**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 On 3/06/2023 at 4:00 AM, upon entering the third-floor dining room. Resident # 9 was observed asleep in a recliner with the footrest propped up by a dining room chair, between a wall and a column/pillar. (Photographic and video evidence) In an interview conducted on 03/06/2023 at 4:11 AM Staff E, a Registered Nurse (Night Supervisor). Was asked why the residents were sleeping in the dining room. Staff E stated The residents are alone in the room; they try to get out of bed. The nurse will bring them here to guarantee that they are not falling. We bring them all in one area. When asked if this was the normal routine? Staff E stated No, it's only if I don't have enough CNAs (Certified Nursing Assistants). I have four CNAs on the floor. These residents are getting out of bed and at risk of falling. We have tried non-pharmacological interventions. During an interview conducted on 03/06/2023 at 04:52 AM Staff E in the presence of the Assistant Director of Nursing (ADON). Staff E stated: On the 3rd floor there are 58 residents, two nurses, three CNAs. On the 2nd floor there are 60 residents, four CNAs and three nurses. If the patients are trying to get out of bed. We ask if they are in pain and if they are hungry. It depends on their level of consciousness. They still want to get out of bed. Staff E stated that the CNAs made the decision on the position of the residents. Staff E was asked about Resident #9 who was placed between the wall and the column with the dining chair propping up the footrest of the recliner restricting the resident's movements. Staff E stated: The patient has a history of falls. We place residents here in the dining room, all in one area so that we can look after them in one spot. The ADON added that the residents in the dining room have a history of falls or have a risk of falls. On 03/06/2023 at 05:03 AM, Staff E, RN was asked; who gave the instructions to place the residents in the dining room?. Staff E reported that for all shifts, if the residents want to get out of bed; We placed them in the dining room. Many of them want to get out of bed and we bring them here. During the 7:00 AM to 3:00 PM shift, we have activities. At night, one CNA will attend to the residents. There were too many residents restless. Staff E reported this quantity is for tonight, 2 or 3 may be in room. The nurses bring the residents. The residents have problem sleeping, so we bring them to the dining room. When asked who was responsible for ensuring care was being provided for the residents, Staff E revealed, a CNA is designated to be in the dining room with the residents. The CNA who is designated for the resident will come pick up the resident to provide care. On 03/06/2023 at 5:15 AM, Staff C, Registered Nurse was asked if he was assigned to any of the residents observed in the third-floor dining area, Staff C Registered Nurse stated, I have four residents here. Staff C was asked about the interventions in place for the residents to help with the behaviors. Staff C reported that Resident # 52 always gets up at 4:00 AM. When a resident gets restless or gets out of bed. We try all the non-drugs therapy such as asking them if they would like water, food, TV, we try everything. If those don't work, we bring them to the dining room. If you don't, the resident is on the floor. We talk to them. If residents have a scheduled or as needed medication, it's at 9:00 PM. The CNA that works here in the dining the room looks after the residents. Long time ago it was one to one. It can be one or two or five at its peak. Usually, one will go to bed, and we may have just three or four for the night. My personal opinion it's not good and it's not good for sleeping. The dining room is for activities. If the resident is unbalanced it's better to put them in a recliner like that. This is not the first night. I was going up and down on the floor. I've been working here for 9 to 10 years. I have abuse and neglect training with other organizations. Staff C was asked if having the residents sleeping in the dining area in recliners with chairs restricting the footrest and not providing care as a form of abuse and neglect. Staff C stated: Yes, you can say that is a neglectful situation. This is not on me. It's not my last decision. Staff C was asked what is expected of Staff K who was sleeping while Resident #52 was complaining of being wet and needed to go to the bathroom what should have been done in that case. Staff C Registered Nurse stated The C.N.A (certified nursing assistant) cannot leave the area. He just has to pass the word and we take it from there. Sleeping is forbidden. Unless he is on break in his car. Staff C was asked if it was ok for Resident # 9 to have been placed between the column and the wall. Who was responsible for checking the resident if he checked the resident and who placed the resident in that position and location. Staff C stated No, this is not acceptable at all (and shook his head). Everybody is supposed to check on the residents. I didn't come here at all .I had to be on my feet. I have two or three who are trying to pull urinary catheter. When asked Does the supervisor do rounds? Staff C stated Yes, [ Staff E] is doing his work. My night was hectic. I was having three or four who trying to pull the urinary catheter or feeding tube. In an interview conducted on 03/06/2023 at 5:40 AM, Staff H a Registered Nurse was asked if this was the norm. Staff H stated It a special situation. It's not always the same residents here. Some are in their bed. But today it's a different situation. I believe they wake up at two or three in the morning. We are to bring them to the dining room. When they go to sleep, we bring them back to bed. When they are brought in here. They are supervised with the television on, and we provide water. I don't know if the television was on today. There are some residents who like to watch TV. Only if the resident asks for the TV (television), we put the TV on. If they are sleeping, we put them back in the room. They call the nurse and CNA we tell the resident. [Resident #52] always ask for the TV. Staff K stated regarding Staff K, No, [Staff K] cannot sleep here. I have been working here for 2 years. Staff H was asked if the situation the residents were in and the position with the chairs under the recliner and Resident #9 between the column and the wall was considered as restraint, and abuse and neglect. Staff H stated It would be better in the room. It's not the best situation. It's not the correct thing. When they are in the bed they are very active, they cannot communicate, they don't push call light and are a high risk for falls. After they identify them, they go and see if they have as needed medication, if they don't, we bring them to dining room for one to two hours. If they fall asleep, we take them back to the room. No, recliners are not supposed to be used as a bed. When they go back to their room, they are placed in the bed Regarding Resident #9, Staff H stated Yes, I am aware that if she was in between the walls she is restrained. I didn't see her. Yes, it is a form of restraint. Staff H was asked if restraining a resident is a type of abuse and if she would have reported abuse and neglect and if in this case abuse and neglect would be reported today? Staff H stated: Yes it's a type of abuse. When I am taking care of resident. If I see the resident is being restrained, I stop it. Yes, I report abuse and neglect. I have not reported neglect. This is not something that happens all day. I come to this floor once in a while. I would have brought this to attention of the supervisor today. Sometimes, I even ask the staff to bring the resident to the room. I didn't know that resident wanted to be taken to restroom. There is a CNA here, staff assigned is supposed to be paying attention to her request. Today, I was in front. In follow up interview on 03/06/2023 at 7:42 AM Staff E was asked who placed Resident # 9 between the wall and a column restricted in the recliner. Staff E reported it was Staff N, a CNA. Staff E was asked if Staff K, (the CNA assigned in the dining room) was aware that the resident was placed between the wall and column? Staff E reported that Staff K, CNA was not aware that Staff N had placed Resident #9 between the column and the wall. Staff E added that: It's not supposed to happen like that. The CNA did that as a mistake. The resident is not supposed to be around the wall and column. Staff E reported Staff N, was the CNA, she made a mistake. Staff E was asked about trainings received. Staff E stated he has been working in the facility for 13 years, and received abuse and neglect training. In that case, the CNA did not accomplish what he was supposed to do. Staff E explained that the purpose of placing residents in the dining room is prevention when the patient does not want to sleep during the night. They must take the residents to an area that they can be monitored for their safety. In that case, we bring them to the dining room, do some type of activity until they sleep. We bring them back to bed. That's the goal. Staff E stated They are supposed to be here watching TV and activities. They are not supposed to stay here the whole night. They are not to be sleeping. The nurses and the night supervisor do rounds. Staff E reported the types of activities would include listening to music or watching television. Staff E acknowledged the television was not on in the dining room where the residents were placed and there was no music playing at the time of the observation. Staff E was asked if he conducted rounds specifically in the dining area where the residents were placed. Staff E responded: No, I didn't go. I used to do rounds in that area. Tonight, I didn't do it because I had paperwork, admission paperwork on my computer. I was supposed to. I was planning to do it through the night. didn't have time to go. Staff E was asked if it was acceptable for the residents to sleep in the recliners, Staff E was also informed that the resident was not provided with incontinent care, and if it was acceptable for Staff K to be asleep with his feet up on another chair instead of monitoring the residents. Staff E stated: The recliners are not meant to be for sleeping purposes. They are not there to sleep. The CNAs are supposed to immediately contact the nurse. Another CNA brings them back to their room. [ Staff K] is not supposed to be sleeping there. This is completely wrong. This is not how we instructed [Staff K]. The CNA did not accomplish the duty to which he was assigned. I didn't know residents were soaked in urine. The CNA is supposed to check on the residents needs and to report to the other staff or the CNAs. In an observation conducted on 03/09/2023 at 10:58 AM, assisted by Staff O, a CNA assessment of Resident #9's skin was completed. Resident # 9's disposable brief was noted dry and skin intact. Review of Resident # 9's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to abnormalities of gait and mobility, Alzheimer's disease. Bipolar disorder, primary insomnia, dysphasia, major depressive disorder, Dementia, and other disease classified elsewhere. Unspecified severity without behavioral disturbance. Psychotic disturbance, Mood disturbance and anxiety. Review of Resident # 9's Annual Minimum Data Set (MDS) dated [DATE] Section C for cognitive pattern indicated a Brief Interview of Mental Status (BIMS of a 3 out of 15 indicating the resident has Severe cognitive impact. The MDS documented the resident has no behavior symptoms or rejections of care exhibited. The resident requires extensive assistance with one person for bed mobility. For transfer the resident requires extensive assistance with one person. For eating the resident required limited assistance with one person. For toileting, the resident requires extensive assistance from one person. There was no schedule or as needed pain medication regimen given and not experiencing pain in the last 5 days. It was documented that the resident received physical therapy between 2/11/2022 and 03/10/2022. The resident received 3 days of restorative nursing which consisted of range of motions and transfer training. Review of the quarterly MDS dated [DATE] documented Resident #9's . For mood and behavior, it was documented that the resident has no behavioral symptoms exhibited or rejection of care. For bed mobility the resident required extensive assistance with one person. For transfer the resident requires extensive assistance with one person. For eating the resident required limited assistance with one person. For toileting, the resident requires extensive assistance from one person. There was no scheduled pain medication or experiencing pain in the last 5 days. Restorative therapy consisted of active range of motion and transfer training in the last 7 days. Review of the resident's physician orders revealed order dated. 60/18/2022 with a start date of 06/18/2022 indicated: Document any exhibited behaviors, interventions, outcome, and side effects. Using codes provided every shift for behaviors. Order dated 06/19/2022: Fall precaution every shift. Every shift for preventative measures. Order dated. 06/18/2022 documented: Is the resident exhibiting signs of or symptoms of pain? Document interventions, outcome and side effects using codes provided. Order dated June 06/19/2022. Offload heels with pillows while in bed every shift for preventative measures. Turn and reposition every shift, and, as needed, every shift for preventative measures. Order dated 03/07/2023 with start date of 03/08/2023: Lorazepam tablet 0.5 milligrams give one tablet by mouth two times a day related to anxiety disorder. Review of the physicians orders dated 03/07/2023 Temazepam capsule 30 milligrams give one capsule by mouth at bedtime for insomnia. Review of care plans initiated on 7/20/2021. There were no care plans related to restraints for Resident #9. The Care plans indicated Resident # 9 is at risk for alteration in skin integrity related to impaired mobility and bowel/bladder incontinence. Interventions are to provide and manage moisture. The care plan indicated Resident # 9 has self-care deficit as evidenced by requires limited to extensive care with activities of daily living. Goal indicated that Resident #9 will continue to actively participate in care for as long as mentally and physically able to do so, through next review date. Resident #9 has impaired cognitive function/dementia or impaired thought processes related to Dementia, impaired decision making. Resident is at risk for fall related to Impaired mobility and use of psychoactive medication. The resident has insomnia. Goal is [Resident #9] will have at least 6 to 7 hours/night of restful sleep with less use of medication through the next review date. Review of documentation for activities of daily living documented in section for toileting documented on 03/05/2023 at 10:59 PM extensive assistance. On 03/06/2023 at 1:25 AM: Total dependence with full staff performance. On 03/06/2023 at 2:38 PM extensive assistance documented. For the section related to bowel and bladder it was documented for 03/05/2023 at 10:59 PM: continent was documented. At 01:25 AM, incontinence episode was documented. At 2:38 PM continent was documented. Resident #52 During an observation conducted on 3/06/2023 at 04:00 AM, upon entering the 3rd floor dining room. Resident #52 was observed in a wheelchair saying in Spanish el [NAME]. Yo necessito ir al [NAME], estoy mojada which means I need to go to the bathroom, I am wet. Staff E was asked about Resident # 52 In an observation conducted on 03/07/2023 at 10:18 AM. Resident #52 was observed in wheelchair assisted by staff in the dining room. Resident says el [NAME] (mean the bathroom) and was taken to restroom near the nursing station. In an observation conducted on 03/07/2023 at 2:28 PM Resident # 52 was observed in the dining room, there were 13 residents in the dining room and Resident # 52 was sitting at table with 2 other residents. Music was playing and the television on. Resident # 52 appeared sleepy. Resident # 52 was noted drowsy and closing her eyes with her head slowly going down. Sitting at table with 2 others. There were 13 residents in dining room. Review of Resident #52 clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to chronic obstructive pulmonary disease unspecified, Unspecified dementia. Unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, Anxiety disorder unspecified, other abnormalities of gait and mobility, other lack of coordination dysphasia oral phase, generalized anxiety disorder and insomnia unspecified Review of Resident # 52's quarterly MDS dated [DATE] in the cognitive pattern section a Brief Interview of Mental Status score of 15 out of 15 indicating the resident is cognitively intact. The section for mood and behaviors indicated the resident has no behavioral symptoms or rejection of care noted. For bed mobility the resident required limited assistance with one person. For transfer the resident required extensive assistance from one person. For eating the resident required limited assistance with one person. For toileting, the resident required extensive assistance with one person. The resident has received scheduled pain medication and has not had any pain in the last 5 days. Speech therapy for 45 individual minutes for 1 day in the past week which started on 11/4/2022. Occupational therapy for 6 days in the past week which started on 11/3/2022. Physical therapy started on 11/3/2022 for 5 days in the last week. In review of physician orders. Restorative therapy for all 4 extremities including transfer and ambulation for 5 days a week. Occupational therapy daily for 5 to days a week for 8 weeks. Related medical diagnosis are abnormalities of gait and mobility. Review of the weekly skin audit note dated 3/3/2023, documented the resident's skin is intact. Review of physicians orders. Dated. 11/02/2022. Indicated aspiration precautions every shift. Order dated. 11/20/02/2022 noted an order for bilateral half side rails, up while in bed for mobility every shift. Order dated 11/02/2022 documented fall precautions every shift for preventative measures. Order dated 11/02/2022 documented: Inspect skin every shift. Order dated 11/02/2022: Oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, if less than 92%. Order dated 11 to 22 turn and reposition every two to three hours, every shift for prevention. Order dated 02/21/2023: Aripiprazole tablet 30 milligrams give one tablet by mouth one time a day related to Schizoaffective disorder unspecified. Order dated 03/07/ 2023: Clonazepam tablet 0.5 milligrams give one tablet by mouth two times a day related to anxiety disorder. Order dated 11/02/2022: Memantine tablet HCL 10 milligrams give one tablet orally. Two times a day for dementia. There was an order dated 03/07/2023 for Psychiatrist consult to evaluate medications. Order dated. 03/07/2023: Temazepam capsule 30 milligrams give one capsule by mouth at bedtime related to insomnia. Review of Resident #52's care plans initiated on 03/5/2021. Care areas indicated: Resident #52 has a self-care deficit and needs limited to extensive staff assistance to perform and complete activities of daily living secondary to weakness, Schizoaffective disorder. Intervention included allow resident to perform task at own pace. Provide assistance only in the areas difficult for the resident. Allow the resident to do for self as much as possible. [Resident #52] is at risk for alteration in skin integrity related to Impaired bed mobility. Interventions included, change promptly when wet or soiled. Incontinence care, manage moisture, keep resident clean and dry as much as possible. The care plan indicated Resident # 52 is at risk for falls related to impaired mobility, unsteady gait, use of psychoactive meds, and diagnosis of dementia. Date Initiated 03/05/2021 and revision on 01/03/2022. Goals indicated the resident will be free of fall related injuries by next review date. Resident has insomnia. Revision on: 06/09/2021. Goal indicated the resident will have at least 6 to 7 hours/night of restful sleep with less use of medication through the next review date. Resident is involved in activities: all the time. Goal is resident will accept the invitation to attend activities at least 3 times a week. Intervention included is Provide leisure materials as available puzzles, movies, reading materials. (Date Initiated 03/05/2021). Also, Provide Spanish music for easy listening (Date Initiated 03/05/2021) Review of Resident #52 documentation for activities of daily living related to toileting it was documented that the resident required extensive assistance. On 03/05/2023 at 10:38 PM documentation noted not available. Documentation for 03/06/2023 at 1:03 AM documented total dependence. On 3/6/2023 at 2:22 PM total dependence documented. Section for bowel and bladder elimination documented on 03/05/2023 at 20:37 incontinent. Documentation on 03/06/2023 at 1:02 AM indicated incontinent. Documentation on 03/06/2023 at 2:16 PM indicated continent. On 03/06/2023 at 05:40 AM; the NHA and DON were informed about the residents found in the dining room in recliners facing the wall. The television (TV) off. Seven residents are in the dining room at this time. The DON reported the residents are placed in the dining room to decrease the pharmacological interventions for the residents and to have an activity. The DON and the Nursing Home Administrator (NHA) were shown the residents in the dining room. They were shown how the chairs were placed underneath the foot of the recliners that prevented the residents from lowering their recliners. They were told this is considered to be a restraint to have a chair wedged under the recliners footrest. By 03/06/2023 at 06:09 AM; all 8 residents that were originally in the 3rd floor dining room at 4:00 AM had been moved to their rooms. Review of the Social Worker's progress notes for Resident # #428, Resident #63,Resident # 81,Resident # 112, Resident #127, Resident #172, Resident # 9 late entry dated 03/07/2023 documented: On 3/6/2023 at approximately 2:30 PM during an interview with state surveyor it was reported than on 3/6/2023 at 4:11 AM during their initial facility tour they observed the residents sleeping in recliner chairs in the third floor dining room. The CNA [Staff K] who was assigned to supervise and care for the resident was sleeping. The residents were taken to their rooms, a skin check was conducted, and residents found with no skin impairment. On 3/7/2023 at 1:30 PM Department of Children and Families (DCF) was notified, spoke with representative and report was not taken. The facility's IJ Removal Plan was accepted on 3/9/2023 and was verified as completed on 3/9/2023. The effective date of the IJ removal was on 3/8/23: The IJ Removal Plan indicated: 1. On 3/7/2023-Reviewed inservice documentation for supervisors completed by the Nursing Home Administrator (NHA) and Director of Nurses (DON) Only Registered Nurses and Licensed Practical Nurses attended this inservice Topic-Providing adequate supervision to residents-Goal-To ensure CNA are supervised. As of 03/08/2023: 29 Registered Nurses out of 32 Registered Nurses and 10 Licensed Practical Nurses out of 12 Licensed Practical Nurses had received inservices. 2. Performance Improvement Plan - Reviewed for residents sleeping in the recliner during the 11:00 PM to 7:00 AM shift; staff placed chair under the recliner which is a restraint; Staff member assigned to supervise the resident was noted to be sleeping, staff failed to check and change to residents who were in the recliner. Documents information on the IJ Removal Plan. 3. Quality Assurance Performance Improvement (QAPI) AD HOC Meeting on 03/7/2023 with the NHA, DON, ADON, Department Heads and Medical Director to review and approve the performance improvement plan. 4. Performance Improvement Project Worksheet Root Cause Analysis dated 03/6/2023. 5. Evaluation of the 8 residents for Pressure Ulcer Prevention - completed by the wound care team on 3/6/23, no new open areas noted. 6. Teachable Moment for supervisor, Staff E on 03/06/2023. 7. Staff K, CNA for the 11:00 PM to 7:00 AM shift was contacted about investigation on 03/06/2023. 8. Inservice on 03/06/2023 - Topic Administrator, Director of Nursing, Assistant Director of Nursing Job Duties and Responsibilities, Resident Rights, Abuse Prevention, Restraints, ADLs, and Toileting. Present by Regional Director of Clinical Services. 9. Inservice 03/06/2023 Resident Rights, Abuse Prevention, Restraints, Activities of Daily Living (ADLs) and Toileting by NHA and DON, attended by all Department Heads, Director of Social Services, Director Activities, Human Resources Director, Infection Preventionist, Nursing Supervisor 3:00 PM to 11:00 PM shift , Business Office Manager, Wound Care Nurse, Charge Nurse 3rd Floor, Maintenance Director, Nursing Supervisor 7:00 AM to 3:00 PM, Nursing Supervisor 11:00 PM to 7:00 AM, Restorative Nurse, Charge Nurse 2nd Floor, Charge Nurse 4th Floor. 10. Inservice Topic - Providing Adequate Supervision to residents by NHA and DON for Nurse supervisors that were on 03/06/2023. Inservice on 03/07/2023, 03/08/2023. 11. Inservice Education - 03/06/2023 to 03/07/2023 Covered Policy & Procedures for Resident Rights, Abuse Prevention, Restraints, ADLS, Toileting Presented by Social Worker, NHA and DON. 12. Facility Administrations - Interview with supervisor Staff E, on 03/06/2023 about the incident. 13. Facility Administration - Interview on 03/06/2023 with Staff H, 11:00 PM to 7:00 AM Registered Nurse about the incident 14. Facility Administration - Interview on 03/06/2023 with Staff C, 11:00 PM to 7:00 AM Registered Nurse about the incident. 15. Facility Administration - Interview on 03/06/2023 with Staff K, CNA, about the incident. 16. Psychiatric Evaluation on 03/07/2023 for Residents #9. #52, #63, #112, #127, #172, #428. 17. Care Plans for 8 residents (Residents #9, #52, #63, #81, #112, #127, #172, #428) updated to at risk for drug related side effect due to use of psychotropic meds. 18. Federal Immediate reports to Department of Children and Family (DCF) on 03/07/2023 at 1:30PM, reported by the Social Services Director (cases #178496, #178503, 178497, 178509, 178490, 178508, 178499 and178507) 19. On 3/09/2023, the surveyors reviewed the case numbers for Resident # 428, Resident #63,Resident # 81,Resident #112, Resident #127, Resident #172, Resident # 9 and Resident # 52. 19. On 03/09/2023, the surveyors Interviewed 36 staff members from shifts 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. All confirmed receiving the education and explained what they learned. 20. The every 2 hour rounds were completed and documentation was started on 03/06/2023 at 3:00 pm and is ongoing. 21. As of 03/08/2023 a total of 180 out of 202 staff members had been educated. Resident # 63 During an observation on 03/06/2023 at 5:10 AM Resident # 63 was observed in the third-floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. During an interview on 03/06/2023 at 05:20 AM, Certified Nursing assistant, Staff K was asked how long the residents were in the dining room, Staff K reported the residents that were in the dining room in the recliners started coming to the dining room around 1:00 AM. On 03/06/2023 at 05:42 AM, Staff D, a Certified Nursing Assistant (CNA) who works the 11:00 PM to 7:00 AM shift, assisted the surveyor with Resident # 63's, skin assessment in the resident's room. Both legs and thighs were clean and intact, healed skin on sacrum, upper extremities were clean and intact. The disposable brief was noted with urine. The resident's bed had bilateral quarter side rails position in middle of bed and bilateral floor mats. On 03/07/2023 at 07:41 AM Resident # 63 was observed in bed asleep. The bed was in lowest position and bilateral floor mats present. Review of the medical records for Resident # 63 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Dementia, Unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia, Other Schizophrenia, and Major Depressive Disorder. Review of the Physician's Orders Sheet (POS) for March 2023 revealed Resident # 63 had orders that included but not limited to: Falling Star Program every shift. Medications included: Temazepam capsule 30 Milligram (MG) give one (1) capsule by mouth at bedtime related to insomnia unspecified. Lorazepam tablet 0.5 MG give one tablet by mouth one time a day related to anxiety disorder, unspecified. Trazodone tablet 100 mg give one tablet by mouth at bedtime related to major depressive disorder. Citalopram hydrobromide tablet 20 MG give one tablet by mouth one time a day for depression related to major depressive disorder, recurrent, unspecified and Divalproex sodium tablet delayed release 250 MG give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 63 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires limited assistance for bed mobility, extensive assistance for transfer, dressing and toilet use with one person assistance and supervision for eating. Section H for bladder and bowel documented the resident is always incontinent of bowel and bladder. Section J for Health Conditions documented the resident had no falls. Section M for Skin Conditions documented-no pressure ulcers, and no skin issues. Section N for Medications documented the resident received antianxiety, antidepressants and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Review of Resident # 63's Bowel and Bladder Elimination Task List documented on 3/5/2023 at 12:16 AM, 2:26 PM and 10:25 PM Resident # 63 was not available for care. On 3/6/2023 at 12:38 AM resident not available for care, at 2:53 PM incontinent care provided, at 6:29 PM not applicable (NA) and at 11:50 PM incontinent care provided. Record review of Resident # 63's psychiatry progress dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident was seen for follow up and medication management. Patient continues to have great difficulty initiating and maintaining sleep. Staff reports that without constant observation, patient attempts to get out of her bed as she does, during the day out of her wheelchair without assistance, increasing her risk of falls. Nursing staff gives medication around 9:00 PM and patient falls asleep within an hour. About 3 to 4 hours later patient is up with disinhibited behaviors. She was found today in the common area, screaming, and cursing at staff. Due to her insomnia at night, patient is somnolent in the morning and then begins with a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 In an observation conducted on 3/06/23 at 4:00 AM, upon entering 3rd floor dining room. Resident # 9 was observed asleep in a recliner with the footrest propped up by a dining room chair. Resident 9 was noted to be wedged between a wall and a column/pillar. In an interview conducted on 03/06/23 at 4:11 AM Staff E, a Registered Nurse (Night Supervisor). Was asked why the residents were in the dining room. Staff E stated The residents are alone in the room; they try to get out of bed. The nurse will bring them here to guarantee that they are not falling. We bring them all in one area. When asked if this was the normal routine? Staff E stated No, it's only if I don't have enough CNAs (Certified Nursing Assistants). I have four CNAs on the floor. These residents are getting out of bed and at risk of falling. We have tried non-pharmacological interventions. During an interview conducted on 03/06/23 at 04:52 AM Staff E in the presence of the Assistant Director of Nursing (ADON). Staff E stated: On the 3rd floor there are 58 residents, two nurses, three CNAs. On the 2nd floor there are 60 residents, four CNAs and three nurses. If the patients are trying to get out of bed. We ask if they are in pain and if they are hungry. It depends on their level of consciousness. They still want to get out of bed. Staff E stated that the CNAs made the decision on the position of the residents. Staff E was asked about Resident #9 who was placed between the wall and the column with the dining chair propping up the footrest of the recliner restricting the resident's movements. Staff E stated: The patient has a history of falls. We place residents here in the dining room, all in one area so that we can look after them in one spot. The ADON added that the residents in the dining room have a history of falls or have a risk of falls. On 03/06/23 at 05:03 AM, Staff E, RN was asked; who gave the instructions to place the residents in the dining room?. Staff E reported that for all shifts, if the residents want to get out of bed; We placed them in the dining room. Many of them want to get out of bed and we bring them here. During the 7:00 AM to 3:00 PM shift, we have activities. At night, one CNA will attend to the residents. There were too many residents restless. Staff E reported this quantity is for tonight, 2 or 3 may be in room. The nurses bring the residents. The residents have problem sleeping, so we bring them to the dining room. When asked who was responsible for ensuring care was being provided for the residents, Staff E revealed, a CNA is designated to be in the dining room with the residents. The CNA who is designated for the resident will come pick up the resident to provide care. On 03/06/23 at 5:15 AM, Staff C, Registered Nurse was asked if he was assigned to any of the residents observed in the third-floor dining area, Staff C Registered Nurse stated, I have four residents here. Staff C was asked about the interventions in place for the residents to help with the behaviors. Staff C reported that Resident # 52 always gets up at 4:00 AM. When a resident gets restless or gets out of bed. We try all the non-drugs therapy such as asking them if they would like water, food, TV, we try everything. If those don't work, we bring them to the dining room. If you don't, the resident is on the floor. We talk to them. If residents have a scheduled or as needed medication, it's at 9:00 PM. The CNA that works here in the dining the room looks after the residents. Long time ago it was one to one. It can be one or two or five at its peak. Usually, one will go to bed, and we may have just three or four for the night. My personally opinion it's not good and it's not good for sleeping. The dining room is for activities. If the resident is unbalanced it's better to put them in a recliner like that. This is not the first night. I was going up and down on the floor. I've been working here for 9 to 10 years. I have abuse and neglect training with other organizations. Staff C was asked if having the residents sleeping in the dining area in recliners with chairs restricting the footrest and not providing care as a form of abuse and neglect. Staff C stated: Yes, you can say that is a neglectful situation. This is not on me. It's not my last decision. Staff C was asked what is expected of Staff K who was sleeping while Resident #52 was complaining of being wet and needed to go to the bathroom what should have been done in that case. Staff C Registered Nurse stated The C.N.A (certified nursing assistant) cannot leave the area. He just has to pass the word and we take it from there. Sleeping is forbidden. Unless he is on break in his car. Staff C was asked if it was ok for Resident # 9 to have been placed between the column and the wall. Who was responsible for checking the resident if he checked the resident and who placed the resident in that position and location. Staff C stated No, this is not acceptable at all (and shook his head). Everybody is supposed to check on the residents. I didn't come here at all .I had to be on my feet. I have two or three who are trying to pull urinary catheter. When asked Does the supervisor do rounds? Staff C stated Yes, [ Staff E] is doing his work. My night was hectic. I was having three or four who trying to pull the urinary catheter or feeding tube. In an interview conducted on 03/06/23 at 5:40 AM, Staff H a Registered Nurse was asked if this was the norm. Staff H stated It a special situation. It's not always the same residents here. Some are in their bed. But today it's a different situation. I believe they wake up at two or three in the morning. We are to bring them to the dining room. When they go to sleep, we bring them back to bed. When they are brought in here. They are supervised with the television on, and we provide water. I don't know if the television was on today. There are some residents who like to watch TV. Only if the resident asks for the TV (television), we put the TV on. If they are sleeping, we put them back in the room. [Resident #52] always ask for the TV. Staff H stated regarding Staff K, No, [Staff K] cannot sleep here. I have been working here for 2 years. Staff H was asked if the situation the residents were in and the position with the chairs under the recliner and Resident #9 between the column and the wall was considered as restraint, and abuse and neglect. Staff H stated It would be better in the room. It's not the best situation. It's not the correct thing. When they are in the bed they are very active, they cannot communicate, they don't push call light and are a high risk for falls. After they identify them, they go and see if they have as needed medication, if they don't, we bring them to dining room for one to two hours. If they fall asleep, we take them back to the room. No, recliners are not supposed to be used as a bed. When they go back to their room, they are placed in the bed Regarding Resident #9, Staff H stated Yes, I am aware that if she was in between the walls she is restrained. I didn't see her. Yes, it is a form of restraint. Staff H was asked if restraining a resident is a type of abuse and if she would have reported abuse and neglect and if in this case abuse and neglect would be reported today? Staff H stated: Yes it's a type of abuse. When I am taking care of resident. If I see the resident is being restrained, I stop it. Yes, I report abuse and neglect. I have not reported neglect. This is not something that happens all day. I come to this floor once in a while. I would have brought this to attention of the supervisor today. Sometimes, I even ask the staff to bring the resident to the room. I didn't know that resident wanted to be taken to restroom. There is a CNA here, staff assigned is supposed to be paying attention to her request. Today, I was in front. In follow up interview on 03/06/23 at 7:42 AM Staff E was asked who placed Resident # 9 between the wall and a column restricted in the recliner. Staff E reported it was Staff N, a CNA. Staff E was asked if Staff K, (the CNA assigned in the dining room) was aware that the resident was placed between the wall and column? Staff E reported that Staff K, CNA was not aware that Staff N had placed Resident #9 between the column and the wall. Staff E added that: It's not supposed to happen like that. The CNA did that as a mistake. The resident is not supposed to be around the wall and column. Staff E reported Staff N, was the CNA, she made a mistake. Staff E was asked about trainings received. Staff E stated he has been working in the facility for 13 years, and received abuse and neglect training. In that case, the CNA did not accomplish what he was supposed to do. Staff E explained that the purpose of placing residents in the dining room is prevention when the patient does not want to sleep during the night. They must take the residents to an area that they can be monitored for their safety. In that case, we bring them to the dining room, do some type of activity until they sleep. We bring them back to bed. That's the goal. Staff E stated They are supposed to be here watching TV and activities. They are not supposed to stay here the whole night. They are not to be sleeping. The nurses and the night supervisor do rounds. Staff E reported the types of activities would include listening to music or watching television. Staff E acknowledged the television was not on in the dining room where the residents were placed and there was no music playing at the time of the observation. Staff E was asked if he conducted rounds specifically in the dining area where the residents were placed. Staff E responded: No, I didn't go. I used to do rounds in that area. Tonight, I didn't do it because I had paperwork, admission paperwork on my computer. I was supposed to. I was planning to do it through the night. didn't have time to go. Staff E was asked if it was acceptable for the residents to sleep in the recliners, Staff E was also informed that the resident was not provided with incontinent care, and if it was acceptable for Staff K to be asleep with his feet up on another chair instead of monitoring the residents. Staff E stated: The recliners are not meant to be for sleeping purposes. They are not there to sleep. The CNAs are supposed to immediately contact the nurse. Another CNA brings them back to their room. [ Staff E] is not supposed to be sleeping there. This is completely wrong. This is not how we instructed [Staff K]. The CNA did not accomplish the duty to which he was assigned. I didn't know residents were soaked in urine. The CNA is supposed to check on the residents needs and to report to the other staff or the CNAs. In an observation conducted on 03/09/23 at 10:58 AM, assisted by Staff O, a CNA assessment of Resident #9's skin was completed. Resident #9's disposable brief was noted dry and skin intact. Review of Resident #9's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to abnormalities of gait and mobility, Alzheimer's disease. Bipolar disorder, primary insomnia, dysphasia, major depressive disorder, Dementia, and other disease classified elsewhere. Unspecified severity without behavioral disturbance. Psychotic disturbance, Mood disturbance and anxiety. Review of Resident #9's Annual Minimum Data Set (MDS) dated [DATE] Section C for cognitive pattern indicated a Brief Interview of Mental Status (BIMS of a 3 out of 15 indicating the resident has Severe cognitive impact. The MDS documented the resident has no behavior symptoms or rejections of care exhibited. The resident requires extensive assistance with one person for bed mobility. For transfer the resident requires extensive assistance with one person. For eating the resident required limited assistance with one person. For toileting, the resident requires extensive assistance from one person. There was no schedule or as needed pain medication regimen given and not experiencing pain in the last 5 days. It was documented that the resident received physical therapy between 2/11/2022 and 03/10/2022. The resident received 3 days of restorative nursing which consisted of range of motions and transfer training. Review of the quarterly MDS dated [DATE] documented Resident #9's BIMS score of 3 out of 15 indicating the resident has severe cognitive impairment. For mood and behavior, it was documented that the resident has no behavioral symptoms exhibited or rejection of care. For bed mobility the resident required extensive assistance with one person. For transfer the resident requires extensive assistance with one person. For eating the resident required limited assistance with one person. For toileting, the resident requires extensive assistance from one person. There was no scheduled pain medication or experiencing pain in the last 5 days. Restorative therapy consisted of active range of motion and transfer training in the last 7 days. Review of the resident's physician orders revealed order dated. 60/18/2022 with a start date of 06/18/2022 indicated: Document any exhibited behaviors, interventions, outcome, and side effects. Using codes provided every shift for behaviors. Order dated 06/19/2022: Fall precaution every shift. Every shift for preventative measures. Order dated. 06/18/2022 documented: Is the resident exhibiting signs of or symptoms of pain? Document interventions, outcome and side effects using codes provided. Order dated June 06/19/2022. Offload heels with pillows while in bed every shift for preventative measures. Turn and reposition every shift, and, as needed, every shift for preventative measures. Order dated 03/07/2023 with start date of 03/08/2023: Lorazepam tablet 0.5 milligrams give one tablet by mouth two times a day related to anxiety disorder. Review of the physicians orders dated 03/07/2023 Temazepam capsule 30 milligrams give one capsule by mouth at bedtime for insomnia. Review of care plans initiated on 7/20/2021. There were no care plans related to restraints for Resident #9. The Care plans indicated Resident #9 is at risk for alteration in skin integrity related to impaired mobility and bowel/bladder incontinence. Interventions are to provide and manage moisture. The care plan indicated Resident #9 has self-care deficit as evidence by requires limited to extensive care with activities of daily living. Goal indicated that Resident #9 will continue to actively participate in care for as long as mentally and physically able to do so, through next review date. Resident #9 has impaired cognitive function/dementia or impaired thought processes related to Dementia, impaired decision making. Resident is at risk for fall related to Impaired mobility and use of psychoactive medication. The [Resident #9] has insomnia. Goal is [Resident #9] will have at least 6 to 7 hours/night of restful sleep with less use of medication through the next review date. Review of documentation for activities of daily living documented in section for toileting documented on 03/05/2023 at 10:59 PM extensive assistance. On 03/06/2023 at 1:25 AM: Total dependence with full staff performance. On 03/06/2023 at 2:38 PM extensive assistance documented. For the section related to bowel and bladder it was documented for 03/05/2023 at 10:59 PM: continent was documented. At 01:25 AM, incontinence episode was documented. At 2:38 PM continent was documented. On 03/06/23 at 05:40 AM, Met with NHA and DON next to 3rd floor elevator, they were informed about the residents found in the dining room in recliners facing the wall. The television (TV) off. Seven residents are in the dining room at this time. The DON reported the residents are placed in the dining room to decrease the pharmacological interventions for the residents and to have an activity. The DON and the Nursing Home Administrator (NHA) were shown the residents in the dining room. They were shown how the chairs were placed underneath the foot of the recliners that prevented the residents from lowering their recliners. They were told this is considered to be a restraint to have a chair wedged under the recliners footrest. By 03/06/23 at 06:09 AM - All 8 residents that were originally in the 3rd floor dining room at 4:00 AM had been moved to their rooms. The facility's IJ Removal Plan was accepted on 03/9/2023 and was verified as completed on 3/9/2023. The effective date of the IJ removal was on 3/8/23: The IJ Removal Plan indicated: 1. On 3/7/2023-Reviewed in-service documentation for supervisors completed by the Nursing Home Administrator (NHA) and Director of Nurses (DON). Only Registered Nurses and Licensed Practical Nurses attended this in-service. Topic-Providing adequate supervision to residents-Goal-To ensure CNA are supervised. As of 03/08/2023: 29 Registered Nurses out of 32 Registered Nurses and 10 Licensed Practical Nurses out of 12 Licensed Practical Nurses had received in-services. 2. Performance Improvement Plan - Reviewed for residents sleeping in the recliner during the 11:00 PM to 7:00 AM shift; staff placed chair under the recliner which is a restraint; Staff member assigned to supervise the resident was noted to be sleeping, staff failed to check and change to residents who were in the recliner. Documents information on the IJ Removal Plan. 3. Quality Assurance Performance Improvement (QAPI) AD HOC Meeting on 03/7/2023 with the NHA, DON, ADON, Department Heads and Medical Director to review and approve the performance improvement plan. 4. Performance Improvement Project Worksheet Root Cause Analysis dated 03/6/2023. 5. Evaluation of the 8 residents for Pressure Ulcer Prevention - completed by the wound care team on 3/6/23, no new open areas noted. 6. Teachable Moment for supervisor, Staff E on 03/06/2023. 7. Staff K, CNA for the 11:00 PM to 7:00 AM shift was contacted about investigation on 03/06/2023. 8. Inservice on 03/06/2023 - Topic Administrator, Director of Nursing, Assistant Director of Nursing Job Duties and Responsibilities, Resident Rights, Abuse Prevention, Restraints, ADLs, and Toileting. Present by Regional Director of Clinical Services. 9. Inservice 03/06/2023 Resident Rights, Abuse Prevention, Restraints, Activities of Daily Living (ADLs) and Toileting by NHA and DON, attended by all Department Heads, Director of Social Services, Director Activities, Human Resources Director, Infection Preventionist, Nursing Supervisor 3:00 PM to 11:00 PM shift , Business Office Manager, Wound Care Nurse, Charge Nurse 3rd Floor, Maintenance Director, Nursing Supervisor 7:00 AM to 3:00 PM, Nursing Supervisor 11:00 PM to 7:00 AM, Restorative Nurse, Charge Nurse 2nd Floor, Charge Nurse 4th Floor. 10. Inservice Topic - Providing Adequate Supervision to residents by NHA and DON for Nurse supervisors that were on 03/06/2023. Inservice on 03/07/2023, 03/08/2023. 11. Inservice Education - 03/06/2023 to 03/07/2023 Covered Policy & Procedures for Resident Rights, Abuse Prevention, Restraints, ADLS, Toileting Presented by Social Worker, NHA and DON. 12. Facility Administrations - Interview with supervisor Staff E, on 03/06/2023 about the incident. 13. Facility Administration - Interview on 03/06/2023 with Staff H, 11:00 PM to 7:00 AM Registered Nurse about the incident 14. Facility Administration - Interview on 03/06/2023 with Staff C, 11:00 PM to 7:00 AM Registered Nurse about the incident. 15. Facility Administration - Interview on 03/06/2023 with Staff K, CNA, about the incident. 16. Psychiatric Evaluation on 03/07/2023 for Residents #9. #52, #63, #112, #127, #172, #428. 17. Care Plans for 8 residents (Residents #9, #52, #63, #81, #112, #127, #172, #428) updated to at risk for drug related side effect due to use of psychotropic meds. 18. Federal Immediate reports to Department of Children and Family (DCF) on 03/07/2023 at 1:30PM, reported by the Social Services Director (cases #178496, #178503, 178497, 178509, 178490, 178508, 178499 and 178507) 19. On 3/09/2023, the surveyors reviewed the case numbers for Resident # 428, Resident #63, Resident # 81, Resident # 112, Resident #127, Resident #172, Resident # 9, and Resident # 52. 19. On 03/09/2023, the surveyors Interviewed 36 staff members from shifts 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. All confirmed receiving the education and explained what they learned. 20. Every 2-hour rounds were completed, and documentation was started on 03/06/2023 at 3:00 pm and is ongoing. 21. As of 03/08/2023 a total of 180 out of 202 staff members had been educated. Resident # 63 During an observation on 03/06/2023 at 5:10 AM Resident # 63 was observed in the third-floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. During an interview on 03/06/2023 at 05:20 AM, Certified Nursing assistant, Staff K was asked how long the residents were in the dining room, Staff K reported the residents that were in the dining room in the recliners started coming to the dining room around 1:00 AM. On 03/06/2023 at 05:42 AM, Staff D, a Certified Nursing Assistant (CNA) who works the 11:00 PM to 7:00 AM shift, assisted the surveyor with Resident # 63's, skin assessment in the resident's room. Both legs and thighs were clean and intact, healed skin on sacrum, upper extremities were clean and intact. The disposable brief was noted with urine. The resident's bed had bilateral quarter side rails position in middle of bed and bilateral floor mats. On 03/07/2023 at 07:41 AM Resident # 63 was observed in bed asleep. The bed was in lowest position and bilateral floor mats present. Review of the medical records for Resident # 63 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified Dementia, Unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia, Other Schizophrenia, and Major Depressive Disorder. Review of the Physician's Orders Sheet (POS) for March 2023 revealed Resident # 63 had orders that included but not limited to: Falling Star Program every shift. Medications included: Temazepam capsule 30 Milligram (MG) give one (1) capsule by mouth at bedtime related to insomnia unspecified. Lorazepam tablet 0.5 MG give one tablet by mouth one time a day related to anxiety disorder, unspecified. Trazodone tablet 100 mg give one tablet by mouth at bedtime related to major depressive disorder. Citalopram hydrobromide tablet 20 MG give one tablet by mouth one time a day for depression related to major depressive disorder, recurrent, unspecified and Divalproex sodium tablet delayed release 250 MG give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 63 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for behaviors documented Behaviors not exhibited, No Potential Indicators of Psychosis. Section N for Medications documented the resident received antianxiety, antidepressants and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received no Special Treatments, Procedures, and Programs. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Record review of Resident # 63's psychiatry progress dated 03/07/2023 documented: Symptom Description and Subjective Report-Resident was seen for follow up and medication management. Patient continues to have great difficulty initiating and maintaining sleep. Staff reports that without constant observation, patient attempts to get out of her bed as she does, during the day out of her wheelchair without assistance, increasing her risk of falls. Nursing staff gives medication around 9:00 PM and patient falls asleep within an hour. About 3 to 4 hours later patient is up with disinhibited behaviors. She was found today in the common area, screaming, and cursing at staff. Due to her insomnia at night, patient is somnolent in the morning and then begins with agitation and aggression towards the afternoon and evening . Plan: 1. Discontinue Lunesta at night. 2. Restart Temazepam 30 MG at night as patient has taken in the past and tolerated well. 3. Decrease Lorazepam to 0.5 mg BID to limit daytime sedation. 4. Continue remainder of psychotropic medications. 5. Monitor closely for psychotropic medication adverse effects. Record review of Resident # 63 's Care Plans Reference Date 03/03/2023 revealed: Resident has insomnia. Interventions included but not limited to: Avoid providing caffeine containing beverages. Discourage resident from taking late afternoon naps. Engage resident in more activities during the day. Give medications as ordered and monitor effectiveness. Monitor resident's sleeping pattern. Provide a quiet, restful environment during hour of sleep. Provide nonpharmacological interventions such as: massage, distractions, music therapy, encourage relaxation, etc. Provide warm beverages at bedtime as desired. Resident is at risk for drug related side effects due to use of psychotropic medications for the diagnosis of: Anxiety, Depression, Major Depressive Disorder, Bipolar Disorder, Schizophrenia, Schizoaffective, Psychosis, Tourette's, and Huntington's disease. Interventions included but not limited to: Assess for fall risk and precautions needed. Change position to promote comfort. Check and change brief as needed. Encourage activities such as TV (television) and music. Monitor behavior and mood every shift and document. Resident is at risk for falls related to Impaired mobility, Unsteady gait, Use of psychoactive meds, and Dementia. Interventions included but not limited to: Bilateral floor mats while in bed to minimize risk of fall injuries .Check at frequent intervals of one hour to monitor for unsafe actions and intervene promptly while in room. Falling Star program. Instruct/ remind to call for assistance with all transfers. Keep bed in lowest position. Observe for safety. Side rail up as an enabler in bed and prompt to assist with positioning/repositioning. Resident # 81 During observation on 03/06/2023 at 05:10 AM Resident #81 was observed in the 3rd floor dining room in a recliner chair facing the wall asleep, the foot of the reclining chair was propped up by a dining room chair. Review of the medical records for Resident #81 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Muscle weakness (generalized), Unspecified Dementia, unspecified severity without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Insomnia unspecified, Unspecified Psychosis not due to a substance or known physiological condition and Major Depressive Disorder recurrent unspecified. Resident # 81 was discharged on 03/06/2023. Review of the Physician's Orders Sheet for March 2023 revealed Resident # 81 had orders that included but not limited to: Falling Star Program, and on 3/6/23- transfer resident to Hospital via 911 Diagnosis: Respiratory Distress. Medications included: Temazepam capsule 15 MG- give 1 capsule by mouth at bedtime related to insomnia, Mirtazapine tablet 7.5 MG give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, unspecified, Quetiapine Fumarate tablet 100 MG -give 1 tablet by mouth three times a day for psychosis related to unspecified psychosis not due to a substance or known physiological condition, and Divalproex Sodium tablet delayed release 250 MG-give 1 tablet by mouth three times a day for mood stabilization. Review of Resident # 81's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns- Brief Interview for Mental status score was unable to be determined, indicating the resident is severely cognitively impaired. Section E for Behaviors documented behaviors not exhibited, No Potential Indicators of Psychosis. Section G for Functional Status documented the resident requires extensive assistance for Activities of Daily Living (ADLs) with one person assistance. Section J for Health Conditions documented the resident had two or more falls since admission, no shortness of breath (SOB), and no scheduled or as needed (PRN) pain medications were received in the last 5 days. Section N for Medications documented the resident received insulin, antipsychotic, antidepressants, and hypnotics in the last 7 days. Section O for Special Treatments and Procedures documented the resident received dialysis in the last 14 days. Section P for Restraints documented No restraints used in bed or chair, and no alarms used. Review of Resident # 81's psychiatry progress note on 03/03/2023 documented: Symptom Description and Subjective Report-Patient has Major Neurocognitive disorder, Insomnia, and Unspecified anxiety disorder on renal dialysis who was seen today for follow up and medication management. Patient has had an overall improvement in mood and sleep since last evaluation. Staff are no longer reporting that patient is up all night and were able to engage today and evaluation. He is more alert and less somnolent during the day. Patient has not been attempting to pull out his lines during dialysis. There have been no reports of difficulty initiating or maintaining sleep. Record review of Resident # 81's Care Plans revealed: Resident is at risk for drug related side effects due to use of psychotropic medications. Interventions included but not limited to: Assess for fall risk and precautions needed. Encourage activities as tolerated. Monitor behavior and mood every shift and document . Resident is at risk for falls related to history of falls, unsteady gait, Dementia, use of psychoactive meds, and new environment. Interventions included but not limited to: Anticipate and meet needs. Assist resident with transfers and mobility. Bilateral floor mats when in bed to minimize risk of injuries . Check at frequent intervals of one hour to monitor for unsafe actions and intervene promptly. Encourage to attend activities. Falling Star Program. Review of the nursing progress notes for Resident # 81 dated 3/6/2023 timestamped 6:39 AM documented: Resident observed in recliner awake, stable condition. Respiration even and unlabored. No signs/symptoms of pain or discomfort noted at this time. Resident ate breakfast 100% and ready to undergo dialysis treatment at this time in house. Review of the nursing discharge summary progress notes for Resident # 81 dated 3/6/2023 timestamped 1:15 PM late entry documented: Transportation arrived at unit to transfer patient .Report given to receiving emergency staff, and patient was transferred safely onto stretcher. MD and family members were notified at time of transfer. On 03/07/2023 at 07:36 AM Registered Nurse Supervisor, (Staff B) reported that Resident # 81 went to the hospital related to respiratory distress. Resident #112 During observation on 03/06/2023 at 5:10 AM Resident # 112 was observed asleep in the third-floor dining room in a recliner chair facing the wall, the foot of the reclining chair was propped up by a dining room chair. On 03/06/2023 at 06:03 AM, Staff D, a CNA for the 11:00 PM to 7:00 AM shift, assisted nurse surveyor with Resident # 112's, skin assessment in the resident's room. The disposable adult brief was noted with urine. Bilateral quarter side rails on upper bed. Review of the medical records for Resident #112 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limi[TRUNCATED]

Based on observation, interview, the facility's administration failed to implement and provide services effectively and efficiently related to ensuring safety measures were in place to prevent negligence and ensure residents are free from restraints and receive the highest practicable quality of care. The facility ' s administration failed to ensure adequate interventions for supervision was assigned to ensure the safety of residents. The facility's administration failed to ensure incontinence care, positioning and implement appropriate and dignified levels care to meet residents identified needs. This affected 8 out 8 sampled residents (Resident #9, #52, #63, #81, #112, #127, #172, #428) observed in the 3rd dining room at 4:00AM on 3/6/2023. On 03/07/2023, it was determined the findings posed Immediate Jeopardy (IJ) to the health and safety of the residents admitted to the facility existed based on the facility's failure to provide care and services to meet the residents' needs by leaving seven residents restrained in recliners and one resident in a wheelchair to sleep in a commingled environment. On 03/9/2023, after receiving an acceptable IJ Removal Plan, it was verified the IJ was removed on 03/8/2023, but deficient practice still existed at a lower scope and severity of (E). (Refer to F600 and F604). The findings included: On 03/06/2023 at 4:00 AM, upon entering the third-floor darkened dining room area seven residents were observed sleeping in recliners with the footrests being held up with chairs (including Residents #9, #63, #81, #112, #127, #172, #428). There was one resident (Resident #52) seated in a wheelchair asking for assistance to go the bathroom. One (Resident #9) out of the seven residents recliner was wedged between a wall and column with a chair under the food rest. (Photographic evidence). There was one Certified Nursing Assistant (CNA) Staff K, in the dining room who was observed to be sitting in a chair with his feet up in another chair under cover and appeared to be sleeping; Staff K woke up when the surveyors entered the darkened dining room, his eyes appeared to be red, and his hair was disheveled. On 03/06/23 at 04:11 AM, Staff E, a Registered Nurse (RN) stated he was the night supervisor. Staff E reported that the residents were in the dining room because when they were alone in their rooms, they tried to get out of bed, so the nurse brought them to the third-floor dining room to guarantee that they would not fall. Staff E further stated; Residents that were like this, we brought them all in one area. It was not the normal routine, only if I did not have enough CNAs. These residents were getting out of bed and at risk of falling. We have tried non-pharmacological interventions. Staff E reported, he only had had 4 CNAs working. On 03/06/23 at 05:18 AM, an interview was conducted with Staff K, CNA. Staff K stated he was a Patient Care Assistant (PCA) and six months ago he did the test to become a CNA and when he started as a CNA, he had orientation on abuse/neglect in-services education. Staff K was asked about the residents observed in the dining area. Staff K reported, that the residents were in the dining area because the residents had a history of falls, and it was a prevention measure and he put the chair under the footrest of the recliners to keep the residents' legs from falling off and his intention was to keep the residents safe and comfortable. Staff K added that the resident that was asking to go to the bathroom, started to ask when the surveyors entered the dining room. Staff K reported, the nurse was in charge of taking the residents to their room. The Nurses for the third floor usually called the nurses for the other floors to get the residents. On 03/06/23 at 05:40 AM, met with NHA and DON next to 3rd floor elevator, they were informed about the residents were found in the dining room in recliners facing the wall. The television (TV) off. Seven residents are in the dining room at this time. The DON reported the residents are placed in the dining room to decrease the pharmacological interventions for the residents and to have an activity. The DON and the Nursing Home Administrator (NHA) were shown the residents in the dining room. They were shown how the chairs were placed underneath the foot of the recliners that prevented the residents from lowering their recliners. They were told this is considered to be a restraint to have a chair wedged under the recliners footrest. During the review of the facility's policies and procedures, it was determined the facility staff failed to follow policies and procedures for: Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin dated implemented 10/20/2019, date reviewed/Revised 10/15/2022 revealed Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Definitions section included: Neglect means failure of the facility, its employee's, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress and The facility's policy and procedures for Side Rails and Restraint Reduction dated 6/4/2020 included in part, Policy: It is the intention of this facility for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Restraints will not be used for staff convenience. The facility's policy and procedure for Administration dated 3/1/2021 includes in part: It is the policy of the facility to provide appropriate Administration in accordance to State and Federal Regulation. Procedure: Item #1 - The facility shall comply with all applicable standards and rules of the agency and shall be under the administrative direction and charge of a licensed administrator. Item #4 - Facility Management is responsible to assist the administrator in overseeing the day to day operations of all department in the facility. Item #6 - Responsible to monitor each department's activities and communications to elevate performance per facility policies and legal requirements. Item #13 - Address and promptly resolve any identified resident care issues. Item #14 - Ensure resident care is provided in accordance with facility policies and meets professional standards of care. Review of the job description for the Administrator included, but was not limited to, the primary purpose of this position is to direct the day to day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. The Duties and Responsibilities included in part: Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing body. Assume the administrative authority, responsibility and accountability for all programs in the facility. Ensure each resident receives necessary care and services to attain and maintain the highest practical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. Ensure that all employee's, residents, visitors and the general public follow the facility's established policies and procedures. Develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property as well as established facility policies and procedures to investigate such allegations and oversee training as required. Review of the job description for the Director of Nurses included, but was not limited to, the primary purpose of this position is to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. The Duties and Responsibilities included in part: Develop and maintain nursing policies and procedures that conform to current standards of nursing practice, facility mission and state and federal regulations. Oversee the staff development program to ensure nursing team members have the tools, training and resources to properly care for residents in accordance with facility policies and the resident assessment. Plan, develop, organize, implement, evaluate and direct the nursing services department as well as its programs and activities in accordance with current rules, regulations and guidelines that govern the nursing care facilities. Assign a sufficient number of Certified Nursing Assistants for each shift to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident. The facility's IJ Removal Plan was accepted on 3/9/2023 and was verified as completed on 3/9/2023. The effective date of the IJ removal was on 3/8/23: The IJ Removal Plan indicated: 1. On 3/7/2023-Reviewed in-service documentation for supervisors completed by the Nursing Home Administrator (NHA) and Director of Nurses (DON) Only Registered Nurses and Licensed Practical Nurses attended this in-service. Topic-Providing adequate supervision to residents-Goal-To ensure CNA are supervised. As of 03/08/2023: 29 Registered Nurses out of 32 Registered Nurses and 10 Licensed Practical Nurses out of 12 Licensed Practical Nurses had received in-services. 2. Performance Improvement Plan - Reviewed for residents sleeping in the recliner during the 11:00 PM to 7:00 AM shift; staff placed chair under the recliner which is a restraint; Staff member assigned to supervise the resident was noted to be sleeping, staff failed to check and change to residents who were in the recliner. Documents information on the IJ Removal Plan. 3. Quality Assurance Performance Improvement (QAPI) AD HOC Meeting on 03/7/2023 with the NHA, DON, ADON, Department Heads and Medical Director to review and approve the performance improvement plan. 4. Performance Improvement Project Worksheet Root Cause Analysis dated 03/6/2023. 5. Evaluation of the 8 residents for Pressure Ulcer Prevention - completed by the wound care team on 3/6/23, no new open areas noted. 6. Teachable Moment for supervisor, Staff E on 03/06/2023. 7. Staff K, CNA for the 11:00 PM to 7:00 AM shift was contacted about investigation on 03/06/2023. 8. Inservice on 03/06/2023 - Topic Administrator, Director of Nursing, Assistant Director of Nursing Job Duties and Responsibilities, Resident Rights, Abuse Prevention, Restraints, ADLs, and Toileting. Present by Regional Director of Clinical Services. 9. Inservice 03/06/2023 Resident Rights, Abuse Prevention, Restraints, Activities of Daily Living (ADLs) and Toileting by NHA and DON, attended by all Department Heads, Director of Social Services, Director Activities, Human Resources Director, Infection Preventionist, Nursing Supervisor 3:00 PM to 11:00 PM shift , Business Office Manager, Wound Care Nurse, Charge Nurse 3rd Floor, Maintenance Director, Nursing Supervisor 7:00 AM to 3:00 PM, Nursing Supervisor 11:00 PM to 7:00 AM, Restorative Nurse, Charge Nurse 2nd Floor, Charge Nurse 4th Floor. 10. Inservice Topic - Providing Adequate Supervision to residents by NHA and DON for Nurse supervisors that were on 03/06/2023. Inservice on 03/07/2023, 03/08/2023. 11. Inservice Education - 03/06/2023 to 03/07/2023 Covered Policy & Procedures for Resident Rights, Abuse Prevention, Restraints, ADLS, Toileting Presented by Social Worker, NHA and DON. 12. Facility Administrations - Interview with supervisor Staff E, on 03/06/2023 about the incident. 13. Facility Administration - Interview on 03/06/2023 with Staff H, 11:00 PM to 7:00 AM Registered Nurse about the incident 14. Facility Administration - Interview on 03/06/2023 with Staff C, 11:00 PM to 7:00 AM Registered Nurse about the incident. 15. Facility Administration - Interview on 03/06/2023 with Staff K, C N A, about the incident. 16. Psychiatric Evaluation on 03/07/2023 for Residents #9. #52, #63, #112, #127, #172, #428. 17. Care Plans for 8 residents (Residents #9, #52, #63, #81, #112, #127, #172, #428) updated to at risk for drug related side effect due to use of psychotropic meds. 18. Federal Immediate reports to Department of Children and Family (DCF) on 03/07/2023 at 1:30PM, reported by the Social Services Director (cases #178496, #178503, 178497, 178509, 178490, 178508, 178499 and178507) 19. On 3/09/2023, the surveyors reviewed the case numbers for Resident # 428, Resident #63, Resident # 81, Resident # 112, Resident #127, Resident #172, Resident # 9, and Resident # 52. 19. On 03/09/2023, the surveyors Interviewed 36 staff members from shifts 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. All confirmed receiving the education and explained what they learned. 20. Every 2-hour rounds were completed, and documentation was started on 03/06/2023 at 3:00 pm and is ongoing. 21. As of 03/08/2023 a total of 180 out of 202 staff members had been educated.