**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#5 and #12) of 14 residents were free from verbal abuse out of 27 sample residents.Resident #5 was admitted to the facility's secured unit with diagnoses of frontal temporal neurocognitive disorder (type of dementia that leads to changes in personality, behavior and language), Huntington's disease (progressive breakdown of the nerve cells in the brain), dementia with behavioral disturbances, tremors, and depression on 6/25/25. Despite the prison referral paperwork that identified Resident #5 had aggressive behaviors, the facility admitted the resident to the secured unit from prison. The resident had spent the majority of his life in prison or homeless. The prison's physician recommended that the resident have a one-on-one caregiver for an adjustment period. However, record review and observations revealed the facility did not consistently implement the one-to-one caregiver.Documentation revealed Resident #5 had verbally aggressive behaviors towards other residents on the secured unit. Observations revealed Resident #5 was aggressive, yelling, screaming and shaking his fists in the faces of residents and staff. He was observed placing his face inches away from Resident #12's face while screaming profanities at him. The facility staff were unable to redirect Resident #5 effectively. Resident #4 said she was afraid of Resident #5 and hid in her room. A staff member locked another resident out in a courtyard due to the concern that their PTSD (post traumatic stress disorder) would be triggered due to Resident #5's behaviors. On 7/21/25 the facility staff called the local police department to come help with Resident #5. Resident #5 was taken to a local hospital and placed on an M1 hold (a mental health hold due to someone being at risk of harm to themselves or others). Specifically, the facility failed to protect Resident #4, Resident #12 and other residents on the secured unit from verbal and physical abuse by Resident #4, which led to Resident #4 hiding in her room due to fear. Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy 6/1/25, was provided by the nursing home administrator (NHA) on 7/24/25 at 2:42 p.m. via email. It read in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Possible indicators of abuse include, but are not limited to: Verbal abuse of a resident overheard. Psychological abuse of a resident observed. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.II. Resident #5 (assailant)A. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included frontal temporal neurocognitive disorder, Huntington's disease, dementia with behavioral disturbances, tremors and depression. The 6/30/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of zero out of 15. He had hallucinations. He had physical behavioral symptoms directed towards others such as hitting, kicking, pushing, scratching and grabbing. He had verbal behavioral symptoms directed toward others such as screaming, threatening, and cursing. The resident required supervision with oral hygiene and bathing. B. Record reviewThe admissions paperwork from the State Department of Corrections revealed the following:Resident #5 had been incarcerated on 7/20/23 until he was admitted to the facility on [DATE]. On 12/4/24 the prison physician wrote Resident #5 was not appropriate for the general prison population given his severe dementia and erratic behaviors around others that were consistent with those seen in dementia patients.On 6/23/25 the facility sent an invoice to the prison for $4,200 for a one-to-one sitter, for five hours a day, for four weeks, for 30 hours. The NHA said the facility decided against billing the prison for a one-to-one sitter for Resident #5. The NHA said the facility did not collect money from the prison for the one-to-one service (see interview below). On 6/24/25 the prison physician's discharge letter was sent to the facility's admission department. It documented Resident #5 required a one-to-one caregiver and he had a diagnosis of alcohol abuse disorder with mental, behavioral and neurological disorders. The discharge letter suggested a one-to-one caregiver for Resident #5 until he acclimatized to the new environment. Resident #5 had severe dementia with intermittent agitation. The comprehensive care plan, implemented 6/29/25, revealed Resident #5 had behavioral problems and impulsivity due to his dementia. The care plan documented he displayed physical/verbal outburst due to his history of dementia with behavioral disturbance. He frequently paced in the hallway, common area, and in his room. The care plan documented the resident could become increasingly agitated with eye contacts, overstimulation, lights, wandering residents into his room or private space. The goal for Resident #5 was to have fewer behavior episodes daily and weekly. The interventions included anticipating and meeting the resident's needs and assisting him to develop appropriate methods of coping and interacting.The 6/30/25 secured unit placement progress note documented the resident exhibited severe behavioral symptoms including frequent physical and verbal aggression toward staff and other residents, such as hitting walls, throwing objects, and using threatening language. These behaviors posed a significant safety risk that could be managed safely on the facility's general unit despite ongoing non-pharmacological interventions and medication adjustments. The resident demonstrated cognitive impairment with poor impulse control, unpredictable agitation and required constant supervision to prevent harm to self or others. Attempts at redirection and de-escalation had been insufficient, necessitating a more controlled and secure environment to ensure the safety and well-being of the resident and others in the facility.No alternatives were attempted prior to the secure unit placement, as this was deemed the least restrictive and necessary approach to ensure the resident's safety and well-being.Review of the progress notes from his admission on [DATE] through his discharge on [DATE] revealed the following: The 6/25/25 admission note documented Resident #5 made many strange vocalizations, when agitated he swears and hits walls. He was known to throw his food tray. He had a preadmission assessment screening and resident risk review (PASARR) Level II, which indicated the resident had a potential serious mental illness (SMI), intellectual disability (ID) or developmental disability (DD).The 6/25/25 social services progress note documented Resident #5 was somewhat cognitively scattered, fidgety, flighty and rambunctious. The 6/26/25 incident progress note documented at approximately 6:10 p.m. revealed Resident #5 started to slam his room door and screamed at his roommate to get out of his bed. The roommate started a heated argument with Resident #5. The nurse stood in between the residents and called for help. No physical violence occurred. The roommate of Resident #5 was moved to another room until the morning.The 6/28/25 nursing progress note documented at 3:41 p.m. revealed Resident #5 swore at one of the residents and told other residents that he was going to kill you. Resident #5 continued to call a resident obscenities. The 6/28/25 nursing progress note documented at 5:00 p.m. revealed Resident #5 exhibited escalating agitation, which included yelling, using profanities toward staff and other residents, banging on walls and he removed pictures from the walls. Multiple nursing interventions were implemented, including redirection, one-to-one supervision, a quiet environment was provided for the resident with calming music and snacks were offered. These measures were not successful in de-escalating the resident's behavior. Prior to dinner, the resident's agitation intensified. He began pacing and roaming the hallways and ultimately threw a chair over the nurses' station barrier. The chair did not strike anyone and no injuries occurred. The medical director (MD) was notified. The 6/28/25 nursing progress note documented at 8:31 p.m revealed the resident's agitated behavior persisted through the dinner hour with continued verbal outbursts and restlessness.The 6/29/25 behavioral progress note documented at 9:50 a.m. revealed Resident #5 was verbally and physically aggressive towards residents and staff. The note documented that all attempts to de-escalate and distractions were ineffective. Resident #5 was spitting, kicking the wall and nurses' station entry door. Resident #5 also punched walls and opened other residents' doors. The resident was observed physically swinging at different residents as they passed by or attempted to enter or exit their own rooms. The resident continued being very agitated and was yelling obscenities at various staff members. The resident entered his room and barricaded the door, and continued hitting the doors and walls while in his room, also he forced the roommate out, denying him access to his room.The 6/29/25 nursing progress note documented at 11:15 a.m. revealed Resident #5 was observed kicking other residents' doors and he punched the wall near the dayroom. He exhibited erratic and aggressive behaviors and made some negative statements toward staff. The resident was placed on 15-minute checks for his safety.The 6/29/25 behavioral progress note documented at 3:18 p.m. revealed Resident #5 was on 15-minute checks. He had punched the wall, kicked doors, verbally abused staff and used obscenities. The nurse instructed the certified nurse aides (CNA) to maintain a safe distance from Resident #5 because his actions were unpredictable. The resident continued to walk from his room to the common area while he screamed, punched a wall and punched doors of various residents. The staff attempted verbal redirection but Resident #5 resisted their attempts. The 6/30/25 nursing progress note documented at 2:25 p.m. revealed Resident #5 was agitated when another resident tried to get into his room. Resident #5 swore and called the resident obscenities. The 7/1/25 social services progress note documented at 2:29 p.m. revealed Resident #5's mood and behaviors escalated quickly without minimal observable triggers. Redirection interventions were only temporarily effective. The care plan was updated to reflect current behaviors and interventions.The 7/2/25 nursing progress note documented at 11:04 a.m. revealed while the nurse was seated with residents in the common area, Resident #5 yelled at another resident who had wandered in the hallway towards his room. Resident #5 attempted to swing at another resident and the nurse intervened to keep the residents from fighting. Resident #5 had paced the hallway all shift and was not easily redirected.The 7/2/25 social services progress note documented at 4:33 p.m. revealed Resident #5 had been aggressive towards staff and also had a verbal altercation with another resident who had accidentally wandered into his room. The 7/3/25 nursing progress note documented at 6:02 a.m. Resident #5 had been aggressive on the overnight shift, used profanities towards staff and threw a chair and a cup at staff. Resident #5 slammed doors on the unit and started flooding a sink. The nurse was concerned for the safety of other residents. The nurse attempted to calm him down but he continued to throw chairs while other residents were near. Resident #5 threw items at the CNAs. The CNAs attempted to keep the residents away from him. The 7/3/25 nursing progress note documented at 12:03 p.m. revealed Resident #5 walked down the hallway and urinated in the hallway three times. He swore at two residents who were seated together. The social services director (SSD) came to the secured unit to help and redirect Resident #5 to his room, where he urinated on the SSD. The CNAs said Resident #5 attempted to throw coffee on other residents.The 7/3/25 social services progress note documented at 1:16 p.m. revealed Resident #5 sat in the common area agitated and he cursed. The 7/4/25 nursing progress note documented at 2:37 p.m. revealed Resident #5 was agitated, swore and called another resident obscenities. Resident #5 continued to urinate on the floor of his room and in the hallway.The 7/8/25 nursing progress note documented at 8:06 p.m. revealed Resident #5 was put a on-one to-one caregiver due to increased agitation.The 7/9/25 nursing progress note documented at 7:51 p.m. revealed Resident #5 was on a one-to-one caregiver due to increased agitation. The 7/11/25 nursing progress note documented at 6:18 p.m. revealed Resident #5 called another resident profanities, ripped a board off of a wall and threw it and a chair towards the nurses' station. Resident #5 tried to swing and kick at a resident but missed the resident.The 7/12/25 nursing progress note documented at 9:48 a.m. revealed Resident #5 yelled obscenities at a female resident. Staff tried to intervene but Resident #5 kept yelling at a female resident, Why are you here (profanity)? The 7/12/25 nursing progress note documented at 3:27 p.m. revealed Resident #5 yelled racial obscenities at other residents. The CNA tried to protect a resident but Resident #5 continued with his agitation and said why are you protecting him? Staff were unable to redirect Resident #5. The 7/13/25 nursing progress note documented at 9:37 a.m. revealed Resident #5 threw a coffee cup at a CNAs arm. The 7/13/25 nursing progress note documented at 11:42 p.m. revealed Resident #5 had behavior issues all through the shift and was not easily redirected. Resident #5 called staff and other residents swear words and racial slurs. Resident #5 slammed doors, threw chairs, tables, and plates without provoked reasons. Resident #5 was not able to be redirected and became a threat to staff and other residents. The 7/14/25 nursing progress note documented at 5:34 a.m. revealed Resident #5 threw chairs at other residents. Resident #5 urinated on the floors and walls.The 7/14/25 nursing progress note documented at 9:41 a.m. revealed Resident #5 was restless, agitated, hit doors and walls and swore. Resident #5 went behind a male resident who was seated at a table and swore at the resident and attempted to pull the chair out from under the male resident. The 7/14/25 nursing progress note documented at 11:59 a.m. revealed Resident #5 slammed doors, yanked on curtains and attempted to kick another resident but staff intervened. The 7/15/25 nursing progress note documented at 2:06 p.m. revealed Resident #5 urinated in the dining room and swore at another resident. The 7/15/25 nursing progress note documented at 9:32 p.m. revealed Resident #5 made continued remarks at another resident and said Why are you praying (profanity)? and then proceeded to call the resident racial slurs. The 7/18/25 nursing progress note documented at 3:19 p.m. revealed Resident #5 and another resident shoved each other. The nurse and a CNA intervened and there were no injuries. The 7/18/25 nursing progress note documented at 7:47 p.m. revealed Resident #5 called residents several obscenities. Staff were unable to redirect Resident #5. The 7/19/25 nursing progress note documented at 9:17 a.m. revealed Resident #5 was in the hallway, slammed and kicked doors and called people obscenities. The 7/19/25 nursing progress note documented at 9:20 a.m. revealed Resident #5 backhanded a CNA.The 7/19/25 nursing progress note documented at 4:15 p.m. revealed Resident #5 threw dishes down the hallway on the secured unit at employees and screamed obscenities. The MD was notified who stated he could not do anything else for Resident #5. The 7/21/25 nursing progress note documented at 3:26 p.m. revealed Resident #5 became more active after 3:00 p.m. and intermittently made inappropriate comments to other residents and staff. The 7/21/25 nursing progress note documented at 7:41 p.m. revealed the staff thought Resident #5 stated he would end his life tonight and the staff thought he had a butter knife. The police were called and they took Resident #5 out of the facility. Resident #5 was taken to a local hospital and placed on an M1 hold for suicidal ideation. Resident #5 did not return to the facility.C. Observations On 7/21/25 at approximately 4:00 p.m. Resident #5 was in the common area of the secured unit. Resident #5 was agitated and moved frantically throughout the common area. Resident #5 continued to run throughout the common area while residents were also in the room. Registered nurse (RN) #1 made several unsuccessful attempts to redirect Resident #5. Resident #5 was not on a one-to-one caregiver for supervision. RN #1 and two CNAs were on the unit who were also caring for the other residents. Resident #5 stopped several times and put his face within three to six inches of Resident #12's face and yelled profanities at Resident #12. Another resident was observed outside in the courtyard and he attempted to open the glass door to reenter the common area but the door was locked. RN #1 said she kept that resident locked outside while Resident #5 was frantic and yelling obscenities. RN #1 said the resident that was outside had PTSD (post traumatic stress disorder) and he was kept outside for his safety. RN #1 said she was concerned that Resident #5 would trigger the PTSD of the resident that was outside. All three staff members tried to redirect Resident #5 without success.D. Resident #5's representatives interviewResident #5's representative was interviewed on 7/21/25 at 3:00 p.m. via telephone. The representative said they had not seen Resident #5 in many years. The representative said Resident #5 had spent most of his life in prison and if not in prison, he preferred to be homeless. The representative said Resident #5 often lived on the streets until he was found by police to have broken his parole and then he returned to prison. The representative said she hoped he was not threatening other residents. III. Resident #4 (victim) A. Resident statusResident #4, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the July 2025 CPO, diagnoses included hypertension (high blood pressure), renal insufficiency, anxiety disorder, bipolar disorder (mental disorder), and dementia. The 7/16/23 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required substantial assistance with showering. She was independent with eating, toileting, and dressing. B. Resident interviewResident #4 was interviewed on 7/21/25 at 11:00 a.m. Resident #4 said she had a mental health situation and preferred to live in a secured unit because it was safe and calm. Resident #4 said that she and the others were often threatened verbally by Resident #5. Resident #4 said Resident #5 could get all of the residents on the secured unit in a nervous uproar. Resident #4 said Resident #5 threw items such as coffee cups and used profanities at her, calling her several different swear words. Resident #4 said she did nothing to provoke Resident #5. Resident #4 said she was afraid of Resident #5 so she stayed in her room more to avoid him.Resident #4 was interviewed again on 7/22/25 at 10:15 a.m. (the day after Resident #5 was removed from the facility by the police). Resident #4 said she was in the dining room last night, when all of the residents were moved into a corner of the dining room for their safety when Resident #5 was frantically moving around the room and yelling. Resident #4 said the police came into the secured unit and the police tried to speak to Resident #5. Resident #4 said Resident #5 punched the policeman. Resident #4 said the police immediately put handcuffs on Resident #5 and made him sit on the floor against the wall. Resident #4 said the ambulance workers came into the unit with a gurney, put Resident #5 on the gurney and took Resident #5 away. Resident #4 said she was relieved that she and the other residents were now safe. Resident #4 said it was not fair to the residents or the staff to put a man like that in the facility. IV. Resident #12 (victim)A. Resident statusResident #12, age less than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included slurred speech, hypertension (high blood pressure), a history of falling, anxiety disorder, cognitive communication deficit, and unspecified dementia with other behavioral disturbances. The 7/10/25 MDS assessment revealed the resident had short and long term memory problems. The resident had severe impairment with cognitive skills for daily decision making, delusions, behavioral symptoms not directed at others, and wandered daily. He was dependent on staff for oral hygiene, toileting, and showering.V. Staff interviewsCNA #1 and CNA #2 were interviewed together on 7/21/25 at 10:30 a.m. Both CNAs said Resident #5 was dangerous to the residents and staff. The CNAs said he was very hard to redirect. The CNAs said generally on the secured unit there were two CNAs and one nurse. The CNAs said Resident #5 was not usually watched by another staff member for one-to-one care. The CNAs said the secured unit generally had three staff members, one nurse and two CNAs. The CNAs said it was up to the three staff members on the secured unit to care for all of the residents as well as to watch Resident #5 closely because of his aggressive behaviors.RN #1 was interviewed on 7/21/25 at 10:40 a.m. She said the general staffing of the secured unit was two CNAs and one nurse. RN #1 said the three staff members were expected to care for all the residents as well as help with Resident #5's behavioral outbursts. RN #1 said when the social worker did stay with Resident #5 one-to-one, it helped keep Resident #5 calm but that did not happen every day. RN #1 was interviewed again on 7/21/25 at 4:00 p.m. RN #1 said the staff tried to do their best to redirect Resident #5, but it was very difficult to do and care for the other residents on the secured unit at the same time. RN #1 said Resident #5 was a toddler times 24 with his behaviors. RN #1 said in order to keep residents safe from Resident #5 she locked a male resident outside in the memory care courtyard. RN #1 said she was concerned the resident outside had PTSD and Resident #5's behavior might trigger a response.The director of marketing was interviewed on 7/22/25 at 4:55 p.m. The director of marketing said she did a zoom call to interview Resident #5 from prison to determine if he was okay to admit to the memory care unit of the facility. The director of marketing determined he should be admitted to the facility. The DON was interviewed on 7/23/25 at 10:45 a.m. The DON said the director of marketing accepted Resident #5 from the department of corrections. The DON said she was told Resident #5 would be admitted to the facility into the memory care unit. The DON said she disapproved of the admission of Resident #5. The DON said she watched a video of Resident #5 in his prison cell. The DON said Resident #5 did not do an interview with facility staff before his admissions that she was aware of. The DON said she did not think Resident #5 was able to provide an interview due to his cognition.The SSD was interviewed on 7/22/25 at 3:35 p.m. The SSD said she was not included in the decision making process to admit Resident #5 into the facility, nor the memory care unit. The SSD said she had sat with Resident #5 one-to-one, but it was not ongoing.The clinical nurse consultant (CNC) was interviewed on 7/23/25 at 1:00 p.m. The CNC said she did not know why the director of marketing accepted Resident #5 from prison with his behaviors. The CNC said the facility now had a plan for admissions into the facility and admissions onto the memory care unit (see facility follow-up below). The CNC said the plan would fix the situation so that accepting someone with aggressive behaviors did not happen again. The NHA was interviewed on 7/23/25 at 4:30 p.m. The NHA said she did not know why the director of marketing accepted Resident #5 for admission into the facility's memory care unit. The NHA said she trusted the director of marketing's decision. The NHA said the facility did not implement a one-to-one caregiver. The NHA said she did not remember why the facility decided not to bill the prison for a sitter. The NHA said the invoice was in Resident #5's electronic medical records (EMR) but it was never acted upon. The NHA said Resident #5 was not provided with a one-to-one caregiver while Resident #5 was admitted to the facility, but it was not consistent. The NHA said Resident #5 would not return to the facility from the hospital. VI. Facility investigation and follow-upOn 7/22/25 at 2:30 p.m. the CNC provided a facility plan for admissions. The document revealed in pertinent part, On 7/21/2025, Resident #5, who had a known history of behavioral issues, exhibited repeated episodes of aggressive behavior on the secure memory care unit. While no physical harm was reported, Resident 5's behavior had the potential to cause emotional distress and fear among other residents. The staff failed to implement immediate behavioral interventions or relocate the resident, resulting in the potential for an unsafe environment for vulnerable residents and failure to ensure their right to live free from abuse and distress. This constituted a concern for the psychological well-being and safety of residents in the secure unit.The plan documented that all affected residents would be assessed by nursing and social services for emotional or psychological distress (implemented 7/22/25).The plan documented that weekly behavioral rounds would be conducted by the interdisciplinary team and resident-to-resident incidents would be reviewed daily in stand-up meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure supervision, and monitor assistive devices and interventions to prevent accidents for three (#1, #8 and #9) of 10 residents reviewed for accidents out of 12 sample residents. Resident #1 was admitted to the facility for long term care on 9/13/23 with a diagnosis of dementia and repeated falls. The resident's care plan directed the staff to utilize a hoyer lift (mechanical lift) for transfers. On 2/25/25 Resident #1 was noticed to have an injury of unknown origin which was discovered to be a fractured ankle. The facility investigation revealed the staff had not been utilizing a hoyer lift to transfer Resident #1, which was indicated on the resident's plan of care and physician's orders. The facility failed to follow physician's orders and properly transfer Resident #1, which led to the resident sustaining a fracture of the left ankle. Resident #8 was admitted to the facility for long term care on 5/16/24 with a diagnosis of dementia. The resident's care plan identified the resident often sat on the floor next to her bed and would crawl on the floor. The care plan indicated a fall mat was to be placed next to the resident's bed at all times when she was in bed. On 3/21/25 certified nurse aide (CNA) #4 was providing care to Resident #8. CNA #4 did not place the fall mat on the ground when he left Resident #8's room. The resident fell out of bed and onto the floor which resulted in a right shoulder clavicle fracture, a fracture of the nasal bone, a large skin tear to the right elbow and superficial abrasions to both knees. The facility failed to ensure the identified person-centered interventions were consistently implemented for Resident #8, which led to the resident sustaining a fall with major injury. Resident #9 was admitted to the facility for long term care on 3/20/25 with a diagnosis of dementia and nicotine abuse. On 3/30/25 the facility implemented a wander guard due to the resident's increased wandering. On 4/6/25, another resident provided Resident #9 with a cigarette and deactivated the door alarm so Resident #9 could leave the facility without sounding the alarm. While Resident #9 was outside, he fell and sustained multiple closed fractures of the facial bone, a closed head injury, multiple abrasions and a closed fracture of one rib on the left side. The facility implemented a plan of correction after Resident #1 sustained a fracture of the left ankle and after Resident #8 sustained a clavicle fracture, nasal bone fracture, a large skin tear to the right elbow and superficial abrasions to both knees. However, the facility failed to implement an effective plan to address accident hazards. Findings include: I. Facility policy and procedure The Accident and Supervision policy, revised April 2025 was provided by the interim nursing home administrator (INHA) on 4/7/25 at 3:03 p.m. via email. It revealed in pertinent part, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); implementing interventions to reduce hazard(s) and risk(s); and monitoring for effectiveness and modifying interventions when necessary. Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident. Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Identification of hazards and risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. Implementation of interventions - using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes communicating the interventions to all relevant staff, assigning responsibility, providing training as needed, documenting interventions, ensuring that the interventions are put into action and ensuring interventions are based on the results of the evaluation. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, anorexia, major depressive disorder, chronic obstructive pulmonary disease (COPD), chronic kidney disease, repeated falls and muscle weakness. The 2/17/25 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory problems and was severely impaired in decision making skills, per staff assessment. The resident was dependent on staff for eating, oral hygiene, toileting, bathing, personal hygiene and upper and lower body dressing. B. Incident investigation The facility investigation was provided on 4/7/25 at 12:00 p.m. by the director of nursing (DON). The investigation documented that on 2/27/25 at approximately 7:15 a.m. a CNA went to assist Resident #1 to get out of bed and into her wheelchair. The CNA said, along with another CNA, they transferred the resident with two people. The CNAs put their arms into a locked position on either side of Resident #1 and lifted her into her wheelchair. The two CNAs did not use a hoyer lift, per physician's orders or the resident's plan of care. After they transferred the resident, one of the CNAs noticed Resident #1's ankle appeared abnormal. The CNAs notified the registered nurse (RN). Upon the RNs assessment it was determined to send Resident #1 to the hospital. C. Record review The activities of daily living (ADL) care plan, revised 10/31/24, revealed Resident #1 had a self-care performance deficit related to Alzheimer's dementia, fatigue and impaired balance. Pertinent interventions included the resident was dependent on two or more staff for all transfers using a hoyer lift and the staff were to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. D. Record review The 2/27/25 hospital record documented Resident #1 sustained a closed fracture of the lower end of her left tibia (shin bone). The note documented the resident had severe dementia. A splint was applied to the resident's leg as it was determined the resident was on hospice services and was not a surgical candidate. E. Plan of Correction The facility's plan of correction was provided by the DON on 4/7/25 at 12:00 p.m. It read in pertinent part, On 2/27/25 Resident #1 was sent to the emergency room and was diagnosed with a fracture of her left ankle. The DON and the INHA initiated an investigation. The facility conducted a full house audit to determine which residents required extensive and total assistance. The resident's care plans were reviewed. The facility determined all residents that required extensive/total assistance were at risk. The facility provided education to the nursing staff that included utilizing the residents' care plan. The facility implemented a flow sheet that was driven by the residents' plan of care. The flow sheet indicated the residents' transfer statuses and other personalized safety interventions. The DON or designee conducted random audits following the injury. F. Staff interviews CNA #1 and licensed practical nurse (LPN) #1 were interviewed together on 4/7/25 at 12:30 p.m. They said after Resident #1 sustained a broken ankle, all of the nursing staff were trained to use the hoyer lift for Resident #1's transfers at all times. The assistant director of nursing (ADON) was interviewed on 4/7/25 at 1:55 p.m. The ADON said after Resident #1 sustained an ankle fracture, several staff members were interviewed in regards to how they transferred Resident #1 from her bed to her wheelchair and from her wheelchair to her bed. The ADON said all of the staff that were interviewed revealed no one used a hoyer lift to transfer the resident. The ADON said the staff said they transferred the resident with a two person assist. The ADON said that meant two staff members conducted the transfer, where there was a staff member on either side of the resident. She said the two staff members locked arms with the resident and transferred Resident #1. The ADON said the staff had not read the care plan or the physician's order that indicated the resident was to be transferred by a hoyer lift. The DON was interviewed on 4/7/25 at 12:00 p.m. The DON said she interviewed all of the nursing staff that provided care to Resident #1 after the resident sustained an ankle fracture. The DON said none of the staff were aware that Resident #1's ankle was swollen prior to 2/27/25. The DON said all of the staff said they transferred the resident with a two person assist and did not utilize the hoyer lift. The DON said after interviewing the nursing staff, she determined the resident sustained an ankle fracture due to the staff not following the care plan, which indicated to use a hoyer lift to transfer Resident #1. The DON said the problem was the facility staff's fault due to miscommunication with staff not utilizing the hoyer lift. The DON said no other injuries had occurred in the facility since 2/27/25 due to improper transfers. III. Resident #8 A. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the April 2025 CPO, diagnoses included anxiety disorder, adult failure to thrive, cerebral infarction (stroke), vascular dementia, muscle weakness and insomnia. The 2/5/25 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of four out of 15. The resident was dependent on staff for eating, oral hygiene, toileting, bathing, personal hygiene and upper and lower body dressing. The resident was always incontinent of bowel and bladder. B. Incident investigation The incident investigation was provided on 4/8/25 at 11:11 a.m. by the DON. The investigation documented that on 3/31/25 at approximately 3:05 a.m. Resident #8, who resided on the secured unit, was found on the ground next to her bed by a CNA. The bed was in the lowest position. The CNA notified the LPN and the RN. Upon assessment, the resident was lying on her right side with a hematoma to the right side of her head. There was also blood noted on the ground around the resident. Resident #8 was complaining of head pain. The staff did not move the resident and called 911. Resident #8 was transported to the hospital emergency department. C. Record review The fall care plan, revised 5/6/24, revealed Resident #8 was at risk for falls, had impaired balance and mobility and poor safety awareness due to cognitive decline. The care plan indicated the resident wished to sit on her fall mat and would crawl on the floor. Pertinent interventions included placing a fall mat on the floor next to the bed when the resident was in bed. The 11/24/24 fall risk assessment revealed the resident was at a high risk for falls. The resident was at high risk due to intermittent confusion and a prior history of falls. The assessment documented the resident was legally blind or the resident's sight ability was unable to be determined. The 3/21/25 hospital record documented Resident #8 sustained a right shoulder clavicle fracture, a fracture of the nasal bone, a large skin tear to the right elbow and superficial abrasions to both knees. D. Facility plan of correction The facility's plan of correction was provided by the DON on 4/9/25 at 11:11 a.m.via email. It read in pertinent part: The plan of correction documented Resident #8 fell and the fall mat was not in place. Resident #8 was transferred to the hospital on 3/21/25 and was diagnosed with a minimally displaced fracture of the left clavicle, minimally displaced right sided nasal bone fracture. The resident's plan of care was reviewed. A new task was entered into the resident's electronic medical record (EMR) that indicated staff was to complete safety checks every two hours. The facility conducted a full house audit and determined that all residents that utilized a fall mat, had fall interventions in place or used an air mattress, had the potential to be affected. The INHA was interviewed on 4/9/25 at 2:00 p.m. The INHA said the DON educated the two CNAs that did not put Resident #8's fall mat on the floor next to the bed when the fall occurred. The INHA said that all nursing staff would be trained about fall mats in an upcoming staff education meeting. E. Staff interviews LPN #2 and CNA #2 were interviewed together on 4/8/25 at 1:15 p.m. They said when Resident #8 fell, the fall mat was not next to her bed. They said when Resident #8 was in bed, the fall mat was to be placed on the floor next to the bed in case Resident #8 fell out of bed. CNA #4 was interviewed on 4/8/25 at 3:26 p.m. via the phone. CNA #4 said he did not put the fall mat on the ground prior to Resident #8 falling out of bed. CNA #4 said he and another CNA went into Resident #8's room because the air mattress was not working properly. CNA #4 said he crawled on the ground and saw some wires that were unplugged. CNA #4 said he plugged the wires back in and the air mattress began to immediately work correctly. CNA #4 said the CNA that was with him left Resident #8's room to go help another resident. CNA #4 said he placed Resident #8's bed in the low position. CNA #4 said he had worked with Resident #8 prior to the fall, and he knew she needed her floor mat next to her bed. CNA #4 said he was distracted, because he heard another resident call for help and forgot to put the fall mat on the floor next to her bed. CNA #4 said shortly after he left Resident #8's room, he heard a noise from Resident #8's room. CNA #4 said when he went back into the resident's room and he saw Resident #8 was on the floor without the fall mat in place. CNA #4 said he noticed Resident #8 was hurt, so he then called for the nurse and Resident #8 was sent to the hospital. CNA #4 said he did not put the floor mat back next to the bed and that was the reason Resident #8 had been injured. IV. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the April 2025 CPO, diagnoses included COPD, alcohol and cannabis abuse, obstructive sleep apnea, unspecified dementia, epilepsy (seizure disorder), other specified forms of tremors, dependence on supplemental oxygen and cognitive communication deficits. The 3/24/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS of eight out of 15. He required partial to moderate assistance with oral hygiene, toileting and upper and lower body dressing. The MDS assessment indicated it was very important for him to go outside when the weather was warm. The assessment documented the resident did not wander and did not have a wander guard. B. Record review The smoking care plan, initiated 3/21/25 and revised 3/31/25, revealed the resident required supervision with smoking. Interventions included ensuring Resident #9's cigarettes were stored in a locked smoking storage container and providing staff assistance to get Resident #9's cigarettes. The 3/26/25 social service assessment revealed, since the last evaluation, Resident #8's behavior symptoms had increased. The resident displayed wandering tendencies. The resident made statements about wanting to leave the facility grounds. He expressed frustrations, anxiety and challenges with adjusting to placement. Non-pharmacological interventions were attempted. The 3/31/25 interdisciplinary team (IDT) progress note revealed the IDT and Resident #9's representative made a decision to place Resident #9 on the secured unit from 3/29/25 to 3/30/25. The 3/30/25 social service progress note revealed Resident #9 expressed that he wanted to move off of the secured unit and return back to live in the original room he was admitted into. Resident #9 said he had no desire to leave the property. Resident #9 agreed to trial a wander guard alarm. Resident #9 was moved into the original room and a wander guard was placed on him. The 3/31/25 physician's assessment revealed the resident received a wander guard alarm that was placed on his right ankle due to poor safety awareness. The 4/6/25 incident progress note, documented at 11:58 a.m., revealed the resident went outside to smoke unsupervised. Resident #9 was brought back into the facility by a nurse and other residents. Resident #9's face and hands were noted to be covered in blood. Resident #9 was sent to the hospital. The 4/6/25 nursing progress note revealed Resident #9 was transferred back to the facility from the hospital at 6:00 p.m. via a stretcher. Resident #9 had multiple bruises and swelling to the face and skull. Resident #9 had multiple bruises and a skin tear to the arms and legs. Resident #9 was placed on one-to-one monitoring. The 4/6/25 hospital record documented the resident sustained multiple closed fractures of the facial bones, a closed head injury, multiple abrasions and a closed fracture of one rib on the left side. C. Staff interviews The INHA was interviewed on 4/9/25 at 2:00 p.m. The INHA said an investigation was underway for the fall that Resident #9 sustained on 4/6/25. The INHA said on 4/6/25 at approximately 7:30 a.m. Resident #9 went to the front lobby unescorted by staff members. The INHA said while he was in the lobby a resident gave him a cigarette and the same resident turned off the front door alarm to help Resident #9 go outside to smoke.He said Resident #9 went out the front door without setting off any alarms. The INHA said while Resident #9 was outside, he fell and sustained injuries. The INHA said the alarm code was immediately changed. The INHA said an electrician would come to the facility as soon as possible to ensure the doors and alarms were working properly. He said it was not certain yet how a resident knew the door alarm code, but it was possible the resident overheard staff members discussing the code and the resident remembered it. The INHA said Resident #9 would be on one-to-one monitoring until further notice. The DON was interviewed on 4/9/25 at 2:35 p.m. The DON said on 4/9/25 the facility had three residents with wander alarms and all three alarms worked correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two resident victims (#12 and #106) from being physically abused (#53 and #174) resident in a resident to resident physical altercation in four resident to resident abuse allegations out of 66 sample residents. The facility failed to provide adequate supervision and effective interventions to prevent two separate incidents of resident or resident altercations resulting in one or more residents being injured. On 9/1/23 at 12:00 p.m. Resident #12 was physically abused by Resident #53. Resident #12 sustained deep scratches and cuts to his right arm from the physical attack on his person by Resident #53 which required ongoing medical treatment by a wound care physician and nursing staff. Resident #12 experienced pain immediately following being injured by Resident #53's aggressive actions. Resident #53 had a history of being physically and verbally aggressive towards others. Starting 7/28/23 the resident's medical record documented that the resident had been in a physical altercation with another resident other than Resident #12. The resident physician along with interdisciplinary team (IDT) input made a determination to increase the resident's antipsychotic medication to help the resident better manage his behavioral aggressions. Nursing staff were to monitor and document the effect of the medication. The resident's behavior continued to escalate and Resident #53 started to refuse medications including his antipsychotic medications on a couple of occasions. On 8/13/23 Resident #53 went after staff with verbal and physical aggression because they removed soiled laundry from his room. Several nursing staff had to intervene to keep him from directing his aggression to other residents who were in the common areas where the resident's aggressive actions occurred. Another resident witnessing the event called 911. The police responded and in that time the resident was able to start to calm down. Despite the resident's increasing agitation and physical aggression, the facility did not revise the resident's care plan or show other documentation that they assessed the effectiveness of the care plan interventions initiated 4/10/23. The facility failed to reassess the resident's care needs and develop more effective interventions to prevent resident #53 from getting physically and verbally aggressive Resident #12 sustained serious injuries requiring ongoing medical treatment by a wound care specialist. Additionally, the facility failed to: -Reassess the resident's unsafe wandering behavior and revise, develop, and implement effective behavior interventions to effectively manage Resident #174's aggressive and violent behaviors towards other residents; -Respond timely to prevent Resident #174 for unsafe wandering; -To protect several residents from being verbally abuse but Resident #174 when he engaging in unsafe wandering and was not supervised or redirected timely; and, -Prevent Resident #106 from being physically abused Resident #174. Findings include: I. Facility policy The Abuse, Neglect, and Exploitation policy, revised April 2022, was provided by the nursing home administration (NHA) on 9/11/23 at 9:33 a.m. The policy read, in pertinent part: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriations of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. The facility will develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. The facility will implement policies and procedures to prevent and prohibit all types of abuse. Identification, ongoing assessment, care, planning for appropriate interventions, and monitoring of residents with needs and behaviors, which might lead to conflict or neglect. II. Resident #53 and Resident #12 1. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the diagnoses included osteoarthritis (arthritis) and depression. According to the 6/30/23 minimum data set (MDS) assessment, the resident was unable to complete a brief interview for mental status. According to the staff's assessment of the resident's cognition revealed the resident did not have short or long-term memory loss. The resident was able to recall the current season, the location of his room, and knew that he was in a nursing facility. The resident was independent with decision-making and made consistent and reasonable decisions. The resident was independent in all activities of living but needed setup assistance with eating. The resident did not walk and used a wheelchair at all times. 2. Resident #53 A. Resident status Resident #53, age [AGE], was admitted on [DATE]. According to the September 2023 CPO diagnoses included dementia with agitation and acute kidney failure. According to the 8/18/23 MDS assessment, the resident was unable to complete a brief interview for mental status. Staff's assessment of the resident's cognition revealed the resident had short or long-term memory loss but the resident knew the location of his room and the names of staff. The resident needed some assistance making decisions in new situations. The resident had potential indications of psychosis as evidenced by hallucinations and delusions. The resident displayed physical and verbal behavior directed toward others one to three times a week. The resident needed limited support from one staff member to complete activities of daily living (ADL) except he did not receive assistance with eating. The resident needed limited assistance walking short distances and used a wheelchair as a primary mode of transportation. B. Record review According to the resident's comprehensive care plan the resident had a care focus, revised 4/10/23, for aggressive behaviors. The care focus documented the resident was aggressive towards others and had poor impulse control and aggressive behaviors that included yelling, hitting, striking out and kicking. Interventions included allowing the resident to make decisions about his care to provide a sense of control; approaching the resident in a calm, gentle manner; assessing, reviewing, and documenting behaviors; and listening to the resident's concerns. According to the progress note dated 7/28/23 at 12:03 p.m. the resident was very agitated, was grabbing at, and trying to hit staff. At 2:30 p.m. the resident started grabbing another resident causing two small skin tears on the other resident's hand. According to a progress note dated 8/2/23, the resident had a medication change to increase Seroquel (an antipsychotic medication) from 25 milligrams (m)g to 50 mg due to increased aggressive behaviors; The nursing staff were to monitor the resident for side effects and effectiveness of the medication therapy. According to a progress note dated 8/8/23 at 10:35 a.m., the resident angrily refused his psychotropics and other medications. According to a progress note dated 8/13/23 at 10:42 a.m., the resident yelled at a certified nurse aide (CNA) about the aide taking dirty linen from the resident's room. The resident got onto the floor. A nurse attempted to help the resident off the floor. The resident grabbed the nurse's ankle attempting to scratch and hit the nurse. According to a progress note dated 8/30/23 at 10:42 a.m. the resident had worsening behaviors over the weekend. The staff was concerned about physical violence. According to a progress note dated 8/30/23 at 7:33 p.m., the resident refused medication that was offered four times. According to the progress note dated 8/30/23 at 9:35 p.m. the resident's wheelchair was next to a vehicle parked in the parking lot and the staff's vehicle the resident was found inside the vehicle smoking a cigarette. The staff who discovered the resident brought the resident back into the facility and put a wander guard bracelet (a bracelet that has a sensor on it to help prevent residents from leaving the facility without staff being alerted by an alarm wandering) onto the resident. 3. Resident-to-resident altercation 9/1/23 A. Resident interview and observations Resident #12 was interviewed on 9/11/23 at 11:20 a.m. Resident #12 said he was attacked by Resident #53 for no reason. Resident #12 said he had just finished smoking and was heading back into the building when Redidnet #53 came out of nowhere and attacked him by grabbing him and scratching at his arms leaving deep wounds on his right hand and forearm. Resident #12 said there were no staff outside when the attack started but after hearing the altercation staff came from the building to help get Resident #53 off of him. The resident showed his wounds. He had had several baseball-sized bruises, with long and deep scratches on his right arm and forearm. B. Record review According to a progress note dated 9/1/23 at 12:00 p.m. there was a resident-to-resident altercation in front of the building between Resident #53 and Resident #12. Resident #12 had skin tears and blood on him. Resident #12 said I was coming down the sidewalk to smoke and this lunatic rammed into me (with his wheelchair); I turned around and he attacked me. I want him thrown in jail. According to a resident witness statement dated 9/1/23 Resident #12 was coming down the sidewalk and Resident #53 was in his wheelchair on the sidewalk. Resident #12 started to turn around in his wheelchair and Resident #53 lunged at Resident #12. Resident #53 hit and clawed at Resident#12. Resident #12 started to bleed. Resident #53 grabbed Resident #12's arm and started beating on Resident #12. Two staff members came from the building and broke up the fight. According to the admissions director's (ADD) witness statement dated 9/1/23, the ADD was walking with another heading back into the facility when he heard yelling. The ADD walked around the corner and saw Resident #53 being held back by staff members. Resident#12 yelling and had blood running down his arm. There were no additional staff witness statements from the staff that initially arrived to break up the resident-to-resident altercation. According to a progress note in Resident #53's medical record, dated 9/1/23 at 1:30 p.m., Resident #53 was sent out to the hospital for a mental health assessment, because he did not seem well. The resident was unable to respond appropriately to staff questions and was moaning when responding. According to the progress note Resident #12 medical record, dated 9/2/23, Resident #12 had multiple skin injuries including deep scratches, skin tears, bruises and was experiencing pain from the injuries to his right forearm. Resident #12 said his pain level was 8out of 10 (with 10 being the worst) and it decreased to 2 out of 10 after taking a hydrocodone (a narcotic pain medication). According to the wound note dated 9/6/23 Resident #12 was seen by a wound physician for the wounds he got during the altercation with Resident #53. The wound treatment note documented that Resident #12 had a traumatic wound to his right forearm measuring 3 centimeters (cm) by 2 cm by 0.1 cm in depth on his right hand and a wound on his right forearm measuring 4 cm by 2 cm by 1 cm. According to a wound care note dated 9/13/23 Resident #12 was seen by the wound physician for wounds he got during the altercation with Resident #53. Resident #12 had a traumatic wound on his right hand and forearm. The wound had to be debrided (a bedside surgical procedure to remove dead tissue). New wound measurements for the right forearm were 2.5 cm by 2 am by 2 cm, and the wound on the right hand measured 4 cm by 2 cm by 2 cm. 5. Staff Interviews CNA #8 was interviewed on 9/18/23 at 10:54 a.m. CNA #8 said when there was a resident-to-resident altercation staff should notify a nurse after they separated the residents that were fighting and ensure everyone's safety. CNA #8 said when a resident showed signs of aggression the CNA should let the nurses before another resident was injured. The nurse would assess the resident and let the CNAs know which interventions to implement. Sometimes CNA #8 said he heard about the altercation between Resident #53 and Resident #12 through gossip but facility leadership did provide the direct care staff with any information about how to prevent future displays of aggression by Resident #53 toward other residents or towards the staff. The director of nursing (DON) was interviewed on 9/20/23 at 2:26 p.m. The DON said that all resident-to-resident altercations need to be investigated and the care plan should be reviewed for effectiveness. The DON said they should have interventions in place for residents who have shown previous aggression. The DON said they would have an IDT meeting if a Resident showed signs of aggression and update care plan interventions as appropriate. The DON said Resident #53 was not showing signs of aggression prior to this incident between Resident #53 and #12 nor did Resident #53 have issues with unsafe wandering prior to the altercation on 9/1/23. III. Resident #106 and Resident #174 A. Resident status 1. Resident # 106 Resident #106, age [AGE] was admitted on [DATE]. According to the September 2023 CPO, the diagnoses included Alzheimer's disease and anxiety disorder. According to the 8/1/23 MDS assessment, the resident had moderately impaired cognition with a BIMS score of nine out of 15. The resident needed set-up help only with all activities of daily living. 2, Resident # 174 Resident #174, under the age of age [AGE], was admitted on [DATE] and discharged on 5/14/23. According to the May 2023 CPO, the diagnoses included anxiety and depression. According to the 5/14/23 MDS assessment, the resident was unable to complete the BIMS exam. Staff's assessment of the resident's cognition revealed the resident had short-term memory loss and needed extensive assistance from one staff member to perform dressing, toileting, and hygiene tasks and limited assistance with all other ADLs. The resident had difficulty making decisions and presented with disorganized thinking. The resident displayed verbal aggressions directed toward others and other behavioral symptoms not directed toward others for one to three days, additionally, the resident wandered four to six days a week. B. Record review According to the resident comprehensive care plan the resident had a care focus for wandering revised 2/9/23. The care plan revealed that Resident #174 wandered into other residents' rooms and wandered behind the nurse's station. Interventions included allowing Resident #174 to freely wander through the facility; determining the root cause of wandering and documenting unsafe wandering. There were no interventions to address resident-to-resident altercations as a result of the staff allowing the resident to wander freely and there was no behavioral care to address Resident #174 verbal and other behavioral symptoms. According to a progress note dated 4/13/23 at 11:13 a.m. Resident #174 had threatening behavior towards another resident. Resident #174 stood over another resident telling the resident to shut up and that they were annoying. According to a progress note dated 4/16/23 at 11:31 a.m. Resident #174 continued to have bouts of yelling, screaming and pulling his arm back with his hand in a fist ready to strike. Staff had to physically remove the resident from other residents to keep the other residents safe. According to a progress note dated 4/17/23 at 3:48 a.m. Resident #174 wandered into a female resident's room. The female resident woke up and yelled at Resident #174 to get out and Resident #174 responded with verbal aggression yelling at the female resident who was in bed. According to a progress note dated 4/17/23 at 6:48 p.m. Resident #174 was aggressive and pointed his finger towards other residents. Resident #174 had to be separated from another resident. According to an IDT note dated 4/19/23, the IDT discussed the resident's wandering habits with Resident #174, but according to this note did not discuss the inappropriateness of his aggressive behaviors with him. According to a progress note dated 4/19/23 at 6:06 p.m. Resident #174 was found in another resident's room. Resident #174 got upset when staff tried to redirect him and began yelling at other residents and staff. According to a progress note dated 4/22/23 at 8:52 a.m., Resident #174 was angry, aggressive and yelling at staff and residents. According to a progress note dated 4/22/23 at 9:36 a.m. Resident #174 was escalating with displays of verbal aggression. Staff were able to redirect the resident and put the resident on one-to-one supervision but documented that they were scared of Resident #174 behaviors. According to a progress note dated 4/23/23 at 7:27 a.m. another resident called 911 on Resident #174. Resident #174 was in the other resident's room displaying aggressive behavior and rummaging through the other resident's closet. According to a progress note dated 4/23/23 at 2:13 p.m. Resident #174 was agitated and aggressive towards staff and residents. According to a progress note dated 4/24/23 Resident #174 was given an Ativan (antianxiety medication) for agitation for seven days, due to verbally aggressive behaviors towards other residents and staff. When that was ineffective the facility sent Resident #174 to the hospital for a mental health evaluation on a M1 hold (an involuntary inpatient hold in a hospital for individuals who are in danger of harming themselves or others). According to a progress note dated 4/26/23, the resident remained in the hospital and was not safe to come back. The resident was readmitted to the facility on [DATE]. According to a progress note dated 5/3/23 Resident #174 continued to wander into other residents' rooms with displays of increasingly aggressive behaviors. According to a progress note dated 5/4/23 Resident #174 was eating on his roommate's bed. Resident #174 became angry and combative towards the roommate when the roommate asked Resident #174 to move. Staff put signs above Resident #174's bed to remind him which was his bed. According to a progress note dated 5/5/23 Resident #174 was threatening his roommate over snacks. According to a progress note dated 5/6/23 Resident #174 continues to wander in and out of other residents' rooms. Resident #174 was unable to redirect at this point. According to a progress note dated 5/7/23 Resident #174 had his side of the room extremely disheveled. Resident #174 had shredded pillows and trash scattered in his room. Resident #174's roommate said he was scared because of Resident #174's irrational behavior. The facility moved the roommate to another room. According to a physician's note dated 5/8/23 Resident #174 got a new roommate. The new roommate was upset because he found Resident #174 in his bed eating his personal food. Staff said Resident #174 had become more aggressive and combative at night. Resident #174 was moved to another room because he had threatened to kill his new roommate. According to a progress note dated 5/9/23 at 4:11 p.m. Resident #174 was behind the nursing station ruffling through a staff's purse. A CNA tried to redirect Resident #174 he swatted at the CNA and called her name. According to a progress note dated 5/10/23 Resident #174 was found trying to urinate in the dining room sink. Resident #174 continued to wander into other residents' rooms. According to a nursing note dated 5/11/23 Resident #174 continues to wander in and out of other residents' rooms. Resident #174 ripped his briefs off in the common areas. According to a nursing note dated 5/11/23 at 3:51 p.m. Resident #174 attempted to open the emergency door. Staff tried to redirect him, but Resident #174 said he was going to beat somebody up. The resident continued to wander in and out of other residents' rooms. According to a progress note dated 5/12/23 Resident #174 had a behavior that needed to be directed by a registered nurse (RN). According to a progress note dated 5/13/23 Resident #174 was urinating in a trash can. Resident #174 was wandering in other residents' rooms and was aggressive towards staff. -Despite all the documentation by nursing staff documenting that Resident #174 displayed unsafe wandering behavior as evidenced by the number of examples written above the facility failed to reassess the resident's wandering care plan and ineffective interventions and develop a care plan focus for the resident's aggressive and violent behaviors towards other residents. C. Resident-to-resident altercation According to a progress note dated 5/14/23 at 5:20 p.m. a CNA heard a loud noise and voices coming out of Resident #106's room. The CNA entered Resident #106 to find him with his wheelchair between him and Resident #174. Resident #106 said Resident #174 came into his room and sat in his wheelchair and would not leave. Resident #106 said he asked Resident #174 to get out of his wheelchair. Resident #174 hit Resident #106 on his cheek. Resident #106 put his fist up to protect himself. The CNA was able to redirect Resident #174 out of Resident #106's room. Resident #174 continued to be hostile. Resident #174 was placed on 15-minute checks. According to progress notes dated 5/14/23 at 7:40 p.m. Resident #174 was placed on a M1 hold and sent to the hospital for a mental health evaluation. According to an incident report dated 5/15/23 Resident #106 had a mild red mark on his cheek. D. Staff interviews CNA #9 was interviewed on 9/18/23 at 11:10 a.m. CNA #9 said he did not know if Resident #174 was aggressive or if he wandered into other residents' rooms. CNA #9 said when a resident has an altercation other CNAs were not told about the altercation unless they were on shift at the time of the altercation. CNA #9 said he did not know where to find interventions for residents who have aggressive or wandering behavior. The director of nursing (DON) was interviewed on 9/20/23 at 2:26 p.m. The DON said if a resident had aggressive behaviors or wanders the facility would set up an IDT meeting to put interventions into place to keep other residents safe. The DON said Resident #174 was ramping up. The DON said they had talked to providers and the provider did not want to make any medication changes. The DON said Resident #174 did not respond well to non-pharmaceutical interventions. The DON said Resident #174 was sent on an M1 hold to the hospital. Resident #174 had remained in the hospital since.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent development and worsening of pressure injuries for two (#29 and #8) of three residents reviewed for pressure injuries out of 66 sample residents. Resident #29 who required extensive assistance with activities of daily living (ADL) from staff members for bed mobility, positioning, transfers, toileting and dressing, was known to be at risk for skin impairment due to impaired mobility and had inability to self reposition and relieve pressure points. Resident #29 developed a deep tissue injury (DTI, a pressure injury to underlying tissue below the skin's surface caused by prolonged pressure (of the body being left against a hard surface) leading to restricted blood flow resulting in skin tissue death and other damage deep in the underlying skin tissue), to the plantar (sole of the foot) surface of the left foot with an initial measurement of 3 centimeters (cm) by 6 cm, depth undetermined and a bruised toe. There was a delay in the resident being assessed and receiving treatment from the wound care physician as evidenced by an email from licensed practical nurse (LPN) #3 who documented that while working shifts on 8/27/23 and 8/28/23 the resident's representative made notification that Resident #29 had a skin problem to the bottom of his left foot (see documentation of LPN #3 email below). LPN #3 documented in the email that following the notification from the resident's representative the facility wound care nurse was notified; however, there were no notes or assessment provided by the facility wound care nurses at that time. It was not until 9/5/23 when the director of nursing (DON) was provided information about the resident's wound that the resident was assessed by the wound care nurse and referred to the wound care physician. Upon notification of the resident's DTI wound to the DON on 9/5/23, days after LPN #3 was made aware of the resident DTI by the resident representative and the wound care physician assessed the resident's new wound. Per the resident medical record and interviews with staff, the facility failed to ensure the resident consistently wore proper foot ware to protect his feet from undue pressure; failed to ensure the resident was positioned properly so that his sock covered foot did not rest constantly against the foot rest of his wheelchair; and failed to conduct routine skin checks of the resident's feet for skin concerns. The facility's failures to ensure the resident was positioned properly to off load pressure points and ensure the resident feet were not resting for extended periods on a hard surface lead to the resident sustaining a DTI to the bottom of the left sole of his foot. Due to the nature of a DTI pressure injury being a closed wound with the damage occurring deep under the skin the extent of damage is unknown. This type of injury puts the resident at risk for other related complications to develop. Specifically, for Resident #8 the facility failed to: -Provide the resident positions assistance to prompt healing of pressure ulcer; -Followed wound physician orders to provide interventions to treat pressure injury; and, -Failed to revise the resident's care plan with up to date interventions to treat pressure injury. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 9/26/23. Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with nonblanchable redness of a localized area usually over a bony prominence.Darkly pigmented skin may not have visible blanching; its color may differ from the surroundingarea. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.-Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/ tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover; and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Risk Factors and Risk Assessment -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries; -Consider individuals with a Category/Stage 1 pressure injury to be at risk of developing a Category/Stage 2 or greater pressure injury; -Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries; and, -When conducting a pressure injury risks assessment: Use a structured approach; Include a comprehensive skin assessment; Supplement use of a risk assessment tool with assessment of additional risk factors; Interpret the assessment outcomes using clinical judgment; Skin and Tissue assessment -Assess the pressure injury initially and as soon as possible after admission/transfer to the healthcare service; -Rre-assess at least weekly to monitor progress toward healing; -Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment; and, -Monitor the pressure injury healing progress. Support Surfaces For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury.Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policies and procedures The Skin Assessment policy, revised January 2023, was provided by the corporate nurse consultant (CNC) #1 on 9/21/23 at 11:44 a.m. The policy read in pertinent part: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury and prevention management. A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse on admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure ulcer. Considerations for darkly pigmented skin is not always possible to identify redness Indicators for pressure related damage, include, localized heat, edema, bogginess, induration, temperature differences in surrounding skin, and skin discolorization. The Wound Management policy, revised October 2022, was provided by the corporate clinical nurse (CNC) on 9/21/23 at 11:44 a.m. The policy read in pertinent part: To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physicians orders. Treatment decisions will be based upon 1). Etiology of the wound, 2). Size of the wound, 3). Volume and characteristics of exudate, 4). Presence of pain, 5). Presence of infection, 6). Condition of the tissue of the wound bed, 7). Condition of peri-wound area, location of the wound, and the preference of the resident/representative. III. Resident #29 A. Resident status Resident #29, under the age of 65, was admitted on [DATE]. According to the computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis (partial weakness), cerebral vascular infarction (stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of the bladder and paranoid schizophrenia. According to the 8/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident required extensive assistance and was dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The MDS assessment revealed the resident was at risk for pressure ulcers/injuries but did not have any unhealed pressure injuries at the time of the assessment. IV. Observations On 9/11/23 at 9:00 a.m. the resident was seated in a Broda chair (specialized high back wheelchair with positioning features to reduce the strain placed on the skin). The head of the Broda chair was positioned upright in alignment with the resident's back. The resident was wearing tennis shoes on his feet; the resident's feet were elevated in alignment with the resident's waist, with both feet pressed against the foot rests. -At 4:15 p.m. the resident's feet were lowered below his waist while remaining in an upright position. The resident was wearing tennis shoes on his feet which were pushed up against the foot rests of the Broda chair. On 9/12/23 at 9:42 a.m. the resident was seated upright in the Broda chair; the resident's spine was in alignment with the back of the chair. The resident was wearing tennis shoes and his feet were elevated to waist level with his covered feet pressed against the foot rests. -At 11:18 a.m. the resident was fully dressed with socks and tennis shoes on his feet. The resident was seated in a Broda chair with the foot peddles elevated to waist level. The resident's feet were pressed against the foot rests. On 9/13/23 at 8:19 a.m. the resident was fully dressed with socks and tennis shoes on his feet. The resident's feet were elevated at waist level and were pressed against the foot rests of the Broda chair. -At 10:08 a.m the resident was seated in the commons area in the Broda chair, the resident was wearing tennis shoes on his feet and the footrests were lowered about eight inches from the floor. The resident remained in this position throughout the day until dinner at 5:00 p.m. On 9/14/23 at 9:18 a.m. the resident was seated in the common area in the Broda chair with his feet elevated to waist level and his feet pressed against the foot rests, the resident was dressed and had socks and tennis shoes on his feet. -At 12:42 p.m. the resident was seated in the Broda chair with the leg rests lowered down approximately six inches from the floor. The resident was wearing tennis shoes and his feet were pressed against the foot rests. -At 3:34 p.m. the resident was seated in the Broda chair with the head of the wheelchair reclined back at a 30 degree angle. The resident leg rests were in the same position as earlier (see above). On 9/18/23 from 10:00 a.m. to 12:00 p.m. the resident was seated in the Broda chair with the footrests elevated to waist level, the resident had the same tennis shoes on his feet that were pressed against the foot rests. V. Record review A. Care plan The comprehensive care plan last revised on 9/6/23, revealed the resident was at risk for skin breakdown and documented resident has actual impaired skin integrity and was at risk for further skin breakdown related to frail fragile skin, incontinence and immobility. Resident has a DTI. The goal resident will have improved wound healing. Interventions included provide preventive skin care, lotion, barrier cream as ordered; apply barrier cream with each cleansing; turn and reposition as tolerated; observe skin for signs/symptoms of skin breakdown, redness, cracking, blistering, decreased sensation, skin that doesn't blanche easily; off load/float heels while in bed; monitor both lower extremities for any pain, heat, edema or erythema. Pressure redistribution surface to bed and low air loss matters; offloading boots while in bed and weekly skin checks by license nurse. B. Facility progress notes, treatment records Nursing note dated 7/21/23 at 4:37 p.m. documented the resident was temporarily placed in a facility Broda chair (as resident's representative had been asking for a new chair for the resident to use). The resident will not be able to stay in the chair long term but was placed in it for a trial period. The resident appears to enjoy the chair. Nursing skin assessment documentation revealed skin checks had occurred on 7/15/23, 7/22/23, 7/29/23, 8/3/23, 8/10/23, 8/17/23, 8/24/23, and 8/31/23 with no observed injury or wounds to the resident's skin. Nurses note dated 8/30/23 at 9:46 a.m., revealed the wound care physician evaluated the resident for skin integrity issues, (a left elbow trauma wound), there were no other wounds present. Nurse practitioner (NP) #1 visit note dated 9/5/23 at 11:07 a.m. revealed the resident was seen for an assessment of the left foot where a bruise like mark was observed. The assessment documented that the resident had a new unstageable pressure ulcer to the underside of left foot that measured at 5.0 cm x 2.5 cm x 0.1 cm. Appears to be due to the resident resting his left foot on the foot of the bed overnight. Wound care to follow. Plan of care included wear shoes during the day and pressure relieving boots overnight while in bed. Wound physician progress note dated 9/6/23 read in pertinent part: Patient presents for an evaluation of a new wound to the foot. Decreased strength and range of motion (ROM) with contractures. Decreased ROM and strength to the left lower extremity with contractures. Wound: Left Foot is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. -Initial wound encounter measurements are 3 cm length by 6 cm width with no measurable depth, with an area of 18 square (sq) cm. The patient reports a wound pain of level 0/10. Wound bed has 100% epithelialization. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Tretment plan: Cleanse and protect wound. Cleanse with wound cleanser. Additional Orders: Preventive measures: low loss air mattress mattress in place (for) offloading. Wheelchair cushion evaluated. General Orders: Monitor for signs and symptoms of infection. Offer moisturizing cream twice a day for dry skin. Provide calorie and protein supplements per registered dietician as needed. Pressure injury interventions: Tum and reposition frequently while in bed and in chair. Shift weight frequently while in bed and/or when in a chair. Place the patient on a low air loss or alternative pressure mattress, if not contraindicated, and check for proper placement and function every shift. Ensure seat or wheelchair cushion in place, if not contraindicated, and check for proper placement and function every shift. Float heels while in bed. Data reviewed/discussions: care coordination provided involving the organization of the patient's care and the sharing of information with nursing staff in order to achieve safe, effective care. Increased physical activity. Healing is expected to be delayed due to identified factors:impaired mobility, inevitable effect of aging, and medications that inhibit optimal wound healing. An email, dated 9/9/23 at 12:23 a.m., from LPN #3 to the DON read in part: Approximately two weeks ago, this writer was the nurse to resident in room (number for resident #29). CNA (certified nurse aide) notified this nurse of the compromised area on (the resident's) left foot. Upon observation, it was noted that the resident had an impression/ mark on the bottom of the lateral (outside away from the middle of the body) side of left foot. The area was intact and not open. This nurse elevated bilateral (both) feet on a pillow and repositioned the resident. Upon morning, the wound care nurse was notified. Wound care nurse stated they would assess the area. -This email correspondence revealed that the wound to the resident's foot was observed over a week before the resident's representative reported the wound and before the wound care physician was consulted. An email, dated 9/13/23 at 11:19 a.m. from the DON to the nursing home administrator (NHA) read in part: On Tuesday September 5th at 8:02 a.m., this writer was made aware via text message from resident's (responsible party) in a group text message with the resident's NP (nurse practitioner), that Resident #29's power of attorney had observed that the bottom of Resident #29's left foot has what looks like a purple bruise. This writer, in the morning meeting, at approximately 9:00 a.m. made the wound nurse, (wound care nurse's name) aware.The resident's representative alerted staff on 9/5/23 at 1:59 p.m. that the resident's left great toe was bruised while she was placing lotion on the resident's feet. Nursing staff completed an assessment of the bruised left great toe and found the resident also had developed a 3 centimeter (cm) deep tissue injury to the plantar surface of the resident's left foot. Nursing note dated 9/5/23 at 3:10 p.m., revealed the resident has a 3 cm by 3 cm DTI on the resident's left foot. The resident rests his feet on the wheelchair Resident was frequently repositioned to avoid this. Writer has moved the resident multiple times throughout the shift. Nutrition assessment dated [DATE] at 11:36 a.m., documented for new deep tissue injury to the left foot, recommending protein supplement four times per day to aid healing. VI. Resident representative interview The resident's representative was interviewed on 9/18/23 at 12:55 a.m. The resident's representative said she was very involved in the resident's care and tried to visit the resident on a daily basis. The resident's representative said she had many concerns about the resident's care related to the facility's lack of skin assessments, primarily because she was the one to find a deep tissue injury on the resident's left foot. The resident's representative said the resident had been complaining of pain to the left foot for at least two weeks prior. If the facility would taken the time to apply lotion and look at the resident's feet as she asked, the left foot wound would have been caught earlier. VII. Staff interviews Registered nurse (RN) #2 was interviewed on 8/14/23 at 8:40 a.m. RN #2 said the resident was placed into the Broda chair every morning between 8:00 a.m. and 8:30 a.m. and remained in the Broda chair until after dinner. RN #2 said the resident slept in the Broda chair if he got tired. RN #2 said restorative staff taught the nursing staff how to adjust the footrests to control pressure points while the resident was up in the Broda chair. RN #2 said the footrests were adjusted every two to three hours and staff took turns helping the resident to remain comfortable. RN #2 said the resident's representative asked the staff to get the resident up by breakfast and put on the resident's tennis shoes immediately after he rose. Certified nurse aide (CNA) #3 was interviewed on 9/14/23 at 10:01 a.m. CNA #3 said the resident's representative had created a helpful hints flier for the nursing staff to guide the resident's care and CNAs use it to reduce the resident's agitation. CNA #3 said the resident's representative wanted foot straps placed over the resident's feet while in the Broda chair to prevent the resident's feet from slipping off but the restorative staff did not agree. CNA #3 said the resident had worn tennis shoes since May 2023 per the resident's representative preference. CNA #3 said all skin alterations including bruising, scratches and pressure injuries noticed during bathing/showering were immediately reported to the nurse. The DON was interviewed on 9/14/23 at 2:42 p.m. The DON said the resident was immobile and was dependent on staff for repositioning while upright in the Broda chair. The DON said it was her understanding that the resident's pressure points were relieved by adjusting the footrests on the Broda chair. The DON said the resident made his needs known with cueing and supervision. The DON said due to the resident's immobility the resident was at greater risk for developing deep tissue injuries/wounds and the resident's skin was monitored weekly to identify injuries/wounds early. The DON said that the CNA staff were often the staff members who noticed skin injuries/wounds due to their role to provide toileting, pericare and bathing/showering assistance to the residents. The CNAs were expected to report any skin integrity issues immediately to the nurse on duty. Restorative aide (RA) #1 was interviewed on 9/18/23 at 11:55 a.m. RA #1 said the restorative program made recommendations on off-loading pressure to the resident pressure points with repositioning to off load pressure points while in bed and while up in a chair. This included bed wedge pillows; arranged for seating cushions and back cushions for the Broda chair. The RA said the restorative program made recommendations on how the resident's feet should be placed on the footrests and lowering the resident's feet and adjusting his legs every two to three hours. The RA said the resident was cooperative with repositioning and would express through facial expression or would grab staff's arm if he felt pain with positioning. The resident was dependent on the nursing staff to ensure his feet were positioned properly and repositioned frequently. III. Resident #8 A. Resident status Resident #8, age [AGE], was admitted [DATE]. According to the September 2023 CPO, diagnoses included chronic respiratory failure, radiculopathy (injury or damage to nerve roots in the area where they leave the spine) and stage 3 pressure ulcer on left buttocks. The 8/29/23 MDS assessment revealed the resident was mildly cognitively impaired with a BIMS score of nine out of 15. She required extensive assistance from one person with dressing; supervision of one person with locomotion on unit and personal hygiene; limited assistance of one person with bed mobility, toilet use and transfers. The resident used a wheelchair and a walker. The resident was frequently incontinent of bladder and bowel and was at risk for developing pressure ulcers. The resident had one unhealed stage 3 pressure ulcer and one venous and arterial ulcer. Skin and ulcer treatments included pressure reducing devices for her chair and bed; a repositioning program; a nutrition or hydration program; and pressure ulcer and wound care services. The resident's wounds were treated with the application of ointments and non-surgical dressings. B. Resident interview and observations Resident#8 was interviewed on 9/11/23 at 12:04 p.m. Resident #8 said she did not have pressure ulcers (however, she did have a pressure ulcer, see record review below). Resident #8 said she did not have any cushion in her wheelchair and her wheelchair was not comfortable to sit in. On 9/11/23 at 12:04 p.m. Resident #8 was sitting in her wheelchair. The resident's mattress was a standard hospital mattress not an air mattress or specialized pressure relieving mattress. The wheelchair cushion looked flat. On 9/13/23 from 9:09 a.m. until 2:45 p.m. continuous observations of Resident #8 revealed: -At 9:09 a.m. the resident was in her room sitting in her wheelchair. -At 10:13 a.m. the resident propelled herself outside to smoke. She passed by staff; they did not interact with her or ask her about repositioning. -At 10:39 a.m. the resident propelled herself back to her room. Staff did not interact with the resident as she went back to her room. The resident did not reposition herself or transfer herself to an alternative surface to off load the consistent pressure on her bottom from sitting for an extended period of time in her wheelchair. -At 11:59 a.m. the resident remains in the same position. The resident did not reposition herself. Staff had not entered the resident's room. -At 12:23 p.m. an unknown nurse went into the resident's room to give her medication. The nurse did not offer to reposition or encourage the resident to offload pressure to her bottom. -At 12:28 p.m. the resident continued to sit in her wheelchair in the same position but was sleeping. An unknown certified nurse aide (CNA) walked past the resident's room and did not encourage the resident or reposition. -At 12:35 p.m. an unknown CNA brought the resident her lunch into her room. The CNA put the resident's food on the table and did not communicate with the resident. -At 1:05 p.m. the resident remained in her wheelchair in the same position. Staff had not entered the residents room or encouraged her to reposition. -At 2:20 p.m. the resident remained in the same position. Staff had not entered the resident's room. -At 2:45 p.m. the resident remained in the same position sitting on her wheelchair. Staff had not encouraged the resident to reposition. C. Record review According to the Braden Risk assessment dated [DATE] the resident was at mild (low) risk for the development of pressure ulcers. -However, the resident had developed pressure injury prior to this assessmnet which would make her at risk (see below). The comprehensive care plan initiated on 8/9/23 documented the resident had impairment to skin integrity related to decreased mobility and incontinence. The resident had a stage 3 pressure ulcer on her right buttock measuring 3 centimeters (cm) by 1 cm by 0.1 cm. Interventions included staff should anticipate the resident's needs for pain relief and respond immediately to any complaint of pain. Monitor and document location, size and treatment of skin injury. Report infection and abnormalities. Wound care for bilateral buttocks included cleaning the wound with spray, pat dry with gauze, cover with dry bordered foam and reinforce with retention tape. According to the wound note dated 5/3/23 the resident had an unavoidable facility acquired pressure ulcers on her buttocks. The wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 3 centimeters (cm) in length, 2 cm width and 0.1cm in depth. There is a small amount of sero-sanguineous drainage (watery bloody drainage). The resident's stage 3 pressure wound on her right buttock measured 3 cm in length, 1 cm width and 0.1 cm depth.The resident was on hospice care due to respiratory failure. According to the wound note dated 5/31/23 the wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 2 cm in length, 2 cm width and 0.1cm in depth. There is a small amount of sero-sanguineous drainage. The residents stage 3 pressure wound on her right buttock measured 3 cm in length, 0.5 cm width and 0.1 cm depth. The wound care orders for treatment of the pressure injury on the right buttock included cleanse with wound cleanser, apply foam every other day and reinforce with tape. Turn and reposition frequently while in bed and in a chair. Shift weight frequently while in bed and in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated and check for proper placement and function every shift. Ensure a seat or wheelchair cushion was in place. Float heels while in bed. According to the wound note dated 6/28/23 the wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 2 cm in length, 2 cm width and 0.1cm in depth. There was a small amount of sero-sanguineous drainage. The resident's stage 3 wound on her right buttock measured 3 cm in length, 2 cm width, and 0.1 cm depth. The wound care orders for treatment of the pressure injury on the right buttock included cleanse with wound cleanser, apply foam every other day and reinforce with tape. Turn and reposition frequently while in bed and in a chair. Shift weight frequently while in bed and in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated and check for proper placement and function every shift. Ensure a seat or wheelchair cushion was in place. Float heels while in bed.If the resident wears briefs and was incontinent, check briefs frequently. According to the wound note dated 7/19/23 The wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 1.2 cm in length, 1.5 cm width and 0.1cm in depth. There is a small amount of sero-sanguineous drainage. The resident's stage 3 wound on her right buttock measured 3 cm in length, 1.5 cm width, and 0.1 cm depth. The wound care orders for treatment of the pressure injury on the right buttock included cleanse with wound cleanser, apply foam every other day and reinforce with tape. Turn and reposition frequently while in bed and in a chair. Shift weight frequently while in bed and in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated and check for proper placement and function every shift. Ensure a seat or wheelchair cushion was in place. Float heels while in bed. If the resident wears briefs and was incontinent check briefs frequently. According to the wound note dated 8/23/23 the wound on the residents left buttock was a stage 3 pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure effective pain management for one (#82) of two out of 66 sample residents. Resident #82 experienced an exacerbation of pemphigus, an autoimmune disease in which the immune system mistakenly attacks cells in the top layer of the skin (epidermis) and the mucous membranes in the skin and the inside of the mouth, nose, throat, eyes and genitals. Typical symptoms begin with painful blisters in the mouth that could spread to other mucous membranes. Oral blisters in the mouth or throat making it hard to swallow and eat. The resident had been complaining of blisters and oral pain for over a month and rather than seeking specialized assessment to determine the root cause of the resident's pain and oral blisters the resident was treated with over the counter symptom management. The resident's family had offered past medical history to help the resident physician seek treatment. The physician's assistant chose to wait to see if less aggressive treatments improved the resident's symptoms. In that time the resident's symptoms worsened and the resident had increased pain that affected her eating and daily comfort level. The resident began seeking out visitors to the facility to request assistance in getting relief for her symptoms. During the time of the survey 9/11/23 to 9/21/23 the facility took a more aggressive approach to consider a diagnosis of pemphigus and the family suggested and reported a historical diagnosis for the resident. The resident's primary care provider moved beyond over the counter medications to prescription level medication treatment to better manage the resident's symptoms. At the time of survey exit 9/21/23 the resident continued to complain of pain and discomfort. The facility's failure to manage the resident's symptoms causes the resident worsening of symptoms and unnecessary pain and anguish leading. The resident asked for help in resolving her pain. Findings include: I. Facility policies and procedures The Pain Management policy and procedure, revised August 2023, was provided by the corporate nurse consultant (CNC) on 9//21/23 at 11:44 a.m. It revealed in pertinent part, The facility must ensure that pain management is provided to residents' who require such services, consistent with professional standards of practice, the comprehensive person centered care, plan, and the residence goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psycho, social well-being, and to prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain in care, upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident goal in preferences. facility, staff will observe for nonverbal indicators, which may indicate the presence of pain if indicators include but are not limited to, changing gait skin color, vital signs, perspiration. Loss of function, or an ability to perform activities of daily living. Fidgeting increased, or recurring, restlessness. Facial expressions. Behaviors such as resisting care, distressing, pacing, irritability, depression, mood, or decreased participation, and usual physical and/or social activities. Difficulty eating or loss of appetite, weight loss, difficulty, sleeping, negative, vocalizations, declining activity, level, or skin conditions. Facility staff will be aware, verbal descriptors a resident may use to report or describe their pain. Descriptors include, but are not limited to, heaviness of pressure, throbbing, hurting, cramping, burning, numbness, tingling, shooting, radiating, spasms, soreness, tenderness, discomfort, pins, and needles, or feeling rough, tearing or ripping. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health professionals, and the resident and/or the residence representatives will develop, implement, monitor and revise as necessary interventions for event or manage each individual residence pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions, or situations that may be associated with the pain or may be included as specific pain management needs or a goal. The interdisciplinary team of resident and or residence representatives will collaborate to arrive at pertinent, realistic, and measurable goals for treatment. Factors influencing the choice of treatment include the cause, location and severity of residents' pain. Pharmacological interventions will follow a systematic approach for selecting medication and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regime that is specific to each resident who has the potential for pain. Evaluate the residents, medical condition, current medication, regime, cause, and severity of the pain and course of illness to determine the most appropriate and Ology tick therapy for pain. consider administering medication around the clock and see if PRN (as needed) or combining longer acting medication with PRN medication for breakthrough pain. Facility staff will notify the practitioner, if the residence pain is not controlled by the current treatment regime. II. Resident #82 A. Resident status Resident #82, over the age of 65, was admitted [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (ischemic stroke) and heart failure. The 8/17/23 minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision from one person with dressing, toilet use and transfers. The resident received as needed (PRN) pain medications and non-pharmacological interventions. The resident occasionally experiences pain at a four out of 10 level. The resident's pain did not affect the resident's functioning such as sleep and day-to-day activities B. Resident observations and interviews On 9/11/23 at 9:15 a.m. the resident was observed in her room crying and grimacing and holding her mouth. Her breakfast was in the room completely untouched. The food had a regular texture. Resident#82 was interviewed on 9/11/23 at 9:25 a.m. Resident #82 said she had tears in her eyes and said she was in extreme pain. Resident #82 said she had pain for months and asked for help to relieve the pain. Resident #82 said she could not eat or sleep because of the pain. Resident #82 said they gave her Orajel and she used to use a special mouthwash but was not using it now. Resident #82 said they would give her Tylenol if she was in too much pain but the pain came back. Resident #82 said she could not handle the pain any longer. Resident #82's daughter was interviewed on 9/11/23 at 9:45 a.m. Resident #82's daughter said Resident #82 has been in pain for a month or maybe longer and did not eat or sleep well because of the pain. The resident's daughter said she talked to nurisng staff about her mom's symptoms but noting was done to resolve Resident #82 pain. The resident's daughter said she asked for her mother to see a specialist to figure out what was wrong but the facility only referred Resident #82 to the primary care physician and the physicain's assistant came to examin the resident. The resident's daughter said that her mom had been diagnosed with pemphigus and she believed it was resurfacing but the facility staff did not take that seriously. She said the nurse and certified nurse aides (CNAs) were ignoring her mom's unresolved pain. On 9/12/23 at 10:10 a.m. the resident was observed sitting in her doorway. The resident motioned to come closer to her. Resident #82 was grimacing and pointing to her mouth. The resident opened her mouth to point to the sores in her mouth and said please help me. On 9/18/23 at 1:55 p.m. the resident was observed sitting in her wheelchair crying and holding her face. Her lunch was in the room and completely untouched. The food was pureed. On 9/19/23 at 3:13 p.m. the resident was crying out moaning. She began sticking out her tongue and motioned to her mouth. The resident had six pea-sized and dime-sized lesions in her mouth. The lesions were white in the middle and bright red around them and were spread through her mouth. C. Record review According to dental notes dated 7/7/23 Resident #82 had a follow-up visit regarding the tooth that had been extracted. The extraction site had healed. According to a progress note dated 8/11/23 the resident had two canker sores on the right side of her tongue and under her tongue. The nursing staff notified the physician. According to a progress note dated 8/25/23 the resident had open sores on her tongue. According to a progress note dated 9/16/23 the resident's mouth sores had worsened. The sores had increased in size and intensified in pain. The resident's daughter said that her mom had pemphigus years ago. According to a progress note dated 9/17/23 the resident's POA was contacted. The POA told the facility his mom had this condition before and it was diagnosed as Pemphigus. The POA said Resident #82 took Valtrex (antiviral medication) and it cleared her sores. The August 2023 CPO the resident was prescribed nystatin mouth throat suspension, 5 milliliters (ml) by mouth for ten days for treatment of oral thrush (yeast infection), starting 8/18/23. The August 2023 pain assessment revealed the resident had six episodes of pain at 2 out of 10 (with 10 being the worst pain) and five episodes of pain at a level 3 out of 10. No other episodes of pain were documented, despite the above observations. The September 2023 CPO the resident was prescribed: -Diet orders: Regular diet, *Pureed texture, Thin consistency, please provide natural purees as possible, order start date 9/13/23. Medication orders: -Tylenol 325 mg two tablets given for pain, as needed, for pain level of 5 out of 10 to start 9/3/23, tapering down to; Tylenol 325 mg two tablets given for pain, as needed, for pain level of 4 out of 10 to start 9/8/23, to; Tylenol 325 mg two tablets given for pain, as needed, for pain level of 5 out of 10 to start 9/11/23, to; Tylenol 325 mg two tablets given for pain, as needed, for pain level of 10 out of 10 to start 9/12/23. -Orajel (instant pain relief for toothaches and sore gums, for nine days, to comfort and the treatment of oral lesions to the left side of the tongue, starting 9/9/23. -Prednisone one tablet one time a day for pemphigus, starting 9/15/2. -Tylenol 325 mg two tablets given for pain, as needed, for a pain level of 4 out of 10 to start 9/10/23. According to the nutrition dated 9/19/23 the resident's weight was fairly stable but the resident was at nutritional risk related to disease and advanced age. The resident experienced a small weight loss in the last 30 days with a 1.6 percent loss from weighing 124.0 pounds on 8/1/23 to weighing 122.0 pounds on 9/1/23. The resident was eating 25 to 75 percent of meals. She was placed on a pureed diet due to mouth soreness during an exacerbation of pemphigus. Other interventions included med pass nutrition supplement and monitoring weight. According to the pain scale documentation the resident did not have pain other than these specific dates. -However, the progress note dated 9/16/23, observations and interviews indicate the resident had worsened pain. -The resident was never prescribed Valtrex (oral medication used to treat infections caused by certain types of viruses like cold sores and shingles) the resident's POA had recommended as a past effective medication. III. Staff interviews Certified nurse aide (CNA) #9 was interviewed on 9/18/23 at 11:10 a.m. CNA #9 said the CNAs were to report to the nurse when a resident complained of pain. CNA #9 said Resident #82 was very hard of hearing and did not always understand. CNA #9 said the resident had been in pain in her mouth for about a month. CNA #9 said Resident #82's daughter would usually be the one to tell the CNAs that her Resident #82 was in pain. Registered nurse (RN) #5 was interviewed on 9/18/23 at 10:58 a.m. RN #5 said when a resident expresses they were in pain or appeared to be in pain the CNAs should tell a nurse the nurse can assess and provide prescribed interventions or notify the resident's physician. RN #5 said Resident #82 had been in pain for some time and had not been able to eat very well or sleep well. RN #5 said the resident was able to eat better because the facility put her on a pureed diet due to her mouth pain. The director of nursing (DON) was interviewed on 9/20/23 at 2:26 p.m. The DON said staff determined the level of pain on a 1 to 10 pain scale. The DON said staff should recognize when a resident could not provide a number and analyze pain by the resident's behaviors, such as crying or not eating. The DON said when a resident was in pain the facility started with medications on an as needed schedule and changed medication if pain did not decrease. The DON said Resident #82 had pain in her mouth. The DON said the resident was on an antibiotic for thrush and was using Orajel for temporary pain relief but the pain was not improving. The DON said the physician saw the resident on 9/18/23 and ordered magic mouthwash. The DON said the physician assistant wanted to wait to see if prescribed prednisone helped before giving the resident a referral to see a rheumatologist (a doctor with specialized treating conditions of inflammation).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#1, #3 and #2) of six out of eight sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #1 was admitted to the facility on [DATE]. Resident #1 had a diagnosis of traumatic subdural hemorrhage (brain bleed). Hypertension (high blood pressure), multiple fractures of ribs, history of traumatic brain injury and dementia. Upon admission on [DATE] Resident #1 weighed 178.2 pounds (lbs). On 10/2/22 Resident #1 weighed 170 lbs. This weight revealed, Resident #1 had a significant weight loss of 4.3% (7.6 lbs) in one week. The family began providing Ensure (nutritional supplement) on 10/22/22. Speech therapy was involved in the resident's care, but no additional nutritional interventions were implemented. The only nutritional intervention provided was initiated by the family providing Ensure. The facility failed to implement a nutritional intervention to prevent further weight loss, for Resident #1. Therefore, Resident #1 sustained a 11% weight loss (19.6 lbs) in five months, which was considered significant. Resident #3 was admitted to the facility on [DATE]. Resident #3 had a diagnosis of type two diabetes mellitus, hypothyroidism (reduced thyroid function), hyperlipidemia (high cholesterol) and personal history of traumatic brain injury. Upon admission on [DATE] Resident #3 weighed 248 lbs. Resident #3 was hospitalized from [DATE] through 3/2/23. During this time he was diagnosed with pneumonia related to a COVID-19 infection. The 3/2/23 discharge summary from the hospital documented the resident weighed 240 lbs and the resident was no longer on Hospice comfort care and the wife wanted to have the resident's medical issues treated. Upon Resident #3's readmission to the facility on 3/2/23, the facility failed to obtain a readmission weight to determine if the resident sustained weight loss while in the hospital and create a baseline for the resident after the hospitalization. Resident #3 sustained a 10.4% (28.4 lbs) weight loss in one month from 2/6/23 through 3/24/23, which was considered significant. Although the resident spent six days in the hospital the facility failed to weigh the resident timely upon readmission to determine if nutritional interventions should be put into place. Resident #3 was not weighed for 22 days after being readmitted to the facility. The resident sustained a 8.5% (20.4 lbs) weight loss from his hospitalization until he was weighed again at the facility on 3/24/23. Additionally, the facility failed for Resident #2 to: -Obtain an admission weight for Resident #2 and follow physician's orders to for weekly weights for the resident's first four weeks after admission; -Document attempts made to weigh the resident; and, -Provide clarification on documented weights in Resident #2's medical record. Findings include: I. Facility policy and procedure The Nutritional Management policy, revised February 2023, was provided by the nursing home administrator (NHA) on 4/18/23 at 4:38 p.m. It revealed in pertinent part, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status: identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. Identification/assessment: nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy, the dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay and a comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Care plan implementation: the resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care, interventions will be individualized to address the specific needs of the residents, real food will be offered first before adding supplements and tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. The physician will be notified of: significant changes in weight, intake, or nutrition status, lack of improvement toward goals and any complications associated with interventions. Informed consent: the resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status, the facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives and the comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative. II. Resident #1 A. Resident status Resident #1, age [AGE], admitted on [DATE] and expired on 2/4/23. According to the February 2023 computerized physician orders (CPO), the diagnoses included traumatic subdural hemorrhage (brain bleed), hypertension (high blood pressure), personal history of traumatic brain injury and dementia. The 12/6/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of six out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. He required supervision of one person assistance for walking in his room and in the corridor. He required supervision with no set-up or assistance for locomotion on and off the unit and he required supervision with set-up assistance for eating. The MDS assessment documented the resident did not have any swallowing difficulties. The resident weighed 167 lbs. The resident did not have any weight changes and was on a mechanically altered diet. -However, Resident #1's electronic medical record weight data documentation revealed the resident had sustained weight changes. B. Record review 1. Nutritional care plan The nutritional care plan, initiated on 9/9/22, revealed Resident #1 was at nutritional risk related to dysphagia (difficulty swallowing). He was tolerating a dysphagia advanced diet with nectar thick liquids. The interventions included: monitoring for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated, monitoring for signs or symptoms of aspiration, providing diet as ordered, weighing resident per protocol and alerting physician and RD (registered dietitian) of any significant weight loss or gain. -All interventions on the nutritional care plan were implemented on 9/9/22. -Resident #1's comprehensive care plan was not updated after he had significant weight loss from 9/23/22 to 10/2/22 and from 8/26/22 through 1/2/23 (see below). 2. Resident #1's weights Resident #1's weights were documented in the resident's medical record as follows: -On 8/26/22, the resident weighed 178.2 lbs. -On 9/5/22, the resident weighed 178 lbs. -On 9/20/22, the resident weighed 176.4 lbs. -On 9/27/22, the resident weighed 177.6 lbs. -On 10/2/22, the resident weighed 170 lbs. -On 11/11/22, the resident weighed 163.8 lbs. -On 12/1/22, the resident weighed 166.6 lbs. -On 1/2/23, the resident weighed 158.6 lbs. -The resident had 4.3% (7.6 lbs) weight loss, which was considered significant from 9/23/22 to 10/2/22 in one week. -The resident had an 11% (19.6 lbs) weight loss, which was considered significant from 8/26/23 through 1/2/23 in five months. 3. Physician orders The August 2022 CPO revealed Resident #1 had the following physician orders related to nutrition: -Weigh weekly X4 (times four) weeks then monthly, ordered 8/26/22. -Resident #1 was not weighed weekly upon admission for four weeks as ordered. (See above). The September 2022 CPO revealed Resident #1 had the following physician orders related to nutrition: -Dysphagia diet, dysphagia advanced texture, thin liquids, ordered on 9/5/22 and discontinued on 9/7/22. The October 2022 CPO revealed Resident #1 had the following physician orders related to nutrition: -Family has provided Ensure (nutritional supplements) drinks in the fridge, please offer with breakfast and dinner, ordered 10/22/22 , discontinued on 11/15/22. The November 2023 CPO revealed Resident #1 had the following physician orders related to nutrition: -Family has provided Ensure (nutritional supplement) drinks in the fridge, please offer with breakfast and dinner. Please make sure to thicken if not cold, ordered 11/15/22 and discontinued on 4/2/23. -Regular/liberalized diet, dysphagia advanced texture, nectar consistency, ordered 11/11/22 and discontinued on 4/1/23. -Hospice eval (evaluation) and treat (treatment), ordered 11/28/22, discontinued on 4/1/23. 4. Nutritional assessments/progress notes The 9/9/22 admission nutritional assessment documented in part, the resident weighed 178 lbs on 9/5/22 and was 70 inches tall on 8/26/22. The resident's body mass index (BMI) was 25.5. The resident was on a regular liberalized diet, dysphagia advanced texture (limit very hard, sticky or crunchy foods) and nectar thick liquids. The resident did not have any food allergies or cultural, ethnic or religious preferences with food. The nutrition history documented the RD met with the resident in the dining room and he was pleasant. The resident was tolerating his diet and was working with speech therapy. The resident was dining in the main dining room and the family requested him to eat there for supervision. The resident was able to feed himself and benefited from set-up assistance. The resident's family was unsure of his usual weight and his current weight was health. The goal was weight maintenance for the resident. The family frequently visited and brought in special foods for the resident. Resident #1 enjoyed smoothies and chili. The assessment documented the resident displayed coughing or choking during meals or when swallowing medications and was tolerating his current diet texture. There was coughing with thin liquids, which promoted the recommendation of nectar thick liquids. The resident had no significant weight weight changes and his BMI was less than 19 or greater than 25. The intake observation said the resident had variable intakes and accepted an average of 50-75%. The assessment documented he had no skin issues and was not appropriate for diet education. The assessment summary documented an [AGE] year old male was admitted for long term care after a hospitalization for traumatic subdural hematoma (brain bleed). His prior medical history included hypothyroidism (overactive thyroid) and hypertension (high blood pressure). Resident #1 was tolerating his diet. Medications and labs were reviewed. The assessment documented further assessment was needed. The resident's nutritional needs were 1950 calories, 81 grams protein and 2430 fluid ounces. The assessment documented the resident's intake was meeting his nutritional needs compared to his calculated needs and had generally good meal intakes and the family was also providing snacks. The nutritional evaluation and plan section documented the resident was admitted for long term care and was on a texture modified for dysphagia. He was eating generally well at this time. There were no nutrition related concerns to address at this time. There was no identified nutrition problem. The 12/7/22 nutritional assessment documented the resident weighed 166.6 lbs on 12/1/22 and his BMI was 23.9. The resident was on a regular/liberalized diet with dysphagia advanced and nectar thick liquids. The nutrition history section documented the resident was being seen due to a change in condition by admitting to hospice services. Resident #1 was tolerating his diet and his meal intakes were variable and accepted partial bottles of Ensure brought in by family. The resident was no longer eating in the main dining room and the family was requesting to offer that he eat in the main dining room if able. Resident #1 was able to feed himself independently, but benefited from set-up assistance. The family was unsure of his usual weight. His current weight was within a healthy BMI range. Weight maintenance was an appropriate goal for the resident moving forward, but had seen a 6% weight loss in the last three months. The swallowing section documented the resident was tolerating current diet texture and thickened liquids. The resident lost 6% weight in three months. It documented the resident had not had any significant/severe loss or gain, the resident had weight loss and the resident did not have a BMI that was less than 19 or greater than 25. The resident had variable intakes that average about 50-75%. The resident's skin was intact and was not appropriate for diet education at that time. The assessment summary documented an [AGE] year old male was admitted for long term care status post hospitalization for traumatic subdural hematoma. He was admitted to hospice per power of attorney decision. The resident tolerated his diet and the family provided Ensure which he usually accepted at least 25%. The resident's medication and labs were reviewed. The evaluation and nutrition plan documented Resident #1 was seen for a change in condition due to family opting hospice services. The resident consumed at least half of his meals most days. The assessment documented the staff will continue to encourage intake as able and offer Ensure at least twice a day. Comfort was the goal. The assessment documented to continue to monitor the resident per protocol and make changes as needed. The nutrition assessment documented there was not a nutrition problem. -However, Resident #1 had a 4.3% (7.6 lbs) weight loss, which was considered significant from 9/23/22 to 10/2/22 in one week. -The assessment mentioned the resident was tolerating his prescribed diet at that time and was accepting nutritional supplements. The assessment did not document the families desire to not provide nutritional interventions (see interview below). In addition, the assessment did not document the resident's wishes for nutritional interventions. -A request was made for the at risk meeting notes (see interview below) for Resident #1 on 5/18/23 and they were not provided by the facility. III. Resident #3 A. Resident status Resident #3, admitted on [DATE] and readmitted on [DATE]. According to the May 2023 CPO, the diagnoses included type two diabetes mellitus without complications, hyperlipidemia (high cholesterol, personal history of traumatic brain injury, viral pneumonia, pneumonia due to coronavirus disease 2019 and history of malignant neoplasm of prostate (prostate cancer). The 4/24/23 MDS assessment documented the resident was moderately impaired with inattention per staff interview for cognitive impairment. He required supervision with one person assistance for bed mobility, walking in the corridor, locomotion on and off the unit, eating and personal hygiene. He required extensive assistance of two people for transfers, supervision with set-up assistance for walking in his room, extensive assistance of one person for dressing and limited assistance of one person for toileting. The MDS assessment documented the resident did not have any swallowing difficulties. The resident weighed 219 lbs. Resident #3 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a prescribed weight loss regimen. He was on a therapeutic diet. B. Record review 1. Nutritional care plan The nutritional care plan initiated on 1/5/23 and revised on 5/4/23 revealed Resident #3 was at nutritional risk related to type two diabetes. Resident #3 had significant weight loss over six months consistent with overall decline. Resident #3 was overweight per his BMI, but weight loss was not a goal of care. The interventions included: encourage 100% consumption of all fluids provided, encouraging the resident to sit up for meals as tolerated, providing supervision and cueing at meals, monitoring for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicted, monitoring for signs and symptoms of hyper/hypoglycemia (high or low blood sugars) and report abnormal findings to physician, offering Boost (nutritional supplement) or house supplement three times a day, providing diet as ordered and encouraging to dine in restorative dining and weighing resident per protocol, alerting RD and physician of any significant weight loss or gain. 2. Resident #3's weights Resident #3's weights were documented in the resident's medical record as follows: -On 12/27/23, the resident weighed 248 lbs. -On 1/2/23, the resident weighed 243.4 lbs. -On 1/18/23, the resident weighed 237 lbs. -On 2/6/23, the resident weighed 244.4 lbs. -On 3/14/23, the resident weighed 219.6 lbs. -On 4/17/23, the resident weighed 217.6 lbs. The resident had a 10.2% (24.8 lbs) weight loss in one month, which was considered significant from 2/6/23 to 3/14/23. The resident had not been weighed in May 2023, at the time of the survey (5/18/23). 3. Physician orders The February 2023 CPO revealed the following physician orders related to nutrition: -House supplement three times a day for supplemental nutrition. Give with meals, ordered 1/7/23 and discontinued on 2/10/23. The March 2023 CPO revealed the following physician orders related to nutrition: -Sugar free house supplement PO (by mouth) BID (twice a day) after meals for DMII (diabetes type two), ordered 3/27/23 and discontinued on 4/4/23. -House supplement three times a day for ongoing supplementation ordered 3/16/23 and discontinued on 3/20/23. -Offer three times a day; offer resident Boost or Premier Protein (nutritional supplement) (provided by family, located in the fridge). If these supplements are unavailable please offer a house supplement, ordered 3/20/23 and discontinued on 5/15/23. -The nutritional supplement orders failed to document how much of the supplement to provide to the resident. The April 2023 CPO revealed the following physician orders related to nutrition: -Sugar free house supplement PO, BID after meals for DMII, ordered 3/27/23 and discontinued on 4/4/23. -Offer three times a day; offer resident Boost or Premier Protein (provided by family located in the fridge). If these supplements are unavailable please offer a house supplement, ordered 3/20/23 and discontinued on 5/15/23. -The nutritional supplement orders failed to document how much of the supplement to provide to the resident. The May 2023 CPO revealed the following physician orders related to nutrition: -Weigh weekly x4 (times four) weeks then monthly, ordered 3/3/23. -Offer three times a day offer resident Boost or Premier Protein(provided by family located in the fridge). If these supplements are unavailable please offer a house supplement, ordered 3/20/23 and discontinued on 5/15/23. -House supplement, three times a day offer resident 4 oz (four ounces) house supplement. Please assist with completion as needed. Document % (percent) completed in the MAR (medication administration record), ordered 5/15/23. -Upon readmission 3/2/23, the resident was not weighed for 14 days, per physician's orders. The resident was not weighed weekly after readmission, per physician's orders. 4. Nutritional assessments/progress notes The 1/5/23 admission/readmission nutritional assessment documented the resident weighed 243.4 lbs on 1/2/23 and was 72 inches. The resident's BMI was 33 and he was [AGE] years old. The resident received a consistent carbohydrate diet with no food allergies. The resident had no cultural, ethnic or religious preferences. The nutrition history section documented the resident was on a consistent carbohydrate diet and was eating in the dining room for most meals. Resident #3 was consuming 75-100% of his meals and enjoyed meat. The resident reported no strong dislikes. The resident was unsure of his weight history, but currently weighed 243.3 lbs and his admission weight was 248 lbs. The resident had no recent labs and received Lasix (diuretic). The resident had no swallowing concerns or had any significant weight changes. The residents BMI was less than 19 or greater than 25. The intake section documented the resident's BMI was 33 (sic) and his oral intake was 75-100% for three meals a day. The resident's skin was intact. Diet education was not provided to the resident as he was not interested at that time, but the RD was available upon request. The assessment summary documented the resident had a history of hypertension (high blood pressure), hyperlipidemia (high cholesterol, diabetes type two, hypothyroidism (overactive thyroid), anemia (low blood count), prostate cancer, benign prostatic hyperplasia (enlarged prostate gland), traumatic brain injury and obstructive sleep apnea. The resident was admitted from home for respite care and was currently on a carbohydrate diet with adequate oral intakes. The 3/7/23 admission/readmission nutritional assessment documented the resident weighed 244.4 lbs on 2/6/23 and was 72 inches. His BMI was 33.1. The resident was on a consistent carbohydrate diet with no food allergies. The nutrition history documented the RD attempted to meet with the resident, but the resident was sleeping during the visit. The resident remained on a consistent carbohydrate diet with generally good meal intakes. The resident had been eating in his room due to COVID-19 precautions. The resident was able to feed himself independently and enjoyed meat. The resident had not been weighed upon admission although the RD suspected that the resident lost weight when he was hospitalized for COVID-19. The resident had no significant weight changes and had a BMI less than 19 or greater than 25. The residents' meals intakes were generally good and he consumed 50-100% of his meals per the documentation. The assessment summary documented the resident was recently hospitalized for COVID-19. The resident remained on a consistent carbohydrate diet with good intakes. The resident's medications were reviewed and there were no recent labs to review. The resident's nutritional needs were calculated, 2210-2650 calories, 88 grams of protein and 2770-3330 milliliters of fluid per day. The assessment evaluation and plan documented the resident was recently hospitalized . Weight loss may be anticipated when the residents monthly weight was obtained related to hospitalization. The RD was to continue to monitor and make changes as needed. -The RD suspected weight loss, but did not recommend obtaining a weight to confirm suspected weight loss or implement a nutritional intervention to prevent further weight loss. The 3/15/23 interdisciplinary (IDT) note documented the IDT team discussed the resident's 11.5% weight loss, which was significant in three months. The resident was requiring more assistance with food and fluid intake. The resident was offered Boost after meals. The resident's fluid intake appeared to be adequate, but the resident was frequently declining food. The resident sustained a general functional decline after having COVID-19. The resident was receiving therapy services to restore previous function. The physician and wife were made aware. The RD was to evaluate and make recommendations for further interventions. The 3/17/23 weight change note documented, Resident #3 was reviewed by the RD for significant weight loss of 11.2% in three months. The resident's weight loss was discussed with the interdisciplinary team and the wife. The resident's current weight was 219.6 lbs. The resident's estimated nutrition needs were calculated at 2495 calories, 99 grams protein and 2495 milliliters of fluid. He was on a carbohydrate diet with overall poor oral intakes. The resident recently had COVID-19, which required a hospitalization. Resident #3 was occasionally offered Boost by his wife. A new intervention was to implement a house supplement three times a day and encouraging the resident to join restorative dining to receive one-on-one observation, cueing and encouragement during meals. The resident was receiving physical, occupational and speech therapy services. The resident was having ongoing diarrhea since the hospitalization. The RD reviewed the resident's medications list and discontinued the magnesium supplement, which could contribute to loose stools. The note documented there were no new or recent nutrition related labs to review. The resident's stool sample was negative for clostridium difficile (C. Diff, a bacterium that causes diarrhea and inflammation of the colon). The RD was to continue to monitor the resident's weight and meal intakes to determine if further interventions were needed. The 3/29/23 IDT note documented the IDT team discussed that the resident continued to have poor oral intake. The resident was offered a house supplement twice a day. The resident had a functional decline since having COVID-19. -However, the IDT team noted the resident had poor oral intake, but did not recommend new nutritional interventions to help promote oral intake. The 4/20/23 nursing progress note documented the resident was now receiving hospice care. -The resident sustained significant weight loss prior to admission to hospice services. The 4/27/23 IDT note documented the IDT team discussed the residents' continued poor appetite. The resident accepted supplements intermittently. The 5/3/23 IDT note documented the IDT team discussed the wife's concerns over the resident's poor oral intake. The wife requested a notebook with concerns and challenges to be available for staff to use as a communication aide for daily struggles with intakes, which was provided and nursing staff was made aware of the process. The resident continued with a poor appetite and was encouraged to eat and offered hands-on assistance with meals. The resident tested positive for C. Diff. The 5/8/23 comprehensive MDS nutritional assessment documented the resident weighed 217.6 lbs on 4/17/23 and was 72 inches tall. His BMI was 29.5 and he was on a consistent carbohydrate diet with no food allergies. The nutrition history documented the resident had not been weighed in the month of May (2023). The resident's weight in April (2023) suggested the resident's weight had stabilized following a significant weight loss trend. The resident remained overweight per BMI, though weight loss was not a goal of his care. Weight loss was likely inevitable with the diagnosis progression. The resident remained on the same diet and had generally poor intakes. The resident often did not get up for meals even when encouraged. The resident had been dining in his room due to C. Diff. The IDR felt the resident required assistance with meals. Nursing staff was to assist the resident with meals in his room until he was off isolation. The resident had no swallowing difficulties. The resident had 8.2% weight loss in three months. The resident had significant/severe loss or gain, had a weight loss/gain trend and had a BMI less than 19 or greater than 25. The resident had variable intakes and was less than 50% at most meals. The resident's skin was intake and he was not appropriate for diet education. The resident nutritional labs were reviewed. The evaluation and plan section of the assessment documented the resident was recently admitted to hospice with comfort as an overall goal of care. The resident had significant weight loss since admission, which appeared to be stabilizing. The resident had inadequate oral intake related to sleeping through meals and poor appetite as evidenced by poor documented meal intakes. The nutrition prescription was to continue with the consistent carbohydrate diet. The nutrition interventions included encouraging the resident to sit up for meals and offer one on one assistance as tolerated and continuing to offer the resident Boost or house supplement three times a day. The nursing staff was to obtain weights and provide assistance with meals. The care plan goals were for the resident to safely consume food and beverages that bring comfort. The 5/11/23 IDT note documented the IDT team discussed the residents' continued poor oral intakes. The resident was sleeping often. Staff continued to document activities of daily living and nutrition assistance attempts in a notebook which was helpful for the wife. The resident was being followed by hospice services. IV. Resident #2 A. Resident status Resident #2, age [AGE], admitted on [DATE]. According to the May 2023 CPO, the diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (left hip fracture), dementia unspecified severity with agitation and cerebral infarction (stroke). The 3/1/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of eight out of 15. He required limited assistance of one person for bed mobility, walking in room and walking in the corridor, locomotion on and off the unit, toileting and personal hygiene. He required extensive assistance from one person for transfers and dressing. He required supervision with set-up assistance for eating. The MDS assessment documented the resident had coughing or choking during meals or when swallowing medications; but did not have loss of liquids or solids from his mouth when eating or drinking, did not hold food in his mouth or cheeks or have residual food in his mouth after meals or had complaints of difficulty or pain when swallowing. The resident weighed 175 lbs. The resident did not have any weight changes. B. Record review 1. Nutritional care plan The nutritional care plan, initiated on 3/2/23, revealed Resident #2 was at nutritional risk related to dementia and a left femur fracture. The interventions included: encouraging 100% consumption of all fluids provided and providing the diet as ordered. 2. Resident #2's weights -On 3/2/23, the resident weighed 175 lbs. -On 4/14/23, the resident weighed 161.6 lbs. -On 5/2/23, the resident weighed 166.4 lbs. -The resident sustained a 7.7% (13.4 lbs) weight loss, which was considered significant in two months from 3/2/23 through 5/2/23. 3. Physician orders The May 2023 CPO revealed Resident #2 had the following physician orders related to nutrition: -Regular/liberalized diet, regular texture, thin consistency, ordered 3/30/23. -Weigh weekly X4 (times four) weeks then monthly, ordered 2/23/23. -However, the resident was not weighed until 3/2/23 which was 19 days after the resident was admitted to the facility (see interviews below). 4. Record review The 3/2/23 admission nutritional assessment documented the resident weighed 175 lbs on 3/2/23 and was 72 inches. The resident had a BMI of 23.7. The resident was on a regular/liberalized diet and had no food allergies or cultural, ethnic or religious preferences with food. The nutrition history section documented the