**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#6) was prevented from an accident during a hoyer transfer with major injury, and from sustaining an avoidable fall from a wheelchair with major injury. The deficient practice could lead to residents being physically harmed, with major injuries or death. Findings Include: -Regarding Resident #6's accident during a hoyer transfer: Resident #6 was initially admitted to the facility June 21, 2024, with diagnoses that included unspecified dementia with other behavioral disturbance, depression, type 2 diabetes mellitus, hypotension, chronic obstructive pulmonary disease, and chronic kidney disease. Review of a care plan dated July 6, 2024, revealed the resident has an activity of daily living (ADL) deficit and requires a hoyer lift for transfers. An additional care plan dated July 5, 2024, revealed Resident #6 is at risk for behaviors due to dementia, with interventions to anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction and attention, stop and talk to the resident as passing by, explain all procedures to the resident before starting and allow the resident time to adjust, and intervene as necessary to protect the rights and safety of others. There was no evidence of a care plan to specifically address behaviors demonstrated during hoyer transfers. A physician Encounter Note dated January 3, 2025, revealed the physician was called to see the resident for a fall from hoyer. The resident was reportedly moving around in the hoyer, when a loop came unhooked from the hoyer, causing the resident to slip out and land face down. The resident sustained a head strike with two lacerations on the forehead, and a contusion/abrasion to the right elbow and right knee. The resident has right knee pain and possible right distal femur deformity, with concerns for femur/knee fracture. EMS arrived. A Nurses Note dated January 3, 2025, revealed the resident had fallen while being transferred using a hoyer lift. The resident was laying on the floor on her back, and was bleeding from two lacerations to her head, and on her right knee. The provider was called and entered the facility shortly, and 911 was called and came for the resident at 11:02 AM. Before the fall, the resident was wiggling and yelling out to everyone that passed by her room to get her up and the resident was told she would be up by lunch time, but continued yelling. The resident was re-admitted to the facility from the hospital on January 7, 2025, with additional diagnoses of nondisplaced transverse fracture of right patella, and displaced articular fracture of head of right femur. A Nurses Note dated January 7, 2025, revealed the resident has an immobilizer brace to the right lower extremity, and to continue non-weightbearing. A physician Encounter Note dated January 8, 2025, revealed Resident #6 had a fall out of a hoyer lift on January 2, 2025, and sent out to the hospital for evaluation. Imaging found a right distal femur fracture and a right patellar fracture, to be treated conservatively with a leg immobilizer brace. On April 14, 2025, at 11:53 AM, a formal request was made to the facility for the incident report and risk management report for Resident #6 for the fall from hoyer incident in January 2025. The administrator signed a statement that incident reports are internal use only and would not be available to be reviewed. An observation was conducted of the hoyer lift on the resident's unit on April 14, 2025, at approximately 1:15 PM. The hoyer lift had hooks that pointed upward by approximately 3-4 inches so that the loop of a hoyer sling could not come off the hook unless it was unweighted and lifted off, or if the loop was not fully hooked or seated correctly on the hook. An interview was conducted with a Certified Nursing Assistant (CNA / Staff #36) on April 14, 2025, at 12:26 PM. Staff #36 stated that the facility requires two staff to operate a hoyer lift for safety during transfers. Staff #36 stated that she was not present at the time of Resident #6's fall from the hoyer, however Staff #36 stated she heard that there were two staff present and questioned, how did that happen?, however was never informed how the incident happened. Staff #36 stated that the resident returned from the hospital with a bruise on her head and a fracture from the fall. An interview was conducted with a Registered Nurse (RN / Staff #80) on April 14, 2025, at 12:49 PM. Staff #80 stated that in January 2025, Resident #6 had a fall from a hoyer lift transfer, and that she was not sure how it happened, whether the sling strap tore or that the hoyer strap loop came off the hook. Staff #80 stated that the resident moves in the hoyer sometimes. Staff #80 stated that the two CNAs who were assisting the resident during the hoyer lift incident were Staff #45 and Staff #62. An interview was conducted with the Director of Rehab and Occupational Therapy Assistant (DOR / Staff #16) on April 14, 2025, at 1:07 PM. The DOR stated that she was familiar with Resident #6 and that she was aware the resident had a fall from the hoyer lift in January 2025. The DOR stated it was discussed in an IDT meeting the following day that Resident #6 was being transferred in a hoyer lift and was displaying behaviors and somehow wiggled herself out of the hoyer sling. The DOR stated that she could see how if someone was flailing in a hoyer sling, then they could possibly work themselves out of the hoyer sling. The DOR also stated that Resident #6 has moderately to severely contracted knees, which significantly limits her movement, and the resident cannot stand or walk. A telephonic interview was conducted with a CNA (Staff #62) on April 14, 2025, at 1:38 PM. Staff #62 stated that she was assisting with the hoyer transfer at the time of the incident. Staff #62 stated that Staff #45 had the resident on the hoyer lift and that Resident #6 was shaking and jiggling the straps of the hoyer sling with her hands. Staff #62 stated that the resident was up in the lift, and Staff #62 then turned around to get the wheelchair and position it. Staff #62 stated by the time she turned around again, one of the sling loops came off the hoyer lift hooks and the resident fell to the ground and hit her leg on the ground, and her head was injured. She stated that the position of the other CNA, Staff #45, at the time of the fall, was standing behind the main upright beam of the hoyer lift, so that the beam was between Staff #45 and the resident in the sling. After the resident's fall, the staff got the nurse right away. A phone call was placed to a CNA (Staff #45), for an interview on April 14, 2025, at 1:39 PM, and a voicemail was left for a return call. The staff did not return the call. An interview was conducted with an Assistant Director of Nursing (ADON / Staff #71) on April 14, 2025, at 2:31 PM. Staff #71 stated that she was aware that Resident #6 had a fall from a hoyer lift in January 2025. Staff #71 stated that she heard of the incident the following morning in the clinical meeting. Staff #71 stated that she did not know what happened during the incident, or how the fall occurred. An additional interview was conducted with an Assistant Director of Nursing (ADON / Staff #29) on April 14, 2025, at 2:41 PM. Staff #29 stated that Resident #6's fall from the hoyer in January 2025, happened before she started her employment with the facility. Staff #29 stated that the resident tends to move around and reach for things during hoyer transfers. Staff #29 stated she was not aware of how Resident #6's fall from the hoyer occurred. A telephonic interview was conducted with Resident #6's responsible party and power of attorney (POA) on April 14, 2025, at 2:57 PM. The POA stated that the facility called him in January, 2025, to inform him of the resident's fall. He stated that he was told by facility staff that the resident fell while reaching and that the staff did not witness it. He stated as an outcome, the resident had lacerations on her forehead and a fracture. An interview was conducted with the Director of Maintenance (Staff #8) on April 14, 2025, at 3:12 PM. Staff #8 stated that if there is an issue with a hoyer lift, that staff will report it, and he will look at the hoyer. He stated that no staff reported an issue with the hoyer lift on Resident #6's unit. An interview was conducted with the Director of Nursing (DON / Staff #86) on April 14, 2025, at 3:37 PM. The DON stated that she has been employed by the facility since February 17, 2025, and prior to that date, the DON position was held by Staff #90, who was no longer employed by the facility. The DON stated that residents and/or staff could be injured if staff does not follow established procedure when using equipment. She stated that she was aware that Resident #6 had a fall from a hoyer lift in January that resulted in a fracture, however she stated that she did not know any further details, and that it was not discussed by the facility. The DON stated that she was not aware of any corrective action that took place. A call was placed on April 14, 2025, at 3:51 PM, to the former DON (Staff #90) for an interview. A voicemail was left for a return call. The staff member did not return the phone call. -Regarding Resident #6's fall from a wheelchair: A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #6 had a brief interview for mental status (BIMS) score of 00, indicating the resident had severe cognitive impairment. Additionally, the assessment revealed the resident had a fall within the recent 2-6 months. A care plan dated July 6, 2024, revealed the resident is at risk for falls due to dementia, with interventions to be sure the residents call light is within reach, ensure appropriate footwear when mobilizing in wheelchair, anticipate and meet the resident's needs, and that the resident needs a safe environment on a secured dementia unit. An additional intervention to the fall risk care plan, initiated April 9, 2025, indicated to adjust Roho cushion to wheelchair to minimize falls. An additional care plan, dated July 2, 2024, revealed the resident is an elopement risk / wanderer due to dementia, with interventions to assess for fall risk, identify pattern of wandering, and to provide structured activities: toileting, walking inside and outside, and reorientation strategies. There was no evidence of a care plan specifying the quantity or times that the resident required supervision from staff. A Behavior Note dated March 2, 2025, revealed the resident was going into other resident's rooms and taking their belongings. A Psychotherapy Note dated March 3, 2025, revealed the resident tends to take items from around the unit and store them in her drawers. A Nurses Note dated April 8, 2025, revealed staff heard shouting coming from a room and observed Resident #6 lying on the floor in the fetal position in another resident's room. The extra wheelchair cushion provided had slid off of the wheelchair with the resident at the time of the fall. The resident sustained a skin tear and bruising to left hand, bruising to left elbow, and a bump to left forehead. Notifications were made to the POA and physician. A Radiology Report dated April 9, 2025, revealed an x-ray of the left ankle with findings: comminuted, displaced and angulated distal fractures of the tibia and fibula. A physician Encounter Note dated April 9, 2025, revealed the resident was being seen to follow up on a fall from wheelchair. The resident had acute tibia and fibula fractures with a recommendation to send out to the emergency department to evaluate and treat the fractures. A Therapy Screen Note dated April 9, 2025, revealed the screen was being completed status post fall. No changes noted at this time as the resident continues to require supervision for wheelchair mobility via manual wheelchair. Dycem (non-slip sheet material) is noted under the Roho cushion to reduce movement, as the Roho is needed to maintain skin integrity. Therapy not warranted at this time. A physician order dated April 9, 2025, indicated to send the resident out to the hospital for evaluation of acute pain and swelling post fall. On April 14, 2025, at 11:53 AM, a formal request was made to the facility for the incident report and risk management report for Resident #6 for the fall from wheelchair in April 2025. The facility administrator signed a statement that incident reports are internal use only and would not be available to be reviewed. An interview was conducted with a Certified Nursing Assistant (CNA / Staff #36) on April 14, 2025, at 12:26 PM. Staff #36 stated that staff supervise residents who require it, and that it is relayed in report between shifts which residents need supervision. Staff #36 stated that if they see a resident somewhere they should not be, then staff remove them from the location. Staff #36 stated that all the residents on Resident #6's unit require supervision because it is a dementia unit. Staff #36 stated that Resident #6 wanders around the unit and takes things from other residents' rooms. Additionally, Staff #36 stated she was aware that Resident #6 had fallen from her wheelchair on April 8, 2025, and that the resident was sent to the hospital. Staff #36 stated she did not know any further details. An interview was conducted with a Registered Nurse (RN / Staff #80) on April 14, 2025, at 12:49 PM. Staff #80 stated that Resident #6 normally wanders into other resident' rooms, she steals things, and starts giggling. Staff #80 stated that Resident #6 was alone in another resident's room, when Staff #80 heard a yell, and three staff members ran to the room. Staff #80 stated that the resident had a new wheelchair cushion from therapy, and recently just before this fall incident, the resident had a near fall from the cushion. Staff #80 stated that she observed the resident on the floor on her side and the cushion was on the floor with the resident, as if the resident had slid out. Further, Staff #80 stated that there was only one piece of dycem under the first wheelchair cushion, and that there were two wheelchair cushions present. Additionally, Staff #80 stated that there should have been a second piece of dycem between the first and second wheelchair cushions prevent it from sliding out. An interview was conducted with the Director of Rehab and Occupational Therapy Assistant (DOR / Staff #16) on April 14, 2025, at 1:07 PM. The DOR stated that she had issued Resident #6 a Roho cushion, and there was concern that the cushion was sliding, and then after the resident fell, staff removed the cushion. The DOR stated that she looked at the wheelchair the following morning after the fall, and there was only one wheelchair cushion at that time. The DOR stated that no staff had reported to her that there had been two wheelchair cushions in the wheelchair, and if there were, then it would be a safety concern. The DOR further stated that when there are two cushions in the wheelchair, it brings the resident up higher in the chair in relation to the armrests, and increases the likelihood for a fall. An interview was conducted with an Assistant Director of Nursing (ADON / Staff #71) on April 14, 2025, at 2:31 PM. Staff #71 stated that Resident #6 is very busy, in and out of other resident's rooms, getting into other residents' belongings. Staff #71 stated Resident #6 requires lots of supervision and redirection, as well as frequent checks. Additionally, Staff #71 stated that last week, the resident fell from her wheelchair, and that staff said that there was a cushion in her wheelchair that contributed to her fall, so the wheelchair cushion was removed from the chair. An interview was conducted with an Assistant Director of Nursing (ADON / Staff #29) on April 14, 2025, at 2:41 PM. Staff #29 stated that Resident #6 does wander into other residents' rooms and takes their belongings. In regard to the resident's fall on April 8, 2025, Staff #29 stated that the nurse was in another room when the resident fell in another resident's room. The ADON stated that the clinical team discussed the fall, and it was determined that the Roho cushion may have been the reason why the resident fell. Staff #29 stated that Roho cushions are much thicker and position the resident higher than other wheelchair cushions, and the Roho cushion had just been put in Resident #6's wheelchair recently. Staff #29 stated that once the clinical team reviewed the fall, it was decided to not have the resident use the Roho cushion, and it was removed. After the fall, the resident went to the hospital, and Staff #29 stated that the nurse called the hospital and received report that Resident #6 did have tibia and fibula fractures. Also, Staff #29 stated that there were no staff in-services done after the resident's fall. An interview was conducted with the Director of Nursing (DON / Staff #86) on April 14, 2025, at 3:37 PM. The DON stated that the facility protects residents from accidents by trying to keep them out of rooms as much as possible, and to check on residents as frequently as staff can. The DON also stated that staff supervise residents with known behaviors, and that it should be specified in the resident's care plan how much supervision that the resident requires. The DON stated that Resident #6 has dementia and wanders in her wheelchair. Regarding the resident's fall on April 8, 2025, the DON stated that the resident fell due to her cushion in her wheelchair and that the resident slid out. The DON stated that we added dycem so the resident would not slip. As an outcome, the DON stated that the resident went out to the hospital and was treated for tibia and fibula fractures. The DON stated that there were not any staff trainings or in-services after the fall incident. Review of the facility's manufacturer's instructions for the hoyer lift on Resident #6's unit, titled EZ Way Smart Lift, 500, 600, and 1,000 lb Capacities, Operator's Instructions, revised August 10, 2018, revealed that all washable EZ Way Slings are capable of bearing a 1,000 lb. weight load. EZ Way slings are made specifically for EZ Way Smart Lifts, for the safety of patients, only EZ Way slings should be used with EZ Way lifts. A pre-operation check should be completed before operating the unit. Ensure the sling is not ripped, frayed, or showing signs of wear. When attaching the sling to the lift, make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars. When lifting the patient, push the UP button, continue the upward motion until there is tension on the sling legs, making sure all the loops on the sling are securely hooked on the hanger bars. Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised March 2019, revealed the IDT will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed all accidents and incidents involving residents shall be investigated and reported to the administrator. The Incident/Accident Report shall include, as applicable: the date and time the incident took place, the nature of injury, the circumstances surrounding the accident or incident, any corrective action taken, follow-up information, and other pertinent data as necessary. Review of the facility policy titled Fall Risk Assessment, revised March 2018, revealed the nursing staff, physician, and therapy staff will establish a resident-centered falls prevention plan based on relevant assessment information. The staff will evaluate functional, psychological, and environmental factors that may increase fall risk. The staff and physician will collaborate to identify and address modifiable risk factors, and interventions to try to minimize the consequences of risk factors that are not modifiable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility documentation and policy, the facility failed to ensure care and treatment according to professional standards of practice was provided to one resident (#1). The deficient practice resulted in the hospitalization of the resident and amputation of his leg. Findings include: Resident #1 was admitted on [DATE] with diagnoses of borderline personality disorder, obsessive-compulsive disorder, epilepsy, and an anxiety disorder. Review of the clinical record revealed documentation that the resident was in a car accident, had metal pieces in his left foot; and that, in October and November of 2019, he was again noted to be limping and complaining of pain to right lower leg. The care plan initiated on 11/11/2022 revealed the resident had a goal related to his potential for impairment to skin integrity related to his potential for poor safety awareness. Interventions included following facility protocols for treatment of injury and identifying and documenting potential causative factors and eliminate and resolve where possible. The care plan dated 03/08/2023 included that the resident had diabetes mellitus and had the potential for pressure ulcer development. The goals were that the resident will not have complications related to diabetes and the resident will have intact skin, free of redness, blisters or discoloration. Interventions included to check all body for breaks in skin and treat promptly as ordered by the doctor; and, to follow facility policies/protocols for the prevention/treatment of skin breakdown. The follow-up encounter notes dated 04/04/2024 included that the resident had red/open areas to the right upper shoulder; and that, there was no edema noted on the extremities. The skin observation dated 04/09/2024 revealed a red area; however, the documentation did not identify the location of the red areas observed. The shower sheet dated 04/10/2024 included that the resident had swelling to his right leg. The clinical record revealed no documentation whether the swelling to the resident's right leg was reported to the nurse or the provider; and that, it was assessed and interventions were put in place to address this. The nursing weekly skin check dated 04/12/2024 revealed the resident had wound to the right bicep which was healing, scabbed and without drainage or swelling. However, there was no documentation of any redness or swelling to the resident's right leg. Per the documentation, the skin was expected color for ethnicity without lesions or rashes, was warm, dry with no edema, and had normal turgor with no tenting. The follow-up NP (nurse practitioner) note dated 04/16/2024 included the resident had red and open areas to the right upper shoulder; and, had no edema on the extremities. The nursing weekly skin check dated 04/18/2024 included the resident had a scab on the right shoulder and the rest of the skin was clean, dry and intact. It also included that the skin color was normal to ethnicity and skin turgor was good. The documentation did not include any redness or swelling to the resident's right leg. The wound progress note dated 04/18/2024 revealed there was no edema or tenderness to the right and left lower extremities. A progress note dated 04/25/2024 at 07:23am documented that a certified nursing assistant (CNA) alerted the nurse that the resident had redness to his right leg. The nurse completed an assessment and took the vitals: -Temperature of100.4 degrees Fahrenheit; -Pulse of 92 bpm (beats per minute); -Respiration-breaths per minutes; -Blood pressure-140/100; and, Oxygen saturation-90%. Per the documentation, these vital were reported to the NP who ordered a stat CBC (complete blood count), CMP (comprehensive metabolic panel), CRP (C-reactive proteins) labs and a chest -X-Ray. The NP progress note dated on 04/25/2024 revealed that a leakage to the right lower extremity sweat pants at groin/leg/thigh was noted; and that, the resident's leg appeared red and swollen from ankle to calf with some open/yellow slough dime-sized areas noted to distal shin on right lower extremity. Per the documentation, when the resident's pants were removed, a variety of items including snacks, straws, and toys fell out; and, these hoarded items were next to the skin which might be a component of the irritation. The documentation included that the NP requested the wound nurse consult promptly for evaluation and treatment and expressed concern for the sudden onset of symptoms. Physical exam included had 2+ edema on the extremities, red/open areas to the right lower extremity from the ankle to the knee, and swelling but no redness to the left lower extremity. Diagnoses included edema bilateral lower extremities and cellulitis on the right lower extremity. Plan was to start Doxycycline (antibiotic) for 7 days and Lasix (diuretic) twice daily for 3 days. Further, the documentation included that the stat labs (CBC, CMP and CRP) and ultrasound were pending: and, an oral antibiotic was to be started for seven days and Lasix (diuretic) for edema to be given twice a day for three days. The physician order dated 4/25/2024 included the following orders: -two STAT (immediate) orders for ultrasounds to his bilateral lower extremities to evaluate for deep vein thrombosis (DVT) related to redness on his leg and cellulitis; -Another STAT order for CBC, CMP and CRP labs; and, -Doxycycline 100 milligrams (mg) tablet by mouth twice a day until 05/02/2024. The Medication Administration Record (MAR) for April 2024 revealed documentation that Doxycycline was administered to the resident as ordered. The clinical record revealed that the orders for physician-ordered laboratory tests were completed on 4/25/2024 at 3:14 p.m. The following results from the STAT labs on 04/25/24 were flagged as high: -White blood cell count (WBC) was 22.9 thousand per cubic millimeter (Normal range was 4.0 to 11.0); -Absolute Neutrophil was 14.6 thousand per microliter (Normal range was 1.5 to 7.8); -Absolute Monocyte 4.3 thousand per microliter (Normal range was 0.2 to 1.0); -Absolute Immature Granulocytes 2.2 thousand per microliter (Normal range was 0.0 to 0.1); -CRP was 173.6 milligrams per liter (mg/L) (Normal range was less than or equal to 4.9 mg/L). The clinical record revealed no evidence that the provider was notified and had reviewed these lab results. The shower sheet dated 4/28/2024 included the resident had swelling and reddened right leg. A nursing progress note from 04/29/2024 revealed that the ultrasound was completed and results were pending. A wound note from 04/30/2024 included that the wound care team was consulted due to the worsening cellulitis of unknown origin in his right leg; and that, the resident was started on Doxycycline by attending NP with no improvement. Wound assessment included an unhealed full thickness cellulitis on the right lower leg measuring 34 cm (centimeters) length x 34 cm width x 0.2 cm depth; had moderate amount of yellow drainage noted; wound bed had 1-25% pink granulation, 51-75% epithelialization; and, periwound skin was warm, had edema and erythema and presented with signs and symptoms of infection. Active problems included cellulitis of the right lower limb. Plan included wound treatment. recommendation was for a wound culture and possible intravenous (IV) antibiotics for severe worsening cellulitis. The NP progress note dated 04/30/2024 revealed that the resident's right lower extremity appeared more swollen, red, and inflamed than previous exam. It also included that the ultrasound was negative and the stat labs were reviewed with concern for sepsis or osteomyelitis. Per the documentation, the NP discussed these concerns with the director of nursing (DON) and wound care provider and recommended sending the resident to the emergency room for prompt IV antibiotics and wound culture as a delay may compromise the patient. The nursing progress note dated 04/30/2024 included that the resident was sent out non-emergent per the wound provider and the NP. Per the documentation, the resident's dressings to the right leg were wet with exudate; there were large red areas and swelling on the right leg below the knee; and, toward the ankle there were blister like areas there was and open areas on the upper leg. The hospital history and physical dated 05/01/2024 included that the facility reported that the resident had been walking around the facility with no change in ADLs (activities of daily living) or mentation from baseline. Per the documentation, the facility noticed possible cellulitis of the right lower extremities initiated Doxycycline 100 mg BID since 04/26/2024; and that, the resident hoarding things and stuff things up his pan leg may have caused the infection. Physical examination included that the right lower extremity had erythema, edema and several areas of purulence extending from the ankle to the mid-upper thigh. Assessment included that the resident presented with a purulent right leg SSTI (skin and soft tissue infection); and, the facility began Doxycycline 100 mg twice daily on 04/26/2024 but the resident had worsening of infection and was transferred to the hospital. Per the documentation, the resident was afebrile, hypertensive, tachypneic (rapid and shallow breathing) and had a WBC of 21.2. Further, the documentation also included that CT scan showed that the resident had a tibial rod on the right lower leg. Active problems included severe purulent cellulitis and sepsis; and that, the right leg was marked to monitor extension of the infection. The hospital progress note dated 05/06/2024 included that the resident presented with chronic osteomyelitis in the setting of longstanding tibial nail that had spread the cellulitis proximally; and that, the resident's family would like to proceed with above the knee amputation. the infectious disease assessment included right lower extremity wounds/ulcerations with SSTI with extensive Pseudomonas. The nursing progress note dated 05/12/2024 included that the resident returned at the facility and that, the resident had an above the knee amputation to the right leg. Per the documentation, the area had multiple stitches with no signs and symptoms of infection noted. The skin evaluation dated 05/19/2024 revealed above the knee amputation to the right leg. The care plan was revised on 05/24/2024 to include a goal for wound care related to the above the knee amputation due to infection. The undated online reportable event record/report submitted by the facility included that a complaint was filed with the State Board of Nursing against the DON (Director of Nursing) alleging negligence on behalf of all the nurses; and that, a resident who was admitted to the behavior unit had severe infection on the right lower extremity that went unnoticed and untreated. It also included that when treatment was initiated, it was by oral antibiotics instead of IV (intravenous) antibiotics. The facility 5-day investigative report revealed an interview with the registered nurse (RN/staff #18) conducted by the facility on 6/24/2024. Per the documentation, The RN reported that he knew the resident had cellulitis and his leg got worse as far as redness, weeping, swelling, and hardness; and that, two providers were present and they originally wanted to treat the resident at the facility before ultimately sending Resident #1 out to the hospital. In an interview with a licensed practical nurse (LPN/staff #9) conducted by the facility included that the nurse recalled when the resident had an infection in his right leg, and that was when she was told the computers were down. She brought it to the DON's attention and was told there was an order for dressing and antibiotics. Continued review of the facility report revealed that based on their investigation, interviews and chart review, the facility cannot conclude that there was negligence on behalf of the nurses, management or practitioners. In an interview with a Licensed Practical Nurse (LPN/staff #45) conducted on 07/01/2024 at 2:42 p.m., the LPN stated that the turn-around time on stat labs can depend on the laboratory provider; and, it was usually sooner but can be up to 24 hours. During the interview, a review of the clinical record was conducted with the LPN who stated that it was not appropriate for labs completed and had results in on 04/25/2024 be reported/reviewed by the provider only on 04/30/2024 which was 5 days after. The LPN said that she would have been concerned and reported the lab result to the provider immediately because of the result on the WBC count of Resident #1. During an interview with a certified nursing assistant (CNA/Staff #23) conducted on 07/01/2024 at 2:49 p.m., the CNA stated that CNAs complete skin checks during showers; and, the CNAs were required to check the full body for redness, breakdown, or bruises. She stated she provided care for Resident #1; but, she does not recall noticing any redness on his leg from April 18- to April 25, 2024. Further, the CNA said that she was unsure if she gave resident #1 a shower during that time. An interview with the LPN (staff #9) was conducted on 07/01/2024 at 3:37 p.m. The LPN said that she knew resident #1 was on oral antibiotic and had an order for dressing, but the wound nurse comes weekly and does wound care. The LPN said that the stat laboratory orders were initially ordered during the shift; and they were taken and completed the same day it was ordered. The LPN said that the lab results were usually back within 24 hours; and that, if it was [NAME] who completed the test, the laboratory staff will call the facility to notify them of the results. The LPN said that if labs were ordered and pending, this was something that would need to be reported at shift change to the oncoming nurse. The LPN said that in her nursing experience, she would not expect a resident on antibiotics to be worsening, though antibiotics can take 7-10 days to be effective; and that, if it was worsening, she would call the doctor and let them know and then follow whatever orders received. Further, the LPN said that 5 days for a STAT lab result would be too long. During the interview, a review of the laboratory result on 04/25/2024 for resident #1 was conducted with the LPN who said that based on the lab results the doctor absolutely should have been called immediately; and that, waiting 5 days to report the results to the provider would be inappropriate, especially if those were the levels while patient was on an antibiotic. During an interview with the Internal Medicine NP (staff #15) conducted on 07/01/2024 at 3:58 p.m., the NP stated that the team first became aware of the concern with right lower leg of resident #1 on the date (04/25/2024) that she documented about it. The NP stated that staff had brought it to her due to the redness, but the resident denied he was in pain and there was no change in mentation. The NP said that her notes on 04/30/2024 was only when she found out about the lab results. She stated that this had been her concern in the past as there have been multiple instances of facility staff not telling her lab results; and, she had to go track down if the labs had come back and what the levels were. A review of the clinical record of resident #1 was conducted with the NP who stated that the length of time between when labs were ordered (04/25/2024) and when they were reviewed by a provider (04/30/2024) was egregiously long; and that, STAT means she wants to know the lab result immediately. Regarding resident #1, the NP stated that she sees the resident on Tuesdays and Thursdays; and that, on that particular Thursday (04/25/2024), resident #1 did not look good and on the following Tuesday (04/30/2024), the resident looked worse. The NP said that resident was not supposed to look worse if the resident was actively on an antibiotic, so the decision was made to send him out immediately. She stated she worked as fast as she could once she had the results and the resident was sent out emergent. The NP stated that with the resident's lab results and the visible physical worsening of his leg, an oral antibiotic would absolutely not suffice due to the speed at which he declined. Further, the NP said that the facility had no record of any hardware the resident had; but, the hospital found a rod in his right leg. The NP said that when she discussed this with the medical director, both she and the medical director agreed that had they known about the hardware, they would have sent him out the first day. She stated she was surprised to find out about the amputation; and, she was unsure if it would have changed the outcome if the resident had been sent earlier. In an interview with the acting DON (Staff #7) conducted on 07/01/2024 at 4:20 p.m., the acting DON stated that the expectation was that STAT lab results should be within 2-4 hours, though they can take longer depending on the day and time they were initially ordered. The acting DON also said that after getting results, nursing staff should have a conversation with the provider; and that, waiting 5 days for the provider to review labs would not be appropriate. The acting DON also said that the expectation was that the nursing staff will reach out to the provider for stat labs as soon as the results come in. During the interview, a review of the STAT lab results was conducted with the acting DON who stated that the facility received the STAT lab results on 04/25/2024 at 1:14 p.m.; and that, white blood cell count should have been reported to the provider immediately. The facility policy on Change in a Resident's Condition or Status last revised February 2021 revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition or of the need to alter the resident's medical treatment significantly. The policy also included that regardless of the resident's current medical or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. In another policy entitled Wound Care, last revised October 2010 it stated that documentation standards require staff document in the chart any change in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, and that they report any other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided for 1 of 3 sampled residents (#12) to prevent elopement; and, failed to ensure safety while providing care resulting to a fall for 1 of 3 sampled residents (#11). The deficient practice could result in avoidable accidents. Findings include: -Regarding Resident #11 Resident #11 was admitted on [DATE] with diagnoses of muscle weakness, history of falling, abnormal posture, anxiety disorder and mood disorder. A care plan initiated on April 10, 2017, revealed resident had self-care deficit. Interventions included limited to extensive assist with activity of daily living (ADL) and incontinent care as needed. A physician order dated April 20, 2020 included to admit resident to hospice for diagnosis of senile degeneration of the brain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE]. 2020 revealed that the resident scored 99 on a Brief Interview of Mental Status (BIMS), which indicated that the interview could not be completed. The MDS included the resident had short-term and long-term memory problems, with rejection of care being exhibited on 1-3 days during the assessment dates, and required extensive assistance for toilet and personal hygiene, with one-person physical assist. The nursing note dated August 13, 2020 included resident was awake but was not responding to verbal stimuli like he used to, was not eating or drinking at this time. It also included that resident was responding to physical stimuli when repositioned or during hygiene care. A psychiatric evaluation note dated August 13, 2020 included that according to staff, the resident had an overall decline with little to no oral intake, had decrease responsiveness and was being followed by hospice for end of life care. Mental status exam included the resident was lethargic, disoriented, non-cooperative, confused and unfocused. The documentation also included the resident had a longstanding psychiatric history but was presenting with significant decline. Diagnosis was dementia with behavioral disturbance and undifferentiated schizophrenia. Plan was to discontinue psychotropic medications and to continue to monitor mood and behavior. The hospice physician order dated August 14, 2020 at 11:45 a.m. revealed that all routine and psychotropic medications were discontinued. This order also included orders for morphine (narcotic opioid) and Ativan (anti-anxiety). Review of nursing progress notes dated August 14, 2020 at 12:53 p.m. revealed the resident remained in bed with continued comfort cares due to expected death. Per the documentation, resident was sedated and occasionally responded to tactile stimuli. The documentation included that at approximately 10:00 a.m. a certified nursing assistant (CNA) was changing the resident who was lying on his left side while the CNA was providing care. It also included that the resident became agitated, rolled towards the wall; and when the resident rolled, the bed moved and the resident fell between the wall and the bed. Per the documentation, the resident sustained laceration to the left temporal area and a skin tear to the right elbow; and that, hospice, POA (power of attorney) and the provider were notified. The nursing progress note dated August 14, 2020 at 02:40 p.m., revealed that resident's comfort level was continued to be monitored; and that, respirations continued to be shallow and was decreasing rate steadily with no apnea. Per the documentation, at 2:27 p.m., resident was noted to be without respiration or apical pulse and with eyes fixed; and that, hospice and provider were notified. Review of a Facility Reportable Event Record/Report dated August 17, 2020 revealed that the resident was being changed by the CNA; and, the resident was lying on his side while the CNA was providing care, the resident became slightly agitated and rolled toward the wall. It also included that the bed moved from the wall when the resident rolled and the resident fell between the wall and the bed. Per the documentation, the resident sustained a temporal laceration measuring 3.8 x 3.8 cm and a J-shaped skin tear to the right elbow measuring 3.8 x 1.8 and was cleansed with saline, edges approximated and covered with tegaderm. Continued review of the facility report revealed that the wheels on the bed were unlocked at the time of the incident because the CNA was walking around the bed to provide care; and that, maintenance was contacted to ensure the bed was functioning properly. The facility report included a written statement from the involved CNA (staff #172) dated August 14, 2020. The documentation included that the CNA (staff #172) provided care at the time of the fall, wrote the resident started to resist during patient care and as the CNA continued patient care the resident rolled from a side position onto the floor. An interview was conducted on March 28, 2023 at 2:24 p.m. with a CNA (staff #97) who stated there would be no reason to move a resident's bed if there was one person providing incontinence care. She also stated that if the wheels of a bed were unlocked to move, the expectation was to re-lock the wheels once the bed had been moved and prior to starting incontinence care. The CNA said the expectation was that once the resident becomes agitated or becomes combative during continence care, staff was to stop care immediately, lower the bed, and ask a nurse to come in and talk to the resident. The CNA stated that if the resident does not agree to continue the care, then staff are to approach the resident later. Further, the CNA stated that if a resident becomes agitated or combative it was the resident's way of communicating to staff that they do not want to continue with the care. In an interview with a licensed practical nurse (LPN/staff #36) conducted on March 28, 2023 at 2:35 p.m., the LPN stated she would not move the bed away from the wall prior to providing incontinent care. She said that if she would move the bed away from the wall, she would re-lock the brakes prior to starting care to ensure the safety of the resident. The LPN further stated that it was the facility's expectation to step away if a resident becomes agitated/combative during incontinent care. An interview was conducted on March 28, 2023 at 3:23 p.m. with the Interim Director of Nursing (interim DON/staff #109) who stated that the expectation was for staff to relock the brakes on the bed after it was moved and prior to starting patient care. She further stated the only reason to move a bed from it being against a wall, would be if two staff were providing care. The interim DON stated that if a resident becomes agitated during care, staff should stop immediately, and call for assistance. During the interview, a review of the facility reportable event record/report was conducted with the interim DON who stated that per the CNA's interview, the care was not provided according to professional standards because the CNA did not stop the care when the resident resisted. The interim DON stated that the risk of continuing care when a resident was agitated and leaving the bed wheels unlocked during resident care could result in resident injury; and that, this did not meet the facility expectations. Review of a facility policy titled, Safety and Supervision of Residents, included that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Environmental hazards include bed safety, safe lifting and movement of residents, and unsafe wandering. Review of a facility policy titled, Dignity, revealed that each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. -Regarding Resident #12 Resident #12 was admitted on [DATE] with diagnoses of hallucinations, encephalopathy, convulsions, cerebral aneurysm and mental disorder to known physiological condition. The elopement/wandering risk data set dated [DATE] revealed no history of elopement in the past 6 months and that the resident was able to transport self independently by ambulation. Per the assessment, the resident had predisposing diagnosis for elopement, had poor safety/environmental awareness and was at risk for elopement. Plan was to follow prevention of elopement protocols. The clinical record revealed no other elopement/wandering risk data set completed after March 6, 2019. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impact. The MDS also included that the resident had no behaviors or wandering behaviors exhibited within the look back period. The quarterly MDS assessment dated [DATE] revealed the resident had short and long-term memory problems, had modified independence for daily decision making and was not coded for the presence of wandering during the look back period. A psychiatric evaluation note dated August 11, 2020 included that the resident had a recent increase in agitation and was verbally aggressive with nursing staff; and that, this was an unusual behavior for the resident. Diagnoses included vascular dementia with behavior disturbance and alcohol-induced persisting dementia. Per the documentation recent aggression and threatening behavior occurred just prior to his diagnosis of COVID and likely represents a psychiatric manifestation of the illness. Further, the documentation included that the resident does not need further psychiatric medication at this time. A social service note dated September 3, 2020 at 6:11 p.m. revealed that social service director (SSD) called the police at 5:30 p.m. due to the resident missing from his doctor's appointment. Despite documentation that the resident was at risk for elopement, there was no evidence found in the clinical record that a care plan was developed with interventions to address the risk for elopement until September 3, 2020. The care plan dated September 3, 2020 included the resident had been successful with elopement. Goal was that the resident will not elope and choose to remain at the facility. Interventions included resident will have an escort for all appointments and to have psychotherapy consult for coping mechanisms. A nursing note dated September 4, 2020 at 9:31 a.m. revealed that at approximately 4:30 p.m., the director of nursing (DON) was notified that the resident did not return from his appointment at the cardiologist. Per the note, the resident's ride did not show up at the scheduled pick-up time; and that, the unit clerk (at approximately 12:10 p.m.) that a second pick up was called and was scheduled to be at the clinic in an hour. Further, the note included that cardiology clinic staff reported seeing the resident getting into a vehicle but did not give specific time. The clinical record revealed that the family and provider was notified of the resident's elopement. A review of the nursing progress note dated September 5, 2020 included the resident arrived at 9:00 p.m. and was placed on precautionary isolation and 15-minute monitoring. Per the documentation the resident appeared to be weak, unsteady when he stood up, was not able to walk and sat back down on the bed. It also included that the resident was alert and oriented x 3, had sunburn on his shoulders and back, both legs from above the knee down to his feet. According to the documentation, the resident reported that he went to another city, to the casino and to a friend's house and was walking to the park when he fell. The note included that the resident said he could not stand up so he crawled to a tree and sat under it all day. Review of a hospital note dated September 5, 2020 revealed the resident was brought into the emergency room for intoxication after he was found outside of a liquor store with altered level of consciousness. The documentation revealed the resident reported he was living in a nursing home facility up to 2 days ago when he escaped. Physical examination included a first-degree sunburn on bilateral anterior lower legs. The report also included that the resident was alert and oriented x 1 and could only reveal his name. Diagnoses were abdominal pain, dehydration, diabetic ketoacidosis, electrolyte imbalance, and confusion. The toxicology reports revealed ethanol, plasma 196, which indicated depression of the central nervous system. A nursing note dated September 6, 2020 included that the resident took the bus, got in the light rail to another city where he went to his friend's house, went to buy vodka bottle. The documentation also included that the resident slept next to the liquor store the first night and his friend made him a bed in the back for him to sleep on the second night. Review of a Facility Reportable Event Record/Report dated September 8, 2020 revealed that resident #12 went to a cardiologist appointment on September 3, 2020, unescorted. The report revealed that the staff member scheduled to escort the resident did not come in and the Director of Nursing and the other members of the management team decided the resident could go unaccompanied. Later in the day at 3:55 p.m., facility management was made aware the resident had not returned to the facility. Staff were dispatched to the physician office and surrounding areas to search on Friday and Saturday in an effort to locate the resident. The report included that the police, family, and state agency were made aware and a silver alert was activated on Friday; and that, the police located the resident at 1:00 p.m. on Saturday (September 5, 2020) and was transferred to the hospital for evaluation. An interview was conducted on March 24, 2023 at 11:51 a.m. with a Social Services Director (SSD/staff #56) who stated that all residents are transported to appointments with an escort, including those that have high risk for elopement. She said that if there was no escort available, the appointment would be rescheduled; and that, the facility expectation was to send all residents to appointments with an escort. The Social Services Director further stated that she could think of any reason that a resident who was an elopement risk would be sent to an appointment alone; and that, this could result in the resident being lost and vulnerable for injury. In an interview with a CNA (staff #103) conducted on March 24, 2023 at 12:22 p.m., the CNA stated that the facility process was to have an escort for all resident scheduled for an appointment; and that, at the time of the incident in September 2020, none of their residents are sent out to an appointment unescorted. The CNA stated this had been that way since she started working in the facility for the past 14 years. Regarding resident #12, the CNA stated she was familiar with the resident and that the resident was an elopement risk. The CNA also said she was in the building on the day the resident went to the appointment; and that, the resident's escort was on the way; but, transportation got in early. The CNA said that they called and informed the DON who made the decision to go send resident #12 by himself. She stated that evaluations for elopement risk are completed on admission and quarterly. An interview was conducted on March 24, 2023 at 12:06 p.m. with an LPN (staff #93) who stated that the facility process was to send an escort with the resident to all appointments outside of the facility. She stated the admitting nurse would complete an elopement risk upon resident admission; and that, residents assessed to be at risk for elopement would have an escort to medical appointments. Regarding resident #12, the LPN stated she was familiar with the resident; and that, the resident went out to an appointment and went with a friend to a casino. The LPN stated resident #12 told her he went off drinking and to the casino. The LPN further stated that if resident #12 was assessed as an elopement risk prior to the appointment at the time of the incident, resident #12 he should have had an escort to the appointment. During an interview with the administrator (staff #45) conducted on March 24, 2023 at 1:55 p.m., the administrator stated resident #12 was found to be an elopement risk and the DON at that time decided to send the resident to the appointment without an escort. A review of the clinical record was conducted with the administrator during the interview. The administrator stated there was no evidence that the provider or other administration had been consulted prior to the DON making the decision to send the resident to the appointment unescorted. She stated that she found no effort in the medical record that the DON followed up on the resident to see that he made it to the appointment and there was no evidence that they asked transport to stay. She stated that this did not follow the facility policy enacted on 2015. She stated that resident #12 was transported out of the facility unsafely, and could result in a severe detriment to the resident. She stated that her expectation was that all residents have an escort when transported to appointments In an interview with the Director of Nursing (DON/staff #95) conducted on March 24, 2023 at 2:39 p.m., the DON stated that all residents receive wandering/elopement assessments on admission and quarterly. She stated that if the resident was assessed to be at risk for wandering/elopement, this should be on the care plan. The DON stated that every resident whether high risk or low risk for elopement at the facility has an escort to all appointments. She stated that sending a resident out to an appointment without an escort does not meet the facility process. She stated that she would expect the facility policy for elopement to be followed; and that the risk for not following protocol could result in resident eloping from the appointment and be lost, resulting in possible resident injury. During the interview, the DON reviewed the care plan for resident #12 and stated that the resident was not care planned for an elopement risk. Further, the DON stated there was no evidence of quarterly elopement risk assessment; and that, this did not meet the facility expectations. Review of the facility policy titled, Transportation Dental Services, revealed that a member of nursing staff or social services will accompany the resident to the office when resident's family is not available. Review of the facility policy titled, Diagnostic Services Transportation, revealed that a member of the nursing staff, or social services, will accompany the resident to the diagnostic center when the resident's family is not available. Review of the facility policy titled, Behavioral Unit Policy for Residents and Staff, revealed that residents may go off the unit only when directly supervised. Review of the facility policy titled, Resident Outside Appointment Process, revealed that the Unit Coordinator will arrange appointments for residents that will include requesting an escort from the resident's insurance company or internal staffing. Lead CNAs on each unit will be responsible for making sure the resident has an appropriate escort with them prior to departure. Review of the facility policy titled, Wandering and Elopements, revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. If identified as a risk for wandering, elopement, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of a facility policy titled, Safety and Supervision of Residents, included the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. Environmental hazards include bed safety, safe lifting and movement of residents, and unsafe wandering. Review of a facility policy titled, Elopement Protocol, revealed that the facility maintains a process to assess all residents for risk and elopement, implement prevention strategies of those identified as an elopement risk, institute measures for resident identification and conduct a missing resident procedure. All residents will be assessed on admission, quarterly and with changes of condition for risk factors that would place the resident at risk for elopement such as wandering or elopement. All residents who are identified at risk for elopement will have their picture taken and be placed in the elopement book and the care plan will be updated. If a resident is identified at risk for elopement an id bracelet containing the facility address and phone number will be placed on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, staff and resident interviews, and the policy and procedures of the facility, the facility failed to ensure two residents (#3 and #8) were not abused by another resident (#12). The deficient practice could result in other residents being abused. Findings include: -Resident #3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer disease with early onset, anxiety, and a traumatic brain injury. The Minimum Data Set (MDS) dated [DATE] included a staff assessment mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the care plan dated January 23, 2023 revealed the resident had the potential for skin tears. On January 22, 2023, the resident had left shoulder swelling and abrasion of the left trapezium. On January 29, 2023 the resident had a one-centimeter open area on the back of his head. Interventions included that if skin tear occurs, treat per facility protocol and notify MD, family. A progress note dated January 22, 2023 revealed that the writer heard a loud noise down the hall, went to check what it was and saw resident #3 on the floor in resident #12's room near the dresser. The certified nursing assistants (CNAs) helped assist resident #3 up from the floor and redirected the resident back to his room. The resident was in bed resting. No injuries noted and neuro checks were started. A progress note dated January 29, 2023 at 8:45 p.m. stated that resident #12 came out of his room into the hallway and pointed at his room. The writer entered the room and found resident #3 on his buttocks on the floor near the bathroom door. Resident #3 was trembling, but there were no signs of seizure noted. The residents (#12 and #21) were both seen sitting on their beds. Resident #21 appeared concerned, and resident #12 noted to be relatively relaxed with no signs of aggression or agitation. The writer and co-nurse assessed resident #3 for any injuries and none noted at the time of the report. Range Of Motion (ROM) intact, neuros within limits. Staff slowly assisted the resident to a standing position and encouraged resident #3 to sit in a chair for further examination. The resident refused to sit in the chair and proceeded to walk in the hallway. The resident was showing signs of agitation, and continued to walk with close supervision. PRN (as needed) Ativan 0.5 ml (milliliter) given for agitation/restlessness. All responsible parties notified. Neuros continuing. Staff continuing to monitor. Resident was wearing non-skid socks at time of the fall. Review of the Order Summary Report revealed an order dated January 29, 2023 to monitor abrasion to back of head for serious symptoms of infection until healed. A progress note dated January 29, 2023 at 9:15 p.m. revealed that 2-hour post fall, staff noted blood from the back of resident's head, approximately one centimeter in length. Notified the Director of Nursing (DON) with orders to monitor and assess daily. Review of the care plan dated February 15, 2023 revealed resident #3 is an elopement risk/wanderer related to the resident wanders aimlessly. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and to reside on a locked unit due to wandering and elopement risk. -Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, anxiety disorder and heart failure. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 99, indicating the resident was not able to complete the interview. Review of the care plan dated February 9, 2023 revealed the resident is an elopement risk/wanderer related to the resident wanders aimlessly. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and to reside on a locked dementia unit. Progress note dated February 15, 2023 revealed that resident was ambulating and wandering in and out of other residents' rooms and when sitting in wheelchair, continues to get out of it. A progress note dated February 18, 2023 at 7:06 p.m. revealed that the writer was alerted by a CNA to resident #12's room. The writer entered the room and found resident #8 lying on the floor on his back. The resident's head was against the wall near the bathroom door. Upon inspection, a laceration was noted to the crown of his head: 4.5 x 0.5 x 0.1 centimeters. -Resident #12 was admitted to the facility on [DATE] with diagnoses that included undifferentiated schizophrenia, restlessness and agitation, and an anxiety disorder. The Minimum Data Set (MDS) dated [DATE] included a BIMS score of 99 indicating the resident was not able to complete the interview. A care plan dated February 18, 2023 revealed that the resident is/has the potential to be physically aggressive, related to dementia, history of harm to others, poor impulse control. On February 18, 2023 he kicked a resident in the stomach. Interventions included the resident triggers for physical aggression when his personal space is invaded, the belief that someone is approaching him to do harm. The resident's behaviors are deescalated by the intervention of staff, providing distractions like snacks and drinks, administer medications as needed, and to place a Velcro sign across the doorway to prevent others from wandering into the room. A progress note dated January 20, 2023 at 9:46 a.m. revealed that the night shift nurse reported that resident #12 was agitated and cussing at the new roommate last night. The resident was extremely territorial, not wanting anyone to come near him or in his room. The roommate is vulnerable and appears uneasy in the room. Reported behavior to administration. A progress note dated January 20, 2023 at 10:04 p.m. revealed that staff entered the room to pick up dishes and the resident started yelling, get the cup and get the fuck out of my room. The roommate was in resting in bed at the time and quickly got up and left the room. The behavior was reported to the administrator and staff was to continue to monitor the resident. A physician progress note dated January 29, 2023 revealed that the physician spoke with guardian who was able to provided that the resident had a history of significant physical aggression at prior placements against both other residents and staff members; had a history of elopement, at one facility he eloped out the window; and, used to live at another facility, from there he was placed at several group homes which he failed. According to the documentation, the guardian was unsure of the exact reason why the recent group home will not take him back; howver, belives that it was because he was cursing at other residents. He has a history of homelessness, history of Traumatic Brain Injury, alcohol dependence, cognitive impairment, and anxiety disorder. He has in the past refused medication which has led to decompensation and increase in physical aggression. A progress note dated January 30, 2023 at 9:29 a.m., revealed that the Psych provider was on the unit. This resident's roommate (resident #21) spoke with the provider, and made the statement that he witnessed resident #12 kick a man that came into their room. The provider sent out a message to leadership thread for further investigation. The psych provider met with resident #12 at this time. Per psych provider, resident #12 confirmed that he did kick a man after being threatened. Update was sent to leadership thread, continue awaiting instructions. A progress note dated January 30, 2022 at 9:42 a.m. revealed that the message received via thread from the DON. Social Services to follow up with residents regarding accusation. A progress note dated February 18, 2023 at 6:19 p.m. revealed that the resident continues 15-minute checks following an incident at approximately 3:05 p.m. when resident reported to staff that another resident was in his room and the other resident was found lying on the floor of the resident's room with a laceration to his head. Arizona Department of Health Services (DHS) notified via website at 4:53 p.m., DHS notified via website as well. Phoenix police (PPD) notified also, unable to give estimated time of arrival. One to one placed outside of resident's door for safety pending investigation. The staff will continue to monitor and await PPD arrival. A progress note dated February 18, 2023 at 7:28 p.m. revealed that at 3:00 p.m., resident #12 approached the nurse's desk asking to use the bathroom. He stated he could not use his own bathroom because there was a man in his room. The CNA entered the room to check and motioned for this writer. The writer entered the room and found resident #12 sitting cross legged on the bed and resident #8 lying on the floor. Resident #12 stated that the other resident came into his room and attacked him so he kicked him in the gut. 15-minute checks and one-to-one safety monitoring initiated. Facility documentation dated February 18, 2023 revealed a statement by a registered nurse (RN/staff #72), who stated that resident #12 stated that resident #8 attacked him and so resident #12 kicked resident #8 in the gut. Facility documentation dated February 20, 2023 revealed resident #12's statement in which he states that resident #8 wanted to fight and walked up to him while he was in bed, so he kicked him in the stomach. A physician's progress note dated February 23, 2023 at 2:37 p.m. revealed that upon exam, resident #12 is noted to be paranoid, states that another resident was trying to kill him and that he kicked him. An interview was conducted on February 23, 2023 at 2:15 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #12 was transferred from the dementia unit to the behavioral unit today at 12:30 p.m. A second interview was conducted on February 23, 2023 at 3:00 p.m. with the (DON/staff #1), who stated the resident #12 originally had a roommate, resident #21, who stated on January 30, 2023 that he was afraid of resident #12 because he had seen him kick another resident, but he was not able to describe the other resident. When asked if it was possible that resident #21 was referring to resident #3, who was found on the floor in resident #12's room on January 29, 2023, she stated that it was possible. She also stated that there was supposed to be Velcro stop sign across resident #12's door to prevent other residents from entering, but it was often missing and easy to pull down. An interview was conducted on February 23, 2023 at 3:20 p.m. with a certified nursing assistant (CNA/staff #84), who stated that there is supposed to be one CNA, who monitors the hall, and is supposed to walk up and down the hall, but staff are too busy. She stated that resident #12 had prior altercations with other residents prior to resident #8 being found on the floor in resident #12's room. She stated that staff knew that resident #12 was not appropriate for the dementia unit. She stated that prior to resident #8 being found on the floor in resident #12's room, he had already stated that he had pushed resident #3. An interview was conducted February 23, 2023 at 3:31 with a licensed practical nurse (LPN/staff #156), who stated that there are residents who wander and there are residents who are aggressive on the dementia hall. She stated that they try to keep one CNA in the hallway to monitor, but they are busy and there is not a specific CNA assigned to monitor the hall. She stated that resident #12 needed supervision all the time. (CNA/staff #10) joined the interview and stated that resident #12 came to the nurse's station and asked to use the bathroom because there was another resident in his bathroom. She went with resident #12 to his room and found resident #3 on the floor. She asked resident #12 what happened and stated that he told her that resident #3 tried to attack him and he kicked him in the gut. An interview was conducted on February 24, 2023 at 9:12 a.m. with the Social Services Director (SS/staff #2), who stated that resident #12's room change occurred yesterday on February 23, 2023 and he was moved from the dementia unit to the behavior unit. She stated that resident #12 was moved because of the incidents that occurred with other residents (#3 and #8). She stated that resident #12 is territorial and doesn't understand that the other residents mean him no harm. She also stated that the residents on the dementia unit should be monitored and should not be wandering in to other residents' rooms. She stated that when resident #3 was found in resident #12's room on the floor, she tried to interview resident #12, but he told her to get the fuck out of his room, resident #3 is nonverbal, and she talked to staff, but did not document anything. She stated that resident #12's roommate, resident #21, requested a transfer to another room because he was afraid of resident #12. On January 31, 2023, resident #21 stated that he saw resident #12 kick another male resident, but he was not able to identify the resident. She stated that when resident #8 was found on the floor in resident #12's room, resident #12 told her that he kicked him in the stomach. She stated that resident #12 had a history of being aggressive at other facilities. On February 24, 2023 at 3:12 p.m. an interview was attempted with resident #12, who stated that he wanted to be left alone. An interview was conducted on February 24, 2023 at 3:18 p.m. with resident #21, who stated that he feels a lot better know that he is no longer a roommate with resident #12. He stated that resident #12 scared him a lot because he saw him kick resident #3. The facility's policy, Abuse and Neglect Policy, revised December 2016 states residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interviews, facility investigations, and facility policy and procedures, the facility failed to ensure one resident (#5) did not physically abuse another resident (#6). The deficient practice could result in other residents being abused. Findings include: -Resident #6 was admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar disorder, adrenocortical insufficiency, conversion disorder with seizures or convulsions, violent behavior, and personal history of other mental and behavioral disorders. -Resident #5 was admitted on [DATE] with diagnoses that included Schizoaffective disorder, major depressive disorder, nicotine dependence, and essential hypertension; and was the identified alleged perpetrator. The interim care plan dated November 4, 2022 revealed the resident had no cognitive impairment and was taking antipsychotic/psychotropic medications. However, the interim care plan did identify behaviors and did not include interventions to direct staff on how to deal with aggressive behaviors of resident #5. The admission summary dated [DATE] included resident #5 was a smoker, was a little irritated that he did not have cigarettes. The physician order summary report revealed the resident was prescribed with the following antipsychotic medications: -Haloperidol 5 mg (milligrams) by mouth three times a day for psychosis (start date of November 4, 2022); and, -Latuda 40 mg two times a day for psychosis (start date of November 5, 2022) These medications were transcribed onto the MAR (medication administration record) for November 2022. However, the MAR revealed that on November 5, 2022, Haloperidol was not marked as administered on the night shift; and, Latuda was not marked as administered on the 8:00 a.m. and 2:00 p.m. shift. Both medications had a code of 9 that indicated to see progress notes. The administration note dated November 5, 2022 included that Latuda was pending delivery from pharmacy. Another administration note dated November 5, 2022 revealed Latuda was not available pending insurance approval; and that, the NP (nurse practitioner) was notified. Review of another administration note dated November 5, 2022 included that Haloperidol was not available; and that, delivery from pharmacy was pending. There was no evidence found in the clinical record that Haloperidol and Latuda was administered as ordered on November 5, 2022. A behavior report dated November 5, 2022 revealed that resident #5 attempted to reach and grab another resident; and that, staff had to get in-between the two residents. The documentation also included that resident #5 said he was trying to get the other resident's hat; and that, a staff asked the resident to keep his hands to his self. The report did include that the physician/provider was notified. A nursing note dated November 5, 2022 included that at approximately 7:25 a.m., the CNA (certified nurse assistant) reported that resident attempted to reach out to grab another resident while in the hall way. Per the documentation, the CNA got in between and resident #5 stated that he was trying to get the other resident's hat. It also included that the CNA attempted to redirect the resident who chose to wait for breakfast by the dining room door. The documentation did not indicate that the physician/provider was notified of the resident #5's behavior. A nursing note dated November 5, 2022 included that at approximately 2:00 p.m. resident #5 demanded to go outside during the smoke break was very agitated for not having cigarettes and was yelling/cursing at staff. Per the documentation, resident #5 stated fuck you I'm getting the hell out of here! You want me to jump the fence to get some 'cigs' I can do it if you want me to. Further, the note included the resident threw the ashtray bucket over the patio fence, went back inside the unit, punched the trash can, went to his bedroom and slammed his door shut. According to the documentation the provider and the psych NP were notified. A nursing note dated November 6, 2022 included that all medications were administered without difficulty and staff will continue to monitor. However, the MAR documentation on November 6, 2022 revealed the MAR coded 1 indicating absent from home without meds for Haloperidol on three shifts and for Latuda on two shifts. A care plan was initiated on November 6, 2022 for behavior problems related to aggressive behavior with a history of resident to resident incidents. The goal was that the resident would have fewer episodes of aggressive behavior. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, intervene as necessary to protect the rights and safety of others, divert attention, remove from situation and take to an alternate location as needed, and to intervene before agitation escalates. A behavior report dated November 6, 2022 included that resident #5 told staff that the next time staff say huh to him, he was going to get aggressive with her. Another behavior note dated November 6, 2022 revealed the resident threatened to get physical with staff due to staff inability to understand him. The documentation did not include that the provider was notified. In another behavior note dated November 6, 2022 it included the resident was in the room throwing a trash can and a chair; and was yelling and screaming at staff. Per the note, the resident continued to yell out at staff, redirection was given but was not effective. The documentation did not include that the provider was notified of the resident's aggressive behavior. A nursing note dated November 6, 2022 included that on November 5, 2022 at approximately 5:30 pm, resident #5 was by nurses' station yelling and was demanding for cigarettes. The note included that resident #5 threw a spoon at the door; and, another resident (#8) yelled at resident #5 from the hall telling resident #5 to shut up and behave! The documentation included that resident #5 yelled back don't tell me to shut up!; and, ran towards resident #8 to try to strike at her. The note included that staff was able to get the female resident out of the way and resident #5 went to his bedroom, was laughing talking to self; and that, the staff continued to monitor resident #5 closely. Despite documentations that smoking triggered the resident's aggressive behaviors, smoking was not addressed in the care plan. A nursing note dated November 6, 2022 revealed that at approximately 6:10 a.m. resident #5 was sitting on a chair in the hallway yelling and cursing at staff; and was cursing another resident who was pacing in the hallway. The note also included that resident #5 yelled I will fuck all you pussies up! There's no fucking men down here. According to the documentation, staff attempted to deescalate resident #5; but was not effective. Despite the resident #5's escalating aggressive behavior towards staff and other residents, there was no evidence found in the clinical record that the provider was notified after each these episodes. Another nursing note dated November 6, 2022 included that resident #5 was in the hallway yelling/cursing at staff; and, at approximately 6:25 a.m. another resident (#6) yelled from his bed and told resident #5 .shut the fuck up. According to the documentation, resident #5 quickly went into resident #6's bedroom and got on top of him, punched the resident (#6) in the face multiple times. The note included that 911 was called immediately and extra staff was called to the unit to assist in de-escalation. It also included that resident #5 sat in wheelchair by unit exit door for a few minutes and then went to his bedroom willingly. According to the documentation, the administrator, DON (Director of Nursing), Psych NP (Nurse Practitioner), and medical provider were all notified; and, at 7:05 am resident #5 was escorted by police out of the facility. A review of another nurse progress note dated November 6, 2022 at 12:57 p.m. (approximately 6 hours after the incident) included that resident #6 had complained of chest pain and pain/blurriness to right eye, the physician was notified and an order was received to send resident #6 to the ER (emergency room) via non-emergency transport for a CT (Computed tomography Scan) and CXR (chest x-ray). A psychiatric evaluation dated November 6, 2022 revealed staff reported resident #5 became angry in the morning of November 6, 2022 and had entered the room and hit resident (#6) in the face. The evaluation included that the NP recommended against accepting the resident back to the facility given his high level of physical aggression despite multiple psychiatric medications. A facility investigation dated November 11, 2022 included that resident #5 had a behavior problem related to aggressive behavior with a history of resident to resident incidents. The investigation included that resident #6 was assessed, had abrasions to the bridge of nose, right cheek, left and right forehead; and was given medication for reported discomfort and pain. The investigation included that due to the diagnoses and behaviors of both residents (#5 and #6) in the high acuity unit, the quick escalation of behaviors can occur and was expected. It also included that both residents had a history of verbal and physical aggression towards staff and residents. Interventions in place to de-escalate did not help. The investigation also included an interview with a CNA (certified nursing assistant) who reported that the doors to the resident rooms should have been shut to protect them while resident #5 was agitated. Further review of the facility investigation revealed that due to the diagnosis and behaviors of residents in high acuity unit, quick escalation of behaviors can occur and was expected; and that, interventions in place to de-escalate did not help resident #5 as he became aggressive towards staff as well. The report included that the facility determined that interventions placed will protect resident #6 and other residents from incidents to occur; and, was unable to substantiate abuse or neglect. An interview was conducted on January 5, 2023 at 1:05 p.m. with a CNA (staff #16) who stated she tries to read the admission paperwork to identify behaviors and triggers of residents being admitted on the high acuity behavioral unit; and that, the triggers and behaviors are communicated to the staff so they know how to approach them. Staff #16 also stated that rounding on the unit is completed every 10-15 minutes. Regarding resident #5, the CNA stated she was present when resident #5 was admitted ; and that, resident #5 was unkempt and looked wild; however, resident #5 was happy to be home because he had been at the facility before. Staff #16 stated resident #5 had been very aggressive; and trigger points for resident #5 included not being able to smoke, being told no, and other residents yelling at him. Staff #16 stated that based on the reviewing of resident's behavior from admission to the morning of November 6, 2022, resident #5 had been escalating. Staff #16 stated there was one regular staff and two agency staff working the unit the morning of November 6, 2022; and, they did not see the triggers. During an interview with a psychiatry NP (staff #22) conducted on January 5, 2023 at 2:26 p.m. the NP stated she was part of the admission process for resident #5; and her acceptance of a resident is based on medication compliance and recent physical aggression. Staff #22 stated that when resident #5 was admitted not all of his notes were beautiful; but, there was room with his medications to make adjustment if needed. Staff #22 stated the resident sort of laughed and his behaviors were sandwiched around good nights so she felt the resident was doing well; and, she knew he had a history of being verbally aggressive. The NP stated that prior to the resident hitting resident #6 in the face she was notified on November 6, 2022 about the behaviors of resident #5. The NP also said that cigarettes were a trigger for the resident in the past; and that, missed doses of medications were not good for him. An interview was conducted with a registered nurse (RN/staff #28) on January 5, 2023 at 3:14 p.m. The RN stated that she was completing a medication administration in the hallway and noted the female resident yelling to herself. Staff #28 stated that she did not know what triggered resident #5 the evening of November 5, 2022 but she just saw him going after the female resident who was removed from the area and was monitored until resident #5 de-escalated. Regarding the incident on November 6, 2022, the RN said she was getting report when she noticed resident #5 yelling in the hallway and she tried to get resident #5 away from other resident's doorways but resident #5 would not budge. The RN stated that was when resident #6 yelled out from his room because resident #5 woke him up; and then resident #5 ran into the room and jumped onto resident #6. During an interview conducted with the Director of Nursing via phone (DON/staff #33), the Assistant Director of Nursing (ADON/staff #40), and the Administrator (staff #37) on January 6, 2023 at 11:35 a.m., the DON stated the expectation was when admitting a resident to the behavior unit, staff had to review the medical record; and that, the staff on the unit have the experience to handle aggressive behavior and use de-escalation. The DON stated the expectation was that staff would call for assistance or the police when a resident continues to have aggression towards the staff and other residents and when de-escalation techniques were not working. The DON also stated that when the staff get the resident to calm down and keep other residents safe, staff will call the provider and document the notification of the behaviors. The DON stated she did not recall seeing much aggression from resident #5 in the hospital records but she knew the staff were concerned about his physical aggression. She stated that after the first aggression towards residents on November 5, 2022 the provider should have been notified. The Administrator who was present during the interview stated there were text messages to the provider but nothing documented in the electronic record that included details of what was discussed. The DON stated she thinks the doors to other resident rooms should have been closed when resident #5 was yelling up and down the hallway. The DON stated that the staff did get an order for Haldol PRN (as needed) after the incident for running in the hallway but it was not documented in the chart. The DON stated that there were communications with the nurse practitioner and the staff were instructed to keep monitoring and de-escalating the situation; and that, there was a huge delay in medications. A facility policy titled Behavioral Assessment, Intervention, and Monitoring (revised March 2019) included that the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individuals' mental status, behavior, and cognition, including onset, duration, intensity and frequency of behavioral symptoms. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Continued review of the policy included that interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, at a minimum: -Description of the behavioral symptoms; -Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; -The rationale for the interventions and approaches; -Specific and measurable goals for targeted behaviors; and, -How the staff will monitor for effectiveness of the interventions. A facility policy titled Abuse Policy (reviewed/revised September 2022) included that the residents have the right to be free from abuse and includes but not limited to freedom from verbal, mental or physical abuse. Abuse is the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. The administration will protect residents from abuse by anyone including other residents.