**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#13) of three residents reviewed for accidents/hazards out of 28 samples residents. Resident #13 had been evaluated and determined to be a supervised smoker, which included she was not able to keep smoking supplies with her. The supplies were to be kept and monitored by the facility. During the scheduled smoke breaks, the facility would provide the resident with the cigarette and light the cigarette with a lighter. On 3/29/24 at 12:30 a.m. certified nurse aide (CNA) #8 heard screams coming from Resident #13's room. When she went in the room to check on Resident #8 she found the dressing on her lower left leg on fire. CNA #8 yelled for help and put out the fire with a towel and water. Resident #8 was transferred to the emergency department (ED) where it was determined she had first and second degree burns. Upon investigation and a care conference with the family, it was determined that, during a family visit, a family member had left a lighter with the resident. The facility failed to implement safety procedures to prevent a family member from providing a lighter to a supervised smoker. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/15/24 to 4/18/24, resulting in the deficiency being cited as past noncompliance with a correction date of 4/2/24. I. Incident on 3/29/24 The facility failed to ensure Resident #13, who had been assessed and determined to be a supervised smoker who's smoking supplies were to be kept locked up by the facility, did not have a lighter in her personal possession. This resulted in Resident #13 attempting to use a lighter she had obtained from her family to burn a dangling thread off of a bandage on her leg in her room on 3/29/24. Due to the facility's failures, the bandage on Resident #13's leg caught on fire. CNA #8 was able to smother the bandage fire with a towel, however, Resident #13 was transferred to the hospital on 3/29/24 where she was discovered to have first and second degree burns to her leg. Record review and interviews during the complaint investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 4/16/24 to 4/17/24. II. Facility correction A. Immediate action The corrective action plan the facility implemented in response to Resident #13's lighter accident on 3/29/24 was provided by the director of nursing (DON) on 4/17/24 at 12:00 p.m. On 3/29/24 a sweep of the supervised smokers for lighters was completed. No lighters were found. On 3/29/24 staff were re-educated on safe smoking practices, ensuring supervised smokers did not have lighters and the facility smoking policy. B. Systemic changes On 3/29/24 the social services assistant (SSA) completed an audit of all the smokers to re-determine if the smoker was supervised or unsupervised. The facility implemented smoking aprons for all smokers regardless of smoking status. On 3/29/24 the facility reached out to families to provide education on the importance of not providing smoking supplies to the smoking residents. Families were educated to give the smoking supplies to the nurses. On 3/29/24 the one unsupervised smoker in the facility was re-educated on the importance of keeping control of his lighter and not giving it to supervised smokers. The unsupervised smoker was receptive to the re-education understanding the severity of the situation and agreed not to share his lighter with supervised smokers. On 3/29/24 housekeeping staff were educated to be more critical and observant for lighters when in a smoker's room. Education included, if a lighter was found, it was to be given to the nurse on duty immediately. On 3/29/24 nursing staff were educated if staff turned in a lighter from a supervised smoker to notify the DON. On 3/30/24 Resident #13 was moved to a different hall with more staff monitoring. Resident #13 was provided with a vape pen in lieu of cigarettes and the vape pen supplies were kept locked up by the facility. On 4/2/24 the facility completed a care conference with the family. During the conference, the family admitted they had given Resident #13 the lighter. The resident's family was educated on the importance of not providing the resident with a lighter. C. Monitoring On 3/29/24 audits of smokers were started and continued weekly to ensure lighters were not in the possession of supervised smokers and if found, family education was conducted. All audits and education were to be reviewed during weekly interdisciplinary team (IDT) meetings and during monthly quality assurance and performance improvement (QAPI) meetings. Interviews and record reviews during the recertification survey revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systemic changes to prevent its recurrence and monitoring to ensure sustained correction were in place. III. Resident status Resident #8, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the April 2024 computerized physician's order (CPO), diagnoses included hemiplegia on the right side, cerebral infarction (stroke) on the right side and need for assistance with personal care. The 3/1/24 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment identified the resident had impairment on one side (right) and she utilized a wheelchair for mobility. She required one to two staff members for transfers. IV. Record review The care plan, initiated on 3/1/24, identified Resident #8 had impaired cognitive function. Interventions included to keep her routine consistent. The care plan, initiated on 3/12/24, identified Resident #8 was a supervised smoker. Interventions included notifying the charge nurse if the resident violated the facility smoking policy, observing the resident's clothing and skin for signs of cigarette burns, conducting a smoking assessment quarterly and as needed and smoking materials were to be kept by staff. The smoking safety screen assessment dated [DATE], documented the resident needed supervision for smoking which included supervised smoking with the staff, a smoking apron and the facility holding her smoking materials. The progress note dated 3/29/24 at 2:21 a.m. documented CNA #8 heard screams coming from Resident #8's room at 12:30 a.m. When she ran into the room she saw the dressing on Resident #8's leg was in flames. CNA #8 smothered the flame with a towel then doused the area with water. The dressing was removed. The provider was notified at 12:40 a.m. The assistant director of nursing (ADON) was notified at 12:45 a.m. The resident was transported by ambulance to the hospital at 1:16 a.m. The progress note written by registered nurse (RN) #4 on 3/29/24 at 5:01 a.m. documented the discharge report was taken from the ED nurse and the resident returned back to the facility with a kerlix (gauze) wrap intact to her lower left leg and it was clean and dry. The hospital records dated 3/29/24 documented Resident #8 was reportedly trying to burn a string hanging from her previous dressing when she lit her entire bandage on fire. The hospital identified the injuries as first and second degree burns. The hospital visit note dated 3/29/24 documented the nursing home staff said the resident had a lighter. The facility was unsure how she had one. The resident was reportedly trying to possibly burn a string on her previous dressing when she lit her entire dressing on fire. CNA (#8) was able to use a towel to put out the flames and the resident's wounds were soaked in cool water. On arrival to the ED, the resident had mid lower extremity circumferential first degree burns with a few second degree burns. The progress note written by RN #3 on 3/29/24 at 3:46 p.m. documented the wound to her lower left leg was 13.0 centimeters (cm) by 20 cm around the circumference of her ankle. The affected area appeared to be blistered to the medial (inner) aspect. Silvadene was applied as the ordered treatment regimen. She had been receiving ibuprofen 600 milligrams (mg) and had not complained of breakthrough pain. The progress note written by the wound care nurse (WCN) dated 3/29/24 at 8:24 p.m. documented the wound on the resident's shin was 13.2 cm by 10.8 cm by 0 cm. There was scant serous (pale yellow or transparent) drainage without odor. The provider note date 4/1/24 documented Resident #13 burned the bandage on her leg which apparently then erupted in flames. From the description given by staff, there seemed to be a loose thread hanging from the bandage and due to her extremely poor judgment and executive dysfunction, she decided to burn the dangling thread. Resident #13 was not able to foresee that the burning thread would soon burn the bulk of the bandage. She was sent to the emergency room where she was treated physically, as this did not appear to be a suicide attempt or a serious attempt at self harm. V. Interviews The nursing home administrator (NHA) was interviewed on 4/16/24 at 5:27 p.m. The NHA said after the resident was transported to the hospital, the staff completed a sweep of all the supervised smokers to ensure they did not have a lighter. He said immediately the facility decided all smokers would have to wear a smoking apron. He said the facility called the family and after a conversation about the resident burning herself, the family had admitted to leaving the lighter with the resident. The facility, along with the family, had decided to make all visits with the family supervised, and moved the resident to another hall. He said the family was educated on the importance of not providing supervised smokers with a lighter to ensure the safety of everyone. CNA #6 was interviewed on 4/16/24 at 5:29 p.m. She said when she was the staff member to go out with the supervised smokers, she walked around them during the break ensuring all the aprons were on correctly. She said all the supervised smokers used an apron. She said she did not know if during family visits if Resident #13's family would take her out for a cigarette without staff. She said the management were the people who determined if someone was a supervised smoker. She said the smoking supplies, including the lighter, were locked up at the nurses station. She said only the nurses had a key to the cigarettes. RN #2 was interviewed on 4/16/24 at 5:37 p.m. RN #2 said the residents had set times for smoking. He said the times were posted at the nurses station where the residents could see. He said he would delegate a CNA to assist the residents to the smoking area where they would ensure the oxygen was removed. He said the CNAs assisted the residents to the smoking area, put on the aprons, and handed them a cigarette and lit the cigarette for the resident. RN #2 said residents were not allowed to save the cigarette if they did not finish it and they were not given the lighter to light the cigarette themselves. He said Resident #13 was a supervised smoker. He said sometimes it was noted the family would come by and go outside to the smoking area to smoke with her. He said it was during one of those times that the family gave the resident the lighter. He said the smoking assessments were completed by social services. He said the smoking supplies were locked up in the medication room. CNA #3 was interviewed on 4/17/24 at 8:45 a.m. CNA #3 said she was new to the facility. She said she knew Resident #13 had a burn from an accident and knew she was a supervised smoker. She said she used a vape pen, not cigarettes. She said she had received education on smoking safety recently but could not recall the date. She said the smoking supplies were kept locked in the medication room and only the nurse could get them for the designated smoke breaks. CNA #4 was interviewed on 4/17/24 at 8:50 a.m. CNA #4 said she had not seen Resident #13's family visit since her room change. She said she knew there was an accident with a lighter and now she used a vape pen instead of a cigarette. She said right after the accident the facility did training on smoking and the use of lighters with supervised smokers and how the supervised smokers were not allowed to have a lighter. She said all the smoking supplies were locked in the medication room and only the nurse could get the smoking supplies. Licensed practical nurse (LPN) #2 was interviewed on 4/17/24 at 8:52 a.m. LPN #2 said since Resident #13 had moved to the new room, the family had not been over for a visit while she was there. She said she knew Resident #13 had an accident and now she used a vape pen instead of a cigarette during the scheduled smoke breaks. She said the facility completed training on smoking safety right after the incident. She said supervised smokers were not allowed to have a lighter, and if one was discovered with a supervised smoker, the charge nurse was to be notified immediately and to ask the individual if they could give it up, but not to fight with them. CNA #7 was interviewed on 4/17/24 at 9:10 a.m. CNA #7 said at the smoking times, the residents all lined up to go out. On their way outside, an apron was put on them. She said she would light the cigarettes and watch all of them to make sure they did not burn themselves. She said if they did not finish the cigarette, it was thrown away and the resident was not allowed to save it for the next break. She said residents were not allowed to light their own cigarettes. She said all the smoking supplies were locked at the nurses station in the medication room and only accessed by the nurse on duty. She said all staff were told if a lighter was found with a supervised smoker, to take it and report immediately to the charge nurse. On 4/17/24 at 10:30 a.m. wound care was completed with the wound care nurse practitioner (WCNP). She said the burn was a partial thickness burn (second degree) and it had improved from first treatment. CNA #1 was interviewed on 4/17/24 at 1:02 p.m. CNA #1 said seven to eight months ago a lighter was discovered with Resident #13. He said he reported it to the charge nurse who was no longer at the facility. He said she went and talked to Resident #13 and was able to retrieve the lighter. He said he did not know if the charge nurse told anyone. LPN #1 was interviewed on 4/17/24 at 1:02 p.m. LPN #1 said Resident #13 was found to have a lighter seven to eight months ago. He said he reported it to the charge nurse. He said the charge nurse had a good relationship with Resident #13. He said she talked to Resident #13 and was able to retrieve the lighter and educate the resident. He said he did not know if it was reported to the DON or not. The DON was interviewed on 4/17/24 at 1:30 p.m. She said Resident #13 was trying to burn off a stray thread and lit the bandage around her leg on fire. She said the staff put out the fire with a towel and then water. She said the RN cut off the bandage and called the provider and an ambulance. She said the resident went out to the hospital and returned with first and second degree burns. She said immediately the staff did a search of the supervised smokers for lighters and none were found. She said that day (3/29/24), the SSA started reinforcing the training on smoking safety with the staff, starting with the staff who were present. She said the facility determined all supervised smokers would use an apron going forward. She said Resident #13 was moved to another unit. She said during the care conference on 4/2/24 with the family, it was the family who said they had provided Resident #13 with the lighter. She said the facility and the family, after a lengthy conversation, mutually agreed to have supervised visits with the family during visits if smoking was involved. The facility provided education to the family about smoking and supervised smoking. The facility and family also agreed to use a vape pen for Resident #13. The facility determined the vape pen would be kept with the smoking materials and given during the smoking breaks and returned at the end of the break. The DON said education was immediately started with the staff and a sweep was completed of all the supervised smokers to ensure no other lighters were found for the safety of all the residents. She said the housekeeping staff were to do visual inspection of supervised smokers rooms keeping a lookout for lighters going forward. The DON said she had never been notified before the accident that the resident had ever had a lighter in her possession.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#34, #62 #65 and #69) residents involved in three facility reported incidents on the South unit out of 46 sample residents. The facility failed to prevent an altercation between Resident #65 and Resident #34. Resident #34 was physically abused by Resident #65, which resulted in Resident #34 requiring hospital treatment where he received 12 staples to his head and medication for pain. Resident #62 was physically abused by Resident #34. Resident #34 pushed Resident #62's wheelchair into a wall resulting in Resident #62's bilateral lower extremities making contact with the wall. Resident #34 also made a comment he wanted to break Resident #62's legs. Resident #69 was physically abused by Resident #65 which in resulted in Resident #69 being shoved to the floor by Resident #65. Cross-reference F744, the facility failed to implement person centered approches to dementia care in order to prevent resident-to-resident altercations. Findings include: I. Facility policies and procedures The Abuse Prevention Program policy, dated 11/1/2017, was provided by the nursing home administrator (NHA) on 9/13/21 at 11:27 a.m. The policy revealed the residents have a right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. (1) The facility was committed to protecting the residents from abuse by anyone including but not necessarily limited to staff, other residents . (3) Comprehensive policies and procedures have been developed to aid the facility in preventing abuse, identification and reporting of abuse, stress management, and dealing with violent behavior or catastrophic reactions, ect. -Timely and thorough investigations of all reports and allegations of abuse, -The reporting and filing of accurate documents relative to incidents of abuse, -An ongoing review and analysis of abuse incidents, and -The implementation of change to prevent future occurrences of abuse. II. Altercation 7/23/21 A. Resident #34 status Resident #34, age [AGE], was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with behaviors, psychoactive substance abuse and alcohol induced anxiety disorder. The 7/12/21 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score. The resident did not have any behaviors. There was no evidence of an acute change in mental status or psychosis. The resident did have wandering tendencies that occurred daily. The resident required staff supervision for bed mobility, transfers, eating, and toileting. B. Record review Physician order dated 11/25/19 at 12:39 p.m., revealed to admit the resident on the facility's secure unit related to the resident had wandering behaviors which placed the resident in danger due to the inability to find his way back to the facility. The care plan for potential abuse related to residing in a unit with residents who occasionally have behavioral disturbances was initiated on 4/29/2020. Some of the interventions were to redirect the resident from escalated residents by offering an activity of choice and/or a snack. Report any agitation/restlessness related to specific residents on the unit. When the resident desired to spend leisure time outside his room, direct the resident to the activity room that was away from the dining room. The care plan for the resident residing on the facility's secure unit for his safety and structure was revised on 4/22/21. The resident habitually wandered or would wander out of this environment and would be unable to find his way back to the facility, placing him in danger. His guardian consented to the secure unit placement. Some of the interventions were to assess the resident quarterly for the appropriateness of placement on the secure unit. Encourage the resident to participate in activities of choice and involve the resident/guardian in the resident's plan of care. The care plan for impaired cognitive function related to dementia was revised on 4/23/21. Some of the interventions were to face the resident when speaking and making eye contact. The resident understood simple, consistent and directive sentences. Reduce any distractions such as turning off the television, radio and closing the door as needed. A nurse note dated 7/23/21 at 5:43 p.m., by the director of nursing (DON) revealed at approximately 4:45 p.m., she received a call from the South Unit from licensed practical nurse (LPN) #2 that Resident #65 had made contact with Resident #34's head multiple times. This occurred in the main dining room and was witnessed by a certified nurse aide (CNA). The two residents were immediately separated and Resident #65 was put on one-to-one staff observations. Resident #34's vital signs and neurological assessments were initiated upon the DON's arrival. Resident #34's assessments were within his normal limits. The resident had abrasions to the top of the right and left side of his skull. A physician's order was obtained to send Resident #34 to the hospital for further evaluation and treatment. Also the order revealed to send Resident #65 to a named medical center for a psychological evaluation and treatment. A message was left for Resident #34's guardian. The local police department was called and a case number was issued. A nurse note dated 7/23/21 at 7:45 p.m., by LPN #2 revealed the resident left the facility at approximately 5:05 p.m., on a stretcher accompanied by three ambulance crew members and was transported by ambulance to the hospital. A nurse note dated 7/23/21 at 10:30 p.m., by a registered nurse (RN) revealed the resident arrived back to the facility at approximately 10:30 p.m. The resident was ambulatory, alert and oriented times three. The resident was accompanied by a staff member from the hospital. A report was given to this nurse. The resident was assessed and started on neurological assessments. The resident had 12 staples in his head with minimal bleeding. The on call provider was notified and orders were received. The wound was dressed as indicated and Tylenol was administered for his pain. The resident was educated to report any increased pain and any increased bleeding to the nurse. A nurse note dated 7/24/21 at 3:16 p.m., by LPN #2 revealed the resident removed the dressing to his head at mid-morning and refused to have it replaced. There was a scant amount of serosanguineous drainage. No signs or symptoms of pain or discomfort noted or reported. The resident was alert and oriented times three. The resident's neurological assessments were within normal limits. A nurse note dated 7/25/21 at 1:39 a.m., by an RN revealed the resident presented with a closed wound related to a resident to resident incident. The wound was dry and open to the air. The resident was educated about the need for wound dressing and he refused. The resident reported a pain scale level of 3/10 (three out of a zero to 10 scale, with 10 being the most severe pain). Tylenol was administered for the pain and his neurological assessments were within normal limits. The interdisciplinary team note dated 7/26/21 at 3:22 p.m., by the DON revealed the team met to discuss Resident #65's aggression related to the incident on 7/23/21 at 4:45 p.m. The staff heard a commotion from the South Hall dining room. Upon entering, the staff noted Resident #34 was bleeding from the top of his head and was in a seated position on the floor. Resident #65 and Resident #34 were separated immediately by staff. Resident #34 was interviewed and said he was unsure what had happened and he did not know Resident #65. Resident #34 said he was unsure why Resident #65 was upset. Both residents denied fear of the other. The DON assessed Resident #34 and neurological assessments were started. A CNA started vital signs on Resident #34. Pressure was applied to the top of the head of Resident #34 until the ambulance arrived. Resident #34 returned to the facility later that evening with 12 staples to the head. There was no brain bleed noted from the emergency room report. Physician orders were followed and the guardian was kept informed by the social service director (SSD). The Ombudsman, local police department and Adult Protection Services were also notified. The resident denied pain at the time of the incident, however he did have a complaint of a headache after arriving back at the facility. As needed Tylenol was administered. The resident's neurological assessments were within normal limits. Resident #34 had a history of dementia without behavioral disturbances and anxiety disorder. The resident had not had any recent medication changes. Interventions implemented were to keep both residents separated, and place Resident #65 on immediate one-to-one staff observations. Send Resident #34 to the hospital for evaluation and treatment. Send Resident #65 to a specified medical center for psychological evaluation and treatment. Resident #65 was currently under the care of the medical center (transferred to hospital 7/23/21). The social services note dated 7/29/21 at 11:55 a.m., by the social service director (SSD) revealed Resident #34 was interviewed for a followup from the recent altercation with Resident #65. He continued to deny any fear and voiced he was doing rather well for being almost [AGE] years of age. He was told Resident #65 would be returning to the facility and he said it was fine with him. He again denied any fear of Resident #65. The resident was provided a personal television for his room. The social services note dated 8/31/21 at 4:33 p.m., by the SSD revealed she interviewed Resident #34 to ensure his safety about residing on the secure unit. He continued to deny any fear of any residents or staff. The SSD asked him if he felt safe living in the facility and he said oh sure. No concerns were voiced during the conversation. The social services note dated 9/1/21 at 2:59 p.m., by the SSD revealed during the weekly call with the Ombudsman the SSD was notified that Resident #34's sister had called the Ombudsman regarding a previous altercation involving the resident and another resident on the unit which resulted in a head injury. The Ombudsman detailed that the sister said Resident #34 voiced fear to the sister. The Ombudsman explained to the sister that during the follow up interactions, Resident #34 had denied any fear of the other resident. The SSD explained she had followed up with the resident as of yesterday and he had no fear at this time. The Ombudsman acknowledged and denied having any concerns with the facility or the resident safety. The Ombudsman wanted a zoom virtual meeting with the resident tomorrow to personally interview the resident. The zoom meeting was scheduled for tomorrow at 2:15 p.m. Immediately after this call, the SSD and a floor nurse interviewed the resident and asked him multiple times during the conversation if he was afraid of any residents or afraid of residing in the facility. He denied being afraid multiple times. The resident said he recalled the incident as being beaten by a tall man. He denied any fear and denied any pain at this time. During the conversation the resident was observed to pace near Resident #65 without any non-verbal signs of fear. The SSD asked the resident if he knew who he could speak to if he had any concerns regarding his safety. He denied any concerns of fear and said that he could speak to the SSD or to a nurse if he needed to. The resident denied he had reported to his sister that he was afraid. He said that he had informed his sister that he had been beaten, however he continued to deny he had told his sister he was afraid. The SSD informed the resident of the zoom meeting with the Ombudsman tomorrow. The resident acknowledged the meeting. The SSD notified the resident's guardian and the guardian also said each time she had talked with the resident he has denied any fear. The guardian was scheduled to visit the resident tomorrow and would ask him again about being afraid, during their conversation. The SSD initiated each shift nurse was to interview the resident regarding being afraid. The SSD informed the staff that if the resident should voice fear, he was to be removed from the unit and the DON and NHA were to be immediately notified for further interventions. C. Resident #65 Resident #65, age [AGE], was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included anxiety, dementia without behaviors and disruptive mood dysregulation disorder. The 8/13/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of eight out of 15 with no behaviors. The resident required staff supervision of bed mobility, transfers, dressing, eating, toileting and personal hygiene. Physician order dated 7/29/21 at 9:25 p.m., revealed to admit the resident to the secure unit due to the risk of wandering out of the facility and placing himself in danger due to the inability to find his way back to the facility. The care plan for occasionally displaying episodes of verbal or physical aggression was revised on 4/15/21. Some of the interventions were to allow the resident to vent his frustration and provide affirmation/validation. Encourage the resident to see staff assistance if/when another resident was disrupting him. Provide a personal television to the resident. Redirect the resident when escalated with one-to-one walks outside. Redirect the resident when escalated with a snack or drink of choice; the resident likes coffee and sweets. When the resident wanted to spend leisure time outside of his room, direct the resident to the dining room and away from the activity room. -No additional interventions were added to the care plan after the altercation on 7/23/21. D. Observations Observations during survey 9/12-9/16/21 revealed Resident #34 wandered often in the hallways and kept away from Resident #65. He was also observed smoking outside in the smoking areas during scheduled times with staff present. No verbal or physical outbursts were observed. Observations during survey 9/12-9/16/21 revealed Resident #65 was either in the common television area watching television or in his room interacting with his computer. He was also observed smoking outside in the smoking areas during scheduled times with staff present. Resident #65 kept away from Resident #34. No verbal or physical outbursts were observed. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/15/21 at 1:43 p.m. regarding the incident on 7/23/21. She said she heard yelling in the main dining room. She said she observed Resident #65 had Resident #34 on the floor. She said Resident #65 was standing over Resident #34. Resident #65 used his hands to grab onto the shirt of Resident #34 and was loudly pounding him onto the floor. Resident #34's head was hitting the floor during the pounding. CNA #1 said the altercation started because Resident #34 wanted to watch a football game and Resident #65 wanted to change the channel. She said when she saw the incident, she ran to go get a nurse and during that time Resident #65 walked out of the dining room and into his room. She said Resident #34's head was bleeding. She said a nurse arrived to assess the resident and an ambulance came to take him to the hospital. She said Resident #34 received staples to his head. CNA #1 said there had not been any further incidents with these two residents. The director of nursing (DON) was interviewed on 9/15/21 at 4:03 p.m. She said she received a call from the nurse on the South Unit that there was a resident to resident altercation in the main dining room. When she arrived both residents were already separated. She said CNA #1 reported that Resident #65 had made contact with Resident #34. She said both residents were watching the football game and Resident #65 asked Resident #34 to move out of the way of the television. The DON said when she entered the room the staff were performing vital signs on Resident #34. The resident had abrasions to the right and left side of his head. The resident did not know what happened. The ambulance service took the resident to the hospital. The resident received 12 staples to his head and the facility received physician orders for wound treatment for ten days. The DON said Resident #65 was placed on one-to-one staff observations. Resident #65 was taken to a specified medical center for psychological and medication evaluations. She said the resident was out of the facility from 7/23/21 to 7/29/21. The DON said to her knowledge the residents had not had any additional interactions. She said neither resident had voiced any fear of the other resident. III. Altercation 9/3/21 A. Resident #62 status Resident #62, under age [AGE], was admitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included dementia with behaviors, post-traumatic stress disorder, muscle weakness, muscle contracture, hemiplegia and hemiparesis (weakness, paralysis) from cerebrovascular disease (stroke) affecting the left non-dominant side. The 8/11/21 minimum data set (MDS) assessment revealed the resident had moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident did not exhibit any behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. B. Resident interview An attempt was made to interview Resident #62 on 9/13/21 at approximately 10:30 a.m. The resident sat in his wheelchair in his room and mumbled at very low levels. The answers he provided to specific questions were undiscernible and vague in relationship to the questions. C. Resident #65 record review Physician order dated 8/26/21 at 7:56 a.m., revealed to admit the resident to the facility's secure unit. The resident's guardian agreed with this voluntary placement. The care plan for the potential for abuse related to residing in a unit with residents who occasionally have behavioral disturbances was revised on 5/28/21. Some of the interventions included encouraging the resident to not invade another resident's personal space. Redirect the resident away from escalated residents by offering an activity of choice or a snack. Report any agitation/restlessness related to specific residents on the unit. The Behavior Monitoring book dated 9/2/21 at 10:00 a.m., revealed that the activity assistant (AA) wrote that Resident #34 was pushing Resident #62 in his wheelchair. Resident #34 pushed Resident #62 into the hallway wall. Resident #34 said he wanted Resident #62 to break his legs and get up from the floor on his own. When asked why he did this Resident #34 said we all sin sometimes. The incident note dated 9/3/21 at 2:12 p.m. by licensed practical nurse (LPN) #1 revealed that it was brought to her attention by the activity assistant (AA) that the resident was observed to make contact with the hallway glass door leading to the outside of the facility. The resident was being pushed in his wheelchair by Resident #34. The AA was taking the residents to attend a church service in the other building. The resident's bilateral lower extremities were observed to make contact with the glass doors. The AA overheard a comment by Resident #34, about his desire to break Resident #62's legs. The AA intervened and asked Resident #62 if he was okay and he stated he was. The AA resumed assisting the residents to the church service. Resident #62 was observed to continue his usual routine yesterday and he did not exhibit any signs or symptoms of fear and he did not report any fear. Today's assessment did not reveal any pain or injury. The resident denied any fear and did not report any pain or injury. Resident #34 was placed on 15-minute checks. The incident note dated 9/3/21 at 2:12 p.m., by LPN #1 revealed the director of nursing (DON), the resident's family, physician and the local police department were notified. All assessments were completed in the resident's computerized clinical record. The interdisciplinary team note dated 9/3/21 at 3:28 p.m., by the DON revealed she, the nursing home administrator, the assistant director of nursing and the social service director met to discuss the physical aggression Resident #62 received on 9/2/21 at 10:00 a.m. The resident was observed to make contact with the hallway glass door which led to the outside of the facility. Resident #62 was being pushed in his wheelchair by Resident #34 to attend a church service. Resident #62's bilateral lower legs were observed to make contact with the door. The AA overheard Resident #34 make the statement that he desired to break Resident #62's legs. The AA intervened and resumed assisting the residents to the church service. The AA asked the resident if he was okay and he stated yes. The resident continued his usual routine yesterday. He was not observed to have any signs or symptoms of fear and he did not report any fear. Today during an assessment he was not observed to have any signs or symptoms of fear nor did he report any pain, injury and he denied any fear. The resident's guardian, physician, ombudsman, SSD, DON and local police department were notified. Resident #62 resided in the facility related to a medical history of hemiplegia and hemiparesis following an unspecified cerebrovascular disease affecting his left non-dominant side. The resident also had dementia with behavioral disturbances. There were no recent medication changes. The intervention was to educate staff on not allowing residents to assist with the ambulation of other residents. The behavior note dated 9/4/21 at 6:03 a.m., by an LPN, revealed charting follow-up for a resident to resident interaction. This resident was being pushed in his wheelchair by another resident when he was pushed into the wall. The resident sustained no injuries, no complaints of pain and no discomfort this shift. D. Resident #34 record review Physician order dated 11/25/19 at 12:39 p.m., revealed to admit the Resident #34 on the facility's secure unit related to the resident had wandering behaviors which placed the resident in danger due to the inability to find his way back to the facility. The care plan for potential abuse related to residing in a unit with resident's who occasionally have behavioral disturbances was revised on 4/22/2021. Some of the interventions were to redirect the resident from escalated residents by offering an activity of choice and/or a snack. Report any agitation/restlessness related to specific residents on the unit. When the resident desired to spend leisure time outside his room, direct the resident to the activity room that was away from the dining room. -No additional interventions were added to the care plan after the altercation on 9/3/21. The care plan for residing in the facility's secure unit for his safety and structure was revised on 4/22/21. The plan revealed the resident habitually wandered or would wander out of this environment and would be unable to find his way back to the facility, placing him in danger. His guardian consented to the secure unit placement. Some of the interventions were to assess the resident quarterly for the appropriateness of placement on the secure unit. Encourage the resident to participate in activities of choice and involve the resident/guardian in the resident's plan of care. -No additional interventions were added to the care plan after the altercation on 9/3/21. The care plan for impaired cognitive function related to dementia was revised on 4/23/21. Some of the interventions were to face the resident when speaking and making eye contact. The resident understood simple, consistent and directive sentences. Reduce any distractions such as turning off the television, radio and close the door as needed. -No additional interventions were added to the care plan after the altercation on 9/3/21. E. Observations Observations during survey 9/12-9/16/21 revealed Resident #62 was observed in his room interacting with his electronics or in the dining television room during meals with staff. He was also observed smoking outside in the smoking areas during scheduled times with staff present. No verbal or physical outbursts were observed. F. Staff interviews The AA was interviewed on 9/14/21 at 2:10 p.m. She reviewed her entry in the Behavior Monitoring book dated 9/2/21 at 10:00 a.m. She said the incident involved Resident #62 who used a wheelchair because he could not stand up. She said the resident was capable of using the wheelchair by himself. She said she was taking residents from the South Unit to a church service in the other building. She said Resident #34 was pushing Resident #62 in his wheelchair. She said Resident #34 pushed Resident #62 into the hallway wall. She said Resident #62's right side and the wheelchair contacted the wall. She said the resident did not call out in pain or state he experienced any pain from the incident. She said Resident #34 said he wanted to break Resident #62's legs because he wanted to see if he could get off the floor on his own. She asked Resident #62 if he was okay and he said yes. She asked Resident #34 why he pushed Resident #62 into the wall and he said we all have to sin sometime. She said they arrived from the church service to the South Unit about 45 minutes later. She said she then notified licensed practical nurse (LPN) #1 of the incident and the comments by Resident #34. The LPN came and assessed Resident #62. The LPN asked Resident #62 if he was afraid of the other resident and he said no. The AA said she wrote the note in the Behavior Monitoring Book at 4:00 p.m., at the end of her shift. The AA said after the incident both residents seemed fine with each other and did not show any fearful signs of being around each other. She said they usually get along well with each other. The AA said she had been working at the facility for almost a year and she did receive abuse training upon hire (4/30/2020). She said she received one-to-one abuse education on 9/3/21 regarding the immediate notification to the nurse and the abuse coordinator immediately after an incident. If she was unable to notify the abuse coordinator she must call the NHA or the SSD until she talked with one of them. Licensed practical nurse (LPN) #1 was interviewed on 9/14/21 at 2:54 p.m. She said the AA was taking the residents to the other building for church services. After they returned, the AA told her that Resident #34 pushed Resident #62 in his wheelchair into the hallway wall. She said she assessed Resident #62 and he had no pain or injuries. She said he was not afraid of the other resident. She said the DON and NHA were not notified at this time because she did not think it was abuse. She said Resident #34 made verbal statements all the time and then laughed about the statements. She said she thought this was his usual type of statement (break his legs) he had made in the past. LPN #1 said the social service director (SSD) reviewed the Behavior Monitoring Book and told her this incident and Resident #34's statement was abuse and she should have written up the incident yesterday, as soon as she became aware of the incident. The SSD said the statement of breaking Resident #62's legs, was intent to do harm. LPN #1 said she had received her initial abuse training upon hire (8/20/2020). She said the SSD provided her with one-to-one abuse education on 9/3/21 regarding the immediate notification to the nurse and the abuse coordinator after an incident. If she was unable to notify the abuse coordinator she must call the NHA or the SSD until she talked with one of them. The LPN said it did not occur to her that Resident #34's comment was an intent to do harm because of his past statements. She said neither residents were fearful of each other and they have not had any further incidents. The social service director (SSD) was interviewed on 9/14/21 at 4:07 p.m. She said the AA was taking a group of residents to a church service in the North building. Resident #34 was pushing Resident #62 in his wheelchair. Resident #34 pushed Resident #62 into the therapy hallway glass door. The AA overheard Resident #34 say he was trying to break Resident #62's legs. She said she became aware of the incident when she reviewed the Behavior Monitoring Book on 9/3/21. The SSD said she interviewed the AA. The AA said she immediately intervened after Resident #34 pushed Resident #62 into the glass door. She said the AA said they continued on to the church service. The AA assisted Resident #62 to the church service by pushing his wheelchair. The AA said she had mentioned the incident to the LPN #1 later in the afternoon. The SSD said LPN #1 did not recall charting on this event. She said she told the LPN #1 that the comment of the intent to break Resident #62's legs was abuse and she should have started an investigation. The SSD said she interviewed both residents and they were not afraid of each other. The SSD said she had a one-to-one conversation with the AA and all of the activity staff regarding abuse and the intent of abuse. She said she did a one-to-one with LPN #1 about the same issues. She said the two residents have not had any other incidents with each other. The DON was interviewed on 9/15/21 at 4:15 p.m. She said it was reported that Resident #34 was pushing Resident #62 in his wheelchair as they were going to a church service. Resident #34 pushed Resident #62 into a door. She said the AA was with them at the time of the incident. She said the AA witnessed the incident and intervened between the residents after the incident. She said the incident occurred on 9/2/21 at 10:00 a.m. The DON agreed the first note that described the incident was dated 9/3/21 at 2:12 p.m., by LPN #1. She agreed the AA wrote the incident in the Behavior Monitoring Book on 9/2/21 at 10:00 a.m. The note was written approximately 28 hours after the incident. She said the AA did make sure the residents were safe, however she should have notified the nurse immediately. The DON said both the AA and LPN #1 were in-serviced on what was abuse and who should be called/notified immediately. She said the LPN #1 should have called the abuse coordinator immediately. The DON said all of the administrative staff were notified of the incident during the next day's morning interdisciplinary team meeting when the Behavior Monitoring Book was reviewed. The SSD placed the information regarding the incident in the state portal reporting system after the meeting on 9/3/21 at 8:37 a.m. The NHA was interviewed on 9/16/21 at 11:13 a.m. She said the AA should have notified the nurse immediately. She said the nurse should have then notified the abuse coordinator and/or the NHA immediately after learning about the incident. She said as soon as the facility was aware of the incident, they did in-service training on all staff and reported the incident in the state portal reporting system. She said they have already completed a second round of abuse training/reporting with staff. The SSD was interviewed on 9/15/21 at 8:27 a.m. She said Resident #34 did have behaviors and dementia. She said to her knowledge he had never exhibited aggressive behaviors towards residents. IV. Altercation 9/7/21 A. Resident status Resident #69, age [AGE], was admitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included violent behaviors, bipolar disorder, and schizoaffective disorder. The 8/18/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and observations, the facility failed to ensure one (#60) of three residents reviewed for post surgical wounds and monitoring out of 46 sample residents received treatment, care and monitoring in accordance with professional standards of practice. Specifically, the facility failed to monitor Resident #60's new post surgical wound and clinically monitor changes in vital signs timely for which she required rehospitalization. Resident #60 admitted to the facility on [DATE] and readmitted on [DATE] with an Intra-abdominal and pelvic mass (which required surgical repair with staples). The facility failed to monitor Resident #60's surgical site for infection for five days (from 9/5/21 to 9/10/21), Resident #60's wound dehisced (the wound had green/yellow discharge) and ultimately was sent to the emergency department and admitted for sepsis and septic shock, required intravenous (IV) antibiotics and an abscess draining procedure (see record review below). Findings include: I. Professional reference [NAME], R. D & Manna, B. (2021) Wound Dehiscence, pp. 1-13, retrieved on 9/27/21 from : https://www.ncbi.nlm.nih.gov/books/NBK551712/ it read, in pertinent part: Dehiscence is a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing. This scenario typically occurs 5 to 8 days following surgery when healing is still in the early stages. The causes of dehiscence are similar to the causes of poor wound healing and include ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. Superficial dehiscence is when the wound edges begin to separate and by increased bleeding or drainage at the site. The clinician should investigate the wound for worrisome signs, including infection or necrosis. Prompt identification is important for preventing worsening dehiscence, infection, and other complications. Evisceration is a complication of complete wound dehiscence, where intra abdominal organs herniate through the open wound. II. Resident status Resident #60, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 9/10/21. According to the September 2021 computerized physician orders (CPO), the diagnoses included Intra-abdominal and pelvic mass, rheumatoid arthritis, depression, anxiety, thyroid disorder and general weakness. The 8/6/21 admission minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for a mental status score of 11 out of 15. She required one person extensive physical assistance with walking on the unit, one person physical assistance with toileting and dressing and supervision with set up help for eating, bed mobility, transfers personal hygiene and bathing. III. Record review The care plan last updated on 8/10/21 did not have interventions or goals for the residents surgical incision. The 9/2/21 hospital discharge orders read the resident had a surgical incision to the lower middle abdomen after a total hysterectomy and tumor removal. The incision needed to be monitored, kept dry and clean and notify the provider about changes and signs or symptoms of infection. The 9/2/21 admission assessment to the facility read the resident was admitted with surgical incision to the midline of her abdomen with staples and it was open to air (did not have a dressing on it). -The record failed to indicate the facility had orders to monitor the surgical incision or other post surgical problems when she was readmitted to the facility. The 9/5/21 progress note read Resident #60 was a skilled resident and she did not have issues about her readmission to the facility from the hospital after her recent surgery. The 9/7/21 physician progress note read the provider was requested to see the resident for recent fevers, chills and some confusion and planned to continue to monitor the resident. There were no new orders for medications, treatments or laboratory requests reflected in the record. Her vital signs were documented as: temperature 98.2 degrees fahrenheit; respiratory rate 20 breaths per minute; heart rate 89 beats per minute; and blood pressure of 100 (systolic) over 80 (diastolic). The September 2021 electronic medication administration record (EMAR) did not have an order or administration history of the resident receiving medications for antibiotics or to treat symptoms of a fever, to monitor the surgical wound or post surgical for unexpected signs and symptoms including an order for Tylenol which was given on 9/9/21 (see interview below). Therefore, there was no documentation Resident #60 was being monitored from 9/5/21 to 9/10/21 (five days), post surgical care while she resided at the facility. The 9/10/21 progress note read the night shift nurse reported the resident had increased lethargy and the nurse attempted to administer medication at 3:30 p.m. the resident was cold and clammy and her vitals were obtained. Her abdominal incision started to dehisce (open) in the lower area and green/yellow discharge from the incision was seen. The 9/10/21 transfer form read the resident was discharged from the facility to the hospital because her blood pressure, heart rate and temperature were critically out of normal readings. Her vital signs were; Temperature 94.0 degrees fahrenheit; Respiratory rate 22 breaths per minute; Heart rate 123 beats per minute; and Blood pressure of 80 (systolic) over 40 (diastolic). -Resident #60's record did not have other documentation about her condition leading up to and including the reason for her transfer to the hospital. The 9/11/21 hospital admission records read Resident #60 was admitted to the inpatient critical unit (ICU) due to severe sepsis with septic shock from a post surgical intra abdominal abscess. She required intravenous antibiotics and an abscess draining procedure. Her midline surgical incision had staples and had some erythema (red and swelling) and no significant drainage. IV. Interviews Certified nursing assistant (CNA) #13 was interviewed on 9/15/21 at 4:00 p.m. She said she worked with Resident #60 often and the day she went out to the hospital she was weak and was more sleepy and did not look good. She had a temperature of 100.8 degrees fahrenheit and it got better after she took medication. I let the nurse know she did not look good, she was pale and could not keep her head up. I was asked to take her vital signs and her blood pressure was really low and she was sent to the hospital right away. LPN #1 was interviewed on 9/15/21 at 4:30 p.m. She said she worked day shift from 6:00 a.m. to 6:00 p.m. She stated Resident #60 had an elevated temperature the last day she worked with her on 9/9/21 and before she left the facility at the end of her shift, her temperature was lowered with a dose of tylenol; however, she did not say how much she gave and there was no order documented in the record. The incision looked red however there was no drainage or other signs of infection. She reported to the night nurse about her elevated temperature. -LPN #1 said she did not document her wound findings or vital signs including fever in the resident's record as well as notification to the physician on 9/9/21 during her shift. The director of nursing (DON) was interviewed on 9/16/21 at 9:30 a.m. She confirmed Resident #60 did not have documentation about monitoring the recent surgical incision or skilled post surgical assessments as well as orders and care plans for the surgical incision from 9/5/21 to 9/10/21. -She said the nursing management team had since been provided education on order transcription and documentation of wounds including but not limited to surgical incisions. The physician was interviewed on 9/20/21 at 3:28 p.m. He stated Resident #60 had a massive surgical procedure to her abdomen on 8/30/21 then readmitted to the facility on [DATE] for skilled nursing care. She went back to the hospital on 9/10/21 when she began to decline and was admitted to the hospital for sepsis from an intraabdominal abscess in relation to her recent abdominal surgery. He expected the staff to monitor Resident #60 at a minimum of once a day for post surgical complications including monitoring the incision, an assessment and vital signs. He said he expected the staff to monitor the resident daily and report abnormal findings as needed until the resident had her follow-up surgical appointment (two week post surgery). He said staff should have transcribed Resident #60's discharge orders correctly to include monitoring of her incision. He said he ordered Tylenol for the resident when she had an elevated temperature on 9/9/21; however there was no order in the resident's record and this was not documented. He said he did not order blood laboratory tests because it would take about four days to have the sample taken and get the results back, even if he requested them emergently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Failure to implement person centered appraches for Resident #50's behaviors A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the 9/13/21 computerized physicians orders (CPO), diagnoses included Alzheimer's disease, dementia with behavioral disturbances, schizophrenia, protein calorie malnutrition, anorexia, fatigue, history of falling, and adult failure to thrive. The 7/30/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. The resident had delusions and rejected cares daily. The resident had verbal and physical behavioral symptoms directed toward others. The resident required supervision by oversight, encouragement or cueing for bed mobility, transfers, eating, dressing and personal hygiene. She required extensive assistance with toilet use. -The resident was documented not to have displayed behavioral symptoms during the seven day look back period. She was observed to display behavioral symptoms during the survey (see below). B. Observations On 9/12/21 at 6:00 p.m. the call light in the hallway for Resident #50 was turned on and visibly seen in the hallway above her door. The resident was heard loudly saying, This light stays on until I get cheese or a cheese board. You will never find where I hid the parts to turn the light off. On 9/12/21 at 6:15 p.m. certified nurse aides (CNAs) #10 and #11 entered Resident #50's room. CNA #10 asked if there was anything they could do for the resident. She told them she was protesting until she got cheese. She said she hid the call light part that would turn the light off and there was nothing they could do about it until she received a cheese board or some cheese she liked. She loudly told the CNAs to get the (expletive) out of my room. The CNAs informed licensed practical nurse (LPN) #3. The CNAs and the LPN did not utilize any strategies to deescalate Resident #50. The behavior was not documented (see below). C. Resident interviews Resident #50 was interviewed on 9/13/21 at 11:20 a.m. She said she would not be eating today because the water they cooked the food with was contaminated. She said she wanted special cheeses and that the facility should buy them for her. Resident #50 was interviewed again on 9/15/21 at 2:37 p.m. She said, I know how to take that call light out of the wall. I know how to unscrew it so that the light will stay on for hours and hours. They tell me to turn that light off. I say no, I am protesting. I am [NAME]. I will leave it on for hours. I want to go to the store and buy my own food but I was told I need transportation. I want cheese and a cheese board. I like raw hard noodles also and I soak the noodles in bottled water. I did not eat the hash browns for breakfast because they boiled the potato in regular water. I will only eat food cooked in bottled water. She said staff just leave her call light on because they do not know what to do to turn it off. D. Record review The 4/12/21 social service progress note revealed, the resident continued to vent about the facility poisoning the food, contaminating her boots, injecting the water with contaminants, and refusing the specially aged cheese she had requested. The 5/14/21 comprehensive care plan revealed: -Focus, the resident had behavior of refusing to allow staff to turn the call light off, and placing the call light on repetitively. -Goal, the resident will utilize call light appropriately and allow staff to turn light off when needs have been met. -Interventions, ensure all of (the) resident's needs are met by asking 'is there anything else I can do for you while I am here' before leaving the room when answering the call light. Remind (the) resident that (the) call light initiates assistance and staff must turn it off to inform other staff that her needs are being met. When refusing to allow light to be turned off, reassure (the) resident that staff are available to assist her needs and will continue to answer the light when initiated. -Focus, the resident chooses to eat vegetarian foods, and frequently orders plain oatmeal, canned and cooked carrots, corn on the cob, plain baked potato, and kidney beans. -Goal, resident's preferences will be honored as long as food will not cause illness being left out. -Interventions, explain to resident shopping trip available weekly to purchase specific food requests not able to be provided by the kitchen. Notify activities of resident's desired purchase requests or if she agreed to speak to activities regarding specific food requests The August 2021 behavior monitoring tracking form revealed: On 8/17/21 the resident was upset and pulled the call light out of the wall. The action taken was staff went in and changed the trash bag and asked are you going to replug the call light? The documentation revealed, light off and signed by registered nurse (RN) #1. No follow up from social services noted. On 8/23/21 the resident unplugged her call light until someone would take her to a nearby city. The action taken was to go in every 15 minutes and try and attempt to reason with her. Resident had no response. On 8/26/21 the resident unplugged the call light because she did not get the kind of bread she wanted from the kitchen. Action taken was to try and reason with her and the resident did not change her response. The September 2021 behavior monitoring tracking form in a behavior monitoring notebook at the nurses station revealed the resident's behavior tracking sheets had blank pages with no behaviors written for the month. There were no behavior monitoring tracking forms written for the evening of 9/12/21 (see observation above) when the resident made the call light stay on permanently because she wanted cheese or a cheese board. E. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 9/12/21 at 6:10 p.m. She said Resident #50 had turned on her call light and did something with the components in the wall which would leave the call light on permanently until the maintenance department would be able to turn it off the following day. LPN #3 said the resident did this quite often. She said the resident did it when she wanted a cheese board or special cheeses to eat. She said this behavior happened frequently and the staff just left the resident alone. She said if they had to go in the resident's room, the staff made sure they entered the room with two staff members so that the resident did not accuse them of anything. She said it was a safe way to protect themselves. She said the resident liked nice cheeses but the facility cannot afford to buy specialty cheeses for her. She said the resident felt the facility should be able to buy her fancy cheese. She said the resident somehow can get into the call light in the room and rewire it so that the light would remain on. She said staff did not know what to do on a Sunday to turn the light off so they leave it on until someone on Monday can come in and turn it off. She said the resident told staff it was her way of protesting that she wanted different types of cheese. LPN #3 said the resident often had behaviors due to her dementia and staff just did the best they could to help her but there was very little they could do to help. CNA #10 was interviewed on 9/12/21 at 6:20 p.m. She said she entered the room of Resident #50 with CNA #11. She said the staff went in the room together in pairs. She said they did it for their own safety in case the resident accused them of anything bad. She said they did not have any special skills to help the resident change her behavior (cross-reference F947 nurse aide training). She said she did the best she could to help the resident if she was allowed to help by the resident. The activity director (AD) was interviewed on 9/14/21 at 3:23 p.m. She said she was not trained to work with the residents with dementia; she just knew how to work with the dementia population because of her nature and personality. She said she just tried to think what she would feel like if her mom was in this place. She said she did not have a special talent to deal with dementia residents, it was just who she was as a person. She said she had activity training maybe two years before but not dementia training. She said, Before I leave (Resident #50's) room I will tell her, I love you. I know she hears me say that. She hates me one day and then we are friends again the next day. I cannot take anything personally with her. I tried to buy her food from the store once but she just threw it in the trash. The AD said she just did the best she could with Resident #50. Licensed practical nurse (LPN) #3 was interviewed on 9/14/21 at 3:35 p.m. She said she did not have dementia training since she started again at the facility at the end of July 2021. She said she had worked in a state hospital so she knew how to handle some uncommon behaviors. She said they were not trained in the facility to handle people like Resident #50. She said just over time working in health care she picked techniques up. She said a few years ago the facility had dementia training that was really good but nothing currently. She said the staff go in the resident's room in pairs in case she would accuse us of anything. She said the staff do that for our own safety. She said the resident did not like her usually but CNA #10 was able to communicate with her sometimes. She said it was helpful if CNA #10 was on the schedule to talk to Resident #50. CNA #2 was interviewed on 9/15/21 at 8:20 a.m. She said Resident #50 wanted a cheese board. She said the staff just keep going back in and try to redirect her. She said there is a behavior tracking book at the nurse's station. She said the staff can write in the behavior book anything that happens with the resident. She said in the morning the social service director (SSD) or someone from management came to get the behavior tracking book. She said the book was brought to manager meetings in the mornings. She said she usually did not know what management did with the behaviors that the staff wrote down. She said she thought the SSD would talk to the person in the behavior tracking book and handle the situation. She said sometimes the SSD shared with the floor staff what was done to handle a behavioral situation. The SSD was interviewed on 9/15/21 at 11:35 a.m. She said Resident #50 sometimes refused care from staff if a specific type of cheese was not supplied. The SSD said the behavior was written in the care plan. She said she did not know what written interventions meant on the written care plan. She said she had made a progress note a few months ago concerning the resident and her wanting cheeses. She said she would look in the electronic records to see if anything was documented on what to do for the resident's behaviors. She said the resident had a thing for cheeses but she did not know where in the record it was documented. She said during the week when she worked she took the behavior monitoring book off of the nurse's station every morning to read what may have happened the night before with behaviors. She said she did not work on the weekends and would read the behavior books on Monday mornings. She was unaware that Sunday night the resident took out the call light in a way to make it stay on until she received cheese. She said she was unaware why staff did not write the situation that happened in the behavior book so that she could handle it. She said no one left her a voicemail either. She said sometimes she would go and talk to a resident who had behaviors. She said other times if the behavior was already documented in the care plan she may not do anything to intervene. She said sometimes she would do on the spot training with floor staff so that the staff would know what she did with the resident. She said she did not have documentation of any on the spot training that she did with the staff. She said all staff can document Resident #50's behavior in the behavior tracking book including CNAs, nurses, activities staff, and anyone else who witnessed anything with behaviors. The nursing home administrator (NHA) was interviewed on 9/15/21 at 2:40 p.m. She said she had only been the NHA since July 2021. She said there was no documentation the facility provided dementia training for the staff (including CNAs, cross-reference F947) prior to her beginning the job and not since she began either. She said dementia training was scheduled on the staff monthly education calendar for April 2022 and she said maybe she could provide some training in the upcoming October 2021 training day. She said she was unaware Resident #50's behavior was not written in the behavior book for the evening of 9/12/21. She said that she and the SSD would update the resident's behaviors in the electronic medical records to reflect the observation on 9/12/21 F. Facility follow-up The SSD was interviewed on 9/16/21 at 9:37 a.m. She said she updated Resident #50's care plan today to include how to take care of her pulling the call light out from the wall. SSD said she updated the care plan to handle when the resident requests cheeses and cheese boards. She said she initiated a personal behavior care card for the staff to keep with them at all times for Resident #50. She said she did an education today for the staff concerning what to do when the resident refused to turn off the call light. The updated care plan revised on 9/15/21 revealed: -Resident #50 will refuse care to be provided if specific cheese was not supplied. -When Resident #50 pulled the call light out of the wall, staff were to do 15 minute checks. -When the resident pulled the call light out for cheese the staff was to offer her carrots, parmesan cheese, and dry oats. Offer her cheese from the kitchen such as grated parmesan, shredded mozzarella or sliced or shredded cheddar. The behavior card was provided by the NHA via email on 9/16/21 at 9:34 a.m. She said the card was to be carried by the staff at all times. The card revealed: -Resident #50 frequently has behaviors which include: Verbally aggressive outburst towards staff including derogatory statements. Refusing to allow call-light to be turned off. Pulling call light from the wall until specific request is honored. Refusing meal trays to be removed from room. -Please ensure behaviors are documented. Notify the SSD of any behaviors you are having difficulty with. The behavior card included a phone number to call. -Redirection techniques for Resident #50 -2 staff at all times, conversation topics: her knowledge of dietary/nutrition, natural remedies, and history of working for her father's shop. Alternatives to special food requests available in the kitchen: dry oats, raw carrots, shredded mozzarella, sliced or shredded cheddar. -When refusing call light to be turned off: attempt to honor request as able, initiate 15 minute checks if unable to, notify SSD of special request unable to honor. Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#34, #62 #65, #50 and #69) of five out of 46 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #65's dementia care services to address triggered physically aggressive behavior in order to prevent physical altercations with other residents on the secured unit. The facility was aware Resident #65 had a diagnosis of dementia and occasionally displayed episodes of verbal and physical aggression. The care plan for Resident #65 revealed the facility was to ensure a calm environment, redirect the resident when escalated, and encourage him to seek staff assistance when another resident was disturbing him. Furthermore, due to the facility's failures, Resident #65 physically assaulted Resident #34 on 7/23/21, resulting in Resident #34 requiring hospital treatment where he received 12 staples in his head. Resident #65 also physically assaulted Resident #69 by shoving Resident #69 to the floor on 9/7/21, resulting in Resident #69 falling to the floor on his butt. Resident #69 received a small red spot to his elbow from the fall. Resident #62 was physically assaulted by Resident #34 on 9/2/21, who shoved Resident #62 into a wall in his wheelchair which resulted in Resident #62's legs coming into contact with the wall. Resident #34 made a verbal threatening comment that he wanted to break Resident #62's legs. Review of the care plans for Residents #34, #62 #65, and #69 indicated that the facility had failed to consistently follow and implement new person-centered interventions to prevent the residents from abusive altercations. (Cross-reference F600 failure to prevent abuse/neglect.) In addition, the facility failed to implement person centered approaches for Resident #50's behaviors. Findings include: I. Census and Conditions demographic The 9/14/21 Census and Condition form documented that 75 total residents resided at the facility. There were 42 residents with dementia and 50 residents with behavioral healthcare needs. The facility was designated with two long-term memory care units with 29 residents residing on the two units. II. Failure to provide person-centered dementia care for Resident #65's triggered physically aggressive behavior. A. Resident #65 Resident #65, age [AGE], was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included anxiety, dementia without behaviors and disruptive mood dysregulation disorder. The 8/13/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of 8 out of 15 with no behaviors. The resident required staff supervision of bed mobility, transfers, dressing, eating, toileting and personal hygiene. B. Record review Physician order dated 7/29/21 at 9:25 p.m., revealed to admit the resident to the secure unit due to the risk of wandering out of the facility and placing himself in danger due to the inability to find his way back to the facility. The care plan for occasionally displaying episodes of verbal or physical aggression was reviewed on 4/15/21. Some of the interventions included: Allow the resident to vent his frustration and provide affirmation/validation. Encourage the resident to see staff assistance if/when another resident was disrupting him. Redirect the resident when escalated with one-to-one walks outside. Redirect the resident when escalated with a snack or drink of choice. When the resident wants to spend leisure time outside of his room, direct the resident to the dining room and away from the activity room. Provide a personal television to the resident. C. Altercation 7/23/21 A nurse note dated 7/23/21 at 5:43 p.m., by the director of nursing (DON) revealed at approximately 4:45 p.m., she received a call from the South Unit from licensed practical nurse (LPN) #2 that Resident #65 had made contact with the Resident #34's head multiple times. This occurred in the main dining room and was witnessed by a certified nurse aide (CNA). The two residents were immediately separated and Resident #65 was put on one-to-one staff observations. Resident #34's vital signs and neurological assessments were initiated upon the DON's arrival. Resident #34's assessments were within his normal limits. The resident had abrasions to the top of the right and left side of his skull. A physician's order was obtained to send Resident #34 to the hospital for further evaluation and treatment. Also the order revealed to send Resident #65 to a named medical center for a psychological evaluation and treatment. A message was left for Resident #34 guardian. The local police department was called and a case number was issued. D. Altercation 9/7/21 The incident note dated 9/7/21 at 10:50 a.m., by the licensed practical nurse (LPN) #1 revealed Resident #69 was overheard by staff with an elevated voice coming from the vicinity of his room. A certified nurse aide (CNA) was near the common television room and observed the resident land in the hallway on his butt. Resident #65 was seated in the common television room and admitted having a verbal altercation over the volume of the television. Resident #65 then reached out and made physical contact with Resident #69. This contact caused Resident #69 to fall backward onto the floor, landing on his butt. Resident #69 said he told Resident #65 the television volume was up too loud and Resident #65 put his hands on my shoulders and I fell backward. Both residents were separated immediately and Resident #65 was taken back to his room. A staff member came and sat with Resident #65 outside in the smoking area and then in the front lobby. Resident #69 was currently in the activity room with staff. The hospice staff were notified. The hospice agency ordered an as needed anti-anxiety medication and a dose was administered. Fall, pain and skin assessments were completed in the resident computerized clinical record. The director of nursing (DON), social services director (SSD), family and the local police department were notified. -The facility failed to identify person-centered interventions to address Resident #65's triggered physically aggressive behavior, which ultimately led to Resident #34 receiving 12 staples to his head resulting in harm on 7/23/21 and Resident #69 falling to the floor on 9/7/21 (cross-reference F600). E. Staff interviews The SSD was interviewed on 9/15/21 at 8:19 a.m. She said Resident #65 had a dementia diagnosis. She said the resident had verbal and physical aggressive outbursts. She said he had a specific care plan that dealt with his behaviors. She said the resident did redirect easily. She said he became angry in a moment and he calmed down quickly. She said the resident was deescalated by coffee, sweets, walks outside in nature, talking about his love for nature, talking about riding his mountain bike, watching television, and spending time using his computer. She said he had a television in his room. The DON was interviewed on 9/15/21 at 11:24 a.m. She said the resident had a dementia diagnosis. She said the resident did have agitated behaviors because he believed he did not belong in a secure unit. She said his care plan did reflect his behaviors. She said the resident deescalated by smoking, going outside in the fresh air, going for walks outside, and watching football on the television. She said he did redirect easily but if he was in an agitated state he was more difficult to redirect. Certified nurse aide (CNA) #1 was interviewed on 9/15/21 at 1:54 p.m. She said the resident did have dementia and did have behaviors. She said he did get mad and push people. She said he did at times scream at people. She said sometimes it took a long time for him to calm down. She said he needed some space and staff kept him away from the other residents. She said to deescalate the resident staff would take him on a long walk, out to smoke, and watch football on television. III. Failure to provide person-centered dementia care for Resident #34's triggered physically and verbally aggressive behavior. A. Resident #34 Resident #34, age [AGE], was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included Alzheimer's disease, and dementia with behaviors. The 7/12/21 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score. The resident did not have any behaviors. There was no evidence of an acute change in mental status or psychosis. The resident did have wandering tendencies that occurred daily. The resident required staff supervision for bed mobility, transfers, eating, and toileting. B. Record review Physician Order dated 11/25/19 at 12:39 p.m., revealed to admit the resident on the facility's secure unit related to the resident had wandering behaviors which placed the resident in danger due to the inability to find his way back to the facility. The care plan for potential abuse related to residing in a unit with resident's who occasionally have behavioral disturbances was initiated on 4/29/2020. Interventions included: Redirect the resident from escalated residents by offering an activity of choice and/or a snack. Report any agitation/restlessness related to specific residents on the unit. When the resident desired to spend leisure time outside his room, direct the resident to the activity room that was away from the dining room. Ensure a calm environment to include temperature, surrounding noises, and/or smells. The incident note dated 9/3/21 at 2:12 p.m. by licensed practical nurse (LPN) #1 revealed that it was brought to her attention by the activity assistant (AA) that the Resident #62 was observed to make contact with the hallway glass door leading to the outside of the facility. The resident was being pushed in his wheelchair by Resident #34. The AA was taking the residents to attend a church service in the other building. The resident's bilateral lower extremities were observed to make contact with the glass doors. The AA overheard a comment by Resident #34, about his desire to break Resident #62's legs. The AA intervened and asked Resident #62 if he was okay and he stated he was. The AA resumed assisting the residents to the church service. Resident #62 was observed to continue his usual routine yesterday and he did not exhibit any signs or symptoms of fear and he did not report any fear. Today's assessment did not reveal any pain or injury, The resident denied any fear and did not report any pain or injury. Resident #34 was placed on 15-minute checks. -The facility failed to identify person-centered interventions to address Resident #34's triggered physically aggressive behavior, which ultimately led to Resident #62's legs coming into contact with a wall and address Resident #34's verbal abusive comment that he wanted to break Resident #34's legs (cross-reference F600 for abuse). C. Staff interviews The social service director (SSD) was interviewed on 9/15/21 at 8:27 a.m. She said Resident #34 had behaviors but he really did not have any aggressive behaviors. She agreed the resident did push another resident in his wheelchair into a wall one time. She said the resident did have a behavior specific care plan that dealt with his behaviors. She said a care plan could be updated as needed. She said the resident really did not need to be deescalated because he did not have any behaviors. She said he enjoyed talking on the phone, drinking Pepsi, and shopping trips to Walmart. The director of nursing (DON) was interviewed on 9/15/21 at 11:40 a.m. She said the resident did have a dementia diagnosis and did exit seek at times. She said he did not get agitated or loud. She said he loved to go outside, exercise and watch football. She said he could be confrontational but for the most part he was mellow (relaxed). She said he was very talkative to everyone. She said to deescalate the resident staff offered him frequent walks, coffee, exercise and watching sports on the television. She said care plans were updated to reflect the resident's behaviors. CNA #1 was interviewed on 9/15/21 at 1:43 p.m. She said the resident never got mad or escalated. She said he never caused any problems. She said he liked coffee, going outside, and watching football games on the television. She said she knew what the resident liked and how he wanted to be treated.