position a resident and to make sure that their hands are free and out of the way. No further redness noted. Resident does not appear to be fearful or guarded during care. No evidence or s/s (signs and symptoms) of abuse noted. There was no documentation this information was reported to the Administrator or of any further effort to investigate. c. On 12/5/18 at 1:46 PM, the resident was in her room sitting in a geri chair watching television. The resident made no response when spoken to. d. On 12/5/18 at 3:41 p.m., the Administrator was asked, Can you tell me about the handprint on (Resident #1's) hip? The Administrator stated, I did not know about this. This is the first time I have seen or heard anything about it. I will have to look into it. The Administrator was asked if the incident had been reported to the Office of Long Term Care (OLTC) and stated, No, I didn't know about it. e. On 12/5/18 at 8:04 p.m., during a phone interview, Certified Nurse Assistant (CNA) #1 was asked, can you tell me about the handprint found on (Resident #1)? CNA #1 stated, I'm the one that found the handprint on her side, on the side of her hip. The CNA was asked which hip and stated, It was her left hip. She was asked, what did you do? She stated, I went to get the nurse; I reported it as soon as I saw it. The CNA was asked, did they ask you to write a statement of what you saw? She stated, I wrote out a statement that day. The CNA was asked, what hours do you work? She stated, 6 a.m. to 2 (p.m.). The CNA was asked, what time did you find the mark on the resident? She stated, It was a little after 6; she is the first person that I get up. The CNA was asked, when you entered the room, how was the resident lying in bed? She stated, She was lying on her right side; when I pulled back the covers, I could see it. The CNA was asked, what hip was the mark on? She stated, The left. The CNA was asked, what happened when the nurse saw it? She stated, I can't tell you that. The CNA was asked, how long was the handprint on the resident's hip? She stated, It was gone by the next day. The CNA was asked if she had seen the handprint on the resident's left hip later in the day and stated, (Director of Nursing) showed me that it was going away. The CNA was asked who was in the room with her and stated, (CNA #2), I think. f. On 12/5/18 at 8:16 p.m., during a phone interview with Licensed Practical Nurse (LPN) #1 was asked, can you tell me about the handprint found on (Resident #1)? She stated, Yes, I was called to her room and, when I got in the room, (CNA #1) pointed to a handprint on the resident's hip. I went out and pulled another nurse in to look at it; I'm still fairly new at this and I wanted someone else to see it. The LPN was asked, which hip? She stated, Left hip. The LPN was asked, what did it look like? She stated, A hand; it had 5 fingers there. The LPN was asked, what did you do? She stated, I took a picture of it and sent it to the DON (Director of Nursing) and called her; she said she would look at it when she got there. The LPN was asked if the mark on the resident's hip could have been the resident's handprint. She stated, No, it couldn't have; it was bigger than her hand. The LPN was asked, did you do an Incident and Accident Report? She stated, No, I was told by the DON that she would take care of it, but today, she called me and told me to come in and do one, and I did. The LPN was asked, do you know what day and time you reported this? She stated, Yes, it was reported on 11/9/18 at 6:20 AM. I feel like it was a handprint. It did fade by the end of the day, but it was there. I took a picture and sent it to the DON when it was brought to my attention. The LPN was asked, do you still have the picture? She stated, I think so, if I haven't deleted my deleted pictures. The LPN sent the picture to the surveyor's email at 8:23 p.m. on 12/5/18. In the photograph, you could see the shape of fingers and was reddish in color that was outlined on the body of the resident. g. On 12/6/18 at 10:00 a.m., the DON was asked, are you aware of anything that happened with (Resident #1) at the beginning of November? The DON stated, (LPN #1) called me on (MONTH) 9 and said it looked like a handprint on the resident's hip. I told her to let me jump in the shower and I will look at it when I arrive. When I arrived, I took the two CNAs on the 400 hall in with me, and there was no mark; there was nothing there. I asked (CNA #1) to point out where it was. It could have been where she laid her hand. The DON was asked, did the nurse send you a picture of the mark? She stated, Yes. The DON was asked, do you still have a picture of it? She stated, Yes. The DON was asked if, based on what she had seen in the photo, the mark on the resident's hip looked like a handprint. She stated, Yes. The DON was asked, did you do an investigation? She stated, I asked the staff with me if she was laying (sic) on her hand. The DON was asked, how did they respond to your question? She stated, They said 'no'. The DON was asked, did the staff write out statements? She stated, No, at least I don't think so; I didn't see any. The DON was asked, was an incident and accident report done? She stated, There was not, but we did one yesterday (12/5/18). The DON was asked, when you talked with the CNAs, did they think it was possible that she was lying on her hand? She stated, No. But it could have been possible. The DON was asked, was her hand on her side when they rolled her over? She stated, I don't know. The DON was asked, what did the picture look like to you? She stated, A handprint. The DON was asked, if you could not identify where the handprint came from, what should have been done? She stated, A reportable. The DON was asked if a reportable was completed and sent to the Office of Long Term Care. She stated, No. The DON was asked, did you interview any of the staff that were there when it was found? She stated. No. The DON was asked, did you do a skin audit at the time of the incident? She stated, No. h. On 12/6/18 at 12:11 AM, the resident was sitting in a Geri chair in the dining room. The resident had a cloth that she was using to wipe her hands. The resident was non-verbal when addressed by a staff member and did not make eye contact or show any reaction to the staff member speaking to her. 3. The immediate jeopardy was removed and the scope and severity lowered to E on 12/6/18 when the facility implemented the following plan of removal: a. Beginning on 12/6/18 at 1:18 p.m., the Administrator will immediately initiate an investigation of area on resident's thigh of reddened finger marks. b. A report will be submitted to OLTC. c. Residents that cannot speak for themselves have the potential to be affected. These residents will have body audit performed by Registered Nurses. d. All employees will be in-serviced by Administrator or DON prior to the beginning of their next shift on reporting abuse, neglect or suspicious injuries of unknown origin and protection of residents. e. Director of Nursing will be in-serviced by Administrator on Abuse, Neglect policy including reporting and investigation. f. Administrator or DON will review Nurse's Notes in the past 30 days to identify suspicious injury of unknown origin. g. Monitoring will include staff interviews 2-3 times per week by Administrator, DON or Social and Activity to ensure they are aware of Protection, Notification and Investigation. i. Monitoring will also include daily review of Nursing Notes by Nurse Management or Administrator to identify any documentation of injuries of unknown origin or possible abuse, neglect or misappropriation. j. Any negative findings will be submitted to the Quality Assurance Committee for further follow-up.

Complaint # (AR 309) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure a suspicious injury of unknown origin (reddened area in shape of handprint) was immediately reported to the Administrator and the Office of Long Term Care (OLTC), which resulted in delays in initiating an investigation and protective measures for 1 (Resident #1) of 2 (Residents #1 and 5) case mix residents who were cognitively impaired. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was observed by staff with a hand-shaped reddened area to her thigh, and had the potential to affect 18 residents who were cognitively impaired, according to a list provided by the Administrator on 12/19/18. The Administrator was informed of the immediate jeopardy situation on 12/6/18 at 11:10 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 9/25/18 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was dependent on 2 plus person(s) for all Activities of Daily Living (ADLs) was inattentive, had disorganized thinking and had altered level of consciousness, had not behaviors and was dependent on 2 plus person(s) for all Activities of Daily Living (ADLs). a. The Care Plan dated as revised of 11/26/18 documented, Dependent on staff x (times) 2 person for assist with ADLs - bathing dressing, transfers with Hoyer lift, turning and repositioning, carrot to right hand in after breakfast and out before supper then in during sleeping hours 9pm-6am (9:00 p.m. - 6:00 p.m.) . Skin observed . bruises and report changes to the nurse. Resident has severely impaired cognitive function . (Resident #1) is and has the potential to be physically aggressive (to staff) r/t (related to) Dementia, Poor impulse control. She appears to have more behaviors in the evening and during care .Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) her posing danger to self and others .She tolerates few people at a time. She may react to touch by Staff during care . b. A Progress Note dated 11/9/18 at 8:51 a.m. and signed by the Director of Nursing (DON) documented. It was reported to this nurse by LPN (Licensed Practical Nurse) that resident had a redden area on her left thigh which appeared to be finger marks. Upon investigation and reassessment, there were no marks noted. Staff showed this nurse where the marks were, which was consistent of where the resident places her hand on her left thigh. Resident is turned and re-positioned q (every) 2 hours and it is observed that she prefers to tuck her hand between her left thigh and the bed when on her left side. Staff in-serviced on the proper way to position a resident and to make sure that their hands are free and out of the way. No further redness noted. Resident does not appear to be fearful or guarded during care. No evidence or s/s (signs and symptoms) of abuse noted. There was no documentation this information was reported to the Administrator or of any further effort to investigate. c. On 12/5/18 at 1:46 PM, the resident was in her room sitting in a geri chair watching television. The resident made no response when spoken to. d. On 12/5/18 at 3:41 p.m., the Administrator was asked, Can you tell me about the handprint on (Resident #1's) hip? The Administrator stated, I did not know about this. This is the first time I have seen or heard anything about it. I will have to look into it. The Administrator was asked if the incident had been reported to the Office of Long Term Care (OLTC) and stated, No, I didn't know about it. e. On 12/5/18 at 8:04 p.m., during a phone interview, Certified Nurse Assistant (CNA) #1 was asked, can you tell me about the handprint found on (Resident #1)? CNA #1 stated, I'm the one that found the handprint on her side, on the side of her hip. The CNA was asked which hip and stated, It was her left hip. She was asked, what did you do? She stated, I went to get the nurse; I reported it as soon as I saw it. The CNA was asked, did they ask you to write a statement of what you saw? She stated, I wrote out a statement that day. The CNA was asked, what hours do you work? She stated, 6 a.m. to 2 (p.m.). The CNA was asked, what time did you find the mark on the resident? She stated, It was a little after 6; she is the first person that I get up. The CNA was asked, when you entered the room, how was the resident lying in bed? She stated, She was lying on her right side; when I pulled back the covers, I could see it. The CNA was asked, what hip was the mark on? She stated, The left. The CNA was asked, what happened when the nurse saw it? She stated, I can't tell you that. The CNA was asked, how long was the handprint on the resident's hip? She stated, It was gone by the next day. The CNA was asked if she had seen the handprint on the resident's left hip later in the day and stated, (Director of Nursing) showed me that it was going away. The CNA was asked who was in the room with her and stated, (CNA #2), I think. f. On 12/5/18 at 8:16 p.m., during a phone interview with Licensed Practical Nurse (LPN) #1 was asked, can you tell me about the handprint found on (Resident #1)? She stated, Yes, I was called to her room and, when I got in the room, (CNA #1) pointed to a handprint on the resident's hip. I went out and pulled another nurse in to look at it; I'm still fairly new at this and I wanted someone else to see it. The LPN was asked, which hip? She stated, Left hip. The LPN was asked, what did it look like? She stated, A hand; it had 5 fingers there. The LPN was asked, what did you do? She stated, I took a picture of it and sent it to the DON (Director of Nursing) and called her; she said she would look at it when she got there. The LPN was asked if the mark on the resident's hip could have been the resident's handprint. She stated, No, it couldn't have; it was bigger than her hand. The LPN was asked, did you do an Incident and Accident Report? She stated, No, I was told by the DON that she would take care of it, but today, she called me and told me to come in and do one, and I did. The LPN was asked, do you know what day and time you reported this? She stated, Yes, it was reported on 11/9/18 at 6:20 AM. I feel like it was a handprint. It did fade by the end of the day, but it was there. I took a picture and sent it to the DON when it was brought to my attention. The LPN was asked, do you still have the picture? She stated, I think so, if I haven't deleted my deleted pictures. The LPN sent the picture to the surveyor's email at 8:23 p.m. on 12/5/18. In the photograph, you could see the shape of fingers and was reddish in color that was outlined on the body of the resident. g. On 12/6/18 at 10:00 a.m., the DON was asked, are you aware of anything that happened with (Resident #1) at the beginning of November? The DON stated, (LPN #1) called me on (MONTH) 9 and said it looked like a handprint on the resident's hip. I told her to let me jump in the shower and I will look at it when I arrive. When I arrived, I took the two CNAs on the 400 hall in with me, and there was no mark; there was nothing there. I asked (CNA #1) to point out where it was. It could have been where she laid her hand. The DON was asked, did the nurse send you a picture of the mark? She stated, Yes. The DON was asked, do you still have a picture of it? She stated, Yes. The DON was asked if, based on what she had seen in the photo, the mark on the resident's hip looked like a handprint. She stated, Yes. The DON was asked, did you do an investigation? She stated, I asked the staff with me if she was laying (sic) on her hand. The DON was asked, how did they respond to your question? She stated, They said 'no'. The DON was asked, did the staff write out statements? She stated, No, at least I don't think so; I didn't see any. The DON was asked, was an incident and accident report done? She stated, There was not, but we did one yesterday (12/5/18). The DON was asked, when you talked with the CNAs, did they think it was possible that she was lying on her hand? She stated, No. But it could have been possible. The DON was asked, was her hand on her side when they rolled her over? She stated, I don't know. The DON was asked, what did the picture look like to you? She stated, A handprint. The DON was asked, if you could not identify where the handprint came from, what should have been done? She stated, A reportable. The DON was asked if a reportable was completed and sent to the Office of Long Term Care. She stated, No. The DON was asked, did you interview any of the staff that were there when it was found? She stated. No. The DON was asked, did you do a skin audit at the time of the incident? She stated, No. h. On 12/6/18 at 12:11 AM, the resident was sitting in a Geri chair in the dining room. The resident had a cloth that she was using to wipe her hands. The resident was non-verbal when addressed by a staff member and did not make eye contact or show any reaction to the staff member speaking to her. 2. The immediate jeopardy was removed and the scope and severity lowered to E on 12/6/18 when the facility implemented the following plan of removal: a. Beginning on 12/6/18 at 1:18 p.m., the Administrator will immediately initiate an investigation of area on resident's thigh of reddened finger marks. b. A report will be submitted to OLTC. c. Residents that cannot speak for themselves have the potential to be affected. These residents will have body audit performed by Registered Nurses. d. All employees will be in-serviced by Administrator or DON prior to the beginning of their next shift on reporting abuse, neglect or suspicious injuries of unknown origin and protection of residents. e. Director of Nursing will be in-serviced by Administrator on Abuse, Neglect policy including reporting and investigation. f. Administrator or DON will review Nurse's Notes in the past 30 days to identify suspicious injury of unknown origin. g. Monitoring will include staff interviews 2-3 times per week by Administrator, DON or Social and Activity to ensure they are aware of Protection, Notification and Investigation. i. Monitoring will also include daily review of Nursing Notes by Nurse Management or Administrator to identify any documentation of injuries of unknown origin or possible abuse, neglect or misappropriation. j. Any negative findings will be submitted to the Quality Assurance Committee for further follow-up.

Complaint # (AR 309) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure a suspicious injury of unknown origin (reddened area in shape of handprint) was thoroughly investigated to rule out possible abuse and failed to ensure protective measures were immediately implemented upon discovery of the injury, to prevent further potential abuse or injury for 1 (Resident #1) of 2(Residents #1 and 5) case mix residents who were cognitively impaired. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was observed by staff with a hand-shaped reddened area to her thigh, and had the potential to affect 18 residents who were cognitively impaired, according to a list provided by the Administrator on 12/19/18. The Administrator was informed of the immediate jeopardy situation on 12/6/18 at 11:10 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly day Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 9/25/18 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was dependent on 2 plus person(s) for all Activities of Daily Living (ADLs) was inattentive, had disorganized thinking and had altered level of consciousness, had not behaviors and was dependent on 2 plus person(s) for all Activities of Daily Living (ADLs). a. The Care Plan dated as revised of 11/26/18 documented, Dependent on staff x (times) 2 person for assist with ADLs - bathing dressing, transfers with Hoyer lift, turning and repositioning, carrot to right hand in after breakfast and out before supper then in during sleeping hours 9pm-6am (9:00 p.m. - 6:00 p.m.) . Skin observed . bruises and report changes to the nurse. Resident has severely impaired cognitive function .(Resident #1) is and has the potential to be physically aggressive (to staff) r/t (related to) Dementia, Poor impulse control. She appears to have more behaviors in the evening and during care .Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) her posing danger to self and others .She tolerates few people at a time. She may react to touch by Staff during care . b. A Progress Note dated 11/9/18 at 8:51 a.m. and signed by the Director of Nursing (DON) documented. It was reported to this nurse by LPN (Licensed Practical Nurse) that resident had a redden area on her left thigh which appeared to be finger marks. Upon investigation and reassessment, there were no marks noted. Staff showed this nurse where the marks were, which was consistent of where the resident places her hand on her left thigh. Resident is turned and re-positioned q (every) 2 hours and it is observed that she prefers to tuck her hand between her left thigh and the bed when on her left side. Staff in-serviced on the proper way to position a resident and to make sure that their hands are free and out of the way. No further redness noted. Resident does not appear to be fearful or guarded during care. No evidence or s/s (signs and symptoms) of abuse noted. There was no documentation this information was reported to the Administrator or of any further effort to investigate. c. On 12/5/18 at 1:46 PM, the resident was in her room sitting in a geri chair watching television. The resident made no response when spoken to. d. On 12/5/18 at 3:41 p.m., the Administrator was asked, Can you tell me about the handprint on (Resident #1's) hip? The Administrator stated, I did not know about this. This is the first time I have seen or heard anything about it. I will have to look into it. The Administrator was asked if the incident had been reported to the Office of Long Term Care (OLTC) and stated, No, I didn't know about it. e. On 12/5/18 at 8:04 p.m., during a phone interview, Certified Nurse Assistant (CNA) #1 was asked, can you tell me about the handprint found on (Resident #1)? CNA #1 stated, I'm the one that found the handprint on her side, on the side of her hip. The CNA was asked which hip and stated, It was her left hip. She was asked, what did you do? She stated, I went to get the nurse; I reported it as soon as I saw it. The CNA was asked, did they ask you to write a statement of what you saw? She stated, I wrote out a statement that day. The CNA was asked, what hours do you work? She stated, 6 a.m. to 2 (p.m.). The CNA was asked, what time did you find the mark on the resident? She stated, It was a little after 6; she is the first person that I get up. The CNA was asked, when you entered the room, how was the resident lying in bed? She stated, She was lying on her right side; when I pulled back the covers, I could see it. The CNA was asked, what hip was the mark on? She stated, The left. The CNA was asked, what happened when the nurse saw it? She stated, I can't tell you that. The CNA was asked, how long was the handprint on the resident's hip? She stated, It was gone by the next day. The CNA was asked if she had seen the handprint on the resident's left hip later in the day and stated, (Director of Nursing) showed me that it was going away. The CNA was asked who was in the room with her and stated, (CNA #2), I think. f. On 12/5/18 at 8:16 p.m., during a phone interview with Licensed Practical Nurse (LPN) #1 was asked, can you tell me about the handprint found on (Resident #1)? She stated, Yes, I was called to her room and, when I got in the room, (CNA #1) pointed to a handprint on the resident's hip. I went out and pulled another nurse in to look at it; I'm still fairly new at this and I wanted someone else to see it. The LPN was asked, which hip? She stated, Left hip. The LPN was asked, what did it look like? She stated, A hand; it had 5 fingers there. The LPN was asked, what did you do? She stated, I took a picture of it and sent it to the DON (Director of Nursing) and called her; she said she would look at it when she got there. The LPN was asked if the mark on the resident's hip could have been the resident's handprint. She stated, No, it couldn't have; it was bigger than her hand. The LPN was asked, did you do an Incident and Accident Report? She stated, No, I was told by the DON that she would take care of it, but today, she called me and told me to come in and do one, and I did. The LPN was asked, do you know what day and time you reported this? She stated, Yes, it was reported on 11/9/18 at 6:20 AM. I feel like it was a handprint. It did fade by the end of the day, but it was there. I took a picture and sent it to the DON when it was brought to my attention. The LPN was asked, do you still have the picture? She stated, I think so, if I haven't deleted my deleted pictures. The LPN sent the picture to the surveyor's email at 8:23 p.m. on 12/5/18. In the photograph, you could see the shape of fingers and was reddish in color that was outlined on the body of the resident. g. On 12/6/18 at 10:00 a.m., the DON was asked, are you aware of anything that happened with (Resident #1) at the beginning of November? The DON stated, (LPN #1) called me on (MONTH) 9 and said it looked like a handprint on the resident's hip. I told her to let me jump in the shower and I will look at it when I arrive. When I arrived, I took the two CNAs on the 400 hall in with me, and there was no mark; there was nothing there. I asked (CNA #1) to point out where it was. It could have been where she laid her hand. The DON was asked, did the nurse send you a picture of the mark? She stated, Yes. The DON was asked, do you still have a picture of it? She stated, Yes. The DON was asked if, based on what she had seen in the photo, the mark on the resident's hip looked like a handprint. She stated, Yes. The DON was asked, did you do an investigation? She stated, I asked the staff with me if she was laying (sic) on her hand. The DON was asked, how did they respond to your question? She stated, They said 'no'. The DON was asked, did the staff write out statements? She stated, No, at least I don't think so; I didn't see any. The DON was asked, was an incident and accident report done? She stated, There was not, but we did one yesterday (12/5/18). The DON was asked, when you talked with the CNAs, did they think it was possible that she was lying on her hand? She stated, No. But it could have been possible. The DON was asked, was her hand on her side when they rolled her over? She stated, I don't know. The DON was asked, what did the picture look like to you? She stated, A handprint. The DON was asked, if you could not identify where the handprint came from, what should have been done? She stated, A reportable. The DON was asked if a reportable was completed and sent to the Office of Long Term Care. She stated, No. The DON was asked, did you interview any of the staff that were there when it was found? She stated. No. The DON was asked, did you do a skin audit at the time of the incident? She stated, No. h. On 12/6/18 at 12:11 AM, the resident was sitting in a Geri chair in the dining room. The resident had a cloth that she was using to wipe her hands. The resident was non-verbal when addressed by a staff member and did not make eye contact or show any reaction to the staff member speaking to her. 2. The immediate jeopardy was removed and the scope and severity lowered to E on 12/6/18 when the facility implemented the following plan of removal: a. Beginning on 12/6/18 at 1:18 p.m., the Administrator will immediately initiate an investigation of area on resident's thigh of reddened finger marks. b. A report will be submitted to OLTC. c. Residents that cannot speak for themselves have the potential to be affected. These residents will have body audit performed by Registered Nurses. d. All employees will be in-serviced by Administrator or DON prior to the beginning of their next shift on reporting abuse, neglect or suspicious injuries of unknown origin and protection of residents. e. Director of Nursing will be in-serviced by Administrator on Abuse, Neglect policy including reporting and investigation. f. Administrator or DON will review Nurse's Notes in the past 30 days to identify suspicious injury of unknown origin. g. Monitoring will include staff interviews 2-3 times per week by Administrator, DON or Social and Activity to ensure they are aware of Protection, Notification and Investigation. i. Monitoring will also include daily review of Nursing Notes by Nurse Management or Administrator to identify any documentation of injuries of unknown origin or possible abuse, neglect or misappropriation. j. Any negative findings will be submitted to the Quality Assurance Committee for further follow-up.

Complaint # (AR 754) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure residents with severe cognitive impairment and aggressive behaviors were free from staff-to-resident abuse for 1 (Resident #1) and free from possible resident-to-resident non-consensual sexual activity between 2 (Residents #1 and #2) of 2 (Residents #1 and #2) case mix residents who resided on the facility's secure wing, were severely cognitively impaired and likely lacked the mental capacity to consent to sexual activity. The facility failed to ensure all staff received complete training on Dementia management and appropriate interventions to deal with aggressive and / or catastrophic reactions of residents and that adequate staff who were trained and competent in Dementia management techniques were on duty to provide the necessary monitoring on the facility's secure unit, which resulted in escalation of the resident's combative behaviors and subsequently, a licensed nurse utilizing a takedown hold on Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 10 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list provided by the Director of Nursing (DON) on 11/22/17. The facility was notified of the Immediate Jeopardy condition on 11/22/17 at 1:53 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/3/17 documented the resident was severely impaired in cognitive skills for daily decision making, per a staff assessment for mental status, required limited assistance of one person for transfer, did not exhibit any behavioral symptoms, and did not reject care. a. The Plan of Care dated 11/3/17 documented, .Resident can be harmful to self or others, self-inflicting bx (behaviors) to self. (Resident #2) may have inappropriate sexual bxs with female residents . 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/10/17 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status; exhibited behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) on a daily basis, wandering on a daily basis and rejecting care on 1 to 3 of the past 7 days. a. The Plan of Care with a revised date of 9/3/17 documented, .(Resident #1) is an elopement risk / wanderer r/t (related to) impaired safety awareness . Monitor location every 15 min (minutes) . Document wandering behavior and attempted diversional interventions in behavior log . (Resident #1) has the potential to be physically aggressive (slapping) r/t Dementia . When she becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . b. Nurses Notes dated 9/11/17 at 4:32 p.m. documented, .Resident is yelling at all peers and staff telling them to get out. Scaring other residents leaving unit and not easily redirected. Tried talking softly to resident to find out what was upsetting her, but she insisted all these people were in her house and she could not afford to feed them and wanted them gone. Unable to calm or redirect. Gave IM (intramuscular) injection at this time . Nurses' Notes dated 10/21/17 at 10:44 p.m. documented, .Resident found kissing a male resident and trying to sleep in his bed with him . Nurses' Notes dated 10/22/17 at 9:13 p.m. documented, .[MEDICATION NAME] Tablet 0.5 MG (milligram). Give 1 tablet by mouth every 8 hours as needed for anxiety . exit seeking with another res (resident), stating, 'He has to go to work, we have to get out of here' . Nurses' Notes dated 10/30/17 at 10:05 p.m. documented, .[MEDICATION NAME] Solution 2 MG/ML (milligrams per milliliter). Inject 0.5 ml intramuscularly every 6 hours as needed for increased anxiety . give 1 mg IM prn (as needed) for increased agitation. Admin (administer) for combative behavior . 2230 (10:30 p.m.) . PRN Administration was: Ineffective. Second dose required . c. The Skin Observation Tool dated 11/01/17 documented, .Notes: two small skin tears to right wrist, approximated, bruising noted to right wrist/forearm other skin warm dry and intact . d. A Nurses Note prepared with a Facility Incident Report dated 10/30/17 at 1:40 a.m., and revised on 11/21/17 at 6:28 p.m. (a period of 22 days after the incident occurred) documented, Witness Name (Registered Nurse (RN) #1) . Date (of incident) 10/30/2017 . Statement: At about 2205 (10:05 p.m.) I was ask (sic) by (Licensed Practical Nurse (LPN) #1) to assist her with separating two residents who were occupying the same bed on the 500 Hall. (Resident #1) (a female resident) was lying in bed with (Resident #2 (a male resident)). She (Resident #1) was ask (sic) to leave (Resident #2's) bed. She was physically assisted to her feet and became combative. (Resident #2) also briefly became combative, but was redirected fairly easily . (Note: There was no documentation the staff attempted to escort Resident #2, who had been redirected fairly easily, from the room, to allow Resident #1 the time and space to calm down before attempting to physically remove her from the room). The Progress Note continued, .(Resident #1) continued to be combative, swinging at staff as she was escorted to her room and again began 'swatting' at staff, insisting they 'get out of her house'. I encircled (Resident #1's) arms with my own and leaned her forward into a supine (sic) position, while (LPN #1) gave (Resident #1) her PRN 0.5 mg [MEDICATION NAME] IM, (Resident #1) continues to curse and scream, attempting to pinch this nurse several times. (Resident #1) was advised several times to calm down, but continued to yell and struggle, (Resident #1) was given a 2nd IM at approximately midnight. (Resident #1) continued above sx (symptoms) until approximately 0030 (12:30 a.m.), when she appeared to calm down somewhat and was released from manual restraint as she (at that point) appeared to have somewhat regained control, no longer cussing and yelling. (Resident #1) laid on the floor with her head on a pillow for approximately 5 minutes longer before being assisted to her room. (Resident #1) did appear to have 2 small skin tears to her left forearm of unknown origin. e. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by RN #1 documented, .After being informed that (Resident #1) was asleep in (Resident #2's) bed, we proceeded to (Resident #2's) room and attempted to encourage (Resident #1) to leave. She became irate, insisted it was her room and refused to leave. (Resident #2) also initially became upset. After a few moments of this, (Resident #1) became more agitated and actively combative. She was escorted to her room and was seated on the bed with (LPN #1) on one side and (Certified Nursing Assistant (CNA) #1) on the other with their arms 'around' hers . hooked at the elbow. During this time, (Resident #2) was out in the hallway, and although he redirected well, (Resident #1) again became more agitated and refused to stay in her room. As we were exiting the room, she again became actively combative and began striking (LPN #1), who was standing in the doorway. I stepped to her side and encircled (Resident #1's) elbows with mine, then took another step to the side and took a knee. (Resident #1) continued to fight and was rolled onto the floor in the prone position. This continued for a few minutes, and when it became evident that (Resident #1) couldn't calm down on her own, (LPN #1) drew up 0.5 [MEDICATION NAME] IM. This was given while the restraint was maintained. After quite some time, it appeared this was ineffective and an additional 1 mg [MEDICATION NAME] IM was given per order. After some time, this appeared to be effective, and manual restraint no longer necessary. I did notice (Resident #1) did have a small skin tear to her left forearm at that time. (Resident #1) continued to lay on the pillow in the hallway for a moment (on the pillow we had gotten her) before again being escorted to her room. Restraint applied/continued using handle with care techniques, I believe all other interventions at that point had failed and/or inappropriate given circumstances. Most staff involved had very shallow lacerations from (Resident #1's) fingernails, and repeated redirection attempts had failed. f. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by LPN #1 documented, .(Female) Resident was found in a male resident's bed, both were half undressed. Resident became combative, hitting, biting + (and) scratching while being assisted from bed + to her room. [MEDICATION NAME] 0.5 given and ineffective. Resident had to be restrained, and another [MEDICATION NAME] 0.5 given before resident calmed enough to be released. g. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by CNA #1 documented, .Night of incident (Resident #1) + (Resident #2) were found in bed by a CNA. Lights turned on, woken up. I came down the hall next to (room number) . when I entered the room I saw (Resident #1) and (Resident #2) 'spooning' naked from the waist down. (Resident #1) was asked to get out of (Resident #2's) bed. She immediately got agitated and (Resident #2) started to get aggressive (and) protective. By (this) time (LPN #1) and (RN #1) had come to see what was going on. Then the nurse wanted (Resident #1) to have an injection as the scene had already gone into the hallway w (with) (Resident #1) being aggressive verbally + (and) physically + (Resident #2) verbally + protective of her. (LPN #1) went to get her an injection. I held (Resident #1) with another aid (CNA) so (LPN #1) could give the injection, (RN #1) held on (Resident #2). (LPN #1) and I proceeded to walk assertively, (Resident #1) arm-in-arm to her room. We got her to her bed and sat on either side of her, to try + wait for the injection to take effect. (Resident #1) got her hand loose at one point and knocked her water glass on the floor, in front of us. A CNA came in and wiped the floor w/ (with) a towel, left towel. (LPN #1) decided to leave her in her room to see if this + the med (medication) would take affect + calm her. (LPN #1) did stand @ (at) doorway to keep her from disturbing other resident on unit (Resident #1) started 'whipping' (LPN #1) w/ (with) the wet towel + pushing on her. When (LPN #1) lost her balance and was about to go down (RN #1) (our other nurse on duty that night) stepped in. Next (Resident #1) was on the floor. (RN #1) was straddling, holding her arms. He asked for a pillow for her head, one was given. I was not holding her too tight because several times she was able to knock the pillow away. Still waiting for shot to take effect. (Resident #2) was way too interested in what was going on so I took him out into the main part of unit. We had a snack, walked, I read to him. He calmed right down. In my opinion, protocol was completely followed and more injuries to herself or others was diverted by the quick and professional action of our nurses. h. As of 11/22/17, the facility's Abuse, Neglect, Exploitation of Resident Policies and (&) Procedures, provided by the Administrator, did not include the required component of staff training on Dementia Management. i. Dementia Hand in Hand In-service documentation, provided by the Director of Nursing on 11/22/17, documented training was provided to staff on 3/20/17 and 9/4/17 that included 10 ways to de-escalate residents who were aggressive or combative. There was no documentation to indicate the in-service included strategies of backing away and giving the resident a chance to calm down. There was no documentation to indicate the in-service included information regarding take-downs ever being appropriate. There was no documentation of any further in-servicing on Dementia Management after the incident between Residents #1 and #2 occurred on 10/30/17. RN #1, LPN #1, and CNA #1's signatures were not included in the documented signatures on the in-service sign-in form to indicate their attendance for the September 4, 2017 in-service, and RN #1 and LPN #1's signatures were not included in the documented signatures on the in-service sign-in form to indicate their attendance for the March 20, 2017 in-service. CNA #1's signature was included in the documented signatures for the in-service dated March 20, 2017. j. On 11/22/17 at 10:34 a.m., LPN #1 was asked if Resident #1 and Resident #2 were involved in inappropriate sexual behaviors prior to the incident on 10/30/17 and how this was handled by the staff. LPN #1 stated, Four to five times, yes, I had to keep them out of each other's beds quite a bit . When asked how long the 10/30/17 incident with Residents #1 and #2 went on, the LPN stated, .I don't know how long it took. About an hour, I don't remember, exactly When asked to describe RN #1's physical 'take-down' of Resident #1, the LPN stated, (RN #1) took her down to the ground. I didn't actually see how he took her down. He was kind of on top of her, but supporting his weight. He was not physically laying (sic) on top of her. At no time, did he lay all his weight down on her . (RN #1) was doing what he had to. I really don't know what we would've done, very thankful he was there . k. On 11/22/17 at 12:07 p.m., CNA #1 was asked if Resident #1 and Resident #2 were involved in inappropriate sexual behaviors prior to the incident on 10/30/17 and how this was handled by the staff. CNA #1 stated, I found them in bed on 2 other occasions. They did not get upset when separated. They had their clothing on. I think I did report it, I know it was an ongoing problem. This problem of (Resident #1 and Resident #2) kissing and hugging has been reported . by one of the other girls. The CNA was asked to describe the incident between Residents #1 and #2 on 10/30/17 and stated, .I was coming down the hallway. They (other staff) just woke them up, turned the lights on . (Resident #1) was already in one of her moods, agitated. We asked them to get out of bed . The CNA was asked to describe RN #1's 'take-down' of Resident #1 and stated, .(RN #1) was toward her side, one knee down and one knee up. He was not on top of her. He asked for a pillow; she kept knocking the pillow away. His arms were interconnected with her arms . The CNA was asked how the RN took the resident to the floor and stated, .I don't remember how he got her on the ground . When asked how long the resident was held down on the floor by RN #1, the CNA stated, .20 to 25 minutes, she was held down . l. On 11/22/17 at 9:22 a.m., RN #1 was asked to describe the events that led to him doing a physical take-down on Resident #1 on 10/30/17. RN #1 stated, .She (Resident #1) became actively combative, again, and I took her to the ground. First standing, then kneeling; I had her arms hooked between mine, her elbows and biceps hooked between mine. This was done to limit the movements of her arms. I took her to the floor, laying (sic) on her lower body, lower limbs, to keep her from kicking. I have been trained on 'Handle with Care'. I worked at (Psychiatric Facility) doing 1-person restraints. I was holding her arms down while laying (sic) on her lower extremities. I had asked and gotten a pillow for her. It took a little while, but she calmed down . When asked if the facility had provided him with any Dementia Management training, the RN stated, .I don't remember any Alzheimer's or Dementia training here. When asked why staff did not attempt to give Resident #1 time and space to calm down on her own, the RN stated, .Creating distance was not an option . This was not a first-time occurrence. (Resident #1) has been in (Resident #2's) room before . When asked about the secure unit being staffed with only one CNA on the night of the incident, the RN stated, We have had staffing issues, and (only) one CNA is on the unit frequently. We open the doors and visualize the hallway. I was under the impression we were doing nothing wrong . The RN was asked if Resident #1 was injured during the incident and stated, .(LPN #1) notified the family of a skin tear to (Resident #1's) left forearm. I thought it could've been from my watch. I didn't see. My elbows were hooked around her elbows. She was lying on her stomach, with my elbows hooked around hers (behind resident's back). I was not holding her wrists with my hands. m. On 11/22/17 at 12:55 p.m., CNA #2 was asked to describe the incident that took place on 10/30/17 involving Resident #1 and Resident #2. CNA #2 stated, (CNA #1) worked 500 Hall that night . when I got there, (Resident #1) was already in (Resident #2's) bed . the lights were already on. Every aide that was working that night came down there to try and get them out of bed. (CNA #1) came to me; she worked it (500 Hall secure unit) by herself. (Resident #1) told me, 'You are not my mother - I am older than 21 - I can do what I want.' I was working the other halls . the (secure unit) doors were wide open on (Resident #1's) hall. n. On 11/21/17 at 6:11 p.m., RN #2 was asked if Resident #1 and Resident #2 were involved in any inappropriate behaviors and what the facility had done to prevent reoccurrences. RN #2 stated, They have been in compromising positions before. That is the main reason he is out here (off of the secure unit). I have helped (Resident #1) back to her room before. They found them in bed together half naked; that's been about 3 weeks ago. We moved (Resident #2) off the unit. He is very friendly; he has not been inappropriate with any (other) residents that I know of. o. On 11/21/17 at 6:30 p.m., LPN #2 was asked if Resident #1 and Resident #2 were involved in any inappropriate behaviors and what the facility had done to prevent reoccurrences. LPN #2 stated, I have had no instances where she has been physically aggressive. I have never had to give her an injection. One time, (Resident #1) was in (Resident #2)'s bed. She told me that they were just cuddling. They separated themselves, peacefully. They both were fully clothed. When asked how many times she had witnessed Residents #1 and #2 in bed together, the LPN stated, Probably, maybe two times. That's why they put him out here. p. On 11/22/17 at 8:55 a.m., the Director of Nursing (DON) provided a typed form that documented, To Whom It May Concern: Staff was instructed to keep residents apart following incident. (Resident #2) was assisted to getting ready for bed while another CNA assisted (Resident #1) simultaneously. (So that (Resident #1) was not compelled to assist (Resident #2)). Out of sight was truly out of mind. (Physician) was notified of incident and behaviors and asked to evaluate medication regime for both residents. No new orders for medications were received. After a few days of trying to keep residents apart and conversations with family members of both residents, it was decided by Department heads to separate residents into different parts of facility. They are separated even during mutual activities. The form was signed by the Director of Nursing on 11/22/17. q. On 11/22/17 at 8:56 a.m., the Administrator was asked how long it took to move Resident #2 off of the secure unit, away from Resident #1. The Administrator stated, He was moved from the secure unit on 11/8/17 (a period of 8 days after the incident occurred). When asked if the facility provided Dementia Management training during staff orientation, the Administrator stated, .No orientation training with Dementia or Alzheimer's residents . r. On 11/22/17 at 10:44 a.m., LPN #3 was asked if she had witnessed any inappropriate behaviors between Resident #1 and Resident #2 and if the facility had done anything about it. LPN #3 stated, I admitted (Resident #2) from a psychiatric facility in (nearby city). He was calm, but medicated. I don't work the unit. I know they were holding hands. You had to try and keep them apart, never seen them in a room together. I have not witnessed any inappropriate behaviors directed (by Resident #2) toward female residents. I know today, he was wanting to go into someone else's room with just his brief on and tee shirt. It was an empty room, two doors down from his room. On the other side of the hall, we have all women. I have never seen him go into another female's room. I know it makes me uncomfortable working with him. He will be highly combative, then he will be hitting on me. He can be super combative or hugging, loving. I think he belongs on an all-male unit. He doesn't have (Resident #1) to instigate him. He has walked out naked on the unit before. s. Based on Resident #1's care plan dated 9/3/17, the resident's location was supposed to be monitored by staff every 15 minutes. The Daily Staffing Log for 10/30/17 documented the facility did not meet minimum staffing requirements for the evening and night shifts on that date. According to the Daily Census Report, a total of 12 residents resided on the secure unit and, on the night of 10/30/17, the unit was staffed with only one CNA. t. The immediate jeopardy was removed and the scope/severity reduced to E on 11/22/17 when the facility implemented the following plan of removal: All employees will be in-serviced prior to the beginning of their next shift on appropriate interventions to address combative behavior and catastrophic reactions. Will review all other incidents in the past 30 days of residents exhibiting combative behavior to determine if staff handled them appropriately. Resident (#1) will be placed on Q (every) 15 minutes monitoring while in the facility for the next 48 hours then decreased to Q 30 mins (minutes) while in the facility to ensure she is not in the same vicinity of the male resident and no combative behaviors. Monitoring will include staff interviews 2-3 times per week to ensure they are aware of appropriate interventions when a resident becomes combative or violent. Revision of Abuse and Neglect policies to include Dementia Management and Abuse Prevention. The male RN was suspended. If he is allowed to return to work, he will be re-trained on Dementia Management and Abuse Prevention to include combative behavior and catastrophic reactions. Monitoring of the male RN will include spot checks for a period of two weeks to ensure the in-servicing was effective.

Complaint # (AR 754) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure residents with severe cognitive impairment and aggressive behaviors were protected from further potential staff-to-resident abuse after a licensed nurse utilized a physical take-down hold on a combative resident for 1 (Resident #1) and failed to ensure adequate monitoring was provided to ensure residents were protected from possible resident-to-resident non-consensual sexual activity between 2 (Residents #1 and #2) of 2 (Residents #1 and #2) case mix residents who resided on the facility's secure wing, were severely cognitively impaired and likely lacked the mental capacity to consent to sexual activity. The facility failed to ensure all staff received complete training on Dementia management and appropriate interventions to deal with aggressive and / or catastrophic reactions of residents and that adequate staff who were trained and competent in dementia management techniques were on duty on the facility's secure unit, which resulted in escalation of Resident #1's combative behaviors and subsequently, a licensed nurse utilizing a takedown hold on Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 10 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list provided by the Director of Nursing (DON) on 11/22/17. The facility was notified of the Immediate Jeopardy condition on 11/22/17 at 1:53 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/3/17 documented the resident was severely impaired in cognitive skills for daily decision making, per a staff assessment for mental status, required limited assistance of one person for transfer, did not exhibit any behavioral symptoms, and did not reject care. a. The Plan of Care dated 11/3/17 documented, .Resident can be harmful to self or others, self-inflicting bx (behaviors) to self. (Resident #2) may have inappropriate sexual bxs with female residents . 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/10/17 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status; exhibited behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) on a daily basis, wandering on a daily basis and rejecting care on 1 to 3 of the past 7 days. a. The Plan of Care with a revised date of 9/3/17 documented, .(Resident #1) is an elopement risk / wanderer r/t (related to) impaired safety awareness . Monitor location every 15 min (minutes) . Document wandering behavior and attempted diversional interventions in behavior log . (Resident #1) has the potential to be physically aggressive (slapping) r/t Dementia . When she becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . b. Nurses Notes dated 9/11/17 at 4:32 p.m. documented, .Resident is yelling at all peers and staff telling them to get out. Scaring other residents leaving unit and not easily redirected. Tried talking softly to resident to find out what was upsetting her, but she insisted all these people were in her house and she could not afford to feed them and wanted them gone. Unable to calm or redirect. Gave IM (intramuscular) injection at this time . Nurses' Notes dated 10/21/17 at 10:44 p.m. documented, .Resident found kissing a male resident and trying to sleep in his bed with him . Nurses' Notes dated 10/22/17 at 9:13 p.m. documented, .[MEDICATION NAME] Tablet 0.5 MG (milligram). Give 1 tablet by mouth every 8 hours as needed for anxiety . exit seeking with another res (resident), stating, 'He has to go to work, we have to get out of here' . Nurses' Notes dated 10/30/17 at 10:05 p.m. documented, .[MEDICATION NAME] Solution 2 MG/ML (milligrams per milliliter). Inject 0.5 ml intramuscularly every 6 hours as needed for increased anxiety . give 1 mg IM prn (as needed) for increased agitation. Admin (administer) for combative behavior . 2230 (10:30 p.m.) . PRN Administration was: Ineffective. Second dose required . c. The Skin Observation Tool dated 11/01/17 documented, .Notes: two small skin tears to right wrist, approximated, bruising noted to right wrist/forearm other skin warm dry and intact . d. A Nurses Note prepared with a Facility Incident Report dated 10/30/17 at 1:40 a.m., and revised on 11/21/17 at 6:28 p.m., (a period of 22 days after the incident occurred) documented, Witness Name (Registered Nurse (RN) #1) . Date (of incident) 10/30/2017 . Statement: At about 2205 (10:05 p.m.) I was ask (sic) by (Licensed Practical Nurse (LPN) #1) to assist her with separating two residents who were occupying the same bed on the 500 hall. (Resident #1) was lying in bed with (Resident #2 (a male resident)). She (Resident #1) was ask (sic) to leave (Resident #2's) bed. She was physically assisted to her feet and became combative. (Resident #2) also briefly became combative, but was redirected fairly easily . (Note: There was no documentation the staff attempted to escort Resident #2, who had been redirected fairly easily, from the room, to allow Resident #1 the time and space to calm down before attempting to physically remove her from the room). The Progress Note continued, .(Resident #1) continued to be combative, swinging at staff as she was escorted to her room and again began 'swatting' at staff, insisting they 'get out of her house'. I encircled (Resident #1's) arms with my own and leaned her forward into a supine (sic) position, while (LPN #1) gave (Resident #1) her PRN 0.5 mg [MEDICATION NAME] IM, (Resident #1) continues to curse and scream, attempting to pinch this nurse several times. (Resident #1) was advised several times to calm down, but continued to yell and struggle, (Resident #1) was given a 2nd IM at approximately midnight. (Resident #1) continued above sx (symptoms) until approximately 0030 (12:30 a.m.), when she appeared to calm down somewhat and was released from manual restraint as she (at that point) appeared to have somewhat regained control, no longer cussing and yelling. (Resident #1) laid on the floor with her head on a pillow for approximately 5 minutes longer before being assisted to her room. (Resident #1) did appear to have 2 small skin tears to her left forearm of unknown origin. e. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by RN #1 documented, .After being informed that (Resident #1) was asleep in (Resident #2's) bed, we proceeded to (Resident #2's) room and attempted to encourage (Resident #1) to leave. She became irate, insisted it was her room and refused to leave. (Resident #2) also initially became upset. After a few moments of this, (Resident #1) became more agitated and actively combative, she was escorted to her room and was seated on the bed with (LPN #1) on one side and (Certified Nursing Assistant (CNA) #1) on the other with their arms 'around' hers . hooked at the elbow. During this time, (Resident #2) was out in the hallway, and although he redirected well, (Resident #1) again became more agitated and refused to stay in her room. As we were exiting the room, she again became actively combative and began striking (LPN #1), who was standing in the doorway. I stepped to her side and encircled (Resident #1's) elbows with mine, then took another step to the side and took a knee. (Resident #1) continued to fight and was rolled onto the floor in the prone position. This continued for a few minutes, and when it became evident that (Resident #1) couldn't calm down on her own, (LPN #1) drew up 0.5 [MEDICATION NAME] IM. This was given while the restraint was maintained. After quite some time, it appeared this was ineffective and an additional 1 mg [MEDICATION NAME] IM was given per order. After some time, this appeared to be effective, and manual restraint no longer necessary. I did notice (Resident #1) did have a small skin tear to her left forearm at that time. (Resident #1) continued to lay on the pillow in the hallway for a moment (on the pillow we had gotten her) before again being escorted to her room. Restraint applied/continued using handle with care techniques, I believe all other interventions at that point had failed and/or inappropriate given circumstances. Most staff involved had very shallow lacerations from (Resident #1's) fingernails, and repeated redirection attempts had failed. f. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by LPN #1 documented, .Resident was found in a male resident's bed, both were half undressed, resident became combative, hitting, biting + (and) scratching while being assisted from bed + to her room, [MEDICATION NAME] 0.5 given and ineffective, resident had to be restrained, and another [MEDICATION NAME] 0.5 given before resident calmed enough to be released. g. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by CNA #1 documented, .Night of incident (Resident #1) + (Resident #2) were found in bed by a CNA, lights turned on, woken up. I came down the hall next to (room number) . when I entered the room I saw (Resident #1) and (Resident #2) 'spooning' naked from the waist down. (Resident #1) was asked to get out of (Resident #2's) bed. She immediately got agitated and (Resident #2) started to get aggressive (and) protective. By (this) time (LPN #1) and (RN #1) had come to see what was going on. Then the nurse wanted (Resident #1) to have an injection as the scene had already gone into the hallway w (with) (Resident #1) being aggressive verbally + (and) physically + (Resident #2) verbally + protective of her. (LPN #1) went to get her an injection, I held (Resident #1) with another aid (CNA) so (LPN #1) could give the injection, (RN #1) held on (Resident #2). (LPN #1) and I proceeded to walk (assertively), (Resident #1) arm in arm to her room. We got her to her bed and sat on either side of her, to try + wait for the injection to take effect. (Resident #1) got her hand loose at one point and knocked her water glass on the floor, in front of us. A CNA came in and wiped the floor w (with) a towel, left towel. (LPN #1) decided to leave her in her room to see if this (and) the med (medication) would take affect (and) calm her. (LPN #1) did stand @ (at) doorway to keep her from disturbing other resident on unit (Resident #1) started 'whipping' (LPN #1) w/ (with) the wet towel (and) pushing on her. When (LPN #1) lost her balance and was about to go down (RN #1) (our other nurse on duty that night) stepped in. Next (Resident #1) was on the floor (RN #1) was straddling holding her arms. He asked for a pillow for her head, one was given. I was not holding her too tight because several times she was able to knock the pillow away. Still waiting for shot to take effect. (Resident #2) was way too interested in what was going on so I took him out into the main part of unit, we had a snack, walked, I read to him. He calmed right down. In my opinion, protocol was completely followed and more injuries to herself or others was diverted by the quick and professional action of our nurses. h. As of 11/22/17, the facility's Abuse, Neglect, Exploitation of Resident Policies and (&) Procedures, provided by the Administrator, did not include the required component of staff training on dementia management. i. Dementia Hand in Hand In-service documentation, provided by the Director of Nursing on 11/22/17, documented training was provided to staff on 3/20/17 and 9/4/17 that included 10 ways to de-escalate residents who were aggressive or combative. There was no documentation to indicate the in-service included strategies of backing away and giving the resident a chance to calm down. There was no documentation to indicate the in-service included information regarding take-downs ever being appropriate. There was no documentation of any further in-servicing on dementia management after the incident between Residents #1 and #2 occurred on 10/30/17. RN #1, LPN #1, and CNA #1's signatures were not included in the documented signatures on the in-service sign-in form to indicate their attendance for the September 4, 2017 in-service, and RN #1 and LPN #1's signatures were not included in the documented signatures on the in-service sign-in form to indicate their attendance for the March 20, 2017 in-service. CNA #1's signature was included in the documented signatures for the in-service dated March 20, 2017. j. On 11/22/17 at 10:34 a.m., LPN #1 was asked if Resident #1 and Resident #2 were involved in inappropriate sexual behaviors prior to the incident on 10/30/17 and how this was handled by the staff. LPN #1 stated, Four to five times, yes, I had to keep them out of each other's beds quite a bit . When asked how long the 10/30/17 incident with Residents #1 and #2 went on, the LPN stated, .I don't know how long it took. About an hour, I don't remember, exactly When asked to describe RN #1's physical 'take-down' of Resident #1, the LPN stated, (RN #1) took her down to the ground, I didn't actually see how he took her down. He was kind of on top of her, but supporting his weight. He was not physically laying (sic) on top of her. At no time, did he lay all his weight down on her . (RN #1) was doing what he had to. I really don't know what we would've done, very thankful he was there . k. On 11/22/17 at 12:07 p.m., CNA #1 was asked if Resident #1 and Resident #2 were involved in inappropriate sexual behaviors prior to the incident on 10/30/17 and how this was handled by the staff. CNA #1 stated, I found them in bed on 2 other occasions. They did not get upset when separated, they had their clothing on. I think I did report it, I know it was an ongoing problem. This problem of (Resident #1 and Resident #2) kissing and hugging has been reported . by one of the other girls. The CNA was asked to describe the incident between Residents #1 and #2 on 10/30/17 and stated, .I was coming down the hallway. They (other staff) just woke them up, turned the lights on . (Resident #1) was already in one of her moods, agitated. We asked them to get out of bed . The CNA was asked to describe RN #1's 'take-down' of Resident #1 and stated, .(RN #1) was toward her side, one knee down and one knee up. He was not on top of her. He asked for a pillow; she kept knocking the pillow away. His arms were interconnected with her arms . The CNA was asked how the RN took the resident to the floor and stated, .I don't remember how he got her on the ground . When asked how long the resident was held down on the floor by RN #1, the CNA stated, .20 to 25 minutes, she was held down . l. On 11/22/17 at 9:22 a.m., RN #1 was asked to describe the events that led to him doing a physical take-down on Resident #1 on 10/30/17. RN #1 stated, .She (Resident #1) became actively combative, again, and I took her to the ground. First standing, then kneeling; I had her arms hooked between mine, her elbows and biceps hooked between mine. This was done to limit the movements of her arms. I took her to the floor, laying (sic) on her lower body, lower limbs, to keep her from kicking. I have been trained on 'Handle with Care'. I worked at (Psychiatric Facility) doing 1-person restraints. I was holding her arms down while laying (sic) on her lower extremities. I had asked and gotten a pillow for her. It took a little while, but she calmed down . When asked if the facility had provided him with any dementia management training, the RN stated, .I don't remember any Alzheimer's or Dementia training here. When asked why staff did not attempt to give Resident #1 time and space to calm down on her own, the RN stated, .Creating distance was not an option . This was not a first-time occurrence. (Resident #1) has been in (Resident #2's) room before . When asked about the secure unit being staff with only one CNA on the night of the incident, the RN stated, We have had staffing issues, and (only) one CNA is on the unit frequently. We open the doors and visualize the hallway. I was under the impression we were doing nothing wrong . The RN was asked if Resident #1 was injured during the incident and stated, .(LPN #1) notified the family of a skin tear to (Resident #1's) left forearm. I thought it could've been from my watch. I didn't see. My elbows were hooked around her elbows. She was lying on her stomach, with my elbows hooked around hers (behind resident's back). I was not holding her wrists with my hands. m. On 11/22/17 at 12:55 p.m., CNA #2 was asked to describe the incident that took place on 10/30/17 involving Resident #1 and Resident #2. CNA #2 stated, (CNA #1) worked 500 Hall that night . when I got there, (Resident #1) was already in (Resident #2's) bed . the lights were already on. Every aide that was working that night came down there to try and get them out of bed. (CNA #1) came to me; she worked it (500 Hall secure unit) by herself. (Resident #1) told me, 'You are not my mother. - I am older than 21. - I can do what I want.' I was working the other halls . the (secure unit) doors were wide open on (Resident #1's) hall. n. On 11/21/17 at 6:11 p.m., RN #2 was asked if Resident #1 and Resident #2 were involved in any inappropriate behaviors and what the facility had done to prevent reoccurrences. RN #2 stated, They have been in compromising positions before. That is the main reason he is out here (off of the secure unit). I have helped (Resident #1) back to her room before. They found them in bed together half naked; that's been about 3 weeks ago. We moved (Resident #2) off the unit. He is very friendly; he has not been inappropriate with any (other) residents that I know of. o. On 11/21/17 at 6:30 p.m., LPN #2 was asked if Resident #1 and Resident #2 were involved in any inappropriate behaviors and what the facility had done to prevent reoccurrences. LPN #2 stated, I have had no instances where she has been physically aggressive. I have never had to give her an injection. One time, (Resident #1) was in (Resident #2)'s bed. She told me that they were just cuddling. They separated themselves, peacefully. They both were fully clothed. When asked how many times she had witnessed Residents #1 and #2 in bed together, the LPN stated, Probably, maybe two times. That's why they put him out here. p. On 11/22/17 at 8:55 a.m., the Director of Nursing (DON) provided a typed form that documented, To Whom It May Concern: Staff was instructed to keep residents apart following incident. (Resident #2) was assisted to getting ready for bed while another CNA assisted (Resident #1) simultaneously. (So that (Resident #1) was not compelled to assist (Resident #2)). Out of sight was truly out of mind. (Physician) was notified of incident and behaviors and asked to evaluate medication regime for both residents. No new orders for medications were received. After a few days of trying to keep residents apart and conversations with family members of both residents, it was decided by Department heads to separate residents into different parts of facility. They are separated even during mutual activities. The form was signed by the Director of Nursing on 11/22/17. q. On 11/22/17 at 8:56 a.m., the Administrator was asked how long it took to move Resident #2 off of the secure unit, away from Resident #1. The Administrator stated, He was moved from the secure unit on 11/8/17 (a period of 8 days after the incident occurred). When asked if the facility provided dementia management training during staff orientation, the Administrator stated, .No orientation training with Dementia or Alzheimer's residents . r. On 11/22/17 at 10:44 a.m., LPN #3 was asked if she had witnessed any inappropriate behaviors between Resident #1 and Resident #2 and if the facility had done anything about it. LPN #3 stated, I admitted (Resident #2) from a psychiatric facility in (nearby city). He was calm, but medicated. I don't work the unit. I know they were holding hands. You had to try and keep them apart, never seen them in a room together. I have not witnessed any inappropriate behaviors directed (by Resident #2) toward female residents. I know today, he was wanting to go into someone else's room with just his brief on and tee shirt. It was an empty room, two doors down from his room. On the other side of the hall, we have all women. I have never seen him go into another female's room. I know it makes me uncomfortable working with him. He will be highly combative, then he will be hitting on me. He can be super combative or hugging, loving. I think he belongs on an all-male unit. He doesn't have (Resident #1) to instigate him. He has walked out naked on the unit before. s. Based on Resident #1's care plan dated 9/3/17, the resident's location was supposed to be monitored by staff every 15 minutes. The Daily Staffing Log for 10/30/17 documented the facility did not meet minimum staffing requirements for the evening and night shifts on that date. According to the Daily Census, a total of 12 residents resided on the secure unit and, on the night of 10/30/17, the unit was staffed with only one CNA. t. The immediate jeopardy was removed and the scope/severity reduced to E on 11/22/17 when the facility implemented the following plan of removal: All employees will be in-serviced prior to the beginning of their next shift on appropriate interventions to address combative behavior and catastrophic reactions. Will review all other incidents in the past 30 days of residents exhibiting combative behavior to determine if staff handled them appropriately. Resident (#1) will be placed on Q (every) 15 minutes monitoring while in the facility for the next 48 hours then decreased to Q 30 mins (minutes) while in the facility to ensure she is not in the same vicinity of the male resident and no combative behaviors. Monitoring will include staff interviews 2-3 times per week to ensure they are aware of appropriate interventions when a resident becomes combative or violent. Revision of Abuse and Neglect policies to include Dementia Management and Abuse Prevention. The male RN was suspended. If he is allowed to return to work, he will be re-trained on Dementia Management and Abuse Prevention to include combative behavior and catastrophic reactions. Monitoring of the male RN will include spot checks for a period of two weeks to ensure the in-servicing was effective.

Complaint # (AR 754) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure the facility's policies and procedures for abuse prohibition were implemented, as evidenced by failure to ensure residents with severe cognitive impairment and aggressive behaviors were protected from further potential staff-to-resident abuse after a licensed nurse performed a physical take-down and hold procedure for 1 (Resident #1) and failure to ensure severely cognitively impaired residents were adequately monitored and supervised to protect them from possible resident-to-resident non-consensual sexual activity between 2 (Residents #1 and #2) of 2 (Residents #1 and #2) case mix residents who resided on the facility's secure wing, were severely cognitively impaired and likely lacked the mental capacity to consent to sexual activity. The facility also failed to ensure a policy and procedure was developed and implemented to ensure all staff received the required training on dementia management and appropriate interventions to deal with aggressive and / or catastrophic reactions of residents and failed to ensure that adequate staff who were trained and competent with dementia management techniques were on duty to provide the necessary monitoring on the facility's secure wing, which resulted in escalation of Resident #1's combative behaviors and subsequently, a licensed nurse utilizing a take-down hold on Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 10 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list provided by the Director of Nursing (DON) on 11/22/17. The facility was notified of the Immediate Jeopardy condition on 11/22/17 at 1:53 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/3/17 documented the resident was severely impaired in cognitive skills for daily decision making, per a staff assessment for mental status, required limited assistance of one person for transfer, did not exhibit any behavioral symptoms, and did not reject care. a. The Plan of Care dated 11/3/17 documented, .Resident can be harmful to self or others, self-inflicting bx (behaviors) to self. (Resident #2) may have inappropriate sexual bxs with female residents . 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/10/17 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status; exhibited behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) on a daily basis, wandering on a daily basis and rejecting care on 1 to 3 of the past 7 days. a. The Plan of Care with a revised date of 9/3/17 documented, .(Resident #1) is an elopement risk / wanderer r/t (related to) impaired safety awareness . Monitor location every 15 min (minutes) . Document wandering behavior and attempted diversional interventions in behavior log . (Resident #1) has the potential to be physically aggressive (slapping) r/t Dementia . When she becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . b. Nurses Notes dated 9/11/17 at 4:32 p.m. documented, .Resident is yelling at all peers and staff telling them to get out. Scaring other residents leaving unit and not easily redirected. Tried talking softly to resident to find out what was upsetting her, but she insisted all these people were in her house and she could not afford to feed them and wanted them gone. Unable to calm or redirect. Gave IM (intramuscular) injection at this time . Nurses' Notes dated 10/21/17 at 10:44 p.m. documented, .Resident found kissing a male resident and trying to sleep in his bed with him . Nurses' Notes dated 10/22/17 at 9:13 p.m. documented, .[MEDICATION NAME] Tablet 0.5 MG (milligram). Give 1 tablet by mouth every 8 hours as needed for anxiety . exit seeking with another res (resident), stating, 'He has to go to work, we have to get out of here' . Nurses' Notes dated 10/30/17 at 10:05 p.m. documented, .[MEDICATION NAME] Solution 2 MG/ML (milligrams per milliliter). Inject 0.5 ml intramuscularly every 6 hours as needed for increased anxiety . give 1 mg IM prn (as needed) for increased agitation. Admin (administer) for combative behavior . 2230 (10:30 p.m.) . PRN Administration was: Ineffective. Second dose required . c. The Skin Observation Tool dated 11/01/17 documented, .Notes: two small skin tears to right wrist, approximated, bruising noted to right wrist/forearm other skin warm dry and intact . d. A Nurses Note prepared with a Facility Incident Report dated 10/30/17 at 1:40 a.m., and revised on 11/21/17 at 6:28 p.m. (a period of 22 days after the incident occurred) documented, Witness Name (Registered Nurse (RN) #1) . Date (of incident) 10/30/2017 . Statement: At about 2205 (10:05 p.m.) I was ask (sic) by (Licensed Practical Nurse (LPN) #1) to assist her with separating two residents who were occupying the same bed on the 500 hall. (Resident #1) was lying in bed with (Resident #2 (a male resident)). She (Resident #1) was ask (sic) to leave (Resident #2's) bed. She was physically assisted to her feet and became combative. (Resident #2) also briefly became combative, but was redirected fairly easily . (Note: There was no documentation the staff attempted to escort Resident #2, who had been redirected fairly easily, from the room, to allow Resident #1 the time and space to calm down before attempting to physically remove her from the room). The Progress Note continued, .(Resident #1) continued to be combative, swinging at staff as she was escorted to her room and again began 'swatting' at staff, insisting they 'get out of her house'. I encircled (Resident #1's) arms with my own and leaned her forward into a supine (sic) position, while (LPN #1) gave (Resident #1) her PRN 0.5 mg [MEDICATION NAME] IM, (Resident #1) continues to curse and scream, attempting to pinch this nurse several times. (Resident #1) was advised several times to calm down, but continued to yell and struggle, (Resident #1) was given a 2nd IM at approximately midnight. (Resident #1) continued above sx (symptoms) until approximately 0030 (12:30 a.m.), when she appeared to calm down somewhat and was released from manual restraint as she (at that point) appeared to have somewhat regained control, no longer cussing and yelling. (Resident #1) laid on the floor with her head on a pillow for approximately 5 minutes longer before being assisted to her room. (Resident #1) did appear to have 2 small skin tears to her left forearm of unknown origin. e. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by RN #1 documented, .After being informed that (Resident #1) was asleep in (Resident #2's) bed, we proceeded to (Resident #2's) room and attempted to encourage (Resident #1) to leave. She became irate, insisted it was her room and refused to leave. (Resident #2) also initially became upset. After a few moments of this, (Resident #1) became more agitated and actively combative, she was escorted to her room and was seated on the bed with (LPN #1) on one side and (Certified Nursing Assistant (CNA) #1) on the other with their arms 'around' hers . hooked at the elbow. During this time, (Resident #2) was out in the hallway, and although he redirected well, (Resident #1) again became more agitated and refused to stay in her room. As we were exiting the room, she again became actively combative and began striking (LPN #1), who was standing in the doorway. I stepped to her side and encircled (Resident #1's) elbows with mine, then took another step to the side and took a knee. (Resident #1) continued to fight and was rolled onto the floor in the prone position. This continued for a few minutes, and when it became evident that (Resident #1) couldn't calm down on her own, (LPN #1) drew up 0.5 [MEDICATION NAME] IM. This was given while the restraint was maintained. After quite some time, it appeared this was ineffective and an additional 1 mg [MEDICATION NAME] IM was given per order. After some time, this appeared to be effective, and manual restraint no longer necessary. I did notice (Resident #1) did have a small skin tear to her left forearm at that time. (Resident #1) continued to lay on the pillow in the hallway for a moment (on the pillow we had gotten her) before again being escorted to her room. Restraint applied/continued using handle with care techniques, I believe all other interventions at that point had failed and/or inappropriate given circumstances. Most staff involved had very shallow lacerations from (Resident #1's) fingernails, and repeated redirection attempts had failed. f. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by LPN #1 documented, .Resident was found in a male resident's bed, both were half undressed, resident became combative, hitting, biting + (and) scratching while being assisted from bed + to her room, [MEDICATION NAME] 0.5 given and ineffective, resident had to be restrained, and another [MEDICATION NAME] 0.5 given before resident calmed enough to be released. g. The Office of Long Term Care Witness Statement form dated 11/22/17 and signed by CNA #1 documented, .Night of incident (Resident #1) + (Resident #2) were found in bed by a CNA, lights turned on, woken up. I came down the hall next to (room number) . when I entered the room I saw (Resident #1) and (Resident #2) 'spooning' naked from the waist down. (Resident #1) was asked to get out of (Resident #2's) bed. She immediately got agitated and (Resident #2) started to get aggressive (and) protective. By (this) time (LPN #1) and (RN #1) had come to see what was going on. Then the nurse wanted (Resident #1) to have an injection as the scene had already gone into the hallway w (with) (Resident #1) being aggressive verbally + (and) physically + (and) (Resident #2) verbally + (and) protective of her. (LPN #1) went to get her an injection, I held (Resident #1) with another aid (CNA) so (LPN #1) could give the injection, (RN #1) held on (Resident #2). (LPN #1) and I proceeded to walk (assertively), (Resident #1) arm in arm to her room. We got her to her bed and sat on either side of her, to try + wait for the injection to take effect. (Resident #1) got her hand loose at one point and knocked her water glass on the floor, in front of us. A CNA came in and wiped the floor w a towel, left towel. (LPN #1) decided to leave her in her room to see if this + (and) the med (medication) would take affect + (and) calm her. (LPN #1) did stand @ (at) doorway to keep her from disturbing other resident on unit (Resident #1) started 'whipping' (LPN #1) w/ (with) the wet towel + (and) pushing on her. When (LPN #1) lost her balance and was about to go down (RN #1) (our other nurse on duty that night) stepped in. Next (Resident #1) was on the floor (RN #1) was straddling holding her arms. He asked for a pillow for her head, one was given. I was not holding her too tight because several times she was able to knock the pillow away. Still waiting for shot to take effect. (Resident #2) was way too interested in what was going on so I took him out into the main part of unit, we had a snack, walked, I read to him. He calmed right down. In my opinion, protocol was completely followed and more injuries to herself or others was diverted by the quick and professional action of our nurses. h. As of 11/22/17, the facility's Abuse, Neglect, Exploitation of Resident Policies and (&) Procedures, provided by the Administrator, did not include the required component of staff training on dementia management. i. Dementia Hand in Hand In-service documentation, provided by the Director of Nursing on 11/22/17, documented training was provided to staff on 3/20/17 and 9/4/17 that included 10 ways to de-escalate residents who were aggressive or combative. There was no documentation to indicate the in-service included strategies of backing away and giving the resident a chance to calm down. There was no documentation to indicate the in-service included information regarding take-downs ever being appropriate. There was no documentation of any further in-servicing on dementia management after the incident between Residents #1 and #2 occurred on 10/30/17. RN #1, LPN #1, and CNA #1's signatures were not included in the documented signatures on the in-service sign-in form to indicate their attendance for the September 4, 2017 in-service, and RN #1 and LPN #1's signatures were not included in the documented signatures on the in-service sign-in form to indicate their attendance for the March 20, 2017 in-service. CNA #1's signature was included in the documented signatures for the in-service dated March 20, 2017. j. On 11/22/17 at 10:34 a.m., LPN #1 was asked if Resident #1 and Resident #2 were involved in inappropriate sexual behaviors prior to the incident on 10/30/17 and how this was handled by the staff. LPN #1 stated, Four to five times, yes, I had to keep them out of each other's beds quite a bit . When asked how long the 10/30/17 incident with Residents #1 and #2 went on, the LPN stated, .I don't know how long it took. About an hour, I don't remember, exactly When asked to describe RN #1's physical 'take-down' of Resident #1, the LPN stated, (RN #1) took her down to the ground, I didn't actually see how he took her down. He was kind of on top of her, but supporting his weight. He was not physically laying (sic) on top of her. At no time, did he lay all his weight down on her . (RN #1) was doing what he had to. I really don't know what we would've done, very thankful he was there . k. On 11/22/17 at 12:07 p.m., CNA #1 was asked if Resident #1 and Resident #2 were involved in inappropriate sexual behaviors prior to the incident on 10/30/17 and how this was handled by the staff. CNA #1 stated, I found them in bed on 2 other occasions. They did not get upset when separated, they had their clothing on. I think I did report it, I know it was an ongoing problem. This problem of (Resident #1 and Resident #2) kissing and hugging has been reported . by one of the other girls. The CNA was asked to describe the incident between Residents #1 and #2 on 10/30/17 and stated, .I was coming down the hallway. They (other staff) just woke them up, turned the lights on . (Resident #1) was already in one of her moods, agitated. We asked them to get out of bed . The CNA was asked to describe RN #1's 'take-down' of Resident #1 and stated, .(RN #1) was toward her side, one knee down and one knee up. He was not on top of her. He asked for a pillow; she kept knocking the pillow away. His arms were interconnected with her arms . The CNA was asked how the RN took the resident to the floor and stated, .I don't remember how he got her on the ground . When asked how long the resident was held down on the floor by RN #1, the CNA stated, .20 to 25 minutes, she was held down . l. On 11/22/17 at 9:22 a.m., RN #1 was asked to describe the events that led to him doing a physical take-down on Resident #1 on 10/30/17. RN #1 stated, .She (Resident #1) became actively combative, again, and I took her to the ground. First standing, then kneeling; I had her arms hooked between mine, her elbows and biceps hooked between mine. This was done to limit the movements of her arms. I took her to the floor, laying (sic) on her lower body, lower limbs, to keep her from kicking. I have been trained on 'Handle with Care'. I worked at (Psychiatric Facility) doing 1-person restraints. I was holding her arms down while laying (sic) on her lower extremities. I had asked and gotten a pillow for her. It took a little while, but she calmed down . When asked if the facility had provided him with any dementia management training, the RN stated, .I don't remember any Alzheimer's or Dementia training here. When asked why staff did not attempt to give Resident #1 time and space to calm down on her own, the RN stated, .Creating distance was not an option . This was not a first-time occurrence. (Resident #1) has been in (Resident #2's) room before . When asked about the secure unit being staff with only one CNA on the night of the incident, the RN stated, We have had staffing issues, and (only) one CNA is on the unit frequently. We open the doors and visualize the hallway. I was under the impression we were doing nothing wrong . The RN was asked if Resident #1 was injured during the incident and stated, .(LPN #1) notified the family of a skin tear to (Resident #1's) left forearm. I thought it could've been from my watch. I didn't see. My elbows were hooked around her elbows. She was lying on her stomach, with my elbows hooked around hers (behind resident's back). I was not holding her wrists with my hands. m. On 11/22/17 at 12:55 p.m., CNA #2 was asked to describe the incident that took place on 10/30/17 involving Resident #1 and Resident #2. CNA #2 stated, (CNA #1) worked 500 Hall that night . when I got there, (Resident #1) was already in (Resident #2's) bed . the lights were already on. Every aide that was working that night came down there to try and get them out of bed. (CNA #1) came to me; she worked it (500 Hall secure unit) by herself. (Resident #1) told me, 'You are not my mother. - I am older than 21. - I can do what I want.' I was working the other halls . the (secure unit) doors were wide open on (Resident #1's) hall. n. On 11/21/17 at 6:11 p.m., RN #2 was asked if Resident #1 and Resident #2 were involved in any inappropriate behaviors and what the facility had done to prevent reoccurrences. RN #2 stated, They have been in compromising positions before. That is the main reason he is out here (off of the secure unit). I have helped (Resident #1) back to her room before. They found them in bed together half naked; that's been about 3 weeks ago. We moved (Resident #2) off the unit. He is very friendly; he has not been inappropriate with any (other) residents that I know of. o. On 11/21/17 at 6:30 p.m., LPN #2 was asked if Resident #1 and Resident #2 were involved in any inappropriate behaviors and what the facility had done to prevent reoccurrences. LPN #2 stated, I have had no instances where she has been physically aggressive. I have never had to give her an injection. One time, (Resident #1) was in (Resident #2)'s bed. She told me that they were just cuddling. They separated themselves, peacefully. They both were fully clothed. When asked how many times she had witnessed Residents #1 and #2 in bed together, the LPN stated, Probably, maybe two times. That's why they put him out here. p. On 11/22/17 at 8:55 a.m., the Director of Nursing (DON) provided a typed form that documented, To Whom It May Concern: Staff was instructed to keep residents apart following incident. (Resident #2) was assisted to getting ready for bed while another CNA assisted (Resident #1) simultaneously. (So that (Resident #1) was not compelled to assist (Resident #2)). Out of sight was truly out of mind. (Physician) was notified of incident and behaviors and asked to evaluate medication regime for both residents. No new orders for medications were received. After a few days of trying to keep residents apart and conversations with family members of both residents, it was decided by Department heads to separate residents into different parts of facility. They are separated even during mutual activities. The form was signed by the Director of Nursing on 11/22/17. q. On 11/22/17 at 8:56 a.m., the Administrator was asked how long it took to move Resident #2 off of the secure unit, away from Resident #1. The Administrator stated, He was moved from the secure unit on 11/8/17 (a period of 8 days after the incident occurred). When asked if the facility provided dementia management training during staff orientation, the Administrator stated, .No orientation training with Dementia or Alzheimer's residents . r. On 11/22/17 at 10:44 a.m., LPN #3 was asked if she had witnessed any inappropriate behaviors between Resident #1 and Resident #2 and if the facility had done anything about it. LPN #3 stated, I admitted (Resident #2) from a psychiatric facility in (nearby city). He was calm, but medicated. I don't work the unit. I know they were holding hands. You had to try and keep them apart, never seen them in a room together. I have not witnessed any inappropriate behaviors directed (by Resident #2) toward female residents. I know today, he was wanting to go into someone else's room with just his brief on and tee shirt. It was an empty room, two doors down from his room. On the other side of the hall, we have all women. I have never seen him go into another female's room. I know it makes me uncomfortable working with him. He will be highly combative, then he will be hitting on me. He can be super combative or hugging, loving. I think he belongs on an all-male unit. He doesn't have (Resident #1) to instigate him. He has walked out naked on the unit before. s. Based on Resident #1's care plan dated 9/3/17, the resident's location was supposed to be monitored by staff every 15 minutes. The Daily Staffing Log for 10/30/17 documented the facility did not meet minimum staffing requirements for the evening and night shifts on that date. According to the Daily Census Report, a total of 12 residents resided on the secure unit and, on the night of 10/30/17, the unit was staffed with only one CNA. t. The facility Abuse Prohibition Policy and Procedure, received from the Administrator on 11/22/17, documented, Each resident of this facility has the right to be free from .physical and mental abuse, corporal punishment .Accordingly this facility prohibits the abuse of a resident by anyone including, but not limited to, facility staff .Protection .Provide for the immediate safety of residents, upon identification of suspected abuse, neglect, mistreatment .move resident to another room or unit .provide 1:1 monitoring as appropriate .immediate suspension of suspected employee(s), pending outcome of the investigation .initiate interventions with behavior management as applicable . The facility's policy and procedure did not include information regarding the required staff training on Dementia Management. u. The immediate jeopardy was removed and the scope/severity reduced to E on 11/22/17 when the facility implemented the following plan of removal: All employees will be in-serviced prior to the beginning of their next shift on appropriate interventions to address combative behavior and catastrophic reactions. Will review all other incidents in the past 30 days of residents exhibiting combative behavior to determine if staff handled them appropriately. Resident (#1) will be placed on Q (every) 15 minutes monitoring while in the facility for the next 48 hours then decreased to Q 30 mins (minutes) while in the facility to ensure she is not in the same vicinity of the male resident and no combative behaviors. Monitoring will include staff interviews 2-3 times per week to ensure they are aware of appropriate interventions when a resident becomes combative or violent. Revision of Abuse and Neglect policies to include Dementia Management and Abuse Prevention. The male RN was suspended. If he is allowed to return to work, he will be re-trained on Dementia Management and Abuse Prevention to include combative behavior and catastrophic reactions. Monitoring of the male RN will include spot checks for a period of two weeks to ensure the in-servicing was effective.