**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident was assessed for and safely transferred in a mechanical lift resulting in actual harm when the resident fell from the mechanical lift sling during a transfer and sustained a fracture to the right tibia (bone in the lower leg) (Resident B), failed to ensure residents were appropriately transferred in mechanical lifts using the correct slings (Residents B and D), and to ensure a resident with multiple falls received updated interventions to prevent further falls (Resident C) for 3 of 4 residents reviewed for accidents. Findings include:1. Resident B’s record was reviewed on 7/22/25 at 11:23 a.m. Diagnoses on the resident’s profile included, but were not limited to, cerebral palsy (a group of neurological disorders that affect movement, muscle tone, and posture) and unspecified fracture of the upper end of the right tibia. A significant change Minimum Data Set (MDS) assessment, dated 7/1/25, indicated the resident had a severe cognitive impairment, was dependent for chair/bed transfers, and had one fall with a major injury since the prior assessment. A physician’s order, dated 8/29/19, indicated the resident was transferred with a mechanical lift. A care plan, initiated on 8/29/19, indicated the resident required staff assistance with activities of daily living (ADLs) related to cerebral palsy. Interventions included, but were not limited to, encourage the use of assistive devices as needed, mechanical lift. Current physician’s orders lacked documentation of orders related to the resident’s right tibia fracture. A fall risk review, dated 6/18/25, indicated the resident was a high risk for falls. A progress note, dated 6/18/25 at 12:00 p.m., indicated it was a late entry. The note indicated the Certified Nurse Aide (CNA) notified the nurse the resident slid out of the mechanical lift. The resident was found lying on the floor on her right side, and there were two CNAs in the room. The CNAs reported the resident slid out of the mechanical lift sling and landed on her right side when the resident began moving during the transfer. One CNA reported she was able to prevent the resident from hitting her head. The resident was assessed and did not complain of pain. The Nurse Practitioner (NP) was in the facility and assessed the resident. The NP stated the resident could be moved to the bed, and the resident was assisted back to bed. The resident’s family member was notified of the incident. The resident requested to get up for lunch, and the NP said the resident was able to get out of bed. The resident was assisted out of bed and went to lunch. A progress note, dated 6/18/25 at 1:10 p.m., indicated the resident fell out of the Hoyer sling, at 11:45 a.m., during a transfer from the bed to the chair. A Situation, Background, Assessment, Recommendation (SBAR) form, dated 6/18/25 at 11:45 a.m., indicated the resident had a fall, and the recommendation was to monitor the patient and use a bigger Hoyer (mechanical lift) sling when transferring. A progress note, dated 6/19/25 at 4:31 a.m., indicated x-rays were ordered for the resident’s right shoulder and right knee. A progress note, dated 6/19/25 at 4:44 a.m., indicated the mobile x-ray company was scheduled to complete the x-rays in the morning. An Interdisciplinary Team (IDT) progress note, dated 6/19/25 at 10:12 a.m., indicated the IDT was reviewing the resident’s fall from 6/8/25 [sic]. The resident slipped out of the mechanical lift sling while being transferred. The root cause was “slid out of Hoyer lift.” The intervention was to ensure the appropriate sling was being used. The IDT consisted of the Dietary Manager, MDS Coordinator, Social Services Director (SSD), and Assistant Director of Nursing (ADON). The medical record lacked documentation of an assessment of the resident for the safe use of the mechanical lift was completed. The incident investigation file contained the following two undated witness statements. A witness statement from CNA 4 stated, “I was in [Resident B’s] room providing care for her…put the Hoyer lift sling under her. [CNA 5] entered the room. We put the sling on the Hoyer lift. As I was pulling out from the bed as I was turning the Hoyer, [Resident B] began to move/wiggle in the sling. I asked her to stop moving. [CNA 5] and I were able to catch her head to prevent it from hitting the floor…” A witness statement from CNA 5 stated, “I…went into [Resident B’s] room to help [CNA 4] transfer her with the Hoyer lift. We put the sling on the Hoyer lift. As [CNA 4] was pulling the Hoyer from out from the bed and turning it, [Resident B] began to move/wiggle in the sling. [CNA 4] asked her to stop moving. I moved closer to help with the transfer, [Resident B] arched her back and slid out of the Hoyer sling. Although we did not keep her from falling, we were able to catch her head to prevent her from hitting her head….” A progress note, dated 6/19/25 at 11:45 a.m., indicated the mobile x-ray company completed the x-rays of the resident’s right shoulder and right knee. An x-ray report, dated 6/19/25, indicated the resident had a right tibia fracture. The physician signed the report and indicated, “apply splint refer to ortho [orthopedics].” A progress note, dated 6/19/25 at 12:29 p.m., indicated the resident’s x-ray results were received, and there was a fracture to the right tibia. The physician was notified and ordered a splint and orthopedic referral. The orthopedic office was contacted to schedule an appointment. A physician’s order, dated 6/20/25, indicated the resident was able to get in the wheelchair. A care plan, initiated on 6/20/25, indicated the resident had a fracture to the right tibia from a fall on 6/18/25. Interventions included, but were not limited to, handle gently when moving or positioning and maintain body alignment. An IDT progress note, dated 6/24/25 at 4:43 p.m., indicated it was an IDT fall follow up clarification. Upon chart review, there was a clarification on the date and events. The fall occurred on 6/18/25, and the IDT note, dated 6/19/25, mistakenly indicated it occurred on 6/8/25. The resident was being transferred via mechanical lift by two CNAs, became restless, and positioned her body in a straight board position. This position caused her to “maneuver herself out of the Hoyer lift sling.” The resident fell approximately three feet, and the CNAs were able to prevent her head from hitting the floor. The resident landed on her right leg. The NP was in the facility, assessed the resident, and indicated she was able to be moved from the floor to the bed. The resident was assessed and was not in pain. The root cause of the incident was the resident became restless and maneuvered herself out of the sling. Interventions included immediate assessment by the NP, staff education for mechanical lift transfers and dealing with residents who had increased agitation during a mechanical lift transfer, x-ray completed, orthopedic consult completed with a new order for a follow-up x-ray in six weeks. An orthopedic physician progress note, dated 6/24/25, stated, “…Given that the patient is nonambulatory, I strongly recommend nonoperative management, and the patient and her family concurred. Supportive care will be provided, including placing support underneath the leg during lifting and transferring. A knee immobilizer or brace is not recommended, as it may lead to increased swelling and complications…The fracture is expected to heal in approximately three to four months….” A progress note, dated 6/25/25 at 2:05 a.m., indicated the resident was seen by the orthopedic physician on 6/24/25, but the nurse had not seen any paperwork from the appointment. During an interview, on 7/22/25 at 1:42 p.m., Resident B indicated she fell out of the mechanical lift because the staff did not have her in the lift “right.” When she fell, her leg hurt. During an interview, on 7/22/25 at 2:41 p.m., Qualified Medication Aide (QMA) 7 indicated she worked 6/18/24 when the resident fell out of the mechanical lift sling. Someone reported to her the resident fell, and she went to get the ADON. The staff stated the resident “bucked” and fell out of the sling. She was not sure if that was unusual for the resident because she did not normally provide direct resident care. After the incident, the staff received training regarding mechanical lift transfers but not regarding sling size. If a resident needed a mechanical lift sling, staff retrieved it from the supply. The size should have been determined by weight. She thought the resident’s height might have been a factor in the mechanical lift sling size as well, but she was not sure about hip size. During an interview, on 7/22/25 at 2:47 p.m., CNA 8 indicated she was familiar with Resident B. There had been issues transferring the resident with the mechanical lift because of her contractures and stiffness. The facility got a new mechanical lift sling for her, and it helped. The new sling crosses between the resident’s legs. The sling they were using before was a “bath sling.” It was a large rectangle that acted like a hammock and seemed too big. She indicated the staff was not trained on which type of mechanical lift sling to use or which size. There have been times when staff used bath slings when they were not really appropriate because they were not sure what to use or the correct equipment was not available. During an interview, on 7/22/25 at 3:01 p.m., the Administrator indicated they purchased personalized mechanical lift slings for each resident who used the lift based on their weights. They wrote the residents’ name on the label. At the same time, the bath sling was observed and was noted to be a large rectangle shape. The sling was not a [mechanical lift brand name] sling. During an observation, on 7/23/25 at 9:50 a.m., CNA 4 and CNA 9 transferred Resident B from the bed to the chair with the mechanical lift. The legs of the lift were closed and under the bed. The CNAs attached the sling loops to the mechanical lift. CNA 4 lifted Resident B up and off the bed, moved the mechanical lift backwards, turned to the right, and positioned it in front of the resident’s wheelchair. Once the mechanical faced the resident’s wheelchair, CNA 4 opened the legs of the mechanical lift and pushed it towards the resident’s wheelchair. CNA 9 guided the resident into the wheelchair as CNA 4 lowered the lift. During the transfer, the straps of the mechanical lift pad were crossed between the resident’s legs, but the resident’s buttocks protruded through the opening of the mechanical lift sling and her legs hung over the sling straps at her knees. The CNAs did not support the resident’s fractured leg during the transfer. At the same time, the ADON indicated the resident’s buttocks were positioned that way due to her contractures. The mechanical lift sling was observed to have the resident’s name on it and was a different brand than the mechanical lift. The CNAs were unable to verbalize what size sling the resident required. On 7/23/25 at 10:27 a.m., the Housekeeping Supervisor provided a document titled, “Hoyer,” and indicated it was a list of residents and their weights provided to her by nursing. When she was provided with this list, she was told to order each resident on it a new mechanical lift sling based on their weight. She was not told to use any other body measurements, such as height or hip width, to determine sling size. Prior to the new slings being ordered, staff used full-body, rectangular slings for the mechanical lift for all residents. The new slings ordered were a different shape and the straps crossed between the residents’ legs. She was approved to order one new sling for the residents who required a mechanical lift for transfers and was supposed to order a second sling for each resident later. If the new sling was soiled, she had one extra of the new style sling, but only one size. Otherwise, the staff would have needed to use the old rectangular style slings they used before until the new sling was laundered. She ordered the slings through the medical supply company she always used and was not told they needed to be [mechanical lift brand name] slings. During an interview, on 7/23/25 at 10:50 a.m., CNA 4 indicated she was not notified of any requirement to do anything with Resident B’s fractured leg during transfers. She was not aware the resident’s fractured leg needed support during transfers. During an interview, on 7/23/25 at 1:22 p.m., CNA 4 and CNA 5 indicated they were the CNAs who transferred Resident B when she fell out of the mechanical lift sling. They used the rectangular lift sling. The resident stiffened up and fell out of the mechanical lift sling. They had new mechanical lift slings that crossed between the residents’ legs, and they worked better. On 7/23/25 at 1:40 p.m., the DON provided a document titled, “Interdisciplinary Resident Screen,” dated 6/19/25, and indicated it was the mechanical lift assessment for Resident B. The document indicated the resident had a recent fall and received a screening for physical therapy. The document did not include an assessment of the resident’s appropriateness or safety for use of the mechanical lift and was not a mechanical lift assessment. At the same time, the DON indicated she was not able to find any other mechanical lift assessments for the resident. On 7/22/25 at 2:55 p.m., the Administrator provided the user manual for the mechanical lift used by the facility, dated 10/1/18. The user manual indicated, “…Use common sense in all lifts. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted. [Mechanical lift brand name] slings and patient lift accessories are specifically designed to be used in conjunction with the [mechanical lift brand name] patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of [mechanical lift brand name] patient lift system…Using the sling…WARNING…If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards…When using an adjustable lift base lift, the legs MUST be in the maximum opened/locked position before lifting the patient…The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately….” On 7/23/25 at 11:18 a.m., the DON provided a document titled, “Guidelines for Mechanical Lift Transfer/Usage,” dated 7/8/24, and indicated it was the policy currently being used by the facility. The policy indicated, “…Getting ready to use a Mechanical Lift…7) Never use a mechanical lift on a resident who is agitated, resistant or combative…10) Make sure that you have the correct sling for the resident. The sling needs to be: a) Compatible with the specific mechanical lift being used b) Correct size for the resident-this is determined using the resident’s size, weight, and hip measurements in accordance with the manufacturer’s recommendations….” 2. On 7/22/25 at 1:00 p.m., the medical record of Resident D was reviewed. The resident’s most recent admission to the facility was on 10/25/24. Admitting diagnosis included but not limited to repeated falls and reduced mobility. Review of physician orders indicated the record lacked an order to use the mechanical lift for transfers. A quarterly Minimum Data Assessment (MDS), dated [DATE], indicated the resident was extensive assist with two persons for transfers and was cognitively impaired. A care plan, dated 4/12/24, indicated the resident was at risk for falls. Interventions included, but were not limited to, antiroll back in wheelchair. A care plan, dated 8/1/24, indicated resident required assistance with activity of daily living care needs. Interventions included, but were not limited to, staff assist with transfers as needed, and assess by therapy as needed. The care plan lacked documentation of use of mechanical lift to transfer. On 7/22/25 at 1:50 p.m., observed Resident D being transferred from wheelchair to bed. Observed Certified Nurse aide (CNA) 4 operating the mechanical lift and CNA 9 assisting to position the resident in the mechanical lift pad. The top back of the pad observed to be approximately 4 inches above the back of the resident’s head. The resident was lifted approximately 18 inches over the wheelchair arm rest and moved to the bed. CNA 9 failed to lock the wheelchair prior to lifting the resident from the chair. CNA 4 failed to lock the brakes on the mechanical lift prior to lowering the resident onto the bed. 3. On 7/22/25 at 2:00 p.m., the medical record of Resident C was reviewed. The most recent admission to the facility was on 10/4/24. Admitting diagnosis included, but not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), weakness, and falls. A care plan, dated 3/29/24, indicated the resident was at risk for falls. Interventions included, but not limited to, anti rollbacks to wheelchair dated 1/24/23, color call light dated 4/4/22, and fall mat while in bed dated 9/6/23. The record indicated the resident had fallen on the following dates. On 6/22/25 the resident fell out of the wheelchair. On 6/28/25 the resident fell on the floor in front of her wheelchair. On 7/11/25 the resident fell out of wheelchair in the hall. On 7/14/25 the resident fell out of bed onto a mat. On 7/18/25 the resident was found sitting on the floor in the hallway in front of the wheelchair. The medical record lacked documentation of new preventive interventions being implemented after each fall. A fall risk assessment, dated 6/28/25, indicated the fall risk score was 13 and the resident was a high fall risk. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired. A fall risk assessment, dated 7/19/25, indicated the fall risk score was 17 and the resident continued to be high fall risk. On 7/23/25 at 11:13 a.m., during an interview the Director of Nurses (DON) indicated the care plans were updated after incidents during the IDT (inter disciplinary team) meeting. The DON indicated the MDS Coordinator would update the care plan with interventions at that time. Review of four employee files hired between 2/7/24 and 7/31/24 lacked documentation of competency skills evaluations for use of mechanical lifts. On 7/23/25 at 11:42 a.m., observed Resident C laying on her back across the bed sleeping. Observed the wheelchair in front of the resident. Call light had red tape on the light, the wheelchair had anti tip bar on the back, there was not a mat on the floor next to the bed. On 7/22/2025 at 2:55 p.m., the provided a document titled, “Guidelines for incidents, accidents, falls,” dated 6/30/23, and indicated it was the policy currently being used by the facility. The policy indicated, “ .11. Each fall needs a new care plan intervention rolled out…15. Based on the results of the incident, accident, fall, the resident’s care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place….” This citation relates to Complaint 1380602. 3.1-45(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from involuntary seclusion (separation of a resident from other residents or from the resident's room or confinement to resident's room against the resident's will, or the will of the resident representative) for 4 of 6 residents reviewed for abuse, when staff confined the residents in their room by tethering the door handles to the handrails in the hallway (Residents G, H, J, and K). Using the reasonable person concept, it is likely that this would lead to mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. Findings include: On 12/8/22 at 10:31 a.m., the area Ombudsman reported she had received multiple anonymous phone calls indicating confused and mobile residents, who had been moved and were currently in isolation rooms on the end of the skilled nursing facility (SNF) hallway, had been secluded in their rooms against their will at the direction of the Director of Nursing (DON). Over the weekend of 12/3/22 evening staff members had used a gait belt and a regular belt to tie the doors to the handrail preventing the residents from leaving their rooms. She had received pictures of the tethered doors as proof from a complainant. Complainants indicated they were upset about the treatment of the residents. During an interview on 12/8/22 at 1:32 p.m., Qualified Medication Aide (QMA) 9 indicated she worked primarily on the Skilled Nursing Facility (SNF) unit. There were currently 3 resident rooms at the end of the hallway with residents in isolation. Residents were kept in their rooms and redirected if they tried to come out. Resident G routinely screamed with all care, or just laid in bed and screamed help for no reason, but she was able to transfer and move around in her wheelchair independently. QMA 9 indicated she had heard girls on 2nd shift barred the door to Resident G's room, but she did not know staff names. During an interview on 12/8/22 at 2:04 p.m., CNA 13 indicated she routinely worked evening shift on the SNF hallway. There were currently 3 rooms with 5 residents in isolation on the end of the hallway due to COVID-19 who had dementia and keeping the residents in their rooms included a lot of redirection. On 12/2/22 she had observed Residents G, H, J, and K's rooms tied shut with a gait belt and what looked like a thread. Upon observation she approached the nurse and was told she was not sure what it was, but they were told to make sure the residents stayed in their rooms. LPN 17 went and looked, and CNA 13 thought she removed it. It was not okay for the resident doors to be tied. During an interview on 12/8/22 at 3:35 p.m., the DON indicated she did not remember but thought she had been informed of the residents being tied into their rooms by the ADON by phone call on Friday 12/2/22 between 7:00 p.m. to 8:00 p.m. She had been informed a gait belt or something was on wandering residents' doors tying Residents G, H, J, and K into their rooms. Staff were told they were not allowed the tie the doors shut. DON indicated if residents wandered out, they were to be redirected back into their room. The DON indicated she had the ability to view the facility camera per her cellphone and looked at footage of the hallway and could see something but could not make out what was on the doors. She then called staff and told them if the doors were tied, they had to remove the ties immediately. There was no reason for the staff to have tied the doors as they were in the hallway and should have just re-directed as best as they could. During an interview on 12/8/22 at 5:20 p.m., the DON indicated she did not have pictures on her phone of the resident doors being tied shut, she must have just been showed the pictures by the ADON on Friday evening 12/2/22 while still in town at a parade the facility was participating in. The DON indicated upon seeing the pictures she had called the facility and spoke to LPN 17 and QMA 18. On 12/9/22 at 10:30 a.m., the DON provided a typed statement, dated 12/3/22, unsigned, indicated it was a statement from the Administrator. The statement indicated, Investigation: Per staff statements: CNAs secured doors to [room numbers] for approximately 90 minutes. Staff entered the room every 15 - 20 minutes. Staff was in area of rooms through the time doors were secured. Doors could be opened to approximately 1 foot. Residents did not appear to be in distress during staff visits to room. It was not the intent of staff to cause harm to residents in these rooms, intent was to prevent other residents from infection [COVID-19]. Conclusion: All staff in-serviced on proper protocol of isolation for COVID-19, Abuse, Customer Service, and Administrator notification. Confidential interviews were conducted during the survey indicated the following: a. The employee indicated there were 3 rooms with 5 residents on the SNF unit where residents were residing temporarily due to COVID-19 and need for isolation. She had heard on Friday evening 12/2/22 Residents G, H, J, and K's rooms had been tied shut on evening shift to prevent them from getting out and wandering in the hallway. During the day on Friday there was an extra aide just to provide oversight for the 3 isolation rooms but only 2 staff members on the evening shift, and when busy the aide on this end of the hallway indicated they could not provide oversight for them and put the other residents to bed. When the night shift came to work, they were not comfortable with having the doors tied closed and untied them. Pictures the employee saw showed Residents J and K's door was tied shut with some type of black belt and Resident's G and H's room was tied shut with a white sheet. b. The employee indicated on 12/2/22 at approximately 9:30 p.m., evening CNAs 13 and 21 were overheard discussing tying the doors shut to Resident G, H, J, and K rooms as the residents had COVID-19 and staff were having a hard time keeping Resident H in her room, she kept coming out and trying to walk per her normal routine. Employee was not comfortable with having the resident doors tied and along with another staff member viewed the doors and untied them. Understanding was day shift had a 3rd aide on the hallway to oversee the isolated residents until 6:00 p.m., and after that aide left CNAs 13 and 21 kept having to put Resident H back into her room so they tied the hallway door shut. Resident H was able to access Residents J and K's room through the connecting bathroom, so their door was tied shut also. Evening staff indicated management knew and had approved of the doors being tied. When the evening staff left the facility the night staff did not know what to do so they took pictures of the situation and sent them to the ADON with text asking if administration had approved of this. The ADON responded to no one had informed her about this. c. Employee indicated on Friday evening 12/2/22 evening CNA's 13 and 21 were overheard talking about tying the doors shut to Resident G, H, J, and K's rooms. Employee indicated this was illegal, so went with another staff member and looked at the doors and found the doors tied with gait belts with a crack in them, maybe could open 2 inches tops. The evening shift employees said management was aware, but the employee did not believe the Administrator or DON would allow this. The employees who had concerns about the doors being tied shut sent pictures as evidence to the ADON between 10:00 p.m. and 10:30 p.m., as she was usually awake late, and then untied the doors. The employee believed the staff had tied the doors out of frustration as these 4 residents had dementia and it was hard dealing with them. The 2 pictures were provided and observed. In the pictures Residents G and H's door was tied tight from the door handle to the railing with a white gait belt. Residents J and K's door was tied tight with a black belt from the door handle and the railing. Neither picture looked as if the doors could have been opened. d. Employee indicated, around 9:30 p.m. had overheard CNAs 13 and 21 discussing Resident H who liked to wander and how they were having a hard time keeping her in her room for isolation, and upper management said to tie her in her room. Employee indicated upper management would never have told staff to do that. Hearing the residents' doors were tied, instantly made the employee mad. What would have happened if a fire broke out, or the residents started fighting? They were all confused residents and had behaviors, like Resident G who threw things. It was not right to tie the residents up. This was abuse. Night CNAs observed the doors and untied them. Care of confused residents with COVID-19 was a little different as doors needed to be closed, but staff could not tie the doors, could not hold the doors shut, or forcefully keep them in there. This was abuse. e. Employee indicated, on 12/2/22 between 9:00 p.m. and 9:30 p.m. it was brought to her attention the doors to Residents G, H, J, and K's rooms were tied closed. They were supposedly the biggest wanderers. CNAs 13 and 21 indicated upper management was aware of it. Night CNAs went and untied the doors. Pictures of the tied doors had been texted to the ADON. This was abuse. During an interview on 12/8/22 at 5:25 p.m., QMA 18 indicated, he had been passing medications on the skilled unit the evening of 12/2/22. Residents G, H, J, and K were supposed to be in isolation, but would routinely wander. At 6:00 p.m. a CNA went home and CNAs 13 and 21 were left trying to figure out how to keep the residents in their rooms and finish their work. So, they decided to tie the doors around the doorknobs until they finished their work. QMA 18 indicated he did not believe LPN 17 gave permission for them to tie the doors, but they both knew about the situation and did not say anything to correct it. He did not know how long for sure the doors were tied shut but thought maybe 1 to 1½ hours before the DON called and said to remove the ties. During a phone interview on 12/9/22 at 8:53 a.m., the ADON indicated on Friday evening 12/2/22 she had received a text message from a CNA during the town parade around 7:00 p.m. to 8:00 p.m. The text was 2 pictures of Residents G, H, J, and K's doors tied shut, and she responded she did not know what that was. ADON indicated the staff had no permission to do that and were to remove it immediately. ADON then showed the picture to the DON, and she thought the DON went to the facility to make sure the ties had been removed after the parade. On 12/3/22 the ADON was informed CNA's 13 and 21 were responsible for tying the resident doors closed, they admitted to tying the doors but indicated they had been told to do so by QMA 9. When asked if they knew tying the doors closed was wrong, CNA's 13 and 21 indicated they had questioned this among themselves but were told to do it and had no answer to why they had not notified the ADON, DON, or Administrator. The plan for keeping isolated residents with dementia in their rooms included re-directing them back to their rooms as they cannot wander the hallways. During an interview on 12/9/22 at 9:53 a.m., CNA 21 indicated on 12/2/22 she had worked the evening shift with CNA 13 on the SNF hallway. There had been another CNA from day shift who stayed until 6:00 p.m., then it was just the 2 CNAs who were working the floor and could not just sit with the isolated residents. They used PPE and went in about every 15 to 20 minutes to check on the residents. Resident H was the main resident coming out, going back and forth to Resident G's room through the adjoining bathroom, wandered and kept coming out of her room. After the belts were applied to the resident doors, Resident H kept knocking on the door asking if anyone was out there. Even with the belt attached the door to Resident H's room opened inches where she could have taken the belt off if she pushed hard enough. CNA 21 indicated she and CNA 13 went to the nurse's desk and asked how they were going to do work and care for the residents, and QMA 9 told them night and day shift had tied the doors shut with belts. QMA 9 then handed the aides a gait belt and one regular belt, so at that point they assumed it was ok. They did not contact management and get approval. About an hour later the DON called and said the belts had to come off. LPN 17 and QMA 18 knew of the belts as they were sitting at the desk and overheard the discussion. CNA 21 indicated at the time they were under the impression the DON had approved the belts for medical purposes, but later found out that was not true as the DON was very upset with them. CNA 21 indicated she had been trained on abuse for years to include involuntary seclusion, so knew it was not right. But took the word of another staff and assumed it was okay. She should have called the DON and questioned the situation but trusted the QMA and took her word. Attempts were made to interview LPN 17 during the survey without a response. On 12/9/22 at 3:20 p.m., DON indicated she had been shown the pictures of the residents' doors being tied shut on Friday evening 12/2/22 by the ADON after the parade around 8:00 p.m. to 8:30 p.m. She did not come to the facility to investigate but called the facility and told them to remove the ties. The DON had the capacity to view video of the hallway to determine how long the ties had been on the doors but did not. She knew the ties were not on the doors at 6:30 p.m. when they left the facility so knew they could not have been on the doors long. When asked if any reasonable person who was alert and oriented had been tied in their room and unable to get out, would you expect them to be upset and angry, the DON indicated oh yea without a doubt. 1. During the initial tour on 12/5/22 at 11:05 a.m., Resident G's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident was in isolation after being symptomatic and testing positive for COVID-19. The resident's normal routine was to wander daily with another resident. The DON indicated Resident G was not doing well with isolation, she would yell and scream unless someone was in the room with her. Resident G's record was reviewed on 12/9/22 at 10:17 a.m. Diagnoses on Resident G's profile included, but were not limited to schizophrenia, dementia, anxiety disorder, history of falls, and convulsions. A physician's order for Resident G, dated 12/1/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident G, dated 12/1/22 at 3:52 a.m., indicated the resident was positive for COVID-19, the family was notified, and the patient was in isolation. A social service notes for Resident G, dated 12/1/22 at 4:55 p.m., indicated resident had a diagnosis of COVID-19 and was in isolation. Resident had exhibited increased behavioral episode today of throwing things at the door and hitting at staff. Resident received an order for Haldol (antipsychotic to treat mental disorders) 0.2 ml (milliliter) and Risperdal (antipsychotic to treat schizophrenia) 0.25 mg (milligram). Resident had a diagnosis of undifferentiated Schizophrenia with Risperdal 0.25 mg twice daily. Resident was able to be redirected and calmed down to where staff could provide care. A progress notes for Resident G, dated 12/1/2022 at 7:04 p.m., indicated resident was extremely agitated this shift. The Physician was notified, and a new order obtained to give the resident Haldol IM (intramuscular). The resident record lacked documentation of behaviors in November 2022, then antipsychotic medications administered 12/1/22 due to increased behaviors after being placed in isolation and the door closed. The resident record lacked documentation the physician or responsible party had been made aware the resident was involuntarily secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. A quarterly Minimum Data Set (MDS) assessment, completed on 12/2/22, assessed Resident G as being unable to complete the BIMS (Brief Interview for Mental Status) assessment as the resident rarely/never understood the questions. She displayed signs and symptoms of delirium to include inattention, and disorganized thinking. Physical, verbal, and other signs of behaviors such as hitting or scratching self, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. There was documentation of rejection of care. Extensive assistance of 2 or more persons (+) physical assist for bed mobility, transfers, dressing, and toilet use. She was a limited assistance of 1 person physical assist for locomotion on and off the unit. Mobility devices included a wheelchair. A care plan for Resident G indicated she was at risk for falls due to a history of falls and dementia. The medical record lacked documentation of a current care plan related to being positive for COVID-19, being placed in isolation, or interventions to address the resident's increased behaviors related to isolation and being prevented from routine wandering. 2. During the initial tour on 12/5/22 at 11:07 a.m., Resident H's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident had been moved from her primary room to cohabitate with another resident in isolation after being symptomatic and testing positive for COVID-19. The resident's normal routine was to wander daily with another resident. When asked how the residents were kept isolated if they liked to wander, the DON and Administrator indicated they did the best they could, but at times the residents were placed in personal protective equipment (PPE), the other resident doorways to the hallway closed, and the residents were allowed to wander at the end of the hallway a bit. Resident H's record was reviewed on 12/9/22 at 10:48 a.m. Diagnoses on Resident H's profile included, but were not limited to, Alzheimer's disease, disorientation, and history of falling. A physician's order for Resident H, dated 5/11/20, indicated up ad lib (as wanted). A physician's order for Resident H, dated 12/2/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident H, dated 12/1/22 at 7:00 p.m., indicated resident tested positive for COVID-19 and was immediately isolated to a room by herself, then moved to another room with another COVID-19 positive resident. A progress notes for Resident H, dated 12/3/2022 at 5:42 p.m., indicated resident alert and oriented to self with noted confusion and forgetfulness per usual self. Trying to wander into hallway, redirected with little difficulty. A progress notes for Resident H, dated 12/4/22 at 3:53 a.m., indicated made some attempts to leave room early in shift, however, staff was able to get resident calmed down drew attention away from door, remains under isolation precautions. A progress notes for Resident H, dated 12/4/2022 at 11:11 a.m., indicated resident with noted confusion and forgetfulness per usual self. Trying to wander into hallway, redirected with little difficulty. Resident record lacked documentation the physician and responsible party had been made aware the resident was involuntarily secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. An annual MDS assessment, completed on 11/29/22, assessed Resident H as being unable to participate in the BIMS assessment due to rarely/never understood the questions. Resident displayed signs or symptoms of delirium to include inattention and disorganized thinking. No symptoms of behaviors or rejection of care but did wander daily. Resident required extensive assistance of one person physical assist for bed mobility, and transfers. Resident required limited assistance of one person physical assist for walking in the room, and limited assistance of 2+ persons physical assist for walking in the corridor. Supervision and one person physical assist were needed for locomotion on and off the unit. No mobility devices were utilized. A care plan for Resident H, dated 5/12/20, indicated the resident wandered without natural purpose. The goal was for the resident to be safe while wandering in the facility. Interventions included, allow resident to vent, offer snacks and fluids, reassure resident as needed, redirect resident to activity of choice, refer to psychologist as needed, tender loving care, and wanderguard placed with placement and function checks every shift. A care plan for Resident H, dated 12/2/22, indicated the resident tested positive for COVID-19 and was to be placed in transmission based-droplet isolation. The goal for the resident was for the resident to be free from signs and symptoms of acute respiratory distress and secondary infections such as pneumonia. Interventions included the resident was to remain in her room with all services proved in her room, and to place in a private room if available. Observe for changes in mood and/or psychosocial changes such as increased confusion, changes in sleep patterns, changes in behavior, nervousness, weight loss, or crying episodes. The resident record lacked documentation of interventions to address the resident's behaviors related to isolation and being prevented from routine wandering. 3. During the initial tour on 12/5/22 at 11:16 a.m., Resident J's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident had been moved from her primary room to cohabitate with another resident in isolation after being symptomatic and testing positive for COVID-19. Resident J's record was reviewed on 12/9/22 at 12:20 p.m. Diagnoses on Resident J's profile included, but were not limited to, schizoaffective disorder bipolar type, delusional disorders, major depressive disorder, dementia, history of falling and repeated falls. A physician's order for Resident J, dated 12/1/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident J, dated 11/30/22 at 4:40 p.m., indicated the resident was symptomatic and tested positive for COVID-19. The resident was moved to the skilled unit. A social service progress notes for Resident J on 12/4/22 at 2:58 p.m., indicated the resident liked to wander with no rational purpose. Resident was currently in isolation due to diagnosis of COVID-19-19. Resident record lacked documentation the physician and responsible party had been made aware the resident was involuntary secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. A Medicare 5 day MDS assessment complete on 12/5/22, assessed Resident J as not being able to complete a BIMS assessment due to her mental status. The resident displayed signs and symptoms of delirium to include inattention and disorganized thinking, and she wandered daily. Extensive assistance of one person physical assist for bed motility and transfers and walking in the room, she did not walk in the corridor. Supervision and one person physical assist for locomotion on the unit. Supervision and set up help only for locomotion off the unit. Mobility devices included a wheelchair. A care plan for Resident J, dated 8/2/22, indicated the resident exhibited physically aggressive behavior toward peer such as hitting at peers. The goal for the resident was to have no further increased behavioral episodes of hitting at peers. Interventions included explain appropriate behavior, redirect, refer to consulting psychologist, and visit with resident routinely to assess for any further behavioral episodes. A care plan for Resident J, dated 3/19/19, indicated the resident tended to speak unkindly to staff and peers at times, and she had exhibited verbal and physical aggressive behaviors. The goal was for the resident to speak kindly to staff and peers, be easily redirected when she was speaking rudely to staff and peers and have no further aggressive behaviors. Interventions included, allow resident to vent in a private location so that other residents cannot overhear her complaints, attempt redirection when resident was becoming rude with staff and/or peers, explain to resident inappropriate behavior when she was speaking rudely or unkindly to staff and/or peers, notify the physician with concerns, and redirect and explain inappropriate behaviors, and refer to consulting psychologist as indicated. The medical record lacked documentation of a current care plan related to being positive for COVID-19, being placed in isolation, or interventions to address the resident's behaviors related to isolation and being prevented from routine wandering, and how her aggressive behaviors toward others were being monitored with the door closed. 4. During the initial tour on 12/5/22 at 11:11 a.m., Resident K's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident had been moved from her primary room to cohabitate with another resident in isolation after being symptomatic and testing positive for COVID-19. Resident K's record was reviewed on 12/9/22 at 1:55 p.m. Diagnoses on Resident K's profile included, but were not limited to schizoaffective disorder bipolar type, vascular dementia, severe manic episodes, and history of falling. A physician's order, dated 11/28/20, indicated up ad lib. A physician's order for Resident K, dated 11/30/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident K, dated 11/30/22 at 7:16 a.m., indicated the resident tested positive for COVID-19 and was placed in isolation. A progress notes for Resident K, dated 11/20/22 at 9:45 a.m., indicated the resident was found lying on the floor between the bed and three drawer chest. Abnormal vital signs included temperature 101.5 F (Fahrenheit) (normal 98.6), blood pressure 160/80 (normal less than 120 /80), pulse 102 (normal 60 - 100), and respirations 18 (normal 13 - 19). New orders for x-rays to left foot and toes. A social service progress notes for Resident K, dated 11/30/22 at 5:20 p.m., indicated resident required cues and redirection and wandered with no rational purpose and wander guard in place. A progress notes for Resident K, dated 12/4/22 at 4:11 a.m., indicated the resident did not appear to feel well, had a poor appetite, was cooperative with care, and remained under isolation precautions. A progress notes for Resident K, dated 12/5/2022 at 5:15 p.m., indicated the resident was found on the floor on her back by staff during rounds. Resident record lacked documentation the physician and responsible party had been made aware the resident was involuntary secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. A quarterly MDS assessment, completed on 12/2/22, assessed Resident K as not being able to participate in the BIMS assessment as she rarely/never understood. She displayed signs and symptoms of delirium to include inattention, disorganized thinking, and altered level of consciousness. She required extensive assistance of one person physical assist for bed mobility, transfers, locomotion on the unit, toilet use, and personal hygiene. She required limited assistance of 2+ persons physical assist for walking in the room and corridor. Limited assistance of one person physical assist for locomotion off the unit and eating. No history of falls was documented. A care plan for Resident J, dated 5/24/22, indicated the resident had to be redirected to her room and would attempt to go in other rooms at times. The goal was for the resident to be safe while lying in different positions and being redirected. Interventions included encourage resident to lie in proper positioning, redirect resident to own room, and sign in bright color for cue of her room. A care plan for Resident J, dated 3/5/22, indicated she was at risk for falls due to decreased mobility and weakness. The goal for the resident to be free from major injury related to falls. Interventions included assist resident with ADL's (activities of daily living) as needed, decreased mobility and weakness, encourage resident to use call light for assistance from staff. Encourage resident to wear non-skid footwear when out of bed. Due to COVID-19 positive changes in environment will be made. She was in isolation and generally weak at this time with new onset of pain. Resident continued with changes related to COVID-19 positive and was generally weak with temperature. A care plan for Resident J, dated 12/2/20, indicated resident wandered without natural purpose. The goal was for the resident to be safe wandering in the facility. Interventions included, allow resident to vent, offer snacks and fluids, reassure resident as needed, redirect to activities, refer to psychologist as needed, tender loving care, and wanderguard in place and check placement and function every shift. The medical record lacked documentation of interventions to address the resident's falls and behaviors related to isolation and being prevented from routine wandering, and how her aggressive behaviors toward others were being monitored with the door closed. On 12/9/22 at 10:30 a.m., the DON provided an Abuse Prevention Policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of this facility to prevent resident abuses, neglect, mistreatment, and misappropriation of property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observed, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Staff who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation .Involuntary seclusion: separation of the resident from other residents or from his or her room or confinement to his or her room [with or without roommates] against the resident's will, or the will of the resident's legal guardian or representative .Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse . Using the reasonable person concept, it is likely that residents being restrained in their rooms would lead to the residents having mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. This Federal tag relates to Complaint IN00396693. 3.1-27(a)(4)