Every finding on record at Twin Oaks Center

Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure pre-employment health requirements and dementia training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Specifically, the facility administration failed to: 1. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, and safe practice. 2. Establish and maintain an IPCP (Infection Prevention Control Program) designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of disease and infection. 3. Develop an Antibiotic Stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Findings include: During the survey process it was identified that the Administration's failure to orient and educate staff on policies and procedures specifically related to dementia care. During the survey process, it was also identified that the Administration's failure to implement an infection control program for identifying, tracking, and monitoring, including the failure to develop and implement an Antibiotic Stewardship Program. During an interview on 6/18/25 at 9:39 A.M., the Administrator said it is his expectation that the clinical staff are trained appropriately and have the required completed clinical competencies on file. The Administrator said he was not aware that 3 out of the 5 new hire employee records reviewed were lacking proof of dementia training. He then said that he could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, antibiotic stewardship or dementia education. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and the vaccinating of residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data. During an interview on 06/18/25 11:10 A.M., the Administrator said that he had not informed the [NAME] president of Operations or the governing body of the lack of QAPI in the facility prior to February. During an interview on 6/18/25 at 11:23 A.M., the [NAME] President of Operations said he was not made aware of the lack of QAPI being performed in the building from September 2024 through February 2025. He then said that he expects the Administrator is ensuring QAPI and infection control programs are in place. I expect them to follow the system and QAPI programs. I do not review the QAPI minutes to make sure that the administration is following the QAPI program. Refer to F837, F880 and F881

Based on interview and record review, the facility failed to ensure that the governing body provided oversight and accountability for: 1. The maintenance of an effective QAPI program. 2. The provision of an infection control/antibiotic stewardship program. Findings include: Review of the facility policy titled, Quality assurance Performance Improvement Plan, dated January 2025, indicated that the Administrator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our facility. QAPI activities and discussion will be a standing item on our governing body board meeting agendas. During the survey period the surveyor requested the infection control program information for tracking infections, including line listings, reporting data and antibiotic stewardship. The facility failed to have any documented information related to tracking and reporting of infections or antibiotic stewardship in the facility. Review of the QAPI program failed to indicate that a QAPI had been initiated for the implementation of the infection control/antibiotic stewardship programs. During an interview on 6/18/25 at 10:50 A.M., the Administrator said that the QAPI program had not been implemented since ownership changed hands in June 2024 until February 2025. The Administrator said that he could not find any QAPI meeting minutes or projects June 2024 through February 2025. The Administrator said that he was not aware that the infection control and antibiotic stewardship programs were not being implemented. The Administrator said that it is his expectation that the facility follows an infection prevention and control program that includes a system for appropriate infection surveillance. The Administrator also said that he would expect that the facility is implementing an antibiotic stewardship program. The Administrator said that the lack of complete infection control and antibiotic stewardship programs would warrant the inclusion in QAPI. During an interview on 6/18/25 at 10:56 A.M., the [NAME] President of Operations/owner said that he was not aware of who the Governing Body representative was for the facility. During an interview on 06/18/25 at 11:10 A.M., the Administrator said that he had not informed the governing body of the lack of QAPI in the facility prior to February. During an interview on 6/18/25 at 11:23 A.M., the [NAME] President of Operations/owner said he was not made aware of the lack of QAPI being performed in the building from September 2024 through February 2025. He then said that he expects the facility to follow the system and QAPI programs. Refer to F880 and F881

Based on interview and document review, the facility failed to implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility developed QAPI plans related to staff education and infection control once these concerns were identified by the Administrator. Findings include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated January 2025, indicated the following: -Purpose: To ensure the delivery of the highest standard of care and services to our residents. Our QAPI program is designed to monitor, assess, and continuously improve all aspects of care and operations, addressing areas for improvement proactively, and ensuring that quality outcomes are consistently achieved. - Program Overview: The QAPI program is comprehensive, facility-wide, data-driven approach aimed at identifying and addressing quality gaps in clinical care, resident safety, patient satisfaction, operational efficiency, and regulatory compliance. Our program aligns with the Centers for Medicare & Medicaid Services (CMS) QAPI standards and promotes a culture of continuous improvement. -The 2025 QAPI program will focus on person-centered care, infection prevention, staff development, resident safety, and regulatory compliance while utilizing ongoing data collection and feedback to guide improvements. -Further review indicated that the QAPI committee will meet monthly and include representatives from key departments. Review of 5 out of 9 new employee records, hired in the past four months, indicated the following: -3 had no dementia training. -3 had no Certified Nurse Aide (CNA) registry check before their hire date. - The Director of Nursing did not have a license check. -1 did not have a preemployment physical. -2 did not have a tuberculin test prior to employment. -1 did not have any indication of a COVID vaccine or declination. During an interview on 6/18/25 at 10:50 A.M., the Administrator said that he had been at the facility for only a couple of months. He said that the Director of Nurses was responsible for the Infection Control and Prevention Program before his arrival at the facility and she was in the process of training the Assistant Director of Nurses to manage the program. The Administrator said that the QAPI program had not been implemented since ownership changed hands in June 2024 until February 2025. The Administrator said that he could not find any QAPI meeting minutes or projects June 2024 through February 2025. The Administrator said that he was not aware that the Infection Control and Antibiotic Stewardship programs were not being implemented. The Administrator said that it is his expectation that the facility follows an infection prevention and control program that includes a system for appropriate infection surveillance. The Administrator also said that he would expect that the facility is implementing an Antibiotic Stewardship Program. The Administrator said that the lack of complete Infection Control and Antibiotic Stewardship programs would warrant the inclusion in QAPI. During an interview on 6/18/25 at 10:50 A.M., the Director of Nursing said that the expectation is that an Infection Control and Antibiotic Stewardship Program is maintained and followed in the facility. She said she does not know how the facility was following antibiotic use prior to her arrival four months ago at the facility but said that currently she is training the Assistant Director of Nursing on the program. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and the vaccinating of residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified quality deficient areas to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes. Findings Include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated January 2025, indicated the following: -Purpose: To ensure the delivery of the highest standard of care and services to our residents. Our QAPI program is designed to monitor, assess, and continuously improve all aspects of care and operations, addressing areas for improvement proactively, and ensuring that quality outcomes are consistently achieved. - Program Overview: The QAPI program is comprehensive, facility-wide, data-driven approach aimed at identifying and addressing quality gaps in clinical care, resident safety, patient satisfaction, operational efficiency, and regulatory compliance. Our program aligns with the Centers for Medicare & Medicaid Services (CMS) QAPI standards and promotes a culture of continuous improvement. The 2025 QAPI program will focus on person-centered care, infection prevention, staff development, resident safety, and regulatory compliance while utilizing ongoing data collection and feedback to guide improvements. Further review indicated that the QAPI committee will meet monthly and include representatives from key departments. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and the vaccinating of residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data. During an interview on 6/18/25, at 10:50 A.M., the Administrator said that the QAPI program had not been implemented since ownership changed hands in June 2024 until February 2025. The Administrator said that he could not find any QAPI meeting minutes or projects June 2024 through February 2025.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. Findings include: Review of the facility policy titled 'Surveillance for Infections', dated as revised September 2017, indicated the following: -The infection preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections (HAI's) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAI's, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on current standard definitions of infections. 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible. 6. If a communicable disease outbreak is suspected, this information will be communicated to the charge nurse and Infection Preventionist immediately. 7. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 8. The charge nurse will notify the attending physician and the IP of suspected infections. 9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infections, the IP will collect data to help determine the effectiveness of such measures. 10. When transmission of HAI's continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or specialist in infections control and epidemiology will be consulted for further recommendations. -The IP or designated infection control personnel are responsible for gathering and interpreting surveillance data and calculating infection rates. The infection control committee and/or QAPI committee may be involved in interpretation of the data. Review of the Facility assessment dated [DATE], indicated the following: Diseases /conditions, physical and cognitive disabilities. -Infectious Diseases: COVID-19, Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections, Infections with Multi-Drug-Resistant Organisms (MDRO), Septicemia, Viral Hepatitis, Clostridium difficile, Influenza. -Infection prevention and control: Identification and containment of infections, prevention of infections -Management of Medical Conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infectious such as UTI (Urinary Tract Infection) and gastroenteritis, pneumonia, hypothyroidism, Hospice/Palliative Care. -Staff training/education and competencies: Infection control training is provided to staff upon hire, annually, and as needed. -Evaluation of Infection Prevention and Control Program: facility conducts monthly/quarterly QAPI meetings, and review infection control trends. Surveillance rounds are completed; clinical rounds are done daily to discuss residents who are on antibiotics and who have active infections. During the survey period the surveyor requested the infection control program information for tracking infections, including line listings and reporting data. The facility failed to have any documented information related to tracking and reporting of infections in the facility. Further review indicated the facility failed to have any documented information for the months of August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025. During the course of the survey the facility was unable to provide surveillance data and documentation of follow-up activity in response to the active antibiotic use in the facility. Review of the electronic Antibiotic Order Listing report dated 6/18/25, indicated the following prescribed antibiotics for the following infections: June 2025 Antibiotics for cystitis. May 2025 Antibiotics for toe infection, wound infection, Urinary Tract Infection (UTI), positive sputum culture. April 2025 Antibiotics oral infection, periodontal infection and UTI. March 2025 Antibiotics for sinus infection, bacterial infections, UTI's, pyelonephritis, cellulitis, respiratory infection and C-diff. February 2025 Antibiotics for sinus infection, bacterial infection, wound infection, and UTI. January 2025 Antibiotics for bacterial infection, respiratory infection, and UTI's. December 2024 Antibiotics for osteomyelitis and bacterial infection. November 2024 Antibiotics for bacterial infection and cellulitis. October 2024 Antibiotics for UTI and skin Infections. August 2024 Antibiotics for bacterial infection and UTI's. During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said infections and surveillance of infections should be tracked, monitored, documented and reported. The DON said she does not know the rate of infections and said she has no data available and relies on what is reported to her by nursing staff. The DON said she is unaware of the infections and has no information available regarding tracking, surveillance or outbreak information available. During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist was not able to provide evidence of any infection prevention program in place in the facility including line listing, antibiotic stewardship, tracking and trending of signs of symptoms of infections, vaccination program for staff and employees, and surveillance criteria. During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Infection Control program should be implemented and followed and said he is not aware of the infections in the building and said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be followed. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and vaccinating residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.

Based on record review and interviews, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship, undated, indicated the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. -The purpose of our Antibiotics Stewardship Program is to monitor the use of antibiotics in our residents. -Orientation, training and education of staff will emphasize the importance of Antibiotic Stewardship and will include how appropriate use of antibiotics affects individual residents and the overall community. -Training and education will include emphasis on the relationship between antibiotic use and: a. Gastrointestinal disorders. b. Opportunistic infections (e.g., C. difficile, candida albicans, etc.). c. Medication interactions; and d. The evolution of drug-resistant pathogens. During the survey period the surveyor requested infection control line listings and antibiotic stewardship information. The facility failed to have any documented information related to tracking, follow up or review with the physician or nurse practitioner following the initiation of the antibiotics for 3 out of 3 active physician antibiotic orders prescribed. Further review indicated the facility failed to have any documented information for the months of August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025. During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said infections and surveillance of infections should be tracked, monitored, documented and reported. The DON said she does not know the rate of infections and said she has no data available and relies on what is reported to her by nursing staff. The DON said she is unaware of the infections and has no information available regarding tracking, surveillance or outbreak information available. During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist was not able to provide evidence of any infection prevention program in place in the facility including line listing, antibiotic stewardship, tracking and trending of signs of symptoms of infections, vaccination program for staff and employees, and surveillance criteria. During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Infection Control program/Antibiotic Stewardship program should be implemented and followed. He then said he is not aware of the infections in the building and said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be followed. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and vaccinating residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.

Based on observations and interviews, the facility failed to ensure 1.) a medication cart was locked when unattended, on one of three nursing units, 2.) medications were labeled, and dated once opened, according to manufacturer's guidelines on one out of three medication carts sampled, 3.) store medications at proper temperatures and other appropriate environmental controls to preserve their integrity. Findings include: Review of the facility policy titled, Storage of Medications, dated as revised April 2007, indicated: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -Only a person authorized to prepare and administer medications shall have access to the medication room, including keys. -Medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication must be stored separately from food and must be labeled accordingly. 1.The facility failed to ensure medications were stored in locked compartments on one of three nursing units. On 6/17/25 at 8:08 A.M., the surveyor observed a medication cart left unlocked and unattended on the third-floor unit. The surveyor was able to open the medication cart and gain access to the medications. There were no staff present at or around the medication cart and residents were observed walking past the unlocked medication cart. During an interview on 6/17/25 at 8:18 A.M., Nurse #3 said the medication cart must be locked at all times and said he did not realize it was unlocked. During an interview on 6/17/25 at 3:20 P.M., the Director of Nursing (DON) said medication carts must remain locked and said no one should have access to the medications except the nursing staff who have the keys to unlock the cart and gain access to the medication stored inside. 2.The facility failed to ensure medications were labeled, and dated once opened, according to manufacturer's guidelines in one out of four medication carts sampled. On 6/17/25 at 8:50 A.M., the surveyor and Nurse #3 observed the following on the 3rd floor medication cart: -Artificial Tears Lubricant Eye Drops ½ FL Oz 15ml., open undated. During an interview on 6/17/25 at 8:52 A.M., Nurse #3 said medications must be dated when opened and said he is not sure when the bottle was opened. During an interview on 6/17/25 at 3:20 P.M., the Director of Nursing (DON) said the Artificial Tears should have been dated when opened and said she expects staff to document on the bottle when a medication if first opened. 3.The facility failed to ensure storage of medications at proper temperatures and other appropriate environmental controls to preserve their integrity. On 6/17/25 at 12:18 P.M., the surveyor made the following observations on the 1st floor unit: -One Medication refrigerator was located inside of the medication storage room. There was no thermometer located inside of the refrigerator and the inside of the refrigerator felt cool not cold. Condensation was observed on the medications located inside of the refrigerator. -There was one digital thermometer located on the outside of the refrigerator that was not operatable and had a blank screen. -One April 2025 Temperature Log containing 12 documented temperatures out of 30 days. The following medications were observed inside of the refrigerator: -One box of Latanoprost Ophthalmic Solution 0.005% Store unopened bottle in refrigeration at 2 degrees Celsius to 8 degrees Celsius (2°C to 46°C) /36 degrees Fahrenheit to 46 degrees Fahrenheit. (36°F to 46°F) -Six Vitals of Humalog CAR 100 Units. Store in a refrigerator at approximately 36°F to 46°F. -15 Insulin Injection Pens. Store in a refrigerator at approximately 36°F to 46°F -1 Box Repatha (evolocumab) Prefilled Syringe Injection - Store in a refrigerator at approximately 36°F to 46°F. -1 Box Risperdal Consta Risperidone Long-Acting Injection Single Use Dose Pack - Store in refrigerator at approximately 36°F to 46°F. During an interview on 6/17/25 at 12:24 P.M., Nurse #2 said the refrigerator should have daily temperature logs and said the overnight staff are responsible for maintaining the logs. Nurse #2 said the Assistant Director of Nursing took the thermometer out this morning because it was not working. During an observation and interview on 6/17/25 at 1:04 P.M., the Assistant Director of Nursing (ADON) said the temperature of the refrigerator was too high and said he took the thermometer out this morning and did not place a new thermometer inside of the refrigerator. The surveyor along with the ADON observed the refrigerator and observed condensation, melting frost and water on the inside of the refrigerator that contained medications. The bottles and bags were wet to the touch. The ADON said the overnight nurse reported to him that the refrigerator was not working and that it was warm. The ADON said the medications must be within parameters and said all he knows is that the temps were high according to the overnight nurse, but he does not know what the temperature was and does not know how long the refrigerator was warm. The ADON then said he does not have any temperature logs and said the staff should be documenting the temperature every night. During an interview on 6/17/25 at 2:37 P.M., the Director of Nursing said it is her expectation that the temperature of the refrigerators are checked each night and monitored for safety within the appropriate temperatures. The DON said she was not aware of the warm refrigerator and said the medications must be thrown away because they do not know how long they have been warm. During an interview on 6/18/25 at 10:38 A.M., the Medical Director said it is his expectation that medications are stored according to the manufactures guidelines and said he expects staff to monitor temperature controls and remove medications that have been compromised.

Based on observations and interviews the facility failed to ensure a dignified dining experience on one out of three units. Specifically on the 1st floor unit, dining room staff failed to provide dignified dining experience and referred to residents as feeders, rather than by their name. Findings include: The facility policy titled Quality of Life- Dignity, dated as revised August 2009, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. - Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. On 6/17/25 beginning at 12:28 P.M., the surveyor made the following observations on the first floor unit: -At 12:41 P.M., a Certified Nursing Assistant (CNA) walked into the dining room, gestured at a resident across the room and asked Nurse #1 if the resident was a feeder. Nurse #1 responded yes and failed to inform the CNA that residents should be referred to by their name, not as feeders. -At 12:46 P.M., a Nurse said out loud We have a feeder left and gestured to a resident sitting at a table with four residents. During an interview on 6/17/25 at 1:27 P.M., the Assistant Director of Nursing said staff should not refer to residents as feeders. During an interview on 6/17/25 at 1:35 P.M., the Director of Nursing said staff should not refer to residents as feeders and said residents should be treated with dignity.

Based on record review and interview, the facility failed to 1.) report a fall, resulting in a head laceration requiring staples and, 2.) report a fall, resulting in a fracture of the right femoral neck (right thigh bone) requiring surgery, to the state agency as required for one Resident (#42), out of a total sample of 21 residents. Findings include: A review of the facility policy titled, Abuse Investigation and Reporting with a revision date of July 2017 indicated the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator or his/her designee to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility. -An alleged violation of abuse, neglect, exploitation, or mistreatment, (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. 1. Resident #42 was admitted to the facility in March 2019 with diagnoses including bradycardia, adjustment disorder with anxiety, and anemia. Review of Resident #42's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident has a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff with activities of daily living. Review of nursing progress notes indicated the following: -Dated 6/11/25: This nurse had just come back from doing rounds, when she heard noise coming from the patient's room. On inspection, patient was observed lying on the floor on his/her left side. Vitals were stable, neuro's intact. At baseline resident is alert and oriented to self therefore, unable to provide a description of what happened. Resident was safely transferred back to his/her bed with the help of the CNA and I. Resident was not moaning or grimacing, he/she did not appear to be in pain. Physician was notified, he stated that they will come in and see him/her and legal guardian was left a message. Later on, when the aids for the next shift got the resident up in his/her wheel chair, they observed him/her bleeding from the scalp. This nurse and the oncoming nurse on duty was notified, this nurse called NP (nurse practitioner) who gave an order to send him/her out to the ED (emergency department)for further evaluation and a head CT scan. (Local) ambulance service was called to pick the resident and transport him/her to hospital, and they let this nurse know that they would be there in an hours time. This nurse let the on duty nurse know and also the ADON was made aware of the situation. -Dated 6/11/25: Resident returned from Hospital s/p (status post) fall with injury to front head; via stretcher accompanied by 2 emergency personnel. Resident presented with laceration on front head. Resident returned with a staple to front of head. Review of Resident #42's Hospital Discharge paperwork dated 6/11/25 indicated the following: - -Head: Midline forehead at the hairline there is an elliptical 2 cm laceration with slight blood oozing. Wound was closed with one staple. CT scan showed left forehead soft tissue laceration and edema. Follow-up with primary care physician in 2-3 days if not improving or for further concerns or follow-up sooner as needed. Staple removal in 7 days. Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the incident to the state agency. During an interview on 6/17/25 at 2:27 P.M., the Director of Nursing said she would expect the incident to have been reported to the state agency and said she thought the Administrator had reported the fall with head laceration with the staple. During an interview on 6/18/25 at 8:08 A.M., the Administrator said he was aware of Resident #42's fall with head laceration and staple and said the injury should have been reported to the state agency but was not. 2. Review of Resident #42's progress notes indicated the following: -Dated 2/23/25, Nurse Practitioner: Fall with injury. Patient had an unwitnessed fall. Patient does not ambulate independently, uses wheelchair at baseline. Staff did not see the fall, but patient was in common area for activity and attempted to get up unassisted, having a fall and was found on the floor. Patient complains of severe pain in the right knee and lower leg and will not allow staff to move or touch the leg. Indicates severe pain with any movements of the knee, not able to bear any weight on the joint with standing and there is moderate swelling/deformity of the knee. He/she also has a small hematoma to right side of forehead without active bleeding at this site. Limited flexion and extension of right knee, moderate right knees [NAME], guarding due to pain. Skin pink and dry, small hematoma about 1.5 inches in diameter to right forehead above the brow. This is an acute new problem condition is worsening. Significant knee pain with swelling and limitations to movement, concern for fracture given the injury/trauma. -Dated 2/27/25, Nursing: Resident alert with baseline confusion. Returned from hospital last night s/p fall 3 days ago where he/she sustained a fracture in his/her right hip. Dressing on right hip intact with no drainage or signs of infection noted. Hip abduction pillow in place during shift. Resident received PRN Tylenol for pain with good effects. Resident was seen today by NP, new order placed to change hip dressing daily and as needed. Review of Resident #42's Hospital Discharge paperwork dated 2/26/25 indicated the following: Fall and right hip fracture. Diagnosis: Close displaced fracture of right femoral neck. Status post-operative repair of closed fracture of right hip. Posterior Hip Precautions for 3months. Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the incident to the state agency until 3/5/25, 10 days after the fall resulting in right femur fracture. During an interview on 6/17/25 at 2:30 P.M., the Director of Nursing said she would expect the incident to have been reported to the state agency as required due to a resulting right leg fracture requiring surgery. During an interview on 6/18/25 at 8:14 A.M., the Administrator said he would expect the fall with fracture to be reported per the state requirement and said he was not present during the time of the incident.

Based on record review and interviews, the facility failed to develop a person-centered behavior care plan for one Resident (#10) out of a total sample of 21 residents. Specifically, the facility failed to develop a person-centered care plan for a history of chronic paranoia and delusions. Findings include: A review of the facility policy titled 'Behavioral Assessment, Intervention and Monitoring' with a revision date of December 2016 indicated the following: -Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. -As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g., bipolar disorder or schizophrenia). -As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations, the resident's usual patterns of cognition, mood and behavior, the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers. Resident #10 was admitted to the facility in April 2025 with diagnoses including schizophrenia, intellectual disability and post-traumatic stress disorder. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment. A review of the hospital discharge medical record dated 3/20/25 indicated the following: -Per social work notes: Resident has a history of chronic delusions, however staff from the respite, report his/her paranoia has been worse. The resident notes he/she does not want to go back to respite because the male staff scare him/her. He/she notes that he/she would like to go to a nursing home and have female staff. Staff confirm that the resident has paranoia around black males, and this has contributed to him/her refusing his/her medication when the staff is a black male. Resident reported his/her neighbors, who drink alcohol, whiskey, and do drugs broke into his/her apartment, beat him/her, did wicked things, sexually. Resident reports urinating in bottles in his/her room because he/she does not want to leave his/her room to use the bathroom.[sic] A review of Resident #10's care plan failed to indicate a history of delusions and paranoia person-centered care plan. During an interview and record review on 6/17/25 at 9:17 A.M., the Social Worker reviewed the hospital discharge paperwork with the surveyor. The Social Worker said a person-centered care plan with the Resident's chronic paranoia and delusions should be added to his/her care plan. During an interview on 6/17/25 at 10:40 A.M., the Director of Nurses said the Resident's paranoia and delusions should be added in the care plan and person centered. Refer to F699.

Based on observations, interviews and record review, the facility failed to provide Nursing services consistent with professional standards of practice for two Residents #24 and #11 out of a total sample of 21 residents. Specifically; 1. For Resident # 24, the facility failed to include how much oxygen the Resident should be taking via nasal cannula, and how often the oxygen tubing should be changed in the physician's orders. 2. For Resident #11, the facility failed to implement a physician's order to administer tube feeding with correct enteral feeding and correct rate. Findings include: A review of the facility policy titled 'Oxygen Administration' indicated the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors. 1. Resident #24 was admitted to the facility in December 2024 with diagnoses including dementia with behavioral disturbances and Chronic Obstructive Pulmonary Disease (COPD). A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 indicating moderate cognitive impairment. On 6/16/25 at 9:17 A.M., and 11:10 A.M., the surveyor observed Resident #24 in bed wearing a nasal cannula, oxygen was set at 4 liters, and the oxygen tubing was not labeled and dated. During an interview on 6/16/25 at 11:10 A.M., Resident #24 said he/she has been on oxygen since admission. On 6/17/25 at 7:47 A.M., and 9:48 A.M., the surveyor observed Resident #24 in bed wearing a nasal cannula, oxygen was set at 4 liters, and the oxygen tubing was not labeled and dated. A review of the Respiratory therapist's progress note date 6/12/25 indicated the following: -The Resident utilizes an oxygen concentrator from O2 (oxygen) safe. Oxygen saturation on 3 LPM (Liters Per Minute) is 97 percent, and his/her respiratory rate is 73 bpm (breatbs per minute). A review of the Respiratory therapist's progress note dated 6/16/25 indicated the following: The Resident utilizes an oxygen concentrator from O2 (oxygen) safe. His/her oxygen saturation on 3 LPM (Liters Per Minute) is 99 percent and his/her respiratory rate is 86 bpm (breaths per minute). A review of Resident #24's physician's orders failed to indicate an oxygen administration via nasal cannula physician's order. Further review of the shortness of breath (SOB) and COPD care plan initiated 4/10/25 failed to indicate an oxygen administration via nasal cannula plan of care. During an interview, observation and record review on 6/17/25 at 10:15 A.M., the surveyor and the Assistant Director of Nurses (ADON) observed the Resident in bed, wearing the nasal cannula, oxygen set at 4 liters, and the oxygen tubing not labeled and dated. The ADON reviewed the physician's orders and could not find an order for oxygen administration. The ADON said there should be a physician's order in place indicating how much oxygen the resident should be taking, and how often the oxygen tubing should be changed. During an interview and record review on 6/17/25 at 10:21 A.M., the Director of Nurses (DON) reviewed Resident #24's physician's orders and said oxygen administration physician's order should be in place. The DON said the physician's orders should indicate how much oxygen the resident should be on and how often the oxygen tubing should be changed.2. Resident #11 was admitted to the facility in March 2021 with diagnoses including respiratory failure, gastrostomy status, tracheostomy, and quadriplegia. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/25/25, indicated Resident #11 had a Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. Further review indicated Resident #11 had tube feedings, and a tracheostomy. Review of Resident #11's physician's order, initiated 5/9/25, indicated: - Enteral Feed Order every shift Jevity 1.5 calories (cal) at 55 milliliters (ml) per hour (hr). On 6/16/25 at 8:02 A.M., the surveyor observed Jevity 1.2 cal at 58 ml/hr being administered via gastrostomy (G-tube) to Resident #11. On 6/17/25 at 7:33 A.M., the surveyor observed Jevity 1.2 cal at 58 ml/hr being administered via G-tube to Resident #11. During an interview on 6/16/25 at 10:45 A.M., Nurse #1 reviewed Resident #11's physician's order and then observed the enteral feeding that was being administered to Resident #11 with the surveyor. She said she was not aware that Resident #11 was not receiving the enteral feeding that was ordered by the physician. She said she would expect that the physician ordered enteral feeding would match what the Resident was receiving. During an interview on 6/17/25 at 11:50 A.M., the Director of Nursing (DON) said nurses should always follow the physician's orders. The DON said that if the enteral feed orders need to be changed for any reason, she would expect the order to be updated and to be followed.

Based on observation, record review and interview the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#56) out of a total sample of 21 residents. Specifically; the facility failed to change a wound dressing for three days. Findings include: Review of the facility policy titled Dressings, Dry/Clean dated revised September 2013, failed to indicate to follow a physician's order. Resident #56 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease, anxiety and depression. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #56 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. On 6/16/25 at 8:10 A.M. the surveyors observed Resident #56 sitting on the edge of the bed. The surveyors then observed a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. The surveyors also observed that the dressing was dated 6/12/25. On 6/16/25 at 12:50 P.M. the surveyor and Nurse #1 observed Resident #56 sitting on the edge of the bed with a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. They also observed that the dressing was dated 6/12/25 and had yellow/brown drainage. Review of the physician's orders dated June 2025 indicated an order for: Day Shift; Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically every day shift for Wound care - Start Date - 05/14/2025 0700 - D/C Date - 06/13/2025 0938 Further review indicated an order for: Day Shift; Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically every day shift for Wound care for 30 Days - Start Date - 06/14/2025 0700 Review of the Medication Administration Record dated June 2025, indicted that on 6/13/25, 6/14/25 and 6/15/25, nurses documented that they changed the dressing as ordered. During an interview on 6/16/25 at 12:50 P.M. Nurse #1 said that the dressing should have been changed daily. During an interview on 6/18/25 at 7:26 A.M. the Director of Nursing said that she expects the nurses to follow the physician's orders for dressing changes.

Based on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility failed to ensure staff implemented Resident #11's, physician ordered, rolled facecloth to contracted [left] hand every shift. Findings include: Review of the facility policy titled 'Resident Mobility and Range of Motion', revised July 2017, indicated: - Residents will not experience an avoidable reduction in range of motion (ROM). - Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. - Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless a reduction in mobility is unavoidable. Resident #11 was admitted to the facility in March 2021 with diagnoses including contracture, unspecified joint. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/25/25, indicated Resident #11 had a Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. This MDS also indicated Resident #11 had functional limitation in range of motion in bilateral upper and lower extremities. Review of Resident #11's physician's order, initiated 4/21/24, indicated: - Cleanse left hand with water and soap and dry. Inspect skin. Notify physician (MD) if impairment is noted and document in progress notes. Place a rolled washcloth to contracted hand, every shift (QS). Review of Resident #11's plan of care related to alteration in musculoskeletal status left hand related to contracture, revised 2/16/22, indicated: - washcloth in palm to prevent further contracture deterioration. On 6/16/25 at 8:02 A.M., the surveyor observed Resident #11 lying in bed without a facecloth in his/her left hand. On 6/17/25 at 7:34 A.M., the surveyor observed Resident #11 lying in bed without a facecloth in his/her left hand. During an interview on 6/17/25 at 10:10 A.M., Certified Nurse Assistant (CNA) #2 said she regularly works on the unit with Resident #11, and he/she usually has a facecloth in his/her left hand, but she does not know why he/she hasn't had it for the past two days. Review of Resident #11's medical record, including medication administration record (MAR), treatment administration record (TAR), and progress notes failed to indicate any rationale regarding why Resident #11 was not using a facecloth to his/her left hand. During an interview on 6/17/25 at 10:45 A.M., Nurse #1 and surveyor reviewed Resident #11's order for facecloth to left hand and then observed that he/she did not have a facecloth in his/her left hand. She said that Resident #11 usually has a facecloth in his/her left hand, and it should be there according to physician's orders. Nurse #1 and surveyor reviewed Treatment Administration Record (TAR) and observed that the order for rolled facecloth to left hand is signed off every shift as completed. On 6/17/25 at 10:50 A.M., the surveyor observed Resident #11 lying in bed without a facecloth in his/her left hand. During an interview on 6/18/25 at 7:25 A.M., the Director of Nursing (DON) said if Resident #11 had a physician's order for a facecloth to be applied to his/her left hand, it should have been in place. The DON said if it was not in place, the rationale should be documented in the medical record.

Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#1) out of a total sample of 21 residents. Specifically, for Resident #1 the facility failed to ensure significant weigh loss was assessed and continually monitored. Findings include: Review of the facility policy titled, Weighing and Measuring the Resident, dated as revised March 2011, indicated the following: -The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. -Reporting: 1. Report significant weight loss/weight gain to the nurse supervisor. 2. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. a. 1 month- 5% loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. 3. Notify the Nurse Supervisor if the resident refuses the procedure. 4. Report other information in accordance with facility policy and professional standards of practice. Resident #1 was admitted to the facility in February 2025 with diagnoses including anxiety, depression, and bipolar disorder. Review of Resident #1's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) of 12 out of a possible 15, which indicated he/she had moderate cognitive impairment. Review of Resident #1's weights indicated the following: -5/12/25 152.0 lbs. -4/1/25 157.1 lbs. -2/6/25 176.5 lbs. -5/24/25 129.3 pounds (lbs.) 14.9 % decrease from 5/12/25; 17.7 % decrease from 4/1/25; 26.7 % decrease from 2/6/25. Review of the Resident's medical record failed to indicate any record of weights during the month of March 2025 and failed to record any reweights or documentation of physician being notified of significant weight loss. Review of the dietary notes indicated the following: 5/12/2025 10:50 Weight Note Note Text: he/she triggered for loss this month -10% from 2/6 176.5 Wt. Hx 2/6 176.5 4/1 157 5/12 152 -10% decrease Diet mech (mechanical) soft in dining room He/she reports UBW (usual body weight) 160. Appetite is variable, prefers sandwiches and cold cereal. He/she agreed to try the house supps (supplements) added to trays to prevent further loss. BMI is wnl [within normal limits] and insight loss x 30 days. Will cont [continue] to monitor and evaluate. [sic] 4/4/2025 12:15 Weight Note Note Text: He/she triggered for wt. loss, -10% from admission. He/she was seen in the dining room in his/her electric wheelchair with others. He/she reports his/her appetite is good and he/she prefers sandwiches. He/she declines supplements or any snacks and reports he/she gets enough to eat. He/she appears to be recorded ht/wt [height/weight] and adequately nourished. BMI is wnl [within normal limits]. Wt. HX 4/1 157 2/6 176.5 BMI 22.5 wnl Diet mechanical soft. Intakes 50-100% Since he/she declines interventions no new concerns. Will cont to monitor. [sic] During an interview on 6/17/25 at 10:45 A.M., Nurse #1 said she would report any significant weight loss to the dietitian and physician. During a follow up interview on 6/17/25 at 1:12 P.M., Nurse #1 said she would ask for Resident to be reweighed if the weight was significantly different compared to previous weight. Nurse #1 said she was unaware of Resident #1's significant weight loss, but she said that he/she recently had mighty shakes ordered. She was unaware if the physician had been notified of weight changes. During an interview on 6/17/25 at 12:52 P.M., the Registered Dietitian (RD) said she works at the facility two times per week. She said that she reviews the weight change progress report weekly to monitor for variances, attends risk meetings weekly and then writes progress notes to address any Resident's discussed. She said she would expect that nursing would identify any changes in Resident's weights or eating patterns before her and let her know so she could review and make recommendations. The RD said that if a weight was significantly different than the previous weight, she would ask for a reweight. If weight loss was still significant, she would expect the physician to be notified. She says that she does request reweights from nursing and that the need for reweights is also discussed in risk meetings but states that she does not have any documentation to support this. Review of the Medication Administration Reports (MAR) for January 2025 to June 2025 failed to indicate the Resident refused the Mighty Shake supplement. During an interview on 6/18/25 at 7:25 A.M., the Director of Nursing (DON) said she expects weights to be obtained at least monthly, reweighs to be obtained and recorded if there is a significant change and dietitian and physician to be notified if a significant weight change has occurred. The DON said she was unaware of Resident #1's weight loss and does not know why it did not get followed up on.

Based on record review and interviews, the facility failed to develop a trauma informed care plan for two Residents #10 and #1 out of a total sample of 21 residents. Specifically: 1. For Resident #10, the facility failed to develop a post-traumatic stress disorder (PTSD) care plan addressing the needs of trauma by minimizing triggers and re-traumatization. 2. For Resident #1, the facility failed to develop a care plan addressing PTSD with a history of suicide attempt. Findings include: A review of the facility policy titled 'Trauma Informed Care' with no revision date indicated the following: -Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. 1. Resident #10 was admitted to the facility in April 2025 with diagnoses including schizophrenia, intellectual disability and PTSD. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment. A review of the hospital discharge record dated March, 2025 indicated the following: -Psycho-social history: History of trauma/life events impacting wellbeing: DDS (Department of Developmental Services) involvement in the childhood due to abuse and exposure to family violence. Chart review indicates there is some concern of prior sexual assault while admitted to the hospital in the past. The resident tells me he/she was raped by a stranger at age [AGE], physically assaulted by a stranger on the street as a young boy/girl. [sic] A review of Resident #10's care plan failed to indicate a person-centered PTSD care plan identifying triggers which may re-traumatize the Resident. A review of Resident #10's Trauma Informed Care Assessment with an effective date of 4/29/25 failed to indicate any identified trauma. During an interview and record review on 6/17/25 at 9:17 A.M., the Social Worker reviewed the hospital discharge paperwork and the Trauma Informed Care Assessment with the surveyor. The Social Worker said the Trauma Informed Care Assessment should have identified the Resident's history of trauma. The Social Worker said a person-centered PTSD care plan identifying triggers that may re-traumatize the Resident should be put in place. During an interview on 6/17/25 at 10:40 A.M., the Director of Nurses said the Resident should have a person-centered PTSD care plan identifying all his/her triggers.2. Resident #1 was admitted to the facility in February 2025 with diagnoses including anxiety, depression, bipolar disorder, and post-traumatic stress disorder (PTSD). A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate cognitive impairment. This MDS indicated a diagnosis of PTSD. A review of physician progress note from a previous facility, dated 12/11/24 indicated the following: -complicated psychiatric history dx of bipolar depression with anxiety, PTSD, insomnia with history of suicide attempt by jumping from 4th floor of building 5 years ago. He/she was last seen by behavioral health NP (nurse practitioner) for medication management on 11/4/24. [sic] A review of Resident #1's care plan failed to indicate a person-centered PTSD care plan identifying triggers which may re-traumatize the Resident and/or identification of history of suicide attempt. A review of Resident #1's Trauma Informed Care Assessment with an effective date of 2/7/25 failed to indicate any identified trauma. During an interview on 6/17/25 at 10:45 A.M., Nurse #1 said she would expect a care plan to be in place to address the Resident's history of suicide attempts so staff would be aware of and monitor for any signs and symptoms. During an interview on 6/17/25 at 10:40 A.M., the Director of Nurses said the Resident should have a person-centered care plan to identify his/her triggers and history of suicide attempt. During an interview and record review on 6/17/25 at 12:42 P.M., the Social Worker reviewed the progress notes and the Trauma Informed Care Assessment with the surveyor. The Social Worker said the Trauma Informed Care Assessment should have identified the Resident's history of trauma. The Social Worker said a person-centered PTSD care plan identifying triggers that may re-traumatize the Resident should be put in place and should also address his/her history of suicide attempt.

Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Specifically, one of two nurses observed made two errors in 33 opportunities resulting in a medication error rate of 6.06%. These errors impacted one Resident (#18) out of four residents observed. Findings include: Review of the facility policy titled Adverse Consequences and Medication Errors dated as revised April 2014 indicated the following: -A medication error is defined as the preparation or administration of drugs or biological's which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. For Resident #18 the facility failed to administer medications as ordered by the physician. Review of the current doctor's orders indicated an order for the following: 1. Lactose Fast Acting Relief Oral Tablet (Lactase) Give 2 tablets by mouth before meals for lactose intolerance. Start Date 6/13/25. 2. Saline Spray Nasal Solution (Saline) 1 spray in each nostril three times a day for dryness. Start Date 3/31/25. During a medication pass on 6/17/25, at 8:50 A.M. the surveyor observed Nurse #3 prepare and administer the following medications: 1.Lactose Fast Acting Relief Oral Tablet (Lactase) -two tablets given after the breakfast meal was consumed. The surveyor observed a staff member feeding Resident #18 just prior to the medication pass. The breakfast tray was observed on the over bed table with consumed food during the medication pass. 2. Saline Spray Nasal Solution (Saline)- two sprays were administered in each nostril. During an interview on 6/17/25 at 8:55 A.M., Nurse #3 said he should have administered the medication before the breakfast meal and said he always gives the Resident two sprays per nostril and said he should have followed the physician order for one spray.

Based on observation, record review and interviews, the facility failed to accurately document in the medical record for one Resident (#56 ) out of a total sample of 21 residents. Specifically, for Resident #56 the facility documented a dressing change was completed for three days when it was not. Findings include: Resident #56 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease, anxiety and depression. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #56 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. On 6/16/25 at 8:10 A.M. two surveyors observed Resident #56 sitting on the edge of the bed. The surveyors then observed a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. The surveyors also observed that the dressing was dated 6/12/25. On 6/16/25 at 12:50 P.M. the surveyor and Nurse #1 observed Resident #56 sitting on the edge of the bed with a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. They also observed that the dressing was dated 6/12/25 and had yellow/brown drainage. Review of the physician's orders dated June 2025 indicated an order for: Day Shift: Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically everyday shift for Wound care. Start Date 5/14/25 7:00 A.M., D/C (discontinued) Date 6/13/25 at 9:38 A.M. Further review indicated an order for: Day Shift: Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically everyday shift for Wound care for 30 Days. Start Date: 6/14/25 at 7:00 A.M. Review of the Medication Administration Record (MAR) dated June 2025, indicated that on 6/13/25, 6/14/25 and 6/15/25, nurses documented that they changed the dressing as ordered. During an interview on 6/16/25 at 1:45 P.M., Nurses #1 and the surveyor observed Resident #56 sitting on the edge of the bed with a dressing on the right ankle dated 6/12/25. The surveyor and Nurse #1 then observed the MAR and Nurse #1 said that nurses should not be documenting they changed the dressing when they did not. During an interview on 6/18/25 at 7:23 A.M., the Director of Nursing (DON) said she expects nurses to document accurately in the medical record. The DON then said that she cannot locate a facility policy regarding accurate documentation in the medical record.

Based on record review and interviews, the facility failed to offer the Influenza vaccine during influenza season to one Resident out of a sample of five residents reviewed. Specifically, the facility failed to offer Influenza vaccination on admission to the facility or during their stay at the facility. Findings include: Review of the facility policy, titled 'Influenza Vaccine', undated, indicated the following: -All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. -Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. A review of five resident medical records indicated one out of the five residents had not been vaccinated for Influenza. During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said she does not track vaccinations in the building but expects the Infection Preventionist to be tracking the vaccinations. During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist said he has only been working in the facility for the past month and did not have any information on the vaccination program. During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Vaccination program should be implemented and followed and said he is not aware of the status of vaccinations in the building at this time. He said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be met. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's Medical Director in April 2025. He said he would expect Residents' vaccination status to be obtained upon admission and for them to be offered the Influenza vaccine if admitted during Influenza season.

Based on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one out of five sampled residents. Specifically, the facility failed to offer a COVID-19 vaccination to a resident on admission to the facility or during their stay at the facility. Findings include: Review of the facility policy, titled 'Coronavirus Prevention and Control', dated as revised January 2023, indicated the following: -Facility leadership and clinical staff are responsible to take reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease (COVID-19). A review of five resident medical records indicated one out of the five residents had not been vaccinated for COVID-19. During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said she does not track vaccinations in the building but expects the Infection Preventionist to be tracking the vaccinations. During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist said he has only been working in the facility for the past month and did not have any information on the vaccination program. During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Vaccination program should be implemented and followed and said he is not aware of the status of vaccinations in the building at this time. He said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be met. During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's Medical Director in April 2025, and he has heard that residents have not been receiving Covid vaccines. He said he would expect residents' vaccination status to be obtained upon admission and for them to be offered the Covid vaccine in the facility if they had not received prior to being admitted .

Based on record review and interview, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#37) out of a total sample of 18 residents. Specifically, the facility failed to provide adequate hydration for a Resident who requires assistance to full dependence for eating and drinking, resulting in a hospitalization due to dehydration, an acute kidney injury, and hypernatremia. Findings include: Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following: -This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. -Nursing will assess for signs and symptoms of dehydration as needed and notify the provider to determine needs for hydration. -If potential inadequate intake and/or signs and symptoms of dehydration are observed, dehydration protocol will be initiated and documented. Provider will be notify [sic] for further interventions. -Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. -If nursing assessment indicates significant signs and symptoms of dehydration, labs may be ordered as needed. Resident #37 was admitted to the facility in 10/2018 with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #37 scored a 9 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS, dated [DATE], indicated Resident #37 required limited assist to one person physical assistance with eating and drinking. Review of the Comprehensive Nutrition Evaluation, dated 9/26/23, indicated Resident #37 had a decline in ability to feed self and required cueing with assistance and, at times, needed to be fed completely. The Dietitian recommended an occupational therapy evaluation. The notes provided by occupational therapy failed to indicate that Resident #37 had been evaluated for eating. Review of the Comprehensive Nutrition Evaluation, dated 12/26/23, indicated Resident #37 required continued assistance to full dependence on staff at meals. Review of the lab results for Resident #37, dated 12/27/23, indicated Resident #37 had an elevated sodium level of 157, an elevated chloride level of 122, and an elevated blood urea nitrogen (BUN) of 32. [BUN is a test used to assess kidney function and hydration status. Sodium and Chloride are tested to assess hydration status. The normal range for BUN is 10-24 mg/dL (milligrams per deciliter), the normal range for sodium is 133-145 mmol/L (millimoles per liter), and the normal range for chloride is 96-108 mmol/L.] Review of the Nurse Practitioner progress note, dated 12/29/23, does not indicate that the Nurse Practitioner addressed the elevated lab values. There is no indication in the clinical record that any hydration protocol was put in place for Resident #37 to address the elevated labs. Review of a second lab panel, dated 1/3/24, 5 days after the initial labs drawn, indicated Resident #37 had a critically high sodium level of 160, an elevated chloride level of 122, and an elevated BUN of 30. During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M. Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility received notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels. Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of Beauport ambulance picked him up at 5:30 pm. Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury. During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital. The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high. The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considers this a delay in treatment for Resident #37. See tag F773.

Based on record review and interview, the facility failed to promptly notify the physician/ nurse practitioner (NP) of a critically high sodium lab for one Resident (#37), out of a total sample of 18 residents. Findings include: Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following: - This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. - Nursing will assess for signs and symptoms of dehydration as needed and notify the provider to determine needs for hydration. - If potential inadequate intake and/or signs and symptoms of dehydration are observed, dehydration protocol will be initiated and documented . Provider will be notify [sic] for further interventions. - Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. - If nursing assessment indicates significant signs and symptoms of dehydration, labs may be ordered as needed. Review of the Laboratory Services Agreement indicated the following: - Notification of Findings: As applicable, Laboratory shall provide immediate telephone notice of results of any critical lab value. Laboratory shall promptly report all other findings as appropriate to the facility. Resident #37 was admitted with 10/2018 with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline. Review of Resident #37's most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #37 scored a 9 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS, dated [DATE], indicated Resident #37 required limited assist to one person physical assistance with eating and drinking. Review of the lab results for Resident #37, dated 12/27/23, indicated Resident #37 had an elevated sodium level of 157, an elevated chloride level of 122, and an elevated blood urea nitrogen (BUN) of 32. [BUN is a test used to assess kidney function and hydration status. Sodium and Chloride are tested to assess hydration status. The normal range for BUN is 10-24 mg/dL (milligrams per deciliter), the normal range for sodium is 133-145 mmol/L (millimoles per liter), and the normal range for chloride is 96-108 mmol/L.] Review of the clinical record failed to indicate that the physician or NP were notified. Review of the Nurse Practitioner progress note, dated 12/29/23, does not indicate that the Nurse Practitioner addressed the elevated lab values. There is no indication in the clinical record that any hydration protocol was put in place for Resident #37 to address the elevated labs. Review of a second lab panel, dated 1/3/24, 5 days after the initial labs drawn, indicated Resident #37 had a critically high sodium level of 160, an elevated chloride level of 122, and an elevated BUN of 30. During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M. Review of the clinical record failed to indicate that the physician or NP was notified of the critically high sodium level upon notification from the laboratory. Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility's initial notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels. Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of ambulance picked him up at 5:30 pm. Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury. During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital. The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high. The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considered this a delay in treatment for Resident #37.

Based on record review and interview, the facility failed to ensure that 2 Residents (#40 and #370), were free of significant medication errors. Specifically, the facility failed to: 1) implement necessary action when daily administration of Clozapine (an antipsychotic) was ordered by the Physician/NP and was omitted from Resident #40's medication administration for six consecutive days resulting in hospitalization . 2) administer a medication used to treat schizoaffective disorder, resulting in Resident #370 having an increase in symptoms of psychosis and distress. Findings include: 1. Resident #40 was admitted to the facility in October 2018 with diagnoses including paranoid schizophrenia, major depressive disorder and diabetes. Review of the manufacture's Clozapine (an atypical antipsychotic used in treatment-resistant schizophrenia) safety information packet indicated that the medication can cause severe Neutropenia (low white blood cell count) which could lead to life threatening infections, so an ANC (Absolute Neutrophil Count) baseline test should be obtained prior to the initiation of the medication and at least every month thereafter. Further review indicated that Clozapine is only available through a restricted program called the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program run by the Food and Drug Administration (FDA). Review of the FDA website, updated 11/2/22, indicated that Abrupt discontinuation of clozapine can result in significant complications for patient treatment. Review of the doctor's orders indicated an order dated 12/17/20, for Clozapine give 150 milligrams (mg) by mouth one time a day at 8:00 A.M Further review indicated an order dated 12/11/20, for Clozapine give 200 mg by mouth at bedtime. Review of the Medication Administration Record (MAR) dated January 2023 indicated that Clozapine, give 150 milligrams (mg) by mouth one time a day at 0800 (8:00 A.M.) was held on 1/23/23, 1/24/23 and 1/25/23. Further review indicated that Clozapine, give 200 milligrams (mg) by mouth at bedtime was held on 1/21/23, 1/22/23, 1/23/23 and 1/24/23. Further review indicated that on 1/25/23 at 8 P.M. and 1/26/23 at 8:00 A.M. and 8:00 P.M. the medication was administered as ordered however, the medication had not been delivered to the facility, by the pharmacy, until 1/28/23. Review of the nurse's notes dated 1/19/23, indicated that the pharmacy informed the nurse that Resident #40's Clozapine could not be refilled because Resident #40 needs to be enrolled in a Clozapine REMS program that Resident #40 is not currently enrolled in. Informed the Doctor (Medical Director) and Nurse Practitioner (#1). Review of the nurse's note dated 1/21/23, indicated that medication (Clozapine) is not available. Pharmacy requested patient to be involved in a program. Doctor (Medical Director) will register patient, if not pharmacy said they will not send medication. Review of the nurse's note dated 1/22/23, indicated medication (Clozapine) not available. Pharmacy requested for patient to be involved in a program. Doctor (Medical Director) aware. Will register the patient. If not pharmacy said they will not send. Review of the Nurse's note dated 1/25/23, indicated that Resident #40 fell to the floor in the bathroom and required an assist of 2 to transfer back to the wheelchair. Review of the nurse's note dated 1/27/23, at 8:37 A.M., (written by the nurse who had worked the previous 3:00 P.M.- 11:00 P.M. and the 11 :00 P.M.- 7:00 A.M. shifts, 1/26/23) indicated that she had place a call to the pharmacy for Resident #40's Clozapine and they assured her that they had everything they need, and will deliver the medication by 11:00 A.M., but by 3:00 P.M. the medication had not arrived. Further review indicated that the nurse called the pharmacy again and the pharmacy told her that they will deliver the medication between 7:00 P.M. and 8:00 P.M. The nurse's note then indicated that the medication had not been delivered as of 8:00 A.M. on 1/27/23. The nurse's note then indicated that the pharmacy was called again and the nurse was given the same assurance that the medication would arrive. Review of the nurse's note dated 1/27/23, at 8:05 A.M., indicated Nurse Practitioner #2 was notified of Resident #40's increasing general weakness. Further review indicated that the Nurse Practitioner #2 gave the order to send Resident #40 to the hospital for evaluation. Review of the hospital psychiatry note dated 1/28/23, indicated that Resident #40 expressed the sensation of being paralyzed to the psychiatrist. Further review indicated that this is most likely a psychotic conversion symptom from being off of his/her Clozeril (Clozapine). Review of the hospital discharge summary dated 2/2/23, indicated that Resident #40 was in his/her usual state of health until about 8 days ago when his/her Clozapine medication was discontinued due to paperwork. Since then, the patient started to have generalized weakness which progressively worsened and prompted an ED (emergency department) visit. During an interview on 5/2/23, at 2:05 P.M., the Medical Director said that all people taking Clozapine have to be registered in the REMS program. The Medical Director said that he became Resident #40's doctor in November of 2022. He said that he knew that both the doctor's and patients needed to be registered with the program in order for Clozapine to be dispensed. He then said that he went into the website and registered Resident #40 as soon as he was made aware of the need but could not tell the surveyor the date he did so. The Medical director then said that the pharmacy needs to have ANC labs entered into the program before they will deliver Clozapine. The Medical Director said he is not sure why the pharmacy did not get the labs that were ordered, sent to them. During an interview on 5/3/23, at 10:10 A.M. the Operations Manager (OM) for the pharmacy the facility uses, said that since the new program started 11/15/21, the pharmacy has been informing the facility of the need to register the Resident but the facility never did. The OM then said that he again notified the facility in October 2022. The OM said that the pharmacy had been entering a rational for why the Resident was not registered, into the REMS program in order to send Resident #40 the Clozapine for a year. The OM then said that the pharmacy had been asking the facility to register Resident #40 again, since the Resident's doctor changed. The OM said that the program would no longer take the pharmacy's rational's as to why the Resident was not registered, at which point he called the facility on 1/19/23, to inform them that the pharmacy could not refill Resident #40's Clozapine until he/she was registered into the REMS program. The OM said that on 1/23/23, he saw that Resident #40 had been registered but that there was no recent ANC in the system. He said that late on 1/25/23 the blood work arrived but that the refill wasn't put in until 1/26/23. The OM then said that the medication was awaiting approval by the insurance and they had difficulty finding a driver to deliver the medication. During an interview on 5/3/23, at 11:15 A.M., Family Member (FM) #1 said that she was aware that Resident #40 had been sent to the hospital 1/27/23. FM #1 said that the hospital told her the reason why Resident #40 had been sent to the hospital was because he/she did not receive the Clozapine for a week and that caused Resident #40 to became very weak and even more confused. FM #1 said it is very detrimental for Resident #40 to miss his/her medication. FM #1 said that she was also told that the reason it took so long for the pharmacy to send out the medication once Resident #40 had been registered was because the pharmacy was in New [NAME] and they couldn't find a driver to deliver so far. 36431 2. For Resident #370 the facility failed to administer a medication used to treat schizoaffective disorder for over 27 days, resulting in Resident #370 having an increase in symptoms of psychosis and distress. Review of the facility's policy, titled Reconciliation of Medications on admitted d 9/1/16, indicated the following: Policy Statement, Resident safety and medication safety is achieved by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Policy Interpretation and Implementation 1. Upon admission, a medication review is completed. 2. Sources of information include a. The resident/patient, b. Family members or caregivers, c. Primary care physician, d. Pharmacy, e. Hospital discharge paperwork, and /or f. Prescriptions bottles. 3. Reconciliation of medications will include; a. Prescription medications, b. Over-the-counter medications, and c. Supplements. 4. Every effort will be made to accurately identify all medications, doses, and routes during the reconciliation process. 5 Medication reconciliation includes medication the resident/patient took at home, took in the hospital, and is currently prescribed upon admission to the facility. 6. All identified discrepancies will be addressed with the physician. 7. The pharmacy will be utilized to assist in the medication reconciliation as needed. Review of the Nursing Drug Book, 2014, by Wolters Kluwer/[NAME] and [NAME] indicated the following: Perphenazine, therapeutic class: Antipsychotics. Nursing considerations: -Don't withdraw drug abruptly unless severe adverse reaction occurs. -After abrupt withdrawal of long-term therapy, gastritis, nausea, vomiting, dizziness, tremor, feeling of warmth or cold, diaphoresis, tachycardia, headache, or insomnia can occur. On 4/30/23, at 8:20 A.M., the surveyor observed Resident #370 resting on his/her bed. During an interview on 4/30/23, at 8:20 A.M., Resident #370 said he/she is in pain. Resident #370 said she/he was beat up by a gorilla and said the gorilla was an animal. On 4/30/23, at 10:30 A.M., the surveyor observed Resident #370 resting on top of his/her bed. Both his/her right and left feet were exposed and observed with yellow and blue areas of discoloration on the outer aspect, extending from the ankle to the smaller toes. Resident #370 was crying and said he/she was beat up by a gorilla. When asked he/she said it was an animal. On 5/3/23, at 12:30 P.M., the surveyor observed Resident #370 in bed, crying and calling out. Nurse #2 said Resident #370 was crying for water and food and was told lunch would be coming soon. Review of Resident #370's medical record indicated the following: *A Discharge Care Plan and Home Medications document from the behavioral health hospital indicated Resident #370 was hospitalized from 9/2022 through 3/2023. Resident #370 was admitted to the facility from the behavioral health hospital for further care. Review of the medication list on the hospital referral indicated: *Perphenazine (an antipsychotic medication, used to treat schizophrenia) oral 16 milligrams tab, start dated 10/10/22, indication (for use) psychosis, PO (by mouth) BID (two times a day) Review of Resident #370 current Medication Review Report indicated Perphenazine was ordered on 4/27/23. Resident #370 was not administered the Perphenazine since his/her admission to the facility. Review of the progress notes failed to indicate any progress note or order to discontinue the Perphenazine upon admission. During an interview on 5/1/23, at 10:47 A.M., Nurse #2 said she was the Nurse who did the admission paperwork for Resident #370. Nurse #2 said when a resident is admitted the medications are reviewed with the nurse practitioner or doctor. Nurse #2 said an on-call service was used to reconcile the medication from the information that came with the Resident. Nurse #2 said although the antipsychotic (Perphenazine) medication was on the hospital paperwork, it was not on the facility medication orders for administration to Resident #370. Review of the document on-call physician's orders document, dated 3/29/23, and timed 7:36 P.M., indicated: Available documentation reviewed, orders and medications approved until patient is evaluated by primary team- except add duration prn (as needed) lorazepam x 14 days, 2. Obtain and review all acute care documentation and orders with primary team when available. During an interview on 5/1/23, at 1:30 P.M., the Assistant Director of Nursing (ADON) said when residents are admitted to the facility, the discharge orders are reviewed with the doctor or the covering service. For Resident #370 the ADON reviewed the medical record and said the order for the Perphenazine was not transcribed on to the facility physician's orders for administration and therefore Resident #370 was not administered the medication and that it (the omission) was an oversight. During an interview on 5/2/23, at 10:36 A.M., the Certified Nurse Practitioner (CNP), who provided behavioral health services to the facility, said she does medication reviews for residents and saw Resident #370 shortly after his/her admission to the facility. The CNP said she did not see documentation in the record as to why the antipsychotic Perphenazine was not continued upon admission for a resident who has a known history of schizoaffective disorder. The CNP said it may have been an issue with consent. The CNP said her first visit with Resident #370 he/she was depressed, tearful and calm and on her second visit (just over 3 weeks later) Resident #370 was more agitated, no longer able to hold a conversation and his/her symptoms were consistent with someone who is not on their antipsychotic medication. The CNP said that on her first visit, the Resident was more based in reality and on the second visit he/she could not put his/her thoughts together but did ask for, and wanted, his/her antipsychotic medication. The CNP then said the Resident was asking for a blood pressure cuff, and other medical items. The CNP said she recommended to start the Perphenazine at 4 milligrams because he/she was off it for a while and wanted to start the medication slower, she said the effect of the medication could take up to 1-2 weeks. The CNP said the absence of the antipsychotic medication became a distressing event for Resident #370. During an interview on 5/2/23, at 12:11 P.M., the Social Worker (SW) said Resident #370 was alert and oriented when he/she was admitted and discussed wanting magazines. The SW said as time went on Resdient #370 was not as lucid and not the same as the beginning, becoming more disoriented and making loud noises. During an interview on 5/2/23, at 2:06 P.M., Resident #370'S facility doctor said the medication Perphenazine should have continued upon admission, for a chronic condition like schizoaffective disorder, to keep the Resident stable. The Medical Director said an antipsychotic medication should not be stopped abruptly and without a plan. During an interview on 5/8/23, at 11:32 A.M., the Legal Guardian for Resident #370 said she has been the Guardian for Resident #370 for nearly nine years. She said Resident #370 has always been treated with an antipsychotic due to the diagnosis of schizophrenia. The Legal Guardian said about five years ago, a doctor discontinued his/her anitpsychotic medication and Resident #370 had a breakdown and never came back to his/her prior level of function. The Guardian said she was not made aware until the last week of April that Resident #370 was not being administered the antipsychotic medication.

Based on interview, observation and record review, the facility failed to 1. ensure that one Resident (#18) received adequate assistance to prevent an injury, and 2. failed to provide supervision for 1 Resident (#31) out of a total sample of 34 residents. Specifically, on 4/22/23, Resident #18 was transferred out of a bed that was elevated too high and prevented his/her feet to reach the floor. As a result, Resident #18 lost his/her footing and hit his/her left leg on his/her wheelchair and sustained a laceration that required sutures. Specifically, on 4/18/23, supervision was not provided to Resident #31, resulting in Resident #31 entering another resident's room, being screamed at, and falling as he/she exited the room, resulting in an injury and emergency room visit. Findings include: 1. Resident #18 was admitted to the facility in January 2022 with a diagnoses including venous insufficiency, muscle weakness, abnormalities of the gait and mobility, dysphagia, anxiety, legal blindness and lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 3/28/23, indicated Resident #18 could make him/her self understood and he/she has the ability to understand others. The MDS indicated his/her vision was severely impaired and required glasses. Resident #18 required an assist of 2 for bed mobility and transfers. The MDS also indicated that during surface-to-surface transfers (transfer between bed and chair or wheelchair) Resident #18 is not steady and only able to stabilize with staff assistance. The MDS further indicated Resident #18 had one venous and arterial ulcers that required dressing changes. Review of Resident #18's plan of care related to falls, dated as revised 4/11/23, indicated he/she is legally blind and for nursing to assist with transfers Review of Resident #18's plan of care related to activities of daily living, indicated self-care performance deficit r/t [related to] activity Intolerance, fatigue, legally blind, pain, history of venous wound and included the following interventions: - 4/9/23, BED MOBILITY: The resident requires extensive assist by 1-2 staff to turn and reposition in bed and as necessary. - 4/9/23, TRANSFER: The resident requires extensive assist of 1-2 by staff to move between surfaces and as necessary. Level of assist varies depending on level of fatigue. During an interview on 4/30/23, at 10:55 A.M., Resident #18 said a 'guy' transferred him/her alone into his/her wheelchair. Resident #18 said that the bed was too high, he/she did not have a walker and his/her feet were not on the floor before he/she was transferred. Resident #18 said that he/she lost his/her footing during the transfer and 'crashed' into the side of the wheel chair and said his/her leg started to bleed. Review of the progress note, dated 4/22/23, indicated during a transfer Resident #18 sustained an open area below the left knee. The note indicated Resident #18 was transferred to the hospital. During an interview on 5/2/23, at 2:36 P.M., Certified Nurse Aide (CNA) #4 said that Resident #18 requires a gait belt and rolling walker for transfers. During an interview on 5/2/23, at 1:52 P.M., Certified Nurse Assistant #3 said that Resident #18 told her that the bed was too high during the transfer. CNA #3 said that she worked with the Director of Nursing (DON) and CNA #5 on 4/22/23, and said she was not asked to assist with the transfer. During an interview on 5/2/23, at 4:20 P.M., Certified Nurse Assistant #5 said that on 4/22/23, he was assigned to Resident #18. CNA #5 said that Resident #18 wanted to go to the bathroom. He said that he brought the wheel chair next to the bed; CNA #5 said the bed was higher than the wheelchair and moved Resident #18 by himself. CNA#5 said he did not use a walker or a gait belt and said he could not remember what was on Resident #18's feet. During an interview on 5/3/23, at 8:57 A.M., the Director of Nursing (DON) said he was the assigned nurse on 4/22/23. The DON said that he was alerted by CNA #5 that Resident #18 was bleeding. The DON said he was not sure what Resident #18 hit his/her leg on but the 'skin tear' would not stop bleeding. The DON and the surveyor reviewed Resident #18's plan of care related to transfers and the DON said 1-2 assist would require constant re-evaluation and is not appropriate. The surveyor asked the DON about precipitating factors regarding this incident. The DON said to the surveyor that you (the surveyor) have already spoken to the staff and you know what the staff has told you. The DON declined to answer any further questions from the surveyor regarding the incident on 4/22/23. The DON told they surveyor what you have in front of you is what you get. During an observation on 5/3/23, at 9:20 A.M., with the Assistant Director of Nursing (ADON) and the Certified Occupational Therapy Assistant (COTA) the surveyor observed Resident #18's sutures. Resident #18 said to the ADON and to the COTA that happened when the 'guy' went to transfer him/her out of bed, the bed was too high and his/her feet were not on the floor when the 'guy' started to transfer him/her. Resident #18 said that he/she lost his/her footing and went 'crashing' into the wheel chair and said his/her leg started to bleed. The COTA said this was not the first time that Resident #18 had mentioned the bed height caused his/her laceration. 36431 2. For Resident #31 the facility failed to ensure supervision was provided, resulting in Resident #31 entering another resident room, being screamed at by the Resident and upon exiting fell and sustained a cut above the right eye. Resident #31 was admitted to the facility in 12/2019 and has diagnoses that include unspecified dementia with other behavioral disturbance, Alzheimer's disease, and generalized anxiety disorder. Review of Resident #31's Minimum Data Set Assessment, with an Assessment Reference Date of 3/7/23 indicated Resident #31 had a staff assessment of severely impaired cognition, ambulated in the hall with supervision and did not use a mobility device. On all days of survey, 4/30/23 through 5/3/23 Resident #31 was observed walking in the hall. Resident #31 was observed with a faded yellow area above his/her right eye. Review of Resident #31's medical record indicated the following: *A fall risk assessment dated [DATE] with a score of 14, indicating Resident #31 was a high fall risk. *A care plan, Focus Falls, Resident has the potential for falls r/t (related to) general weakness, psychotropic drug use, history of falls, wandering, incontinence, poor safety awareness, revision on 3/23/23. Interventions: Assist with transfers, *A care plan Focus Resident has an ADL (activities of daily living self-care performance deficit, r/t Alzheimer's, he/she refuses haircuts, revision on 6/20/22. Interventions: Locomotion on/off unit, Resident is continual supervision on unit as he/she is intrusive wanders unit daily, needs assist in evenings when fatigued, date initiated 12/23/19. Review of an un-witnessed incident report dated 4/18/23 at 20:20 (8:20 P.M.,), indicted the following: Incident location: hallway. *Incident description: Resident entered into room [ROOM NUMBER] and was screamed at by the other resident. When he/she ran out of the room, he/she hit him/herself at the door and fell . Sustained a cut on right sided eye. Resident was non-compliant to care. Called third eye (on-call medical service) and was ordered to transfer to the ER (emergency room .) During an interview on 5/3/23 at 8:08 A.M., Nurse #2 said she was not here at the time of the fall but was told about it on report that he/she (Resident #31) hit his/her head on the doorway on the way out of a resident's room. Nurse #2 said Resident #31 is not oriented and could have been frightened by what happened. During further interview on 5/03/23 at 8:21 A.M., Nurse #2 said both Resident (#31) and Resident (#67) who screamed at Resident #31 have behaviors. Nurse #2 Resident #31 requires redirection from staff, and staff need to keep an eye on him/her. Nurse #2 said the unit has 2 CNA's and 1 Nurse on in the evening shift and if staff are with other residents providing care, they listen to hear if he/she is being told to get out (of rooms) by others. Review of the hospital paperwork from the emergency room , dated 4/19/23 at indicted Face: Soft tissues: right periorbital hematoma.

Based on interview and record review, the facility staff failed to monitor and maintain weight parameters for 3 Residents (#51, #26 and #62) out of a total sample of 20 Residents. Findings include: 1. Resident #51 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set assessment (MDS), dated [DATE], Resident #51 was cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status and required extensive assistance with activities of daily living, including bathing, dressing and grooming. Section H indicated that Resident #51 admitted to the facility with a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Review of the undated facility policy, titled, Weight Management Program indicated the following: - the nursing staff will measure resident weights on admission and weekly for four weeks - weights will be recorded in the individual's medical record - any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the 5% weight variance is verified, nursing will notify the Dietitian in writing. Verbal notification must be confirmed in writing. - the dietician will review the weight records by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met - the threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month 5%, 3 months 7.5% and 6 months 10%. Review of the physician orders [REDACTED].#51 required a pureed diet with thin liquids, to be out of bed for all meals in chair to 90 degrees for 30-45 minutes after meals, assist with feeding as needed, eat/drink slowly, small bites/sips, alternate food and liquid, aspiration precautions. There was also an order [REDACTED]. Review of the clinical record failed to indicate an admission weight was obtained in 3/2019 or weekly weights for four weeks. (MONTH) weights included 167.5 on 4/2/19 and 168 on 4/22/19. The next weight obtained was 145.5 on 5/8/19 which would be a significant weight loss of 13.39% between 4/22/19 and 5/8/19. Review of the Dietician note, dated 5/15/19, indicated there was a weight warning due to the weight loss triggering a significant weight loss. Review of the Dietician note, dated 5/22/19 indicated that there was no recent weight despite repeated requests. Discussed today at the interdisciplinary team weight meeting. As per the Director of Nursing, the Speech Therapist met with the resident who refused to participate. Question texture upgrade as refuses puree foods, tolerating tube feed well, continues with stage IV on coccyx. Urinary tract infection noted. Will continue to request weight as question of tube feed increase. Further review of the weights indicate that the next weight was not obtained until 6/3/19, more than 2 weeks after the initial weight warning. The weight obtained on 6/3/19 was 155 pounds, a significant 6.89% weight gain. During an interview with Nurse #6 on 6/04/19, at 10:37 [NAME]M., she said that if there was a change in weight of more than 3 lbs there should be an immediate reweigh. She further said that communication with the Dietician is verbal (not written as the policy states) and should followed up immediately. After review of Resident #51's weights she said there was not an admission weight or was there a weekly weight for four weeks as there should be according to the facility policy. She said there would be no other place to locate weights for Resident #51. During an interview with the Dietician on 6/4/19 at 10:27 [NAME]M., she said that she was aware that Resident #51 had a significant weight loss but she was waiting for a verification of the loss before she made any recommendations. She said she has made multiple requests in writing to nursing but is not confident of the result. She was not aware of the 6/4/19 weight of 155, but would again request a reweigh as it would be another significant change in weight and still would not feel comfortable making recommendations with a weight that had not been verified. During an interview with the Director of Nurses on 6/04/19, at 12:04 P.M., she said that Resident #51 had been reweighed and was 152 pounds. She said it was a significant weight loss and needed to be evaluated by the Dietician immediately. 2. Resident #26 was admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set assessment ((MDS) dated [DATE], revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated that he/she had moderate cognitive impairment. Review of Resident #26's record on 5/31/19, at 10:00 [NAME]M., indicated the Resident weighed 133.8 pounds on 4/24/19 and weighed 154.2 pounds on his/her next weight on 5/24/2019. This indicated a 15.25 % weight gain. During an interview on 5/31/19, at 10:33 [NAME]M., Nurse #2 said that she was unaware of Resident #26's weight gain. She then used her computer to look up the Resident's weight. She acknowledged that Resident #26 had gained weight and said it may be because he/she drinks a lot of juice in the morning. When asked if Resident #26 had any cardiac issues such as [MEDICAL CONDITION] that could possibly contribute to a weight gain she said no. She then was unaware of the facility policy regarding significant weight gain/loss and if a re-weigh would be indicated. Record review on 6/03/19, at 11:26 [NAME]M., indicated a weight note dated 5/26/19 from the Dietician that requested a re-weight to be obtained. There was no evidence that the re-weight was completed until 6/3/19, 9 days after the request. Record review also indicated that resident #26's Physician order [REDACTED]. During an interview on 6/3/19 at 11:33 [NAME]M., the Dietician confirmed that Resident #26 had a significant weight gain. She said that the facility policy is to get a re-weight for any significant change in weight status within 2 days. She said that re-weights are often missed in the facility and it is a problem that she has identified. She also said the expectation is that the nursing staff reports the weight change to the Physician. During an interview on 6/3/19 the Physician Assistant said that she was unaware of Resident #26's weight gain. 3. Resident #62 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. On the latest quarterly minimum data set ((MDS) dated [DATE], the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The latest quarterly MDS dated [DATE] indicated the Resident required assistance or supervision with most aspects of his/her activities of daily living. On 5/30/19, review of Resident #62's weight summary indicated the following: 02/07/19 207.8 pounds (lbs) 03/20/19 207 lbs 04/01/19 208 lbs 05/01/19 194.6 lbs Resident #62 had a 13.4 lb (6.44%) weight loss within 30 days from 4/1/19 to 5/1/19. Review of Resident #62's progress note dated 5/8/19 indicated the Dietician requested a reweight be obtained for the Resident. Further Review of Resident #62's progress notes from 5/2019 failed to indicate a reweight had been obtained during 5/2019 and failed to indicate the physician or physician's assistant had been notified of the weight change. The Resident's progress notes from 5/2019 failed to indicate the Dietician had assessed Resident #62 after the change in weight. Review of Resident #62's Physician Assistant's progress note dated 5/13/19 failed to indicate the weight loss was reported. Review of Resident #62's care plan failed to indicate a plan of care was developed for weight loss. During an interview on 6/3/19 at 11:33 [NAME]M., the Dietician said once a weight loss is identified she requests a reweight, which should be done by the next day she is at the facility. After the reweight is obtained and the weight is verified, she assesses the Resident with weight loss and writes recommendations for the Resident to be reported to the physician by nursing. She said a 5% weight loss in 30 days would constitute a significant weight loss. She also said she could not recall if the Resident had been discussed at the weekly risk meeting. Review of the risk meeting notes for 5/2019 failed to indicate Resident #62's weight loss was discussed. During an interview on 6/03/19 at 1:33 P.M., Nurse #4 said if a resident had a change in weight he would notify the dietician and then notify the doctor for any change in care or recommendations.

Based on interview and record review, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from an unnecessary physical restraint. At approximately 3:00 P.M. on 4/9/15, staff placed Resident #1 in a reclined geri chair, which restricted him/her from leaving the chair. Facility staff described Resident #1's behavior as "agitated", but provided no other assessment, or clinical indication for the restraint. Resident #1's Plan of Care did not include the use of a physical restraint. At 3:30 A.M. on 4/10/15, more than 12 hours later, Resident #1 was shouting to be taken out of the geri chair, then swung his/her legs over the arm of the chair and climbed out, stood up, and as staff physically attempted to reseat him/her, Resident #1 punched CNA #1 and then fell to the floor. Resident #1 sustained a left eye orbit fracture and lacerations and bruising to the face. Findings include: The Facility's Restraint Policy, dated 1/2/14, indicated, "If the device cannot be easily removed by the patient and/or restrict freedom of movement, the Restraint Evaluation/Reduction of the Device Evaluation will be completed: prior to the application of any restraint...". Review of Resident #1's clinical record indicated there was no assessment indicating a need for a restraint, and no physician's order for a restraint. Resident #1's current Plan of Care did not include the use of a physical restraint. The Director of Nurses' written statement, dated 5/8/15, indicated Resident #1 did not have a restraint assessment. The Care Plan for Falls, dated 1/9/15, indicated Resident #1 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included staff assistance when getting out of bed, utilize a low bed, and monitor for and assist toileting needs. The Care Plan for Falls did not include the use of a restraint, including placing Resident #1 in a reclined geri chair, or the use antipsychotic medications. The Care Plan for Behavior, dated 1/19/15, indicated Resident #1 exhibited physical aggression, including hitting, resistance to care, yelling and wandering. Care Plan goals included "0" episode of inappropriate behavior and that he/she will wander safely throughout the unit. Interventions include toileting, addressing pain, fatigue and hunger, providing activities and objects of interest. The Care Plan did not include the use of a physical restraint. Resident #1's admission Minimum Data Set, dated dated [DATE], indicated he/she did not use physical restraints; rarely/never understood others; had severely impaired cognitive skills for daily decision making (never/rarely made decisions); exhibited physically aggressive behaviors toward others; frequently wandered on the unit; required extensive staff assistance for transfers and walking; was unsteady on his/her feet; used a walker or wheelchair for mobility and was diagnosed with [REDACTED]. Resident #1's Care Plan (for lower leg [MEDICAL CONDITION]), dated 2/26/15, indicated he/she may use a geri chair to elevate his/her feet. Care Plan goals indicated Resident #1's feet will be less swollen (2/26/15), and he/she will use the recliner geri chair to assist in comfort and positioning on a daily basis (3/6/15). Following the 4/9/15 incident, Resident #1's Care Plan was revised on 4/13/15 to include the use of a reclined geri chair when Resident #1 exhibited, "tiredness and sleepiness when (he/she) is in wheelchair and when climbing out of bed." The Surveyor interviewed Nurse #3 at 1:10 P.M., on 4/17/15. Nurse #3 said Resident #1's plan of care included the use of a reclined geri chair for periods of rest and elevation of his/her legs for relief of [MEDICAL CONDITION] (swelling). Nurse #3 said Resident #1 used a wheelchair for mobility (propelled self with feet) and to allow him/her to wander on the unit. The Nurse's note, dated 4/9/15 (3:00 P.M. to 11:00 P.M. shift), indicated Resident #1, "continues with confused behavior," was slightly combative after lunch, and staff redirected him/her with good effect. The Nurse's note, dated 4/9/15 (3:00 P.M. to 11:00 P.M. shift, later note), indicated Resident #1 was out of bed and did not exhibit any aggressive behaviors during the shift. The Nurse's note, dated 4/10/15, indicated Resident #1 was awake during the 11:00 P.M. to 7:00 A.M. shift, in his/her geri chair recliner, located in the dining room with a CNA. The Nurse's note indicated Resident #1 was restless at the beginning of the shift and staff administered an as needed (PRN) dose of the antipsychotic medication [MEDICATION NAME] 25 milligrams (mg) at 11:45 P.M., "with some effect." The Nurse's note, dated 4/10/15, indicated at approximately 3:30 A.M., Resident #1 tried to self-transfer from the geri chair and stand up. The Nurse's note indicated CNAs tried to reposition him/her back into the geri chair and Resident #1 became combative toward staff and he/she fell to the floor and sustained a laceration to the forehead and bruise to the left eye. The Nurse's note indicated staff contacted emergency medical services and Resident #1 was transferred to the Hospital. Review of the Hospital emergency department note, dated 4/10/15, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:53 A.M., on 4/17/15. CNA #1 said she worked on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #1 said when she arrived to the unit at 3:00 P.M., Resident #1 was seated in a reclined geri chair. CNA #1 said she did not know why he/she was placed in the reclined geri chair. CNA #1 said she and other staff supervised Resident #1 because he/she was "agitated" and made 3 to 5 attempts to climb over the armrests and out of the reclined geri chair. CNA #1 said Resident #1 was at risk for falling. CNA #1 said she did not know why Resident #1 was not placed in his/her wheelchair. CNA #1 said that at approximately 9:30 P.M., she and other staff tried to put Resident #1 into bed to sleep, but Resident #1 attempted many times to get out of bed. CNA #1 said she and other staff then returned Resident #1 to the reclined geri chair. CNA #1 said Resident #1 continued to try to climb out of the geri chair and she told Nurse #2 about this behavior. CNA #1 said staff toileted Resident #1 and provided snacks to him/her throughout the shifts. CNA #1 said staff did not offer a wheelchair to allow Resident #1 to wander, or offer any activities. CNA #1 said Nurse #2 administered medication to Resident #1 to help him/her sleep, but the medication was ineffective. CNA #1 said staff placed a chair behind the reclined geri chair, and on either side of the reclined geri chair, to try to prevent Resident #1 from climbing out over the arms of the chair. CNA #1 said, despite the geri chair in the reclined position and with the chairs surrounding the chair, Resident #1 was still able to climb out by swinging his/her legs over the armrest. CNA #1 said that at approximately 3:30 A.M., Resident #1 was shouting to get out of the reclined geri chair and then swung his/her legs over the armrest and stood up on the floor. CNA #1 said CNA #2 was behind him/her and tried to lower Resident #1 back into the geri chair. CNA #1 said Resident #1 then punched her (CNA #1) in the chest, and then Resident #1 fell to the floor. The Surveyor interviewed CNA #2 at 12:40 P.M., on 4/17/15. CNA #2 said she worked with CNA #1 on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #2 said Resident #1 was in the reclined geri chair during the 3:00 P.M. to 11:00 P.M. shift, and during this time Resident #1 was upset and several times tried to swing his/her legs over the arms rests of the reclined geri chair to climb out. CNA #2 said she did not know why Resident #1 was upset. CNA #2 said Resident #1 told her and CNA #1 he/she did not want to be in the reclined geri chair. CNA #2 said that at approximately 9:30 P.M., she and CNA #1 tried to place Resident #1 in bed to sleep. CNA #2 said Resident #1 climbed out of bed, and staff returned him/her to the recliner geri chair. CNA #2 said they put him in the reclined geri chair because they did not want Resident #1 to fall and they could closely watch him/her if he/she was in the reclined geri chair. CNA #2 said Resident #1 continued to try to climb out of the reclined geri chair and told staff to, "Get me out," or words to that effect. CNA #2 said sometime during the early morning Resident #1 was angry and upset, and he/she slid his/her legs over the armrest of the reclined geri chair and stood up on the floor. CNA #2 said Resident #1 punched CNA #1, and then Resident #1 fell to the floor. The Surveyor interviewed Nurse #2 at 11:37 A.M. on 4/17/15. Nurse #2 said she worked on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift, from 4/9/15 to 4/10/15. Nurse #2 said Nurse #1 told her, during the change of shift report, that Resident #1 had tried to get out of bed and was now in the reclined geri chair, located in the dining room. Nurse #2 said when Resident #1 was unable to sleep, he/she routinely tried to get out of bed and staff placed him/her into the reclined geri chair. Nurse #2 said that at 11:00 P.M., Resident #1, "was wide awake and beginning to get restless," or words to that effect. Nurse #2 said Resident #1 could use a wheelchair for locomotion and could self-propel. Nurse #2 said she did not offer a wheelchair to Resident #1 because he/she wandered and might fall, he/she "got into things," it was the night time, and staff wanted to be able to supervise him/her. Nurse #2 said she administered a PRN dose of [MEDICATION NAME] to Resident #1 at approximately 11:30 P.M., because he/she was restless and agitated. Nurse #2 said Resident #1 sometimes fell asleep in the reclined geri chair, but on this night he/she did not. Nurse #2 said Resident #1 tried multiple times to climb out of the reclined geri chair, but the CNAs were able to redirect him/her with food. Nurse #2 said that at approximately 3:30 A.M., she heard voices coming from the dining room and then saw Resident #1 standing on the floor and swinging his/her arms. Nurse #2 said Resident #1 was upset, but she did not know why. The Surveyor interviewed Nurse #4 at 1:00 P.M., on 4/17/15. Nurse #4 said Resident #4 was able to scoot his/her feet to self-propel his/her wheelchair, without staff assistance.

Based on interview and record review, for 1 of 3 sampled residents (Resident #1), the Facility failed to implement Resident #1's Care Plan for Falls. At approximately 3:00 P.M. on 4/09/15, staff placed Resident #1 in a reclined geri chair, which restricted him/her from leaving the chair, and later administered an antipsychotic medication. At 3:30 A.M. on 4/10/15, Resident #1 was shouting to be taken out of the geri chair, then climbed out of the geri chair and stood up, and as staff physically attempted to reseat him/her, Resident #1 punched CNA #1 and then fell to the floor. Resident #1 sustained a left eye orbit fracture and lacerations and bruising to the face. Resident #1's Plan of Care for Falls indicated staff were to assist Resident #1 to transfer in and out of bed. The Care plan did not include the use of a recliner geri chair, or a physical restraint, to prevent falls. Findings include: The Care Plan for Falls, dated 1/9/15, indicated Resident #1 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included: staff assistance when getting out of bed, utilize a low bed, and monitor for and assist toileting needs. The Care Plan for Falls did not include use a restraint, or placing Resident #1 in a reclined geri chair, or the use of antipsychotic medications. Resident #1's admission Minimum Data Set, dated dated [DATE], indicated he/she did not use physical restraints; rarely/never understood others; had severely impaired cognitive skills for daily decision making (never/rarely made decisions); exhibited physically aggressive behaviors toward others; frequently wandered on the unit; required extensive staff assistance for transfers and walking; was unsteady on his/her feet; used a walker or wheelchair for mobility and was diagnosed with [REDACTED]. Resident #1's Care Plan (for lower leg [MEDICAL CONDITION]), dated 2/26/15, indicated he/she may use a geri chair to elevate his/her feet. Care Plan goals indicated Resident #1's feet will be less swollen (2/26/15), and he/she will use the recliner geri chair to assist in comfort and positioning on a daily basis (3/6/15). Following the 4/9/15 incident, Resident #1's Care Plan was revised on 4/13/15 to include the use of a reclined geri chair when Resident #1 exhibited, "tiredness and sleepiness when (he/she) is in wheelchair and when climbing out of bed." The Surveyor interviewed Nurse #3 at 1:10 P.M., on 4/17/15. Nurse #3 said Resident #1's plan of care included the use of a reclined geri chair for periods of rest and elevation of his/her legs for relief of [MEDICAL CONDITION] (swelling). Nurse #3 said Resident #1 used a wheelchair for mobility (propelled self with feet) and to allow him/her to wander on the unit. The Nurse's note, dated 4/10/15, indicated Resident #1 was awake during the 11:00 P.M. to 7:00 A.M. shift, in his/her geri chair recliner, located in the dining room with a CNA. The Nurse's note indicated Resident #1 was restless at the beginning of the shift and staff administered an as needed (PRN) dose of the antipsychotic medication [MEDICATION NAME] 25 milligrams (mg) at 11:45 P.M., "with some effect." The Nurse's note, dated 4/10/15, indicated at approximately 3:30 A.M., Resident #1 tried to self-transfer from the geri chair and stand up. The Nurse's note indicated CNAs tried to reposition him/her back into the geri chair and Resident #1 became combative toward staff and he/she fell to the floor and sustained a laceration to the forehead and bruise to the left eye. The Nurse's note indicated staff contacted emergency medical services and Resident #1 was transferred to the Hospital. Review of the Hospital emergency department note, dated 4/10/15, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:53 A.M., on 4/17/15. CNA #1 said she worked on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #1 said when she arrived to the unit at 3:00 P.M., Resident #1 was seated in a reclined geri chair. CNA #1 said she did not know why he/she was placed in the reclined geri chair. CNA #1 said she and other staff supervised Resident #1 because he/she was "agitated" and made 3 to 5 attempts to climb over the armrests and out of the reclined geri chair. CNA #1 said Resident #1 was at risk for falling. CNA #1 said she did not know why Resident #1 was not placed in his/her wheelchair. CNA #1 said that at approximately 9:30 P.M., she and other staff tried to put Resident #1 into bed to sleep, but Resident #1 attempted many times to get out of bed. CNA #1 said she and other staff then returned Resident #1 to the reclined geri chair. CNA #1 said Resident #1 continued to try to climb out of the geri chair and she told Nurse #2 about this behavior. CNA #1 said staff toileted Resident #1 and provided snacks to him/her throughout the shifts. CNA #1 said staff did not offer a wheelchair to allow Resident #1 to wander, or offer any activities. CNA #1 said Nurse #2 administered medication to Resident #1 to help him/her sleep, but the medication was ineffective. CNA #1 said staff placed a chair behind the reclined geri chair, and on either side of the reclined geri chair, to try to prevent Resident #1 from climbing out over the arms of the chair. CNA #1 said, despite the geri chair in the reclined position and with the chairs surrounding the chair, Resident #1 was still able to climb out by swinging his/her legs over the armrest. CNA #1 said that at approximately 3:30 A.M., Resident #1 was shouting to get out of the reclined geri chair and then swung his/her legs over the armrest and stood up on the floor. CNA #1 said CNA #2 was behind him/her and tried to lower Resident #1 back into the geri chair. CNA #1 said Resident #1 then punched her (CNA #1) in the chest, and then Resident #1 fell to the floor. The Surveyor interviewed CNA #2 at 12:40 P.M., on 4/17/15. CNA #2 said she worked with CNA #1 on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #2 said Resident #1 was in the reclined geri chair during the 3:00 P.M. to 11:00 P.M. shift, and during this time Resident #1 was upset and several times tried to swing his/her legs over the arms rests of the reclined geri chair to climb out. CNA #2 said she did not know why Resident #1 was upset. CNA #2 said Resident #1 told her and CNA #1 he/she did not want to be in the reclined geri chair. CNA #2 said that at approximately 9:30 P.M., she and CNA #1 tried to place Resident #1 in bed to sleep. CNA #2 said Resident #1 climbed out of bed, and staff returned him/her to the recliner geri chair. CNA #2 said they put him in the reclined geri chair because they did not want Resident #1 to fall and they could closely watch him/her if he/she was in the reclined geri chair. CNA #2 said Resident #1 continued to try to climb out of the reclined geri chair and told staff to, "Get me out," or words to that effect. CNA #2 said sometime during the early morning Resident #1 was angry and upset, and he/she slid his/her legs over the armrest of the reclined geri chair and stood up on the floor. CNA #2 said Resident #1 punched CNA #1, and then Resident #1 fell to the floor. The Surveyor interviewed Nurse #2 at 11:37 A.M. on 4/17/15. Nurse #2 said she worked on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift, from 4/9/15 to 4/10/15. Nurse #2 said Nurse #1 told her, during the change of shift report, that Resident #1 had tried to get out of bed and was now in the reclined geri chair, located in the dining room. Nurse #2 said when Resident #1 was unable to sleep, he/she routinely tried to get out of bed and staff placed him/her into the reclined geri chair. Nurse #2 said that at 11:00 P.M., Resident #1, "was wide awake and beginning to get restless," or words to that effect. Nurse #2 said Resident #1 could use a wheelchair for locomotion and could self-propel. Nurse #2 said she did not offer a wheelchair to Resident #1 because he/she wandered and might fall, he/she "got into things," it was the night time, and staff wanted to be able to supervise him/her. Nurse #2 said she administered a PRN dose of [MEDICATION NAME] to Resident #1 at approximately 11:30 P.M., because he/she was restless and agitated. Nurse #2 said Resident #1 sometimes fell asleep in the reclined geri chair, but on this night he/she did not. Nurse #2 said Resident #1 tried multiple times to climb out of the reclined geri chair, but the CNAs were able to redirect him/her with food. Nurse #2 said that at approximately 3:30 A.M., she heard voices coming from the dining room and then saw Resident #1 standing on the floor and swinging his/her arms. Nurse #2 said Resident #1 was upset, but she did not know why.

Based on interview and record review, for 1 of 3 sampled residents (Resident #1), the Facility failed to: 1. Ensure it followed its Restraint Policy, 2. Implement Resident #1's Care Plan for Falls and 3. Manage Resident #1's attempts to self-transfer in an appropriate manner when they physically restrained him/her for more than 12 hours, which resulted in his/her decline in behavior and mood. At approximately 3:00 P.M. on 4/09/15, staff placed Resident #1 in a reclined geri chair, which restricted him/her from leaving the chair. Staff described Resident #1's behavior as "agitated", but provided no other assessment, clinical indication for the restraint, or less restrictive intervention. At 11:30 P.M., Nurse #1 administered an antipsychotic medication to Resident #1. At 3:30 A.M., on 4/10/15, Resident #1 was shouting to be taken out of the geri chair, then climbed out of the geri chair and stood up, and as staff physically attempted to reseat him/her, Resident #1 punched CNA #1 and then fell to the floor. Resident #1 sustained a left eye orbit fracture and lacerations and bruising to the face. Findings include: The Facility's Restraint Policy, dated 1/2/14, indicated, "If the device cannot be easily removed by the patient and/or restrict freedom of movement, the Restraint Evaluation/Reduction of the Device Evaluation will be completed: prior to the application of any restraint...". Review of Resident #1's clinical record indicated there was no assessment indicating a need for a restraint, and no physician's order for a restraint. The Director of Nurses's written statement, dated 5/8/15, indicated Resident #1 did not have a restraint assessment. The Care Plan for Falls, dated 1/9/15, indicated Resident #1 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included: staff assistance when getting out of bed, utilize a low bed, and monitor for and assist toileting needs. The Care Plan for Falls did not include the use of a restraint, including placing Resident #1 in a reclined geri chair, or the use of antipsychotic medications. The Surveyor interviewed Nurse #3 at 1:10 P.M., on 4/17/15. Nurse #3 said Resident #1's plan of care included the use of a reclined geri chair for periods of rest and elevation of his/her legs for relief of [MEDICAL CONDITION] (swelling). Nurse #3 said Resident #1 used a wheelchair for mobility (propelled self with feet) and to allow him/her to wander on the unit. Resident #1's admission Minimum Data Set, dated dated [DATE], indicated he/she did not use physical restraints; rarely/never understood others; had severely impaired cognitive skills for daily decision making (never/rarely made decisions); exhibited physically aggressive behaviors toward others; frequently wandered on the unit; required extensive staff assistance for transfers and walking; was unsteady on his/her feet; used a walker or wheelchair for mobility and was diagnosed with [REDACTED]. Resident #1's Care Plan (for lower leg [MEDICAL CONDITION]), dated 2/26/15, indicated he/she may use a geri chair to elevate his/her feet. Care Plan goals indicated Resident #1's feet will be less swollen (2/26/15), and he/she will use the recliner geri chair to assist in comfort and positioning on a daily basis (3/6/15). Following the 4/9/15 incident, Resident #1's Care Plan was revised on 4/13/15 to include the use of a reclined geri chair when Resident #1 exhibited, "tiredness and sleepiness when (he/she) is in wheelchair and when climbing out of bed." The Nurse's note, dated 4/9/15 (3:00 P.M. to 11:00 P.M. shift), indicated Resident #1, "continues with confused behavior," was slightly combative after lunch, and staff redirected him/her with good effect. The Nurse's note, dated 4/9/15 (3:00 P.M. to 11:00 P.M. shift), indicated Resident #1 was out of bed and did not exhibit any aggressive behaviors during the shift. The Nurse's note, dated 4/10/15, indicated Resident #1 was awake during the 11:00 P.M. to 7:00 A.M. shift, in his/her geri chair recliner, located in the dining room with a CNA. The Nurse's note indicated Resident #1 was restless at the beginning of the shift and staff administered an as needed (PRN) dose of the antipsychotic medication [MEDICATION NAME] 25 milligrams (mg) at 11:45 P.M., "with some effect". The Nurse's note, dated 4/10/15, indicated at approximately 3:30 A.M., Resident #1 tried to self-transfer from the geri chair and stand up. The Nurse's note indicated CNAs tried to reposition him/her back into the geri chair and Resident #1 became combative toward staff and he/she fell to the floor and sustained a laceration to the forehead and bruise to the left eye. The Nurse's note indicated staff contacted emergency medical services and Resident #1 was transferred to the Hospital. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:53 A.M., on 4/17/15. CNA #1 said she worked on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #1 said when she arrived to the unit at 3:00 P.M., Resident #1 was seated in a reclined geri chair. CNA #1 said she did not know why he/she was placed in the reclined geri chair. CNA #1 said she and other staff supervised Resident #1 because he/she was "agitated" and made 3 to 5 attempts to climb over the armrests and out of the reclined geri chair. CNA #1 said Resident #1 was at risk for falling. CNA #1 said she did not know why Resident #1 was not placed in his/her wheelchair. CNA #1 said that at approximately 9:30 P.M., she and other staff tried to put Resident #1 into bed to sleep, but Resident #1 attempted many times to get out of bed. CNA #1 said she and other staff then returned Resident #1 to the reclined geri chair. CNA #1 said Resident #1 continued to try to climb out of the geri chair and she told Nurse #2 about this behavior. CNA #1 said staff toileted Resident #1 and provided snacks to him/her throughout the shifts. CNA #1 said staff did not offer a wheelchair to allow Resident #1 to wander, or offer any activities. CNA #1 said Nurse #2 administered medication to Resident #1 to help him/her sleep, but the medication was ineffective. CNA #1 said staff placed a chair behind the reclined geri chair, and on either side of the reclined geri chair, to try to prevent Resident #1 from climbing out over the arms of the chair. CNA #1 said, despite the geri chair in the reclined position and with the chairs surrounding the chair, Resident #1 was still able to climb out by swinging his/her legs over the armrest. CNA #1 said that at approximately 3:30 A.M., Resident #1 was shouting to get out of the reclined geri chair and then swung his/her legs over the armrest and stood up on the floor. CNA #1 said CNA #2 was behind him/her and tried to lower Resident #1 back into the geri chair. CNA #1 said Resident #1 then punched her (CNA #1) in the chest, and then Resident #1 fell to the floor. The Surveyor interviewed CNA #2 at 12:40 P.M., on 4/17/15. CNA #2 said she worked with CNA #1 on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #2 said Resident #1 was in the reclined geri chair during the 3:00 P.M. to 11:00 P.M. shift, and during this time Resident #1 was upset and several times tried to swing his/her legs over the arms rests of the reclined geri chair to climb out. CNA #2 said she did not know why Resident #1 was upset. CNA #2 said Resident #1 told her and CNA #1 he/she did not want to be in the reclined geri chair. CNA #2 said that at approximately 9:30 P.M., she and CNA #1 tried to place Resident #1 in bed to sleep. CNA #2 said Resident #1 climbed out of bed, and staff returned him/her to the recliner geri chair. CNA #2 said they put him in the reclined geri chair because they did not want Resident #1 to fall and they could closely watch him/her if he/she was in the reclined geri chair. CNA #2 said Resident #1 continued to try to climb out of the reclined geri chair and told staff to, "Get me out," or words to that effect. CNA #2 said sometime during the early morning Resident #1 was angry and upset, and he/she slid his/her legs over the armrest of the reclined geri chair and stood up on the floor. CNA #2 said Resident #1 punched CNA #1, and then Resident #1 fell to the floor. The Surveyor interviewed Nurse #2 at 11:37 A.M. on 4/17/15. Nurse #2 said she worked on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift, from 4/9/15 to 4/10/15. Nurse #2 said Nurse #1 told her, during the change of shift report, that Resident #1 had tried to get out of bed and was now in the reclined geri chair, located in the dining room. Nurse #2 said when Resident #1 was unable to sleep, he/she routinely tried to get out of bed and staff placed him/her into the reclined geri chair. Nurse #2 said that at 11:00 P.M., Resident #1, "was wide awake and beginning to get restless," or words to that effect. Nurse #2 said Resident #1 could use a wheelchair for locomotion and could self-propel. Nurse #2 said she did not offer a wheelchair to Resident #1 because he/she wandered and might fall, he/she "got into things," it was the night time, and staff wanted to be able to supervise him/her. Nurse #2 said she administered a PRN dose of [MEDICATION NAME] to Resident #1 at approximately 11:30 P.M., because he/she was restless and agitated. Nurse #2 said she did not understand why Resident #1 was restless. Nurse #2 said Resident #1 sometimes fell asleep in the reclined geri chair, but on this night he/she did not. Nurse #2 said Resident #1 tried multiple times to climb out of the reclined geri chair, but the CNAs were able to redirect him/her with food and toileted him/her. Nurse #2 said that at approximately 3:30 A.M., she heard voices coming from the dining room and then saw Resident #1 standing on the floor and swinging his/her arms. Nurse #2 said Resident #1 was upset, but she did not know why. The Surveyor interviewed Nurse #4 at 1:00 P.M., on 4/17/15. Nurse #4 said Resident #4 was able to scoot his/her feet to self-propel his/her wheelchair, without staff assistance. Review of the Hospital emergency department note, dated 4/10/15, indicated Resident #1 was diagnosed with [REDACTED].

Based on interview and record review, for 1 of 3 sampled residents (Resident #1), the Facility failed to prevent an avoidable fall sustained by Resident #1. At 3:30 A.M. on 4/10/15, Resident #1 shouted to be taken out of a reclined geri chair, then climbed out of the geri chair and stood up. As staff physically attempted to reseat him/her, Resident #1 punched CNA #1 and then fell to the floor. Resident #1 sustained a left eye orbit fracture and lacerations and bruising to the face. There was no clinical indication for a restraint to manage Resident #1's risk for falls. Findings include: The Facility's Restraint Policy, dated 1/2/14, indicated, "If the device cannot be easily removed by the patient and/or restrict freedom of movement, the Restraint Evaluation/Reduction of the Device Evaluation will be completed: prior to the application of any restraint...". Review of Resident #1's clinical record indicated there was no assessment indicating a need for a restraint, and no physician's order for a restraint. The Director of Nurses's written statement, dated 5/8/15, indicated Resident #1 did not have a restraint assessment. The Care Plan for Falls, dated 1/9/15, indicated Resident #1 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included: staff assistance when getting out of bed. utilize a low bed, and monitor for and assist toileting needs. The Care Plan for Falls did not include the use of a restraint, including placing Resident #1 in a reclined geri chair, or the use of antipsychotic medications. The Surveyor interviewed Nurse #3 at 1:10 P.M., on 4/17/15. Nurse #3 said Resident #1's plan of care included the use of a reclined geri chair for periods of rest and elevation of his/her legs for relief of edema (swelling). Nurse #3 said Resident #1 used a wheelchair for mobility (propelled self with feet) and to allow him/her to wander on the unit. Resident #1's admission Minimum Data Set, dated dated [DATE], indicated he/she did not use physical restraints; rarely/never understood others; had severely impaired cognitive skills for daily decision making (never/rarely made decisions); exhibited physically aggressive behaviors toward others; frequently wandered on the unit; required extensive staff assistance for transfers and walking; was unsteady on his/her feet; used a walker or wheelchair for mobility and was diagnosed with [REDACTED]. Resident #1's Care Plan (for lower leg edema), dated 2/26/15, indicated he/she may use a geri chair to elevate his/her feet. Care Plan goals indicated Resident #1's feet will be less swollen (2/26/15), and he/she will use the recliner geri chair to assist in comfort and positioning on a daily basis (3/6/15). Following the 4/9/15 incident, Resident #1's Care Plan was revised on 4/13/15 to include the use of a reclined geri chair when Resident #1 exhibited, "tiredness and sleepiness when (he/she) is in wheelchair and when climbing out of bed." The Nurse's note, dated 4/10/15, indicated at approximately 3:30 A.M., Resident #1 tried to self-transfer from the geri chair and stand up. The Nurse's note indicated CNAs tried to reposition him/her back into the geri chair and Resident #1 became combative toward staff and he/she fell to the floor and sustained a laceration to the forehead and bruise to the left eye. The Nurse's note indicated staff contacted emergency medical services and Resident #1 was transferred to the Hospital. Review of the Hospital emergency department note, dated 4/10/15, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:53 A.M., on 4/17/15. CNA #1 said she worked on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #1 said when she arrived to the unit at 3:00 P.M., Resident #1 was seated in a reclined geri chair. CNA #1 said she did not know why he/she was placed in the reclined geri chair. CNA #1 said she and other staff supervised Resident #1 because he/she was "agitated" and made 3 to 5 attempts to climb over the armrests and out of the reclined geri chair. CNA #1 said Resident #1 was at risk for falling. CNA #1 said she did not know why Resident #1 was not placed in his/her wheelchair. CNA #1 said that at approximately 9:30 P.M., she and other staff tried to put Resident #1 into bed to sleep, but Resident #1 attempted many times to get out of bed. CNA #1 said she and other staff then returned Resident #1 to the reclined geri chair. CNA #1 said Resident #1 continued to try to climb out of the geri chair and she told Nurse #2 about this behavior. CNA #1 said staff toileted Resident #1 and provided snacks to him/her throughout the shifts. CNA #1 said staff did not offer a wheelchair to allow Resident #1 to wander, or offer any activities. CNA #1 said Nurse #2 administered medication to Resident #1 to help him/her sleep, but the medication was ineffective. CNA #1 said staff placed a chair behind the reclined geri chair, and on either side of the reclined geri chair, to try to prevent Resident #1 from climbing out over the arms of the chair. CNA #1 said, despite the geri chair in the reclined position and with the chairs surrounding the chair, Resident #1 was still able to climb out by swinging his/her legs over the armrest. CNA #1 said that at approximately 3:30 A.M., Resident #1 was shouting to get out of the reclined geri chair and then swung his/her legs over the armrest and stood up on the floor. CNA #1 said CNA #2 was behind him/her and tried to lower Resident #1 back into the geri chair. CNA #1 said Resident #1 then punched her (CNA #1) in the chest, and then Resident #1 fell to the floor. The Surveyor interviewed CNA #2 at 12:40 P.M., on 4/17/15. CNA #2 said she worked with CNA #1 on Resident #1's unit from 3:00 P.M. on 4/09/15 until 7:00 A.M. on 4/10/15. CNA #2 said Resident #1 was in the reclined geri chair during the 3:00 P.M. to 11:00 P.M. shift, and during this time Resident #1 was upset and several times tried to swing his/her legs over the arms rests of the reclined geri chair to climb out. CNA #2 said she did not know why Resident #1 was upset. CNA #2 said Resident #1 told her and CNA #1 he/she did not want to be in the reclined geri chair. CNA #2 said that at approximately 9:30 P.M., she and CNA #1 tried to place Resident #1 in bed to sleep. CNA #2 said Resident #1 climbed out of bed, and staff returned him/her to the recliner geri chair. CNA #2 said they put him in the reclined geri chair because they did not want Resident #1 to fall and they could closely watch him/her if he/she was in the reclined geri chair. CNA #2 said Resident #1 continued to try to climb out of the reclined geri chair and told staff to, "Get me out," or words to that effect. CNA #2 said sometime during the early morning Resident #1 was angry and upset, and he/she slid his/her legs over the armrest of the reclined geri chair and stood up on the floor. CNA #2 said Resident #1 punched CNA #1, and then Resident #1 fell to the floor. The Surveyor interviewed Nurse #2 at 11:37 A.M. on 4/17/15. Nurse #2 said she worked on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift, from 4/9/15 to 4/10/15. Nurse #2 said Nurse #1 told her, during the change of shift report, that Resident #1 had tried to get out of bed and was now in the reclined geri chair, located in the dining room. Nurse #2 said when Resident #1 was unable to sleep, he/she routinely tried to get out of bed and staff placed him/her into the reclined geri chair. Nurse #2 said that at 11:00 P.M., Resident #1, "was wide awake and beginning to get restless," or words to that effect. Nurse #2 said Resident #1 could use a wheelchair for locomotion and could self-propel. Nurse #2 said she did not offer a wheelchair to Resident #1 because he/she wandered and might fall, he/she "got into things," it was the night time, and staff wanted to be able to supervise him/her. Nurse #2 said she administered a PRN dose of Seroquel to Resident #1 at approximately 11:30 P.M., because he/she was restless and agitated. Nurse #2 said Resident #1 sometimes fell asleep in the reclined geri chair, but on this night he/she did not. Nurse #2 said Resident #1 tried multiple times to climb out of the reclined geri chair, but the CNAs were able to redirect him/her with food. Nurse #2 said that at approximately 3:30 A.M., she heard voices coming from the dining room and then saw Resident #1 standing on the floor and swinging his/her arms. Nurse #2 said Resident #1 was upset, but she did not know why.