**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect four of 19 residents (R) (R200, R60, R66, and R73) right to be free from physical abuse by R154 and R160. Specifically, the facility failed to ensure R60 was free from physical abuse by R160 resulting in scratches on the face and R154's abuse towards R66 that resulted in actual harm when she sustained a sprained ankle and required an emergency room (ER) visit where an ankle immobilizer was initiated. R154's abuse towards R73 resulted in psychosocial harm using the reasonable person concept when dragged and pinned to the floor by R154. Findings include: Review of the facility's Abuse, Neglect, and Exploitation, policy dated 4/2024 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R154 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies and dementia. R154 was discharged on 4/1/2025; his closed record was reviewed. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/2024 in the EMR under the MDS tab revealed R154 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) of four out of 15 indicating severe cognitive impairment. R154 required supervision or partial/moderate assistance with most activities of daily living (ADLS). R154 exhibited physical behaviors toward others and verbal behaviors towards others one to three days during the assessment period. Review of the EMR 2024 Progress Notes revealed the first incident involving R154, occurred on 1/18/2024 in when R154 grabbed R200 by the back of the neck and pushed her. Review of the undated admission Record in the EMR under the Profile tab revealed R200 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. R200 was discharged on 2/9/2024. R200's closed record was reviewed. Review of R200's Care Plan dated 12/31/2021 revealed R200 was confused and required redirection. In addition, R200 was documented with behavior problems including spending most of her day wandering throughout the unit and into other residents' rooms. R200 had an ADL self-care deficit and required assistance with some ADLs. Review of the facility's Five Day Investigation, dated 1/24/2024 and provided by the facility, revealed R200 had diagnoses including Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. R200 was impaired in short- and long-term memory, and decision-making. R200 wandered on the secure unit without the use of assistive devices. The investigation revealed, On 1/18/2025 [name] charge nurse [Licensed Practical Nurse (LPN)16], who oversees the care of [R200] states that she observed [R154] get up from his wheelchair and grab [R200] by the shoulder at the base of her neck and push her. She did not fall. The residents were separated, and [R200] was moved to safety with no apparent injuries. The Responsible Party for both [R154] and [R200] were notified of incident. The MD [physician's name] was notified . A 1013 [psychiatric hold detaining someone experiencing a mental health crisis for an involuntary psych evaluation and treatment within 48 hours] was received from the MD and [R154] was sent to [hospital name] ER [emergency room] for a psych evaluation. The family [sic] were notified. Social Service Director spoke to [name] [ER charge nurse] due to resident's behavior. Law enforcement was notified for transportation. NP, MD, Psych NP, and Ombudsman were also notified of the incident. Both resident's care plans were updated. Upon [R154's] return to the facility, a 30-day discharge notice will be immediately presented due to concerns of safety for himself and the other residents . Review of the staff Witness Statement dated 1/18/2024 from LPN16 revealed, Resident [R154] observed grabbing another resident [R200] by the neck and shoving her, resident [R200] did not fall. LPN16 was not employed at the facility at the time of the survey and was not available for interview. Review of the behavior Care Plan dated 3/1/2023 in the EMR under the Care Plan tab revealed, Per behavior monitoring and nurse notes, resident struggles with yelling, wandering, rejection of care, verbal aggression, and physical aggression. The goal was, [R154] will have less refusal during the next review period. The behavior Care Plan was updated on 1/23/2024 with, On 1/18/2024 Resident grabbed fellow female wandering resident by her shoulders pushing her out of his room. [On] 12/30/2024 Aggressive outburst towards female staff grabbing her neck. The goal was, Resident will not injure self or others when agitated thru [sic] review date. Interventions included, [R154] was sent to [name] hospital for a psych eval. MD, Psych NP, and NP was notified dated 1/23/2024 . b. The second incident involving R154 occurred on 12/26/2024, when R154 pushed R66 down to the floor and R66 sustained a sprained ankle as follows: Review of the undated admission Record in the EMR under the Profile tab revealed R66 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. Review of the annual MDS with an ARD of 2/18/2025 in the EMR under the MDS tab revealed R66 was rarely or never understood. The BIMS test was not conducted. R66 exhibited wandering behavior for four to six days during the assessment period. R66 was dependent on most ADLs. Review of the facility's Five Day Investigation dated 1/2/2025 revealed that on 12/26/2024, [R66] is a . female . Her diagnosis includes Alzheimer's disease and dementia with short- and long-term memory impairment. [R66] ambulates on the unit and often wanders into other residents' rooms. Her BIMS is 99. [R154] is a . male . His diagnosis includes neurocognitive disorder with Lewy bodies, dementia . severe with other behavioral disturbance . His BIMS is a 4. Investigation: [R66] wanders aimlessly with an unsteady gait about the unit. She is not aware of other's personal space or their personal items. At 1520 [3:20 PM] during shift change, .NA [nurse aide] observed [R154] sitting in his wheelchair outside his room when [R66] approached him. She [NA] was unable to intervene due to the distance between her and the two residents. She witnessed [R154] grab [R66] by her right arm, turn her around and push her in an attempt to redirect her . When she [R66] was attempting to ambulate, it was noted that she was unable to bear weight on her right leg and was placed into a wheelchair . NP [nurse practitioner] was notified and gave orders for [R66] to be transferred to the hospital for x-rays. RP [responsible party] notified . 911 was called . The Resident was transferred via stretcher to [name] hospital at 1614 [4:14 PM]. The . Police Department was notified with officer [name] responding to the facility . [R66] returned from the hospital at 2225 [10:25 PM] via stretcher. She was noted to have an immobilizer to her right ankle with a diagnosis of sprained ankle . She received a new order for cephalexin [antibiotic] . and trazadone [antidepressant] . A trauma assessment was completed for both residents. Both are followed by psychiatric services. Both of their care plans were updated. Actions put in place: The staff on Heritage Hall have been educated on close monitoring of the resident and to engage [R66] in activities during periods where she wanders into the space of others [R154] received a new order for Divalproex Sodium [anticonvulsant medication] . for impulse control. Review of a staff Witness Statement by Certified Nurse Aide (CNA)5 dated 12/26/2024 revealed, Yes I see [sic] [R154] turned around and push [R66] down to the floor. Other witness statements corroborated this statement. CNA5 was not available for interview during the survey. Review of R154's Behavior Care Plan dated 3/1/2023 in the EMR under the Care Plan tab revealed new interventions of 12/26/2024 - Consult psychiatric to eval and treat. 12/26/2024 - medication review and adjustment. 12/26/2024 - Staff to redirect resident behavior when observed aggression towards peers. c. The third incident involving R154 occurred on 4/1/2025, when R154 dragged R73 by her arm/sweater out of his room and pinned her down on the floor in the hallway and would not let her go until staff came and intervened. Review of the undated, admission Record in the EMR under the Profile tab revealed R73 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder and aphasia (language disorder affecting the ability to communicate). Review of the admission MDS with an ARD of 2/24/2025 in the EMR under the MDS tab revealed R73 was rarely/never understood, was severely impaired in decision making, and was impaired in memory. The BIMS test was not attempted. R73 exhibited wandering behavior one to three days during the assessment period. R73 was 5'2 tall and weighed 145 pounds. Review of the facility's Five Day Investigation dated 4/8/2025 and provided by the facility revealed, [R73] was observed by staff being dragged by a male resident out of his room with him holding onto her arm/sweater. Both parties were separated to different locations. Upon skin assessment, half of dollar discoloration noted to [R73's] left upper arm, and some redness was noted on her back with no open area. Range of motion was done with no limitation to all extremities and no pain or discomfort. The resident was assisted into her wheelchair with assist x2. Neuro check initiated per facility protocol with no changes in mental status. Administration, [psychiatrist], and RP notified . A trauma assessment was completed for [R73] There were no negative findings . Both of their care plans were updated. Actions put in place: Staff remained with [R154] until he left. [R154] was 1013'd and left facility on 4/1/2025 accompanied by officers x4 to [name] hospital with paperwork and bed hold policy. Upon departure, the resident was alert and oriented x3 with some forgetfulness. No bruise or open areas noted. He has not returned. Review of the Witness Statement dated 4/1/2025 for CNA4 provided by the facility read, I was standing at the nurses station I heard commotion down the hall. I saw resident [R154] dragging [R73] out the room and he had her pinned on the floor by her arms and shirt and did not let her go until me [sic] and other staff approached him and then he got verbally abusive after that. During an interview on 6/25/2025 at 8:37 AM, the Psychiatrist stated R154 was agitated and aggressive and had continued behavior during his stay. The Psychiatrist stated R154 was a veteran and exhibited symptoms of post-traumatic stress disorder (PTSD), stating R154 had been violent at home prior to admission. The Psychiatrist stated R154 got agitated when residents came into his room unannounced. The Psychiatrist stated R154 came in on Seroquel (antipsychotic medication) but had no history of mental illness warranting the medication, so it was discontinued, and Depakote was initiated for impulse control. The Psychiatrist stated non-pharmacological interventions were initiated including videos of his family and military service that were played on this TV. The Psychiatrist stated R154 abused residents, was an imminent threat and that was why he was sent on the 1013 holds. During an interview on 6/25/2025 at 9:12 AM, Certified Medication Aide (CMA), who also worked as a CNA, stated R154 did not want anyone in his room. CMA stated R154 yelled and screamed and was both verbally and physically aggressive with staff. CMA stated the main intervention was to redirect other residents if they were going towards his room which worked some of the time. CMA stated she witnessed the incident between R154 and R200. CMA stated R154 grabbed R200 by the back of her neck and pushed her out of his room. CMA stated R200 screamed and cried when the incident occurred. CMA stated R200 was significantly cognitively impaired and did not know she should avoid R154. CMA stated she did not remember R154 having increased supervision or being put on one-to-one supervision after this incident or the other ones. During an interview on 6/25/2025 at 12:11 PM, LPN6 stated she worked in the Heritage unit during R154's entire stay in the facility. LPN6 stated R154 was originally admitted to the Heritage unit and was later transferred to [NAME] hall but started exit seeking and he was brought back to Heritage unit. LPN6 stated R154 was capable of doing ADLs with supervision and he could walk. LPN6 stated R154 was alert and could express his needs; however, expressed some confusion about events and needs. LPN6 described R154 as being irritable and confrontational and he did not like wanderers. LPN6 stated if residents tried to wander in his room, R154 would try to get them out by whatever force. LPN6 stated there were quite a few residents on the Heritage unit that wandered. LPN6 stated these residents were redirected out of R154's space and offered diversional activities. LPN6 stated she was working when the incident on 12/26/2024 with R66 occurred. LPN6 stated when she came to the scene, R66 was lying on the floor and R154 was in the area. LPN6 stated R66 was startled and was later diagnosed with an ankle sprain after having difficulty walking. LPN6 stated staff were cautious around R154 and stated R154 had the potential to be a threat to residents. LPN6 stated R154's room was at the very end of the hallway. During an interview on 6/25/2025 at 1:08 PM, the Social Service Director (SSD) and Social Service Assistant (SSA) who were interviewed together stated R154 could be verbally and physically aggressive and spent most of his time in his room or in his doorway. The SSD stated R154 did not like people in his space and most of the incidents with other residents were a result of other residents coming into his room. The SSD stated her role in investigations of abuse was to complete trauma assessments after the incident and to check on the residents. The SSD stated all three of the residents (R66, R200, and R73) were severely cognitively impaired and would not remember the incidents after they occurred, indicating they were negative on the trauma screens. During an interview on 6/25/2025 at 3:01 PM, CNA4 stated R154 did not want other residents in his room and cursed at them if they tried to come in or tell them to get out. CNA4 stated it was normal to have wandering residents on the Heritage unit. CNA4 stated she witnessed the final incident on 4/1/2025 between R154 and R73. CNA4 stated she observed R154 in a standing position dragging R73 out of his room and then holding her down on the floor in the hallway. CNA4 stated R154 sat down in the hallway with his leg pinning R73 down on the floor. CNA4 stated several staff ran down there to make R154 let go of R73 and R154 cursed at the staff and let go of R73. CNA4 stated R73 does not talk but she was crying and upset when the incident occurred. CNA4 stated staff took R73 to her room and staff stayed with R154 until he was taken by the police to the hospital. CNA4 stated staff were to redirect R154 or walk away when became aggressive towards them and were to redirect residents who wandered near or into R154's room. CNA4 stated she was physically assaulted by R154 once when she was in R154's room and tried to leave the room. CNA4 stated R154 stood up from his wheelchair, blocked her from leaving his room and grabbed her neck, popping her necklace. CNA4 stated she yelled for help and was able to pry R154's hands from her neck when two other staff entered the room to assist. CNA4 stated R154 was strong, had been in the military, and stated he tried to choke her. During an interview on 6/25/2025 at 4:16 PM, the Administrator verified she was the abuse coordinator. The Administrator stated she had spoken with the Medical Director about discharging R154 and the 30-day notice for discharge was issued on 1/29/2024. The Administrator stated R154 had incidents of aggressive behaviors and posed a safety concern. The Administrator stated the normal process was for the unit manager and the SSD to talk with the family and see what area specific facilities a referral would be sent to. The Administrator stated she would not have handled referrals and placement. There should have been documentation about efforts to find placement after 30-day notice was issued. The Administrator stated R154's behavior had improved after the 30-day notice was issued. The Administrator stated the final incident on 4/1/2025 resulted in the daughter of R73 being afraid for R73 to remain in the facility on the unit with R154. A decision was made to issue the immediate discharge notice on 4/1/2025 due to the fear that R154 was going to hurt someone. The discharge notice was issued on 4/2/2025 after speaking with the Medical Director. During an interview on 6/25/2025 at 6:24 PM, Family Member (F)1 stated he and one other family member were next of kin for R154. F1 stated he was aware of R154's aggressive incidents towards other residents and did not condone this behavior. F1 stated that residents roamed freely on the Heritage unit and family had observed many instances of other residents entering or trying to enter R154's room. F1 stated R154 kept his door shut to keep people from coming into his room. F1 stated, From our perspective they do not have control of roaming patients. This does not seem right. 2.Review of the Census tab in the EMR revealed R60 was admitted on [DATE]. Review of the Med Diag tab in the EMR revealed R60 had diagnoses including paraplegia and complete lesion of the C5, C6, and C7 level of cervical spinal cord Review of the Care Plan under the Care Plan tab in the EMR revealed R60 had a focus with interventions related to C5-C7 lesion of the spinal cord initiated on 2/24/2022. A focus with interventions related to restorative nursing for passive range of motion as tolerated was initiated on 1/24/2025. A focus with interventions related to paraplegia with complaints of pain/spasm to bilateral extremities initiated on 2/24/2022. Review of a quarterly MDS with an ARD of 12/1/2024 under the MDS tab in the EMR revealed R60 had a BIMS score of 15 out of 15 indicating no cognitive decline. R60 was impaired on both arms and both legs. In an interview on 6/24/2025 at 5:10 PM, R60 stated he remembered R160 well. R60 stated R160 was a good roommate for the longest time and then changed one day. He stated they were talking about stuff one day and then R160 said to him, Shut up or I will kick your ass. R60 stated he immediately became and remained silent because he was a little freaked out by the statement. R60 stated R160 came over and punched him on his ear, cheek, and across his nose. Observation of R60 indicated he was unable to move his arms. Review of a communication note dated 1/3/2025 under the Prog Note tab in the EMR revealed, resident alert and verbal . Being monitored for altercation with roommate. He was hit in the face by his roommate. No active bleeding noted at this time, no swelling, or c/o voiced. Call light in reach. Review of a communication note dated 1/3/2025 under the Prog Note tab in the EMR revealed, spoke with resident RP .[granddaughter] via phone whom [sic] called back concerning 1/2/2025 physical incident with resident and resident roommate. Resident RP made aware of full details of incident and well as resident current status. Plan of care ongoing safety maintained. Review of a communication note dated 1/7/2025 under the Prog Note tab in the EMR revealed, attempt made to call resident RP .[granddaughter] via phone. No answer. Voicemail full. Call was concerning resident request to press charges on former roommate for incident on January 2nd, 2025. The local police dept. contacted and resident made aware an officer will be in to receive his statement. will attempt to contact RP again. Review of a nurse note dated 1/2/2025 under the Prog Note tab in the EMR revealed, it was reported that resident [R160] verbally assaulted his roommate [R60], resident was immediately removed from room, Resident denied incident and took no accountability for alleged incident. Nursing supervisor made aware. 911 was contacted, resident RP contacted, and Tele med notified. Resident removed from room with belonging to room [room number] until further investigation. Plan of care on going, and safety maintained. A nurse note dated 1/2/2025 revealed, Resident [R160] left his room, sat next to the ice cooler in the hallway for a long time before we found out that he assaulted the roommate [R60], when asked what happened he denied ever touching the roommate, when asked to move out of the room, he refused, the police was called in, we all wrote down our statements and gave them, Meanwhile he [R160] has been transferred to room [room number]. His sister came to the facility to talk with him. Review of the facility self-report to the State Agency revealed that on 1/2/2025 the charge nurse was passing meds when staff asked her to look at R160's roommate. The nurse noted scratches on the roommate's face and the tip of his nose. The roommate stated R160 had hit him. The two residents were kept separated as R160 was sitting in the hall when the nurse assessed the roommate. The police were called to the scene. R160 denied striking his roommate but did admit to them arguing about some food that was brought in for R160. A trauma assessment was completed for the roommate, R160 was referred to psychiatric services, staff were re-educated on Managing Aggression and Behaviors which included de-escalation techniques, and both care plans were updated. Other residents were interviewed during the investigation. All timeframes for reporting were per requirement. The facility could confirm a verbal altercation but did not substantiate physical abuse. In an interview on 6/26/2025 at 12:00 PM Unit Manager (UM) stated she remembered the incident between R60 and R160. She stated she was informed there was an altercation, so she went to investigate. When she arrived at the room, R160 was sitting outside the door and the privacy curtain was pulled between the beds in the room. UM stated R160 would not look up at her when she asked what was going on. When she questioned R60, he stated R160 had hit him and that his face hurt. UM assessed scratches to his face and nose. UM cleaned R60's wounds and administered his pain medication. UM stated she then took R160 to another room to keep them separated and made the calls to the representatives, physician, and 911. UM stated she believed by what she saw and heard that R160 meant to hit R60 and the interaction was abuse. In an interview on 6/25/2025 at 1:45 PM the Administrator confirmed that R60 had requested a police officer so he could press charges against R160.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility policies titled Notification of Changes and Accidents/Incidents, the facility failed to promptly notify the Physician and responsible party (RP) timely for a change in condition including a fall and self-injurious behavior after a fall for one of three residents (R) R#119. Actual harm occurred when R#119 had a fall on 2/19/2022 and suffered a laceration to the residents' scalp that required 10 staples and the resident exhibited a change in behavior of banging his head on doorframe of bathroom. The Physician was not notified until the following day at 4:25 p.m., 37 hours after the residents fall. Findings include: Review of the facility policy titled, Notification of Changes dated November 2017 revealed the purpose is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring a notification. Circumstances requiring notification include but are not limited to: 1. Accidents resulting in injury or the potential to require physician intervention 2. Significant change in the resident's physical, mental or psychosocial condition such as a deterioration in health, mental or psychosocial status 3. Circumstances that require a need to alter treatment Review of the undated facility policy titled, Accidents/Incidents revealed accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. Assessment, Medical Assistance, Documentation 2.1.3 the Nurse will notify the Physician/Advanced Practice Provider (APP) of the accident, report the physical findings and extent of injuries, and obtain orders as indicated. 2.1.3.1 if the injury is of an emergent nature, the patient will be transported to the hospital. 2.1.5 the patient's responsible party/family will be notified of the accident and any follow-up treatment needed. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, anemia, psychosis, anxiety, dementia, repeated falls, difficulty walking and weakness. The resident's admission Minimum Data Set (MDS) dated [DATE] was coded as 10, which indicated moderate cognitive impairment. Section G revealed he required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Section J revealed resident had falls prior to admission to facility. Review of a document taped to the glass at the desk on the dementia unit, during the survey with the Director of Nursing (DON) name and cell phone number that states weekends and after hours please call for: falls, staff incident/staffing concerns, injury of unknown origin, change in condition, emergency room/hospital visits, unexpected deaths, State, and Police. Review of Progress Note dated 2/19/2022 at 3:50 a.m. written by Registered Nurse (RN) BB, revealed resident (R#119) in the bathroom washing his face. Resident stated he was sitting in chair, fell asleep and leaning forward. Upon assessment, abrasion noted in his head and bruise under right eye. Resident complains of pain and was medicated. Abrasion cleaned with normal saline, pat dry and apply triple antibiotic ointment (TAO), leave in air [sic]. Nurse Practitioner and responsible party will be notified in the a.m. Review of Progress Note dated 2/20/2022 at 6:50 a.m. written by LPN DD, revealed resident hit his head in the bathroom door three times and each time a new dressing was replaced. The Certified Nursing Assistant (CNA) and nurse observed resident taking dressing off and hit his head to the door corner and calling for help. At 7:00 a.m., he did it again. Review of the Progress Note dated 2/20/2022 at 4:25 p.m. written by Unit Manager (UM) EE, revealed Physician HH was notified of the fall that took place Friday. Physician HH gave order to send resident to the emergency room (ER) for eval [sic] related to head injury from the fall. Responsible party was notified of resident going to the ER. Review of the Interact Change in Condition Evaluation V 5.1 dated 2/20/2022 at 7:20 p.m. completed by UM EE, revealed the physician wasn't notified of the change in condition for R#119 until 2/20/2022 at 4:05 p.m. Review of the Progress Note dated 2/19/2022 at 1:56 p.m. written by Licensed Practical Nurse (LPN) CC revealed call was made to family member regarding fall. There is no documentation that the Physician was notified of R#119 fall with injury at this time. Interview on 2/20/2022 at 3:50 p.m. with the DON stated she was not aware R#119 had a fall or that he had a head injury but would have expected staff to call her and the MD immediately. Interview on 2/21/2022 at 10:00 a.m. with LPN AA stated R#119 had taken off his bandage 3 to 4 times the previous day. LPN AA stated she should have reported his head injury immediately when she changed his bandage after starting her shift yesterday morning, and saw what it looked like, but stated she did not tell anyone. Telephone interview on 2/21/2022 at 10:51 a.m. with Physician GG stated he has not known R#119 to physically harm himself, but if he were hitting his head against a door frame, he would expect staff to notify him immediately. He revealed the facility did not inform him R#119 was hitting his head against the door of the bathroom, when the DON called him on 2/20/2022, sometime after 2:00 p.m. During further interview, he stated that he would expect the facility to notify him right away for behaviors of self-harm or injury. Interview on 2/21/2022 at 7:05 p.m. with LPN DD revealed R#119 had a fall on 2/19/2022 during the 11:00 p.m. to 7:00 a.m. shift between 2:00 a.m. and 3:00 a.m. She stated the morning of 2/20/2022 at approximately 6:30 a.m. she heard a CNA yelling for help. When she arrived at R#119's room, he was observed hitting his head on the bathroom door frame. During further interview, LPN DD stated she did not call the physician regarding the resident hitting his head because she did not feel it was bad enough to notify the Doctor. Interview on 2/22/2022 at 2:30 p.m. with the DON stated she had no prior knowledge of R#119 having behaviors of hitting his head against things. She revealed she had concerns that the Physician was not notified of resident hitting his head against the doorframe of the bathroom. During further interview, she stated her expectation is that staff should contact the Physician immediately for any accident or a change in condition. During a telephone interview on 2/22/2022 at 8:30 p.m. with RN BB revealed she was the nurse on duty 2/19/2022 when R#119 fell from his chair. She revealed she did not see him fall but found him at the sink in his bathroom washing blood from his face. She stated R#119 told her he fell out of his chair. RN BB stated the resident had an abrasion on his head and it was bleeding, so she held pressure and once it slowed down, she cleaned his head and put a bandage on it. She stated she did not call the MD because it was between 2:00 a.m. and 3:00 a.m. and it was too early to call him and stated she didn't believe it was serious enough to call the Doctor. Post survey telephone interview on 3/15/2022 at 2:30 p.m. with the DON revealed the nurses are expected to be charting in the electronic medical record (EMR) in real time, meaning that as soon as things happen, the staff should be documenting it. She further stated that she does believe that the staff are doing as they are required, with documentation. During further interview, she stated that staff are to call the Physician and responsible party for all incidents and changes in condition and stated it is not acceptable to postpone notification until later in the day, or the next day. Cross refer F600

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the facility policy titled Abuse Prohibition, the facility neglected to ensure that one of three residents (R) R#119 received timely treatment following a fall and change of condition. Actual harm was identified to have occurred on 2/19/2022 when R#119 had a fall and suffered a laceration to the scalp which required 10 staples. The facility neglected to send the resident to the emergency room (ER) for treatment of the laceration on his head for 37 hours after the resident fell. Findings include: Review of the facility policy titled Abuse Prohibition dated 8/2019, revealed the policy is to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, anemia, psychosis, anxiety, dementia, repeated falls, difficulty walking and weakness. The resident's most recent admission Minimum Data Set (MDS) dated [DATE] was coded as 10, which indicated moderate cognitive impairment. Section G revealed he required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Section J revealed resident had falls prior to admission to facility. Review of Progress Note dated 2/19/2022 at 3:50 a.m. written by Registered Nurse (RN) BB, revealed during rounds, writer noted resident in the bathroom washing his face. Resident stated he was sitting in chair, fell asleep and leaning forward. Upon assessment, abrasion noted on his head and bruise under right eye. Moderate amount of blood noted on his head. Neuro checks initiated. Resident complains of pain and was medicated. Abrasion cleaned with normal saline, pat dry and apply triple antibiotic ointment (TAO), leave in air [sic]. Review of Progress Note dated 2/20/2022 at 6:50 a.m. written by LPN DD, revealed resident (R#119) was observed to hit his head on the bathroom door three times and each time a new dressing was replaced. The Certified Nursing Assistant (CNA) and nurse observed resident taking dressing off and hitting his head to the door corner and calling for help. Review of the February 2022 Medication Administration Record (MAR) revealed an order dated 1/28/2022 for Hydrocodone five milligram (mg) tablet every six hours as needed for pain. Further review had no evidence that R#119 was medicated for pain. Observation on 2/20/2022 at 3:30 p.m. R#119 sitting in a wheelchair in the doorway of his room. He had a bandage on the top of his head, near his forehead, taped to his hair. There was blood noted on his shirt and pants. The dressing was removed by Licensed Practical Nurse (LPN) and noted to have large lump and gash that went down to the crown of his head. There was dried blood in his hair. He was also noted to have bruising under his right eye. Interview on 2/20/2022 at 3:30 p.m. with R#119 revealed he had a fall a day or two ago from his chair and stated his head hurts. Observation on 2/20/2022 at 3:35 p.m. with LPN AA removed the bandage from R#119 head to reveal a laceration with a large hematoma. Observation revealed a large amount of a reddish-brown substance in the top part of the resident's hair. Interview on 2/20/2022 at 3:35 p.m. with LPN AA stated she was informed that R#119 fell when she arrived to work today. She stated with a head injury, the resident should have been sent to the hospital for evaluation. During further interview she stated she changed the dressing to R#119's scalp earlier that morning and did not tell anyone about the laceration and large hematoma to his head. Interview and observation on 2/20/2022 at 3:50 p.m. with the Director of Nursing (DON) revealed she was not aware R#119 had a fall or that he had a head injury. She stated she would expect staff to call her and the Doctor immediately. The DON observed the resident's scalp wound, at this time, and confirmed the resident had a laceration to his head. Review of the Interact SNF/NF to Hospital Transfer Form dated 2/20/2022 at 4:50 p.m. completed by Unit Manager (UM) EE, revealed reason for transfer as trauma (fall related). The usual mental status/cognition function for R#119 before the acute change in condition was alert, oriented, follows instructions with behavioral issues of yelling with verbal reminders from staff to call for help. Further review revealed there was not any evidence of documentation of the observations of R#119 hitting his head and calling for help. Review of the Interact Change in Condition Evaluation V 5.1 dated 2/20/2022 at 7:20 p.m. completed by UM EE, revealed the change in condition was documented to be a laceration to top of the head related to injury to site which started on 2/19/2022 at night. Further review of the document revealed the physician wasn't notified of the change in condition until 2/20/2022 at 4:05 p.m. Review of the hospital ER record encounter date 2/20/2022 revealed chief complaint as fall. The patient (R#119) came from nursing home via EMS with a fall. Patient hit their head causing a laceration on the forehead. Patient is on blood thinners upon arrival bleeding is controlled. General appearance is disheveled, cachectic, altered, does not answer questions appropriately, laceration with dried blood to head, refuses to open eyes. Interview on 2/20/2022 at 10:30 p.m. with the ER Physician II, revealed R#119's head injury was a laceration with contusion and not an abrasion. He stated he was not aware that the resident's fall happened after midnight on 2/19/2022. The ER Physician II stated he thought R#119 fell and received the head injury the same day he came to the ER on [DATE]. During further interview, ER Physician II revealed he would be using staples to close the laceration. Interview on 2/21/2022 at 10:00 a.m. with LPN AA revealed she had never known R#119 to have behaviors of physically harming himself or beating his head against anything. She stated that when she changed R#119's dressing on 2/20/2022 she should have reported it immediately. Interview on 2/21/2022 at 7:05 p.m. with LPN DD revealed R#119 had a fall on 2/19/2022 during the 11:00 p.m. to 7:00 a.m. shift between 2:00 a.m. and 3:00 a.m. She stated yesterday morning, on 2/20/2022, she heard a CNA yelling for help. When she arrived at R#119's room, she observed R#119 hitting his head on the bathroom door frame. She stated his head was bleeding, so she applied pressure, put ice on his head, tried to stop the bleeding, and even tried cutting his hair to get to the laceration on his head, to be able to clean it. During further interview, LPN DD stated she did not call the physician because she did not feel it was bad enough to notify the Doctor. Telephone interview on 2/21/2022 at 10:39 p.m. with Medical Doctor (MD) HH revealed he received a call on 2/20/2022 around 3:00 p.m. to 4:00 p.m. related to R#119 head injury. He stated he was informed R#119 had a fall and had a hematoma on top of his head but was not made aware he was hitting his head against the bathroom door frame. During further interview, he stated he would have expected staff to notify him, or one of his partners, immediately about a fall with injury. Interview on 2/22/2022 at 2:30 p.m. with the DON revealed the facility is investigating what happened related with the fall and head injury to R#119. She stated she has no prior knowledge of R#119 having behaviors of hitting his head against things. She revealed she had concerns related to the fall with a head injury and the resident not being sent to the hospital. Telephone interview on 2/22/2022 at 8:30 p.m. with RN BB, revealed she was on duty when R#119 fell from his chair. She stated he told her he fell out of his chair. RN BB stated the resident had an abrasion on his head and it was bleeding, so she held pressure and once the bleeding slowed down, she cleaned his head and put a bandage on it. She stated she did not call the Doctor because it was 2:00 a.m. - 3:00 a.m. and it was too early to call him and stated she didn't believe it was serious enough to call the Doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled Person Centered Care Plan, the facility failed to implement the person-centered care plan for one resident (R) R#119 care plans reviewed, related to notifying the Physician after a fall. Actual harm was identified to have occurred on 2/19/2022 when R#119 had a fall and suffered a laceration to the scalp which required 10 staples. In addition, the facility failed to follow the care plan for one resident (R#24) reviewed for active range of motion (AROM) to bilateral upper extremities. The sample size was 38. Findings include: Review of the undated facility policy titled, Person Centered Care Plan revealed the purpose is to structure and guide therapeutic interventions to meet patient needs and achieve expected outcomes. Practice standards include develop individualized plan of care based upon social history and initial assessments, Care Area Assessment (CAA) triggers, and observations. Review, evaluate, and update care plans as required. 1. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses that included fracture of right femur, anemia, psychosis, anxiety, dementia, repeated falls, difficulty walking and weakness. The resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated moderate cognitive impairment. Section G revealed he required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Section J revealed resident had falls prior to admission to facility. Review of the resident's care plan dated 1/31/2022 revealed he was at risk for repeated falls with a fall resulting in hip fracture. Interventions to care included assist with mobility as needed, be sure call light is within reach and encourage resident to use for assistance, prompt response to all requests, and notify Medical Doctor (MD) and family as needed. Observation on 2/20/2022 at 3:30 p.m. R#119 was observed to have large lump and gash that went down to the crown of his head. There was dried blood in his hair. He was also observed to have bruising under his right eye. Interview on 2/20/2022 at 3:30 p.m. with R#119, stated that he fell out of his chair yesterday. He stated he did not go to the hospital. Interview on 2/20/2022 at 3:35 p.m. with LPN AA stated she was informed of R#119 fall when she arrived to work today. She stated with a head injury, the resident should have been sent to the hospital for evaluation. During further interview she stated she changed the dressing to his scalp and did not tell anyone about the laceration and large hematoma to his head. Interview on 2/21/2022 at 7:05 p.m. with LPN DD revealed R#119 had a fall on 2/19/2022 during the 11:00 p.m. to 7:00 a.m. shift between 2:00 a.m. and 3:00 a.m. LPN DD stated she did not call the physician because she did not feel it was bad enough to notify the Doctor. Cross refer F600, F580 2. Review of the clinical record for R#24 revealed she was admitted to the facility on [DATE] with diagnoses of but not limited to chronic respiratory failure with hypoxia, emphysema, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD). The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 9, which indicated moderate cognitive impairment. Section G revealed she required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. Section O revealed resident received active range of motion four of seven days. Observation on 2/22/2022 at 11:04 a.m., R#24 lying in her bed, wearing a hospital gown, with therapeutic boots on bilateral lower extremities. Review of the care plan revised on 7/13/2021, revealed restorative nursing program for active range of motion (AROM) to bilateral upper extremities as indicated. Interventions to care include provide verbal cues, demonstration, and physical assistance for active range of motion (AROM) to bilateral upper extremities (BUE) 15 minutes/day for a minimum of five days per week. Review of the February 2022 Order Summary Report revealed a physician's order for Restorative Nursing PRN [as needed] per the P.O.C [plan of care], ordered 7/1/2021. Review of facility documentation related to R#24 restorative services/AROM to BUE revealed service was provided from 1/26/2022 through 2/23/2022. The facility could not provide any documentation of restorative activities from July 2021 through December of 2021. Interview on 2/22/2022 at 11:04 a.m. with R#24 stated her therapy was stopped because Medicare stopped paying for it. She stated she is not getting any kind of rehab at all. She stated she wanted to go home but she can't walk and without therapy, she can't go home. Interview on 2/23/2022 at 3:36 p.m. with the Director of Nursing (DON) stated she was not sure if R#24 was receiving restorative services but would investigate it and provide documentation, if applicable. Interview on 2/23/2022 at 4:15 p.m. with [NAME] President of Operations (VPO), Regional Nurse Consultant, and Administrator revealed, since the fall of 2021, the facility has experienced a massive turnover of leadership, including the Administrator, the DON, the Infection Preventionist, and several key nursing personnel. During further interview, the VPO stated a review of all facility processes was in progress and identified issues with documentation and record keeping. Interview on 2/23/2022 at 5:35 p.m. with Administrator stated she would continue to look for documentation related to restorative care/services for R#24 and would provide it to the State Survey Agency. Post survey interview on 3/15/2020 at 3:35 p.m. with Administrator, confirmed that the facility could not provide documentation of restorative services for AROM during the period of July 2021 through December 2021. Cross Refer 825