Every finding on record at Traditions Memory Care of Newton

Based on schedule review, staff interviews, Payroll Based Journal Data Report and facility policy review, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day for 11 days for February and March 2026. The facility reported a census of 44 residents. Findings include:Review of Payroll Based Journal (PBJ) Staffing Data Report dated January 1, 2026 to March 31, 2026, triggered No RN Hours for February 2nd, 3rd, 15th, and March 7th, 8th, 24th, 25th, 26th, 27th, 28th, and 29th. Review of provided Daily Assignment Nursing Schedules for February 2nd, 3rd, 15th, and March 7th, 8th, 24th, 25th, 26th, 27th, 28th, 29th failed to provide eight consecutive hours of RN coverage. In an email dated 8/12/26 at 2:36 PM, Facility Administrator acknowledged the facility did not have 8 hours of RN coverage on the days triggered on the PBJ. Review of facility provided Nursing Services and Sufficient Staff Policy, dated 2/23/25 documented: It is the policy of this facility to provide sufficient staff with appropriate competencies and skillsets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.Policy Explanation and Compliance Guidelines:.8) Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observations, interviews, and policy review, the facility failed to follow infection food handling guidelines when Staff A, Cook, did not properly use gloves. During an observation of lunch service, Staff A, [NAME] wore gloves while touching non food items, then while wearing the same gloves, touched bread and served the bread. The facility reported a census of 44. Findings include: On 8/12/26 at 2:58 PM, during pureed food observation beginning at 11:38 a.m., Staff A was wearing gloves. She had placed 4 pork chops in the food processor. She then grabbed a loaf of bread, opened the packaging and reached in with her gloved hands. She pulled out 4 slices of bread, then placed them in the blender. She had already touched the lid on the food processor, the lid covering the pork chops, tongs, and a scoop to add liquid to the food processor. She did all of these above while wearing the same pair of gloves. This cook then finished pureeing food and started service. Staff A served the pureed pork chops to 3 residents. At 1:15 p.m., this [NAME] grabbed the bread while wearing a pair of gloves. She then pulled two pieces of bread out of the bread bag, along with the peanut butter and jelly. She lifted a piece of the bread up and put it in her palm, then spread peanut butter on it and then spread jelly on the second piece of bread after lifting that piece of bread up as well. This cook then placed the sandwich on a plate, added a container of pudding and served this to a resident. At 1:22 p.m., after the completion of meal service, Staff A and the Certified Dietary Manager (CDM) acknowledged the improper handling of food. They both acknowledged the bread should not have been touched with the same gloved hands that had previously touched other objects. The CDM stated that gloves can be tricky and that tongs should have been used to grab the bread. At 1:30 p.m., the Administrator acknowledged the above concern. A Bare Hand Contact with Food and Use of Plastic Gloves policy dated 2021, directed the following:Policy:Single-use gloves will be worn when handling food directly with hands to assure that bacteria arenot transferred from the food handlers' hands to the food product being served. Bare hand contactwith food is prohibited.Procedure:1. Staff will use good hygienic practices and techniques with access to proper hand washingfacilities (available soap, hot water, and disposable towels and/or heat/air drying methods).Antimicrobial or antiseptic gel will not be used in place of proper hand washing techniques.2. Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas whenhandling food.3. Gloved hands are considered a food contact surface that can become contaminated or soiled.If used, single use gloves shall be used for only one task (such as working with ready-to-eatfood or with raw animal food), used for no other purpose, and discarded when damaged orsoiled, or when interruptions occur in the operation.4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves(before beginning work with food) and after removing single use gloves.5. Clean barriers such as single-use gloves are to be used when:a. Handling ready-to-eat foods.b. Handling raw meat, poultry, raw eggs, fish, and shellfish.c. Preparing foods such as meatloaf or meat salads.d. Hand tossing salad, mixing coleslaw, potato or macaroni salad.e. Bagging bread or cookies.f. Anytime hands would otherwise touch food DIRECTLY.6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, thegloves must be changed, and hands must be washed:a. After coughing or sneezing into hands, using a handkerchief or tissue, using tobacco ortouching hair or face.b. After handling garbage or garbage cans.c. After handling soiled trays or dishes.d. After handling anything soiled.e. After handling boxes, crates or packages.f. After picking up any item from the floor.g. During food preparation, as often as necessary to remove soil and contamination and toprevent cross contamination when changing tasks.h. When switching between working with raw food and working with ready-to-eat food.i. After engaging in other activities that may possibly contaminate the hands with bodily fluids.j. After using the rest room.k. After caring for or handling service animals or aquatic animals.l. Any time a contaminated surface is touched.7. Hands should be washed after removing gloves.

Based on record review, staff interview and policy review the facility failed to revise resident's care plan to indicate diagnosis and interventions for Post Traumatic Stress Disorder (PTSD) status for 1 of 12 residents reviewed. (Resident #7) Facility reported a census of 44 residents. Findings include:Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #7's Brief Interview for Mental Status (BIMS) of 5, indicating severe cognitive impairment. MDS also documented diagnoses of non-Alzheimer's dementia, depression, psychotic disorder and PTSD. Review of Resident #7's Care Plan failed to provide a focus of PTSD with goals and interventions. Review of Resident #7's Trauma Informed Care assessment dated [DATE] documented Resident #7 having a history of imprisonment, traumatic loss of a loved one, and symptoms related to the trauma to include depression. The assessment also documented Resident #7's triggers include loud noises and large groups. Resident #7 has had increased anger and anxiety as a result of these situations and tends to be a loner. During an interview on 8/13/26 at 12:45 PM, Facility Administrator and Director of Nursing (DON) acknowledges Resident #7's diagnosis of PTSD should be on Resident #7's Care Plan. Review of facility provided Comprehensive Care Plan Policy, dated 12/3/25 stated: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure each resident receives adequate assistance to prevent accidents while providing cares and transfers for 1 of 3 residents reviewed for falls (Resident #1). The facility reported a census of 44 residents. Findings include:During an observation on 8/12/26 at 6:58 AM Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA provided incontinence care for Resident #1 requiring two person assistance to roll resident left side to right side, cleaning peri area, brief change, and placing mechanical lift sling underneath Resident #1 to prepare for mechanical lift transfer. Review of Minimum Data Set (MDS) dated [DATE] revealed Brief Interview Mental Status (BIMS) of 00, indicating severe cognitive impairment. MDS documented diagnoses of Alzheimer's Disease, non-alzheimer's dementia, seizure disorder, anxiety, and history of other mental and behavioral disorders. Resident #1 is dependent on all cares and mobility with use of mechanical lift and wheelchair. Review of Resident #1's Care Plan documented:1. Resident #1 is at risk for injury from falls related to diagnoses of Alzheimer's Dementia with behavioral symptoms and severe impairment to cognitive functions, revised 8/6/26. An intervention dated 8/10/26 noted staff educated to have two people in the room when placing the sling under the resident. 2. Resident #1 has a self-care deficit, revised 8/6/26, requiring assistance of two with bathing, bed mobility, dressing, eating, and mechanical lift transfers. Review of facility provided Incident Report dated 8/10/26 at 4:10 PM documented Director of Nursing (DON) was alerted to go to Resident #1's room. Upon entering, Resident #1 was found lying on his right side on the floor next to his bed. Staff D, CNA reported to DON, while attempting to put mechanical lift sling under Resident #1, he was resisting and pushing against Staff D, CNA. Staff D, CNA's feet slid on the floor and Resident #1 was lowered to the floor. Resident #1 did not hit his head when being lowered. After being lowered to the floor Resident #1 turned his head and scratched his nose on the dresser. In an interview on 8/12/26 at 12:05 PM, Staff D, CNA stated she had gone into Resident #1's room to change him because his brief and place sling under him, while the other CNA was in another room. When other CNA would be available she would assist with the mechanical lift transfer. Staff D, CNA, turned and rolled resident towards the wall, away from Staff D, CNA. Resident #1 needed to be adjusted some due to having his arms out pushing against the wall. Staff D, CNA stated she adjusted Resident #1 using the bed pad underneath him. When Staff D, CNA adjusted him, Resident #1 started to roll back towards CNA. As Resident #1 was rolling back towards CNA, Staff D, CNA was not able to stop Resident #1, as his legs were already off the bed and she was slipping. Staff D, CNA was able to support Resident #1's torso and chest against her legs and assist Resident #1 to the floor. Once Resident #1 was on the floor, he turned his head causing an abrasion on his face from the dresser. Staff D, CNA also stated We can roll the sling like a brief to place under a resident by ourselves. We do this so the resident is ready for transfer when a second CNA is available to assist with the mechanical lift. Staff D, CNA stated Resident #1 was an assist of one prior to this incident and was told Resident #1 will now be an assist of two when placing the sling. During an interview on 8/13/26 at 12:25 PM, Staff E, CNA stated she was working when Resident #1 had rolled out of bed when Staff D, CNA was providing care and placing sling, but had not witnessed the incident. Staff E, CNA stated she does place slings under residents independently, to have the resident ready when a second CNA is available to assist with the mechanical lifter transfer. Review of Facility CNA Competency for mechanical lift (Hoyer) Lift Checklist dated 5/11/2021 documented the steps for Hoyer Lift transfers. 1.Prior to conducting the transfer task, the twocaregivers agree on who will take the lead andwho will be the helper. 5. To place the total body sling, the resident is rolledtowards one caregiver; the sling is placed along theback side of the resident according to themanufacturer's directions.6. The resident is rolled then toward the secondcaregiver to place them in the center of the sling .On 8/12/26 at 12:00 PM, Facility Administrator and DON provided CNA training documents used for the mechanical lift. Review of the provided training document indicated two staff when placing sling under residents. The Administrator also provided signed training documents for Staff D, CNA, dated 6/2026 indicating this training had been provided and completed. During the interview, DON stated education had been provided to Staff D, CNA immediately after the incident with Resident #1 occurred.Review of facility provided Nursing Services and Sufficient Staff Policy dated 2/23/25 documented: 1. It is the policy of this facility to provide sufficient staff with appropriate competencies and skillsets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.6. The facility must ensure that nurse aides are able to demonstrate competency in skillsand techniques necessary to care for residents' needs, as identified through residentassessments, and described in the plan of care.

Based on observations, interviews and record review, the facility failed to use oxygen as ordered and failed to appropriately assess the residents who were administered oxygen (O2) for 2 out of 2 residents reviewed Resident #9 and Resident #31. The facility failed to document and assess the need for oxygen during the day, and they failed to assess oxygen saturation levels for the appropriate liter per minute flow during the day for Resident #9. The facility failed to document the liter flow rate at HS nor was there a place to document liter flow for as needed oxygen. The facility failed to accurately assess for signs and symptoms of respiratory distress, to include checking the oxygen saturation levels for Resident #31 per the physician's order. The facility reported a census of 44 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for resident #9 included non-traumatic brain dysfunction, anxiety, pulmonary fibrosis (a lung disease where deep lung tissue becomes thick, stiff, and scarred over time), chronic respiratory failure with hypoxia (low level of oxygen). A Brief Interview for Mental Status (BIMS), documented a score of 09 out of 15, which indicated moderate cognitive impairment. This MDS documented that this resident was not on oxygen at the time the MDS was done. A doctor's order dated 5/30/26, directed staff to apply oxygen at 2 liters (L) via a nasal cannula (NC) at HS (hour of sleep). May titrate up to 4 liters to keep saturations above 90%. Do not go above 4 liters. May use as needed (PRN) with activity one time a day for chronic respiratory failure with hypoxia and as needed related to chronic respiratory failure with hypoxia. A Medication Administration Record (MAR) for the month of August 2026, documented that O2 was administered at HS from August 1st through August 10th. It did not document the liter flow. No PRN O2 usage was administered per this record. On 8/10/26 at 4:07 PM, Resident #9 was walking back to her room with an O2 tank. The O2 was on at 2L. The order is for titration. On 8/11/26 at 11:11 AM, Resident #9 was sitting in a recliner in her room with her legs up. She gave permission to look at the oxygen level. It was at 2L. Resident said it should be at 2. On 8/11/26 at 4:00 p.m., the Administrator stated understanding that the oxygen was being used outside of the doctor's order. The Director of Nursing, questioned the concern, but then nodded to understanding after further explanation was given . 2. Review of MDS dated [DATE] revealed Resident #31's BIMS of 13, indicating cognitively intact. Diagnoses include congestive heart failure (CHF), chronic bronchitis, type 2 diabetes, dementia, anxiety, and delusional disorder. Review of Resident #31's Nursing Progress notes revealed:-7/20/26 7:42 PM, Resident #31 had been noted to sleep through supper, documenting Registered Nurse indicated overhearing a Certified Nursing Assistant (CNA) state, Resident #31 had also slept through lunch, which was unusual for Resident #31. On assessment RN found Resident #31's color to be pale, lips appearing purple, with rapid breaths using intercostals to breathe. Oxygen saturation found to be 69% on room air. Oxygen applied to Resident #31 at 4L with saturations increasing to 93% over two minutes. -7/20/26 8:59 PM, On call provider had been notified of Resident #31's status. On call provider ordered portable chest x-rays, labs, and vitals to be obtained every 8 hours for 3 days. -7/21/26 1:34 PM, Verbal orders obtained for Resident #31 for additional labs and oxygen at 2-4 liters to keep saturations above 90%. -7/21/26 5:32 PM, Verbal order to send Resident #31 to hospital for CT scan.-7/21/26 8:30 PM, Resident #31 returned to facility with a diagnosis of acute bronchitis. Received orders for prednisone 40mg daily for 5 days and Duo-nebulizer breathing treatments 4 times daily for 5 days. Review of Resident #31's July Medication Administration Record (MAR) revealed an order to monitor for signs and symptoms of CHF, shortness of breath, and edema two times a day. Documented check marks to indicate completion of monitoring provided, MAR failed to provide documented oxygen saturation levels or vitals. Further review of Resident #31's Electronic Health Record revealed, documented occasional monitoring of symptoms, records failed to provide consistent documentation of oxygen saturations to indicate the needed oxygen level to keep oxygen saturation above 90% per physician's orders. Records also failed to provide the documented effectiveness of the Duo-Neb treatments. Review of Resident #31's Census indicated admission to Hospice level of care on 8/12/26. During an interview on 8/13/26 at 12:36 PM, Facility Administrator and DON acknowledged further monitoring and documentation of oxygen saturation levels should be obtained. Email communication received on 8/13/26 at 1:12PM, Facility Administrator stated the facility does not have a policy related to oxygen treatment and nursing staff are to follow the professional standards of care related to oxygen treatments and monitoring.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to develop effective care plan interventions protect the resident's right to be free from physical abuse for 4 of 7 residents reviewed for resident to resident altercations(Residents #2, #5, #6, #7). The facility reported a census of 46 residents.Findings included: 1. The Minimum Data Set(MDS) assessment tool, dated 8/4/25, listed diagnoses for Resident #1 which included psychotic disorder(a mental health condition characterized by a loss of touch with reality, leading to significant disturbances in thoughts, perceptions, and behavior), schizophrenia(a chronic mental health condition characterized by a combination of symptoms that can significantly impact a person's thoughts, feelings, and behavior), and anxiety disorder. The MDS stated the resident was independent with walking and had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) which occurred 4 to 6 days out of the 7 day review period. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 0, indicating severely impaired cognition. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated 10/19/22, stated residents must not be subjected to abuse by anyone including other residents. The policy defined dependent adult abuse to include assault of a dependent adult, which meant the commission of any act which was generally intended to cause pain or injury to a dependent adult, or which was generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which was intended to place another in fear of immediate physical contact which would be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.Care Plan entries, dated 7/31/25, directed staff to provide reassurance and consult psychiatric services as needed, change rooms if indicated, assess for contributing factors, and move to a quiet area to deescalate behavior.An 8/1/25 Care Plan entry directed staff to carry out non-pharmacological interventions such as offers of food, fluids, toileting, activities, family calls, pain assessments, repositioning, and one on one staff supervision. An 8/14/25 Care Plan entry directed staff to redirect the resident out of other resident rooms.An 8/29/25 Care Plan entry stated the resident relaxed and rested when she cuddled with staff.A 9/1/25 Care Plan entry stated the resident was one on one with staff as needed for safety while she ambulated.The Care Plan lacked interventions shown to be effective in preventing the resident from physical aggression with other residents.A 4/24/25 hospital Provider Progress Note stated the resident was involuntarily discharged from her nursing home and stated in the Emergency Department, she was very aggressive, hit staff, and required multiple security guards.A 7/28/25 admission Summary stated the resident admitted to the facility. A 7/28/25 Health Status Note stated the resident wandered all shift and went in and out of other's rooms, crawled in bed with them, and sat in occupied chairs.A 7/30/25 Health Status Note stated the resident continuously wandered and entered peer rooms, upsetting them.An 8/2/25 Health Status Note stated the resident wandered, trespassed, and took peer belongings. She attempted to get into bed or sit in a chair with others which caused peer agitation. She was aggressive and combative and had two incidents of increased agitation with peers. She attempted to sit on a male peer's lap and attempted to kiss another male peer on the mouth.A 9/27/25 Health Status Note stated the resident told staff she would hit them and slapped a staff member on the back.A 10/5/25 Health Status Note stated the resident had an increase in her behaviors. She was mean and took her peer's meals away from them. She grabbed food off their plates and cursed at them. She hit, kicked, and bit when anyone tried to redirect her. Her morphine(a narcotic pain reliever) and Haldol(an antipsychotic medication) had zero effectiveness. A 10/13/25 Health Status Note stated each day the resident became more aggressive with staff, peers, and even guests. She had no boundaries and called names, hit, kicked, and grabbed other's food. She was not redirectable and it required two staff to attempt to take care of her. A 10/14/25 Health Status Note stated the resident had multiple medication changes without benefit. The resident continued to wander into other's rooms, grabbed their belongings, and caused irritation to other residents. She swore at staff and called them [NAME] and vulgar names. She told them to die and to go to hell. She hit a staff member which caused a bruise and skin tear to the staff member. Her medication regimen changes were completely ineffective regardless if they were scheduled or as needed(prn). A 10/21/25 Health Status Note stated the resident was agitated after dinner and repeatedly went in and out of resident rooms. Staff carried out 1:1 supervision with the resident to prevent further incidents. The administration of prn medication was ineffective. A 10/27/25 Orders-Administration Note stated the resident stuck staff hard with an open hand across the face when staff redirected her out of a male peer's room. The resident in one minute told staff she loved them but then a few seconds later was irritable and called staff names. On 10/27/25 at 10:23 a.m. Resident #1 walked out of the dining room. At 10:24 a.m., a staff member quickly got up and went down the hall and brought the resident back. The resident again stood up and went down the same hall and staff did not go after her until 10:26 a.m. The resident was in a room occupied by two other residents who were in bed at the time. While Resident #1 was still in the other resident's room, Staff A Hospice Social Worker stated to Resident #1 that she shouldn't hit people. Staff A stated that the Resident hit a staff member in the face. The resident then went into a different resident's room before staff assisted her out. Resident #1 then went down the opposite hall and went into room [ROOM NUMBER] and closed the door before Staff A arrived and went in and got her. The room was unoccupied at this time. Observations on 10/27/25 from 10:41 a.m. to approximately 11:18 a.m. revealed the resident constantly pacing down different hallways. She sat down at the dining table at 11:16 a.m. but only stayed there for approximately two minutes before getting up again. a. Resident #1 and Resident #5The MDS assessment tool, dated 6/23/25, listed diagnoses for Resident #5 which included diabetes(a disease which caused alterations in blood sugars), non-Alzheimer's dementia, and schizophrenia. The MDS listed the resident's BIMS score as 3 out of 15, indicating severely impaired cognition. Care Plan entries, dated 7/20/24, stated the resident had dementia with behavioral disturbances and stated the resident would remain safe over the next review period. An 8/25/25 Health Status Note stated staff heard Resident #5 yell get out and then heard Resident #1 scream. (Staff) entered the room and Resident #1 sat on Resident #5's bed on top of one of his legs and Resident #5 kicked her with the other leg. After staff assisted Resident #1 up to free Resident #5's legs, it freed his other leg and he began kicking her with both legs. b. Resident #1 and Resident # 6The MDS assessment tool, dated 7/28/25, listed diagnoses for Resident #6 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. The MDS listed her BIMS score as 3 out of 15, indicating severely impaired cognition. Care Plan entries, dated 2/12/25, stated the resident had altered thought processes related to Alzheimer's disease, anxiety disorder, and severe cognitive impairment. The Care Plan directed staff to reassure the resident to decrease frustration. A 10/4/25 Physical Aggression Initiated form stated Resident #1 sat in Resident #6's chair in Resident #6's room and Resident #6 took Resident #1's hands to try to get her out of the chair. Resident #1 swung at Resident #6 and hit her in the left arm. c. Resident #1 and Resident #7The MDS assessment tool, dated 9/8/25, listed diagnoses for Resident #7 which included Alzheimer's, non-Alzheimer's dementia, and bipolar disorder(a chronic mental health condition characterized by extreme mood swings). The MDS listed her BIMS score as 13 out of 15, indicating intact cognition.Care Plan entries, dated 10/11/23, stated the resident had altered thought processes/cognition related to Alzheimer's dementia and directed staff to reassure the resident to decrease frustration. A 10/17/25 Health Status Note stated on 10/16/25 at 1:15 p.m. Resident #1 entered Resident #7's room and Resident #7 reported that Resident #1 hit her on the head. Staff then witnessed Resident #7 hit Resident #1. d. Resident #1 and Resident #2The MDS assessment tool, dated 9/22/25, listed diagnoses for Resident #2 which included Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder. The MDS listed the resident's BIMS score as 4 out of 15, indicating severely impaired cognition. A 1/27/25 Care Plan entry directed staff to reassure the resident to decrease frustration. A 6/16/25 Care Plan entry stated the resident had altered thought processes/cognition related to Alzheimer's Dementia with behavioral disturbances, generalized anxiety disorder, delusional disorders, and major depressive disorder. A 10/16/25 Health Status Note stated the resident sat in the dining room and Resident #1 came up to him and hit him on the right shoulder area.A 10/16/25 Physical Aggression Initiated form stated a nurse gently placed her hand on the resident(Resident #1) for her to come and the resident immediately stood up, jerked away from the nurse, turned to face the other resident(Resident #2), and took her right hand and hit the other resident's right shoulder. The nurse was unable to intervene in time as a dining room chair was between the resident and the nurse.A 10/19/25 Health Status Note stated Resident #1 hit Resident #2 on the right shoulder.On 10/27/25 at 10:44 a.m., Staff A Hospice Social Worker walked in the hall with Resident #1. Staff A stated she visited 1-2 times per week and was worried about other residents so kept an eye on Resident #1. On 10/27/25 at 3:52 p.m. via phone, Staff B Registered Nurse(RN) stated Resident #1 went in and out of other resident rooms and she observed Resident #1 hit Resident #2. She stated they tried to keep her one on one with staff when they had staff to do this.On 10/27/25 at 4:01 p.m. via phone, Staff C Certified Nursing Assistant(CMA) stated she observed Resident #1 slap the back of Resident #2's shoulder. She stated Resident #1 was all over all of the time and hard to redirect. She stated they kept an eye out for her when she was up and awake but thought it was impossible for them to care for her and her behaviors. She stated she did not think it was possible to prevent her from physically lashing out. On 10/28/25 at 8:22 a.m., Staff D Licensed Practical Nurse(LPN) stated Resident #1 was constantly moving and didn't rest. She stated none of her medications were effective. She stated when they went towards her, she started swinging and hitting people. She stated there was not enough staff to watch her and when asked if she thought the other residents were safe from Resident #1, she said no.On 10/28/25 at 8:47 a.m., Staff E LPN stated the resident was not on one on one supervision and she roamed all over and they tried to keep an eye on her. She stated it was not possible for them to prevent her from going in other rooms and stated she did not feel this was the facility for her.On 10/28/25 at 9:10 a.m., Staff F CNA stated Resident #1 was very mean to other residents and sometimes aggressive. She stated she slapped the other residents. She stated she was on 15 minute checks currently but she was able to get into other resident rooms without them knowing. On 10/28/25 at 9:20 a.m., Staff G CNA stated the facility did not have enough staff to keep an eye on Resident #1 at all times.On 10/28/25 at 9:27 a.m., the Director of Nursing(DON) stated Resident #1 had a 30 second switch and could go from saying she loved her to calling her vulgar names. She went into other resident's rooms and if they became agitated, she became agitated and would hit. She stated they carried out numerous medication changes and stated one on one supervision may agitate her more. She stated if she was not on one on one supervision, there was no guarantee(she wouldn't physically lash out at staff again). She stated the sent out referrals to other smaller facilities which may suit her better. On 10/28/25 at 12:23 p.m., the MDS Coordinator, was queried as to if there were any interventions which kept the resident out of other resident rooms. She stated this would be staff watching her but stated one on one supervision was probably not an option staffing wise.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide adequate supervision to protect the resident's right to be free from physical abuse for 4 of 7 residents reviewed for resident -to-resident altercations (Residents #2, #5, #6, #7). The facility reported a census of 46 residents. Findings include:1. The Minimum Data Set (MDS) assessment tool, dated 8/4/25, listed diagnoses for Resident #1 which included psychotic disorder (a mental health condition characterized by a loss of touch with reality, leading to significant disturbances in thoughts, perceptions, and behavior), schizophrenia (a chronic mental health condition characterized by a combination of symptoms that can significantly impact a person's thoughts, feelings, and behavior), and anxiety disorder. The MDS stated the resident was independent with walking and had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) which occurred 4 to 6 days out of the 7-day review period. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 0 out of 0, indicating severely impaired cognition. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated 10/19/22, stated residents must not be subjected to abuse by anyone including other residents. The policy defined dependent adult abuse to include assault of a dependent adult, which meant the commission of any act which was generally intended to cause pain or injury to a dependent adult, or which was generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which was intended to place another in fear of immediate physical contact which would be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act. Care Plan entries, dated 7/31/25, directed staff to provide reassurance and consult psychiatric services as needed, change rooms if indicated, assess for contributing factors, and move to a quiet area to deescalate behavior.An 8/1/25 Care Plan entry directed staff to carry out non-pharmacological interventions such as offers of food, fluids, toileting, activities, family calls, pain assessments, repositioning, and one on one staff supervision. An 8/14/25 Care Plan entry directed staff to redirect the resident out of other resident rooms.An 8/29/25 Care Plan entry stated the resident relaxed and rested when she cuddled with staff.A 9/1/25 Care Plan entry stated the resident was one on one with staff as needed for safety while she ambulated. A 4/24/25 hospital Provider Progress Note stated the resident was involuntarily discharged from her nursing home and stated in the Emergency Department, she was very aggressive, hit staff, and required multiple security guards. A 7/28/25 admission Summary stated the resident admitted to the facility. A 7/28/25 Health Status Note stated the resident wandered all shift and went in and out of other's rooms, crawled in bed with them, and sat in occupied chairs. A 7/30/25 Health Status Note stated the resident continuously wandered and entered peer rooms, upsetting them. An 8/2/25 Health Status Note stated the resident wandered, trespassed, and took peer belongings. She attempted to get into bed or sit in a chair with others which caused peer agitation. She was aggressive and combative and had two incidents of increased agitation with peers. She attempted to sit on a male peer's lap and attempted to kiss another male peer on the mouth. A 9/27/25 Health Status Note stated the resident told staff she would hit them and slapped a staff member on the back. A 10/5/25 Health Status Note stated the resident had an increase in her behaviors. She was mean and took her peer's meals away from them. She grabbed food off their plates and cursed at them. She hit, kicked, and bit when anyone tried to redirect her. Her morphine (a narcotic pain reliever) and Haldol (an antipsychotic medication) had zero effectiveness. A 10/13/25 Health Status Note stated each day the resident became more aggressive with staff, peers, and even guests. She had no boundaries and called names, hit, kicked, and grabbed other's food. She was not redirectable and it required two staff to attempt to take care of her. A 10/14/25 Health Status Note stated the resident had multiple medication changes without benefit. The resident continued to wander into other's rooms, grabbed their belongings, and caused irritation to other residents. She swore at staff and called them [NAME] and vulgar names. She told them to die and to go to hell. She hit a staff member which caused a bruise and skin tear to the staff member. Her medication regimen changes were completely ineffective regardless if they were scheduled or as needed(prn). A 10/21/25 Health Status Note stated the resident was agitated after dinner and repeatedly went in and out of resident rooms. Staff carried out 1:1 supervision with the resident to prevent further incidents. The administration of prn medication was ineffective. A 10/27/25 Orders-Administration Note stated the resident stuck staff hard with an open hand across the face when staff redirected her out of a male peer's room. The resident in one minute told staff she loved them but then a few seconds later was irritable and called staff names. On 10/27/25 at 10:23 a.m. Resident #1 walked out of the dining room. At 10:24 a.m., a staff member quickly got up and went down the hall and brought the resident back. The resident again stood up and went down the same hall and staff did not go after her until 10:26 a.m. The resident was in a room occupied by two other residents who were in bed at the time. While Resident #1 was still in the other resident's room, Staff A Hospice Social Worker stated to Resident #1 that she shouldn't hit people. Staff A stated that the Resident hit a staff member in the face. The resident then went into a different resident's room before staff assisted her out. Resident #1 then went down the opposite hall and went into room [ROOM NUMBER] and closed the door before Staff A arrived and went in and got her. The room was unoccupied at this time. Observations on 10/27/25 from 10:41 a.m. to approximately 11:18 a.m. revealed the resident constantly pacing down different hallways. She sat down at the dining table at 11:16 a.m. but only stayed there for approximately two minutes before getting up again. a. Resident #1 and Resident #5 The MDS assessment tool, dated 6/23/25, listed diagnoses for Resident #5 which included diabetes (a disease which caused alterations in blood sugars), non-Alzheimer's dementia, and schizophrenia. The MDS listed the resident's BIMS score as 3 out of 15, indicating severely impaired cognition. Care Plan entries, dated 7/20/24, stated the resident had dementia with behavioral disturbances and stated the resident would remain safe over the next review period. An 8/25/25 Health Status Note stated staff heard Resident #5 yell get out and then heard Resident #1 scream. (Staff) entered the room and Resident #1 sat on Resident #5's bed on top of one of his legs and Resident #5 kicked her with the other leg. After staff assisted Resident #1 up to free Resident #5's legs, it freed his other leg and he began kicking her with both legs. b. Resident #1 and Resident # 6 The MDS assessment tool, dated 7/28/25, listed diagnoses for Resident #6 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. The MDS listed her BIMS score as 3 out of 15, indicating severely impaired cognition. Care Plan entries, dated 2/12/25, stated the resident had altered thought processes related to Alzheimer's disease, anxiety disorder, and severe cognitive impairment. The Care Plan directed staff to reassure the resident to decrease frustration. A 10/4/25 Physical Aggression Initiated form stated Resident #1 sat in Resident #6's chair in Resident #6's room and Resident #6 took Resident #1's hands to try to get her out of the chair. Resident #1 swung at Resident #6 and hit her in the left arm. c. Resident #1 and Resident #7 The MDS assessment tool, dated 9/8/25, listed diagnoses for Resident #7 which included Alzheimer's, non-Alzheimer's dementia, and bipolar disorder (a chronic mental health condition characterized by extreme mood swings). The MDS listed her BIMS score as 13 out of 15, indicating intact cognition. Care Plan entries, dated 10/11/23, stated the resident had altered thought processes/cognition related to Alzheimer's dementia and directed staff to reassure the resident to decrease frustration. A 10/17/25 Health Status Note stated on 10/16/25 at 1:15 p.m. Resident #1 entered Resident #7's room and Resident #7 reported that Resident #1 hit her on the head. Staff then witnessed Resident #7 hit Resident #1. d. Resident #1 and Resident #2 The MDS assessment tool, dated 9/22/25, listed diagnoses for Resident #2 which included Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder. The MDS listed the resident's BIMS score as 4 out of 15, indicating severely impaired cognition. A 1/27/25 Care Plan entry directed staff to reassure the resident to decrease frustration. A 6/16/25 Care Plan entry stated the resident had altered thought processes/cognition related to Alzheimer's Dementia with behavioral disturbances, generalized anxiety disorder, delusional disorders, and major depressive disorder. A 10/16/25 Health Status Note stated the resident sat in the dining room and Resident #1 came up to him and hit him on the right shoulder area. A 10/16/25 Physical Aggression Initiated form stated a nurse gently placed her hand on the resident (Resident #1) for her to come and the resident immediately stood up, jerked away from the nurse, turned to face the other resident (Resident #2), and took her right hand and hit the other resident's right shoulder. The nurse was unable to intervene in time as a dining room chair was between the resident and the nurse. A 10/19/25 Health Status Note stated Resident #1 hit Resident #2 on the right shoulder. On 10/27/25 at 10:44 a.m., Staff A Hospice Social Worker walked in the hall with Resident #1. Staff A stated she visited 1-2 times per week and was worried about other residents so kept an eye on Resident #1. On 10/27/25 at 3:52 p.m. via phone, Staff B Registered Nurse (RN) stated Resident #1 went in and out of other resident rooms and she observed Resident #1 hit Resident #2. She stated they tried to keep her one on one with staff when they had staff to do this. On 10/27/25 at 4:01 p.m. via phone, Staff C Certified Nursing Assistant (CMA) stated she observed Resident #1 slap the back of Resident #2's shoulder. She stated Resident #1 was all over all of the time and hard to redirect. She stated they kept an eye out for her when she was up and awake but thought it was impossible for them to care for her and her behaviors. She stated she did not think it was possible to prevent her from physically lashing out. On 10/28/25 at 8:22 a.m., Staff D Licensed Practical Nurse (LPN) stated Resident #1 was constantly moving and didn't rest. She stated none of her medications were effective. She stated when they went towards her, she started swinging and hitting people. She stated there was not enough staff to watch her and when asked if she thought the other residents were safe from Resident #1, she said no. On 10/28/25 at 8:47 a.m., Staff E LPN stated the resident was not on one-on-one supervision and she roamed all over and they tried to keep an eye on her. She stated it was not possible for them to prevent her from going in other rooms and stated she did not feel this was the facility for her. On 10/28/25 at 9:10 a.m., Staff F CNA stated Resident #1 was very mean to other residents and sometimes aggressive. She stated she slapped the other residents. She stated she was on 15-minute checks currently but she was able to get into other resident rooms without them knowing. On 10/28/25 at 9:20 a.m., Staff G CNA stated the facility did not have enough staff to keep an eye on Resident #1 at all times. On 10/28/25 at 9:27 a.m., the Director of Nursing (DON) stated Resident #1 had a 30 second switch and could go from saying she loved her to calling her vulgar names. She went into other resident's rooms and if they became agitated, she became agitated and would hit. She stated they carried out numerous medication changes and stated one on one supervision may agitate her more. She stated if she was not on one-on-one supervision, there was no guarantee (she wouldn't physically lash out at staff again). She stated the sent-out referrals to other smaller facilities which may suit her better.

Based on record review, observation, staff interview, and policy review, facility failed to properly transfer a resident with a mechanical lift for 2 of 2 mechanical lift observations (Residents #27). The facility reported a census of 44. Findings include: The Quarterly Minimum Data Sample (MDS) dated [DATE] documented Resident #27 had diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, hemiplegia or hemiparesis and seizure disorder. Resident #27 required supervision or touching assistance for transfers. A Significant Change MDS dated [DATE] revealed currently in progress and documented Resident #27 recently had a fall requiring a change of condition MDS. In a Progress Note dated 6/24/25 at 2:52 PM documented that Resident #27 had a fall and was sent to the Emergency Department (ED). The Progress Note dated 6/24/25 at 6:00 PM, documented that the resident returned from the ED and had a diagnoses of fracture to the fifth metacarpal (finger bone) and right maxillary (upper jaw bone). The resident complained of pain, the resident was given his scheduled pain medication to help with his pain management. The Care Plan for Resident #27, last revised on 6/11/25, documented the resident required a mechanical lift with assist of two due to a right rotator cuff tear. Observation on 7/1/25 at 11:20 AM Staff B, Certified Nurses Aide (CNA) and Staff C, CNA, performed a mechanical lift transfer with an Invacare Reliant 450 mechanical lift. Resident #27 was in a lift sling and the sling was attached to the lift. The stability legs were closed under the bed. During the transfer, Resident #27 was lifted off the bed. Staff moved the resident in the lift approximately 4-5 feet and turned the lift approximately 45 degrees to face the wheelchair with the stability legs closed. The stability legs were then opened and the resident was moved forward and lowered into the wheelchair. Observation on 7/2/25 at 7:20 AM, Staff D, CNA and Staff E, CNA, performed a mechanical lift transfer. Resident #27 was in a lift sling and attached to the lift with the stability legs closed under the bed. During the transfer, the resident was lifted off the bed, moved approximately 4-5 feet from the bed, and turned approximately 45 degrees to face the wheelchair with the stability legs closed. The stability legs were then opened and the resident was moved forward and lowered into the wheelchair. On 7/1/25 at 11:25 AM with Staff B and Staff C, both reported that Resident #27 was changed to a mechanical lift transfer last week after her fall. Staff C stated that her roommate was also a mechanical lift transfer but prior to that they had not had a mechanical lift transfer in some time. Staff B stated that the mechanical lift legs are together under the bed and are opened to get around the wheelchair. When questioned about deployment of the mechanical lift legs for further distances, Staff B stated that the stability legs would be closed so they would not trip on them. Review of the Manufacturer's user manual for the mechanical lift used during the observations, with a copyright of 2022, documented the following on page 40: a. It warns users that failure to follow these instructions creates a potentially hazardous situation which could result in injury or death. b. The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. On 7/3/25 at 2:30 PM the Director of Nursing (DON), reported that all nursing staff get a competency check prior to operating the mechanical lifts. The DON stated her expectation is that the legs of the lift may be together under the bed as it might otherwise not fit but that when the lift is removed from under the bed, the legs should be opened and remain open until resident is moved to the wheelchair or bed. She added that the resident should not be moved with the legs together. The facility's undated Mechanical Lift Policy lacked information related to operation of the mechanical lift.

Based on record review, staff interview, and policy review, the facility failed to ensure 2 of 5 residents reviewed for immunizations were provided up-to-date pneumococcal vaccinations (Resident #38 and #1). The facility also failed to ensure 3 of 5 residents reviewed for immunizations were offered or received the Influenza vaccine for 2024 (Resident #38, #1, and #40). The facility reported a census of 44 residents. Findings include: 1. Resident #38's Face Sheet listed an age of [AGE] years old and an original admission date of 1/4/2025. The Immunization Record revealed Resident #38 had a Pneumovax 23 historically on 11/7/2017. The record lacked any indication of receiving the Influenza vaccine for 2024. The Immunization Registry Information System (IRIS) report indicated Pneumococcal 23 was given on 11/7/2017 with no other pneumococcal vaccines listed. It also listed the last Influenza seasonal vaccination given on 11/14/2022. CDC guidelines indicated to give one dose of PCV15 (Pneumococcal Conjugate Vaccine 15), PCV20 or PCV21 at least one year after the last dose of PPSV23 (Pneumococcal Polysaccharide Vaccine 23) to complete his pneumococcal vaccinations. In a document titled admission Packet, on page 20, Resident #38 representative signed on 1/13/25 that Resident #38 received the Pneumovax vaccine and the Influenza vaccination in October, 2024. No further documentation of pneumococcal vaccination or Influenza vaccination found in the Electronic Health Record (EHR) or the paper chart for Resident #38. 2. Resident #1's Face Sheet listed her age as [AGE] years old and an original admission date of 11/18/2024. The Immunization Record for Resident #1 indicated her pneumococcal vaccination status as having Pneumococcal conjugate PCV 13 historically on 11/29/2017 and no indication of receiving the Influenza vaccine for 2024. IRIS report indicated PCV13 was given on 11/29/17 with no other pneumococcal vaccines listed. It also listed the last Influenza seasonal vaccination was given on 9/20/2011. CDC guidelines indicated to give one dose of PCV20 or PCV21 at least one year after the last dose of PCV 13 to complete her pneumococcal vaccinations. 3. Resident #40's Face Sheet listed her age as [AGE] years old and an original admission date of 2/6/2025. The Immunization Record for Resident #40 had no indication of receiving the Influenza vaccine for 2024. In a document titled admission Packet, on page 11, Resident #40 representative signed on 2/6/25 that Resident #40 received the Influenza vaccination in 2024. No further documentation of Influenza vaccination found in the EHR or the paper chart for Resident #40. On 7/2/25 at 3:20 PM, Staff A, Assistant Director of Nursing (ADON) stated she was unable to show documentation of pneumococcal vaccination for Resident #38 other than the signed admission form that stated received 10/2024. She did not attempt to confirm that this information was correct. She also stated she is unable to show documentation of pneumococcal vaccination for Resident #1. She added that she is working on a vaccine clinic for about 20 residents which includes Resident #1. Once the details are figured out, she will offer the pneumococcal vaccine and obtain consents. She also indicated that she was unable to show that Resident #1 received or was offered the Influenza 2024 vaccination. Finally, she indicated she is unable to show documentation of influenza status for Resident #40 other than the signed admission form that stated she received in 2024. She did not attempt to confirm that this information was correct. Review of policy Pneumococcal Vaccinations indicated that all residents will be provided the opportunity and encouraged to receive pneumococcal vaccination, and, on admission each resident will be questioned regarding history of receiving the pneumococcal vaccinations. Each resident will be educated and offered the pneumococcal vaccine if they have never had the vaccine. The Director of Nursing/designee will be responsible for following up with the Physician's office when question arises, as to whether resident has had vaccine in the past. The policy lacked guidance on keeping up with CDC guidelines. Review of policy Influenza Vaccination indicated that all residents at the facility will be questioned on admission in regards to if they have had the Influenza Vaccine for the present flu season. Each year during the months of October through March, each resident/family will be educated and offered the flu vaccine injection.

Based on clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan that included targeted behaviors for 2 of 5 residents reviewed for unnecessary medication review (Resident #37, #19). The facility also failed to develop a comprehensive care plan that included focus, goal, and intervention for 1 of 1 residents reviewed for Edema (Resident #19). The facility reported a census of 44 residents. Findings include: 1. The Quarterly Minimum Data Sheet (MDS) assessment for the Resident #37 dated 8/8/24 identified a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS revealed the resident independent with eating, maximal assistance with toileting hygiene, shower/bathe self, dressing upper and lower body, supervision/touching assistance with personal hygiene. The MDS revealed the resident frequently incontinent of urine and bowel. The MDS documented diagnoses that included: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, Diabetes Mellitus (DM), Non-Alzheimer's Dementia, Seizure Disorder or Epilepsy, Anxiety Disorder, Depression, Unspecified Mononeuropathy of unspecified lower limb (a condition that occurs when a nerve or group of nerves in the left lower limb is damaged), Coronary Artery Dissection, Unspecified Tremor, and Insomnia. The MDS revealed Insulin, Antipsychotic, Antianxiety, Antidepressant, Antibiotic, Opioid, and Antiplatelet. The Care Plan revised 5/24/24 for the Resident #37 revealed no documentation for targeted behavior for unnecessary medication. On 8/11/24 at 12:43 PM MDS Coordinator, LPN revealed that the care plan should reflect the targeted behaviors the resident is taking the antipsychotic medication for. 2. The MDS assessment for the Resident #19 dated 7/2/24 identified a BIMS score of 12 which indicated moderate cognitive impairment. The MDS revealed the resident had rejection of care 1 to 3 days. The MDS revealed the resident independent with eating, set-up assistance with oral hygiene, toileting hygiene, dressing for upper/lower body, putting on/taking off footwear, and personal hygiene. The MDS revealed the resident occasionally incontinent of urine and always continent of bowel. The MDS documented diagnoses that included: Unspecified Dementia without behavioral disturbance, Hypertension, Dysphagia, Age-Related physical debility, and Generalized Edema. The MDS revealed no documentation for high-risk drugs. The Care Plan revised 7/1/24 for the Resident #19 revealed no documentation for goal and intervention related to generalized edema. The Care Plan revealed the focus of Dementia without behaviors, disturbance, psychotic disturbance and mood, anxiety, vitamin D deficiency, constipation, age related physical debility, edema hypertension, dysphagia, low cognitive functions. On 8/9/24 at 2:19 PM The resident sat in recliner with bilateral lower extremities slightly elevated. The right lower extremity edema appeared to be a +3 and left lower extremity edema appeared to be a +2. On 8/10/24 at 2:27 PM The resident sat in recliner with bilateral lower extremities slightly elevated. The resident denied any pain and any concerns related to the edema. The resident stated, they are fine, they always look like that. On 8/11/24 at 1:13 PM The MDS Coordinator, LPN and Director of Nursing (DON) reported the Care Plan should reflect the assessment and interventions for edema. The staff denied knowledge of the residents baseline regarded to bilateral lower extremities edema and any nurse documentation of monitoring. The staff stated the house Doctor assessed during the residents visits. The facility policy titled Comprehensive Care Plan revised 1/30/24 instructed the staff to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive Care Plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The Care Plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive Care Plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to revise the Care Plan for 2 of 12 residents reviewed for revision of care plan (Resident #37, #31). The facility reported a census 44 residents. Findings include: 1. The Minimum Data Sheet (MDS) assessment for the Resident #37 dated 8/8/24 identified a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS revealed the resident independent with eating, maximal assistance with toileting hygiene, shower/bathe self, dressing upper and lower body, supervision/touching assistance with personal hygiene. The MDS revealed the resident frequently incontinent of urine and bowel. The MDS documented diagnoses that included: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, Diabetes Mellitus (DM), Non-Alzheimer's Dementia, Seizure Disorder or Epilepsy, Anxiety Disorder, Depression, Unspecified Mononeuropathy of unspecified lower limb (a condition that occurs when a nerve or group of nerves in the left lower limb is damaged), Coronary Artery Dissection, Unspecified Tremor, and Insomnia. The MDS revealed Insulin, Antipsychotic, Antianxiety, Antidepressant, Antibiotic, Opioid, and Antiplatelet. The Care Plan revised 5/24/24 for the Resident #37 revealed no documentation for pain, including the resident started on Gabapentin (Anticonvulsants) scheduled started 6/28/24, Tramadol (opioid) scheduled and as needed started 8/6/24, and Tylenol scheduled started 8/6/24 and as needed 11/1/23. The Care Plan lacked personalized interventions or assessment for Pain and Mononeuropathy of unspecified lower limb. The Care Plan also revealed no documentation for Hemiplegia of left limb including goal and interventions. On 8/9/24 at 1:48 PM The resident #37 revealed pain increased in legs. The resident stated pain has been going on for a while, I know they started me on some more medicine to help my pain. The resident also stated my left hand does not seem to work much since my stroke, I wish it would do more. On 8/11/24 at 12:50 PM The Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse (LPN) stated pain should be listed as a focus with a goal and interventions. On 8/11/24 at 12:54 PM MDS Coordinator, Licensed Practical Nurse (LPN) and Director of Nursing (DON) stated the resident's dominant hand is her right hand, staff will correct the diagnosis. The staff stated the resident refused restorative program for her left hand, the resident does her own exercises in her room to keep her hand moving. The resident recently finished skilled therapy from having the stroke. The resident also refused any splint or brace that was recommended. 2. The Quarterly MDS assessment for the Resident #31 dated 6/25/24 identified a BIMS score of 1 which indicated severe cognitive impairment. The MDS documented the resident independent with eating, supervision with oral hygiene, dependent with toileting hygiene, dressing upper and lower body, personal hygiene, and maximal assistance with shower/bathe. The MDS revealed the resident frequently incontinent of urine and occasionally incontinent of bowel. The MDS documented diagnoses that included: Alzheimer's disease, Coronary Artery Disease, Non-Alzheimer's Disease, Malnutrition, Depression, Unspecified Mood Disorder, Primary Insomnia, Unspecified Osteoarthritis, Fibromyalgia, and Malaise. The MDS revealed Antipsychotic and Antidepressant. The Care Plan revised 6/21/24 for the Resident #31 lacked documentation for oxygen therapy, including assessment, monitoring pulse ox, diagnosis, changing the tubing, etc. On 8/9/24 at 1:56 PM The Resident # 31 revealed oxygen therapy at 2 liters nasal cannula, the concentrator was on, oxygen tubing was on bedside, the resident was sitting at side of bed, pleasantly confused. The staff member passing by placed oxygen therapy back on the resident. On 8/10/24 at 2:26 PM The resident #31 observed sleeping in bed with oxygen therapy in place, oxygen concentrator on at 2 liters nasal cannula, and tubing dated 8/8/24. On 8/11/24 at 8:00 AM The Resident #31 sat in the dining room, for the breakfast meal, the resident attempted to remove the oxygen therapy multiple times, the staff intervened and adjusted the tubing, and the staff provided education each time for the resident. On 8/11/24 at 1:09 PM The MDS Coordinator and DON stated the Care Plan should be updated with oxygen therapy as a focus, goal, and intervention. The staff stated the oxygen tubing should be changed weekly and the pulse ox monitoring as ordered by the doctor. The staff documents in the orders for these particular assessment and maintenance of tubing. The facility policy titled Comprehensive Care Plan revised 1/30/24 instructed the staff to develop and implement a comprehensive person-centered Care Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive Care Plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The Care Plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on clinical record review, observations, staff interview, and facility policy review, the facility failed to provide staff assistance for activities of daily living by not offering an opportunity to complete oral hygiene for 1 of 2 residents reviewed (Resident #197). The facility reported a census of 44 residents. Findings include: The Admission Minimum Data Sheet (MDS) assessment for the Resident #197 dated 8/14/24 revealed the resident admitted to the facility on [DATE]. The Baseline Care Plan initiated 8/7/24 documented the resident is assist of one staff for oral hygiene. The Care Plan initiated 8/10/24 revealed the resident is assist of one staff for grooming and hygiene. The Certified Nurses Aides documentation dated 8/7/24 to 8/11/24 revealed the staff supervised, set up/clean up assistance, moderate assistance, independent, or not applicable assistance with completion of oral hygiene. On 8/9/24 3:38 PM Noted a strong mouth odor from the resident during conversation. On 8/10/24 at 2:20 PM Noted the residents oral hygiene products: toothpaste dated 8/8/24 no signs of usage, toothbrush in plastic wrapper sat in oral basin, and mouthwash dated 8/8/24 sealed and full of liquid. The resident noted to have strong mouth odor during conversation. On 8/11/24 at 8:50 AM Noted the residents oral hygiene products: toothpaste no signs of usage, toothbrush had plastic wrapper on, and mouthwash sealed and full of liquid. On 8/11/24 at 12:03 PM Staff C, CNA stated the resident is assist of one with oral hygiene. The staff stated she supervised the resident, completed oral hygiene. The staff revoked statement, stated oh no I didn't someone else did the oral care on the resident. The staff unable to state who completed the oral hygiene for the resident. The staff confirmed she charted the resident oral hygiene, stated she had so many residents to chart on, it was an accident. The staff confirmed location of the residents oral hygiene products. The staff member acknowledged the toothbrush in plastic wrapper sat in basin, mouth wash full and sealed, and toothpaste, I see the residents oral care apparently is not getting done, if the tooth brush is still in the wrapper. On 8/11/24 at 1:23 PM Director of Nursing (DON) stated the resident is assist of one with hygiene. The staff should be assisting with oral care as the resident allows. The Administrator stated the facility does not have a specific policy related to oral hygiene, we follow standards of care.

Based on document review, observations, and interviews, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to complete regular smoking assessments for Resident #31. The facility reported a census of 41 residents at the time of the survey. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool dated 1/17/22, Resident # 16 scored 3 of 15 possible points on the Brief Interview for Mental Status, which meant the resident demonstrated severely impaired cognitive abilities. The MDS identified the resident as at risk for pressure ulcers with 1 venous/arterial ulcer, and open lesion. The MDS documented the resident received wound treatments including the application of non-surgical dressings, ointments and dressings to feet. The electronic medical record listed Resident # 16's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 16's care plan identified or initiated on 9/8/21 an actual alteration in skin integrity related to PVD/venous insufficiency. The care plan documented a goal: skin alterations will resolve with treatment over the next review period. The care plan directed staff to implement interventions that included: giving medication as appropriate, following treatment instructions, providing a balanced diet to promote wound healing, assessment by the dietician if appropriate, and follow physician's instructions. The care plan also included Resident #16's potential for a self-care deficit related to Alzheimer's dementia with severely impaired cognitive functions including maintaining good hygiene. The care plan directed staff members to follow treatments as ordered. The facility's Skin Management Protocol dated 10/14/21, directed staff to notify the Clinical Quality Team if the skin ulcer or non-ulcer has not made improvements after the first two weeks. The existing orders from 2/24/22 through 4/6/22 related to Resident # 16's wound management directed: A. Pro Stat Liquid Amino Acids Protein Hydrolysis Give 30 ml [milliliters] by mouth once a day for wound healing (ordered on 10/16/21). B. [MEDICATION(S)] Rapid Relief Cream 13% ([MEDICATION(S)]), apply to right medial ankle every 72 hours. Apply [MEDICATION(S)] mixed with collagen powder to peri-wound related to unspecified open wound on the right lower leg, cover with Optilock dressing, and wrap with Kerlix. Change every 3 days and as needed (ordered for 2/24/22 to 3/14/22). C. The Wound Treatment Plan dated 3/11/22 and noted by Staff B, directed staff to cleanse (the area) with wound cleanser, apply a large sheet of calcium alginate, cover with Optilock, and wrap with Kerlix. Change 3 x [times]/week and PRN [as needed]. However, the medication administration record (MAR) directed staff to provide the wound treatment every 3 day(s) and as needed, contrary to the Wound Treatment Plan, D. The Wound Treatment Plan dated 4/1/22, directed staff to Please cleanse with wound cleanser, apply triamcinolone cream to all eurhythmic areas, and then apply a sheet of calcium alginate, cover with Optilock, wrap with Kerlix. Change 3 x/week and PRN. In an observation on 4/5/22 at 11:12 AM, Resident # 16 walked slowly and in an awkward manner in the hallway of the CCDI (Chronic Care and Dementing Illness) unit toward the dining room for lunch. A closer observation of Resident # 16's right ankle revealed it wrapped with a white dressing that appeared dirty and soiled with a yellowish to brownish substance On 4/6/22 at 2:51 PM, observations for dressing change on Resident # 16's right medial ankle showed the following: A. Staff A, Certified Medication Aide (CMA) was in Resident # 16's room to assist Staff B Registered Nurse (RN) provide the dressing change. Staff A slowly unwrapped the wound area by removing the soiled Kerlix (bandage gauze) dressing which emitted a foul odor into the room. The outermost dressing (Kerlix) was very dirty with brownish wound drainage and Staff A verified that the dressing was very soaked. The poor condition of the dressing and the foul odor prompted inquiry as to when dressing was last changed, and if the dressing change procedure included writing a date on the top dressing, Staff A replied that dressings were dated but verified that Resident # 16's old dressing that was just removed did not contain a date. B. Staff B removed the alginate (wound dressing used to absorb exudates) dressing, which broke apart as Staff B lifted the dressing and removed it from direct contact with the moist wound surfaces. C. Staff A sprayed the wound/skin areas with wound cleanser as directed by Staff B. D. Staff B picked up a medication tube labeled, [MEDICATION(S)] 0.5% ointment apply to left forearm, and squeezed out ointment contents, and applied it all over the wound areas on Resident #16's right medial ankle. E. When asked to verify the label of the ointment medication tube/container, Staff A read, [MEDICATION(S)] 0.5% and verified with Staff B. Staff B reported that the ointment medication was applied to Resident # 16's wound on right ankle according treatment order and also stated that the wound treatments and dressing changes are being done every 3 days and PRN [As needed] when the dressing gets soaked. Staff B also verified that Resident # 16's dressing today was very soaked prior to change. On 4/7/22 at about 10:45 Am, the Director of Nursing (DON) provided the package insert (prescribing information) for the [MEDICATION(S)] 0.5% which described it as a potent corticosteroid indicated for the relief of swelling and itching such as in dry and scaly skin conditions, [CONDITION(S)], and discoid lupus erythematous. The information directed that ointment was especially appropriate for dry or scaly [CONDITION(S)]. Resident # 16's Medication/Treatment Administration Record or MAR and progress notes from 2/27/22 through 4/6/22 revealed Resident 16's consistent and ongoing refusal of nutritional supplement ordered for wound healing; treatment orders for wound on right medial ankle were not followed; and an unqualified staff member provided the treatments, as follows: A. Pro Stat Liquid Amino Acids Protein Hydrolysis (Protein supplement clinically proven for wound healing) Give 30 ml [milliliters] by mouth once a day (10/16/21): -January 2022, Resident # 16 took the Protein supplement for 4 days (1/3, 1/10, 1/20 and 1/31) only, but refused for the other 27 days of the month; -February 2022, Resident # 16 took the Protein supplement for 3 days (2/7, 2/14, and 2/28) but then refused for the other 25 days of the month; -March 2022, Resident # 16 took the Protein supplement for 5 days (3/13, 3/21, 3/22, 3/26, and 3/28) but refused the other 26 days of the month; and -April 2022 (1-6), Resident # 16 only took the Protein supplement for 1 day (4/2/22) but refused on the other 5 days. Review of the aforementioned documents revealed a lack of documentation to show and evaluation or review of Resident # 16's ongoing refusal of the protein supplement, in order to develop or address the ongoing ineffective intervention. B. Apply [MEDICATION(S)] Rapid Relief Cream 13% ([MEDICATION(S)]) to right medial ankle every 72 hours (2/24/22 to 3/14/22): -On 2/27/22, Staff W Registered Nurse (RN) completed Resident # 16's wound treatment as indicated in the progress notes. -On 3/2/22, Resident # 16 refused treatment, as documented. -On 3/5/22 (on the 6th day after the last treatment provided), Staff W completed the treatment and documented in the progress notes. -On 3/8/22, Resident # 16 refused treatment. -On 3/11/22 (on the 6th day from the last treatment provided), Staff W completed the treatment as documented in the progress notes. Resident # 16's wound dressing changes and treatments were completed every 6 days from 2/27/22 to 3/11/22. The record lacked documentation of other interventions and/or an evaluation or action taken related to the treatment refusals. C. Cleanse the wound with cleanser, apply large sheet of calcium alginate, cover with Optilock, wrap with Kerlix and change 3 x/week and PRN. The dressings were not changed according to treatment plan/orders, instead, for the period reviewed (3/11/22 to 4/6/22), the dressings were changed for 4 times (excluding CMA's) out of 26 days, on the following dates: -On 3/22/22, completed as documented in the MAR; -On 3/25/22, Staff S completed the treatment as noted in the MAR; -On 3/28/22, the Assistant Director of Nursing (ADON) completed a dressing change as noted in the MAR; -On 3/31/22, Staff A, (CMA) completed the dressing change as noted in the MAR; -On 4/6/22 or 6 days after Staff A's completed the dressing change, and 9 days after the ADON did the dressing change, Staff B with assistance from Staff A, completed the dressing change and applied the ([MEDICATION(S)] 0.5%) ointment medication (indicated for dry areas) to a draining wound without an order during the observation on 4/6/22 beginning at 2:51 PM. D. Apply triamcinolone cream to eurhythmic areas (4/1/22): -Observation on 4/6/22 showed that Staff B failed to apply this medication. On 4/7/22 at 3:54 PM, the DON verified that the facility's policy is not specific to wound treatment procedures and did not identify who should be performing the dressing changes. However, the DON reported that assessments and treatments are nursing responsibilities and added that she expected nurses to complete wound treatments (such as Resident # 16's vascular wound). The DON verified that Resident # 16's wound was first identified in 9/21, saying, The wound has been there for a while. The DON also stated she expected staff to follow treatment plan/orders and said dressings to weeping wounds such as Resident # 16's vascular wound dressing should not go unchanged for longer than the maximum period ordered, and to check the condition of dressings and change as needed. The DON further stated if confused residents refused treatments, she expected staff to re-approach the resident and document all actions taken in the residents' medical records. On 4/11/22 at 10:05 AM, the Wound Nurse/Nurse Practitioner (NP) verified they come to the facility every Friday and measured the wounds but did not provide any wound treatments when visiting. The NP verified they recommend the treatments and the facility implements them. The NP added they did not know what happened after they unwrap the wound for the assessment and stated they were not aware of the facility's procedures for wound dressing changes and documentation. During inquiry if wound healing could be delayed for failure of staff members to follow treatment orders, the NP answered, yes, potentially. Review of the progress notes completed by the above Wound Nurse/Nurse Practitioner (NP) revealed the following Skin Inspection documentation related to Resident #16's right medial ankle venous stasis ulcer: - 03/11/22: the wound measured 8.2 cm long x 5.7 cm wide x 0.1 cm deep and unable to assess wound bed. Tissue 15% macerated epithelial, 85% slough. The wound drained yellow to serous, heavy to thin drainage with no odor. - 03/18/22: the wound measured 22 cm x 12 cm x 0.1 cm, wound bed contained slough and epithelial, tissue 20% slough, 80% macerated epithelial exudate and periwound margins macerated. The wound drained yellow to serous, heavy to thin drainage with a foul odor. -03/25/22: the wound measured 16 cm x 28.5 cm x 0.1 cm, wound bed contained slough and epithelial, tissue 15% slough, 85% macerated epithelial and periwound margins macerated. The wound drained yellow to serous, heavy to thin drainage with a foul odor. - 04/01/22: the wound measured 15 cm x 30.1 cm x 0.1 cm, wound bed contained slough and erythemic epithelial, tissue 20% slough, and 80% macerated epithelial exudate and periwound margins macerated. The wound drained yellow to serous, heavy to thin malodorous drainage. 04/20/22 11:56 PM the Medical Director (MD) stated that he absolutely expects the facility to follow and implement treatments recommended by wound nurses including the frequency of treatments/dressing changes and the application of the correct medications. The MD said that in cases when residents frequently refuse treatments, staff should notify him so that the team can address the problem/s with a different plan. When asked if the wound could have healed or improved sooner if treatment orders have been followed, the MD replied, I totally understand! 2. The annual MDS assessment tool dated 6/17/21 revealed Resident #31 utilized tobacco. The care plan initiated on 6/3/19 with a revision date of 10/6/21 documented a goal for the resident to remain safe over the next review period and directed staff to allow Resident #31 to smoke with supervision in designated smoke area, and specified the resident could smoke one cigarette during smoking times but could have an extra cigarette if having behaviors to calm him down as needed. On 4/4/22 the facility provided a list of residents that smoked cigarettes which included Resident #31's name. On 4/06/22 at 10:12 AM, Resident #31 smoked with staff supervision in the facility's designated smoking area. A smoking assessment dated [DATE] revealed Resident #31 smoked 2-5 cigarettes per day and could light his own cigarette. The clinical record did not contain any follow-up or additional or regular smoking assessments for Resident #31 since 3/18/20. During an interview 4/06/22 at 11:09 AM, the Director of Nursing verified no smoking assessments completed quarterly as expected for Resident # 31 since 3/18/20 and added the MDS nurse usually completed them.

Based on clinical record review, observation, family and staff interviews, review of therapy staff education and training, and manufacturer user manual, the facility failed to provide adequate nursing supervision and assistance devices to prevent injury for 1 of 4 residents reviewed for accidents and hazards (Resident #42). The facility also did not consistently formulate interventions to prevent or minimize injury related to falls, and did not conduct a thorough follow-up investigations in order to manage/analyze the cause of the falls for 2 of 4 residents (Resident # 4 and Resident # 24) at risk for falls. As a result, Resident #4 sustained a wrist fracture and Resident #24 a femur fracture. The facility also failed to keep medications locked for 2 of 3 medication and treatment carts. The resident listed on the incident was included in the sample. The facility reported a census of 41 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 admitted to the facility on [DATE]. The MDS documented the resident had diagnoses of [CONDITION(S)], [CONDITION(S)], and a fractured left humerus (long bone between the elbow joint and shoulder). The MDS indicated the resident had a fall with a fracture prior to admission. The MDS documented the resident had a brief interview for mental status score of 9 out of 15, indicating moderately impaired cognition. The MDS documented the resident required extensive assistance of one staff for bed mobility, transfers, toilet use and dressing. The MDS documented the resident had impaired range of motion (ROM) to her upper extremity on one side, and had physical therapy (PT) and occupational therapy (OT) services that started on 2/3/22. A physician's history and physical dated 1/31/22 revealed Resident #42 had a deformity and proximal left humeral fracture with mild displacement, complicated by [CONDITION(S)], advanced age, and malnutrition. A diagnostic imaging x-ray report dated 1/31/22 revealed Resident #42 had a left comminuted and mildly displaced fracture of her left humeral neck. The care plan initiated 2/2/22 revealed Resident #42 had a self-care deficit and a fracture to her left humerus due to a recent fall at home. The staff directives included administer medications as ordered, assess for change in condition, provide assistance of one staff for ambulation and transfers, and therapy as indicated. The physician's order sheet dated 3/10/22 revealed PT AROM (active range of motion) to the left shoulder and PT/ OT evaluate and treat as indicated. The progress notes revealed: a. On 3/2/2022 at 10:38 PM, resident on skilled level of care after a recent fall at home which resulted in a left humerus fracture. Resident alert and oriented times three (person, place, time). b. On 3/10/2022 at 7:00 PM, resident returned from a doctor appointment with new orders to discontinue the sling on her arm, PT/OT evaluate and treat, and resident may use walker and have weight bearing as tolerated to her arm. c. On 3/24/2022 at 5:58 PM, resident sat in her room and complained of pain in her left upper arm. Ice pack placed to resident's upper arm, but resident still complained of pain. Nurse reported plan to call clinic and get an x-ray of her left arm since the resident had worked more with her arm in therapy. d. On 3/24/2022 at 6:19 PM, telephone order received to obtain left humerus x-ray. Nurse contacted x-ray vendor and requested order stat (right away). e. On 3/24/2022 at 7:15 PM, the resident complained of pain to her left subacute proximal humerus fracture area, rated at a 10. At 7:20 PM, the x-ray technician arrived and obtained an x-ray of Resident #42's left upper extremity. At 8:15 PM, x-ray findings received via fax. Findings were concerning for an acute on subacute to chronic proximal humerus fracture. Staff H called the Director of Nursing (DON). The DON planned to inform the resident and family of the findings: Resident's left upper extremity accidentally struck by some machine while in therapy in the AM and resident had increased pain. The DON requested to send the resident to the emergency department (ED) for alternative pain management versus [MEDICATION(S)] which had been ineffective for the resident's increased pain to her left humerus. At 8:30 PM, [MEDICATION(S)] 25 mg and Tylenol administered for pain rated at 10. Resident reported little to no relief of discomfort and had verbal and facial cues of pain with any slight movement or repositioning. At 8:55 PM, order received from the on-call physician to send the resident to the ED. Report called to the ED nurse, and resident sent to the ED at 10:00 PM. f. A late entry note on 3/24/2022 revealed at approximately 8:15 PM and in addition to previously entered interaction with resident and family members, the resident and family had reiterated several different times they did not want to get anybody in trouble and were adamant that the writer not speak with other staff about their conversation, as, again, they didn't want to get anybody in trouble, and that's why they call them accidents. At 12:50 AM (on 3/25/22), the resident's family member called and said the resident's arm was badly broken. An incident report dated 3/24/22 at 10:00 AM, revealed at approximately 5:30 PM, the resident's family member reported she had taken Resident #42 to the bathroom. The resident yelled out in pain while she walked down the hall. Staff I, Licensed Practical Nurse (LPN), assessed the resident and grew immediately concerned when the resident's pain was completely different than it had been all day. Staff I called to obtain a STAT x-ray order. A family member then told Staff I therapy had bumped the resident's arm with equipment that AM. The resident stated it was an accident and didn't want to get anyone in trouble. Staff I placed an ice pack on the resident's left arm and placed a pillow under her arm. After x-ray obtained and x-ray results received, Staff H, LPN, notified the resident and family member of the results. The facility sent the resident sent to the ED for further evaluation and pain management. A note included on the resident's incident report under a section for the resident's mental status revealed resident only stated ow at the time of the incident in therapy, but nothing else reported. The resident continued therapy after the incident and had no increase in complaints of pain or decrease in mobility. That evening, her pain was unbearable. X-ray reported an acute on subacute or chronic fracture of the left humerus. Proper use of equipment marked under a section for predisposing environmental factors. A section for other information included the following note: therapy reported as COTA student positioned diathermy on resident she stated it needed to be higher. The COTA student adjusted the machine approximately one inch away from her skin and three inches distal from the shoulder joint when the head of the Diathermy machine dropped on the resident's arm. The electronic health record orders revealed a STAT x-ray left humerus ordered due to increased pain and limited ROM on 3/24/22 at 6:08 PM, and also an order to transfer resident to the ED for evaluation and pain management related to increased pain and findings from left humerus x-ray. A diagnostic Imaging report dated 3/24/22 and compared to prior x-ray 1/31/22 revealed an increased deformity with cortical offset of 8 millimeters medially at the level of the proximal (near the point of attachment to the body) left humeral shaft fracture, and mild inferior subluxation (partial dislocation of one of the bones of a joint) of the humeral head. The medication administration record (MAR) dated 3/1- 3/31/22 revealed PRN [MEDICATION(S)] 25 mg given by mouth for pain on 3/24/22 at 08:30 AM for pain level rated at 8, 2:36 PM for pain level rated at 8, and at 8:30 PM for pain level rated at 10. Review of the OT evaluation and plan of treatment dated 3/21/22 revealed the resident had a left humeral fracture and the planned treatment approach included supervised diathermy modality application. An OT treatment encounter note dated 3/24/22 at 10:02 AM, revealed diathermy applied to the resident's left shoulder for 15 minutes in order to decrease [CONDITION(S)], increase ROM, and reduce chronic pain. A late entry dated 3/25/22 at 7:42 AM revealed while the student positioned the diathermy machine, the head (of the machine) fell and struck Resident #42 on the left upper extremity. Post treatment pain intensity 9 out of 10 to the left upper extremity shoulder. The OT discharge summary note dated 3/24/22 revealed resident discharged to the hospital due to re-injury. An interdisciplinary discharge summary created 4/12/22 revealed the resident suffered a re-fracture of her left humerus and did not return to the facility. The facility's investigation file related to incident on 3/24/22 revealed the following: a. On 3/25/22 10:30 AM Staff H, LPN, reported to the Executive Director and DON that on 3/24/22 at approximately 6:00 PM, Staff I, LPN, informed Staff H they were waiting on x-ray to arrive due to an injury that occurred in therapy. X-ray arrived at 7:20 PM. After the x-ray was completed, Staff H returned to the resident's room and offered her pain medication. While in the room, the resident stated she didn't want to say anything because she didn't want to get anyone in trouble. The COTA student felt really bad and even came down to the resident's room before she left the building. A family member reported they didn't want to get anyone in trouble, and that's why it was called an accident. The resident stated the machine was placed incorrectly and it bumped her and it hurt so badly, she screamed. Family reported resident not able to eat her food because it hurt too bad. Staff H informed the resident and family she would send her to the ED for further evaluation and pain management. b. On 3/25/22 at 10:49 AM, the COTA student reported to the Executive Director and DON an incident occurred on 3/24/22 at approximately 10:00 AM in the therapy gym. The COTA student positioned a diathermy on Resident #42 while she was seated. The resident complained of pain 9 out of 10 previous to the incident. The resident stated the diathermy needed to go higher. As the COTA student stated she adjusted the machine one inch away from the resident's skin, and three inches distal from the shoulder joint when the head of the diathermy dropped on the resident's arm. She heard the resident say Ow. The resident continued with isometric bilateral strengthening during diathermy treatment. The resident used her right hand to lift her shoulder and stated it was due to over-exertion. The COTA student reported she felt bad so she checked on the resident before she left. She looked at the area and noted previous bruising. The COTA student stated she did not report incident to anybody because the COTA instructor and Rehabilitation Director (RD) were present and didn't think the injury was extreme. The resident routinely said ow during therapy, but after incident the ow was slightly louder than usual. c. On 3/25/22 at 11:07 AM, the COTA instructor reported to the Executive Director and DON that she stood behind the resident and COTA student during the incident. Resident #42 sat in a chair while the diathermy got set up by the COTA student. She heard the resident say ow, then heard the COTA student say I'm so sorry and then Resident #42 said I'm alright. d. On 3/25/22 at 1:42 PM, Staff I, LPN, reported to the Executive Director and DON she worked 6 AM-6 PM on 3/24/22. A family member told her a machine bumped Resident #42's left arm. The resident complained of pain 8 out of 10 in the morning and afternoon, and took two pain pills on 3/24/22. Staff I noted the resident's pain was not excruciating as she had not yelled out in pain. At approximately 5:30 PM, the resident's family member said she took the resident to the bathroom and walked her down the hallway. The resident yelled out in pain while she walked in the hallway. Staff I told the resident when she could have pain medication, then gave her an ice pack. The resident used her right arm to lift her left arm up in order to place a pillow underneath, but the resident screamed out in pain. Staff I grew concerned as it was totally different than the pain she displayed earlier. Staff I called the physician and got a STAT order for an x-ray. When she let the resident and family know the plan for the x-ray, the family member told Staff I that therapy had bumped the resident's left arm with equipment. The resident stated it was an accident. e. On 3/25/22 at 2:15 PM, the RD reported to the DON and ADON an incident that occurred on 3/24/22 at 10:00 AM. After she heard resident say Ow, she turned around and the COTA student said it slipped. She did not witness the incident as she had her back turned and heard resident say ow. The resident did not seem to be in any excessive pain or abnormal pain during therapy. The RD reported she treated resident right after the incident with leg activity and walking. The resident was able to grip her walker and push it from the therapy room back to her room at end of the East Hall. The resident did not complain of any additional pain during therapy. f. On 3/25/22 at 2:42 PM Staff Q, CNA reported to the Executive Director and DON she heard therapy bumped Resident #42's arm on 3/24/22. Staff Q reported she assisted the resident to the bathroom around 2:30 PM on 3/24/22. The resident appeared to be in pain. She informed Staff I, LPN, and Staff I gave the resident a pain pill. The resident had no stabbing pain prior to supper. g. On 3/25/22 at 3:00 PM, Staff X, CNA, reported to the Executive Director and DON she worked 6 AM to 2 PM on 3/24/22. She gave Resident #42 a shower before breakfast. The resident complained her arm hurt but this was normal behavior for this resident. She did not note any skin issues. Review of ED triage note and hospital history and physical dated 3/24/22 at 10:20 PM revealed Resident #42 presented to the ED for evaluation of a broken arm. The resident lived in a nursing home due to a fractured humerus and as she worked with PT, they hit her arm on a piece of equipment. The resident had severe pain, and an x-ray noted she had a second fracture. Resident sent to the ED for pain control. The nursing home staff told the ED staff medical equipment in PT malfunctioned which caused the fracture to her arm. The resident reported a machine hit her today but no malfunction of any equipment. She broke her arm on 1/31/22 and it had been healing well. An left humerus x-ray 3/24/22 at 11:18 PM revealed an increased deformity with cortical offset of 8 mm medially at the level of the fracture through the proximal shaft of the left humerus. Recommended treatment included immobilization with a sling, outpatient follow up at an Orthopedic Clinic, ice to the area, and [MEDICATION(S)] for pain. In an interview 04/06/22 at 10:55 AM, a family member reported the resident's arm got broken during therapy when staff placed a machine over her arm. The family member was uncertain what the machine was called but described the machine as white and it went around the resident's arm, and put air or heat to the area. In an interview 04/06/22 at 2:30 PM, Staff I, LPN reported she worked the 6 AM-6 PM shift. Resident # 42 admitted to the facility with a left humerus fracture. The resident fell at home and came to the facility for therapy. Staff I stated she worked on the day of the incident with Resident #42, but was unable to recall the date. Staff I reported the resident complained of pain in her left arm and had worked with therapy that day. She gave the resident a pain pill before she went to therapy that day, and again at 2:20 PM when the resident requested another pain pill. The resident's family member came to the facility to visit. Around 5:30 or 5:45 PM, the family member came to the nurse's station and asked when the resident could have a pain pill. Staff I told her a pain pill was not due until around 8:00 or 8:30 PM. She reported the resident complained of her left arm hurting. The family member took the resident to the bathroom and then walked with her down the hall. The resident yelled out in pain from her left shoulder. Staff I stated she took the resident an ice pack to put on her left shoulder. At that time, she observed the resident had facial grimacing and pain that was not her norm. She called the doctor and got an order for an x-ray, then called the x-ray vendor to obtain an x-ray on the resident's arm. She gave report to Staff H, LPN, when she left at 6:00 PM. In an interview 04/07/22 at 08:19 AM, Staff H, LPN, reported she had worked at the facility for 6 months, and worked the 6 PM - 6 AM shift. Staff H reported Resident #42 admitted from the hospital and had a fractured humerus. She was a frail little lady. On 3/24/22, Staff H reported she came to work at 6:00 PM. Staff I told her the x-ray company was coming to do an x-ray on Resident #42. After report she walked to Resident #42's room and asked her if she wanted a pain pill since x-ray may move her arm during the x-ray. The resident requested a pain pill, so she gave her something. The resident said her arm got bumped by a machine in therapy, but the resident told her not to say anything because it was an accident. The family member told her the resident said the therapist had bumped it, and it was an accident. Staff H told them she needed to report the incident. The x-ray vendor came and got x-ray on resident, then when she got the x-ray report, she contacted the physician, and then sent the resident to the ED. She gave report to the ED nurse. Later, the resident's family member called her and asked did you tell them the machine malfunctioned? Staff H said she told them the machine bumped her arm because that is what the resident and family member told her. Staff H stated she could see something like that happen as the (therapy) room is pretty tight quarters. When three people in therapy room it's tight. Staff H stated she reported the incident to the DON. In an interview 04/07/22 at 10:02 AM, the RD reported their company contracted with the facility for therapy services. The RD stated she had been a PTA since 1998. The RD reported diathermy treatment was used to help relieve pain, decrease swelling, decrease bruising, and helped stretch a muscle or contracture. She documented on the therapy evaluation the modalities needed such as diathermy and then the physician signed off on the therapy evaluation. The RD stated on the day of the incident, a student worked with Resident #42. The resident sat in a chair in the therapy room. The RD reported she worked with another resident at the parallel bars and had her back turned, not paying attention to Resident #42 at that time. She heard Resident #42 say ow. The RD reported she turned around and looked, and everything seemed ok. She noted the resident had no increase in pain from her norm. Resident #42 already had a fractured humerus. The RD stated she asked the COTA student what happened. The COTA student said the drum slipped a little and hit the resident's arm. The RD said she asked the resident if everything was ok. The resident said it was ok, it was an accident. After diathermy treatment, she worked with the resident for OT, did normal therapy exercises, and walked her back to her room. The resident had no increased pain, other than normal complaints of pain due to a prior fracture. The RD reported the COTA student had worked at the facility for two weeks, and had worked with Resident #42 before. In an interview 04/07/22 at 10:00 AM, the COTA student reported she had worked 4 weeks in the facility with the OTA (occupational therapy assistant) program, and went between the facility's East and West campus. The COTA student reported she had clinical once a week, in addition to classroom time and learning modalities for the OTA program. The COTA student reported the COTA instructor was present in the building whenever she had clinical. On the day of the incident with Resident #42, it was her 2nd week at the West facility. She had worked with Resident #42 during the first week in therapy. On the second week at the facility, which was the day of the incident, she spoke with the resident in her room. She had increased pain, 9 out of 10, and requested pain medication from the nurse. She placed a gait belt around her and ambulated with the resident to the therapy room. The resident sat down in a chair in the therapy room, she positioned the resident in the chair, and placed the diathermy by the resident's left side. The resident asked her to move the machine up a bit, so she moved the diathermy and when she tightened the diathermy, the drum dropped down. The drum was about 3-4 inches from tuberosity (a large prominence on bone). The resident said ow. The COTA student said oh my goodness I'm so sorry. This was the third time she had used the diathermy and adjusted it. She found out later she should move the drum away to tighten it. After diathermy treatment, she had the resident use one pound weights on her right arm, but the resident said the weight was took heavy and she had too much pain whenever used the weights on her left arm. The resident did ROM but used her right hand to lift her left arm. The resident had an audible response or moan with any kind of movement. She was recovering from a fracture already. The resident reported pain 9 out of 10, and had no change in pain after diathermy treatment completed. The resident ambulated with a walker back to her room after therapy, and had no indication of anything different from her previous fracture. The COTA student stated she later checked the resident before she left the facility. The resident had a bruise on her arm but she already had a bruise before the incident. The resident told her she had overexerted herself on prior days in therapy 2-3 days beforehand. The resident had used the pulleys on the prior therapy session but not the day of the incident. The resident told her she was super sore and required pain medication. In an interview 04/07/22 at 11:20 AM, the COTA instructor reported Resident #42 came to therapy with the COTA student on the day of the incident. The COTA instructor stated she helped the RD stand another resident up in the therapy room and heard Resident #42 complain of pain 9 out of 10, but was agreeable to work with therapy. The COTA instructor reported she heard Resident #42 say ow, then heard the COTA student say I'm so sorry, are you ok? The COTA student told her the drum of the diathermy machine had swung and hit the resident, and bumped the resident's arm. The COTA student readjusted the drum because Resident #42 said it needed adjusted. The resident had her arm inside the chair at the time. After that happened, the resident said she was ok to continue the therapy session. The COTA student did AROM exercises after diathermy treatment, and the resident agreed to work with PT after OT. The COTA instructor reported the COTA student later checked the resident to see if she was ok. The resident continued to complain of pain 9 out of 10. On 04/07/22 at 11:30 AM, the COTA student demonstrated application of the diathermy machine on the Regional Therapy Director as the surveyor observed. The COTA student placed the diathermy by his left arm and then as she tightened the knob on the drum, the drum dropped down. The COTA student said she didn't know why it did that, it could be finicky. The COTA student readjusted the knob again until the diathermy drum was positioned within 1 inch of the Regional Therapy Director's arm. In an interview 04/07/22 at 12:12 PM, the RD reported an outside company performed maintenance checks on diathermy equipment, and placed a sticker on the back of diathermy machine whenever inspected. The sticker revealed 1/24/22. At the time, no owner's manual found on or by the machine. At 12:25 PM, the RD reported owner's manual on digital CD and provided user manual information to the surveyor. In an interview 04/11/22 at 2:00 PM, the Maintenance Director reported he had worked at the facility since 8/2021. The Maintenance Director reported they used the TELS system for work orders and to know what repairs or maintenance needed on equipment. The Maintenance Director reported he didn't touch or check equipment in the therapy room. In an interview 04/11/22 at 06:30 PM, a local hospital Emergency Department (ED) nurse reported she worked on the evening when Resident #42 came to the hospital ED. She took report from the facility's nurse. Initially she was told a piece of equipment bumped the resident's arm a few days before arrival to the ED. The resident had a broken arm. What resident told her was different than what facility nurse told her. The resident reported she worked with a therapy student, and equipment accidentally bumped her arm, the same arm that already had a fracture. In the ED, she had a left humeral head fracture but the break was worse than the original break. A comparison x-ray showed a new and displaced fracture that was bigger than the original fracture. The ED nurse stated when she spoke with the same nurse who gave her report, the nurse told her a piece of equipment malfunctioned, and it had happened that day (the day the resident came to the ED). Upon arrival to the ED, the resident appeared to be in pain and had a hard time moving. The resident didn't want to say anything because the incident occurred with a student, and she felt really bad about it. In an interview 04/12/22 at 09:00 AM, the diathermy vendor technician reported he serviced the equipment at the facility, and recently checked the diathermy at the facility. A bolt was stripped and he fixed it, but uncertain on date when he serviced the equipment. He needed to check his computer for the dates. In an interview 04/12/22 at 02:42 PM, the DON reported Resident #42 admitted to the facility and had an acute left arm fracture. She had her left arm in a sling, but started therapy after the physician discontinued her sling. The DON stated on the day of the incident, the resident walked down the hall for therapy. Nobody told her about what happened until she got a call from the evening nurse who reported the resident had severe pain in her arm and said a piece of equipment bumped her in therapy. The nurse called and got an x-ray, then called the DON back after they got the x-ray results that showed a possible fracture. The DON said she told the nurse to go tell the resident and family about the x-ray results and requested to send the resident to the ED. The DON said the facility did an investigation and found out why the incident was not reported to nursing. The resident always said ow and was not in any acute pain after her arm got bumped. It was reported the machine was approximately three inches from her shoulder and one inch from her skin. After the machine bumped the resident's arm, the student said she was sorry and asked the resident if she was ok, then proceeded to do therapy. The resident ambulated with walker from therapy to her room after therapy. At 2:30 PM, the resident complained her arm hurt but nothing to trigger acute pain. The nurse gave the resident pain medication. Just before supper, a family member took the resident to the bathroom. As the resident walked from her room toward the dining room, the resident cried out in pain. The nurse said the resident was really hurting so she gave her an ice pack, and placed a pillow under her arm. The resident yelled out in severe pain when she moved her arm. In an interview 04/13/22 at 01:00 PM, the diathermy vendor technician reported he checked his records and was incorrect when he stated he came to the facility to repair the diathermy. He reported he was at another facility and worked on a diathermy machine where the rear handwheel was stripped out, and the arm was not holding up and he had to switch that out. The technician reported he last performed annual preventative maintenance (PM) at the facility on 1/24/22. The PM entailed checking the diathermy machine. The technician reported the diathermy drum adjusted with a screw knob. The diathermy had multiple screws or knobs. One on the bottom that made the drum swivel back and forth, one that made the arm go up and down, and one that made the drum swivel sideways. The drum weighed about 2 lbs. If the drum dropped down, then most likely the bolt got stripped. Through the years customers tighten the knob really tight and it could cause the bolt to get stripped and then the drum drops down. Staff should tighten the bolt as much as they can and then loosen a little to swivel the drum in place and place it into the position desired. The bolt could strip out over time. The technician acknowledged the facility had not mentioned anything to him about the diathermy drum dropping down or any issues related to the diathermy. When he did the PM in 1/2022, the bolt worked just fine and the machine drum did not drop down. If machine not functioning as it should, then the facility should call and let their company know. On 04/13/22 at 01:20 PM, the RD provided a copy of COTA student competencies. In an interview 04/13/22 at 01:25 PM, the COTA student reported she started webinar trainings on 3/15/22, and also went to class and had clinical time, so the webinar/ competency trainings required by therapy organization took her some time to complete. The COTA student reported she watched the overview of biophysical agents which included modalities such as diathermy on 3/29/22, and completed the competency checklist on 4/11/22. In an interview 04/13/22 at 01:30 PM, the RD confirmed the last time the technician came to service diathermy was 1/24/22 per sticker on the machine. The RD stated she did not call the company after the incident occurred with Resident #42. The RD reported the diathermy wheel had teeth or grooves, so if staff didn't get the teeth seated in the grooves of the wheel just right, the wheel may not get tightened enough to hold the drum where you want it. The RD stated if they had a problem with the diathermy equipment, she would call the company to check the machine. After the incident, she didn't think there was anything wrong with the diathermy equipment so she did not contact the company to check it. At 02:06 PM, RD reported she was uncertain if diathermy equipment used at school is the same as the diathermy equipment in the facility's therapy department. She thought it had similar features but possibly not the same brand used at the facility. In an interview 04/14/22 at 10:15 AM, the RD reported diathermy equipment preventative maintenance check and service were required once a year. Whenever equipment was not working properly or something was wrong, she put a do not use sign on the equipment, and let the facility know, and equipment was not used until it got repaired. After incident with Resident #42 she checked the diathermy but determined it wasn't broken, so she did not call for service on the equipment. The RD reported she worked with residents in therapy, in addition to her director position. The COTA instructor responsible for overseeing students whenever students were in the building. The RD reported the COTA student had worked with Resident #42 a couple times, but she was uncertain how many times the COTA student had used the diathermy at the facility. The RD reported the home office investigated the incident. The RD acknowledged she was uncertain if the training manual was the same information as the user manual for the diathermy, she hadn't watched the user manual video. The required training competency was a general video about the use of the diathermy machine. The RD reported the therapy company that contracted with the facility had the same brand of diathermy equipment. The RD stated she was unaware of any other staff h [TRUNCATED]

Based on record review and staff interview the facility failed to provide eight consecutive hours of registered nurse coverage seven days a week. The facility reported a census of 41. Findings: The facility provided documents titled Daily Assignment Sheets and the Nurses schedule that revealed no registered nurse scheduled to work on: 3/19/22 3/20/22 The Director of Nursing (DON) provided a document that revealed she was gone from March 11th through March 20th, 2022 with illness. In an interview on 4/7/22 at 1:20 PM, the DON stated there was not a Registered Nurse (RN) on duty for 3/19/22 and 3/20/22.

Based on clinical record review and staff interview, the facility failed to ensure residents' Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #18, #31 and #38). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated [DATE] documented Resident #31 admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident scored 0 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated severely impaired cognitive abilities. score of 0 indicating severe cognitive impairment. Review of the resident's care plan revised on [DATE] documented Resident #31's advanced directive as cardiopulmonary resuscitation (CPR) with full treatment preference (also commonly known or identified as Full Code). Resident #31's Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The form did not contain a mandatory signature by the resident or legal representative. The resident's progress notes also lacked documentation that showed the facility communicated with the resident's representative regarding advanced directive preferences or wishes for their loved one. 2. According to the MDS dated [DATE], Resident #38 admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed a BIMS score of 0 (severe cognitive impairment). The resident's care plan revised on [DATE] documented their advanced directives as DNR (Do NOT Resuscitate). Review of Resident #38's IPOST signed by the physician on [DATE] included their DNR preference but lacked a mandatory signature from the resident or their legal representative. The resident's progress notes failed to contain documentation to show staff communicated with the resident or their representative with regard to advanced directives. 3. The MDS dated [DATE] identified Resident #18 as under the care of hospice with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented Resident # 18 demonstrated confusion due to dementia and directed staff to follow advance directives (AD) per resident and/or family request over the next review period. The care plan also documented Resident # 18's advanced directive as: do not resuscitate (DNR). However, the IPOST form signed by Resident # 18's legal representative and the physician on [DATE] directed staff members to administer cardiopulmonary resuscitation (CPR) if Resident # 18 had no pulse and was not breathing. On [DATE] at 11:12 AM, the Director of Nursing (DON) verified Resident #18's AD form in the physical or hard chart contained information that conflicted with documentation in Resident # 18's electronic records; the AD form in the hard chart directed staff to provide CPR while the orders in the e-chart documented the resident's preference as DNR. The DON acknowledged the importance of consistent information throughout all of Resident # 18's records, and verified the facility needed to update the resident's AD form. During a subsequent interview on [DATE] at 8:30 AM, the Director of Nursing (DON) revealed the facility expected staff to obtain the resident or their representative's signature on the IPOST at the time of admission. The Iowa Department of Public Health website titled, IPOST Form and Guidance, Description of the IPOST form visited [DATE] and copyrighted 2021, directed in accordance with the statute that the IPOST form shall be a uniform form and shall have all of the following characteristics: patient's name and date of birth, and signatures and dates from the patient or patient's legal representative, the patient's physician, advanced registered nurse practitioner (ARNP), or physician assistant (PA) and the facilitator if the preparation of the form was completed by an individual other than the patient's physician, ARNP or PA.

Based on record review and staff interviews, the facility failed to ensure residents remained free from abuse for 3 of 15 residents reviewed (Resident #28, #34, #43). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 4/8/21 documented Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #43 required extensive assist of 1 staff for dressing, hygiene and toilet use and limited assist of 1 staff with transfers and ambulation (walking). The care plan dated 4/6/21 documented Resident #43 showed an altered mood or behavior and directed staff to assess for behavior changes and re-approach the resident when more calm. The Care Plan also identified the resident experienced impaired communication due to dementia and directed staff to allow the resident time to respond to communication and added staff may need to repeat or rephrase requests and give simple, calm explanations with cares. In an interview on 04/12/22 at 12:20 PM, Staff S, Certified Nursing Assistant (CNA) stated Resident #43 would physically act out at times and added, You could not rush him. On 04/12/22 at 12:30 PM, Staff R, CNA reported Resident #43 could sometimes be be really sweet and other times sometimes really combative. Staff are stated the resident could carry on a conversation, but then he forgets. The facility's investigative report dated 4/30/21 at 9:15 PM, documented Staff M, Licensed Practical Nurse (LPN), heard, as she stood in the bathroom, Staff O, CNA in the hallway yelling profanity and calling Resident #43 profane names. Staff O then went into another resident's room when she exited the bathroom. 2. An MDS dated [DATE] documented Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also documented the resident needed extensive assist of 2 for bed mobility, transfers, dressing, and toilet use and was always incontinent of bowel and bladder. The MDS revealed Resident #34 scored 6 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident experienced severe cognitive impairment. The Care Plan dated 3/24/21 directed staff to approach and speak to Resident #34 in a calm manner and provide extensive assist of 1-2 staff for bed mobility, dressing, and personal hygiene and assist of 2 staff for transfers with a Hoyer lift. The Care Plan included a goal for the resident to remain free of tissue injury and instructed staff to use caution with contact. The facility's investigative report dated 4/30/21 at 9:30 PM, documented Staff N, CNA notified Staff M, LPN that Staff O, CNA treated Resident #34 in a physically aggressive manner when he slammed the resident into the side rail while ranting about his work. Staff N, CNA reported that during the encounter Resident #34 had a terrified look on his face. The report revealed Staff N, CNA took over for Staff O, CNA to finish caring for the resident. Staff M, LPN spoke with Resident #34 and he reported a sore hand from being tossed to the side. 3. The MDS dated [DATE] indicated Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident exhibited severe cognitive impairment and required extensive assist with bed mobility, transfers, dressing, and toilet use. The MDS documented Resident #28 as always incontinent of bladder and frequently incontinent of bowel. The Care Plan dated 2/18/21 directed staff to allow the resident time to respond to communication and rephrase or repeat as needed, provide care with simple and calm explanations, and transfer Resident #28 with assist of 2 staff and a Hoyer lift. and . An incident report dated 4/30/21 at 9:45 PM documented Staff M, LPN was in another resident's room and heard Resident #28 yell, Ow, that hurts! Staff O, CNA responded, I'm just trying to get you into f*****g bed. The report revealed Staff M, while in the middle of an assessment of Resident #34, did not take any immediate action; Staff 0 left facility before Staff M had addressed the incident. Staff M, LPN then notified the Administrator, DON and ADON of Staff O's behavior. In a telephone interview with Staff M, LPN on 04/12/22 at 01:18 PM, she reported she overheard Staff O, CNA swearing at Resident #43. She exited the bathroom and was called to another unit to address a resident to resident verbal altercation. Staff M stated when she returned, Staff N, CNA described the incident between Staff O and Resident #34. Staff M reported she assessed Resident #34 who told her, he threw me over and hurt my hand. Staff M said she overheard a verbal altercation between Resident #28 and Staff O while assessing Resident #34, and then Staff O left the building before she could address the situations with him, so she called the DON to report the incidents with the 3 residents. The facility's Abuse Investigative Tool forms for Residents #28, #34, and #43 revealed the facility notified the Newton Police Department on 4/30/21 at 9:35 PM and the Department of Inspections and Appeals (DIA) Hotline at 9:29 PM. A police report of the incidents involving Staff O, CNA and Residents #28, #34, and #43 and included hand written interviews with Staff M, LPN, Staff N, CNA and the DON. A typed report by the DON revealed she called Staff O, CNA and requested an emailed statement of interactions with Residents #28, #34, and #43. The report showed the DON told Staff O, CNA he was suspended without pay while the facility completed an investigation. An undated typed copy of an email from Staff O, CNA contained an apology for being in a bad mood all night. In the email he wrote that he cannot deny talking inappropriately around residents. A typed document dated 5/4/21, revealed the DON and VP of Human Resources called Staff O and told him their investigation revealed there was enough evidence to conclude resident abuse occurred and then terminated him effective immediately. Documentation in an Employee Corrective Action Form dated 5/5/21 revealed Staff M, LPN overheard [Staff O] violate the facility's abuse policy when he used vulgar and inappropriate language and she had the responsibility to address the staff member involved and ensure the safety of other residents. The form contained signatures from Staff M, LPN, the DON, and the Administrator. The facility's Abuse Prevention, Identification, Investigation, and Reporting Policy dated 10/1/2019 revealed that all residents have the right to be free from abuse. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Two (2) All Abuse Reporting Within 2 Hours - Education sheets directed staff to separate victim from perpetrator immediately and if alleged perpetrator is a staff member, staff member will be separated from all residents and then the Administrator. Staff N, CNA had signed and dated one form on 5/3/21 and Staff M, LPN had signed and dated another.

Based on record review and staff interviews, the facility failed to implement their abuse policies with incidents that involved 3 of 15 residents reviewed for abuse (Resident #28, #34, #43). The facility reported a census of 41 resident. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 4/8/21 documented Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #43 required extensive assist of 1 staff for dressing, hygiene and toilet use and limited assist of 1 staff with transfers and ambulation (walking). The facility's investigative report dated 4/30/21 at 9:15 PM, documented Staff M, Licensed Practical Nurse (LPN), heard, as she stood in the bathroom, Staff O, CNA in the hallway yelling profanity and calling Resident #43 profane names. Staff O then went into another resident's room when she exited the bathroom. 2. An MDS dated [DATE] documented Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also documented the resident needed extensive assist of 2 for bed mobility, transfers, dressing, and toilet use and was always incontinent of bowel and bladder. The MDS revealed Resident #34 scored 6 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident experienced severe cognitive impairment. The facility's investigative report dated 4/30/21 at 9:30 PM, documented Staff N, CNA notified Staff M, LPN that Staff O, CNA treated Resident #34 in a physically aggressive manner when he slammed the resident into the side rail while ranting about his work. Staff N, CNA reported that during the encounter Resident #34 had a terrified look on his face. The report revealed Staff N, CNA took over for Staff O, CNA to finish caring for the resident. Staff M, LPN spoke with Resident #34 and he reported a sore hand from being tossed to the side. 3. The MDS dated [DATE] indicated Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident exhibited severe cognitive impairment and required extensive assist with bed mobility, transfers, dressing, and toilet use. The MDS documented Resident #28 as always incontinent of bladder and frequently incontinent of bowel. An incident report dated 4/30/21 at 9:45 PM documented Staff M, LPN was in another resident's room and heard Resident #28 yell, Ow, that hurts! Staff O, CNA responded, I'm just trying to get you into f*****g bed. The report revealed Staff M, while in the middle of an assessment of Resident #34, did not take any immediate action; Staff 0 left facility before Staff M had addressed the incident. Staff M, LPN then notified the Administrator, DON and ADON of Staff O's behavior. In a telephone interview with Staff M, LPN on 04/12/22 at 01:18 PM, she reported she overheard Staff O, CNA swearing at Resident #43. She exited the bathroom and was called to another unit to address a resident to resident verbal altercation. Staff M stated when she returned, Staff N, CNA described the incident between Staff O and Resident #34. Staff M reported she assessed Resident #34 who told her, he threw me over and hurt my hand. Staff M said she overheard a verbal altercation between Resident #28 and Staff O while assessing Resident #34, and then Staff O left the building before she could address the situations with him, so she called the DON to report the incidents with the 3 residents. A typed report by the DON revealed she called Staff O, CNA and requested an emailed statement of interactions with Residents #28, #34, and #43. The report showed the DON told Staff O, CNA he was suspended without pay while the facility completed an investigation. An undated typed copy of an email from Staff O, CNA contained an apology for being in a bad mood all night. In the email he wrote that he cannot deny talking inappropriately around residents. A typed document dated 5/4/21, revealed the DON and VP of Human Resources called Staff O and told him their investigation revealed there was enough evidence to conclude resident abuse occurred and then terminated him effective immediately. The facility's Abuse Prevention, Identification, Investigation, and Reporting Policy dated 10/1/2019 revealed that all residents have the right to be free from abuse. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and includes verbal abuse, sexual abuse, physical abuse, and mental abuse. In an interview on 04/13/22 at 10:40 AM, the Director of Nursing, (DON), stated Staff O, she was notified of the incident with Staff O, CNA and residents, came to the facility right away and conducted the investigation, called the police and reported it right away, suspended Staff O, CNA until the investigation was done, and then suspended Staff M, LPN for failing to separate Staff O, CNA from the residents. She stated she had a disciplinary training with Staff M, LPN and then brought her back to work. In an interview on 04/13/22 at 10:50 AM, the Administrator stated her expectation for staff is for them to separate the staff member from the residents who may be doing the suspected abuse then notify the DON and Administrator.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to provide restorative program activities in order to maintain the resident's functional range of motion and ability to carry out activities of daily living for 5 of 16 current residents reviewed for restorative activities (Residents #4, #6, #34, #38 and #40). The facility reported a census of 41 residents. Findings include: 1. The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe impaired cognition. The MDS dated [DATE] documented Resident #6 required two person physical assistance with walking in the corridor, set-up assistance only for locomotion on the unit and one person physical assistance with dressing. The MDS dated [DATE] documented Resident #6 did not walk in the corridor, locomotion on the unit required one person physical assistance and dressing required two person physical assistance. The MDS further revealed zero number of days of following restorative nursing programs in the last 7 calendar days. Review of Resident #6's Care Plan with a revision date 1/6/21 and a goal to maintain highest practicable level of mobility documented restorative therapy as indicated as an intervention initiated 7/29/20. Review of facility form titled Restorative Nursing Programs and signed 3/17/22 by the Rehab Director revealed recommendations for Resident #6 including range of motion (ROM) to lower extremities with special instructions for the bike for 15 minutes, ambulation to walk resident up as tolerated with front wheeled walker and 1-2 staff assistance 2 times a day with staff and wheelchair to follow. Clinical record review revealed Resident #6 completed restorative care for the minimum 15 minutes on 4 occassions since 1/1/22. 2. The annual MDS assessment dated [DATE] for Resident #34 documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed Resident #34 required 2 person physical assistance with bed mobility, transfers and dressing and received ROM 1 day during the last 7 calendar days. Review of Resident #6's Care Plan with a revision date 10/9/21 and a goal to maintain highest practicable level of mobility documented restorative therapy as indicated as an intervention initiated 9/24/18. Review of facility form titled Restorative Nursing Programs and signed 1/18/22 by Staff E, Physical Therapist, revealed recommendations for Resident #34 including ROM to lower extremities, active ROM, passive ROM, active assisted ROM and special instructions for bike 15 minutes for lower extremities and pulleys on the bike for upper extremities. Clincal record review revealed Resident #34 completed restorative care for the minimum 15 minutes on 2 occassions since 1/7/22. 3. The quarterly MDS assessment dated [DATE] for Resident #38 documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed a BIMS of 0 indicating severe impaired cognition. Review of facility form tilted Restorative Nursing Programs and signed 3/15/22 by the Rehab Director revealed recommendations for Resident #38 including active ROM to upper and lower extremities and special instructions for the bike for 15 minutes, ambulation as tolerated with front wheeled walker and staff assistance of 1 twice daily with wheelchair to follow. Clinical review lacked documentation in regards to the restorative program recommendation for Resident #38 from 3/15/22 until 4/6/22. Review of facility form titled Restorative Program Progress updated 10/26/21 revealed a purpose to ensure resident(s) achieve and maintain their highest level of function. The form further revealed the licensed nurse will monitor staff and resident(s) to ensure compliance with the restorative nursing program and the licensed nurse will write a monthly restorative nursing summary to track the resident(s) progress. During an interview 4/06/22 at 11:26 AM the Assistant Director of Nursing (ADON) revealed restorative care has not been completed on a consistent basis since Covid the Covid pandemic started. During an interview 04/06/22 at 11:31 AM the Director of Nursing (DON) acknowledged restorative care has not been completed as expected due to staffing. The DON further revealed the facility Restorative Aide (RA) who is also a Certified Medication Aide (CMA) has not been able to provide restorative care due to staffing. During an interview 04/07/22 at 11:06 AM the ADON revealed she was not able to locate monthly restorative nursing summaries to track resident(s) progress. During an interview 04/07/22 01:20 PM , Staff A, Restorative Aide (RA), revealed she does not remember the last time she worked on the floor as the RA due to staffing. Staff A, RA further revealed she is the only RA in the facility. 4. The annual minimum data set (MDS) assessment dated [DATE] revealed Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident needed extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, and toileting, limited assistance on once staff for eating. and no limitations in range of motion to her upper and lower extremities (UE/LE's). The resident had impaired short and long-term memory. The MDS indicated the resident had restorative nursing program activities performed 3 days and no physical therapy (PT) during the seven day look- back period. A significant change MDS assessment dated [DATE] revealed the resident required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and eating. The MDS documented ROM not impaired to the UE'/LE's, and the resident had one fall since the prior admission assessment. The MDS recorded the most recent PT regimen occurred 12/3/21, and active range of motion (AROM) restorative nursing program activities performed three of seven days during the MDS look back period. The quarterly MDS dated [DATE] revealed the resident required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and eating. The MDS documented the resident had impaired ROM to LE's bilaterally. The MDS indicated the resident had one fall since the prior assessment. The MDS revealed no PT or restorative nursing program activities for at least 15 minutes such as AROM / PROM (passive range of motion) or skills such as walking or transfers occurred during the 7 day lookback period. The MDS documented Occupational Therapy (OT) started on 3/17/22, A care plan revised on 12/21/21 indicated the resident had a self care deficit and risk for falls related to dementia and a decline in mental and physical abilities. The care plan instructed staff to use adaptive equipment as indicated, provide assistance of one or two staff for ambulation, transfers, and toileting, and use a wheelchair at times, physical therapy/occupational therapy as ordered, and restorative therapy if indicated. The order summary report revealed on 12/2/21 PT / OT evaluation and treat as indicated and discontinue when completed, and 3/17/22 OT therapy evaluation and treat as indicated and discontinue when completed. A fall risk assessment dated [DATE] revealed resident a moderate risk for falls, had 1-2 falls in past six months, exhibited a loss of balance whenever she stood, and has decreased muscle coordination. A change in condition report dated 2/12/22 at 12:30 PM, revealed the resident stumbled as she walked to the bathroom. Staff lowered the resident to the floor. During observations 04/07/22 at 09:37 AM, Staff V, certified nursing assistant, donned a gait belt on Resident #40. Staff V and the Assistant Director of Nursing (ADON) ambulated the resident to the shower room. The resident took little steps and sometimes walked on her toes as she walked. A rehabilitation screen request form dated 12/1/21 revealed the resident demonstrated declines in ADL's and functional mobility per nursing report, and PT/OT indicated. A PT evaluation and plan of treatment dated 12/3/21 revealed the resident had difficulty walking and [CONDITION(S)], and required increased assistance with mobility and transfers. The resident's had shortened steps and her right toes drug as she walked. A physical therapy discharge note dated 1/27/22 revealed the resident ambulated 50 foot with partial to moderate assistance, and required partial to moderate assistance for transfers PT recommendations included a functional maintenance or restorative nursing program and ambulation and restorative ROM program. At the time, the resident had an established ROM and LE bike exercises. The resident had an excellent prognosis to maintain current level of function with continued participation in RNP. Review of Restorative Nursing Programs form signed 1/27/22 by the therapist revealed restorative program recommendations consisted of active ROM to the LE's, and bike for 15 minutes. Staff A, restorative aide, and the restorative nurse coordinator signed the form on 3/1/22. Review of the documentation survey report for Resident #40 revealed the resident received AROM to her LE's: bike for a minimum of 15 minutes 3-7 days per week only 4 times between 1/2022 - 4/12/2022. The medical record lacked any other restorative exercise activities completed. Review of facility form titled Restorative Program Progress updated 10/26/21 revealed the purpose of a restorative program to ensure resident(s) achieve and maintain their highest level of function. The form further revealed the licensed nurse will monitor staff and resident(s) to ensure compliance with the restorative nursing program and the licensed nurse will write a monthly restorative nursing summary to track the resident(s) progress. 5. Resident # 4's significant change MDS dated [DATE] indicated decline in ADL needs as compared to previous quarterly MDS dated [DATE], which showed the following changes: bed mobility - from independent/set up only to limited/1 person assistance; transfer - from supervision/set up only to limited/1 person assistance; ambulation in room and corridor - from supervision/set up only to limited/1 person assistance; dressing - limited/1 person assistance to extensive/1 person assistance; and toilet use - limited/1 person assistance to extensive/1 person assistance. Resident # 4's care plan identified a focus area for self-care deficit related to impaired cognitive functions and fracture of distal ulna on 12/2/21. The care plan noted a goal for Resident # 4 to maintain highest practicable level of mobility over the next review period. The care plan directed staff to provide restorative therapy as indicated. On 4/7/22 at 9:09 AM, the Rehabilitation Director (RD) reported that Resident # 4 just started back on the rehabilitation therapy program yesterday or on 4/6/22 because of recent falls. The RD also reported that Resident # 4 has been on the restorative program from 1/18/22 to 3/15/22 and then recommended to continue with restorative nursing program, and should have started 3/15/22. The facility's document titled, Restorative Nursing Programs form showed that on 3/15/22, Resident # 4 had a recommendation to be on range of motion program for the upper and lower extremities that include, bike L-3X15 min, bike VF l3 15 min and the facility's task documentation showed a frequency of 3-7 times per week. However, the recommendation in Resident # 4's Restorative Nursing Programs form indicated that it was acknowledged as signed by Staff A, Restorative Aide only on 4/6/22, when Resident # 4 started back on the therapy programs. The restorative nursing program's documentation showed Resident # 4's inconsistent active range of motion activities (AROM) for the last 3 weeks, as recorded: 5 times from 3/15/22 to 3/21/22; 1 time from 3/22/22 to 3/28/22; and 2 times from 3/29/22 to 4/4/22. The progress notes showed that Resident # 4 had 2 falls after 3/15/22, on 4/2/22 and on 4/4/22. The restorative nursing progress notes dated 4/6/22, noted that in relation to recent falls, Resident # 4's restorative nursing program will change as was picked up for evaluation and treat after receiving order from Dr. Pak.

Based on documents review, interviews, and observations, the facility failed to provide grooming for 3 of 15 residents ( Resident # 24, # 36, and # 44) randomly observed in the Chronic Care and Dementing Illness (CCDI) unit. The facility reported a census of 41 residents at the time of the survey. Findings include: 1. The significant change minimum data set (MDS) dated [DATE], listed Resident # 24's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that Resident # 24 needs extensive assistance of 1 staff for personal hygiene and totally dependent on staff for bathing. The care plan identified Resident # 24 as dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, and directed staff to assist with activities of daily living (ADL). The care plan also identified Resident # 24 to have potential for self-care deficit related to Alzheimer's/vascular dementia/paranoid [CONDITION(S)]. The care plan further noted that Resident # 24 is unaware of keeping self groomed thereby needing support of 1 staff for grooming/hygiene. During observations on 4/7/22 at 10:29 AM Resident # 24 was at the hallway, walking with the use of walker, stopped for about 2 minutes by surveyor's table, and then resumed walking towards the TV room, where he/she joined 2 other residents. Resident # 24's facial hair was unshaved at approximately 0.5 centimeters (cm) long. At 10:39 AM, Resident # 24 walked to Room # 6 and sat on the edge of the bed closest to the door. On 4/07/22 at 10:48 AM, when asked if Resident # 24 preferred to grow facial hair, Staff F, Certified Nurse Aide (CNA) replied, No. [Resident # 24] has always been clean cut. Staff F said, That was supposed to have been shaved. I did not give [Resident # 24's] shower on Tuesday [shower day] but I will give [his/her] shower tomorrow and will take care of that. Staff F reported that residents are supposed to get shaved during shower days. 2. The admission record showed Resident # 36's admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE], indicated that Resident # 36 requires extensive assistance of 2 staff members for personal hygiene and dressing, and is totally dependent on staff for bathing. The care plan indicated that Resident # 36 has self care deficits related to Alzheimer's dementia with severely impaired cognitive functions without awareness for personal hygiene and other grooming and basic cares. The care plan directed 1-2 staff members to assist with grooming/hygiene and dressing. On 4/07/22 at 10:10 AM, Resident # 36 was in room sitting on the bed with FM (Family Member) # 1. Resident # 36 asked FM #1, Don't you think it would be better if we get rid of all these? while touching hair around his face. Resident # 36's beard was about 2.5 cm long. At 10:18 AM, when asked who was in the room currently cutting and shaving Resident # 36's hair and beard, Staff Certified Medication Aide (CMA) A answered, [FM # 1] identifying him/her as a family member. Staff A reported that staff members are expected to provide grooming for residents according to care plan, and also stated, [Resident # 36] may not have had a haircut since [he/she] got here. At 10:32 AM, FM # 1 asked, Do you feel better? to which Resident # 36 responded, Yes and again touching his/her face. At 11:07 AM, FM # 1 verified that he/she cut Resident # 36's hair and shaved beard because they were long. FM # 1 reported that Resident # 36 was also wearing pants that were 4 inches undersized saying that the pair of pants was not Resident # 36's. FM # 1 also reported that he/she checked Resident # 36's closet to change Resident # 36's shirt because it was full of hair from the cutting and shaving, but he/she did not find any to use saying, There's not clean shirt in there. 3. Resident # 44's admission record showed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 44's care plan indicated potential for self care deficit related to Alzheimer's dementia with severely impaired cognitive functions along with decision making skills. The care plan directed staff to provide assistance of 1 staff for bathing, dressing, and grooming/personal hygiene. On 4/6/22 at 3:20 PM, Resident # 44 and family visitors were in the hallway, in front of Resident # 44's room. Resident # 44's FM # 2 asked Staff G for Resident # 44's razor so he/she could shave Resident # 44. Resident # 44's facial hair was observed to be approximately 0.5 cm. At about 3:40 PM, FM # 2, a companion, and Resident # 44 were coming out from Resident # 44's room and Resident # 44's facial hair has been shaved. On 4/7/22 at 10:18 AM, Staff A verified that Resident # 44 had a care plan directing staff to provide grooming for Resident # 44 but was not done, and also verified that a family member shaved Resident # 44's facial hair yesterday or on 4/6/22. On 4/11/22 at 9:12 AM, the Director of Nursing (DON) reported that the facility does not have policy for ADLs and that they follow the regs [regulations].

Based on observation, record review, resident and staff interviews, the facility failed to implement interventions and provide adequate supervision to prevent accidents for residents reviewed for safety. The facility failed to provide adequate supervision to ensure Resident #1 remained separated from other residents as evidenced by multiple incidents of resident to resident altercation/abuse (with Residents # 3, #7, #8, #5, #9, #6, #10, and #2). Residents and staff expressed fear of Resident #1. The facility also failed to reassess Resident #1's care plan to address his/her safety needs. In addition, Resident #9 fell from the Hoyer lift during a transfer when staff used a frayed sling for the transfer. Resident #5 fell from the toilet because staff did not have a toilet riser placed properly. Facility census was forty-three (43) residents with nine residents review. Findings include: 1. A Minimum Data Set (MDS,) with assessment reference date of 9/17/12, assessed Resident #1 with impaired long and short term memory and severely impaired decision making skills. The MDS documented the resident's ability to understand others as highly impaired and others could sometimes understand the resident. The MDS identified the following behavior symptoms: physical and verbal behaviors directed toward others, and other behavioral symptoms not directed toward others. All behaviors were identified as occurring 4 to 6 days out of 7 but not daily. The MDS identified the behaviors impacted others by placing others at significant risk for physical injury and the behaviors significantly disrupted care/living environment. The resident rejected care daily. The MDS identified the resident's behaviors worsened since the prior assessment. The MDS identified bed mobility, transfer, dressing, eating, toileting, personal hygiene and bathing. The resident did not ambulate. The resident had functional limitations in range of motion of both upper and lower extremities. The resident was always incontinent of bowel and bladder. The resident was 66 inches tall and weighed 125 pounds. The resident received antipsychotic and antianxiety medications. A nursing admission assessment, dated 3/30/12 revealed Resident #1 admitted to the facility on that date with [DIAGNOSES REDACTED]. The resident received the following psychoactive medication on admission: Abilify (antipsychotic) 30 milligrams (mg) at bedtime. Resident #1 nurses notes identified the following information regarding behavior: On 4/13/12 5:30 p.m. Resident #1 threw glasses and plates on the floor breaking them. A 4/17/12 care plan entry directed staff to not provide the resident with glass plates or glasses because the resident throws them on the floor for attention. On 4/14/12 10:55 a.m. Resident #1 grabbed the nurse's stethoscope around her neck and tried to bite the nurse. A nurse aide pried the stethoscope from the resident's hands and got it from the resident. Resident to Resident Incident: On 4/27/12 11:30 a.m. Staff heard a resident yell from the living room area. Resident #1 grabbed Resident #3's wrists and pulled the other resident's watch off and broke it. Resident #1 scratched Resident #3 on the left forearm leaving a 2 centimeter (cm.) skin tear and a 2.4 cm. scratch. The resident also left 2 scratches on Resident #3's right hand. Staff separated the residents. A Quality Assurance (QA) tool dated 4/27/12 at 11:30 a.m. did not identify the resident caused injury to another resident or that the resident broke the other resident's watch. The intervention listed following the incident was: Will keep resident arm ' s length away from other residents. Resident #1's care plan entry dated 4/27/12 directed staff to "keep other residents out of reach". Victim Information: Resident #3's MDS with assessment reference date of 2/13/12 identified the resident with long and short term memory impairments. The resident required extensive/total staff assistance with transfers, dressing, eating, toileting, personal hygiene and bathing. The resident could not ambulate and was totally dependent on staff for locomotion. Observation showed, on 10/4/12 at 3:40 p.m. the resident leaning to the right while seated in a chair in his/her room. When asked if any resident grabbed him/her the resident shook head "no". A 4/27/12 QA tool identified the resident sustained [REDACTED]. superficial scratch to the left wrist. A non-pressure skin condition report identified the areas as healed on 6/5/12. 5/11/12 at 6 p.m. While in the dining room, Resident #1 wheeled his/her wheelchair over to the clock on the wall and knocked it to the floor. A Quality Assurance (QA) tool dated 5/11/12 at 6 p.m. revealed the resident broke the clock when he/she knocked it from the wall. The QA tool identified the intervention following the incident as: Lock wheelchair while at meal 5/13/12 at 4:10 p.m. At 11:40 a.m. Resident #1 grabbed a nurse aide by the shirt and bra strap pulling staff down to the resident's tray table causing scratches on her left shoulder. A QA tool dated 5/13/12 at 11:40 a.m. identified the staff as new staff and remainder given about using caution when in arms reach of resident. Resident #1's care plan entry dated 5/13/12 stated the facility provided a memo to staff "to remind staff of being within arm's reach". Resident to Resident Incident: 5/19/12 at 10:15 a.m. Resident #1 threw breakfast plates on the floor. While sitting in the front lounge, Resident #1 pulled Resident #7's hair. Staff separated the residents. The resident then sat in the dining area screaming. Staff could not redirect the resident. A QA tool dated 5/19/12 at 10 a.m. identified the staff as new staff who received education regarding keeping Resident #1 separate from other residents. Victim Information: Resident #7's MDS with assessment reference date of 4/23/12 identified the resident with long and short term memory impairments. The resident required extensive/total staff assistance with transfers, ambulation, dressing, eating, toileting, personal hygiene and bathing. The resident had [DIAGNOSES REDACTED]. Observation showed, on 10/4/12 at 10:15 a.m. the resident asleep in a recliner in the front lounge. Resident #7's nurses notes dated 5/19/12 at 10 a.m. stated another resident pulled Resident #7's hair while the resident sat in the front lounge. No injuries. Staff Interview regarding 5/19/12 incident: On 10/4/12 at 1:27 p.m. Staff P (housekeeper) stated she saw Resident #1 grab Resident #7's sweater. She then told a staff to get help. Staff P stated Resident #1 almost got her the other day but she backed up. This occurred in the dining room with another staff present. When asked if she thought the resident presented a danger to others, Staff P stated yes I certainly do. She stated some of the residents act frightened of Resident #1 and Staff P identified herself as afraid of the resident. Residents complain Resident #1 is noisy so they don't sleep well. On 5/19/12 at 7 p.m. Resident #1 yelled and knocked over a chair. Resident #1's care plan entry dated 5/19/12 directed staff to keep other residents out of Resident #1's reach. Resident to Resident Incident: On 5/22/12 at 6 p.m. Physician made aware of Resident #1 pulling another resident's hair (no other information available about incident in nurses notes) A QA tool dated 5/22/12 at 11:40 a.m. identified an incident occurred in the north hallway. Resident #1 sat in the north hallway in his/her wheelchair. Resident # 8 wheeled by and Resident #1 grabbed Resident #8's arm and tried to bite Resident #8 but was unsuccessful. Resident #8 received 2 skin tears during the incident. The QA tool identified the intervention following the incident as: No independent wheeling. A facsimile to the physician dated 5/22/12 regarding the incident identified Resident #8 received a 6 centimeter (cm.) and 1 cm. skin tear to the arm. Victim Information: Resident #8's MDS with assessment reference date of 9/24/12 identified the resident with a brief interview for mental status (BIMS) score of 15 (no cognitive impairments). The resident required limited staff assistance with transfers, dressing, toileting and personal hygiene. The resident was in the hospital during the investigation. and could not be interviewed. Nurse ' s notes dated 5/22/12 at 11:45 a.m. revealed Resident #8 propelled self down the hallway in a wheelchair when another resident grabbed Resident #8's right arm and attempted to bite. The resident did not succeed in biting Resident #8. Resident #8 received a 6 cm. skin tear and a 1 cm. skin tear to the right arm during the incident. Resident #1's care plan entry dated 5/22/12 stated the facility educated staff to keep resident in dining room until ready to lay down in bed/out of reach of other residents. On 5/23/12 at 11 a.m. Resident #1 yelled out and grabbed and tried to bite nurse aide. At 8:30 p.m. the resident tipped over a stool in the dining room after supper. On 5/26/12 at 8:30 p.m. At supper Resident #1 threw food on the floor and yelled until the Director of Nursing sat by him/her. The resident grabbed at other residents ambulating to their rooms. On 5/27/12 at 8:30 a.m. While staff fed Resident #1 breakfast, the resident unexpectedly slapped the nurse aide's arm making eggs fly into the air and onto the floor and stated, "I'm done". On 6/7/12 at 11:30 a.m. When staff fed Resident #1 on 6/6/12, the resident grabbed staff putting her head to tray on wheelchair trying to bite. Resident #1 would not release the staff until 2 other staff intervened. Staff had red area on neck and arm that faded. Following this incident, the physician ordered a psychiatric consultation. A QA tool, dated 6/6/12 at 8:45 a.m. identified the intervention as "stay at arm ' s length". Staff Interviews regarding 6/7/12 incident: On 10/3/12 at 3:45 p.m. Staff E (food service supervisor) stated on the day of the incident, she was the morning cook but the Administrator asked her to feed Resident #1. As she fed the resident, the resident stated he/she wanted to go to bed and the next thing Staff E knew, the resident grabbed her apron straps and had her head locked down to the resident's tray and the resident held it to the tray. On 10/3/12 at 4:07 p.m. Staff F (licensed practical nurse) stated she saw Resident #1 pull Staff E's head down and try to bite Staff E. Staff F stated she thinks Resident #1 is a danger to others and a danger to self. the resident pulled a TV off his/her dresser. The resident is noisy at night and yells and scream all night. Resident #1's care plan entry dated 6/6/12 directed staff to "keep at arm ' s length". A facsimile to the physician regarding Resident #1 dated 6/7/12 directed staff to obtain a psychiatric consult for aggressive behaviors. On 6/10/12 at 12:40 p.m. While family member assisted Resident #1 with eating, the resident tried to grab him/her. The family member was able to back away. The family member laid resident down after the meal and during transfer, the resident bit the family member ' s shoulder without breaking the skin. The QA tool, dated 6/9/12 at 12 p.m., identified the intervention as: Resident has intermittent explosive disorder and there will be an appointment with psychiatrist. The psychiatric consultation completed by a behavioral health organization documented an intake date of 6/15/12 and discharge date of [DATE]. The summary identified Resident #1 was not considered to be at risk of harm to him/her (self) or others. On 6/17/12 at 9:15 a.m. Resident #1 exhibited agitation for unknown reason and slapped at nurse and nurse aide. The resident knocked food all over staff and threw plate and drinks on floor. The QA tool dated 6/17/12 at 9:15 a.m. identified the psychiatrist would adjust medications. Resident #1's care plan entry dated 6/17/12 stated the psychiatrist would adjust medications. Resident to Resident Incident: On 6/18/12 at 12 p.m. revealed staff observed Resident #5 with his/her head pinned down by Resident #1 on Resident #1's wheelchair tray with Resident #1 biting Resident #5. A QA tool dated 6/18/12 at 12 p.m. identified Resident #1 bit Resident #5's head. The QA tool listed the intervention as separating the residents. Victim Information: Resident #5's MDS with assessment reference date of 8/6/12 identified the resident with long and short term memory impairments. The resident required extensive staff assistance with transfers, ambulation, dressing, eating, toileting, personal hygiene and bathing. The resident utilized a wheelchair for mobility. Observation showed, on 10/4/12 at 8:38 a.m. the resident up to the table in a wheelchair with a pillow behind back leaning forward in the wheelchair. . Staff Interview regarding 6/18/12 incident: On 10/3/12 at 4:07 p.m. Staff F (licensed practical nurse) identified the resident involved in the 6/18/12 incident as Resident #5. She stated the incident occurred during mealtime. Staff F passed medications and the nurse aides assisted residents, when staff heard Resident #5 scream. Staff F observed Resident #1 grab Resident #5 and pin Resident #5's head down. Resident #1 had his/her mouth open to bite Resident #5's head and then placed his/her mouth on Resident #5's head. Staff F stated she did not see bite marks when she examined Resident #5's head after the incident. She stated Resident #5 was visibly shaken. The resident took Staff F's hand and stated, "I'm so scared. " Resident #5's head was wet from Resident #1's mouth on it. Staff F stated Resident #1 can release his/her brake on the wheelchair and wheel self. Resident #1's care plan entry dated 6/18/12 directed staff to rearrange seating arrangement and conduct medication review. On 6/19/12 at 3 p.m. A nurse aide stood next to Resident #1 who laid in bed. The resident grabbed the nurse aide's arm. When the nurse aide tried to get away, the resident tried to bite her. The resident scratched the nurse aide's right inner forearm and also bruised it. A QA tool intervention following the incident listed as: Medication review. On 6/23/12 at 10:30 a.m. Tried to bite nurse aide Resident #1's care plan entry dated 6/23/12 directed staff to keep safe distance from resident and keep physical contact to a minimum. On 6/26/12 at 7:30 p.m. the facility received an order to discontinue the resident's Abilify and begin Haldol (antipsychotic) 0.5 milligrams (mg) daily, Trazodone (antidepressant) 50 mg daily and Depakote 250 mg daily (seizures and behaviors) On 6/27/12 at 9:30 a.m. A resident's daughter walked by Resident #1. Resident #1 reached out and grabbed her and tried to bite her. No injury. Staff assisted her to free herself from Resident #1. A QA tool dated 6/27/12 at 9:45 a.m. identified the intervention as "visitor education to maintain proper distance from resident". Resident #1's care plan did not contain an intervention following this incident. On 6/29/12 at 2:30 p.m. Tried to knock chair over Resident to Resident Incident: On 7/1/12 at 6 p.m. While nurse aides passed trays, Resident #1 wheeled over to Resident #5 and pulled Resident #5's hair and then attempted to bite the resident. Nurse aides and nurse intervened and pulled Resident #1 away from Resident #5. A QA tool dated 7/1/12 at 6 p.m. identified Resident #1 attempted to bite Resident #5's head after pulling the resident's hair. The intervention following the incident was: Do not bring (resident) to the table until somebody can sit with him/her. Resident #1's care plan entry dated 7/1/12 directed staff to get resident out to meals when staff is able to assist the resident to reduce anxiety and medication review. On 7/20/12 at 6:20 p.m. revealed at 6:15 p.m. 2 nurse aides hoyered Resident #1 into the wheelchair. When one nurse aide attempted to buckle the resident's seat belt, the resident grabbed the staff's left hand and bit the staff two times. The nurse sustained bruising by the left thumb and 0.3 centimeter broken skin on first knuckle of index finger. No new intervention following incident. Resident #1's care plan did not contain a new intervention following this incident. On 7/21/12 at 11 p.m. Resident #1 began to tip a chair over and move a table in the dining room at supper. When explained this is not acceptable, the resident quieted down. Resident #1's care plan did not contain a new care plan intervention following this incident. On 7/22/12 at 3 a.m. Resident #1 screamed and bit the siderail. Staff turned television station but resident screamed if commercial came on. Resident scooted bed several feet. Resident to Resident Incident: 7/25/12 at 10:45 a.m. Resident #1 grabbed Resident #9 and tried to bite Resident #9 but only got the resident's shirt stretching it and scaring the resident who cried. A QA tool dated 7/25/12 at 8:30 a.m. identified the intervention following the incident as: Keep separate. Resident #1's care plan entry dated 7/25/12 directed staff to "keep separate". Victim Information: On Resident #9's MDS with assessment reference date of 9/10/12 identified the resident with a brief interview for mental status (BIMS) score of 7 (severe impairment). The resident required extensive/total staff assistance with transfers, dressing, eating, toileting, personal hygiene and bathing. The resident did not ambulate. Observation showed, on 10/3/12 at 11:40 a.m. the wheeling self in hallway. At that time, the surveyor asked the resident if anyone pulled his/her hair or hurt him/her. The resident stated no. When asked if he/she feared anyone in the facility the resident replied yes and pointed at Resident #1's room. When asked why Resident #9 feared that resident, he/she stated, "Because he/she bites". Resident #9 then stated Resident #1 grabbed him/her and also another resident who is Resident #9's friend. Resident #9 stated Resident #1 yells at night too and keeps him/her awake. Staff Interviews regarding 7/25/12 incident : On 10/4/12 at 1:33 p.m. Staff N (nurse aide) stated she pushed Resident #9 in the wheelchair and stopped in the hallway. Resident #1 reached out and grabbed the handle of Resident #9's wheelchair enough that Resident #1 could reach the collar of Resident #9's shirt. Resident #1 pulled the shirt tight around Resident #9's neck. Two or three staff had to loosen Resident #1's grip. Staff N stated the resident is inhumanly strong. One day he/she got Staff N and it took 3 staff to get him/her off. The resident took Staff N by the shirt and had it tight against her neck. Staff N stated she thought the resident was a danger to others. It is sad now because the resident is more or less isolated in his/her room. On 10/3/12 at 4:07 p.m. Staff F (licensed practical nurse) stated staff wheeled Resident #1 and Resident #9 wheeled to his/her room when Resident #9 stopped to talk to the business office manager. While there, Resident #1 lunged at Resident #9 and grabbed his/her shirt stretching the neck out. Staff separated the residents. Resident #9 is very emotional and it scared Resident #9 who cried about the incident. Staff F stated Resident #1 could get Resident #9 because Resident #9 is a large resident and the hallway is small. Resident #1 can reach a good distance. On 7/27/12 at 4:30 p.m. the facility received a new order to increase Resident #1's Seroquel (antipsychotic) 125 mg. every night. On 8/4/12 at 9:15 p.m. Resident #1 tipped a chair over and yelled at supper. Resident to Resident Incident: On 8/5/12 at 1:40 p.m. during breakfast, Resident #1 grabbed Resident #6's hair and sweater and attempted to bite. A QA tool dated 8/5/12 at 9:30 a.m. identified the intervention following the incident as "keep separate". Victim Information: Resident #6's MDS with assessment reference date of 4/19/12 identified the resident with a brief interview for mental status (BIMS) score of "2" (severe impairment). The resident required limited staff assistance with transfers, ambulation, dressing, toileting, personal hygiene and bathing. Observation showed, on 10/4/12 at 8:40 a.m. the resident in a wheelchair asking the surveyor if he/she was the beautician. At 10:18 a.m. the surveyor spoke with Resident #6. When asked if anyone grabbed the resident or pulled his/her hair, the resident referred to a resident without naming the resident and stated that resident may grab you if you get too close to him/her. Resident #6 denied the other resident grabbed him/her. The resident then asked, "What day is it?" Staff Interviews regarding 8/5/12 incident: On 10/3/12 at 1:42 p.m. Staff D (cook) stated she just opened the kitchen door and saw Resident #1 attack Resident #6. There were no staff in the dining area. She stated Resident #6 came around from the lounge area as Resident #6 wheeled self into the dining room. Resident #1 reached out and grabbed Resident #6 by the hair. Resident #6 screamed "help!" Staff D ran over there and took Resident #1's arm. Resident #1 would not let go. Resident #1 had a lot of Resident #6's hair in hand. Staff D called for help and Staff I (housekeeper) was the only one that responded to the call. The nurse aides were getting residents up or laying then down. Staff D then stated, "All I know is no one was in the dining room". Staff D stated she thinks Resident #1 is a danger and stated she thinks the resident will hurt someone "really bad". Staff D stated she stays 6 feet away from the resident. On 10/3/12 at 1:52 p.m. Staff I (housekeeper) stated she heard Staff D yell. Staff I arrived and saw Resident #1 with approximately a one inch diameter amount of Resident #6's hair in his/her hands. Staff I separated the residents and then the nurse arrived. Staff I stated it was just her and the cook (Staff D) until the nurse arrived and, at the time of the incident, no one was in the dining room. Staff I stated residents told her Resident #1 screams all night and they can ' t sleep. On 10/3/12 at 1:15 p.m. Staff J (licensed practical nurse) stated on the day of the incident, she was the only nurse on the floor and was in the unit giving insulin. She stated Resident #6 wheeled by Resident #1 who grabbed the other resident by the shoulders and tried to bite his/her neck and then Resident #1 pulled the other resident's hair. After the incident, the hair appeared as if broken off. For an hour after the incident, Resident #6 seemed more quiet than usual then the resident was back to his/her normal self. Resident #1's care plan entry dated 8/5/12 directed staff to "keep separate". Resident to Resident Incident: On 8/9/12 at 10:15 a.m. During breakfast grabbed Resident #6 by the hair and attempted to bite. The intervention in place when the incident occurred (according to prior QA tool intervention and care plan dated 7/1/12) directed staff to not bring the resident to table until someone can sit with resident. A QA tool dated 8/9/12 at 9:45 a.m. identified the intervention following the incident as one to one. Staff Interviews regarding 8/9/12 incident: On 10/3/12 at 3:45 p.m. Staff E (food service supervisor) stated she witnessed one of the incidents between Resident #1 and Resident #6. She saw Resident #1 grab Resident #6. Staff E came of out the kitchen to help. Resident #1 had a good handful of Resident #6's hair. Resident #6 had his/her head tilted. Staff E stated the resident is a danger to self because the resident could go after someone that could defend themselves and they could hurt Resident #1. She stated she did not know how the resident did not shock self when the resident destroyed his/her air conditioning unit. On 10/3/12 at 1:15 p.m. Staff J (licensed practical nurse) stated the 8/9/12 incident occurred the same way as the 8/5/12 incident. Staff J saw Resident #6 come around the corner for the lounge area and Resident #1 grabbed the other resident. After separation, Resident #1 had Resident #6's hair in his/her hand. Resident #6 stated, "Ow" Resident #1 pulled the hair. Staff J stated staff has locked Resident #1's chair and staff comes back and finds the chair unlocked so Resident #1 must have the ability to unlock it per self. Resident #1's care plan did not contain an entry for 8/9/12 until 10/1/12. The care plan stated "one to one". On 8/10/12 at 6:10 p.m. Before supper staff left the resident in room until staff could provide one to one. While waiting, the resident knocked closet doors off the rollers and closet doors leaned into the closet. Resident #1's care plan did not contain a new intervention following this episode. 8/17/12 at 4:30 p.m. While attempting to calm Resident #1, the resident bit staff on the thumb when staff attempted to calm the resident. A QA tool dated 8/17/12 at 4:30 p.m. identified the new intervention after the incident as Reinforce not to approach or touch resident when agitated. Resident #1's care plan entry dated 8/17/12 directed staff to not approach the resident if the resident is agitated. On 8/22/12 at 1:40 The facility received a facsimile to increase the resident's Seroquel to 100 mg twice per day. Resident to Resident incident: 8/23/12 at 6:10 p.m. Resident #1 grabbed Resident #10 by the glasses and ripped them off Resident #10's face and mangled them. A QA tool dated 8/23/12 at 5:45 p.m. identified the new intervention as nurse aide counseling. Victim Information: Resident #10's MDS with assessment reference date of 9/25/12 identified the resident with a brief interview for mental status score of "9" (moderate cognitive impairment). The resident required limited staff assistance with transfers, dressing, ambulation, toileting, personal hygiene and bathing. Observation showed, on 10/3/12 at 3:35 p.m. the resident in a wheelchair in his/her room. When asked if any resident grabbed his/her glasses, the resident stated the guy down the hall. The resident stated the wheelchair wheels were barely through the door when Resident #1 grabbed the glasses and pulled them off his/her head "so fast you wouldn't believe it". The resident stated Resident #1 broke the frames and "just mashed them to pieces". The resident stated it did scare her for a second and stated he/she was always afraid of Resident #1 "even at the beginning". Resident #10 stated Resident #1 grabbed another resident's elbow and hurt it pretty bad. Resident #10 stated she thinks Resident #1 should move. Resident #1 is also noisy at night and keeps him/her awake. Staff Interview regarding 8/23/12 incident: On 10/3/12 at 1:15 p.m., Staff J (licensed practical nurse) stated Resident #10 and Resident #1 are separated by one or two rooms. Resident #10 often sits in his/her doorway and looks out. Staff J was by the nurse ' s station. Staff sat Resident #1 in the hallway and Resident #1 reached out and grabbed Resident #10's glasses. Resident #1 can pull self along the hall by pulling the handrail and he/she pulled self up to Resident #10. Resident #10 was upset. It scared him/her. Resident #10 ducked back into the room when Resident #1 grabbed at his/her face so all Resident #1 got was the glasses. Resident #1's care plan entry dated 8/23/12 stated "nurse aide education". On 8/26/12 at 10:20 a.m. revealed Resident #1 yelled out, refused care and grabbed a nurse aide's hair pulling it out from the scalp. Resident #1's care plan did not contain a new intervention following this incident. On 8/29/12 at 6:30 p.m. Resident #1 yelled out at supper and knocked supper plate, silverware and glasses to the floor. Resident #1 attempted to wheel over to another resident. On 9/5/12 at 3:30 p.m. Resident #1 grabbed and attempted to bite. The resident ripped electrical outlet cover from wall and rolled over to dresser and kicked at dresser until the TV fell off onto floor. The resident continued yelling on and off most of shift. Resident #1's care plan did not contain an intervention after this incident until 10/1/12. At that time, the intervention was "covered electric outlets with face plates". Resident #1's care plan entry dated 9/6/12 directed staff to conduct 15 minute checks, medication changes, dresser fixed to wall and conference with family. Resident to Resident Incident: On 9/13/12 at 3 p.m. Resident #1 rolled out of bed and crawled over to roommate (Resident #2). Resident #1 bit Resident #2. A QA tool dated 9/13/12 at 6:45 a.m. and written by Staff F (licensed practical nurse) identified the intervention following the incident as: staff will take Resident #2 to the north shower room to use the bathroom. Victim Information: Resident #2's MDS with assessment reference date of 9/17/12 identified the resident with long and short term memory impairments. The resident required extensive/total staff assistance with transfers, dressing, eating, toileting, personal hygiene and bathing. The resident did not ambulate and required limited assistance of staff for wheelchair mobility. Observation showed, on 10/3/12 at 11:50 a.m. the resident in a wheelchair. The resident replied "yes" when asked if he/she had a roommate and if they liked the roommate. The resident denied anyone scratching or biting him/her. A QA tool for Resident #2 identified the resident received teeth marks on the right knee. No measurements. Staff Interview regarding 9/13/12 incident: On 10/3/12 at 4:07 p.m., Staff F (licensed practical nurse) stated the nurse aides assisted Resident #2 to the commode and left the room with Resident #2 on the commode. Resident #1 laid on the low bed. While staff was out of the room, Resident #1 crawled over to Resident #2 biting Resident #2 on the knee. Staff F assessed the knee and observed bite mark indentations but no broken skin or scratches. After the incident, Resident #2 hit him/herself thinking it was their fault the incident occurred. Staff F stated, "That was the sad part". On Resident #2's QA tool dated 9/13/12 at 6:45 a.m., identified staff observed teeth marks on Resident #2's right knee. Skin intact but area slightly red. The QA tool identified the intervention following the incident indicated staff would take Resident #2 to the bathroom in the shower room. Resident #1's care plan did not contain a new intervention following this incident. Resident to Resident Incident: 9/15/12 at 10:45 a.m. Resident #1 crawled out of bed and over to Resident #2 and bit and scratched Resident #2 on the right leg. A QA tool dated 9/15/12 at 9 a.m. indicated the new intervention was: disciplinary action to staff. The QA tool identified the QA review of the incident date as 9/18/12. A QA tool for Resident #2 dated 9/15/12 at 9 a.m. identified 3 scratches measuring 3 centimeters (cm.) on Resident #2's upper inner right thigh, 3 scratches measuring 4 cm. on lower right leg and one scratch on the left hand measuring 2 cm. Nonpressure skin condition records revealed all areas as healed on 10/3/12. Staff Interviews regarding 9/15/12 incident: On 10/3/12 at 2:04 p.m. Staff G (nurse aide) stated she was the nurse aide that placed Resident #2 on the commode prior to the incident. When she placed Resident #2 on the commode, Resident #1 appeared asleep in his/her low bed. Staff G left the room. Staff G went back to room after approximately 20 minutes and found Resident #1 on the floor next to Resident #2. Resident #2 had scratch marks on his/her leg that appeared as if nails dug in Resident #2's leg and there were purple bite mark indentations. Staff G stated Resident #2 can ' t yell for help and staff did not hear anything. She stated Resident #2 appeared upset. She didn't know how long Resident #1 had scratched and bit Resident #2. Resident #1 could have started it right after she left or it could have started later in the 20 minute time frame. Staff G stated she did not know that Resident #2 should use the North shower room toilet instead of the room commode. She stated the information was in the communication book and she probably did not have time to look at it that morning. Staff G stated she thinks Resident #1 is a danger to residents and staff. Resident #1 can sit there quiet and then out of nowhere will act out. Residents complain of Resident #1's yelling. Staff G has not heard residents say they are afraid of Resident #1 but they are careful to stay away from the resident and the residents who witness incidents are fearful. On 10/3/12 at 1:15 p.m. Staff J (licensed practical nurse) stated Resident

Based on record review and staff interview, the facility to adequately assess a wound and provide timely services to promote healing. Resident #1 acquired a superficial pressure ulcer located over a boney prominence (lower buttock) on 3/9/2012. The wound developed into a Stage IV ulcer which required hospitalization and debridement on 12/31/2011 (Resident #1). The facility identified a pressure ulcer on the inner aspect of the buttock of Resident #4. The facility did not further assess the wound once it had been identified. The sample consisted of 2 residents and the facility identified a census of 33 residents. Findings include: 1. Resident #1 had a quarterly MDS assessment with a reference date of 12/20/2012. The assessment identified no pressure ulcers, arterial or venous ulcer but determined the resident at risk for pressure sore development. The assessment indicated the resident frequently experienced bowel and bladder incontinent episodes and facility currently did not manage a bladder or bowel toileting program. The facility had a pressure reducing device for the chair and bed. The facility did not implement a turning/repositioning program. The resident had [DIAGNOSES REDACTED]. Resident #1 required extensive assistance from staff for bed mobility, transfers, dressing and depended upon staff for toilet use. The Minimum Data Set (MDS) assessment with a reference date of 3/11/12 identified Resident #1 had scored a 15 on the Brief Interview for Mental Status (BIMS) evaluation. A score of 13 to 15 identified that the resident demonstrated intact cognition. The MDS also documented the resident required total dependence of 2 staff for mobility, transfer, dressing, and toilet use. The MDS documented the resident had one, unhealed Stage 4 pressure ulcer that measured 5.1 by 4.6cm by 2 cm. The Treatment Record dated April 2012 directed staff to assess the resident's skin condition weekly. The Care Plan initiated 6/7/11 and revised and updated quarterly directed staff to monitor for signs and symptoms of infection and to notify the physician as needed. The Braden Skin Assessment completed on 12/28/10 identified the resident as a mild risk for a pressure ulcer (15-18 mild risk). On 3/16/2011, 6/7/11 and 8/30/11 the Braden scale identified the risk to be at a moderate risk (13-14). The resident had a score of 14 through 4/17/12. The Skin Condition Report (for non-pressure sore skin conditions) indicated on 3/9/2011 a 2 cm (centimeter) by 0.5 cm non pressure sore had been identified and located on the right eschewal tuberoses area (lower buttock region). The facility began to apply barrier cream twice a day. The staff contacted the physician on 3/9/2011 and on 3/10/2011 the physician ordered staff to continue the present care and observe the area. The Skin Condition Report continued to identify the area as improved until 5/7/2011. The area had 3 open areas present at the same location. The area measured 3 cm by 3 cm. The physician was not contacted until 5/10/2011 (3 days later) at 4:00 p.m. The staff requested an order to discontinue the barrier cream and to apply [MEDICATION NAME] to the area twice a day. The physician replied on 5/11/2011 and ordered the treatment as requested. The physician ordered to increase the supplement from 2 ounces to 4 ounces three times a day. The Skin Condition Report dated 6/19/2011 indicated the wound had not change/improved. The wound measured 1 cm by 1.8 cm. The facility documented the initial treatment (barrier with zinc) used. The area measured 0.8 cm by 1.0 cm. on 6/26/2011. The nurse described the non pressure area as pink, open, granulation tissue and no signs of infection. The facility did not make recommendations to the physician until 7/13/2011. On 7/10/2011 the area continued to measure 0.8 cm by 1.0 cm. On 7/15/2011, the physician ordered [MEDICATION NAME]/Opsite (transparent film adhesive dressing-holds moisture to the wound). On 7/15/2011, the Skin Report indicated the Director of Nursing identified the area located on the lower buttock (ischeal tuberosity) to be pressure ulcer. The Weekly Pressure Ulcer Progress Report described the stages as the following: Stage 1: a persistent area of skin redness without a break in the skin and does not disappear when pressure is relieved. Stage 2: a partial thickness loss of skin layers that present clinically as an abrasion, blister or shallow crater. Stage 3: a full thickness of skin lost or exposing the subcutaneous tissues-present as a deep crater with or without undermining adjacent tissue. Stage 4: a full thickness of skin and subcutaneous tissue lost, exposing muscle or bone. On 7/15/2011, the area measured 1.0 cm by 2.5 cm. and identified as a Stage II. The Weekly Pressure Ulcer Progress Report indicated a cushion was placed in the wheelchair and the resident had a pressure reducing mattress on the bed. The resident received high protein supplements. The report indicated staff did not off load pressure from the area. The facility began Zinc 220 milligrams per mouth twice a day to promote wound healing to the pressure ulcer located on the resident's right buttock. On 7/18/2011, the physician order [REDACTED]. The physician ordered [MEDICATION NAME] ointment to the wound twice a day and as needed and to cover with a dry dressing. The area had a red appearance. The area measured 2.0 cm by 2.5 cm (enlarged) and continued as a Stage II pressure ulcer. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The report indicated the facility did not implement an off loading program (turning or repositioning) until 7/21/2011. The report indicated the staff began to turn the resident every 2 hours. The pressure ulcer progress report indicated on 9/1/2011, the Stage II pressure ulcer had yellow slough (deteriorated). The wound continued to have slough present on 10/5/2011 and 10/12/2011. The treatment records indicated the physician ordered Santyl (debridement) on 10/14/2011. On 10/28/2011 the treatment records for November identified the staff had continued to use Santyl with Alginate packing and covered with Alginate and [MEDICATION NAME] twice a day. The pressure ulcer progress report indicated the wound continued to show slough and on 11/2/2011 the slough had increased from 75% to 100%. The wound on 11/2/2011 had increased in size to 1.6 cm by 1.2 cm. The Nurse's Notes dated 11/2/2011 at 1:38 p.m. identified the wound with a very foul order .The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The staff began the administration on 11/18/2011 at 8:00 a.m. The last dose was administered on 11/27/2011 at noon. The Nurse's Notes dated 11/30/2011 at 12:45 p.m. indicated the physician ordered [MEDICATION NAME] (antibiodic) 500 milligrams four times a day for 7 days. The physician progress notes [REDACTED]. The physician ordered another culture to the area. The Nursing Notes dated 12/10/2011 indicated the resident received the last dose of [MEDICATION NAME]. The resident continued to receive medication for thrush (white patches in mouth) which began on 12/2/2011. The Nursing Notes dated 12/12/11 at 4:00 p.m. documented a wound culture specimen was sent to the laboratory. On 12/12/2011 at 10:00 p.m. the nurse documented in the Nurse's Notes that the ulcer at the time of the dressing change had a foul odor. The Nursing Notes from 12/16/11 to 12/29/11 documented the resident received [MEDICATION NAME] 250 milligrams each day (antibiotic) treatment for [REDACTED]. The Nursing Notes dated 12/29/11 at 10:00 a.m. documented the nursing staff informed the physician of the wound deterioration. The nurse documented the physician ordered labs and directed staff to make an appointment for the resident to be assessed by the wound center at the identified hospital although the clinical record lacked a copy of the physician order [REDACTED]. The physician History and Physical report dated 12/30/12 documented the resident's family was informed by the nursing home only 2 days prior to hospitalization of the decline in the wound status. The report documented the ulcer area measured 4 cm by 4 cm. with black discoloration of the surrounding tissue and questioned the possibility of the ulcer depth to the bone. The consultant referred the resident to plastic surgery for [REDACTED]. According to the care plan dated 1/17/12, the resident returned from the hospital with a pressure area on the buttock that required wound care. The care plan directed staff to reposition the resident every 2 hours, float the heels, place bunny boots on to the resident's feet and to record the amount of fluids the resident consumed. The Physician admission orders [REDACTED]. The report on 1/25/12 documented the pressure ulcer as 5.8 cm by 4.9 by 2 cm. with undermining (tunneling) of 3 cm. On 2/1/12 the report revealed the pressure ulcer as 5.4 by 4 by 2.1 cm. and 4.1 cm of undermining present. On 2/8/12 the report revealed the pressure ulcer as 5.3 cm by 4 cm by 2 cm. The report lacked the undermining measurement. The 3/30/12 report documented the measurements as 4.1 cm by 3.3 cm by 1.5 cm with undermining of 3.8 cm present. The 4/2/12 report documented the measurements as 4 cm by 4.5 cm by 2 cm. The skin report did not identify the undermining. The 4/9/12 report documented the measurements as 4 by 4.3 cm by 2 cm. and did not reflect undermining The 4/16/12 report documented the measurements as 4 cm by 4 cm by 2 cm with no assessment of the undermining. The 4/23/12 report documented the measurements as 4 cm by 4 cm by 2 cm with no assessment of the undermining. The 4/30/12 report documented the measurements as 3 cm by 2.7 by 2 cm. with undermining 3 cm at 11:00 and 2 cm at 2:00 (measured by the symbol of a clock). The reports documented the presence of drainage as serosanguinous, no odor, beefy red in color and the nurse documented the wound was improving. On 5/2/12 at 3:30 p.m., the Director of Nursing stated she expected the nursing staff to complete the Admission/Readmission Assessment and to notify the physician of any changes. 2. An MDS 5 day assessment with a reference date of 2/26/12 identified Resident #4 with the following Diagnoses: [REDACTED]. The resident scored 15/15 on the Brief Interview for Mental Status which indicated an intact memory and cognitive function related to daily decision making skills. The MDS reflected the resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS coded the resident as occasionally incontinent of both bowel and bladder. An initial MDS with a reference date of 1/13/12 coded the resident with no pressure ulcers and no vascular ulcers present. The admission orders [REDACTED]. The resident care plan dated 1/13/12 identified a potential for/actual changes in skin integrity related to diabetes, impaired mobility, and [MEDICAL CONDITION]. The care plan interventions included: dietary measures, assess skin condition, specialty mattress to bed, turn and reposition, treatment per Dr. order, meds per Dr. order, keep nails short and smooth, increase mobility as tolerated, increase activity as tolerated, assess footwear, notify Dr. as needed, therapy as ordered, and monitor for signs and symptoms of infection. The care plan did not address a pressure relief device when Resident #4 sat in the chair. A facsimile dated 1/5/12 and sent to the physician noted a 2 cm by 1.1 cm superficial area to the left inner buttock and requested an order for [REDACTED]. The facility did not initiate a pressure ulcer skin sheet upon the discovery of the open area on the buttocks and provided no documentation related to the resolution of the area. Review of the January and February MAR's (Medication Administration Records) revealed the above mentioned treatment continued until the resident returned to the hospital on [DATE]. A multidisciplinary progress note dated 2/17/12 from a local hospital during a wound consult identified open areas along the medial left buttock- the upper one measuring 1.7 cm by 0.7 cm and the lower one measured 1 cm by 0.6 cm. Both areas had granulation tissue present. On 2/22/12 the resident returned back to the facility with the following orders for Stoma powder to the open area on the buttocks, cover the area with [MEDICATION NAME], then dust the top with stoma powder twice daily and as needed until healed. On 2/22/12 the facility did initiate a non-pressure area skin sheet for the buttocks and obtained the following measurements: 1.3 cm by 1.6 cm and identified the source of the wound as a skin tear. The facility completed weekly skin assessments until the resident returned to the hospital on [DATE]. An observation made on 4/30/12 at 7:40 a.m. revealed an open area on the inner aspect of the left buttock proximal to the rectal vault in location. The surface of the skin appeared absent with a red beefy center of the wound bed present. The surrounding skin tissue appeared intact and pale pink in color. The diameter of the wound approximated the size of a quarter. A dressing did not cover the wound but it did not appear to be weepy or wet with drainage or exudate. Upon review of the nursing note documentation and skin sheet assessments, the facility did not identify the date and time when the wound appeared open and did not initiate a skin assessment sheet with measurements and description of the wound or identify whether the wound met criteria for a pressure or non-pressure area. The open area on the left buttock coincided with the location on the buttocks where the majority of the resident's weight distribution would be when sitting up in a chair or wheelchair so therefore fit the pressure ulcer criteria. An interview conducted on 5/1/12 at 11:15 a.m. with the DON (Director of Nursing); regarding completion of skin assessments revealed the nursing staff did skin assessments with skin sheets for all bruises, abrasions, skin tears, and stasis and pressure ulcers. The DON stated the nursing staff completed weekly skin assessments with measurements until the area resolved. The DON stated if a resident received a skin treatment, then the charge nurses needed to complete a weekly skin assessment with measurements as appropriate and include a detailed description of the area until that area resolved or healed.