Based on record review and staff and resident interviews, the facility failed to treat 1(Resident #1) of 3 residents reviewed with dignity by denying the resident access and assistance to the bathroom. The findings included:Review of the facility provided incident investigations revealed on 7/25/25 the facility initiated an investigation for Resident #1 related to staff denying him access to the bathroom in the therapy department. The facility's investigation noted that on 7/25/25 at approximately 11:30 a.m., Resident #1 needed to use the bathroom and stopped in the therapy department to use their restroom. Resident #1 stated that staff denied him access and assistance to the therapy department bathroom, resulting in an incontinence episode, causing the resident to miss a doctor's appointment. Resident #1 stated that he was embarrassed and angry. The facility's investigation included statements of staff involved. Review of the facility provided staff statements revealed:Physical Therapist (PT) Staff D stated that on 7/25/25 at approximately 11:00 a.m., she entered the therapy room to start a group session. Several residents, including Resident #1 were present. Resident #1 wanted to use the bathroom. Physical Therapy Staff C told Resident #1 that he could not use the restroom without assistance, and she had another resident in the room at the time. PT Staff C offered to take Resident #1 to his unit to use the bathroom. He refused her assistance. PT Staff D said Resident #1 began cussing and flailing his arms and she was extremely uncomfortable with his behavior. Physical Therapist Staff E stated that on 7/25/25 at approximately 11:00 a.m., Resident #1 entered the therapy gym and headed for the bathroom stating he was going to use the toilet. PT Staff C told him that he could not use the toilet in the gym because he needed assistance and she was busy treating a patient. PT Staff C told Resident #1 that the Director of Rehab (DOR) had told him that he could not use the toilet independently or use the gym's toilet is he was not in treatment. Resident #1 reposted urgency to use the toilet. PT Staff C said she could take him to his room. PT Staff C asked PT Staff E if she could assist the resident to the toilet. She stated that she could not. PT Staff C and PT Staff D again stated that Resident #1 needed assistance to transfer. Resident #1 began cussing and left the room. Licensed Practical Nurse (LPN) Staff F provided a statement that on 7/25/25 at approximately 11:15 a.m., she heard Resident #1 coming down the hall, cussing. She asked the resident what was wrong. He stated that therapy told him he could not use the restroom, that he had to use the restroom in his room. Resident #1 told her that PT Staff D put a wheelchair in front of the bathroom door to block the entrance. LPN Staff F said that the driver was here to take him to his appointment. He told her to send the driver away because he had to get cleaned up. The investigation noted that Resident #1 was a 1 assist transfer (stand and pivot) as well as using the sit to stand lift when requested. Resident #1's therapy notes stated that the resident was able to use the restroom with minimal to no assistance. Resident #1 was going to therapy 3 times a week at the time of the event but was not on therapy caseload for that day. On 8/4/25 the facility documented in the conclusion of their investigation, This event will be verified due to the 3 therapy staff members not personally assisting (Resident #1) to the restroom. The therapists are professionally trained to assist with standing and pivoting individuals. (Resident #1) was offered assistance to get back to his room but never assistance with the toilet nor was he allowed to toilet himself due to placing a wheelchair in front of the bathroom door. The three individuals never requested assistance from the nursing department nor notified them of his need. (Resident #1) is alert and oriented and is capable of toileting himself but is recommended by therapy to have staff present to prevent falls per therapy notes.On 8/20/25, review of the clinical record for Resident #1 revealed an admission date of 3/4/21. Diagnoses included Parkinson's disease, Alzheimer's disease.Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 7/28/25 revealed Resident #1 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The care plan initiated on noted the resident assistance of 1 for transfers (stand and pivot). Resident #1 also used a sit to stand lift when requested. On 8/20/25 at 10:30 a.m., in an interview the Regional Administrator, Risk Manager, and Assistant Director of Nursing said they were aware of the incident of Resident #1 not being allowed to use the restroom in the Physical Therapy Department which resulted in Resident #1 soiling himself. They said all three therapists involved in the incident were contracted from an outside company to provide Physical Therapy services to all state facilities. On 8/20/2025 at 12:45 p.m., in an interview Resident #1 said the incident on 7/25/2025 made him very angry. He said that he was dressed and, on his way up front to catch his ride for a doctor's appointment. He said he suddenly realized he needed to poop and the Physical Therapy room was right there. They wouldn't let him use the restroom. He said PT Staff D threw a wheelchair in front of the bathroom door to block him from entering. He said he tried to make his way back to his room but soiled himself before he made it back. Resident #1 said the incident made him feel angry and embarrassed. He said that behavior cannot be tolerated. He said he has been a resident at the facility for 9 years now and has always been treated with respect and dignity by all the employees except for this incident. Resident #1 said he did not require assistance to use the restroom. Due to his back issues, he can only stand for about 10 seconds before he loses his balance. On 8/21/2025 at 9:45 a.m., in an interview the Director of Rehab said she was not working on 7/25/25 but was told Resident #1 stopped in and said he needed to use the restroom. She said their verbal policy is to accommodate all residents to use the restroom. She said she even has tape in front of the bathroom door to ensure it stays free of clutter and not blocked. She said there was no excuse for denying the resident access to the therapy bathroom.

Based on review of facility policy and procedures, record review and staff and resident interviews, the facility failed to protect the resident's right to be free from physical abuse by failing to use the proper mechanical lift during a transfer for 1(Resident #899) of 3 residents reviewed for abuse.The findings included:Review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation/Misappropriation of Resident Property with a revised date of 3/01/2024 revealed, The goal is to achieve and maintain an abuse-free environment for the residents . Abuse means any willful act or failure to act which causes or is likely to cause significant injury to a resident's physical, mental or emotional health . Prevention . Identify, correct and intervene in situations in which abuse . is more likely to occur . This includes an analysis of . The supervision of staff to identify inappropriate behaviors such as . rough handling .Review of the clinical record for Resident #899 revealed an admission date of 2/14/25. Diagnoses included restlessness, dementia with psychotic disturbance, anxiety and flaccid hemiplegia (paralysis) affecting the right side.Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 5/20/25 revealed Resident #899 scored 03 on the Brief Interview for Mental Status, indicating severely impaired cognition. The resident required partial to moderate assistance with activities of daily living, including transfers.Review of the care plan initiated on 2/21/25 and edited on 7/1/25 revealed Resident #899's ability to transfer, dress, eat, toilet and maintain personal hygiene had deteriorated related to CVA (Cerebrovascular accident) with right side flaccid hemiplegia.The approaches as of 2/21/25 included to provide 2 person assistance for transfers.On 6/12/25, the care plan noted Resident #899 had a recent incident of placing himself on the floor.On 7/16/25, review of facility provided incident investigations revealed that on 7/1/25 the facility initiated a staff to resident physical abuse investigation for Resident #899.The detailed description of the allegation/incident noted:Resident #899 was allegedly pulled approximately 4 to 5 feet. Resident placed self on the floor, as per his care plan. CNA (Certified Nursing Assistant) was attempting to move him from in front of the door way [sic] to prevent injury.CNA Staff B provided a statement that on 7/1/25 CNA Staff A grabbed Resident #899 by his shirt and dragged him on the floor so that she could place him closer to the mechanical lift.CNA Staff A provided a statement that on 7/1/25 at approximately 10:00 a.m., Resident #899 was laying on his bedroom floor in front of the doorway. She did not want the door to injure him, so she requested assistance to move him back into the bed. CNA Staff A stated that she took the shoulder and the other CNA (CNA Staff B) took the legs and they moved him in his room under the ceiling lift track. CNA Staff A stated that initially she pulled Resident #899 out of the doorway to his armoire, approximately 2 inches, unassisted by holding the resident's left arm, shoulder. Once positioned, CNA Staff B assisted her getting the resident positioned in the lift sling for the mechanical lift.Review of CNA Staff A's handwritten statement revealed that on 7/1/25 Resident #899 was in the doorway and they had to move him in the room. She took the shoulders and the other CNA took the legs and they moved the resident in his room under the (brand name) mechanical lift tract. She avoided touching the resident's paralyzed arm and they hooked him up to the lift.Review of CNA Staff B's written statement revealed that Resident #899 was on the floor by the dresser. She asked CNA Staff A if she needed help getting the resident up. Resident #899 was not close to the (brand name) mechanical lift track. She (CNA Staff A) dragged him by the collar of his shirt to be closer to the track, got him in the sling and back to bed.The investigation noted that on 7/1/25 at approximately 1:45 p.m., the Nursing Home Administrator and the Risk Manager interviewed CNA Staff B. Staff B stated that she was in a different room caring for a resident. She exited the room and walked past Resident #899's room. She noted CNA Staff A standing over Resident #899. The resident was laying on the floor in front of his armoire. She offered her assistance to CNA Staff A, which she accepted. She closed the door. At this time, CNA Staff A grabbed Resident #899 by his shirt and moved him closer to the track of the lift to get the resident off the floor. CNA Staff B demonstrated to the Risk Manager and the Nursing Home Administrator the location of Resident #899 when she entered the room. CNA Staff B stated to the Risk Manager and the Nursing Home Administrator that this was not right, she was not going to participate in moving a resident this way. Staff B said when she presented this to CNA Staff A, the response was, This is how I do it.On 7/1/25 at approximately 2:00 p.m., the Nursing Home Administrator and the Risk Manager spoke with CNA Staff A regarding the concerns brought to their attention. CNA Staff A stated that she noted Resident #899 in the doorway and wanted to move him away from the doorway. She grabbed his left arm and shoulder, and he assisted by scooching himself. CNA Staff A stated that she only moved Resident #899 2 inches and the other CNA (CNA Staff B) assisted by lifting the legs. CNA Staff A went to the resident's room and demonstrated for the Nursing Home Administrator and the Risk Manager what she did. Resident #899's head was by the room to his door. CNA Staff A used the resident's left arm and shoulder and moved him approximately 4 to 5 feet from the door, spinning him around to have his head by the armoire in his room.The conclusion of the investigation documented, The investigation determined that the allegation of abuse was verified by improperly transferring the resident without properly utilizing a lift sling or lift equipment provided by the facility as per policy. CNA [Staff A] action replay and verbal recollection of the event determined that she did not use the provided equipment nor follow facility policies for transferring a resident safely resulting in potential injury both physically and emotionally on the resident's behalf.On 7/16/25 at 9:15 a.m., in an interview the Risk Manager said the root cause of the incident involving Resident #899 was negligence. CNA staff A's story kept changing during the interview. On 7/16/25 at 9:26 a.m., an attempt was made to interview Resident #899. He did not respond to interview questions.On 7/16/25 at 9:50 a.m., in an interview CNA Staff B said that on 7/1/25 she was walking past Resident #899's room and saw CNA Staff A standing over the resident who was on the floor. She asked CNA Staff A if she needed help because 2 people are needed to use the mechanical lift. She said she entered the room and closed the door. Resident #899 was not in front of the door, otherwise, she would not have been able to close the door. CNA Staff B said, The next thing I saw was she [CNA Staff A] grabbed the resident by the shirt, spun him around and pulled him across the floor by the shirt.She said the resident's head was facing the bed, [CNA Staff A] whipped him around by his shirt and pulled him over about 4 to 5 feet. I don't know why she didn't just use the portable lift to get him off the floor. I know what I saw and I told the DON. That is not how you treat residents, you can't pull on them.On 7/16/25 at 11:12 a.m., in a telephone interview CNA Staff A said Resident #899 was on the floor and she needed help to get him into bed. She said, I didn't see him get on the floor, but he does that. He was by the wall in his room, about one foot from the bed. She needed help to get him to the lift and put the sling under the resident. CNA Staff B came into the room. She grabbed the resident's arms and CNA Staff B grabbed his legs. They placed the lift pad under Resident #899. She said, I did not in any way pull him by the arm or the shirt. It did not happen. I did not grab him or pull him by the arm.On 7/16/25 at 11:30 a.m., in an interview Registered Nurse (RN) Staff C said on 7/1/25 she was the nurse on duty and asked CNA Staff B to help CNA Staff A with Resident #899 who was on the floor. She did not see where the resident was in the room. She clocked out and went to lunch for 30 minutes. She later found out what had happened. RN Staff C said, I never saw CNA Staff A hit a resident, but she was rough with them on occasions when she was transferring them. By rough I mean, she was fast when she was transferring them. A lot faster than I or anyone else would do it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records review and interviews, the facility failed to protect the resident's right to be free from neglect by failing to ensure 1 (Resident #2) of 3 residents reviewed received incontinent care to meet their needs. The findings included: Review of the Facility's Abuse, Neglect and Exploitation/Misappropriation of Resident Property policy (last revised 3/1/2024) revealed, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy noted under prevention to, identify, correct and intervene in situation in which abuse, neglect and/or exploitation/misappropriation of resident property is more likely to occur. The facility policy noted to, identify the staff member(s), the length of time involved, and any outcome of the victim. Be specific. Review of the clinical record revealed Resident #2 was admitted on [DATE]. Diagnoses included Dementia, Parkinson's Disease and overactive bladder. Review of the Brief Interview for Mental Status dated 4/2/25 revealed Resident #2 scored 14, indicative of intact cognition. Review of the Discharge Minimum Data Set (MDS) assessment with a target date of 5/7/25 revealed Resident #2 was frequently incontinent of bladder. The MDS noted the resident required partial/moderate assistance for sit to stand and supervision or touching assistance for toileting hygiene. Review of the care plan Resident #2's Care Plan noted Problem: (Resident #2) may experience urinary incontinence R/T (related to) overactive bladder and dementia. (Resident #2) is incontinent of bowel. The approaches included 2 urinals at bedside for large nighttime urine output. Review of the facility's grievance investigations revealed on 4/2/25 the facility initiated a neglect investigation when Resident #2 complained about calling all night for help and no one came. Review of facility investigation revealed: On 4/2/2025 Certified Nursing Assistant (CNA) Staff L said she entered Resident #2's room around 6:45 a.m. and his urinal was full. He stated that he was calling for help all night, and no one came. Once getting him out of bed I saw that his pull up and his bed was [sic] wet. I asked the CNA (Certified Nursing Assistant) if he's been in there, and he told me that him and the other CNA changed him (Resident #2) at 1:00 a.m. On 4/2/25 CNA Staff K stated she entered the resident's room to provide personal care at 6:55 a.m. Resident #2 said he was not going to get out of bed until the nurse came, because he spent all night calling, and no one came to help him. His urinal was full. She emptied it and found that his pull up was wet. The Medical Record Clerk said that on 4/2/25 at around 7:30 a.m., Resident #2 said that he was upset and wanted to file a complaint because he tried calling the staff all night because he was wet. Registered Nurses (RN) Staff N, RN Staff O and RN Staff P when interviewed said Resident #2 stated, Nobody cared for me last night, and I needed help. The investigation noted Resident #2 frequently becomes agitated during morning shift change and quickly calms down when he receives care. The facility's investigation conclusion noted the allegation of neglect was verified. Resident #2 stated that he did not receive care during the 11:00 p.m., to 7:00 a.m. shift on 4/1/25. Staff stated that he was awake most of the night, in and out of bed, asking for food, and being toileted 1 to 3 times throughout the night. Resident #2 is a 2-person assist due to confabulation and 2 staff attended to his needs throughout the shift. When the 7:00 a.m., to 3:00 p.m. shift arrived, his urinal was full, and his bed and brief were wet. Although staff statements and interviews differ in account of the occurrence, there was a lack of sufficient evidence to disprove Resident #2's allegation. The investigation noted CNA Staff H who was assigned to Resident #1 during the 11:00 p.m. to 7:00 a.m. was placed on administrative leave and returned pending disciplinary actions. On 6/25/2025 at 10:03 a.m. the Nursing Home Administrator (NHA) said the investigation found that Resident #2 did receive care. The NHA said between 4 CNAs, 2 nurses and the CNA in question statements, staff had been in Resident #2's room multiple times throughout the night. The NHA confirmed that Resident #2 was found that morning with a full urinal and wet bed. The NHA also said that the report they submitted should have noted the neglect as unverified. When asked for intake and output records, they said there is no documentation because they don't document every time they empty urinals. On 6/25/2025 at 10:51 a.m., in an interview Resident #2 said, night shift is very bad I use the call light, and they don't come. Resident #2 said it is always the night shift between 11 p.m. and 7 a.m. Resident #2 said he made a mess recently when he had an episode of incontinence. Resident #2 said the sheet, pillows and blanket were soaked. Resident #2 said the nurse came in, shut off the light and left. Resident #2 said she didn't do nothing. Resident #2 was unable to identify the nurse. On 6/25/2025 at 11:10 a.m., in an interview CNA Staff K said CNAs are responsible for checking incontinent residents. When asked how often incontinent residents are checked, Staff K said we check after every meal and anytime the resident needs it. When asked about how Resident #2 uses the bathroom, Staff K said if he will hit the call light if he needs to go. Staff K also said he will ask for help if he feels wet. Staff K said if Resident #2 is in the chair in the common room, he will lift his hat in the air when he needs to go to the bathroom. Staff K said Resident #2 uses a urinal and incontinence pad when he is in bed. Staff K showed documentation of urine output in the system where small, medium and large can be documented for urine output. CNA Staff K said, I put in the amount and color. On 6/25/2025 at 12:05 p.m., in an interview CNA Staff L said nurses and CNAs are responsible for checking incontinent residents. Staff L said that documentation of incontinence is done on the computer. CNA Staff L said refusals of care are documented in the progress notes. Staff L said Resident #2 is someone we frequently check. Staff L said Resident #2 was with it and he will let you know if he needs to be changed or needs to go to the bathroom. When asked if there have been issues with residents having full urinals or being soaked in the morning when coming on shift at 7:00 a.m., Staff L said, I'd be lying if I said no. Staff L said they will come in and urinals are overflowing and beds are soaking wet. Staff L said the call lights are all on and flickering fast. Staff L explained that the light above the door flickers faster the longer they have been on. When asked if staff are around when they are flickering, Staff L said yes. During an interview on 6/25/2025 at 12:12 p.m. LPN Staff M said nurses and CNAs check incontinent residents. Staff M said incontinent residents are checked every 2 hours and as needed. Staff M said CNAs document the output in the resident's chart. Staff M said, we document refusals in the progress notes. During a telephone interview on 6/25/2025 1:02 p.m., Licensed Practical Nurse (LPN) Staff J said on 4/1/25, she provided care for Resident #2 at the beginning and end of the shift. Staff J said CNAs were going in and out of the room that night. Staff J said Resident #2 was very behavioral that night. When asked what that meant, Staff J said Resident #2 was verbally resistant and refused things. When asked if refusals were documented, Staff J said, refusals are usually documented. Review of the clinical record for Resident #2, including progress notes, urine output record, intake and output record, resident's level of control with bladder function from 3/25/25 through 4/4/25 failed to reveal documentation of Resident #2's bladder function, and incontinent care provided on 4/1/25 for the night shift. The clinical record did not contain documentation Resident #2 refused care during the night shift of 4/1/25. On 6/25/2025 at 12:37 p.m., in an interview the Director of Nursing (DON) said there was no policy for documentation. On 6/25/2025 at 2:42 p.m., in an interview the Nursing Home Administrator (NHA) said the CNAs and nurses are responsible for checking incontinent residents. When asked what the process is when they receive a report that a resident didn't receive incontinence care, the NHA said it should be reported to a supervisor. The NHA said if it is a neglect issue, it goes to risk management, the Director of Nursing (DON) and then herself. The NHA said based on staff statements, Resident #2 was constantly receiving care and attention throughout the night. When asked about the lack of documentation of care provided, the NHA stepped out of the interview to get the DON. On 6/25/2025 at 2:47 p.m., a joint interview was conducted with the NHA and the DON to discuss Resident #2's neglect and the lack of documentation of incontinent care provided on 4/1/25 during the night shift . The NHA and DON said Resident #2 was care planned for confabulation. The DON reviewed the bowel and bladder documentation for Resident #2 and verified the lack of documentation Resident #2 received incontinent care during the day, evening and/or night shifts on 3/25/25 (evening and night), 3/26/25 (evening) 3/27/25 (evening and night), 3/28/25 (evening and night), 3/29/25 (day, evening and night), 3/30/25 (day, evening and night), 3/31/25 (day, evening and night), 4/1/25 (evening and night), 4/2/25 (evening and night), 4/3/25 (day and night), and 4/4/25 (evening).

Based on record review and interview, the facility failed to protect the residents' right to be free from misappropriation of resident's property by failing to have effective processes in place to prevent the misappropriation of controlled substances for 2 (Residents #1 and #4) of 3 residents reviewed. The findings included: Review of the facility's policy titled Abuse, Neglect and Exploitation/Misappropriation of Resident Property with a revision date of 3/1/24 revealed Exploitation and Misappropriation of Resident Property means a deliberate misplacement, wrongful, temporary or permanent use of a resident's belongings without the resident consent. Examples included: stealing from a client/resident. Review of the clinical record for Resident #1 revealed a physician's order for Oxycodone-APAP 10 mg/325 mg (Controlled substance), 1 tablet ever 6 hours for non-acute pain. The medication was scheduled to be administered each day at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Review of the Controlled Substance Record of Use logs for Resident #1 revealed on 5/15/25 the pharmacy delivered 2 packs of 60 tablets each of Oxycodone-APAP 10 mg/325 mg to the facility. Each pack of Oxycodone-APAP 10 mg/325 mg contained a 15 day supply of the medication. Review of the Controlled Substance Record of Use log for pack #1 revealed the 60 tablets of Oxycodone-APAP 10 mg/325 mg were documented as administered within 12 days: The first dose of Oxycodone-APAP 10 mg/325 mg was administered on 5/16/25 at 6:00 a.m. The last dose of Oxycodone-APAP 10 mg/325 mg was administered on 5/28/25 at 6:00 a.m. Review of the Administration History for the Oxycodone-APAP 10 mg/325 mg from 5/16/25 at 6:00 a.m., to 5/28/25 at 6:00 a.m., revealed 44 tablets of Oxycodone-APAP 10 mg/325 mg had been administered during that time frame. The doses of Oxycodone-APAP 10 mg/325 mg were documented as missed on 5/17/25 (12:00 p.m., and 6:00 p.m.), 5/18/25 (6:00 a.m., and 12:00 p.m.) and 5/23/25 (6:00 a.m.). Review of the Controlled Substance Record of Use for pack #2 for Resident #1 revealed the 60 tablets of Oxycodone-APAP 10 mg/325 mg were administered within 11 days: The first dose of Oxycodone-APAP 10 mg/ 325 mg was administered on 5/28/25 at 12:00 p.m. The last dose of Oxycodone-APAP 10 mg/325 mg was administered 11 days later on 6/7/25 at 12:00 a.m. Review of the Administration History for the Oxycodone-APAP 10 mg/325 mg from 5/28/25 at 12:00 p.m., to 6/7/25 at 12:00 a.m., revealed 36 tablets of Oxycodone-APAP 10 mg/325 mg had been administered during that time frame. The doses of Oxycodone-APAP 10 mg/325 mg were documented as missed on 6/1/25 (12:00 p.m., and 6:00 p.m.), and 6/6/25 (6:00 p.m.). The Controlled Substance Record of Use logs for Packs #1 and #2 of Oxycodone-APAP 10 mg/325 mg revealed multiple dates had been scribbled or written over making it illegible or difficult to make out the date for the doses of Oxycodone-APAP 10 mg/325 mg administered. On 6/25/25 at 10:25 a.m., in an interview the Administrator said on 6/6/25 they discovered discrepancies in Resident #1's Oxycodone-APAP 10mg/325 mg when a refill of the medication was requested and the Pharmacy Consultant informed the facility it was too soon for a refill. On 5/15/25 120 tablets of Oxycodone-APAP 10 mg/325 mg (30 day supply) were delivered for Resident #1. The physician's order for the Oxycodone-APAP 10 mg/325 mg was to administer 1 tablet 4 times a day and the medication was not due for a refill until 6/12/25. Resident #1 should have received a maximum of 4 tablets daily. The Pharmacy audited the controlled substance record of use and found that on multiple days Resident #1 received more than 4 tablets of the Oxycodone-APAP 10 mg/ 325 mg. The Administrator said when you compared the count documented on the controlled substance record of use against the blister pack (package of medications), the count was correct. However, some days it looked like Resident #1 received 8 or 11 doses of the Oxycodone-APAP 10 mg/325 mg when he should have only received 4 per day. The declining narcotic inventory sheets looked like there were dates changed, scribbled out, started on a previous day. The end count was correct but the nurses were not catching that it was documented more than 4 times per day. The Administrator said during their investigation they discovered a similar issue with the pain medication for Resident #4. The Administrator said there were no ill effects to the residents, and they did not go without their scheduled pain medication. Review of the clinical record for Resident #4 revealed a physician's order for Oxycodone HCL (IR) 5 mg , 1 tablet every 6 hours for non-acute pain. Review of the controlled substance record of use revealed 60 tablets of Oxycodone (IR) 5 mg were delivered on 5/27/25 for Resident #4. Multiple dates were scribbled or written over making it difficult to make out or illegible. The dates on the controlled substance record of use were not in order. The controlled substance record of use showed Oxycodone 5 mg was administered on 5/30/25, then 5/31/25, then went back to administration of the Oxycodone 5 mg on 5/30/25. The first dose of Oxycodone (IR) 5 mg was administered on 5/27/25 at 6:00 p.m. On 6/6/25 at 12:50 p.m.,10 tablets of Oxycodone (IR) remained in the blister pack, indicating 50 tablets of Oxycodone IR 5 mg from the blister pack had been signed out between 5/27/25 at 6:00 p.m., and 6/6/25 at 12:50 p.m. Review of the Administration History for the Oxycodone (IR) 5 mg revealed 38 tablets of Oxycodone (IR) 5 mg were documented as administered from 5/27/25 at 6:00 p.m., through 6/6/25 at 12:50 p.m. Review of the facility's investigation revealed: A statement by the Consultant Pharmacist dated 6/10/25 which indicated: Pharmacy received a request for Resident #1 for Percocet 10/325mg, 1 tab po 4 times daily 120 tabs dispensed. Previous order for 120 tabs was filled on 5/15/25, which is a 30 day supply. Saw that it was not due to be refilled until 6/12 (28 days from last fill). In the morning Registered Nurse (RN) supervisor Staff E called to inquire about the refill and I told him it wasn't due until 6/12 at the soonest. I checked for any PRN (as needed) orders that would equate to more use of the standing order and there was none. RN Staff E checked also for any PRN orders pharmacy may have missed and found none. The order was technically 8 days early for filling. I reviewed the documentation and found multiple days that had more than 4 tablets taken. On 6/4 for example, 11 doses were signed out. I reported this to Staff E and the 3-11 RN supervisor (do not remember name). They asked that I tell the Director of Nursing (DON). Around 3:50 pm I went to the DON's office and showed her what I found with reviewing the tracking sheets and she understood the concern, more tablets being signed out than prescribed. On 6/25/25 at 12:42 p.m., in an interview the Director of Nursing (DON) said on 6/6/25 RN Staff E reported that the Pharmacy Consultant identified what they believed to be an error in a narcotic count for Resident #1. The DON said she and RN Staff E counted how many tablets of Percocet had been given. 120 tablets were delivered, 115 were administered with 5 remaining tablets. She said Staff E and her felt the count was accurate. The DON said the Pharmacy Consultant showed her the pages from the narcotic book and pointed out the dates. It sowed on certain days the medication was signed out 6, 7, 10 or 11 times in one day. The order was for 1 tablet 4 times a day. In counting the days, there should have been approximately 25 tablets left and there were only 5. The DON said they conducted an audit of all controlled substances and the Risk Manager found further issues. On 6/25/25 at 1:21 p.m., in an interview Registered Nurse (RN) Staff E said he reordered the Oxycodone-APAP for Resident #1. The pharmacy said the medication was not due for a refill yet. When the Pharmacy Consultant reviewed the controlled substance record of use, he found that Resident #1 had been receiving more than the 4 doses of pain medication ordered daily. RN Staff E said he reported it to the DON and didn't know what happened after that. On 6/25/25 at 1:25 p.m., in an interview the Risk Manager (RM) said the facility investigated, reviewed the controlled substance logs for all the residents receiving Oxycodone and found the following concerns: With Resident #4's pain medication they found the count was all right but found concerns similar to Resident #1. She said these instances all related to Licensed Practical Nurse (LPN) Staff A. She said she and the Administrator met with LPN Staff A regarding multiple discrepancies on the controlled substances administration documents. LPN Staff A claimed that multiple of the signatures were not hers and she could not recall who she signed off on her cart for multiple events. LPN Staff A also stated that she had changed multiple dates on several of the medication documents. When asked why she would do that she stated, I must have made a mistake. The Risk Manager said that LPN Staff A was adamant that she did not take any pills and also denied over medicating any resident. She said when the presented LPN Staff A with the evidence of multiple discrepancies, she became overwhelmed and began to cry. LPN Staff A requested to undergo a drug treatment program in lieu of notifying the state board of nursing. On 6/25/25 at 4 p.m., in an interview the Administrator said LPN Staff A was no longer employed at the facility, the incident was reported to law enforcement, the Drug Enforcement agency and the Board of Nursing. A performance Improvement Plan was put in place and audits were ongoing to ensure logs were legible and pharmacy was auditing as well to ensure documentation was legible. All nurses have been educated on drug diversion.

Based on record review, and staff interview, the facility failed to ensure 2 Residents (#48, and #220) of 3 sampled residents reviewed received the Skilled Nursing Advanced Beneficiary of Non-coverage form (CMS-10123) to inform the resident of potential liability for payment, and right to appeal. The findings included: The facility policy titled Advance Beneficiary Notice of Medicare Non-Coverage with effective date 12/18/2009, Revised date 04/2/2024, specified Skilled Nursing Facilities are required to notify residents before .services are .terminated and Medicare is not expected to pay. The Notice of Medicare Non-coverage (NOMNC) is given by the facility to all Medicare residents at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The resident's appeal rights must be explained to the representative. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on the same day. Place a dated copy of the notice in the beneficiary's medical file and document the telephone contact to include the: the name of the person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. Social Services will notify and document notification of resident or resident's representative . Social Services will mail notification via certified return receipt and provide the Business Office a copy for tracking and auditing. Review of Resident #48's census data information revealed Resident #48's Medicare part A skilled service episode started on date 1/12/24. The last covered day of Part A service was 2/29/24. The durable power of attorney signed the Advanced Beneficiary form of non-coverage on 3/13/24. Review of Resident #220's census data information revealed Resident #220's Medicare Part A skilled service episode start date was 5/10/24. The Last covered day of Part A service was 05/15/24. The durable power of attorney signed the Advanced Beneficiary form of non-coverage on 5/20/24. Review of the Beneficiary Protection Notification Review form revealed the facility initiated Resident #48 and #220's discharge from Medicare Part A Services with benefit days remaining. Record review of Resident #48 and Resident #220's coverage notice records failed to reveal any documentation that either resident had been provided with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10123) prior to the end of their services. On 9/06/24 at 2:42 p.m., during an interview, Staff K, Social worker program manager, said her process for advance notification is to give the beneficiary or the durable power of attorney notice when services are being terminated, including the date of the service being terminated, via regular mail, not certified mail. Staff K said there was no documentation of when the notice was sent via regular mail. Staff K said notice was provided verbally, but she said there was no documentation indicating notice was provided within 2 days prior to the end of service, and the right to appeal the decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review The facility failed to ensure nursing staff were competent in completing Neurological (Neuro) checks for one resident who had had a fall with a head injury (Resident #114) of seven resident surveyed for falls by not obtaining a complete neuro check and allowing the resident to sleep after noting a significant drop in blood pressure. The findings included: Resident #114 was an [AGE] year-old male who was admitted to the facility on palliative care with a history of Type 2 Diabetes, Dementia, Anxiety Disorder, Hypertension, Atrial Fibrillation, Makor Depressive Disorder, seizures, Anemia, with a Cardiac Pacemaker. According to the timeline provided by the facility, on 8/20/24 at 2:40 p.m. Resident #114 was redirected from an exit in the facility and while walking away from the exit had a witnessed fall with a head injury. Review of the Fall Occurrence (Form 110514) show after the fall the resident complained of a headache. The resident was observed holding his head and a quarter size reddened spot was noted to the left posterior of the resident's head. Documentation of the Neuro checks form showed at 2:45 p.m. Resident #114's blood pressure was 161/96. At 3:30 p.m. the resident's blood pressure was documented as 152/80. On 8/20/24 at 5:30 p.m. a significant drop in blood pressure is noted on the Neuro Checklist documented as 100/50. Pupil reaction and hand grasp are not documented on the form on 8/20/24 at 5:30 p.m. Licensed Practical Nurse, Staff H documented Asleep under pupil reaction time on the form. Staff H documented Resting in bed. On 8/20/24 at 6:09 p.m., Staff H documented shortly before 6:00 p.m. the resident was found with no vital signs. On 9/6/24 at 1:00 p.m., the Administrator said the facility did not a have policy for completing neuro checks. On 9/6/24 at 2:30 p.m., in a telephone interview, Staff H said Resident #114 was arousable when she obtained his vital signs on 8/20/24 at 5:30 p.m. When asked why she did not check his pupils or hand grasp, she stated the resident was sleeping and she did not want to wake him. When asked about the decrease in Resident #114's blood pressure after his injury, Staff H said she did not think a blood pressure of 100/50 was low blood pressure. Staff H said she never noticed the drop in blood pressure. On 9/06/24 at 3:27 p.m., the Director of Nursing verified the Neuro checks were not completed on 8/20/24 at 5:30 p.m. She said neuro checks should be completed for any resident with a head injury. The Director of Nursing verified a resident should be awakened so the neuro checks can be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 resident (Resident #16) based on the resident's ongoing clinical assessments and identified risks for falls. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/24 effective 5/15/2017, documented The facility will ensure that the residents environment remains as free from accident hazards as possible and each resident receive adequate supervision and assistive devices to prevent accidents .A fall is defined as an unintentional coming to rest on the ground, floor or other lower level that is not the result of external force .Based on resident assessment, the facility will identify interventions related to the resident's specific risk and behaviors and develop a plan of care to try to prevent the resident from falling and to minimize complications if a fall does occur . Facility staff will identify appropriate resident specific interventions to reduce the risk of falls .The clinical team will monitor and document each residents response to interventions intended to reduce falls or the risk of falls .If a resident continues to fall, the clinical team in consultation with the physician will re-evaluate the situation and determine whether it is appropriate to continue and or change current information. Review of the clinical record showed Resident #16 was admitted to the facility on [DATE]. Resident #16's diagnoses included Parkinson's disease with Dyskinesia (uncontrolled involuntary muscle movement), unspecified dementia, other abnormalities of gait and mobility, tremor, unspecified, Insomnia. The admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 4/22/24 documented Resident #16 required the assistance of 1 person for supervision of transfers, ambulation and toileting. The MDS noted the Resident #16's cognitive status was moderately impaired. The care plan initiated on 4/15/22 identified Resident #16 as a fall risk, had falls, was at risk for falls due to poor safety awareness, forgetting to ask for assistance and had a history of falls with a hip fracture. Fall prevention interventions included to keep personal items within reach, keep call light within reach at all times, anti-roll backs on wheelchair. On 4/15/22 a fall risk assessment documented Resident #16 had a fall risk score of 17, indicating he was at risk for falls. A fall risk score of 10 or higher represents a high risk for falls. Additional fall risk assessments scored 18, and were completed on 3/14/24, and 6/10/24 which continued to indicate a high risk for falls. The facility fall record review revealed Resident #16 had 18 falls since 11/17/23. Unwitnessed falls occurred on 11/27/23 at 5:49 a.m., 1/1/24 at 6:45 p.m., 1/27/24 at 10:30 a.m., 1/29/24 at 1:20 p.m., 2/2/24 at 9:19 p.m., 2/26/24 at 4:49 p.m., 3/12/24 at 12:28 a.m., 3/15/24 at 4:50 a.m., 7/16/24 at 8:45 a.m., 7/25/24 at 10:01 a.m., 8/4/24 at 7:30 a.m., 8/14/24 at 3:30 a.m., 8/23/24 at 8:23 a.m., 8/29/24 at 5:25 a.m. Witnessed falls occurred on 2/16/24 at 5:20 a.m., 5/9/24 at 11:15 p.m., 7/16/24 at 7:44 p.m., and 7/21/24 at 8:46 a.m. On 9/6/24 at 1:08 p.m., during an interview the Director of Nursing (DON) said she did not see any documentation of new interventions added to the care plan following each fall, except for 1/1/24 when nonskid footwear was added, and 8/29/24 when a protective bumper was added to the sink and for the caregiver to assist Resident #16 with brushing his teeth because he has a history of falling near the sink. The DON said the facility fall report noted Resident #16 sustained 7 skin tears following a fall on 2/26/24. The care plan was updated on 2/27/24 and specified new interventions to use handrails and hand grips. The DON said, he would not be able to remember to do that intervention. The fall program encourages purposeful rounding which means frequent rounding. The DON said, short of putting someone 1:1 with him all the time I'm not sure what else we can do. The DON stated Resident #16 is not cognitive enough for new interventions. The only possible intervention would be one-on-one supervision, but we did not want to take away his independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility policy and procedure, and record review the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 3 (Residents #109, #31 and #62) of 3 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to anxiety, boredom, agitation, wandering and a decline in the residents' physical, mental, and psychosocial well-being. The findings included: The facility policy #1303 Activity Program (revised 7/1/23) documented Activity programs are designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. The activity programs are designed to support the well-being of residents and to encourage independence and community interaction. 1. Review of the clinical record revealed Resident #109 had an admission date of 2/9/24 with diagnoses including dementia, Parkinson's disease, anxiety, major depressive disorder and restlessness and agitation. The record documented Resident #109 had vision and hearing loss and a history of falls. On 9/3/24 at 9:50 a.m., Resident #109 was observed sitting in the television (TV) area on the unit, but he had no awareness of the TV program. He was noted to be restless, combative and was calling out. Certified Nursing Assistant (CNA) Staff F said the resident was often combative with care and attempts to climb out of the wheelchair unassisted. Staff F said the nurse had just given the resident medication to calm him down. At 3:40 p.m., the resident was observed sitting in the w/c in front of the TV and was speaking to himself, he was unaware of the program on the TV. Review of the activity calendar for 9/3/24 specified the activities for the day were BINGO at 10:00 a.m., Wellness Group at 11:00 a.m., [NAME] T entertainment at 2:00 p.m., and Bible study at 3:00 p.m. During random observations on 9/4/24 at 10:54 a.m., and 9/5/24 at 9:55 a.m., Resident #109 was observed sitting in the TV area and was noted to be restless, attempting to climb out of his w/c. He required frequent redirection from the staff for safety. The TV was on, but he showed no awareness or interest. Review of the activity calendar for 9/4/24 documented non-denominational church at 10:00 a.m., Crafts at 11:00 a.m., Room chats at 3:00 p.m., Poker at 5:45 p.m. The activity calendar for 9/5/24 documented 10:00 a.m., BINGO, 11:00 a.m., Port [NAME] AM Vet, 11:15 Darts, 2:00 p.m., Entertainment, 3:00 p.m., Room visits. 2. Review of the clinical record revealed Resident #31 had an admission date of 7/18/23 with diagnoses including dementia, Alzheimer's disease, major depressive disorder, post-traumatic stress disorder, unspecified mood disorder, hearing and vision loss. On 9/3/24 at 10:51 a.m., Resident #31 was observed sitting at the counter on the secured memory care unit. Music was playing but the resident was sleeping. Several other residents were seated at the counter and a staff member was seated behind the counter. Review of the activity calendar documented the following activities for the day with no designated times: Balloon exercise, Music and Poems, Joke of the day. At 2:00 p.m., Entertainment. On 9/4/24 at 11:02 a.m., Resident #31 was observed in his w/c sitting at the counter on the secured unit. No scheduled activity was in progress. Resident #31 smiled and made eye contact but did not respond when spoken to. CNA Staff C said the resident was Spanish speaking and spoke to him in Spanish, but he did not reply. CNA Staff C said the resident was able to speak when he wanted to and understands English. On 9/4/24 at 2:02 p.m., Resident #31 was seated at a table in the dining area of the unit, sleeping. Review of the activity calendar documented the following activities for the day: Non-Denominational Church, Exercise, Snoezeien and Nail Care. On 9/4/24 at 3:00 p.m., in an interview licensed practical nurse (LPN) Staff E said no one from activities was on the unit today during her 7 a.m., to 3 p.m., shift. Staff E said we play music and turn the TV on for them but no one from activities was here today on the unit. On 9/5/24 at 9:04 a.m., Resident #31 was observed sitting at the counter on the secured unit with a newspaper in front of him, but he made no attempt to hold it or look at it. Music was playing on a radio, but no structured activity was in progress. Review of the activity calendar specified the following activities for 9/5/24: Sit and be fit, Matching game, Room chats, 2:00 p.m., Entertainment, Socializing. 3. Review of the clinical record revealed Resident #62 had an admission date of 4/30/24 with diagnoses including Parkinson's disease, seizures, and vision and hearing loss. The record noted the resident's cognition was severely impaired. On 9/3/24 at 9:46 a.m., Resident #62 was observed sitting in a reclining chair in front of the TV with a group of other residents. CNA Staff F said the resident was blind only able to see shadows and hard of hearing. Staff F said the resident does not always comprehend when spoken to and did not keep his hearing aids in. At 2:48 p.m., Resident #62 was observed in the same chair in the TV area. The TV was on, but he was unaware and showed no interest. Review of the activity calendar for 9/3/24 specified the activities for the day were BINGO at 10:00 a.m., Wellness Group at 11:00 a.m., [NAME] T entertainment at 2:00 p.m., and Bible study at 3:00 p.m. During random observations on 9/4/24 at 9:50 a.m., and 2:28 p.m., Resident #62 was observed in the recliner in front of the TV. He was not able to hear or see the TV. There were no activities in progress. Review of the activity calendar for 9/4/24 documented non-denominational church at 10:00 a.m., Crafts at 11:00 a.m., Room chats at 3:00 p.m., Poker at 5:45 p.m. On 9/4/24 at 3:07 p.m., a joint interview was conducted with CNA Activity Staff A and CNA Activity Staff B. Staff A said there are 2 separate calendars one for the secured memory care unit and another one for the rest of the facility residents. She said for Resident #62 we do provide 1-1 visits for him and bring him out to music programs. Staff A confirmed she did not have the necessary credentials in therapeutic recreational activities as required. Staff A said I'm an Activity Staff member and I do activities. CNA Activity Staff B said we bring the residents who can attend the activity program to the activity room. We have someone stay with them while we get the rest of the residents and bring them in. Staff B said not everyone wants to attend or can attend the activity programs. Staff B confirmed there were no activities provided to the residents who were not able to attend the scheduled activity program. On 9/4/24 at 3:15 p.m., in an interview CNA Activity Supervisor Staff G confirmed no one in the activity department had the necessary credentials in therapeutic recreational activities. Staff G said, right now I am supervising what is done. We are short one activity staff who has been out sick. We can't always get to the secured unit and not everyone there can come off the unit or is able to participate in the activity. We do 1-1 room visits with the residents who are not able to come off the secured unit 1-2 times a week for 10 minutes. Staff G said, we are very short staffed right now and we don't have the time to do activities on the units or to follow the activity calendars. Staff G confirmed she did not do any special individualized activities for residents with vision and hearing loss. On 9/4/24 at 3:21 p.m., in an interview the Administrator confirmed the facility has not had a qualified Activity Director since 8/1/24. She said we are looking to hire someone. The Administrator said, we had a regional interim Activity Director here last week and she was here for the entire week to oversee everything. On 9/5/24 at 10:05 a.m., in an interview LPN Staff D said the activity department does activities at times on the secured unit. Staff D said they are short staffed so sometimes they do the activities but not every day. Staff D said the activity aids will come and take residents off the unit to different activities but said not all the residents could attend off unit activities. She said there were usually 4 residents who could attend the activities off the unit. Staff D confirmed that no activities were provided for the residents who could not go off the unit.

Based on review of the facility Position Description for the Activity Directory and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility. The findings included: The Position Description for the Activity Director Duties and Responsibilities specified, The Activities Director is responsible for the development, implementation, supervision and ongoing evaluation of the activity programs. Provides and properly documents an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well-being of each resident on a daily basis. On 9/4/24 at 3:15 p.m., in an interview, Activity Staff A confirmed she did not have the necessary credentials in therapeutic recreational activities as required. Staff A said I'm an Activity Staff member and I do activities. On 9/4/24 at 3:15 p.m., in an interview, Activity Supervisor Staff G confirmed no one in the activity department had the necessary credentials in therapeutic recreational activities. Staff G said right now I am supervising what is done. We are short one activity staff who has been out sick. We can't always get to the secured unit and not everyone there can come off the unit or is able to participate in the activity. We do 1-1 room visits with the residents who are not able to come off the secured unit 1-2 times a week for 10 minutes. Staff G said, we are very short staffed right now and we don't have the time to do activities on the units or to follow the activity calendars. Staff G confirmed she did not do any special individualized activities for residents with vision and hearing loss. On 9/4/24 at 3:21 p.m., in an interview, the Administrator confirmed the facility has not had a qualified Activity Director since 8/1/24. She said we are looking to hire someone. The Administrator said we had a regional interim Activity Director here last week and she was here for the entire week to oversee everything. On 9/6/24 at 5:15 p.m., in an interview, the Administrator said we had someone with the required necessary credentials in therapeutic recreational activities to oversee the activities program here last week for the entire week. The Administrator confirmed the staff member was on site for one week only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policies and procedures, and staff interviews, the facility failed to provide the appropriate supervision and assistance to prevent avoidable fall related accidents for 1 (Resident #16) of 7 residents identified as being at risk for falls and sustained falls with injury while at the facility. The findings included: The facility policy 5240, Fall and Fall Risk Management effective 5/15/24 effective 5/15/2017, documented The facility will ensure that the residents environment remains as free from accident hazards as possible and each resident receive adequate supervision and assistive devices to prevent accidents .A fall is defined as an unintentional coming to rest on the ground, floor or other lower level that is not the result of external force .Based on resident assessment, the facility will identify interventions related to the resident's specific risk and behaviors and develop a plan of care to try to prevent the resident from falling and to minimize complications if a fall does occur . Facility staff will identify appropriate resident specific interventions to reduce the risk of falls .The clinical team will monitor and document each residents response to interventions intended to reduce falls or the risk of falls .If a resident continues to fall, the clinical team in consultation with the physician will re-evaluate the situation and determine whether it is appropriate to continue and or change current information. Review of the clinical record showed Resident #16 was admitted to the facility on [DATE]. Resident #16's diagnoses included Parkinson's disease with Dyskinesia (uncontrolled involuntary muscle movement), unspecified dementia, other abnormalities of gait and mobility, tremor, unspecified, Insomnia. The admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 4/22/24 documented Resident #16 required the assistance of 1 person for supervision of transfers, ambulation and toileting. The MDS noted the Resident #16's cognitive status was moderately impaired. The care plan initiated on 4/15/22 identified Resident #16 as a fall risk, had falls, was at risk for falls due to poor safety awareness, forgetting to ask for assistance and had a history of falls with a hip fracture. Fall prevention interventions included to keep personal items within reach, keep call light within reach at all times, anti-roll backs on wheelchair. On 4/15/22 a fall risk assessment documented Resident #16 had a fall risk score of 17, indicating he was at risk for falls. A fall risk score of 10 or higher represents a high risk for falls. Additional fall risk assessments scored 18, and were completed on 3/14/24, and 6/10/24 which continued to indicate a high risk for falls. The facility fall record review revealed Resident #16 had 18 falls since 11/17/23. Unwitnessed falls occurred on 11/27/23 at 5:49 a.m., 1/1/24 at 6:45 p.m., 1/27/24 at 10:30 a.m., 1/29/24 at 1:20 p.m., 2/2/24 at 9:19 p.m., 2/26/24 at 4:49 p.m., 3/12/24 at 12:28 a.m., 3/15/24 at 4:50 a.m., 7/16/24 at 8:45 a.m., 7/25/24 at 10:01 a.m., 8/4/24 at 7:30 a.m., 8/14/24 at 3:30 a.m., 8/23/24 at 8:23 a.m., 8/29/24 at 5:25 a.m. Witnessed falls occurred on 2/16/24 at 5:20 a.m., 5/9/24 at 11:15 p.m., 7/16/24 at 7:44 p.m., and 7/21/24 at 8:46 a.m. On 9/05/24 at 9:07 a.m., Resident #16 was observed alone in his room, standing at the sink and brushing his teeth. There was no Certified Nursing Assistant (CNA) assisting him to brush his teeth per the care plan intervention added 8/29/24. On 9/5/24 at 9:08 a.m., CNA Staff I said she was assigned to Resident #16. She said, he [Resident #16] was in the dining room, but I don't know where he went. He falls easy, we are supposed to monitor him, but he likes to move around. On 9/5/24 at 9:15 a.m., Resident #16 said he fell a couple of weeks ago but was not able to explain how it happened. On 9/05/24 at 9:35 a.m. during an interview, Staff I, CNA said the staff checked on him every 2 hours. Resident #16 goes around in his wheelchair to the library, and the porch. We have to go find him. On 9/5/24 at 10:47 a.m., Resident #16 was observed in his wheelchair near the front door, leading to the lobby. He was rolling towards 300 unit without supervision. On 9/5/24 at 11:00 a.m., Resident #16 was observed in his wheelchair on the outside patio, no staff were observed in sight of him. On 9/6/24 at 1:08 p.m., during an interview the Director of Nursing (DON) said she did not see any documentation of new interventions added to the care plan following each fall, except for 1/1/24 when nonskid footwear was added, and 8/29/24 when a protective bumper was added to the sink and for the caregiver to assist Resident #16 with brushing his teeth because he has a history of falling near the sink. The DON said the facility fall report noted Resident #16 sustained 7 skin tears following a fall on 2/26/24. The care plan was updated on 2/27/24 and specified new interventions to use handrails and hand grips. The DON said, he would not be able to remember to do that intervention. The DON said Resident #16 complained of left rib pain on 8/22/24 and was sent to the emergency room for evaluation but not until 8/23/24. Resident #16 returned from the hospital with a new diagnosis of left 7th rib fracture. The fall program encourages purposeful rounding which means frequent rounding. The DON said, short of putting someone 1:1 with him all the time I'm not sure what else we can do. The DON stated Resident #16 is not cognitive enough for new interventions. The only possible intervention would be one-on-one supervision, but we did not want to take away his independence.

Based on Review of facility policy and procedures, record review, staff and resident interviews, the facility failed to have documentation of prompt efforts to resolve grievances expressed during resident council meetings. The findings included: The facility policy Resident Grievances documented The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The resident has the right and the facility must make prompt efforts by the facility to resolve the grievances the resident may have. The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Review of the resident council minutes for 2/21/23 showed documentation, Residents do not like it when staff speak in other languages. The resident council minutes for 3/21/23 noted in the old business section, Education being provided regarding only speaking English in the building. There was no documentation if the actions taken resolved the grievance. The form noted the Administrator, and the Social Worker were invited and attended the meeting. The Resident Council minutes for April 18, 2023 showed 17 residents attended the meeting. The Administrator, and the Social Worker were invited and attended the meeting. In the New Business, the form noted, Perception is on weekends there is not enough CNAs (Certified Nursing Assistants). There are currently 14 open CNA positions. On 5/31/23 at 10:30 a.m., during Resident Council meeting, attended by five residents, all residents in attendance said they have brought up the lack of adequate staffing to meet their needs and the failure of staff to respond to call lights in a timely manner in the last council meeting with no improvement, and no response from the facility's administration. Resident #34 said, The weekend staffing and the holidays are very short with little to no staff here. A few weeks ago the CNA told me he had 30 patients to care for. The issues I discuss don't reflect the real issues. They breeze over it and do not document it in the Resident Council minutes. If you complain about the care, they get mean and treat you badly. I have filed a grievance about the staff attitudes. I feel if the request is reasonable, they should do it but most of the time they don't. The Hoyer lift station in the rooms has been out of service at least four or five months. It is a necessity here. The staffing here has been an issue for the last year, they are always short staffed at night and on the weekends. It is terrible, you don't get the help you need. Resident #34 said the facility's administration does not address the concerns and the administrator does not show up to scheduled meetings to discuss the concerns. Review of the facility Grievance Log documented on 5/2/23 Resident #34 filed a grievance due to low staffing on 4/30/23. Resident #22 said the evening (3:00 p.m., to 11:00 p.m.) shift is the worst. He said, the staff have attitudes and don't care and are uneducated. They are short-staffed here and use agencies, they don't know us or what we need, and they don't answer the call lights. The facility does not address our concerns. The Administrator does not address our concerns. They need to put away the cell phones and take care of us. They are always on the phone here. Resident #94 said, the weekends are much worse. For me on the weekends sometimes they don't even get the medications right. He said during meetings, we report on the staff and the attitudes they have. They do not have enough staff here. They don't answer the call lights. I must go to the bathroom frequently and they don't want to come and answer my call light all the time. Their answer was to put a diaper on me. I don't want to wet myself and then sit in a wet diaper. I had to put three urinals hanging on my nightstand handle. That is how I solved the problem of no one coming to empty it. I'm a veteran and I deserve better. I told them about things, but they don't listen, they say I complain too much. Resident #13 said she had to wait over an hour before the call light was answered. She said, If I had a stroke or something I would be dead. They don't know what our problem is when we put the light on. They don't know if we need to use the toilet or if we had a fall. They are not answering the call light. It rings and rings and the staff on 3-11 are terrible. They ignore us on the 3-11 shift they don't keep an eye on you. They should not be allowed to use cell phones here at work unless on break. They sit on the phone all day. The call light is the biggest issue and sometimes the aides don't put it in your reach. The agency staff is the worst, they don't answer the call light. Last night they had a agency CNA and I waited an hour for the call light to be answered. They do not have enough staff here. The weekends and nights are the worst time, they will not answer the call light if you need help. Resident #399 said the facility was short staffed and staff are rude. He said, They retaliate against you if you report anything, they are mean to you. If you complain they just walk out and don't provide the care. When I need help, I need it. The resident said they don't answer the call lights, or they come in with an attitude. The group said staff do not answer the call lights. They turn the call lights off at the unit. The resident said they complain all the time. They said they report the concerns to the staff nurse and the Social Service Director. On 5/31/23 at 11:51 a.m., the Administrator said the process for grievances was the department who was responsible for the grievance would be given the grievance to resolve and the resident would sign it once it was resolved. The Administrator said some of the Hoyer lifts were broken and some were working. She said they were not functioning because they needed repair. On 6/1/23 at 9:09 a.m., the Director of Nursing (DON) said she was aware of the residents' concern brought up in Resident council meeting, including staffing. The DON said the Administrator attends Resident Council meetings and was aware of the staffing concerns. She said she has spoken to some residents individually. She said, I try to put two CNAs on each unit and one nurse. We have just received approval for a new hiring salary, and we have received several new hires/applicants. I try to staff to the acuity of the resident's care needs. If I have call offs or staff are a no show, I use an agency to ensure there are two CNAs on each unit this way one aide can be assisting a resident and the other can answer the lights. The nurses assist in feeding residents and answer call lights. The DON said, there is no policy on call lights, but the expectation would be the call lights were to be answered within 15 minutes. The DON said, the language of the facility is English, and they should not be speaking another language in front of the residents. The staff know they are not to use the cell phones when at work and no ear buds. On 6/1/23 at 9:20 a.m., the Human Resource Director said the staff are instructed upon hire they are not to be on the cell phones, and they are to speak English. She said It is in the new hire packet, and I review it with them. On 6/1/23 at 9:23 a.m., the Activity Director (AD) said she has been employed at the facility for four weeks. The AD said I just had my first Resident Council meeting with the residents and the Social Service Director (SSD). The SSD types the minutes from the meeting. I start with food/dietary concerns first. I do a review of the previous minutes and concerns that is the second step and then we discuss new business. The AD said the process is for Resident Council concerns was the concern gets reviewed by me and then in morning meeting I review the concerns with the other department heads. The concerns then go to the Administrator. The AD said the facility Care and Concern forms and Grievances are completed by the SSD. The AD said, I can tell you staffing issues have been a concern with the Resident Council since I started here. On 6/1/23 at 10:44 a.m., the Social Service Director said the Resident Council did voice complaints about the staffing needs in the facility. The SSD confirmed she records and types the minutes from the Resident Council meetings and said the concerns with the call lights were brought up in one-to-one meetings with residents that the staff are slow to respond to the call lights. The SSD said she was responsible to follow up with the residents to ensure the grievances are resolved. The SSD had no documentation of actions taken, and responses to address the concerns voiced by the resident council group.

Based on observation, resident and staff interview and record review, the facility failed to provide sufficient and consistent nursing staff to meet the needs of 5 residents (Resident #13, #22, #34, #94, #399) of 5 residents sampled. The failure to maintain sufficient and consistent staffing, resulted in the inability of nursing staff to respond to call lights and provide nursing related services to the residents to maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: The facility policy #8702 Staffing Guidelines Per Resident Per Day (revised 3/20/17) documented The facility will provide sufficient nursing staff on a 24-hour basis to provide nursing and related services to residents as determined by resident assessment and individualized resident care plans. On 5/31/23 at 10:30 a.m., during Resident Council meeting, attended by five residents, all residents in attendance said they have brought up the lack of adequate staffing to meet their needs and the failure of staff to respond to call lights in a timely manner in the last council meeting with no improvement, and no response from the facility's administration. Resident #34 said, The weekend staffing and the holidays are very short with little to no staff here. A few weeks ago, the CNA told me he had 30 patients to care for. The issues I discuss don't reflect the real issues. They breeze over it and do not document it in the Resident Council minutes. If you complain about the care, they get mean and treat you badly. I have filed a grievance about the staff attitudes. I feel if the request is reasonable, they should do it but most of the time they don't. The staffing here has been an issue for the last year, they are always short staffed at night and on the weekends. It is terrible, you don't get the help you need. Resident #34 said the facility's administration does not address the concerns and the administrator does not show up to scheduled meetings to discuss the concerns. Review of the facility Grievance Log documented on 5/2/23 Resident #34 filed a grievance due to low staffing on 4/30/23. Resident #22 said the evening (3:00 p.m., to 11:00 p.m.) shift is the worst. He said, the staff have attitudes and don't care and are uneducated. They are short-staffed here and use agencies, they don't know us or what we need, and they don't answer the call lights. The facility does not address our concerns. The Administrator does not address our concerns. They need to put away the cell phones and take care of us. They are always on the phone here. Resident #94 said, the weekends are much worse. For me on the weekends sometimes they don't even get the medications right. He said during meetings, we report on the staff and the attitudes they have. They do not have enough staff here. They don't answer the call lights. I must go to the bathroom frequently and they don't want to come and answer my call light all the time. Their answer was to put a diaper on me. I don't want to wet myself and then sit in a wet diaper. I had to put three urinals hanging on my nightstand handle. That is how I solved the problem of no one coming to empty it. I'm a veteran and I deserve better. I told them about things, but they don't listen, they say I complain too much. Resident #13 said she had to wait over an hour before the call light was answered. She said, If I had a stroke or something I would be dead. They don't know what our problem is when we put the light on. They don't know if we need to use the toilet or if we had a fall. They are not answering the call light. It rings and rings and the staff on 3-11 are terrible. They ignore us on the 3-11 shift they don't keep an eye on you. They should not be allowed to use cell phones here at work unless on break. They sit on the phone all day. The call light is the biggest issue and sometimes the aides don't put it in your reach. The agency staff is the worst, they don't answer the call light. Last night they had a agency CNA and I waited an hour for the call light to be answered. They do not have enough staff here. The weekends and nights are the worst time, they will not answer the call light if you need help. Resident #399 said the facility was short staffed and staff are rude. He said, They retaliate against you if you report anything, they are mean to you. If you complain they just walk out and don't provide the care. When I need help, I need it. The resident said they don't answer the call lights, or they come in with an attitude. The group said staff do not answer the call lights. They turn the call lights off at the unit. The resident said they complain all the time. They said they report the concerns to the staff nurse and the Social Service Director. On 6/1/23 at 9:23 a.m., in an interview the Activity Director (AD) said this was her fourth week here at the facility. The AD said, I can tell you staffing issues have been a concern with the Resident Council since I started here. On 6/1/23 at 10:44 a.m., in an interview the Social Service Director (SSD) said the Resident Council did voice complaints about the staffing needs in the facility and the staff are slow to respond to the call lights. On 6/1/23 at 9:09 a.m., in an interview with the Director of Nursing (DON) said she was aware the residents had concerns with staffing. The DON said I have spoken to some of the residents one to one regarding the staffing issues. The DON said, the Administrator and I are aware of the residents' concerns regarding staffing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, review of facility policy and procedures and resident and staff interviews, the facility failed to develop and implement resident centered care plan and interventions to ensure the residents individualized behavioral health needs were met for 1(Resident #14) of 2 residents reviewed with Post Traumatic Stress Disorder (PTSD). The findings included: The facility policy 8516, Trauma Informed Care documented, The facility will develop, implement and maintain an ongoing facility wide program to ensure that the residents identified as trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful threatening and lasting adverse effects on the individuals functioning and physical, social, emotional or spiritual well-being. Trauma informed care is an approach to delivering care that involves understanding, recognition and response to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into policies, procedures and practices to avoid re-traumatization. Based on results of the information gathered by clinical team, a plan of care will be developed by the interdisciplinary team to address the needs of the resident. Review of the clinical record for Resident #14 showed an admission date of [DATE] with diagnoses including Lewy Bodies Dementia, insomnia, left below knee amputation and major depressive disorder. The clinical record for Resident #14 revealed a Trauma Informed Care Screening dated [DATE] completed by the Social Services Director. The form documented Resident #14 had experienced an event that was frightening, horrible or upsetting. The following questions were asked: Have you ever served in a active combat zone where you may have been injured or witnessed causalities? - yes. Have you ever experienced a major disaster such as but not limited to fire, tornado, hurricane, flood, or earthquake? Yes, hurricane [NAME]. Do you recall ever having been attacked, beaten, or mugged? -yes. Any traumatic event not listed above? - yes fell in a swamp, witnessing [NAME] and shootings, killing the enemy during Vietnam war. When experiencing periods of distress what symptoms are present? - flashbacks and nightmares. What contributes to you feeling distress (triggers)? - War movies. Care plan developed? - yes. Review of the care plan for resident #14 showed no documentation of a care plan to address the resident's symptoms of trauma and interventions to avoid re-traumatization. Review of the Psychiatry Consultation dated [DATE] documented the resident's chief complaint I'm depressed. Review of the psychiatry progress note dated [DATE] documented the resident's mood was depressed. The patient is with decreased impulse control. The diagnosis for the visit was major depressive disorder, recurrent severe without psychotic features and unspecified dementia with agitation. On [DATE] at 12:56 p.m., Resident #14 said he served 20 years in the [NAME] Corps. I was in Vietnam. I did reconnaissance, one shot one kill. We were the first ones in and the last ones out. I have PTSD and depression. I had a buddy, and we were going on furlough. I was supposed to go to [NAME] Kong, and he was to go to another area. He asked me to trade with him and on the way back from the furlough, the plane went down, they all died, and it should have been me. Now his name is on the Vietnam Memorial Wall, and it should have been me, my name should be on the wall not his. He was young, a really nice kid, I was 17 and he was younger. The resident said, we killed a lot of people more than in the picture, even women and children, you did what you had to do. Resident #14 was tearful, opening and closing his right hand, making a fist anxiously. He was rocking back and forth in his wheelchair using his right leg. He said, sometimes I just have to keep moving to forget about things for a while. No one here believes me about the things I've seen, no one talks about it. He said he did attend some activities and enjoyed playing bingo. On [DATE] at 10:55 a.m., the Social Service Director (SSD) said Resident #14 had PTSD and mental health care needs. The SSD said Resident #14 has depression and emotionally eats. He wants to go home, but his wife is not able to care for him, we did discuss his goals for a return home for him and his options. The SSD said we have a trauma informed screen here for PTSD and when completed we look at medications and review the documentation provided for medical and psychiatric history and develop a care plan. The SSD said I look for resources for the resident with PTSD, we develop a care plan and identify their flash backs and triggers what can send them into a PTSD episode. I ask them what they do for healthy coping strategies, and it is in the care plan as well. It could be certain music, quite time or cognitive behavioral therapy I do that as well. I am responsible for finding out the triggers are for the residents. I have identified triggers for Resident #14, he said war movies were a trigger and he has flash backs and nightmares due to combat in Vietnam. The resident said Hurricane [NAME] was disturbing to him as well. Once I identify the trigger, I develop a trauma informed care plan. The SSD was not able to provide a copy of a care plan addressing Resident #14's behavioral health needs. She said, I do not see a trauma informed care plan for him. I don't see where I developed one, I will have to add one. The SSD confirmed she had not developed and implemented a trauma informed care plan for Resident #14.

Based on observation, record review, and staff and resident interviews, the facility failed to ensure 1(Resident #69) of 1 resident reviewed for accidents was assessed for alternative interventions prior to the use of bed rails. In addition, the facility failed to have ongoing routine maintenance of the bed rails. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: On 10/4/21 at 3:18 p.m., during an observation Resident #69 had 1/4 bed rails raised on both sides of the bed. The same observation was made on 10/5/21 at 11:14 a.m. On 10/6/21 at 9:08 a.m., a review of the clinical record showed an admission date for Resident #69 of 9/16/20. A Bed Rail Assessment form with a date of 10/29/20, documented resident demonstrated ability to independently operate bed rails up and down on both sides of the bed. No alternative interventions were documented before the bed rails were placed. The record showed Bed Rail Assessment forms were completed on 6/22/21 and 9/21/21 with no documentation of alternative interventions for the use of the bed rails. On 10/6/21 at 9:46 a.m., in an interview, Registered Nurse (RN) Staff B said the process for side rails and halo assist devices was, the resident would be screened by therapy and the therapist would make the determination to use the bed rail or halos. RN Staff B said nurses did not assess the residents for side rails or halo devices. On 10/6/21 at 10:00 a.m., in an interview, the Regional [NAME] President (RVP) of Therapy said residents were screened upon admission for use of the halo devices and bed rails, if they had a device, then they were screened quarterly. The RVP said she did not know what alternatives were attempted prior to the bed rails for Resident #69, he was assessed for mobility and required the rails to assist him. On 10/6/21 at 10:46 a.m., in an interview, the Occupational Therapist (OT) said the alternatives attempted prior to the use of bed rails were completed only on admission and the quarterly screens were used to determine if the bed rail or halo device was still appropriate. On 10/6/21 at 12:00 p.m., during an observation and interview, Resident #69 said he never asked for the bed rails to be used but he did use it to hang things from. The resident had a flashlight and a yellow mesh bag that contained personal items tied to the bed rail. The pull string to the overhead light was tied to a hanger and then wrapped around the bed rail. There were additional personal items hanging from the bed side rail. Resident #69 said, if I put the head of the bed up and the side rail is down, then my papers fall off the bed, so I keep the side rails up. Resident #69 had stacks of personal papers stuffed between the side rails and mattress. Resident #69 said he was not afraid of falling out of the bed and said he used the bed rail once in a while to pull himself up but can get up without them. On 10/7/21 at 10:04 a.m., the Director of Nursing (DON) provided a maintenance log that showed a Facility Wide Bed Safety Check form with a date of 1/13/21 and 2/18/21. The DON confirmed the bed rail log did not contain documentation the side rails were checked after 2/18/21. On 10/7/21 at 11:19 a.m., in an interview, Maintenance Worker Staff A said he did not check the bed rails, the Maintenance Director was responsible, but he had been on leave for several months. Maintenance Worker Staff A said he did not know when the bed rails were checked, or how often.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1(Resident #10) of 4 residents reviewed for dementia and mental health care needs. This led to Resident #10 being sent to the hospital under the [NAME] Act (allows people with a mental illness to be held for 72 hours in a mental health facility). The findings included: The facility policy number 1607, [NAME] Act Transfer (revised 10/18/17) documented, The staff of the facility will make every effort to provide appropriate psychiatric interventions in an attempt to avoid referrals to a receiving facility. However, if all appropriate on-site interventions prove ineffective and are fully documented in a resident's record, a referral to a [NAME] Act receiving facility may be necessary. On 10/5/21 a review of the clinical record for Resident #10 showed an admission date of 4/22/21. Resident #10's diagnoses included urinary tract infection, altered mental status, advanced dementia, and Alzheimer's disease. A Brief Interview for Mental Status completed on 4/22/21 documented a score of 7, indicating severe cognitive impairment. The care plan for Resident #10 identified, resident might perceive that his daily routine was very different from prior patterns. Interventions specified, Refer to psych interventions and other supportive services if needed. A review of the progress notes for Resident #10 revealed the following: The activities progress note dated 4/26/21, documented Resident #10 was a very pleasant resident who loved to talk about his past jobs and where he used to live. The Interdisciplinary team note on 4/26/21, documented the team completed a phone care plan with daughter. Resident appeared to be happy with no complaints. The nursing progress note on 5/2/21 at 1:00 p.m., documented Resident #10 wandered off the unit where he was located around lunch time as he was heading to lunchroom, resident was normally confused and frequently redirected. He continued walking and went past the dining room to [NAME] unit. Staff immediately went looking for resident when he was not seen in the dining room and found him sitting at table in [NAME] 1. Assessment was done no mental/cognitive changes noted. On 5/3/21 at 11:02 a.m., the nursing progress note documented resident walked around Alpha looking around, confused, encouraged to sit in recliner and relax, resident agreed. On 5/3/21 at 9:33 p.m., documented Resident #10 was confused, sitting on side of bed. said he had to sit there because he had no chair to sit on, pointed to a chair on the other side of his bed and he said it wasn't his, assured him that it was. He then made a sound like the chair was possessed or something. On 5/10/21 at 10:10 p.m., resident was up in day room most of the shift. Confused, saying he was waiting for a bus to take him to worksite. Reminded him he was retired and didn't go to work. On 5/15/21 at 6:05 p.m., nursing progress note documented resident confused to time and place, wandered to the [NAME] unit, and redirected by this staff, call to daughter as well as his brother, he spoke with them and stated wanted to leave, staff made aware and close monitoring in progress. On 5/18/21 at 9:23 p.m., nursing progress note documented Resident alert but confused, friendly most of the time but did have occasional anger outbursts. Like tonight he couldn't find his room and was arguing with Certified Nursing Assistant that another resident's room was his room. On 5/20/21 at 8:02 p.m., the nursing progress note documented friendly most of the time but did have occasional outbursts. Resident was not found in his room or common areas, was found in another resident's room. On 5/23/21 at 7:46 p.m., documented confused, could not remember where he was. Friendly most of the time but occasional anger outbursts. On 5/27/21 at 11:16 a.m., the registered nurse documented, approached resident while he stood in doorway of room and offered a mask if he was coming out of room. Resident looked outside of room to both sides of doorway, stated they took the belt and returned to his room. Heard loud talking 5 minutes later and observed resident lying on his right side in bed calling out to get me to the hospital. When writer approached resident, resident kicked writer in left hip. Social Worker then approached resident and resident grabbed her wrists and adamantly stated he wanted to go to the hospital. Resident then placed himself on the floor on side of bed. Resident refused assistance to get up and threatened to hit and kick staff. 911 was called. Ambulance and Sheriff responded, sent to hospital for evaluation and treatment. On 5/27/21 at 11:37 a.m., Licensed Clinical Social Worker (LCSW) documented notified by unit that resident physically violent, trying to harm staff. LCSW went to unit, visually saw resident physically violent. During his attempts, he hurt right wrist/hand area. Resident unable to focus any conversation with the writer. LCSW alerted Administrator and then 911 who sent police and ambulance. On 10/6/21 at 11:40 a.m., in an interview, the Registered Nurse Risk Manager said Resident #10 had an acute change in his mental status on 5/18/21 and began to exhibit behaviors. The Risk Manager (RM) said, we do not notify the Physician for every behavior or change in a resident. The RM confirmed the Physician was not notified of Resident #10's ongoing change in behaviors. The RM said they did not make a psychiatric referral for Resident #10 because he did not have any behaviors until 5/18/21. The RM said, we do not have a psychiatrist on site, it could take 1-2 weeks or more before they are seen. The RM said on 5/27/21 Resident #10 was a risk for harming himself and others, you cannot do 1-1 or other interventions, you need to keep the resident safe from harm, it is the main priority. The RM confirmed there was no documentation of interventions provided to Resident #10 to address his behaviors prior to the [NAME] Act. On 10/6/21 at 11:45 a.m., in an interview, LCSW said, Resident #10 had an acute change and I never saw anyone like that before. He was harming himself and others. I made the decision to [NAME] Act him, I did not get a physician order for that because I can [NAME] Act residents, I do it all the time. The LCSW confirmed a Physician order documented, send the resident to the hospital for eval and treatment. The LCSW said, that is what we did. I [NAME] Acted him because we needed the police and EMS to do it because Resident #10 was combative and out of control. 911 and EMS were needed to subdue him. The LCSW confirmed there was no documentation of interventions attempted to address Resident #10's behaviors prior to the [NAME] Act on 5/27/21. The LCSW said the interventions attempted were documented in the care plan for Resident #10, the care plan was the intervention.