**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from abuse by failing to honor the residents' right to refuse care for 1 (Resident #999) of 3 sampled residents when the resident displayed agitated and aggressive behaviors during care. The findings included: The facility policy Abuse Policy and Procedure Manual with a review date of 3/24/23 noted, Each person served has the right to be free from abuse and mistreatment . Some examples, rough handling a resident. Prevention. Appropriate supervision of staff to maintain the mission of caring for, serving and satisfying all residents is provided .Signs and Symptoms Dementia residents in distress may exhibit the following: Aggressiveness, agitation, yelling out, delusions, wandering etc. Be aware of risk factors (age, cognitive and or physician limitations, etc.) . Listen to residents . If they say stop, stop! The facility Employee Agreements signed upon hire specified, If a resident refuses care at any time, I will inform the nurse and or supervisor of the refusal of care. I will respect the residents wishes and reapproach with the nurses' help to offer care at a later time. Review of the clinical record revealed Resident #999 had an admission date of 8/27/24. Diagnoses included dementia, and major depressive disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with a reference date of 11/27/24 documented Resident #999 required substantial/maximum assistance with toileting. The MDS noted Resident #999's brief interview for mental status score was 03, indicating her skills for daily decision making were severely impaired. The care plan initiated 11/26/24 noted Resident #999 had a behavior problem and, exhibits periods of anxious behavior and physical aggression toward staff due to a diagnosis of Dementia. Resident can become combative, spitting on staff/throwing feces. The care plan also noted Resident #999 at times, resists/refuses care The interventions for Resident #999 included: Approach in a calm manner, make eye contact and reassure the resident. Use a pleasant voice and identify self when approaching resident. Offer friendly nonverbal cues by smiling and using friendly tone of voice when speaking to resident. If resident refuses/resists care, reapproach and reintroduce care or task to be performed at a later time. Further review of the clinical record revealed an initial psychiatric note dated 9/3/24 documented new patient with dementia and depression. Patient has been confused and combative with care, impulsive. Arrived on Paxil and Trazadone (antidepressants). Per sitter gets fearful with care and agitated. Will decrease Paxil to 10 milligrams (mg) and add Depakote 125 mg twice a day for impulse control. Review of the Psychiatric note dated 12/20/24 documented [AGE] year-old lady with a history of dementia has been smearing feces, combative and throwing things . I am going to substitute current medications with Seroquel (an antipsychotic) 25 mg twice a day and re-evaluate. Review of the facility's incident investigation revealed on 12/19/24 the facility initiated an investigation of abuse related to observation of bruising , redness and swelling of Resident #999's left hand. Resident #999 had voiced pain in the thumb and finger. The resident was unable to describe how the injury occurred. The resident was assessed and sent to the emergency room for evaluation. An x-ray of the left hand revealed no fracture or acute process. The investigation findings revealed Licensed Practical Nurse (LPN) Staff D in the shift -to -shift reported the incident occurred on 12/18/24 on the evening shift. The nursing progress dated 12/19/24 at 7:09 a.m., by Staff D documented, Resident #999 was fighting, biting, kicking with her legs and hands. The resident required three staff members to change her. The facility investigative findings noted statements were obtained from the staff. The Interviews Conducted revealed the following: LPN Staff D indicated Resident #999 had two episodes of combativeness during the evening shift. During the second episode at approximately 9:00 p.m., Certified Nursing Assistant (CNA) Staff E called him to come to Resident #999's room because they were trying to clean her up and she was combative. LPN Staff D said he walked into the room and the resident was kicking, swinging her arms in the air. LPN Staff D said he held Resident #999's legs down while CNA Staff E changed. He said CNA Staff C was trying to hold Resident #999's arms. LPN Staff D said when they were done, CNA Staff E had asked him to do a skin check on Resident #999 because she did not want anyone to say the resident had an injury. CNA Staff E said Resident #999 was combative when trying to clean her, so she asked CNA Staff C and CNA Staff B to assist her. Staff E said they were not able to clean Resident #999 and she asked one of the CNA's to get LPN Staff D to help. CNA Staff E said she cleaned the resident but did not remember where the other staff were. CNA Staff E asked LPN Staff D to check the resident's skin because she didn't want anyone saying the resident had bruising. CNA Staff C revealed that she went with another staff member to assist CNA Staff E to clean Resident #999. CNA Staff C said when CNA Staff E was trying to clean Resident #999 was kicking and swinging her arms in the air. CNA Staff C said she observed Resident #999 hitting the bed with her hand. CNA Staff B said on 12/18/24 at approximately 9:00 p.m., LPN Staff D asked her to assist CNA Staff E to change Resident #999's bed linen because she was combative. CNA Staff B said when she walked into the room CNA Staff E and CNA Staff C had already cleaned the resident. CNA Staff B said she assisted with changing the bed linens but did not touch Resident #999. On 1/16/25 at 11:15 a.m., during an interview with Resident #999 said she was fine and had no problems with the staff. She said everyone was good to her and she had no recall of the event of 12/18/24. On 1/16/25 at 10:55 a.m., in an interview LPN Staff A said, I was here the next day on 12/19/24. I sent her (Resident #999) out to the emergency room, and I was the one who noticed her hands when I helped to toilet her. Her left hand was not like that the day before. The left hand was just different, swollen and bruised. I spoke with my supervisor and had her assess her (Resident #999) as well. I did not know how it occurred. I don't know how it happened. The night before I worked with her and she was ok, her hand was not like that when I had her. I notified her family. I notified the physician. LPN Staff A said If the resident refuses care, we re-approach, redirect and speak with the resident. We try to make them as comfortable as we can. They have a right to refuse, but most of the residents on this unit do not understand. We just try and take care of them as they allow us. I speak with the family and the provider to see what we can do. On 1/16/25 at 12:15 p.m., in a telephone interview CNA Staff B said she was working on 12/18/24 on the secured unit. She said, I was on my break when the nurse (LPN Staff D) called me into the room to help them. He told me to change the sheet, so I pulled the sheets off the bed. The resident was in the bed and I put new sheets on. I did not see anything. I did not observe anyone holding the resident, that is the only thing I can tell you. I was called to change the sheets, and I did it and left the room. That is it. I did not see anything. The resident was in bed on her side, and I took the dirty sheets off the bed and I left the room. I never saw anyone holding the resident or touching her. I did not see anything. On 1/16/25 at 5:18 p.m., in a telephone interview CNA Staff E said on 12/18/24 Resident #999 was in the dining room about 8:00 or 8:30 p.m., and she was playing in feces. Resident #999 had all of her clothes off and they were on the floor. She took the resident to her room, o the bed to clean her up. Resident #999 started fighting me and I tried to speak to her very nicely and explained to her that she had feces all over her and I needed to change her. That night she was agitated, so I left her in bed for 30 minutes and I came back, and she was still agitated with me. I explained to her what I needed to do but she tried to hit me. She was yelling and tried to hit me. I put the call light on, and I asked CNA Staff C and LPN Staff D to help me because we are told to always use two people. I asked them to stand there and make sure Resident #999 did not roll onto the floor, and I cleaned her. She was fine when I left that night, there was nothing on her hands. I never told anyone to hold her. I just asked them to stay on either side of the bed, so she does not fall out of the bed. I never saw them holding Resident #999 by her arms or her hands. I work with Alzheimer's residents, and I know you have to be patient. Resident #999 always wants to fight you. She could have hit her hand in the dining room before I found her. On 1/17/25 at 2:30 p.m., in a phone interview LPN Staff D said on 12/18/24 I had just received the change of shift report. It was approximately 7:30 p.m., and Resident #999 was in the dining room, and she had blood running from her ankle. She had scratched her ankle, and she had no clothes on. Everything was off and on the floor. She had her hand in her brief, and she had feces all over her. It was everywhere and on both of her hands. The other nurse was still there, LPN Staff A. I asked her what happened, and she did not know. I told her to go, I would take care of it. I cleaned the wound and put a dressing on it. I asked CNA Staff E to come and get Resident #999, to take her to her room and take care of her and she did. Staff E came to me and said the resident was combative, hitting and throwing feces, so I told her to wait a bit and go back. At approximately 8:00 p.m., Staff E went back to the room to help Resident #999, and she asked CNA Staff C to help her. The resident accepted the care. Staff C came to get me approximately 8:30 p.m., to tell me the dressing to the ankle needed to be changed because there was feces on it. I went into the room and changed the dressing. The resident had already been cleaned by CNA Staff E. I put the dressing on the wound, I never held her legs down. I did not say that in my witness statement. CNA Staff B came into the room and took the dirty linen out, she never touched the resident. No one did that, no one was holding her. She had nothing, no bruising or nothing that I saw on her all night. On 1/16/25 at 12:00 p.m., in an interview the Chief Nursing Officer (CNO) said CNA (Staff E) felt the resident required changing because she had soiled herself and she wanted to clean her. In the end her decision to ask someone to hold her down was not appropriate and the staff were terminated. It may not be in the best interest of the residents to leave them soiled, but sometimes you have to do it and you keep trying. Resident #999 can be combative, but she has the right to refuse if she wants to, all we can do is to continue to try to provide her care. The CNO said the root cause of the event was the staff did not respect the resident's rights. On 12/24/24 the facility completed the investigation of abuse and documented The facility verifies that the injuries to Resident #999's hand was a result of physical abuse committed jointly by CNA Staff E, CNA Staff C and LPN Staff D. Their actions of holding Resident #999 down to provide care was a physical restraint of resident #999 as well as violated her right to refuse care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement necessary interventions to prevent avoidable accidents for 1 (Resident #143) of 4 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, and a fracture requiring a transfer to a higher level of care. The findings included: The facility policy Fall Management Program origination 3/8/17 (revised 11/22) documented, The Falls Management Program is an interdisciplinary quality improvement program that provides resident fall processes and outcomes. The program utilizes a systemic approach to assessment, individualized intervention and monitoring that will result in injury reduction and minimizing fall risk to our residents . The IDT [interdisciplinary team] will complete a thorough investigation as well as a root cause analysis of all falls by completing a Post Fall Review form. The care plan, and staff assignment sheets will be adjusted as needed to reflect current and appropriate fall interventions. The nursing staff will observe, interview as appropriate and document resident's post fall status as well as effectiveness of identified fall interventions in place on each shift for the next 3 days in the resident record. It is important to recognize that on size does not fit all when considering interventions for residents fall management. Review of the clinical record revealed Resident #143 had an admission date of 12/26/22 with readmissions on 1/20/23 and 2/18/23 with diagnoses including Alzheimer's, dementia, left hip fracture, frequent falls, and aphasia (loss of ability to express or understand speech). The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 1/26/23 documented Resident #143 required limited assistance of one person with bed mobility, transfers, and ambulation. Resident #143 was frequently incontinent of urine, and bowel. A urinary and bowel toileting program was not being used to manage the resident's incontinence. The MDS noted a Brief Interview for Mental Status (assessment of a resident's cognitive function) was 99 indicating the resident was unable to complete the interview. The facility initiated a care plan on 12/26/22 indicating Resident #143 was at risk for falls due to weakness, low endurance and decreased mobility as a result of acute or chronic health conditions and aphasia. The care plan interventions on 12/28/22 included to orient resident to room, call light, and need to call for, and wait for assistance, maintain adequate lighting in resident's room, keep bed in lowest position possible, attempt to keep resident as active in activities during the day as resident will allow. The facility fall assessment dated [DATE] determined the resident was a moderate risk for falls. Review of the incident reports revealed: On 1/20/23 at 6:30 a.m., Resident #143 was found on the floor in her room and was unable to state what she was doing at the time of the fall. Resident #143 sustained a skin tear to the right side of her abdomen. On 1/21/23 at 3:31 p.m., Unit Manager, Licensed Practical Nurse (LPN) Staff F completed the investigation follow up and documented Resident #143 was agitated, had dementia and restlessness. LPN Staff F documented, IDT (interdisciplinary team) meeting regarding found on floor next to bed. Regular mattress in place. Work for grab bars placed. Intervention: Staff to ensure wheelchair to be placed at bedside. The facility lacked documentation of an investigation to determine the root cause of the fall and implement appropriate interventions to prevent further avoidable falls. On 1/24/23 at 1:00 a.m., Resident #143 was found on the floor in her room. After assessment, a bump noted on the back of the head. Resident complained of pain. Tylenol given as ordered and ice pack applied. On 1/25/23 at 4:48 p.m., LPN Staff F completed the investigation follow up and documented Visual reminder to use call bell for assistance. There was no documentation of an investigation to determine the root cause of the fall and implement appropriate interventions to prevent further avoidable falls. On 1/29/23 at 6:25 p.m., Resident #143 was found sitting on the floor. The incident report documented this nurse was notified by neighboring resident family that she heard a big bang. Upon arrival resident was observed sitting, guarding LLE (left lower extremity) and being in distress/teary. Three wheeled walker next to her. The nurse documented the resident reported pain pointing to the left knee. The nurse assessed Resident #143 and documented the left lower extremity appeared shorter and rotated with substantial bruising. The resident was sent to the local hospital emergency room (ER). Review of the ER nursing documentation revealed Resident #143 had left knee swelling and laceration to the left forehead. A left knee x-ray was obtained. The x-ray report documented no acute fracture or dislocation. The clinical impressions were closed head injury, contusion, acute pain of the left knee. Resident #143 was transferred back to the facility. On 2/27/23 at 1:03 p.m., (29 days after the fall), LPN Staff F completed the investigation follow up and documented, IDT meeting regarding fall 1/29/23. Resident returned from ER (Emergency Room) continue B&B (bowel and bladder) observation and set up B&B schedule for resident. The clinical record lacked documentation a bowel and bladder schedule was initiated for the resident. The admission MDS with a target date of 2/23/23 noted a toileting program was not being used to manage the resident's urinary and bowel continence. On 3/16/23 at 11:40 a.m., Unit Manager LPN Staff F said the root cause of the fall on 1/29/23 was Resident #143 got up to go the bathroom because she does not get up unless she has to go to the bathroom. The resident is nonverbal and took herself to the bathroom. She was found next to the bed with the walker so, I figured she was going to the bathroom. The investigation as to why she fell was she was getting up to go to the bathroom it is what she always does. LPN Staff F confirmed there was no documentation the bowel and bladder schedule was initiated. On 2/10/23 at 9:00 p.m., a facility incident report documented 2/9/23 resident complained of left hip pain, primary nurse notified, some bruising and edema on left hip. Resident #143 was sent to the local hospital emergency room where an x-ray result documented an acute left hip fracture. The resident was admitted to the hospital and had a surgical repair of the left hip fracture on 2/12/23. On 3/14/23 at 12:57 p.m., an observation showed Resident #143's room door was closed and no staff were observed in the hallway. The resident was in her room alone and the call light was on the floor out of her reach. On 3/15/23 at 9:37 a.m., Certified Nursing Assistant (CNA) Staff G said Resident #143 will yell, no words just screams when she wants assistance. She is able to use the call light, but she does not. The CNA said Resident #143 was able to use the toilet and ambulates with the rolling walker and assistance. Staff G said the resident will go to a few activity programs a week and she has family and friends who come to visit her. She does not speak but she understands you. I was not here when she fell and hurt her hip. She could walk with the walker but not by herself, she always needed help. The CNA said, Resident #143 did not like to get out of bed, and she will yell out. On 3/16/23 at 9:40 a.m., the Administrator confirmed the incident report did not specify if the care plan interventions were in place at the time of the fall on 1/29/23. The Administrator confirmed Resident #143 had multiple falls and said, we review the falls and update the care plan. Review of Resident #143's care plan showed the care plan interventions were not updated after the falls on 1/20/23, 1/24/23 and 1/29/23. On 3/16/23 at 1:53 p.m., the Rehab Director said prior to Resident #143 sustaining the left hip fracture she required supervision with bed mobility and stand by assistance. She was ambulating with supervision walking household distance of 100 feet with a three wheeled walker and contact guard. She was not able to toilet herself and was not able to dress her lower body. The Rehab Director said as long as someone was in the general area with eyes on her, she was safe to ambulate. The Rehab Director confirmed Resident #143 had a decline in ambulation and activities of daily living since she sustained the left hip fracture.