Every finding on record at Village Manor of Cascadia

Based on interview and record review, it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 sustained multiple pelvic fractures. Findings include:Resident 1 was admitted to the facility in 2025, with diagnoses including dementia. Resident 1's 7/25/25 Care Plan revealed Resident 1 was a fall risk because of a prior fall and was a one-person max assist for dressing. Resident 1 was care planned for supervision and touch assistance for bathing, used a shower bench or bathtub, and was to wear non-skid footwear when up. A 7/28/25 FRI indicated Staff 5 (Housekeeping) and Staff 6 (Housekeeping) reported Resident 1 had a fall in the shower room. Staff 5 and 6 found staff to assist Resident 1. The report indicated staff found Resident 1 down in the shower, unattended, and not fully clothed. Resident 1 was transferred to the hospital for evaluation. The FRI indicated Resident 1 sustained multiple complex fractures of the pelvis and was bleeding internally. The FRI indicated the fall occurred due to Resident 1's care plan not being followed.Between 8/11/25 at 11:00 AM to 8/12/25 at 10:00 AM, Staff 2 (CNA), Staff 3 (CNA), Staff 4 (CNA), Staff 5 (Housekeeping) and Staff 6 (Housekeeping) all provided statements, which included Resident 1 was found down in the shower room unattended. Resident 1 was wearing underwear and pants. The resident's pants were not fully up and her/his belt was not buckled. Staff 2, Staff 3, and Staff 4 recalled Resident 1 was not wearing socks or shoes. All staff interviewed did not see a shower bench anywhere near the resident and she/he was found to have been in a shower stall, not a bathtub. On 8/11/25 at 10:48 AM, Staff 1 (CNA) indicated she left the shower room when she thought the resident was done with her/his shower and safe. Staff 1 confirmed a shower bench was not used and Resident 1 was left unattended in the shower room. On 8/12/25 at 10:00 AM, Staff 8 (LPN) was called for a witness statement. Staff 8 did not answer and did not return the phone call. On 8/12/25 at 10:45 AM, Staff 7 (Administrator) confirmed the accident occurred and Resident 1's care plan was not followed.

Based on interview, and record review it was determined the facility failed to develop comprehensive care plans that included interventions for the use of psychotropic medication for 1 of 5 sampled resident (#57) reviewed for unnecessary medications. This placed the resident at risk for side effects and unnecessary medication. Findings include: Resident 57 was admitted to the facility in 2/2025 with diagnoses including anxiety, hallucinations and disorientation. A review of Resident 57's physician orders found the following active orders for psychotropic medications: Buspirone HCl oral tablet. Give 15 mg by mouth in the morning for irritability related to anxiety disorder, unspecified and give 15 mg by mouth one time a day for irritability at 4 PM. Do not give at 6 PM per provider. Lamotrigine oral tablet. Give 25 mg by mouth one time a day for mood stabilization related to major depressive disorder, recurrent. Mirtazapine Oral tablet. Give 7.5 mg by mouth one time a day related to insomnia. Duloxetine HCl oral capsule delayed release sprinkle 30 MG. Give 1 capsule by mouth one time a day for mood/depression related to major depressive disorder, recurrent, unspecified. Olanzapine oral tablet disintegrating. Give 15 mg by mouth one time a day related to hallucinations, unspecified. Haloperidol oral tablet. Give 5 mg by mouth as needed for twice daily as needed for hallucinations or aggression for 14 Days. A review of Resident 57's 2/24/25 care plan found no interventions for the use of psychotropic medications. There was no evidence resident-specific interventions for the use of psychotropic medications were developed in Resident 57's health record. On 5/9/25 at 9:11 AM Staff 2 (DNS) confirmed Resident 57's clinical record lacked interventions for the use of psychotropic medication.

Based on interview and record review it was determined the facility failed to act upon pharmacist recommendations for 1 of 5 sampled residents (#57) reviewed for unnecessary medications. This placed residents at risk for a decrease in their quality of life. Findings include: Resident 57 was admitted to the facility on ,d+[DATE] with diagnoses including anxiety, hallucinations and disorientation. A review of Resident 57's physician orders found an active order for Olanzapine oral tablet disintegrating (an antipsychotic medication). Give 15 mg by mouth one time a day related to hallucinations. A review of pharmacy recommendations for Resident 57 dated 3/19/25 included the following recommendation for the use of Olanzapine: 'If the antipsychotic order is to continue, please update the medical record to include . a list of symptoms or target behaviors (e.g., hallucinations) including their impact on the resident (e.g., increases distress, presents a danger to the resident or others, interferes with their ability to eat) AND documentation that other causes (e.g., environmental) and medications have been considered, that individualized nonpharmacological interventions are in place and that ongoing monitoring has been ordered.' A review of Resident 57's clinical record lacked specific target behaviors and their impact on the resident, documentation that other causes and medications had been considered and individualize nonpharmacological interventions were in place. There was no evidence in Resident 57's health record that the facility followed up or implemented the pharmacy recommendations. On 5/09/25 at 9:11 AM Staff 2 (DNS) confirmed the pharmacist's recommendation were not followed.

Based on interview and record review it was determined the facility failed to provide therapy services for 1 of 3 sampled residents (#28) reviewed for falls. This placed residents at risk for falls. Findings include: Resident 28 was admitted to the facility in 8/2020 with diagnoses including dementia. A review of Resident 28's Physician Orders revealed an 4/8/25 order for PT to evaluate due to frequent falls. On 5/5/25 at 10:15 AM a motion detector alarm was heard going off in Resident 28's room. Resident 28 was observed standing at her/his bedside and turning the alarm off. On 5/8/25 at 10:20 AM Staff 26 (RN) stated Resident 28 had multiple falls in 4/2025, no falls in 3/2025, and two falls in 2/2025. Staff 26 stated Resident 28 had frequent falls related to self-transferring and weakness. On 5/8/25 at 11:06 AM Staff 2 (DNS) stated Resident 28 had eight falls in 4/2025. Staff 2 stated Resident 28's falls were related to Resident 28's impulsiveness and self-transferring. Staff 2 stated Resident 28 was on therapy in 3/2025 and therapy had ordered Resident 28 a wheelchair to help decrease the risk for falls. Staff 2 stated Resident 28 finished PT on 3/15/25. On 5/8/25 at 11:23 AM Staff 4 (RNCM) stated Resident 28 had a lot of falls, mostly in her/his room. Staff 4 stated Resident 28 was impulsive, did not use her/his call light, and would self-transfer which led to falls. Staff 4 stated Resident 28 started PT due to frequent falls. On 5/8/25 at 1:37 PM Staff 4 stated she saw the 4/8/25 order for PT but was unable to see when PT was started. On 5/9/25 at 8:24 AM Staff 29 (Therapy Manager) acknowledged Resident 28's 4/8/25 order for PT. Staff 29 stated she discussed the order for PT with Staff 4 and Staff 29 stated therapy was not appropriate for Resident 28 because she/he was seen by therapy 30 days prior. On 5/9/25 at 10:28 AM Staff 4 stated she emailed Staff 29 on 5/8/25 to request the PT notes for Resident 28. Staff 4 stated she was informed on 5/9/25 by Staff 29, via email, Resident 28's PT evaluation was not completed as ordered on 4/8/25. Staff 4 stated she was informed by Staff 29 Resident 28 was not appropriate for PT because she/he just came off therapy four weeks ago. Staff 4 stated she had not discussed this with Resident 28's provider, because she just became aware of it on 5/9/25. On 5/9/25 at 11:40 AM Staff 2 acknowledged there was an order for Resident 28 to have PT evaluation due to frequent falls on 4/8/25. Staff 2 stated Staff 29 sent an email which stated therapy was not indicated for Resident 28. Staff 2 stated this decision was discussed as an IDT (interdisciplinary team) group on 4/8/25 and she assumed the provider was informed verbally. On 5/9/25 at 12:18 PM Staff 29 stated Resident 28 was at risk for falls due to impulsiveness and poor safety awareness. Staff 29 stated she did not have a discussion with Resident 28's provider related to the appropriateness of Resident 28's 4/8/25 PT order for evaluation.

Based on interviews and record review, it was determined the facility failed to protect the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#52) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 49 was admitted to the facility in 5/2023 with diagnoses including schizoaffective disorder (a mental health condition where a person experiences symptoms of schizophrenia, such as hallucinations and delusions, and a mood disorder, such as mania or depression). Resident 52 was admitted to the facility in 1/2024 with diagnoses including psychosis (a state where a person loses touch with reality, experiencing hallucinations and delusions). On 1/22/25 a Facility Reported Incident (FRI) was received by the State Survey Agency, which alleged Resident 49 slapped Resident 52 on the left side of her/his face. A 1/22/25 Progress Note indicated Resident 49 hit Resident 52 in the face. A 1/27/25 facility investigation revealed on 1/22/25 at 4:30 AM staff heard yelling from room [ROOM NUMBER] and found Resident 49 standing over Resident 52's bed yelling at her/him. Staff got in between the residents and kept them separated until EMTs arrived. Resident 49 was sent to the hospital. On 5/6/25 at 8:41 AM Resident 52 revealed on 1/22/25 in the middle of the night, she/he was woken up by Resident 49 hitting her/him. Resident 52 stated she/he sat up in bed and kicked Resident 49 away from her/him. Resident 52 stated staff came in and kept Resident 49 away from her/him until Resident 49 left with EMTs. Resident 52 denied injury from the incident and stated Resident 49 was moved to a new room because Resident 52 was not comfortable sleeping in the same room as Resident 49. Resident 49 refused to be interviewed. On 5/8/25 at 1:16 PM Staff 26 (RN) stated Resident 49 had an incident a few months ago where she/he hit Resident 52 while Resident 52 was sleeping. Staff 26 stated Resident 52 had no injuries from the incident. However, Resident 52 expressed feeling scared about sleeping in the same room as Resident 49, so Resident 49 was moved to a new room. On 5/8/25 at 1:24 PM Staff 4 (RNCM) stated there was an incident between Resident 49 and Resident 52 in 1/2025. Staff 4 stated Resident 49 hit Resident 52 in the face while Resident 52 was sleeping. Staff 4 stated after the incident, Resident 49 was placed on a psychiatric hold for medication adjustment and when Resident 49 returned to the facility, she/he was moved to a new room. On 5/9/25 at 11:48 AM Staff 2 (DNS) acknowledged the incident between Resident 49 and Resident 52 occurred and the incident met the definition of abuse.

Based on interview and record review it was determined the facility failed to ensure residents were free from chemical restraints for 1 of 5 sampled residents (#57) reviewed for unnecessary medications. This placed residents at risk for changes to psychosocial well-being. Findings include: Resident #57 was admitted to the facility in 2/2025 with diagnoses including anxiety, hallucinations, and disorientation. A 3/31/25 physician order indicated Resident 57 was prescribed haloperidol Oral Tablet 5 MG (antipsychotic medication) twice daily as needed for 14 days. The Indication for use was hallucinations. A 4/14/25 physician order indicated Resident 57 was prescribed haloperidol Oral Tablet 5 MG twice daily as needed for 14 days. Indications for use were hallucinations or aggression. A 4/21/25 physician order indicated Resident 57 was prescribed haloperidol Oral Tablet 5 MG twice daily as needed for 14 days. Indications for use were hallucinations or aggression. Resident 57's MAR, behavior monitor and progress notes for 4/2025 and 5/2025 indicated she/he received haloperidol with no indication for use on the following days: 4/2/25 and 4/15/25 Resident 57 received two doses of haloperidol. On 4/3/25, 4/4/25, 4/5/25, 4/8/25, 4/11/25 and 4/14/25, 4/27/25, 4/30/25, 5/1/25 and 5/5/25 she/he receceived a single dose of haloperidol. On 5/8/25 11:55 AM Staff 31 (LPN) stated she was unsure why she would have given haloperidol if Resident 57 was not having behaviors on 4/30/25. She further stated she should have documented the specific behaviors in a progress note but did not. On 5/8/25 01:09 PM Staff 9 (LPN) stated she administered haloperidol on on 4/4/25, 4/5/25 and 4/8/25.because Resident 57 would not sleep for long periods of time. Staff 8 stated stated she should have documented the specific behaviors in a progress note but did not. On 5/8/25 at 1:30 PM Staff 22 (LPN) stated he administered haloperidol for agitation and because Resident 57 was difficult to control. Staff 22 could not specifically remember why he administered haloperidol on 4/11/25. Staff 22 further stated he should have documented the specific behaviors in a progress note but did not. On 5/8/25 at 1:54 PM Staff 19 (LPN) stated she administered haloperidol at the instruction of two other nurses because Resident 57 pulled the fire alarm multiple times on 5/4/25. On 5/8/25 at 2:02 PM Staff 32 (LPN) stated she administered haloperidol on 5/1/25 because Resident 57 thought there were people coming in and out of his/her room and wanted to get up. Staff 32 stated she should have documented whether the administration was effective. On 5/8/25 at 3:31 PM Staff 28 (LPN) stated she gave haloperidol when Resident 57 had behaviors and agitation and stated he was not aggressive on 4/3/25. She further stated she should have documented the specific behaviors in a progress note but did not. On 5/9/25 at 9:11 AM Staff 2 (DNS) stated Resident 57 was only to receive haloperidol for aggression or hallucinations. Staff 2 stated nurses should have documented the specific hallucinations or aggressive behaviors, as well as all non-pharmacological interventions attempted with Resident 57 prior to the administration of haloperidol, in a progress note. Staff 2 further stated staff should have documented whether the administration was effective in resolving the behaviors.

Based on interview and record review it was determined the facility failed to ensure residents received trauma informed care for 2 of 3 sampled residents (#s 18 and 30) reviewed for behavioral and emotional care needs. This placed residents at risk for re-traumatization. Findings include: The facility's 10/2022 Trauma Informed Care Policy and Procedure revealed the following: -Screen residents for a traumatic event, series of events, or set of circumstances which resulted in actual harm or threat of harm. Determine how the individual perceives the event, as stressful or not. Evaluate how the event adversely impacts the person. -Collaborate with the resident and/or resident advocate to plan for treatment or intervention(s) of resident choice, as indicated and/or appropriate. -Person-centered care planning addresses the following: a. Identify the effects of the trauma on the resident and how that may be manifested in a resident's behavior. b. Address triggers for re-traumatizing and interventions to avoid such an experience, such as loud noises, smells, textures, cold/hot, confinement, invasion of perceived privacy, etc. c. Develop interventions to reduce potential triggers and promote coping techniques. d. Coordinate recovery concepts with counseling and/or therapy, as indicated. 1. Resident 18 was admitted to the facility in 11/2023 with diagnoses including schizophrenia (chronic brain disorder) and PTSD (Post-Traumatic Stress Disorder). Resident 18's 4/7/25 Quarterly MDS indicated the resident was cognitively intact. Resident 18's 4/16/25 Behavior/Psychoactive Quarterly Assessment indicated Resident 18 had auditory hallucinations that bothered her/him and occurred anytime of day. No evidence was found in Resident 18's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. On 5/7/25 at 8:30 AM Resident 18 stated she/he did not recall if the facility had asked her/him about any triggers she/he had. Resident 18 stated she/he heard voices that would get loud and would cause her/him to scream out for help. On 5/7/25 at 12:55 PM Staff 10 (CNA) and at 1:00 PM Staff 9 (LPN) stated they thought Resident 30 might have PTSD because she/he was a veteran but were unaware if the resident had any triggers. Staff 9 and Staff 10 stated the only behavior Resident 18 displayed was she/he would yell out. On 5/7/25 at 1:50 PM Staff 6 (Social Services) stated resident trauma screenings were to be completed at the time of admission for all residents. Staff 6 stated a care plan had not been developed related to Resident 18's history of trauma or potential triggers. Staff 6 stated she was not aware if Resident 18 had any triggers. On 5/7/25 at 1:58 PM Staff 2 (DNS) and Staff 7 (Clinical Resources) acknowledged Resident 18 had a diagnosis of PTSD and nothing was implemented related to Resident 18's trauma or her/his trauma triggers. 2. Resident 30 was admitted to the facility in 8/2022 with diagnoses including major depressive disorder and PTSD (Post-Traumatic Stress Disorder). Resident 30's 3/1/25 Quarterly MDS indicated the resident was cognitively intact. No evidence was found in Resident 30's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. On 5/7/25 at 9:52 AM Staff 8 (Activity Director) stated Resident 30 had a few behaviors and could become frustrated with other residents. Staff 8 stated he thought Resident 30 probably had some triggers and could easily become frustrated or lose her/his patience, but was not aware if the resident had any specific triggers. On 5/7/25 at 10:47 AM Resident 30 stated no one at the facility discussed the cause of her/his PTSD or potential triggers for re-traumatization. Resident 30 stated she/he would easily lose her/his patience with others and become frustrated. When asked what triggered her/his behaviors the resident stated I don't want to talk about it. On 5/7/25 at 12:55 PM, Staff 10 (CNA) and at 1:00 PM Staff 9 (LPN) stated they did not know if Resident 30 had PTSD and were unaware if the resident had any triggers. On 5/7/25 at 1:50 PM Staff 6 (Social Services) stated resident trauma screenings were to be completed at the time of admission for all residents. Staff 6 stated a care plan had not been developed related to Resident 30's history of trauma or potential triggers. Staff 6 stated she was not aware if Resident 30 had any triggers. On 5/7/25 at 1:58 PM Staff 2 (DNS) and Staff 7 (Clinical Resources) acknowledged Resident 30 had a diagnosis of PTSD and nothing was implemented related to Resident 30's trauma or her/his trauma triggers.

Based on interview and record review it was determined the facility failed to report an allegation of abuse to the State Agency (SA) within the mandated timeframe for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation policy, last revised 8/1/23, indicated the following: -Allegations of verbal, sexual, physical, mental, corporal punishment, involuntary seclusion, and neglect of the resident, as well as mistreatment, injuries of unknown source, exploitation, deprivation of goods and services by staff, and misappropriation of resident property are reported to the administrator immediately and the state agency within two hours if there was alleged abuse or serious bodily injury as a result of an event. Resident 2 was admitted to the facility in 10/2019 with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and history of traumatic brain injury. Resident 59 was admitted to the facility in 4/2025 with diagnoses including dementia and delirium (a disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The facility's FRI received on 4/20/25 at 11:14 PM, revealed on 4/20/25 at 4:50 PM, Resident 59 forcefully shoved Resident 2 against the wall, staff intervened, separated the residents and escorted Resident 2 to her/his room. On 5/8/25 at 10:20 AM, Staff 20 (LPN) stated around 4:50 PM, Resident 2 attempted to walk past Resident 59 and Resident 59 charged at Resident 2; pushing her/him into the wall. Resident 59 then took her/his hands and threw Resident 2 into the wall. Staff 20 stated she was a new nurse and had not previously completed a FRI so she contacted Staff 2 (DNS) who provided assistance and later a night shift nurse also helped with the report. As a result, the FRI was not submitted to the SA within the mandated timeframe. On 5/9/25 at 8:22 AM, Staff 2 (DNS) stated Staff 20 was in contact with her several times regarding the incident on 4/20/25 between Resident 2 and Resident 59. Staff 2 acknowledged the FRI was not completed within the mandated timeframe.

Based on interview and record review it was determined that the facility failed to ensure residents were free from unnecessary bowel and antihypotensive medications for 2 of 5 sampled resident (#s 20 and 35) reviewed for unnecessary medications. This placed the resident at risk for adverse side effects from medication complications. Findings include: 1. Resident 20 was admitted to the facility in 3/2025 with the diagnosis including hypotension. Resident 20's 3/21/25 through 4/22/25 Physician Orders indicated the resident received midodrine (used to raise blood pressure) three times daily and was to be held for SBP (systolic blood pressure) greater than 120. A review of Resident 20's 3/2025 and 4/2025 MARs revealed Resident 20 received the midodrine on the following dates with the SBP above 120: -3/23/2025 AM dose, SBP was 122. -3/23/2025 AM dose, SBP was 122. -3/24/2025 Mid-day dose, SBP was 121. -3/27/2025 AM dose, SBP was 131. -3/27/2025 Mid-day dose, SBP was 131. -3/27/2025 PM dose, SBP was 130. -3/29/2025 PM dose, SBP was 127. -3/31/2025 PM dose, SBP was 132. -4/11/2025 AM dose, SBP was 146. -4/11/2025 Mid-day dose, SBP was 146. -4/12/2025 PM dose, SBP was 136. -4/14/2025 AM dose, SBP was 145. -4/14/2025 Mid-day dose, SBP was 145. -4/17/2025 AM dose, SBP was 134. -4/17/2025 Mid-day dose, SBP was 134. -4/18/2025 AM dose, SBP was 141. -4/18/2025 Mid-day dose, SBP was 141. -4/19/2025 PM dose, SBP was 140. -4/21/2025 PM dose, SBP 137. Resident 20's 4/23/25 through 5/9/25 Physician Orders indicated the resident received midodrine three times daily and was to be held for SBP greater than 130. A review of Resident 20's 4/2025 and 5/2025 MARs revealed Resident 20 received the midodrine on the following dates with the SBP above 130: -4/25/2025 AM dose, SBP 140. -4/25/2025 PM dose, SBP was 140. -5/1/2025 AM dose, SBP was 132. -5/1/2025 Mid-day dose, SBP was 142. -5/2/2025 AM dose, SBP was 138. On 5/8/25 at 9:11 AM Staff 15 (LPN) stated she administered the midodrine medication to Resident 20 on 5/2/25 when she should not have, as her/his SBP above 130. On 5/8/25 at 1:12 PM Staff 24 (LPN) stated Resident 20's midodrine should have been held when her/his SBP above 130. On 5/8/25 at 1:19 PM Staff 2 (DNS) reviewed Resident 20s's MARs from 3/2025, 4/2025, and 5/2025 and acknowledged the medication was given unnecessarily 24 times when it should have been held. 43691 2. Resident 35 was admitted to the facility in 5/2022 with diagnoses including bipolar disorder and a hip fracture. A 3/14/25 physician order stated Resident 35 was to receive two 8.6 mg tablets of senna twice a day for constipation and the medication was to be held for loose stools. The medication was scheduled to be received between 6:00 AM and 10:00 AM for the AM dose and between 4:00 PM and 7:00 PM for the PM dose. Review of Resident 35's 4/2025 and 5/2025 MARs revealed Resident 35 received her/his senna medication twice a day every day from 4/1/25 through 5/7/25. Review of Resident 35's 4/8/25 through 5/7/25 Bowel Movement Consistency records revealed the following errors of administration of senna: - On 4/8/25 at 3:17 AM Resident 35 had a type 7 bowel movement (Watery, no solid pieces. Entirely liquid). On 4/8/25 Resident 35 received her/his AM and PM doses of senna. On 4/8/25 at 7:09 PM Resident 35 had bowel movement recorded at type 7. - On 4/10/25 at 7:30 PM Resident 35 had a type 6 bowel movement (Fluffy pieces with ragged edges, a mushy stool). Resident 35 received her/his AM dose of senna on 4/11/25. Resident 35 did not experience a normal consistency bowel movement until 4/11/25 at 1:59 PM. - On 4/13/25 at 9:19 PM Resident 35 had a type 6 bowel movement. On 4/14/25 at 5:59 AM Resident 35 had another type 6 bowel movement. Resident 35 received her/his AM dose of senna on 4/14/25. Resident 35 did not experience a normal consistency bowel movement until 4/14/25 at 1:31 PM. - On 4/17/25 at 12:59 PM Resident 35 had a type 7 bowel movement. On 4/17/25 at 5:04 PM Resident 35 had another type 7 bowel movement. Resident 35 received her/his PM dose of senna on 4/17/25 and her/his AM dose on 4/18/25. Resident 35 did not experience a normal consistency bowel movement until 4/18/25 at 12:59 PM. - On 4/21/25 at 4:36 PM and 6:06 PM Resident 35 had type 6 bowel movements. Resident 35 received her/his 4/21/25 PM and 4/22/25 AM doses of senna, but did experience a normal consistency bowel movement until 4/12/25 at 12:37 PM. - On 4/26/25 at 3:33 PM Resident 35 had a type 7 bowel movement. Resident 35 received her/his PM dose senna on 4/26/25, her/his AM and PM doses of senna on 4/27/25, and her/his AM dose of senna on 4/28/25. Resident 35 did not experience a normal consistency bowel movement until 4/28/25 at 1:35 PM. - On 5/5/25 at 8:36 PM Resident 35 had a type 6 bowel movement. Resident 35 received her/his AM dose of senna on 5/6/25. Resident 35 did not experience a normal consistency bowel movement until 5/6/25 at 1:10 PM. On 5/8/25 at 9:42 AM Staff 27 (CNA) stated she had been instructed to report a loose stool bowel movement, which was at type 6 or type 7, to the CMA and charge nurse. On 5/8/25 at 9:53 AM Staff 4 (RNCM) stated she considered type 6 and type 7 to be loose stool. Staff 4 stated none of the bowel movement consistency ratings included the words loose stool which made it challenging to define. Staff 4 confirmed Resident 35's senna medication should have been withheld until her/his stool consistency returned to normal after experiencing loose stool on the dates listed above.

Based on observation, interview and record review it was determined the facility failed to provide care planned safety interventions for 1 of 4 sampled residents (#24) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 24 was admitted to the facility in 2018 with diagnoses including Wernicke's encephalopathy (a neurological disorder) and dementia. Resident 24's 4/30/25 Quarterly Smoking Evaluation indicated the resident was to use smoking gloves when smoking. A review of Resident 24's 5/2/25 Quarterly MDS Assessment revealed she/he had moderate cognitive impairment. Resident 24's 8/7/22 Care Plan indicated she/he used smoking materials and was to wear smoking gloves when smoking. On 5/6/25 at 8:33 AM Resident 24 was observed smoking in the facility designated smoking area without smoking gloves on. On 5/6/25 at 8:35 AM Resident 24 stated she/he was not wearing her/his smoking gloves because staff did not offer to provide them to her/him. On 5/6/25 at 8:36 AM Staff 18 (CNA) confirmed Resident 24 was smoking without her/his smoking gloves on and stated she/he should have had them on. On 5/6/25 at 8:39 AM Staff 2 (DNS) stated Resident 24 was care planned to wear smoking gloves to prevent her/his knuckles from burns. Staff 2 acknowledged Staff 18 did not offer Resident 24 her/his smoking gloves.

Based on interview and record review it was determined the facility failed to timely assess and implement appropriate interventions for a change of condition or accident for 1 of 1 sampled resident (#27). This placed the residents at risk for choking. Findings include: Resident 27 admitted to the facility in 10/2019 with diagnoses including stroke. Resident 27's 4/20/25 comprehensive assessment noted coughing and choking during meals and when swallowing medications. A 4/18/25 physician orders revealed Resident 27 was on a dental/mechanical soft texture, nectar thick liquids consistency. A 5/2/25 progress note found Resident 27 choked during dinner and the Heimlich maneuver was administered successfully by Staff 28 (LPN). A 5/5/25 physician order revealed Resident 27's diet was changed to a pureed texture, three days after Resident 27's choking episode On 5/8/25 at 3:42 PM Staff 28 stated during dinner on 5/2/25 Resident 27 choked and became very rigid. Staff 28 did the Heimlich maneuver with a CNA and Resident 27 recovered. Staff 28 notified the on-call provider and stated she should have downgraded Resident 27's diet texture to puree at that time but did not. There was no evidence in Resident 27's health record the speech language pathologist was notified after his/her choking episode on 5/2/25. On 5/9/25 at 10:15 AM Staff 30 (Director of Rehabilitation) stated she was not notified until 5/5/25 regarding Resident 27's choking incident, which occurred on 5/2/25 (three days later). She immediately placed orders to downgrade the diet texture to puree and stated she consulted with the speech-language pathologist for safety. Staff 30 stated she would have done so on 5/2/25 if she were notified of the chocking incident. On 5/9/25 at 10:29 AM Staff 2 (DNS) acknowledged Resident 27's diet should have been downgraded immediately after the choking incident on 5/2/25.

Based on observation, interview and record review, it was determined the facility failed to maintain a homelike environment for 1 of 1 resident (#9) reviewed for homelike environment. This placed residents at risk for lessened quality of life. Findings include: Resident 9 admitted to the facility in 5/2020 with diagnoses including borderline personality disorder. Resident 9's 2/28/25 care plan found no indication for having a short chain on his/her bedside light. On 5/5/25 at 9:58 AM Resident 9 was observed to have a three to four inch chain on the light on the wall over his/her bed. Resident 9 stated she/he was unable to use it due to the short length and was unable to turn on the light independently. Resident 9 stated she/he became frustrated and had to ring his/her bell to have someone come turn on the light. Resident 9 further stated she/he should be able off her/his own light without assistance. On 5/6/25 at 1:54 PM Staff 30 (CNA) stated she thought Resident 9 was able to turn his/her bedside light on and off with the use of a reacher. On 5/7/25 at 9:36 AM Staff 12 (LPN) stated she did not think Resident 9 was capable of turning the bedside light on or off. However, Resident 9 frequently called for assistance. On 5/7/25 at 10:34 AM Staff 3 (RNCM) stated she was unaware that the bed light was short there was no intentional reason for keeping it short. On 5/7/25 at 11:13 AM Staff 13 (Environmental Services Director) stated the chain was short because Resident 9 had previously pulled on it with his/her body weight to reposition. It was unsafe for him/her to use it that way because it would break and send him/her backwards out of control. Staff 13 was unaware that Resident 9 was not able to turn the light on with the short chain. On 5/7/25 at 2:53 PM Staff 2 (DNS) confirmed Resident 9 should be able to turn on and off the bedside light. She knew it was short, but did not know Resident 9 was unable to turn it on and off without asking for help.

Based on interview and record review it was determined the facility failed to determine if residents had or wished to formulate an advance directive upon admission to the facility for 3 of 3 sampled residents (#s 9, 18 and 56) reviewed for advance directives. This placed residents at risk for not having their health care wishes honored. Findings include: 1. Resident 9 was readmitted to the facility in 6/2023 with a diagnosis of suicidal ideations. A review of Resident 9's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. On 1/12/24 at 10:57 AM Staff 3 (Social Services Director/Administrator in Training) was asked to provide evidence Resident 9 was asked if she/he had, or wished to formulate, an advance directive on admission to the facility. No additional information was provided. 2. Resident 18 was readmitted to the facility in 12/2022 with a diagnosis of stroke. A review of Resident 18's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. On 1/12/24 at 10:57 AM Staff 3 (Social Services Director/Administrator in Training) was asked to provide evidence Resident 18 was asked if she/he had, or wished to formulate, an advance directive on admission to the facility. No additional information was provided. 3. Resident 56 was admitted to the facility in 7/2023 with a diagnosis of stroke. A review of Resident 56's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. On 1/12/24 at 10:57 AM Staff 3 (Social Services Director/Administrator in Training) was asked to provide evidence Resident 56 was asked if she/he had, or wished to formulate, an advance directive on admission to the facility. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents (#s 42, 55 and 58) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed regarding their legal rights. Findings include: The facility's undated Admission Agreement included the following: The Resident and/or Legal Representative understands that his Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution, this Arbitration of its execution. If not rescinded within 10 days of its execution, this Arbitration Agreement shall remain in effect for all claims arising out of the Resident's stay at the Facility. If the acts underlying the dispute are committed prior to the revocation date, this Arbitration Agreement shall be binding with respect to said acts. THE UNDERSIGNED ACKNOWLEDGE THAT EACH OF THEM HAS READ THIS ARBITRATION AGREEMENT AND UNDERSTANDS THAT BY SIGNING THIS ARBITRATION AGREEMENT EACH HAS WAIVED HIS/HER RIGHT TO A TRIAL, BEFORE A JUDGE OR JURY, AND THAT EACH OF THEM VOLUNTARILY CONSENTS TO ALL OF THE TERMS OF THE ARBITRATION AGREEMENT. 1. Resident 42 was admitted to the facility in 10/2023 with a diagnosis of schizophrenia (a mental health disorder). Resident 42's 11/1/23 Admission MDS indicated the resident was moderately cognitively impaired. On 1/16/23 at 1:58 PM Resident 42 stated she/he could not recall signing paperwork and did not know what the arbitration agreement was. As of 1/17/23 there was no signed arbitration agreement in Resident 42's chart. On 1/16/23 at 2:30 PM Staff 3 (Social Services Director/Administrator in Training) stated she was responsible for reviewing and explaining the facility binding arbitration agreement with the residents. Staff 3 stated the Arbitration Agreement was hard to explain to residents, so she simplified the information so residents could understand the arbitration process. When asked about the resident's right to withdraw the Arbitration Agreement within 30 days of signature, Staff 13 stated she was not familiar with that information and thought it was 10 days like the Admission Agreement stated. 2. Resident 55 was admitted to the facility in 5/2023 with a diagnosis of schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). Resident 55's 8/10/23 Quarterly MDS indicated the resident was moderately cognitively impaired. On 1/16/23 at 2:06 PM Resident 55 stated she/he could not remember anything about an arbitration agreement or signing one. As of 1/17/23 there was no signed arbitration agreement in Resident 55's chart. On 1/16/23 at 2:30 PM Staff 3 (Social Services Director/Administrator in Training) stated she was responsible for reviewing and explaining the facility binding arbitration agreement with the residents. Staff 3 stated the Arbitration Agreement was hard to explain to residents, so she simplified the information so residents could understand the arbitration process. When asked about the resident's right to withdraw the Arbitration Agreement within 30 days of signature, Staff 13 stated she was not familiar with that information and thought it was 10 days like the Admission Agreement stated. 3. Resident 58 was admitted to the facility in 8/2023 with a diagnosis of frontotemporal neurocognitive disorder (brain damage). Resident 58's 8/29/23 Admission MDS indicated the resident was cognitively intact. On 1/16/23 at 2:15 PM Resident 58 stated the facility asked her/him about a lot of stuff, but could not remember anything about an arbitration agreement. As of 1/17/23 there was no signed arbitration agreement in Resident 58's chart. On 1/16/23 at 2:30 PM Staff 3 (Social Services Director/Administrator in Training) stated she was responsible for reviewing and explaining the facility binding arbitration agreement with the residents. Staff 3 stated the Arbitration Agreement was hard to explain to residents, so she simplified the information so residents could understand the arbitration process. When asked about the resident's right to withdraw the Arbitration Agreement within 30 days of signature, Staff 13 stated she was not familiar with that information and thought it was 10 days like the Admission Agreement stated.

Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalization s for 2 of 4 sampled residents (#s 36 and 50) reviewed for hospitalization s. This placed residents at risk of lack of access to an advocate to inform them of their options and rights, and a decreased quality of life. Findings include: 1. Resident 36 was admitted to the facility in 5/2022 with a diagnosis of bipolar schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). A review of Resident 36's 10/11/23 Quarterly MDS Assessment revealed she/he was cognitively intact. A review of Resident 36's nursing progress notes revealed she/he was discharged to the hospital on 6/28/23 due to hypokalemia (low blood potassium level) and was readmitted to the facility on [DATE]. No evidence was found in Resident 36's health record to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. On 1/16/24 at 3:29 PM Staff 2 (DNS) confirmed the facility did not provide residents or their representatives with transfer documents, nor was the Office of the State Long-Term Care Ombudsman notified when they were discharged to the hospital. Staff 2 stated she expected these documents to be provided to residents or their representatives as well as the State Ombudsman's office upon discharge from the facility. 2. Resident 50 was admitted to the facility in 9/2022 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 50's 12/15/23 Quarterly MDS Assessment revealed she/he was cognitively intact. A review of Resident 50's medical records revealed she/he was discharged to the hospital on 11/30/23 due to a bilateral pulmonary embolism (a blood clot in the lungs blocking blood flow) and was readmitted to the facility on [DATE]. No evidence was found in Resident 50's health record to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. On 1/16/24 at 3:29 PM Staff 2 (DNS) confirmed the facility did not provide residents with transfer documents, nor was the Office of the State Long-Term Care Ombudsman notified when they were discharged to the hospital. Staff 2 stated she expected these documents to be provided to residents or their representatives as well as the State Ombudsman's office upon discharge from the facility.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed-hold policy at the time of transfer to the hospital for 2 of 4 sampled residents (#s 36 and 50) reviewed for hospitalization . This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: The facility's 11/28/17 Bed-Hold Readmission policy indicated Facilities are required by Federal regulation to have policies addressing holding a resident's bed during periods of absence such as hospitalization or therapeutic leave. Additionally, facilities provide this written information about these policies to residents prior to and upon transfer for such absences. 1. Resident 36 was admitted to the facility in 5/2022 with a diagnosis of bipolar schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). A review of Resident 36's 10/11/23 Quarterly MDS Assessment revealed she/he was cognitively intact. A review of Resident 36's nursing progress notes revealed she/he was discharged to the hospital on 6/28/23 due to hypokalemia (low blood potassium level) and was readmitted to the facility on [DATE]. On 1/9/24 at 2:22 PM Resident 36 stated she/he was admitted to the hospital in 2023 but was not told by facility staff they would hold her/his room until she/he returned to the facility. No evidence was found in Resident 36's health records to indicate the facility provided her/him with written notification of their bed hold policy. On 1/16/24 at 3:29 PM Staff 2 (DNS) stated the facility did not provide residents with written notification of the facility's bed hold policy at the time they discharged to the hospital. She confirmed she expected these documents to be provided to residents upon discharge from the facility. 2. Resident 50 was admitted to the facility in 9/2022 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 50's 12/15/23 Quarterly MDS Assessment revealed she/he was cognitively intact. On 1/9/24 at 12:55 PM Resident 50 reported she/he was sent to the hospital in 12/2023, but did not recall the details of her/his transfer or if the facility provided documentation of their bed hold policy. A review of Resident 50's medical records revealed she/he was discharged to the hospital on 11/30/23 due to a bilateral pulmonary embolism (a blood clot in the lungs blocking blood flow) and was readmitted to the facility on [DATE]. No evidence was found in Resident 50's health records to indicate the facility provided her/him with written notification of their bed hold policy. On 1/16/24 at 3:29 PM Staff 2 (DNS) stated the facility did not provide residents with written notification of the facility's bed hold policy at the time they discharged to the hospital. She confirmed she expected these documents to be provided to residents upon discharge from the facility.

Based on interview and record review it was determined the facility failed to ensure resident's records were complete and accurate for 1 of 1 sampled resident (#56) reviewed for change of condition. This placed residents at risk for incomplete clinical records. Findings include: Resident 56 was admitted to the facility in 7/2023 with a diagnosis of dementia. A Progress Note dated 12/19/23 indicated the resident was referred for hospice services but it was unclear if the referral was completed. A review of Resident 56's clinical record revealed no documentation of a hospice evaluation and determination. On 1/12/24 at 11:04 AM Staff 2 (DNS) verified the hospice services evaluation was not in Resident 56's clinical record.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 1 sampled resident (#59) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 59 was admitted to the facility in 6/2023 with a diagnosis of schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). The resident was discharged from the facility on 10/18/23 as a resident initiated discharge. A review of Resident 59's medical record indicated there was no discharge summary documentation. On 1/12/24 at 3:29 PM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 59. Staff 2 stated the facility did not discharge residents often and did not have a great discharge process in place.

Based on observation, interview and record review it was determined the facility failed to ensure staff performed appropriate and adequate hand hygiene during meal delivery for 1 of 2 halls observed during dining. This placed residents at risk for infection. Findings include: The Centers for Disease Control and Prevention (CDC) website section titled, Hand Hygiene in Healthcare Settings indicated healthcare personnel should use an alcohol based hand rub (ABHR) or wash with soap and water immediately after touching a patient and the patient's immediate environment. Healthcare facilities should require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. The facility's 2/11/22 Hand Hygiene Policy and Procedure indicated hand hygiene was the single most important procedure for preventing the spread of infection. Hand hygiene consists of either washing with soap and water or ABHR. Opportunities for hand hygiene included before entering a resident room, before preparing food and before handling food. On 11/29/22 from 11:30 AM to 11:38 AM Staff 9 (CNA), Staff 10 (CNA) and Staff 11 (CNA) delivered meal trays to rooms one through eight, for a total of 24 residents. During the meal tray delivery, Staff 9, Staff 10 and Staff 11 touched items within each of the residents' immediate environment and moved items on the residents' overbed tables to clear a space for the meal dishes, utensils and drinkware. Staff 9, Staff 10 and Staff 11 touched the residents' individual privacy curtains, television remotes and other personal items. Upon completion of each resident's meal delivery, Staff 9, Staff 10 and Staff 11 exited the room, opened the meal delivery cart and retrieved the next resident's meal tray. Throughout the meal delivery observation, Staff 9 and Staff 10 performed hand hygiene one time upon exit of a room and Staff 11 did not perform hand hygiene at all. On 11/29/22 at 11:38 AM Staff 9, Staff 10 and Staff 11 confirmed they touched and moved items in each of the resident's immediate environment during the meal delivery. Staff 11 stated she did not perform hand hygiene during the meal delivery and it should have been performed between each resident. Staff 9 and Staff 10 stated they performed hand hygiene once during the meal delivery and acknowledged hand hygiene opportunities were missed between each resident. On 12/7/22 at 9:59 AM Staff 2 (DNS) was informed of Staff 9's, Staff 10's and Staff 11's lack of hand hygiene during the meal delivery and before and after handling items within each of the resident's immediate environment. Staff 2 stated she expected staff to perform hand hygiene during the meal delivery and before and after resident contact.

Based on observations, interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 4 sampled residents (#s 11 and 41) reviewed for abuse. This placed residents at risk for physical abuse by other residents. Findings include: 1. The facility's Preventing Abuse Policy and Procedure revised on 7/13/18 revealed the facility had a process to prevent abuse which included monitoring residents with behaviors. Resident 41 was admitted to the facility in 11/2021 with diagnoses including Parkinson's disease and schizophrenia. Resident 41's 9/2022 Quarterly MDS assessment revealed she/he had a BIMS of 15 (cognitively intact). Resident 42 was admitted to the facility in 1/2021 with diagnoses including aphasia (a loss of ability to understand or express speech) after having a stroke. Resident 42's 7/2022 Annual MDS assessment revealed she/he had a BIMS of 15 (cognitively intact). The facility's 10/15/22 Resident to Resident Event Assessment revealed on 10/15/22 at 4:46 PM Resident 41 reported to staff she/he was hit by Resident 42 and her/his head hurt. Resident 42 indicated she/he hit Resident 41 because she/he did not want Resident 41 to sit by her/him. A 10/15/22 progress note written at 5:37 PM by Staff 5 (LPN) revealed staff informed her of an altercation in the dining hall between Residents 41 and 42. Resident 41 stated her/his head hurt and pointed to the left side of her/his head. Staff 5 noted a red abrasion/scratch approximately 0.5 x 0.2 x 0 cm. On 11/29/22 at 1:31 PM Resident 41 was observed sitting at a table in the dining hall and stated Yea I've been hit. Staff helped. I didn't need to go to the hospital but it hurt like heck. He hit me right on the head. On 11/30/22 at 9:40 AM Resident 42 was observed laying in bed and refused to be interviewed. On 11/30/22 at 4:09 PM Staff 2 (DNS) stated Resident 42 didn't use her/his words and hit Resident 41 instead. Staff 2 stated it was her expectation residents were free from abuse. On 12/1/22 at 2:35 PM Staff 3 (CNA) stated Resident 41 informed him Resident 42 hit her/him in the head. Staff 3 stated Resident 41 pointed to an area just to the side and above her/his ear. Staff 3 stated he asked Resident 42 if she/he hit Resident 41. Resident 42 said Yea. I don't want him to sit by me. On 12/1/22 at 4:40 PM Staff 5 (LPN) stated a CNA reported Residents' 41 and 42 had a fight. She stated she assessed Resident 41 and found she/he did not have an injury. Staff 5 stated Resident 42 admitted she/he hit Resident 41. 12/2/22 3:45 PM Staff 1 (Administrator) was informed of the findings and had no additional information to provide. 2. Resident 11 was admitted to the facility in 4/2022 with diagnoses including schizophrenia and bipolar disorder. Resident 11's 9/14/22 Significant Change MDS assessment revealed she/he was not assessed for BIMS due to being rarely or never understood. Resident 29 was admitted to the facility in 11/2021 with diagnoses including dementia with behavioral disturbance. Resident 29's 9/23/22 Quarterly MDS assessment revealed she/he had a BIMS of 06 (severe cognitive impairment). A 10/26/22 progress note revealed Resident 29 hit Resident 11 on the head with a closed fist and tried to pull Resident 11's hair. The facility's 10/28/22 Resident to Resident Event Assessment revealed Residents 11 and 29 were in the day area. Resident 29 attempted to get by Resident 11. Resident 11 refused to move. Resident 29 hit Resident 11 on the side of the head with a closed fist and attempted to pull Resident 11's hair. Resident 29 indicated Resident 11 was in her/his way and would not move. The assessment revealed Resident 29 had a history of altercations with Resident 11. Resident 29 was quick to react when frustrated and would verbally and physically strike out at others. On 11/30/22 and 12/1/22 Resident 11 was in her/his bed and refused to be interviewed. On 11/30/22 at 4:09 PM Staff 2 (DNS) stated Resident 29 had a history of aggression towards others and confirmed Resident 11 was hit by Resident 29 on 10/26/22. She stated she expected residents to be free from abuse. On 12/01/22 at 2:35 PM Staff 3 (CNA) stated he witnessed the incident between Resident 29 and Resident 11. Resident 29 and Resident 11's wheelchair wheels meshed together and Resident 29 hit Resident 11. Staff 3 stated he got between the two residents, stepped in and blocked the residents from hitting each other. On 12/01/22 at 4:30 PM Staff 4 (LPN) stated she witnessed Residents' 11 and 29's wheelchairs lock up and then Resident 29 hit Resident 11. She said CNA's ran over to help to separate the residents to prevent further fighting. On 12/2/22 at 4:00 PM Staff 1 (Administrator) was informed of the findings and had no further information to provide.

Based on interview and record review it was determined the facility failed to follow the care plan to prevent falls for 1 of 3 sampled residents (#4) reviewed for accidents. Resident 4 sustained a spinal fracture as a result of a fall. This placed residents at risk for injury. Findings include: Resident 4 admitted to the facility in 2016 with diagnoses including Alzheimer's disease. A 3/18/21 Physical Restraint/Device Record of Informed Consent revealed Resident 4 was to have a floor pressure mat alarm and seat belt alarm in place for fall preventions. A 4/10/21 Fall Assessment revealed the following: - Resident 4 was found on the ground outside on 4/10/21 at 4:00 PM - Resident 4 was to have frequent checks, wear a seatbelt with alarm while in the wheelchair, and have a floor sensor alarm in place - Resident 4 was last seen 30 minutes prior in bed when a staff member helped her/him lay down - Resident 4 was to have a floor mat with an alarm - The alarm on Resident 4's floor mat did not sound when the CNA was in the room 30 minutes before the fall - The alarm on Resident 4's floor mat was unplugged earlier in the day and it was reported but due to a language barrier the staff notified did not understand - Resident 4 got out of bed, the alarm did not sound, she/he walked out of the room, out of the side door to the building, down a ramp and fell at the bottom of the ramp where there were no hand rails - Resident 4 complained about new pain to the back of her/his head following the fall. A 4/10/21 Progress Note revealed Resident 4 fell outside on the west ramp, reported pain in her/his neck and was sent to the emergency room for evaluation. A 4/14/21 Transfer Order revealed Resident 4 returned from the hospital on 4/14/21 with a new diagnosis for a adenoid fracture (spinal fracture). In an interview on 8/5/21 at 11:43 AM Staff 18 (RN) stated he found Resident 4 outside when she/he had fallen on 4/10/21, Staff 14 did not recall if fall interventions were in place at the time of the fall. In an interview on 8/5/21 at 12:40 PM Staff 7 (RN/RCM) stated Resident 4 broke her/his neck during the fall on 4/10/21. Staff 7 stated Resident 4 was to have a floor mat plugged into an alarm, however this was unplugged prior to the fall and the staff did not know how to fix the alarm. Staff 7 stated Resident 4 was in bed at 3:30 PM on 4/10/21, was found on the ground at 4 PM, the floor alarm did not sound. Staff 7 stated Resident 4 was assessed and sent out to the hospital.

Based on observation, interview and record review it was determined the facility failed to ensure residents were secured during transfers and transportation and care plans were followed for 3 of 5 sampled residents (#s 1, 4, & 5) reviewed for incidents. Resident 5 fell , sustaining a concussion and a head laceration requiring staples. Resident #s 1 & 3 were at risk for injuries. Findings include: 1. Resident 5 was admitted to the facility in 2007 with [DIAGNOSES REDACTED]. The 1/1/17 ADL CAA and 2/22/17 ADL Care Plan noted the resident had hemiparesis on the left side and was dependent for two person, Hoyer lift transfers. The 9/2017 Physician order [REDACTED]. The 9/2017 MAR noted the resident did not receive the Acetaminophen or Oxycodone from 9/1/17 to 9/15/17. The 9/15/17 at 7:19 pm Progress Note disclosed Staff 22 (RN) was called to the resident's room and found the resident on the floor on her/his back with blood coming from the resident's head. Resident had slipped from hoyer lift and hit head on one of hoyer legs. At the time of the assessment the resident's left lower extremity was on the right Hoyer leg and her/his head was by the left Hoyer leg. The transfer was completed by Staff 20 (CNA) and Staff 25 (CNA). The resident was initially noted as alert and oriented only to self and after five minutes the resident was able to state the names of people in the room. The resident was sent to the hospital. The facility's correlating investigation disclosed the resident complained of head and coccyx pain. The resident reported she/he fell out of the Hoyer lift. Both CNA staff reported after dinner when Staff 20 (CNA) and Staff 25 (CNA) attempted the transfer Staff 25 initially hooked the resident up in the sling. Staff 20 observed the resident did not have her/his night clothes on and Staff 20 unhooked the Hoyer to change the resident's clothes. Staff 20 stated she hooked the resident back up in the Hoyer sling and crossed the legs of the sling like they were supposed to. When staff started to raise the Hoyer it sounded like the sling had snapped or ripped and the resident fell out of the sling, hitting the back of her/his head on the leg of the Hoyer. Staff 25 described the sound as a pop and the left leg strap was no longer attached to the Hoyer with the resident falling head first on the left side. The Hoyer lift and sling were evaluated by facility staff and a Hoyer representative was consulted. The Hoyer was found in working order and functioning properly and the sling was in good condition with no issues to the integrity of the fabric. The sling was noted to be a half sling which was usually used for showers or commode and not for daily care. Staff were unable to state if the sling was correctly placed on the arm of the hoyer lift and reported the arm for attaching the sling had difficulties at times locking the strap into place. .Upon investigation of the events of 9/15/17 and speaking with witnesses it has been determined that the sling used to assist the resident with transfers to/from the bed was improperly placed .All information provided stating Hoyer sling was secured, however, during the investigation it appears the sling was not secured. Staff were in-serviced on the correct and proper use of the Hoyer. The 9/15/17 Emergency Department Discharge Instructions noted the resident was diagnosed with [REDACTED]. and a head laceration requiring sutures or staples. The 9/15/17 at 11:28 pm Progress Note revealed the resident received three staples to the one inch wide wound to the back of the head and the resident was treated with Ibuprofen 400 mg prior to discharge. The 9/16/17 at 12:27 am Progress Note Late Entry disclosed the resident returned to the facility. The 9/2017 MAR noted on 9/16/17 at 12:43 pm the resident complained of a pain level of eight on a scale of one to 10 and received Oxycodone. The 9/16/17 at 2:09 pm and 9/17/17 at 12:45 am Progress Notes disclosed the resident complained of headache pain. The 9/2017 MAR noted on 9/17/17 at 3:16 am the resident complained of a pain level of seven on a scale of one to 10 and received Oxycodone. On 10/13/17 at 9:50 am Resident 5 was observed lying in bed. When asked about the 9/15/17 incident Resident 5 stated she/he fell from the Hoyer, hit the floor and split her/his head open. Per Resident 5 the staples were recently removed. In interviews on 10/10/17 at 10:24 am and 10/16/17 at 1:45 pm Staff 20 (CNA) stated on 9/15/17 she and Staff 25 (CNA) were transferring the resident to bed after dinner. It was easier to change the resident's clothes when the resident was in the Hoyer due to the resident's hemiparesis. After the resident's clothes were changed she hooked the sling onto the Hoyer. When the resident was lifted up in the Hoyer the sling came off the hook and the resident fell out of the sling. After the incident it was learned the type of sling used in the transfer was for showers and toileting and facility staff were not aware there were certain slings designated for that Hoyer. Staff 20 stated she was not used to that type of Hoyer as it only had two hooks versus four hooks, she was only trained on using a four hook Hoyer/sling when she was trained as a CNA approximately four years ago, and did not ask for assistance with hooking the sling to the Hoyer from Staff 25 or other staff on 9/15/17. Staff 20 stated she previously used the two hook Hoyer prior to the 9/15/17 fall without incident. When asked what was different about the two types of Hoyers/slings Staff 20 stated she felt there was more support for the resident with a four hook Hoyer/sling. In interview on 10/10/17 at 11:56 am Staff 25 (CNA) stated on 9/15/17 he assisted Staff 20 (CNA) with the resident's transfer. Staff 25 stated the sling used was a bit shorter for the resident and was the wrong size for the resident. During the transfer Staff 20 reported she hooked up the Hoyer sling, the resident was lifted up, the sling looked like it was broken but it did not break and the sling slipped off the Hoyer. The resident fell and hit her/his head on the Hoyer lift leg. After that incident the Hoyer sling was removed from service. Staff 25 stated in the past a former DNS trained CNAs on how to use the Hoyer lifts upon hire, however, he did not think the recently hired CNAs were trained. In interview on 10/11/17 at 10:56 am Staff 22 (RN) stated on 9/15/17 CNA staff reported the resident slipped out of the sling, landed on the floor and hit her/his head on the Hoyer leg. CNA staff reported the sling slipped off the Hoyer. In interview on 10/11/17 at 3:46 pm Witness 2 (Hoyer Lift Representative) stated he did not know which Hoyer or sling were used during the 9/15/17 transfer. Witness 2 stated it did not matter if a bath sling was used for the transfer, it mattered how the sling was placed and once the sling was crossed at the leg the resident could not get out of the sling. Witness 2 stated the only thing that caused the resident's fall was staff not correctly placing the resident's leg straps. In interview on 10/13/17 at 11:38 am Staff 39 (RN Consultant) stated on 9/15/17 the sling used during the transfer did not appear faulty and it was a half shower sling. After the incident the facility learned the half sling was appropriate to use for the transfer. Maintenance evaluated the Hoyer and no issues were found. Staff 39 stated Staff 20 (CNA) should have asked for assistance from the more experienced CNA if she was unfamiliar with the Hoyer. The 9/15/17 incident was discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS) on 10/13/17 at 11:56 am. Staff 1 stated Staff 20 (CNA) worked in the facility in 2016 and was re-hired in 2/2017. Staff 2 stated she started working for the facility on the day the incident occurred. Staff 2 stated Staff 20 should have asked for help if she had any questions with the equipment. Staff 2 stated she investigated the two hook verses four hook Hoyer concern and learned the facility had not used a four hook Hoyer in a long time and there were no previous incidents prior to 9/15/17. The Hoyer had a bar with two little clips and Staff 20 reported a problem with one of the clips springing back. Maintenance evaluated the Hoyer and sling and found no malfunction. Staff 2 stated there was no spring to the clip and there was no way the clip would have moved unless it broke which did not occur. Due to the resident sliding through the sling with her/his legs forward and hitting her/his head on the Hoyer leg the only determination she could make was the improper placement of the sling by the staff member. Refer to F281 2. Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 9/8/16 In Room ADL Care Plan noted the resident required 1 person with gait belt otherwise 2 people for transfers. The resident had an unsteady gait with a left lower extremity amputation. The 9/18/16 Fall Care Plan included placing the resident's bed in the low position at night and a fall mat at the bedside. The 10/11/16 at 4:16 pm Progress Note disclosed Resident 1 fell over in her/his wheelchair while in the facility vehicle when the vehicle made a left turn. The resident's wheelchair did not fall to the ground, however, the resident bumped her/his elbow on the wheelchair lift. The correlating facility investigation noted the front left latch on the wheelchair was not properly latched and upon making a left turn two residents, including Resident 1, were tilted to their right alongside one another. The resident stated she/he hit her/his elbow pretty good. The 10/14/16 at 3:36 am Progress Note disclosed Resident 1 was found sitting on her/his buttocks in front of the bed. The resident stated she/he was reaching for the urinal and slid out of bed. No injury was noted. The correlating facility investigation noted NA for the use of a fall mat and the low bed was not in use. The 1/4/17 at 4:53 pm Progress Note disclosed Resident 1 was found on the floor. The resident was in a sitting position with her/his hands on the bedside pole. The correlating facility investigation noted NA for a fall mat/non-skid mat. The 1/23/17 care plan update noted the resident used a non-slip mat beside the transfer pole. On 9/7/17 at 10:15 am Resident 1 was observed sitting in a wheelchair and was assisted to her/his room. A transfer pole was placed next to the resident's bed, however, the non-slip mat was not in the room. The resident had a lower left leg amputation and when asked about her/his falls stated she/he could not recall details other than having falls before a transfer pole was placed next to the bed. At the conclusion of the interview the resident was assisted by staff from her/his room. At 2:15 pm Resident 1 was observed asleep in bed with no non-skid mat in place. Staff 16 (CNA) stated the resident was to have a mat in her/his room but it was possibly in the laundry. The lack of a fall mat in the resident's room was discussed with Staff 1 (Administrator) on 9/7/17 at 2:39 pm. During the interview Staff 40 (Environmental Services Supervisor) stated staff probably removed the mat during the night while the resident was in bed asleep and there were back up mats available. Staff 40 stated the resident's non-slip mat was washed/dried and placed back in the resident's room. Staff 1 acknowledged another mat should have been placed while the current one was being washed. In interview on 10/9/17 at 11:50 am Staff 38 (Activity Assistant) stated on 10/11/16 he got in too big of a hurry and did not properly latch the wheelchairs in the vehicle. In interview on 10/10/17 at 1:15 pm Staff 35 (Former RN) stated she did not recall the resident having a fall mat in place when the resident fell on [DATE]. In interview on 10/11/17 at 4:11 pm Staff 31 (Former RNCM) stated regarding the 10/14/16 fall investigation Resident 1's fall mat was always in place. The resident was care planned for a low bed but typically raised up the bed. When asked if the resident raised up the bed on 10/14/16 Staff 31 stated she did not know. On 10/13/17 at 10:14 am Resident 1 was observed in bed asleep with no non-skid mat in place. Staff 41 (CNA) stated the mat was not in place and verified the resident was care planned for a mat. At 10:18 am Staff 2 (Interim DNS) stated the mat should have been in place. At 10:20 am Staff 42 (Laundry) stated she had not seen the resident's non-skid mat and it was not in laundry. The lack of ensuring resident safety during transportation and not following the care plan on 10/14/16, 1/4/17, and during the survey was discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS) on 10/13/17 at 11:56 am. Staff 2 stated she spoke with Staff 42 (Laundry) who reported there was a mat in laundry which she three away as it was pretty worn. Staff 1 stated in a previous interview Staff 40 (Environmental Services Supervisor) reported there were additional mats available for the resident. 3. Resident 4 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. The 5/10/16 ADL CAA noted Resident 4 had a history of [REDACTED]. The 10/11/16 at 3:51 pm Progress Note disclosed the resident fell over in her/his wheelchair while on an outing in the facility vehicle during a left turn. The resident's wheelchair fell over onto Resident 1's chair and did not fall to the ground. The facility's correlating investigation noted the left front latch was not properly latched and during a left turn the resident's wheelchair tipped to the right. In interview on 10/9/17 at 11:50 am Staff 38 (Activity Assistant) stated on 10/11/16 he got in too big of a hurry and did not properly latch the wheelchairs in the vehicle. The lack of ensuring resident safety during transportation was discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS) on 10/13/17 at 11:56 am. No additional information was provided.

Based on observation, interview and record review it was determined that Staff #20 (CNA) failed to ensure professional standards were followed during a transfer for 1 of 5 sampled residents (#5) with incidents. Resident 5 fell , sustaining a concussion and a [MEDICAL CONDITION] requiring staples. Findings include: Oregon State Board of Nursing Division 63 Standards and Authorized Duties For The Certified Nursing Assistant and Certified Medication Aide 851-063-0090 Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to . (3) Conduct related to client safety and integrity: (a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities . Resident 5 was admitted to the facility in 2007 with [DIAGNOSES REDACTED]. The 1/1/17 ADL CAA and 2/22/17 ADL Care Plan noted the resident had [MEDICAL CONDITION] on the left side and was dependent for two person, Hoyer lift transfers. The 9/15/17 at 7:19 pm Progress Note disclosed Staff 22 (RN) was called to the resident's room and found the resident on the floor on her/his back with blood coming from the resident's head. Resident had slipped from hoyer lift and hit head on one of hoyer legs. At the time of the assessment the resident's left lower extremity was on the right Hoyer leg and her/his head was by the left Hoyer leg. The transfer was completed by Staff 20 (CNA) and Staff 25 (CNA). The resident was sent to the hospital. The facility's correlating investigation disclosed both CNA staff reported when Staff 20 (CNA) and Staff 25 (CNA) attempted the transfer Staff 25 initially hooked the resident up in the sling. Staff 20 observed the resident did not have her/his night clothes on and Staff 20 unhooked the Hoyer to change the resident's clothes. Staff 20 stated she hooked the resident back up in the Hoyer sling and crossed the legs of the sling like they were supposed to. When staff started to raise the Hoyer it sounded like the sling had snapped or ripped and the resident fell out of the sling, hitting the back of her/his head on the leg of the Hoyer. Staff 25 described the sound as a pop and the left leg strap was no longer attached to the Hoyer with the resident falling head first on the left side. The Hoyer was found in working order and functioning properly and the sling was in good condition with no issues to the integrity of the fabric. The sling was noted to be a half sling which was usually used for showers or commode and not for daily care. Staff were unable to state if the sling was correctly placed on the arm of the hoyer lift and reported the arm for attaching the sling had difficulties at times locking the strap into place. .Upon investigation of the events of 9/15/17 and speaking with witnesses it has been determined that the sling used to assist the resident with transfers to/from the bed was improperly placed .All information provided stating Hoyer sling was secured, however, during the investigation it appears the sling was not secured. Staff were in-serviced on the correct and proper use of the Hoyer. The 9/15/17 Emergency Department Discharge Instructions noted the resident was diagnosed with [REDACTED]. and a [MEDICAL CONDITION] requiring sutures or staples. The 9/15/17 at 11:28 pm Progress Note revealed the resident received three staples to the one inch wide wound to the back of the head. The 9/16/17 at 12:27 am Progress Note Late Entry disclosed the resident returned to the facility. On 10/13/17 at 9:50 am Resident 5 was observed lying in bed. When asked about the 9/15/17 incident Resident 5 stated she/he fell from the Hoyer, hit the floor and split her/his head open. Per Resident 5 the staples were recently removed. In interviews on 10/10/17 at 10:24 am and 10/16/17 at 1:45 pm Staff 20 (CNA) stated on 9/15/17 she and Staff 25 (CNA) were transferring the resident to bed after dinner. It was easier to change the resident's clothes when the resident was in the Hoyer due to the resident's [MEDICAL CONDITION]. After the resident's clothes were changed she hooked the sling onto the Hoyer. When the resident was lifted up in the Hoyer the sling came off the hook and the resident fell out of the sling. After the incident it was learned the type of sling used in the transfer was for showers and toileting and facility staff were not aware there were certain slings designated for that Hoyer. Staff 20 stated she was not used to that type of Hoyer as it only had two hooks versus four hooks, she was only trained on using a four hook Hoyer/sling when she was trained as a CNA approximately four years ago, and did not ask for assistance with hooking the sling to the Hoyer from Staff 25 or other staff on 9/15/17. Staff 20 stated she previously used the two hook Hoyer prior to the 9/15/17 fall without incident. When asked what was different about the two types of Hoyers/slings Staff 20 stated she felt there was more support for the resident with a four hook Hoyer/sling. In interview on 10/10/17 at 11:56 am Staff 25 (CNA) stated on 9/15/17 he assisted Staff 20 (CNA) with the resident's transfer. Staff 25 stated during the transfer Staff 20 reported she hooked up the Hoyer sling, the resident was lifted up, the sling looked like it was broken but it did not break and the sling slipped off the Hoyer. The resident fell and hit her/his head on the Hoyer lift leg. In interview on 10/11/17 at 10:56 am Staff 22 (RN) stated on 9/15/17 CNAs reported the sling slipped off the Hoyer and the resident slipped out of the sling. In interview on 10/11/17 at 3:46 pm Witness 2 (Hoyer Lift Representative) stated it did not matter if a bath sling was used for the transfer, it mattered how the sling was placed and once the sling was crossed at the leg the resident could not get out of the sling. Witness 2 stated the only thing that caused the resident's fall was staff not correctly placing the resident's leg straps. In interview on 10/13/17 at 11:38 am Staff 39 (RN Consultant) stated on 9/15/17 the sling used during the transfer did not appear faulty and it was a half shower sling. After the incident the facility learned the half sling was appropriate to use for the transfer. Maintenance evaluated the Hoyer and no issues were found. Staff 39 stated Staff 20 (CNA) should have asked for assistance from the more experienced CNA if she was unfamiliar with the Hoyer. The 9/15/17 incident was discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS) on 10/13/17 at 11:56 am. Staff 1 stated Staff 20 (CNA) worked in the facility in 2016 and was re-hired in 2/2017. Staff 2 stated Staff 20 should have asked for help if she had any questions with the equipment. Staff 2 stated she investigated the two hook verses four hook Hoyer concern and learned the facility had not used a four hook Hoyer in a long time and there were no previous incidents prior to 9/15/17. The Hoyer had a bar with two little clips and Staff 20 reported a problem with one of the clips springing back. Maintenance evaluated the Hoyer and sling and found no malfunction. Staff 2 stated there was no spring to the clip and there was no way the clip would have moved unless it broke which did not occur. Due to the resident sliding through the sling with her/his legs forward and hitting her/his head on the Hoyer leg the only determination she could make was the improper placement of the sling by the staff member. Refer to F323, Example 1

Based on interview and record review it was determined the facility failed to promptly follow up with the PCP regarding lab results for 1 of 3 sampled residents (#1) who were reviewed for change in condition and overall care and services. This resulted in Resident 1 being sent to the hospital and placed in ICU (intensive care unit) on a ventilator (a machine which forces air in and out of the lungs) [MEDICAL CONDITION] (a life threatening complication of infection). Findings include: Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. A review of Resident 1's Interdisciplinary Progress Notes, laboratory diagnostic request form and laboratory test results revealed the following: - On 5/9/16 Resident 1's urine was darker than usual and had increased odor. A urine sample would be obtained for a urinalysis (diagnostic test for UTI). - On 5/10/16 a urine sample was obtained and a dip (test strip urine test) indicated positive results for infection. The laboratory was called for stat (immediate) pick up. The physician was notified and the resident was placed on alert. Fluids would be increased. - On 5/10/16 a urinalysis with culture and sensitivity if indicated was ordered by the facility. - On 5/10/16 preliminary and final laboratory urinalysis results were faxed to the PCP. The urinalysis was abnormal for protein, [MEDICATION NAME] (byproduct of fat metabolism), blood, bilirubin (yellow pigment in bile), leukocyte esterase (enzyme produced by white blood cells), white blood cells, red blood cells, [MEDICATION NAME] cells (cells which line blood vessels and organs), bacteria and triple [MEDICATION NAME] crystal (associated with UTI typically with Proteus species). - On 5/11/16 through 5/14/16 the resident's urine continued to be dark and odorous and the resident's fluid intake was low. The urinalysis culture and sensitivity (laboratory diagnostics to determine the infectious bacteria involved and which antibiotics it was susceptible to) results were still pending. - On 5/14/16 the facility called the laboratory for the culture and sensitivity results. The laboratory indicated no culture was ordered or performed. A new order was obtained to obtain another urine sample for culture and sensitivity. - On 5/14/16 Resident 1's blood pressure was 84/70 (a systolic blood pressure, the top number, less than 90 is considered low). - On 5/14/16 through 5/15/16 the resident had poor fluid intake and staff were unable to obtain another urine sample. - On 5/16/16 Resident 1 had dyspnea (difficulty breathing), a decreased level of consciousness, a temperature of 100.1 (normal is 98.6), and heart rate of 121 (normal is 60 to 100). While attempting to obtain a urine sample a scant amount of greenish discharge came out of the resident's urethra. The resident was sent to the hospital. Signs and symptoms [MEDICAL CONDITION] can include: high temperature, rapid heart beat, difficulty breathing, low blood pressure, altered level of consciousness and insufficient urine production. A review of Resident 1's clinical record revealed no indication the PCP replied to the 5/10/16 lab results or provided the facility with any new orders while the culture and sensitivity was pending. There was no indication the facility followed up with the PCP to ensure she received the urinalysis results or requested new treatment orders while the culture and sensitivity was pending. There was no indication the facility ensured the PCP was aware of Resident 1's poor fluid intake, poor urine production from 5/14/16 through 5/16/16 or low blood pressure on 5/14/16. On 5/16/16 a faxed complaint was received in which Witness 2 (Complainant) indicated Resident 1 was in the ICU (intensive care unit) on a ventilator (a machine which forces air in and out of the lungs) [MEDICAL CONDITION] (a life threatening complication of infection). On 5/16/16 at 12:15 pm Witness 1 (ICU RN) confirmed Resident 1 was in the ICU on a ventilator and [MEDICAL CONDITION]. On 5/17/16 at 2:03 pm Staff 2 (DNS) stated she would have expected staff to call the PCP as well as fax the lab results and follow up right away for a response. Staff 2 stated she did not know why the PCP did not respond to the faxed urinalysis.

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision and update care plan interventions related to elopement for 1 of 1 sampled residents (#1) reviewed for elopement. Resident 1 sustained a fall and a dislocated shoulder during an elopement. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5/31/13 Nursing Note disclosed Resident 1 asked for help getting out of the facility, stating he/she did not live there and wanted to go home. The resident was re-directed from the outdoor courtyard fence. A 6/15/13 12:45 am Nurse's Note revealed Resident 1 was placed on alert for eloping from the facility. The resident stated he/she climbed over the fence. The correlating facility investigation indicated on 6/14/13 at 11:40 pm, the resident was found at the main gate asking to be let in. The resident had been checked every 15 minutes for being a new admit and was last seen at 11:30 pm. Staff noted a walker was found right next to the gate. The resident stated "I climbed over the fence to buy a pack of cigarettes." To prevent re-occurrence CNAs were instructed to monitor the resident one to one if he/she was observed to be exit seeking. A 6/15/13 4:05 pm Nurse's Note revealed Resident 1 was agitated, not re-directable and was trying to jump the fence. A 6/16/13 Nurse's Note disclosed Resident 1 "has been obsessed with leaving to buy own packs of cigarettes." The 6/17/13 elopement care plan interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food; identify pattern of wandering, intervene as appropriate; monitor location every 15 minutes; provide resident with PRN medications if exit seeking behavior are present and redirection with activities/snacks is ineffective. A 6/18/13 12:20 am Nurse's Note indicated Resident 1 attempted to jump the fence by using a walker to stand on and made "continuous verbal remarks" related to getting out and getting a cigarette. A 6/18/13 6:17 am Nurse's Note disclosed Resident 1 woke up at 3:00 am and began obsessing about jumping the fence. A 6/18/13 9:31 pm Nurse's Note indicated Resident 1 "was pacing anxiously and making comments about trying to find a way out of here." 6/19/13 6:02 am and 3:00 pm Nurse's Notes revealed Resident 1 had been vocalizing elopement ideations. A 6/19/13 6:22 pm Nurse's Note disclosed Resident 1 was seen by a staff member at 4:05 pm crossing the street out in front of the facility. The physician was contacted, who ordered medication changes. The correlating facility investigation noted the resident had a strong compulsion to drink beer and was obsessed with smoking cigarettes. The resident had eloped and was headed to the store across the street when the staff member saw him/her. To prevent re-occurrence, staff provided one to one monitoring "as needed." According to Nurse's Notes and correlating facility investigations, the resident eloped from the facility on 6/22/13, 7/18/13, 7/19/13 and 7/21/13. It noted the resident was on 15 minute checks at the time of those elopements. The 7/18/13 facility investigation noted the resident was able to "make it to the fence & over in only a couple (minutes)." The 7/19/13 facility investigation noted to prevent re-occurrence one to one monitoring was to be done when the resident was outside wandering. At the time of the survey, there was no documented evidence the care plan was updated after the 6/22/13 to 7/19/13 incidents. The 7/21/13 3:15 pm and 3:45 pm Nurse's Notes disclosed Resident 1 was noticed missing and spotted through the windows shortly after. When staff went to get the resident from the store, the resident's hand was bleeding. The resident reported he/she had fallen in the street and was found to have a large bump on his/her upper right arm. The resident reported the injury was from his/her fall and he/she "popped the muscle back into place." An x-ray was obtained, which came back with evidence of a fracture or dislocation and the resident was sent to the hospital. The 7/21/13 Emergency Department Discharge Instructions revealed Resident 1 had a dislocated shoulder. The care plan was not updated until 7/24/13. Staff were directed to provide one to one monitoring if the resident was outside wandering the fence line or was looking like he/she was thinking about eloping. According to Nurse's Notes and correlating facility investigations, Resident 1 continued to have elopements on 8/5/13, 8/6/13 and 8/10/13. It noted the resident was on 15 minute checks at the time of those incidents and did not address the lack of one to one monitoring when the resident was outside attempting to elope. For example, according to the 8/6/13 4:45 am and 2:10 pm Nurse's Notes, once awake, Resident 1 began exit seeking, trying to buy cigarettes and attempted to climb the gate twice. The resident was described as continuing to pace the hallways and outside grounds, trying to get to the store or back home. Between the 7:15 am and 7:30 am checks, the resident eloped and was found at the gas station across the street from the facility. The care plan was updated for staff to offer an additional cigarette and one to one supervised smoking if the resident was exit seeking and stating he/she wanted a cigarette. On 8/14/13 at 9:30 am, Resident 1 was observed independently wandering around the television room on the main floor, then walked downstairs. Once downstairs the resident was escorted by staff into the dining room. In interview on 8/14/13 at 2:25 pm, Staff 2, DNS, stated Resident 1 eloped by climbing over the facility's six foot fence. Staff 2 stated he had not realized there had been so many elopements until information was requested during the survey. In interview on 8/14/13 at 2:41 pm, Staff 4, CNA, stated prior to the 7/18/13 elopement, the resident kept going out to the smoke patio and back inside, wanting a cigarette. Staff 4 stated she would open the door and make sure the resident was still there and was not trying to go anywhere. Staff 4 stated Resident 1 was on 15 minute checks and was to be placed on one to one monitoring when the resident went to the back gate about five times. Per Staff 4, since they were so limited with CNAs, it was difficult to put the resident on one to one monitoring. In interview on 8/14/13 at 2:50 pm, Staff 5, CNA, stated if Resident 1 was going outside on the property, the resident was not monitored one to one, but if staff observed the resident go outside, they were to watch and see if the resident went to the gate. Staff were to check the resident "whenever they can, every five minutes or sooner to make sure (Resident 1) is still here." In interview on 8/14/13 at 3:51 pm, Staff 23, CNA, stated Resident 1 was placed on one to one monitoring when the resident started talking about going out, when he/she was by the fence a lot and was more "antsy" than usual. Staff 23 stated if the resident was outside on the smoke patio, staff were to continue with the 15 minute checks and check on the resident every few minutes to see what he/she was doing. If the resident was talking about leaving and wanted to get out, staff would monitor the resident one to one if there was staffing for it, if not, they would monitor the resident more often than every 15 minutes. In interview on 8/15/13 at 7:30 am, Staff 21, RN, stated regarding the 7/21/13 incident, the resident sustained [REDACTED]. Regarding the 8/6/13 elopement, Staff 21 stated the resident "knows our schedule..knows when we are busy." Staff 21 stated if Resident 1 was looking at the fence "a couple of times" he/she was placed on one to one monitoring. Staff 21 stated "it is hard to tell the difference between when (Resident 1) is just walking along the fence vs walking with intention." In interview on 8/15/13 at 5:43 am, Staff 18, LPN, stated regarding the 8/10/13 elopement, Resident 1 was up most of the night talking about wanting a cigarette, which was the resident's baseline. The resident was on 15 minute checks and CNA staff had last seen the resident at 5:45 am. A housekeeper saw the resident outside at approximately 5:50 am. At that time, CNAs were doing their last rounds and he was checking resident's blood sugars, which was a busy time of shift. Staff 18 stated if the resident was observed trying to jump the gate, he/she would be placed on one to one monitoring, but only to the best of their ability because CNAs were taking care of other residents too, "we try to do our work and keep an eye on (Resident 1) at the same time."

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision, and/or develop and/or implement care plan interventions to de-escalate and prevent resident to resident altercations for 6 of 6 (#s 1, 2, 3, 4, 5 & 6) sampled residents reviewed for altercations. Resident 1 sustained facial lacerations, required a hospital visit and stitches. Resident 2 sustained a head injury, required hospitalization and subsequently died . Findings include: 1. Resident 1, a [AGE] year old resident was admitted in ,[DATE] with [DIAGNOSES REDACTED]. Resident 1's care plan dated [DATE] indicated Resident 1 had resident to resident altercations and required a low stimulus environment. The "Activities" care plan, dated [DATE] indicated the resident became easily agitated in group settings which quickly escalated to physical aggression. The "Goal" included to join group events with 1:1 supervision. The resident was to be escorted to and from her/his room to lunch in the dining room, Monday through Friday, by two (identified) staff members from the activities department. "They will remain with (her/him) 1:1 while (the resident) eats. If neither is available to be with (Resident 1), (she/he) is to remain in (her/his) room." An Incident/Witness Report dated [DATE] indicated Resident 1 had a "long violent altercation history." The "In Room ADL Care Plan" dated [DATE] included the directive to "NEVER leave (Resident 1) without 1:1 supervision at a group activity and coordinate supervision EVERY time with the activity person in charge." On [DATE] (Thursday) Interdisciplinary Progress Notes indicated Resident 1 was in a resident to resident altercation in the hallway. The resident sustained [REDACTED]. The sheriff investigated and determined the altercation was "mutual" and no charges were filed. Hospital Emergency Department Notes dated [DATE] indicated Resident 1 sustained lacerations above and below the left eye and two lacerations around the left eye. Stitches and tape strips were applied to lacerations. The resident was alert and oriented and CT scan showed no acute changes. The resident was sent back to the facility with [DIAGNOSES REDACTED]. On [DATE] (Saturday) Interdisciplinary Progress Notes, Target Behavioral Monitoring reports and an Incident Report indicated Resident 1 was at a social activity at 2:30 pm and witnessed a fight between two residents, Resident 2 and Resident 5. Resident 1 got up and "slammed" Resident 2 to the floor, causing the Resident 2 to hit her/his head "hard, opening it." Interdisciplinary Progress Notes dated [DATE] indicated police advised Resident 1 be placed in a locked room at the facility. When police were informed the facility had no locked room, the police advised the resident be sent to the hospital. Resident 1 was sent to the hospital to "de-escalate until determined otherwise." The hospital returned Resident 1 to the facility at 9:05 pm that night. Police indicated they were unable to take the resident to jail due to the resident's past "medical history," and the jail was "unwilling to accept" the resident. The resident was placed on 1:1 supervision provided by CNA staff. Emergency Department Notes dated [DATE] indicated Resident 1 hit a resident on [DATE], and on [DATE] assaulted a resident that was giving a caregiver a "difficult time." The resident "volunteered to come to the ED (Emergency Department) to get a psych evaluation" related to (her/his) "anger issue." The resident answered questions appropriately and was negative for hallucinations and paranoia, and her/his thought content was normal. Findings included "aggressive behavior due to situational stressors," and [DIAGNOSES REDACTED]." Resident 2's Hospital Emergency Department records dated [DATE], and a Discharge Summary dated [DATE] indicated Resident 2 was "in a conflict with another resident of (her/his) nursing home when (she/he) was picked up and thrown to the ground." Resident 2 suffered a large subdural hematoma and passed away on [DATE]. Interdisciplinary Progress Notes dated [DATE] indicated police were concerned with confining Resident 1 to prevent any further altercations. A police officer stated Resident 1 had a previous warrant for missing court related to a "similar incident" and an arrest might be made depending on Resident 1's mental status. There was no evidence of an arrest and the resident remained in the facility. On [DATE] at 12:45 pm Staff 16, Social Services Director (SSD) stated he did not know Resident 1's history, including any arrest for assault or a similar incident. Staff 16 stated Resident 1 had very impulsive behavior, but he had not reassessed the behavior. Staff 16 stated he had no background/training in social services, and believed when two residents were fighting, staff should try to redirect and/or step between the two residents, and "try not to get hit." On [DATE] at 2:45 pm Staff 14, CNA stated he was assigned to Resident 1 at the time of the incident on [DATE]. Staff 14 stated he considered the ice cream social to be low stimulus. Although kitchen staff and Staff 7, RA/CNA were in the dining room serving ice cream, Staff 14 left Resident 1 without arranging for 1:1 supervision during the activity. Staff 14, CNA continued with stating activity staff had not been scheduled to work on weekends, leaving CNA/nursing staff (with kitchen staff) to conduct activities. There were no additional CNAs scheduled to provide care for residents who were not in the activity, or to provide for 1:1 supervision. Direct Care Staff Daily Reports dated [DATE] (Thursday) through [DATE] (Saturday) indicated the facility met the minimum shift ratio/staffing for CNA/NAs. There was no evidence of additional CNAs on Saturday. On [DATE] at 3:05 pm Staff 7, RA/CNA stated she was helping two kitchen staff to serve ice cream in the dining room on [DATE]. Staff 7 remembered seeing Resident 1 sitting at a corner table alone and she wondered who was assigned to the resident. Residents 2 and 5 started a fist fight, and kitchen staff and Staff 7 got between them. Resident 2 attacked Staff 7, hitting, punching, attempting to pull her clothes off and yelling at her. Resident 1 got up and grabbed Resident 2 by the arm and threw Resident 2 to the floor. Throughout the survey, Resident 1 was observed to stay in her/his room with the door closed. When the door was opened briefly and the resident was approached by the surveyor, the resident did not respond to questions. Throughout the survey, multiple staff related they had stood between residents who were punching each other, in attempts to stop the fighting. Some staff stated they had been attacked by residents, and did not know how to break up fights. Interviews included: *On [DATE] at 12:30 pm, Staff 6, CNA stated a resident (#1) attacked him and wrestled him to the floor. Staff 6 managed to get up and run from the room, and stated he feared he would have been beaten if he had not been able to get away. *On [DATE] at 3:05 pm Staff 7, RA/CNA stated she got between two fighting residents (#'s 2 & 5) on [DATE] and got beaten, punched, and her clothes pulled (partially) off. A resident (#1) intervened by throwing the attacking resident (#2) to the floor. *On [DATE] at 12:30 pm Staff 14, CNA stated he had prior experience working in a mental health setting. In that setting he was taught how to intervene in fights between residents, by restraining the residents. In the nursing home setting, Staff 14 was unsure what the protocol was for separating fighting residents, as restraints were not appropriate. On [DATE] at 2:00 pm, a discussion with Staff 2, Assistant Administrator, Staff 3, RNCM; Staff 4, DNS; and Staff 5, RNCM included the lack of supervision and implementation of 1:1 supervision while the resident was in a social activity. They confirmed activities staff had been discontinued on weekends for about 2 months prior to the incident. There was no further information provided the facility had considered the risk of removing activity staff on weekends, without providing additional CNA staff for resident oversite and /or 1:1 supervision. 2. Resident 2, a [AGE] year old resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Interdisciplinary Progress Notes included 12 incidents of verbal and/or physical aggression toward residents or staff between [DATE] and [DATE]. Resident 2's Care Plan dated [DATE] indicated the resident sometimes became verbally abusive and physically aggressive towards others in activities. The Approach included to remove to a safer, less stimulating environment. "If a pattern of behavior develops during group activities, 1:1 activities with activity staff may be utilized." The In Room ADL Care Plan dated [DATE] indicated the resident was often confrontational toward staff and other residents at activities and was to be on every 15 minute safety checks. Interdisciplinary Progress Notes included a physician's note dated [DATE], indicating the resident had "highly labile agitation" and was verbally abusive to staff. A "late entry" physician note dated [DATE] indicated the resident was getting more irritable over the course of the past several days. Target Behavior Monitoring reports and Interdisciplinary Progress Notes included: *On [DATE] at 3:35 pm (a late entry written on [DATE]): Resident 2 came into the dining room where Staff 15, Activities Director (AD) was cleaning up. The resident told Staff 15 to "stop and get out." The resident grabbed her wrist and she backed away to the wall. The resident called her a "worthless b----" and used foul language. It was two to three minutes before other staff heard the commotion and came to help. Staff 15 did not leave before staff came, because the resident might have "turned aggression" on another resident. *On [DATE] at 9:40 am: Resident 2 was yelling at staff about not wanting a roommate. The resident became agitated and tried to start a fight with another resident (#4). *On [DATE] at 9:45 am a message was left with the resident's physician regarding the difficulty re-directing the resident. *On [DATE] at 9:50 am: Resident 2 was still agitated. As the resident started walking back to her/his room, the resident started yelling at Staff 16, Social Services Director (SSD) who was talking to Resident 4 in Resident 4's room. At first Resident 2 was angry at Staff 16, and then started yelling at Resident 4 and tried to start a fight. Staff separated the residents, but Resident 2 would not stop yelling or trying to pick a fight with Resident 4. *On [DATE] at 10:15 am: The physician called back about the resident's increased agitation. Staff 3, RNCM told the physician the resident had calmed down and was re-directable at that time. *On [DATE] at 10:30 am: Resident 2 tried to enter another resident's (#4's) room again. Staff 17, Medical Records stepped between the resident and the doorway and shut the door behind her. Resident 2 "came charging at me and tried to push me out of the way. I didn't move then (she/he) grabbed my hand and bent my finger as far back as (she/he) could." Staff 17 told the resident to stop and that (she/he) "was not being nice." The resident continued to yell, but finally walked away. *On [DATE] at 2:45 pm the resident was very agitated, had many concerns and did not want a new roommate. The resident became very aggressive and threatened another resident, yelling and standing outside of the resident's room. Staff was able to calm the resident "after some time." *On [DATE] at 2:45 pm: Resident 2 was leaving a social activity and went up to Resident 4 and hit her/him in the back of the head. As Staff 7, RA/CNA was escorting Resident 2 out of the dining room, an argument broke out with Resident 5, which escalated into a fist fight. Resident 2 was punching staff and Resident 5. Resident 1 then got up and "slammed" Resident 2 to the ground, causing the resident to hit her/his head. Resident 2 was sent to the hospital. A hospital CT head scan report dated [DATE] indicated Resident 2 had a large subdural hematoma. The hospital Discharge Summary dated [DATE], indicated that "Due to the extent of the brain damage, family decided on comfort care only," and the resident passed away on [DATE]. On [DATE] at 2:45 pm Staff 14, CNA stated activity staff had not been scheduled to work on weekends, leaving CNA/nursing staff (with kitchen staff) to conduct activities. There were no additional CNAs scheduled to provide care for residents who were not in the activity, or to provide 1:1 supervision. Direct Care Staff Daily Reports dated [DATE] (Thursday) through [DATE] (Saturday) indicated the facility met the minimum shift ratio/staffing for CNA/NAs. There was no evidence of additional CNAs on Saturday. On [DATE] at 3:05 pm Staff 7, RA/CNA stated she was helping kitchen staff to serve ice cream in the dining room on [DATE]. Resident 2 had ice cream and was leaving the room, when the resident went over to Resident 4 and "socked" (her/him) in the back of the head. Staff 7 got between/separated those two residents. Resident 5 was standing by the ice cream cart and Resident 2 at first walked past Resident 5, but then turned around and "lunged" at Resident 5. A kitchen staff and Staff 7 got between Resident 2 and Resident 5. Resident 2 attacked Staff 7, hitting, punching, attempting to pull her clothes off and yelling at her. Then Resident 1 approached and grabbed Resident 2 and threw her/him to the floor. Throughout the survey, multiple staff related they had stood between residents who were punching each other, in attempts to stop the fighting. Some staff stated they had been attacked by residents, and did not know how to break up fights. Interviews included: *On [DATE] at 12:30 pm, Staff 6, CNA stated a resident (#1) attacked him and wrestled him to the floor. Staff 6 managed to get up and run from the room, and stated he feared he would have been beaten if he had not been able to get away. *On [DATE] at 3:05 pm Staff 7, RA/CNA stated she got between two fighting residents (#'s 2 & 5) on [DATE] and got beaten, punched, and her clothes pulled (partially) off. A resident (#1) intervened by throwing the attacking resident (#2) to the floor. *On [DATE] at 12:30 pm Staff 14, CNA stated he had prior experience working in a mental health setting. In that setting he was taught how to intervene in fights between residents, by restraining the residents. In the nursing home setting, Staff 14 was unsure what the protocol was for separating fighting residents, as restraints were not appropriate. On [DATE] at 1:35 pm Staff 16, Social Services Director (SSD) stated Resident 2 "hated the idea of a roommate" which triggered the behavior on [DATE]. Staff 16 was unable to provide evidence the care plan was updated to include the behaviors triggered by the proposed roommate, or that Resident 2 was targeting Resident 4. On [DATE] at 3:00 pm Staff 17, Medical Records stated Resident 2 and 4 had argued for a long time about a wrist watch, and it was known that Resident 2 and Resident 4 did not get along. Staff 17 stated she believed the care plan indicated the two should not be in the dining room together. On [DATE] Resident 2 was told about a prospective new roommate and Resident 2 became very agitated. Resident 2 turned anger first towards Staff 16, SSD and then targeted Resident 4. On [DATE] Resident 2's behavior was "so escalated" and she/he was so angry, that Staff 3, RNCM was going to send the resident to the hospital, but the physician requested the resident not be sent out. Staff 3 would not go against the physician's orders [REDACTED]. On [DATE] at 3:30 pm Staff 3, RNCM stated Resident 2 and 4 had been in an altercation before and were supposed to be kept separate. The intervention was not on Resident 2's care plan. On [DATE] at 2:00 pm, a discussion with Staff 2, Assistant Administrator, Staff 3, RNCM; Staff 4, DNS; and Staff 5, RNCM included Resident 2's escalating pattern of aggression towards staff and Resident 4 on [DATE]. Staff had not identified a pattern of behavior, and no interventions were in place to keep Resident 2 and Resident 4 apart. There was no provision made for additional CNA staff when activities staff were not present to provide activities. No further information was provided. 3. Resident 3, a [AGE] year old resident was admitted in ,[DATE] with [DIAGNOSES REDACTED]. Interdisciplinary Progress Notes dated [DATE] indicated Resident 3 threatened her/his roommate with "(I will) cut your throat while you're sleeping." On [DATE] the resident told staff she/he would not harm her/his roommate but would continue to be "very verbal" towards her/him. Resident 3 was moved on [DATE] and was rooming with Resident 1 on [DATE]. Resident 1, a [AGE] year old resident was admitted in ,[DATE] with [DIAGNOSES REDACTED]. An Incident Report dated [DATE], indicated Resident 1 had a history of [REDACTED]. An Incident/Witness Report dated [DATE] indicated Resident 1 had a "long violent altercation history." Resident 3 had a PASRR Level II Mental Health Evaluation dated [DATE]. [DIAGNOSES REDACTED]." It was recommended "If the resident should pose a real threat to others... impose (her/himself) by force on others, damage property, ..or do anything considered 'illegal' -- call the police; press charges." Interdisciplinary Progress Notes dated [DATE] indicated Resident 3 yelled and made threats of violence towards staff, and threatened to hit another resident with her/his fist. Staff intervened, but Resident 3 continued to yell and was aggressive. The police were called to de-escalate the resident. There was no evidence the facility pressed charges. On [DATE], Interdisciplinary Progress Notes and an Incident Report indicated Resident 3 got in a fist fight with her/his roommate, Resident 1. The two residents were difficult to separate. Resident 1 sustained 2 lacerations, above the left eye brow and one under the left eye, and later had a black eye. Resident 1 was sent to the emergency room where the resident received stitches. Police were called; the sheriff found the altercation to be mutual and no charges were filed. Hospital Emergency Department Notes dated [DATE] indicated Resident 1 sustained lacerations above and below the left eye and two lacerations around the left eye. Stitches and tape strips were applied to lacerations. The resident was alert and oriented and CT scan showed no acute changes. The resident was sent back to the facility with [DIAGNOSES REDACTED]. According to the Incident Report dated [DATE], Resident 1 and Resident 3 were fighting over an unmarked notebook. There was no evidence of an assessment of the residents' prior histories of verbal and/or physical aggression towards roommates, prior to placing them in the same room together. There were no care plans related to the new roommates. On [DATE] at 12:45 pm, Staff 16, Social Services Director (SSD) acknowledged there was no assessment of the history of verbal and physical aggression of both Resident 1 and Resident 3 towards previous roommates, prior to moving them in together. On [DATE] at 2:00 pm, a discussion with Staff 2, Assistant Administrator, Staff 3, RNCM; Staff 4, DNS; and Staff 5, RNCM included the lack of assessment of the two residents histories of abuse to previous roommates prior to moving them in together. No further information was provided. 4. Resident 4, a [AGE] year old resident was admitted in ,[DATE] with [DIAGNOSES REDACTED]. Target Behavior Monitoring reports dated [DATE] indicated Resident 4 became very upset about a dispute with Resident 2 over a wrist watch. Resident 4 was "really upset" and yelling at a CNA, because she/he wanted the wrist watch back. An Incident Report dated [DATE] indicated Resident 4 was in the dining room when Resident 2 approached her/him and "initiated conversation." Resident 2 then struck Resident 4 in the back of the head. Resident 2 was directed from the dining room. On [DATE] at 12:45 pm Resident 4 was observed seated in a wheelchair in the dining room. Resident 4 stated (she/he) had started the fight on [DATE] when Resident 4 called Resident 2 names and used racial slurs. Resident 2 and Resident 4 had been arguing over a wrist watch. Resident 2 started to walk away from Resident 4, but then turned back and threatened Resident 4 that (she/he) was "coming back" for Resident 4. On [DATE] at 2:35 pm Staff 11, Dietary Aide stated Resident 2 argued with Resident 4 about a watch, and Staff 7, RA/CNA tried to redirect Resident 2 from the room. On the way out of the room, Resident 2 hit Resident 4 in back of the head and then rubbed shoulders with Resident 5 who was entering the room. A fight then started between Resident 2 and Resident 5. On [DATE] at 12:45 pm Staff 16, Social Services Director (SSD) stated he did not know that racial slurs had been used. Staff 16 stated he had no background/training in social services, and believed when two residents were fighting, staff should try to redirect and/or step between the two residents, and "try not to get hit." On [DATE] at 3:15 pm Staff 17, Medical Records, stated Resident 2 had been threatening Resident 4, saying she/he was going to "beat Resident 4 up." The argument was about a wrist watch and who it belonged to. On [DATE] at 3:30 pm Staff 3, RNCM stated Resident 2 and 4 had been in an altercation before and were supposed to be kept separate. The intervention was not on Resident 4's care plan. On [DATE] at 2:00 pm, a discussion with Staff 2, Assistant Administrator, Staff 3, RNCM; Staff 4, DNS; and Staff 5, RNCM included the lack of supervision in keeping Resident 2 and 4 separated, or attempts to resolve the dispute over the wrist watch prior to the altercation. No further information was provided. 5. Resident 5, a [AGE] year old resident was admitted in ,[DATE] with [DIAGNOSES REDACTED]. Resident 5's Care Plan dated [DATE] indicated the resident had difficulty with communication and staff were to be available to offer assistance to the resident during activities and to watch for frustration. Target Behavior Monitoring reports included: *[DATE]: The resident became verbally abusive toward staff during lunch. *[DATE]: There were two incidents in the dayroom. One with verbal name calling and throwing the remote control across the day room, and one with calling a female resident abusive names. *[DATE]: Resident 5 poured soda pop in her/his roommate's mouth while the roommate was in a recliner chair and the roommate began to vomit. *[DATE]: The resident elbowed someone making that person spill coffee on her/his arm. *[DATE]: A verbal altercation occurred with Resident 2, which escalated to a fight when Resident 2 starting punching Resident 5. Staff were trying to separate the two residents when Resident 2 was thrown to the floor by Resident 1. Resident 5's Care Plan did not include information regarding verbal threats or physical aggression. On [DATE] at 2:00 pm, a discussion with Staff 2, Assistant Administrator, Staff 3, RNCM; Staff 4, DNS; and Staff 5, RNCM included the lack of supervision, and lack of assessment and care plan related to the resident's verbal threats and physical aggression. No further information was provided. 6. Resident 6, a [AGE] year old resident was admitted in ,[DATE] with [DIAGNOSES REDACTED]. Resident 6's Care Plan dated [DATE] indicated the resident had "inappropriate behavior" with physically aggressive behavior towards other residents. There were altercations on [DATE] and [DATE]. Approaches included to set limits, redirect and re-orient the resident to prevent injury, and decrease agitation/anxiety. There were no instructions related to what limits to set, or how to redirect/reorient the resident. Triggers related to the resident's PTSD were not identified. Target Behavior Monitoring reports and Incident reports indicated the following: *On [DATE], the resident was in a verbal altercation with another resident, and hit the other resident in the back. *On [DATE], the resident elbowed Resident 1 multiple times and the situation escalated until the two residents exchanged punches. *On [DATE] the resident was aggressive toward residents and staff. The resident grabbed a CNA's wrist and "threatened to break" her arm. Three staff had to redirect other residents away from Resident 6. The resident kicked at staff and tried to "punch with fist." *On [DATE] the resident went up to another resident (#3) who was yelling at staff from the bottom of the stairway. Resident 6 told Resident 3 to "shut up" and leave the staff alone. Resident 3 got up and cocked her/his fist back as if to hit Resident 6. Staff intervened and took Resident 6 to her/his room. The police were called to de-escalate Resident 3. Resident 6's care plan was not updated with the [DATE] or the [DATE] incidents, and no new approaches developed to intervene or prevent physical aggression, or to keep Resident 3 and 6 apart from each other. On [DATE] at 2:00 pm, a discussion with Staff 2, Assistant Administrator, Staff 3, RNCM; Staff 4, DNS; and Staff 5, RNCM included the lack of supervision, and lack of assessment and care plan related to keeping Resident 3 and 6 separated, or new approaches to prevent verbal threats and physical aggression. No further information was provided.