Based on observation, interview, and review of facility policy, the facility failed to demonstrate acceptable infection control procedures to help prevent and control the spread of disease and infection for one of three residents (Resident (R) 80) observed during medication administration. The findings include: Review of the facility policy titled, Policies and Procedures - Infection Prevention and Control revised December 2023, revealed the facility adopted infection prevention and control policies and procedures were intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infection. Review of the section titled, Policy Interpretation and Implementation under bullet point 1 revealed Infection prevention and control policies apply to all personnel, consultants, contractors, residents, visitors, and volunteers. Review of the facility policy titled, Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner. The section titled Policy Interpretation and Implementation, revealed under bullet point number 25 that staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Observation on 8/29/2024 at 8:59 AM during medication administration, revealed Licensed Practical Nurse (LPN) 6 walked away from the medication cart to obtain keys and then returned to the medication cart; however, the LPN did not sanitize or wash her hands upon return. LPN6 then opened the medication drawer and located the medications for R80. LPN6 used her bare hand to transfer the pill from the medication card to the medication administration cup. After repeating the bare hand technique for an additional three medications, the surveyor asked LPN6 if handling medications with bare hands was good infection control practice. LPN6 stated it would not be and stated she was nervous. Per LPN6, she usually would pop the pills out of the medication card into the medication cup and not use her bare hands. LPN6 then disposed of the contaminated medications, sanitized her hands, and removed R80 medications directly from the medication card into the medication cup. During an interview on 8/29/2024 at 8:59 AM, LPN6 stated it was not good infection control practice to handle medication with bare hands and there could be a risk of spreading infection or disease. During an interview on 08/29/2024 at 5:00 PM, the Director of Nursing (DON) stated the facility educated staff that hand hygiene should be performed at the start of med pass, if med pass is broken, or if the hands are contaminated during med pass. For example, a pill was dropped on the floor or on the med cart and the nurse had to pick it up then the DON stated she would expect hand hygiene to be performed. She stated medications should not be touched with bare hands due to the risk of contamination or infection. During an interview on 08/29/2024 at 5:15 PM, the Administrator stated it was her expectation that infection prevention practices were to be followed by staff to prevent the transmission of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were free from abuse for two (2) of twenty-one (21) sampled residents (Residents #46 and Resident #200) Staff interviews and review of the facility Investigation, revealed Resident #46 alleged Resident #200 hit him/her five (5) times in the arm on 05/19/18, due to an argument over the bathroom. The findings include: Review of the facility Abuse Prevention Program Policy, dated November 2010, revealed residents have the right to to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion. Resident privacy is to be protected and mental abuse is to be prohibited related to photographs and audio/video recordings by nursing home staff. Review of the facility Reporting Abuse to the Facility Management Policy, revised April 2012, revealed, Our facility does not condone abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, other residents, friends, or other individuals. Policy definition of abuse is the willful infliction of injury with resulting physical harm, injury, or mental anguish. Review of the facility Reportable documentation, revealed the Department of Community Based Services (DCBS) was notified on 05/20/18 at 10:27 AM, by the facility of an incident that occurred on 05/19/18 at 3:20 PM. Resident #46 reported Resident #200 hit Resident #46 due to them arguing over the bathroom. Review of the Incident/Condition Report, completed by the Director of Nursing (DON), dated 05/21/18, revealed on 05/19/18 at 3:20 PM in the resident bathroom, there was an unwitnessed resident to resident altercation. Resident #46 stated, {he/she} hit me five (5) times referring to Resident #200. Skin Assessment completed for Resident #46 with no injuries noted. Per the Report, the residents needed to toilet at the same time resulting in agitation. [NAME] of Attorney for both residents were notified of the allegation. Per the Report, Resident #200 was moved to a different room, and the Physician was notified. Review of the Investigation, revealed there was a witness statement written by Licensed Practical Nurse (LPN) #6, dated 05/19/18 at 3:20 PM. Per the Statement, LPN #6 saw Resident #46 come out of room [ROOM NUMBER] and state, {he/she} hit me five (5) times, referring to Resident #200. Resident #200 then stated, I hit {him/her}. Residents had argued over the bathroom, and the residents were separated. Further review of the Statement, revealed Resident #46 was assessed and there was no red areas or bruises to skin. Resident #46 was reassessed again at 4:00 PM, and there still was no bruising or redness noted. Resident #200 was moved to room [ROOM NUMBER]-1. Both resident POAs were notified. Review of Resident #46's Medical Record, revealed the facility admitted the resident on 03/30/16 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Dementia without behavioral disturbance, Anxiety Disorder, Delusional Disorder and Paranoid Personality Disorder. Review of Resident #46's Annual Minimum Data Set (MDS) Assessment, dated 05/02/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of (15) out of (15) indicating the resident was cognitively intact. Further, the facility assessed the resident as having no behaviors. Review of Resident #46's Comprehensive Care Plan, initiated 05/04/18, revealed the resident was short tempered and became angry when there was a situation he/she did not like and was very paranoid at times. The goal stated the resident would have behavioral symptoms managed with new and current interventions. The interventions included staff to speak with calm and positive voice with good eye contact related to Paranoia. Review of Resident #46's Bedside Skin Assessment Worksheet, dated 05/19/18 at 3:25 PM, and 4:00 PM, completed by LPN #6, revealed there was no redness or bruising noted. Review of Resident #46's Social Worker's Note, dated 05/21/18 at 2:36 PM, revealed she documented, Spoke with this resident related to psychosocial well-being related to reported incident this weekend. {He/she} reported {he/she} is fine and seemed pleasant with this writer. Review of Resident #200's medical record revealed the facility re-admitted the resident on 10/12/17 with diagnoses including Systolic and Diastolic Heart Failure, Atherosclerotic Heart Disease, Cerebral Infarction, and Hemiplegia and Hemiparesis. Review of the Resident #200's Annual MDS Assessment, dated 05/14/18, revealed the facility assessed the resident as having a BIMS score of (15) out of (15) indicating no cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as having no behaviors. Review of Resident #200's Comprehensive Care Plan, initiated 03/14/19, revealed a focus of Mood State related to history of generalized anxiety disorders. The goal stated the resident Resident would have a PHQ (Patient Health Questionnaire for psychological assessment tool) less than five (5) (which would suggest the resident would not need depression treatment). Interventions included allow resident to call his/her daughter if he/she becomes anxious or upset; continue medications for mood, depression and anxiety; encourage frequent family visits; and psychotherapy as ordered. Review of Resident #200's medical record, revealed the resident was placed on fifteen (15) minute checks for the dates of 05/19/18, 05/20/18, 05/21/18, 05/22/18, 05/23/18, and 05/24/18. Review of Physician's Orders, dated 05/21/18 at 3:40 PM, revealed orders for Resident #200 to have a room change from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-1. Interview with Resident #46, on 07/16/19 at 10:46 AM, revealed someone came into the room and beat me up. Interview further revealed the incident happened a while ago and had not happened since. The resident was unable to further elaborate on the event. Interview with LPN #6, on 07/19/19 at 10:35 AM, revealed on 05/19/18, she was getting ready to perform medication pass when Resident #46 came out of his/her bedroom and was arguing with Resident #200 (his/her roommate). Interview further revealed the two (2) residents were separated and Resident #200 was placed on fifteen (15) minute checks and moved to a different room. Per interview, the altercation on 05/19/18 between these two (2) residents was the first time she knew of the residents arguing or having any disagreements and there had been no physical altercations prior to this incident. LPN #6 stated she reported the incident immediately to the Director of Nursing (DON), Administrator, the [NAME] of Attorney for both residents and the Physician. State Registered Nurse Aide (SRNA) #8 who was working on the 500 Unit where Resident #46 and Resident #200 resided at the time of the incident on 05/19/18, was phoned for interview by the State Agency Representative; however, could not be reached. The State Agency Representative phoned on 07/19/19 at 11:01 AM. SRNA #9 who was the other staff on the unit at the time of the incident no longer worked at the facility. Interview with the Director of Social Services, on 07/19/19 at 10:20 AM, revealed there had been no history of arguments or altercations between Resident #46 and Resident #200 prior to the incident on 05/19/18 and the facility felt it was an isolated event. Interview with the Assistant DON, on 07/19/19 at 4:45 PM, revealed it was her expectation staff ensure there were no physical altercations between residents. Per interview, she was unaware of Resident #46 and Resident #200 having any physical altercations or arguments prior to 05/19/18. Interview with the DON, on 07/19/19 at 4:05 PM, revealed the facility had a responsibility to protect the residents from abuse. Per interview, the allegation of physical abuse between Resident #46 and Resident #200 was unwitnessed; however, the facility took steps to protect the resident after the allegation including placing Resident #200 on fifteen (15) minutes checks and moving Resident #200 to a different room. She stated there had been no further concerns with the two (2) residents getting along. Per interview, residents had the right to be free from abuse. Interview with the Administrator on 07/09/19 at 6:45 PM, revealed residents had the right to be treated with dignity, respect and to be free from abuse.

Based on interview, record review, and review of facility Policies, it was determined the facility failed to develop and implement written policies related to reporting and investigating allegations of abuse. This affected four (4) of of twenty one (21) sampled residents (Resident #41, #46, #49 and #200). There was no documented evidence the facility implemented their written abuse policies related to completing a thorough investigation related to an allegation on 05/19/18, of a physical altercation between Resident #46 and Resident #200. In addition, there was no documented evidence this allegation of abuse was reported to State Agencies within two (2) hours as per regulation. (Refer to F-600, F-609 and F-610) In addition, there was no documented evidence the facility implemented their written abuse policies related to completing a thorough investigation after staff witnessed Resident #41 kiss Resident #49 on the mouth on 04/23/19 and also witnessed Resident #41 kiss Resident #49 on 04/27/19 two (2) different times. In addition, there was no documented evidence these allegations were reported to State Agencies within two (2) hours as per regulation. (Refer to F-609 and F-610) Furthermore, there was no documented evidence the facility written abuse policies had been developed with verbage to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services). The findings include: Review of the facility's Reporting Abuse to Facility Management Policy, revised 04/2012, revealed should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator or designees, will provide verbal/written notices to State Agencies within twenty-four (24) hours including the survey and certification agency, Adult Protective Services, the local police department, the ombudsman, and others as may be required by state or local laws. However, the facility Policy had not been developed related to ensuring that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the facility Resident-to-Resident Altercations, Policy, dated November 2010, revealed all investigations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Review of the facility Accidents and Incidents - Investigating and Reporting Policy, revised July 2017, revealed all accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. Staff interviews and record review revealed Resident #46 alleged Resident #200 hit him/her five (5) times in the arm on 05/19/18, due to an argument over the bathroom. However, there was no documented evidence the facility notified State Agencies within two (2) hours of the allegation, nor was there documented evidence a thorough investigation was completed related to the allegation. (Refer to F-600, F-609 and F-610) Interview with Social Service Director, on 07/19/20 at 10:20 AM, revealed it was her understanding the facility had twenty-four (24) hours to report abuse unless there was an injury and then it had to be reported within two (2) hours. Further interview revealed usually she, the Administrator, or the DON initiated the abuse investigations, but ultimately the Administrator would oversee the investigations. Continued interview revealed for resident-to-resident altercations, the residents involved and any resident or staff witnesses would need to be interviewed. Interview with the Director of Nursing (DON), on 07/19/19 at 4:05 PM, revealed she thought the facility had twenty-four (24) hours to report abuse allegations to the Office of Inspector General (OIG) and the Department of Community Based Services (DCBS). Further interview revealed the investigation related to the altercation between Resident #46 and Resident #200 was a joint effort between herself, the SSD and the Administrator. She stated corrective actions were taken after the altercation to keep the residents safe including fifteen (15) minute checks and a room change for Resident #200. However, she further stated she was unaware of any statements obtained related to the altercation other than LPN #6's statement, and she was unaware of any interviews with other staff who were on the unit at the time of the incident, or other residents who may have been nearby at the time of the incident. Additional interview revealed she was unaware of any documented individual interviews with the residents involved (Resident #46 and Resident #200), other than the remarks made by the residents documented in LPN #6's witness statement. Interview with the Administrator, on 07/19/19 at 6:45 PM, revealed her interpretation of the regulation, was that if there was serious bodily injury the abuse allegation had to be reported within two (2 hours), but otherwise abuse allegations could be reported within twenty-four (24) hours. Further interview revealed the investigation submitted for review related to the altercation between Resident #46 and Resident #200 was not as thorough as she would have liked it to be. She confirmed there were no other witness statements besides the one written by LPN #6 and no other interviews obtained from other staff who were on the unit at the time of the incident. Additional interview revealed LPN #6 included the residents immediate statements from Resident #46 and Resident #200 at the time of the incident in her witness statement; however, there was no further interviews obtained from these resident in order to gather additional information related to the altercation. 2. Staff interviews and record review revealed Resident #41 kissed Resident #49 on the mouth on 04/23/19 and also Resident #41 kissed Resident #49 on 04/27/19 two (2) different times. However, there was no documented evidence the allegations were reported to State Agencies, nor was there documented evidence a thorough investigation was completed related to the allegations in order to substantiate or unsubstantiate abuse occurred. (Refer to F-609 and F-610) Interview with the Director of Social Services (DSS), on 07/19/19 at 3:00 PM, revealed State Agencies were not notified of the incidents related to Resident #41 kissing Resident #49 to her knowledge. She further stated she was aware of all the incidents where Resident #41 kissed Resident #49 as per the documentation in the medical record. However, she did not conduct a formal investigation related to the incidents as she felt the kissing behavior was consensual between Resident #41 and #49. Interview with the Director of Nursing (DON), on 07/19/19 at 5:35 PM, revealed they had discussed the incidents related to Resident #41 and Resident #49 kissing in the Interdisciplinary Team (IDT) meeting and did not think the incidents needed to be reported as they were not sexual in nature. Further interview revealed the team did not think the incidents needed to be fully investigated. Interview with the Administrator, on 07/19/19 at 5:45 PM, revealed the instances of Resident #41 kissing Resident #49 was not reported to the State Agencies as the facility did not consider it to be sexual abuse. However, the Administrator was unable to submit an investigation related to the incidents in order to substantiate abuse did not occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #49's medical record revealed the facility admitted the resident on 10/03/18 with diagnoses including Cerebral Infarction, Dysphagia, Dementia in other Diseases Classified Elsewhere with Behavioral Disturbances, and Depressive Disorder. Review of Resident #49's Significant Change MDS Assessment, dated 02/17/19, revealed under Section E for Behaviors, the resident exhibited physical behavioral symptoms directed towards others one (1) to three (3) days, during the seven (7) day look back period. Review of the Social Service Note, dated 04/29/19 at 8:56 AM, revealed she spoke with this resident who had received kisses on the cheek from another resident. Per the Note, he laughed and said he was not bothered by it. Review of Resident #41's medical record revealed the facility admitted the resident on 03/21/18 with diagnoses including Bipolar Type Schizoaffective Disorder, Bipolar Disorder, and Anxiety Disorder. Review of Resident #41's Quarterly MDS assessment dated [DATE], revealed under Section E for Behaviors, the resident exhibited no behaviors during the seven (7) day look back period. Review of Resident #41's Nurse's Note, dated 04/23/19 at 6:10 AM, revealed the nurse on the A side called to inform the nurse on the B side, that Resident #41 went into room [ROOM NUMBER] and kissed Resident #49 on the mouth. Per the Note, a State Registered Nurse Aide (SRNA) was in the room giving care and said she told Resident #41 he/she wasn't allowed in the room, and the resident ignored the SRNA. Review of Resident #41's Social Services Note, dated 04/24/19 at 10:49 AM, revealed the resident had been educated on not kissing other residents. Per the Note, this resident was not kissing as a sexual kiss, but this was how the resident says hello. Per the Note, Resident #41 indicated he/she would not kiss anymore. The resident was educated on how this could be seen as inappropriate and the resident gave verbal understanding. Further review revealed the other resident involved was not under any distress and was friends with Resident #41. Review of Resident #41's Progress Notes, dated 04/27/19 at 1:33 PM revealed a Nurse's Note signed by LPN #2, which stated Resident #41 was walking down the hall and Resident #49 was wheeling down the hall. Resident #41 reached over and kissed other resident in the mouth. Other resident attempted to push him/her away and this resident grabbed him/her by the arm and still kissed him/her. After Resident #41 kissed Resident #49, Resident #41 leaned up and told Resident #49 see you later sexy. The writer told Resident #41 that he/she could not do that and it was inappropriate. Resident #41 told LPN #2 to shut up and that he/she could kiss who he/she wanted. Review of Resident #41's Nurse's Note, dated 04/27/19 at 4:35 AM, revealed Resident #41 came over to side A and saw Resident #49 sitting in his/her chair by the nurse's station. Per the Note, Resident #41 went up and gave Resident #49 a kiss. The Nurse explained to Resident #41 this was inappropriate behavior and the resident mumbled something under his/her breath as he/she left. Interview with the Director of Social Services (DSS), on 07/19/19 at 3:00 PM, revealed she felt the kissing was consensual between Resident #41 and #49, and therefore did not further investigate the incidents after speaking to Resident #41 on 04/24/19. Per interview, State Agencies were not notified of the incidents to her knowledge. Interview with the Director of Nursing (DON), on 07/19/19 at 5:35 PM, revealed they had discussed the incidents related to Resident #41 and Resident #49 kissing in the Interdisciplinary Team (IDT) meeting. She stated the team did not think the incidents needed to be reported as they were not sexual in nature. Interview with the Administrator, on 07/19/19 at 5:45 PM, revealed the instances of Resident #41 kissing Resident #49 was not reported to the State Agencies as it was not considered sexual abuse. However, the Administrator was unable to submit an investigation completed by the facility related to the incidents in order to substantiate abuse did not occur. Based on interview, and record review, it was determined the facility failed to ensure all alleged violations involving abuse or neglect, were reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility and to State Agencies for four (4) of of twenty one (21) sampled Residents (Resident #41, #46, #49 and #200). Staff interviews and review of the facility Investigation, revealed Resident #46 alleged Resident #200 hit him/her five (5) times in the arm on 05/19/18, due to an argument over the bathroom; however, there was no documented evidence the facility notified State Agencies within two (2) hours of the allegation. (Refer to F-600 and F-610) In addition, staff interviews and record review, revealed staff witnessed Resident #41 kiss Resident #49 on the mouth on 04/23/19 and also witnessed Resident #41 kiss Resident #49 on 04/27/19 two (2) different times. However, there was no documented evidence the allegations were reported to State Agencies. (Refer to F-610) The findings include: Review of the facility's Reporting Abuse to Facility Management Policy, revised 04/2012, revealed should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator or designees, will provide verbal/written notices to State Agencies within twenty-four (24) hours including the survey and certification agency, Adult Protective Services, the local police department, the ombudsman, and others as may be required by state or local laws. However, the facility Policy had not been developed related to ensuring that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 1. Review of the facility Reportable documentation, revealed the Department of Community Based Services (DCBS) was notified on 05/20/18 at 10:27 AM, by the facility of an incident that occurred on 05/19/18 at 3:20 PM. Resident #46 reported Resident #200 hit Resident #46 due to them arguing over the bathroom. However, there was no documented evidence the allegation was reported to the Office of Inspector General (OIG), nor was there documented evidence the allegation was reported to DCBS within the two (2) hour required timeframe. Review of the Incident/Condition Report, signed by the Director of Nursing (DON), dated 05/21/18, revealed on 05/19/18 at 3:20 PM in the resident bathroom, there was an unwitnessed resident to resident altercation. Resident #46 revealed {he/she hit me five (5) times referring to Resident #200. A Skin Assessment completed for Resident #46 revealed no injuries. Per the Report, the residents needed to toilet at the same time which resulted in agitation. The [NAME] of Attorney for both residents were notified of the allegation, Resident #200 was moved to a different room, and the Physician was notified. The Investigation consisted of one (1) Witness Statement written by Licensed Practical Nurse (LPN) #6, dated 05/19/18 at 3:20 PM. Per the Witness Statement, LPN #6 saw Resident #46 come out of room [ROOM NUMBER] and state, {he/she} hit me five (5) times, referring to Resident #200. Resident #200 then replied, I hit {him/her}. The residents had argued over the bathroom, and the residents were then separated. Continued review of the Statement, revealed Resident #46 was assessed and there was no red areas or bruises to skin. Resident #46 was then reassessed at 4:00 PM, and there still was no bruising or redness noted. Resident #200 moved to room [ROOM NUMBER]-1. Both resident POAs were notified of the incident. Interview with Social Service Director on 07/19/20 at 10:20 AM, revealed it was her understanding the facility had twenty-four (24) hours to report abuse unless there was an injury and then it had to be reported within two (2) hours. Interview with the Director of Nursing (DON) on 07/19/19 at 4:05 PM, revealed she thought the facility had twenty-four (24) hours to report abuse allegations to OIG and DCBS. Interview with the Administrator, on 07/19/19 at 6:45 PM, revealed it was her expectation for the initial report to start immediately after the facility learned of an allegation of abuse. She further stated her interpretation of the regulation, was that if there was serious bodily injury the abuse allegation had to be reported within two (2 hours), but otherwise abuse allegations could be reported within twenty-four (24) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #49's clinical record revealed the facility admitted the resident on 10/03/18 with diagnoses including Cerebral Infarction, Dysphagia, Dementia in other Diseases Classified Elsewhere with Behavioral Disturbances, and Depressive Disorder. Review of the Significant Change MDS Assessment, dated 02/17/19, revealed under Section E for Behaviors, the resident exhibited physical behavioral symptoms directed towards others one (1) to three (3) days, during the seven (7) day look back period. Review of Resident #49's Comprehensive Care Plan, initiated 02/21/19, revealed a focus of cognitive loss due to severely impaired cognition and exhibited poor safety awareness and poor decisional capacity. The goal revealed the resident would maintain cognitive ability. There were several interventions including monitor BIMS quarterly, encourage to allow care, and interchange staff should resident prefer one (1) staff member to another. Additional review of Resident #49's Comprehensive Care Plan, initiated 02/21/19, revealed a focus of behavioral symptoms as the resident had a history of having his hand in his brief or hands on his penis, and could be combative. There was a notation on the Care Plan stating the resident's Daughter indicates resident is very sexual. The goal revealed the resident would have fewer combative episodes. Interventions included encourage to allow care, report behavioral symptoms to staff nurse, and in house psyche per orders. Review of Resident #49's Social Service Note, dated 04/29/19 at 8:56 AM, revealed she spoke with this resident who had received kisses on the cheek from another resident. Further review revealed he laughed and said he was not bothered by it. Review of Resident #41's clinical record revealed the facility admitted the resident on 03/21/18 with diagnoses including Bipolar Type Schizoaffective Disorder, Bipolar Disorder, and Anxiety Disorder. Review of Resident #41's Quarterly MDS Assessment, dated 02/28/19, revealed under Section E for Behaviors, revealed the resident exhibited no behaviors during the seven (7) day look back period. Review of Resident #41's Comprehensive Care Plan revealed a focus of behavioral symptoms initiated on 07/04/18. The goal stated the resident would have behavioral symptoms managed. There were several interventions including encourage activities as he/she will allow, Psychotherapy per the Interdisciplinary Team, firmly redirect resident should resident attempt to kiss another resident, and re-direct resident to an activity at the facility that the resident likes. Review of Resident #41's Nurse's Note, dated 04/23/19 at 6:10 AM, revealed the nurse on the A side called to inform the nurse on the B side, that Resident #41 went into room [ROOM NUMBER] and kissed Resident #49 on the mouth. Per the Note, a State Registered Nurse Aide (SRNA) was in the room giving care and stated she told Resident #41 he/she wasn't allowed in the room, and the resident ignored the SRNA. Review of Resident #41's Social Services Note, dated 04/24/19 at 10:49 AM, revealed the resident had been educated on not kissing other residents. Further review revealed this resident was not kissing as a sexual kiss, but this was how the resident says hello. According to the Note, Resident #41 indicated he/she would not kiss anymore. Per the Note, the resident was educated on how this could be seen as inappropriate and the resident gave verbal understanding. Additional review revealed the other resident involved was not under any distress and was friends with Resident #41. Review of Resident #41's Progress Notes, dated 04/27/19 at 1:33 PM revealed a Nurse's Note written by LPN #2, which stated Resident #41 was walking down the hall and Resident #49 was wheeling down the hall. Resident #41 was observed to reach over and kiss other resident in the mouth. The other resident attempted to push him/her away and this resident grabbed him/her by the arm and still kissed him/her. After Resident #41 kissed Resident #49, Resident #41 told Resident #49 see you later sexy. The writer told Resident #41 that he/she could not do that as it was inappropriate. Per the Note, Resident #41 then told LPN #2 to shut up and that he/she could kiss who he/she wanted. Interview with LPN #2, on 07/19/19 at 10:36 AM, revealed she had observed Resident #41 kiss Resident #49, as per the Progress Note. She stated, to her knowledge this was the only time she has seen it occur. Review of Resident #41's Nurse's Note, dated 04/27/19 at 4:35 AM, revealed Resident #41 came over to the side A and saw Resident #49 sitting in his/her chair by the nurse's station. Further review revealed Resident #41 went up and gave Resident #49 a kiss. According to the Note, the nurse explained to Resident #41 this was inappropriate behavior and the resident mumbled something under his/her breath as he/she left. Interview with the Director of Social Services (DSS), on 07/19/19 at 3:00 PM, revealed she was aware of all the incidents where Resident #41 kissed Resident #49 as per the documentation in the medical record. She stated she felt the kissing was consensual between Resident #41 and #49. Per interview, she had observed the residents kiss each other once before, but she did not document this instance as again she felt it was consensual. She stated she did not further investigate the incidents after speaking to Resident #41 on 04/24/19. Interview with the Director of Nursing (DON), on 07/19/19 at 5:35 PM, revealed they had discussed the incidents related to Resident #41 and Resident #49 kissing during the Interdisciplinary Team (IDT) meeting. She further stated the team did not think the incidents needed to be further investigated as they were not sexual in nature. Interview with the Administrator, on 07/19/19 at 5:45 PM, revealed there was no documented investigation to submit for review related to the instances of Resident #41 kissing Resident #49 as this was not investigated or considered sexual abuse. However, the Administrator acknowledged due to there being no documented investigation, it could not be substantiated that abuse did not occur. Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure all alleged violations of abuse are thoroughly investigated for two (2) of twenty-one (21) sampled residents (Resident #41 and #46). On 05/19/18, Licensed Practical Nurse (LPN) #6 reported an allegation of resident-to-resident abuse involving Resident #46 and Resident #200 to the Administrator. However, there was no documented evidence of a thorough investigation related to the allegation. (Refer to F-600 and F-609) In addition, staff interviews and record review, revealed staff witnessed Resident #41 kiss Resident #49 on the mouth on 04/23/19 and again witnessed Resident #41 kiss Resident #49 on 04/27/19 two (2) different times. However, there was no documented evidence an investigation was completed related to the allegations. (Refer to F-609) The findings include: Review of the facility Resident-to-Resident Altercations, Policy, dated November 2010, revealed all investigations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Review of the facility Accidents and Incidents - Investigating and Reporting Policy, revised July 2017, revealed all accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. Review of the facility Reportable documentation, revealed on 05/20/18 at 10:27 AM, the facility notified the Department of Community Based Services (DCBS) of an incident that occurred on 05/19/18 at 3:20 PM. Per the allegation, Resident #46 reported Resident #200 hit Resident #46 due to them arguing over the bathroom. Review of the Incident/Condition Report, completed by the Director of Nursing (DON), dated 05/21/18, revealed on 05/19/18 at 3:20 PM in the resident bathroom, an unwitnessed resident to resident altercation occurred. Resident #46 stated, {he/she} hit me five (5) times, referring to Resident #200. A Skin Assessment was completed for Resident #46 with no injuries noted. Per the Report, the residents needed to toilet at the same time, and this resulted in agitation. The [NAME] of Attorney for both residents were notified of the allegation, the Physician was notified of the allegation, and Resident #200 was moved to a different room. Review of Resident #46's Medical Record, revealed the facility admitted the resident on 03/30/16 with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Dementia without behavioral disturbance, Anxiety Disorder, Delusional Disorder and Paranoid Personality Disorder. Review of Resident #46's Annual Minimum Data Set (MDS) Assessment, dated 05/02/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of (15) out (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having no behaviors. Review of Resident #46's Comprehensive Care Plan, initiated 05/04/18, revealed the resident was short tempered and would become angry when there was a situation he/she did not like and was very paranoid at times. The goal revealed the resident would have behavioral symptoms managed with new and current interventions. The interventions included: staff to speak with a calm and positive voice and make good eye contact related to Paranoia. Review of Resident #46's Bedside Skin Assessment Worksheet, dated 05/19/18 at 3:25 PM, and 4:00 PM, signed by LPN #6, revealed there was no redness or bruising noted. Review of Resident #46's Social Worker's Note, dated 05/21/18 at 2:36 PM, revealed she documented she had spoken with this resident related to psychosocial well-being related to reported incident this weekend. Further review revealed the resident seemed pleasant. Review of Resident #200's medical record revealed the facility re-admitted the resident on 10/12/17 with diagnoses to include Systolic and Diastolic Heart Failure, Atherosclerotic Heart Disease, Cerebral Infarction, and Hemiplegia and Hemiparesis. Review of the Resident #200's Annual MDS Assessment, dated 05/14/18, revealed the facility assessed the resident as having a BIMS score of (15) out (15) which indicated no cognitive impairment. Additional review of the MDS Assessment, revealed the facility assessed the resident as having no behaviors. Review of Resident #200's Comprehensive Care Plan, initiated 03/14/19, revealed a focus of Mood State related to a history of generalized anxiety disorders. The goal revealed the resident Resident would have a PHQ (Patient Health Questionnaire for psychological assessment tool) less than five (5) (which would suggest the resident would not need depression treatment). The interventions included: allow resident to call his/her daughter if he/she becomes anxious or upset; continue medications for mood, depression and anxiety; encourage frequent family visits; and psychotherapy as ordered. Further review of Resident #200's medical record, revealed the resident was placed on fifteen (15) minute checks on the dates of 05/19/18, 05/20/18, 05/21/18, 05/22/18, 05/23/18, and 05/24/18. Review of Resident #200's Physician's Orders, dated 05/21/18 at 3:40 PM, revealed orders for the resident to change rooms from 601-1 to room [ROOM NUMBER]-1. Interview 07/16/19 at 10:46 AM, with Resident #46, revealed someone came into the room and beat me up. Further interview revealed the incident happened a while ago and had not happened since. The resident was unable to further elaborate on the event. Interview with LPN #6, on 07/19/19 at 10:35 AM, revealed on 05/19/18, as she was getting ready to perform medication pass, Resident #46 came out of his/her bedroom and was arguing with Resident #200 (his/her roommate). Continued interview revealed the two (2) residents were separated and Resident #200 was placed on fifteen (15) minute checks and moved to a different room. LPN #6 stated she wrote up a witness statement as requested by the Administrator when she notified her by phone. State Registered Nurse Aide (SRNA) #8 who was working on the 500 Unit where Resident #46 and Resident #200 resided at the time of the incident on 05/19/18, was phoned for interview on 07/19/19 at 11:01 AM, by the State Agency Representative. However, SRNA #8 could not be reached. SRNA #9, who was the other staff on the unit at the time of the incident no longer worked at the facility. Review of the facility Investigation, revealed there was only one (1) witness statement obtained, which was written by LPN #6, dated 05/19/18 at 3:20 PM. According to the Statement, LPN #6 saw Resident #46 come out of room [ROOM NUMBER] and stated, {he/she} hit me five (5) times, referring to Resident #200. Resident #200 stated, I hit {him/her}. The residents had argued over the bathroom, and the residents were separated. Continued review of the Statement, revealed Resident #46 was assessed and there was no red areas or bruises to skin. Resident #46 was then reassessed at 4:00 PM, and there still was no bruising or redness noted. Resident #200 moved to room [ROOM NUMBER]-1. Both resident [NAME] of Attorney were notified of the incident. However, further review of the Investigation, revealed there was no documented evidence other staff on the unit at the time of the incident or other residents who may have been nearby at the time of the incident on 05/19/18 were interviewed. In addition, there was not documented evidence of a thorough interview documented with Resident #46 and Resident #200 in order to find the root cause of the altercation. Interview with the Director of Social Services (SSD), on 07/19/19 at 10:20 AM, revealed usually she, the Administrator, or the DON initiated the abuse investigations, but ultimately the Administrator would oversee the investigations. She further stated for resident-to-resident altercations, the residents involved and any resident or staff witnesses would need to be interviewed. Interview with the DON, on 07/19/19 at 4:05 PM, revealed the investigation related to the altercation between Resident #46 and Resident #200 was a joint effort between herself, the SSD and the Administrator. Per interview, corrective actions were taken after the altercation to keep the residents safe including fifteen (15) minute checks and a room change for Resident #200. However, she stated she was unaware of any statements obtained related to the altercation other than LPN #6's statement, and she was unaware of any interviews with other staff who were on the unit at the time of the incident, or other residents who may have been nearby at the time of the incident. Further, she was unaware of any documented individual interviews with the residents involved (Resident #46 and Resident #200), other than the remarks made by the residents documented in LPN #6's witness statement. Interview with the Administrator, on 07/19/19 at 3:18 PM, revealed the investigation submitted for review related to the altercation between Resident #46 and Resident #200 was not as thorough as she would have liked it to be. She verified there were no other witness statements besides the one written by LPN #6 and no other interviews obtained from other staff who were on the unit at the time of the incident. Further, although LPN #6 included the residents immediate statements from Resident #46 and Resident #200 at the time of the incident in her witness statement, there was no further interviews obtained from these resident in order to gather additional information related to the altercation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to submit the Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for one (1) of twenty-one (21) sampled residents (Residents #41). Resident #41 was re-admitted to the facility on on 04/15/19; however, his/her Entry MDS Assessment was not submitted until 05/12/19. The findings include: Review of the facility MDS Completion and Submission Timeframes Policy, revised 07/2017 revealed the Assessment Coordinator was responsible for ensuring resident assessments were submitted to CMS in accordance with federal and state guidelines. Further review of the Policy, revealed timeframes for submission of assessments was based on the current requirement published in the Resident Assessment Instrument (RAI) Manual. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, Version 1.16, dated October 2018, Chapter 5 Submission and Correction of MDS Assessments, revealed Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records). Review of Resident #41's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including Schizophrenia and Hypertension. Review of the MDS 3.0 NH Final Validation Report (CMS Submission Report), dated 05/12/19, revealed one (1) of twelve (12) MDS Assessment records was transmitted late. The facility received warning error message -3810a, assessment submitted late, the submission date is more than fourteen (14) day after A1600 on this new (A0050 equals 1) entry tracking record ( A0310F equals 01) for Resident #41. Interview with the MDS Coordinator, on 07/19/19 at 12:00 PM, revealed she had been working in the role of MDS Coordinator at this facility for twenty (20) years. Per interview, she used the RAI Manual 3.0 Guidelines to know when to complete and submit MDS Assessments; and entry assessments should be transmitted fourteen (14) days after completion. Further, she stated the assessment for Resident #41 was missed when the resident returned to the facility on [DATE]. However, she stated the assessment should have been completed and submitted as per the RAI Manual. Interview with the Director of Nursing (DON), on 07/19/19 at 5:46 PM, revealed she had been in the DON role at the facility since 2017. Per interview, the facility utilized the RAI Guidelines for reference related to timeliness and completion of assessments, and submission timeframes. She stated she was unaware the entry Assessment for Resident #41 was submitted late; and it was her expectation the Assessments be completed per the RAI guidelines. Continued interview revealed the facility had no auditing process in place to ensure MDS Assessments were completed per RAI Guidelines and relied on the Submission Reports to ensure assessments were timely. Interview with the Administrator, on 07/19/19 at 6:49 PM, revealed she had been in her current role for twenty (20) years. She stated it was her expectation the MDS Coordinators follow the RAI Manual related to completing and submitting MDS Assessments, for timeliness and accuracy of resident assessments. Per interview, the facility relied on the MDS Coordinator to review the Submission Reports to ensure the MDS Assessments were completed and submitted timely. Further interview revealed Resident #41's entry Assessment should have been submitted per RAI Guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to assure the accuracy and completion of Section E related to Behaviors on the Minimum Data Set (MDS) Assessment, for two (2) of twenty-one (21) sampled residents (Resident #41 and #69). Resident #41's Annual Minimum Data Set (MDS) Assessment, dated 05/31/19, revealed the resident exhibited no behaviors; however, review of the Nurse's Notes dated 05/29/19 and 05/30/19, and the Monthly Flow Record dated 05/24/19 through 05/31/19, revealed the resident was demanding, and impatient and exhibiting explosive and attention seeking behaviors. In addition, Resident #69's Quarterly Minimum Data Set (MDS) Assessment, dated 06/25/19, revealed the resident had no hallucinations, and no delusions. However, review of the Nurse's Notes dated 06/19/19, and 06/20/19 and the Social Services Note, dated 06/21/19, revealed the resident exhibited behavioral symptoms as well as hallucinations and delusions. The findings include: Review of the facility Certifying Accuracy of the Resident Assessment Policy, revised 12/2009, revealed all personnel who complete any portion of the Resident Assessment (MDS) certify the accuracy of that portion of the assessment. Further, falsification in the resident assessment would be promptly addressed. Review of the Centers for Medicare and Medicaid Services: Resident Assessment Instrument (RAI) Manual 3.0, Version 1.15, dated October 2017, revealed the primary purpose of the MDS Assessment was to identify resident care problems, address resident problems in individualized care plans, and monitor the quality of care provided to residents. Additional review revealed the Assessment should be an accurate reflection of the resident's status. Further review revealed identification of behavioral symptoms and frequency during the Assessment Reference Date (ARD) was the focus of Section E - Behavior, to accurately determine, evaluate, and develop care plan interventions to improve the symptoms or reduce their impact. 1. Review of Resident #41's clinical record revealed the facility admitted the resident on 03/21/18 with diagnoses including Bipolar Type Schizoaffective Disorder, Bipolar Disorder, and Anxiety Disorder. Review of Resident #41's current July 2019 Monthly Physician's Orders, revealed orders for psychotropic medication including Klonopin 0.5 milligram (mg) (anti-anxiety medication) three (3) times a day related to Anxiety with a start date of 04/15/19; Depakote 500 mg (medication to treat Bipolar Disorder) tablet twice a day for Bipolar Disorder with a start date of 04/15/19; Invega 6 mg tablet ( antipsychotic medication) related to Bipolar Disorder once a day with a start date of 05/201/9; and Seroquel 400 mg ( antipsychotic) at bedtime and 100 mg in the morning for Bipolar Disorder with a start date of 04/19/19. Review of the Nurse's Note, date 05/29/19 at 2:08 PM, revealed the resident continues to be demanding and impatient with staff. Further review revealed there was no adverse drug reactions related to medications noted. Review of Resident #41's Nurse's Note dated 05/30/19 at 2:08 PM, revealed the resident continues with gradual dose reductions of Depakote and Invega. No adverse reactions observed. Further review revealed the resident continues with usual behaviors and staff will continue to monitor. Review of Resident #41's Behavior/Intervention Monthly Flow Record dated 05/24/19 through 05/31/19, revealed the resident had no changes in his/her explosive and attention seeking behaviors. Review of Resident #41's Annual Minimum Data Set (MDS) Assessment, dated 05/31/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status of a fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident in Section E as exhibiting no behaviors in the last seven (7) days. However, review of the Nurse's Notes dated 05/29/19 and 05/30/19, and the Monthly Flow Record dated 05/24/19 through 05/31/19, revealed the resident was demanding, and impatient and exhibiting explosive and attention seeking behaviors. 2. Review of Resident #69's medical record revealed the facility admitted the Resident on 05/29/19 with diagnoses including, but not limited to Alzheimer's Dementia, Dementia with Lewy Bodies, Visual Hallucinations, Anorexia, and Anxiety Disorder. Review of Resident #69's current Monthly July 2019 Physician's Orders, revealed orders for ABH Gel gel 0.5 milliliter (ml) to wrist every six (6) hours for behaviors, with a start date of 05/31/19; sertraline twenty five (25) mg (antidepressant medication) at night (HS) for depression, with a start date of 06/04/19; lorazepam one (1) milligram (mg) at bedtime (HS) for anxiety (anti-anxiety medication), with a start date of 06/06/19; and Ziprasidone twenty (20) mg twice a day for psychosis (antipsychotic), with a start date of 06/19/19. Review of Resident #69's Nurse's Note, dated 06/19/19 at 10:30 PM, revealed the resident was having tearful episodes related to being lonely and had nobody to talk to and felt like family was not caring about him/her anymore. Further review of the Note, revealed tender loving care was given to the resident, and the resident was calmer. Review of Resident #69's Nurse's Note, dated 06/20/19 at 9:00 PM, revealed the resident was noted sitting naked on the floor with the television on his/her right foot. Per the Note, the resident kept saying, the man gave {him/her} pajamas. Review of Resident #69's Social Services Note, dated 06/21/19 at 11:23 AM, revealed the resident became argumentative with staff when introduced to a potential new roommate. Per the Note, the resident stated he/she had paper work from the judge and had bought the whole facility and was not to have a roommate. Additional review revealed the resident became more aggravated and more delusional as the discussion progressed and the potential new roommate was not safe in the resident's room. Further review revealed the resident's representative was notified of the resident not being accepting of a roommate and the need for the resident to change rooms. Review of the subsequent Social Services Note, dated 06/25/19 at 10:43 AM, revealed Resident #69 continued to exhibit hallucinations and delusions. Review of Resident #69's Quarterly Minimum Data Set (MDS) Assessment, dated 06/25/19, revealed the facility assessed the resident as usually able to make himself/herself understood and understand others and assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Additional review of the MDS Assessment, revealed the facility assessed the resident as receiving antipsychotic, antianxiety, and antidepressant medications seven (7) days out of the last seven (7) days. Further reviewed the MDS Assessment, revealed the facility assessed the resident as having no delirium, no hallucinations, and no delusions Continued review of the MDS Assessment revealed the facility assessed the resident as exhibiting no physical, verbal or other behavioral symptoms directed towards others; and as having no rejection of care present and no wandering present. However, review of the Nurse's Notes dated 06/19/19, and 06/20/19 and the Social Services Note, dated 06/21/19, revealed the resident exhibited behavioral symptoms as well as hallucinations and delusions. Interview with the MDS Coordinator, on 07/19/19 at 12:00 PM, revealed the Social Worker was responsible for completing Section E of the MDS Assessment related to Behaviors, during the Assessment period. Additional interview revealed Resident #41 and Resident #69's medical record, including Progress Notes and Social Service Notes should have been reviewed during the seven (7) day look back period, to accurately complete the Assessment. Continued interview revealed if behavioral symptoms were documented in the medical record they should have been captured in the MDS Assessment. Further, it was important to ensure the MDS Assessment was completed accurately because information on the Assessment drove the development and revision of the Comprehensive Care Plan and ensured care was provided to meet the residents' needs. Interview with the Social Services Director, on 07/19/19 at 12:16 PM, revealed she was responsible for completing section E related to Behaviors for the MDS Assessments. She stated she gathered information/data for the MDS Assessment through staff and resident interviews and documentation in the medical record; such as flowsheets and progress notes. Per interview, if behavior symptoms were documented in the medical record during the Assessment look back period it was included in the MDS assessment. Continued interview revealed it was Important for the MDS Assessment to be an accurate reflection of the residents' current status and needs during that look back period. She further stated the MDS Assessment was a tool to monitor cognition and psychosocial wellbeing, to establish a base line of the resident and to develop or revise the care plan to meet the resident needs. Further interview with the Social Services Director, revealed Resident #41's Progress Notes on 06/19/19, 06/21/19 and 06/25/19 noted behavioral symptoms which should should have been included on the MDS assessment dated [DATE]. She also acknowledged Resident #69's behavioral symptoms, hallucinations and delusions exhibited during the look back period should have been reflected on the MDS assessment dated [DATE]. Interview with the Director of Nursing, (DON), on 07/19/19 at 5:46 PM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were completed. Per interview, the MDS Assessments guided the development of the Comprehensive Care Plans and therefore the MDS Assessment was to be an accurate reflection of the resident's status to ensure residents received appropriate services and individualized care. Further interview revealed it was important to provided treatment and services for residents with behavioral health needs to improve symptoms or reduce their impact and to ensure quality care to the residents. Continued interview revealed the MDS Assessment for Resident #41 and Resident #69 should have identified his/her behavioral symptoms documented in the medical record during the Assessment look back period. Additionally, the DON stated the facility had no audit process in place to ensure MDS Assessments were completed accurately per RAI Guidelines. Interview with the Administrator, on 07/19/19 at 6:49 PM, revealed the facility was to utilize the RAI Manual and facility policy as resources to ensure accuracy of the MDS Assessments. Per interview, it was important for a resident with behavioral health needs to be assessed accurately to ensure each resident's individual needs were met and resources were provide as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Incident/Condition Report, completed by the Director of Nursing (DON), dated 05/21/18, revealed on 05/19/18 at 3:20 PM there was an unwitnessed resident to resident altercation in the resident bathroom. Resident #46 stated, {he/she} hit me five (5) times and was referring to Resident #200. Per the Report, a Skin Assessment was completed for Resident #46 with no injuries noted. Further review of the Report, revealed the residents needed to toilet at the same time resulting in agitation. [NAME] of Attorney for both residents and the Physician were notified of the allegation and Resident #200 was moved to a different room. Review of the facility Investigation, revealed a Witness Statement written by Licensed Practical Nurse (LPN) #6, dated 05/19/18 at 3:20 PM. Per the Statement, LPN #6 observed Resident #46 come out of room [ROOM NUMBER] and state, he/she hit me five (5) times, referring to Resident #200. Resident #200 stated, I hit {him/her}. Per the Statement, the residents had argued over the bathroom, and the residents were separated. Further review of the Statement, revealed Resident #46 was assessed after the incident and again at 4:00 PM, and there was no red areas or bruises to his/her skin. Per the Statement, Resident #200 was moved to room [ROOM NUMBER]-1, and both resident [NAME] of Attorney were notified. Review of Resident #46's Medical Record, revealed the facility admitted the resident on 03/30/16 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Dementia without behavioral disturbance, Anxiety Disorder, Delusional Disorder and Paranoid Personality Disorder. Review of Resident #46's Annual Minimum Data Set (MDS) Assessment, dated 05/02/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of (15) out (15) indicating the resident intact cognition. Further review revealed the facility assessed the resident as having no behaviors. Review of Comprehensive Care Plan, initiated 05/04/18, revealed Resident #46 was short tempered and became angry when there was a situation he/she did not like and was very paranoid at times. Per the goal, the resident would have behavioral symptoms managed with new and current interventions. The Care Plan interventions included staff to speak with calm and positive voice with good eye contact related to Paranoia. Review of Resident #46's Social Worker's Note, dated 05/21/18 at 2:36 PM, revealed she spoke with this resident related to psychosocial well-being related to reported incident this weekend. He/she reported he/she was fine and seemed pleasant with this writer. Further review of Resident #46's Comprehensive Care Plan, revealed there was no revision related to the physical altercation that occurred on 05/19/18, with interventions to prevent recurrence. Review of Resident #200's medical record revealed the facility re-admitted the resident on 10/12/17 with diagnoses which included Systolic and Diastolic Heart Failure, Atherosclerotic Heart Disease, Cerebral Infarction, and Hemiplegia and Hemiparesis. Review of the Resident #200's Annual MDS Assessment, dated 05/14/18, revealed the facility assessed the resident as having a BIMS score of (15) out (15) indicating the resident was cognitively intact. Additional review of the MDS Assessment, revealed the facility assessed the resident as having no behaviors. Review of Resident #200's Comprehensive Care Plan, initiated 03/14/19, revealed a focus of Mood State related to a history of generalized anxiety disorders. Per the goal, the resident would have a PHQ (Patient Health Questionnaire for psychological assessment tool) less than five (5) (which would suggest the resident would not need depression treatment). The interventions included: allow resident to call his/her daughter if he/she becomes anxious or upset; continue medications for mood, depression and anxiety; encourage frequent family visits; and psychotherapy as ordered. Review of Resident #200's medical record, revealed the resident was placed on fifteen (15) minute checks on 05/19/18, 05/20/18, 05/21/18, 05/22/18, 05/23/18, and 05/24/18. Review of Resident #200's Physician's Orders, dated 05/21/18 at 3:40 PM, revealed orders for the resident to have a room change from room [ROOM NUMBER]-1 to room [ROOM NUMBER]-1. Further review of Resident #200's Comprehensive Care Plan, revealed there was no revision related to the physical altercation that occurred on 05/19/18, with interventions to prevent recurrence. Interview with the Social Service Director, on 07/19/19 10:20 AM, revealed it was her role to update the Comprehensive Care Plan related to psychosocial issues. When questioned if she was to revise the Care Plans when there were resident to resident altercations with interventions to prevent recurrence, she stated she was not sure this would need to be care planned. Further interview revealed this was because staff had a heightened awareness about the history of the aggressive residents and they would know to look for behaviors for those residents. Interview with the DON, on 07/19/19 at 4:05 PM, revealed the allegation of physical abuse between Resident #46 and Resident #200 was unwitnessed; however, the facility took steps to protect the residents after the allegation including placing Resident #200 on fifteen (15) minutes checks and moving Resident #200 to a different room. Per interview, the incident and the interventions implemented should have been care planned. Interview with the Administrator, on 07/19/19 at 6:49 PM, revealed if a resident were to hit another resident, that would be considered a change in condition or unusual incident and she would expect the altercation to be addressed in the Comprehensive Care Plan in order for both residents' behaviors to be monitored by staff. Per interview, it was her expectation the Comprehensive Care Plans be revised after resident to resident altercations for the protection of the residents. Based on observation, interview, record review and review of facility policies, it was determined the facility failed to revise the Comprehensive Care Plan for three (3) of twenty-one (21) sampled residents (Resident #46, #57 and #200). Record review revealed Resident #57 was observed to be shaving his/her head with a razor on 07/09/19 and sustained several nicks to the scalp. However, there was no documented evidence the Comprehensive Care Plan was revised in order to prevent recurrence. In addition, review of the Incident/Condition Report, dated 07/16/19, revealed Resident #57 was found with small nicks noted on the left posterior scalp, and was noted to have two (2) disposable razors and small scissors in the drawer by the sink in the resident's room. However, again there was no documented evidence the Comprehensive Care Plan was revised to prevent recurrence. (Refer to F-689) Furthermore, record review revealed on 05/19/18, Licensed Practical Nurse (LPN) #6 reported an alleged resident-to-resident physical altercation involving Resident #46 and Resident #200 to the Administrator. However, there was no documented evidence the Comprehensive Care Plan was revised to prevent recurrence. (Refer to F-600) The findings include: Review of the Using the Care Plan Policy, revised 08/2006, revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Per Policy, changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. Further review revealed documentation must be consistent with the resident's care plan. Review of the Behavior Management Policy, dated 12/21/15, revealed the facility was to make a reasonable effort to ensure when a resident displays mental or psychosocial adjustment difficulties that he she receives appropriate treatment and services to address the identified problems. Further review revealed, Distressed behavior is behavior that reflects discomfort or emotional strain. It may present as crying, apathetic or withdrawn behavior. Or, as a verbal and physical action such as pacing, cursing, scratching, tearing things or grabbing others. Continued review of the Policy, revealed upon identification of contributing factors of the resident's mood and/or behavior problems the interdisciplinary team will review interventions and effectiveness for further recommendations and update the plan of care. Review of the Resident-to-Resident Altercation Policy, dated November 2010, revealed if two (2) residents are involved in an altercation, staff will make any necessary changes in the care plan approaches to any or all of the involved individuals. 1. Review of Resident #57's clinical record revealed the facility admitted the resident on 05/17/17 with diagnoses including, but not limited to Alcohol Dependence With Alcohol-Induced Persisting Dementia, and Aphasia following unspecified Cerebrovascular Disease. Review of Resident #57's Quarterly Minimum Data Set (MDS) Assessment, dated 06/21/19, revealed the facility assessed the resident as having no expressive aphasia and was sometimes understood. Additionally, the resident was assessed as having a Brief Interview for Mental status (BIMS) score of three (03) out of fifteen (15) indicating severe cognitive impairment. Review of the Progress Notes, dated 07/09/19 at 2:44 PM, revealed Resident #57 was noted to be shaving his/her head with a razor. Further, Social Services searched the room to remove razors, educated the resident of the dangers, and also noted the resident had several nicks on the scalp. Review of the Nurse's Notes, dated 07/10/19, 07/11/19, 07/12/19, and 07/13/19, revealed the resident's room was checked and no razors were found. However, review of Resident #57's Comprehensive Care Plan, revealed there was no documented evidence of a revision related to the resident shaving his/her head resulting in razor nicks on 07/09/19. In addition, there was no documented evidence the Care Plan was revised with interventions to prevent recurrence. Review of Resident #57's Nurse's Progress Notes, dated 07/16/19 at 1:35 PM, revealed the resident was in the dining room and staff reported the resident's head was bleeding. Per the Note, the resident was escorted back to the nurse's station, and the resident's left posterior scalp was bleeding, due to two (2) nicked areas where the resident had used a razor on his/her head. Further review revealed the resident's Power of Attorney and the Physician were notified and new orders were obtained for wound care to the area. Further review of Resident #57's Comprehensive Care Plan, revealed no documented evidence of the razor nick incident on 07/16/19, or interventions related to the new order for wound care or interventions to prevent recurrence. Review of the Nurse's Notes, dated 07/17/19 at 2:23 PM, completed by Licensed Practical Nurse (LPN) #8, revealed State Registered Nurse Aide (SRNA) #6 had taken Resident #57 out for a supervised smoke break, and SRNA #6 informed the nurse, the resident got angry at her and shoved her out of the chair. Per the Note, the SRNA sustained a fall and during this incident, Resident had grabbed three (3) packs of cigarettes. Further review of the Note, revealed LPN # 8 attempted to retrieve the cigarettes from the resident and the resident cursed and would not give the cigarettes back to LPN # 8. Per the Note, Resident #57 then shoved LPN #8 twice against her shoulders in the day room and she notified Social Services. Review of the Facility Timeline, undated, revealed on 07/17/19, Resident #57 had an explosive episode in the courtyard; and Social Services heard yelling and responded to the incident. Social Services remained with the resident and attempted to calm him/her. Resident #57 was then placed on every fifteen (15) minute checks. Review of the Physicians Orders, dated 07/17/19, revealed order for Behavioral Health to evaluate and admit the resident if needed related to physical aggression and hitting multiple staff. However, further review of Resident #57's Comprehensive Care Plan revealed no documented evidence of a revision related to the explosive episode in the courtyard with interventions to prevent recurrence. Interview with LPN #8, on 07/18/19 3:23 PM, revealed after the incident related to Resident #57 shaving his/her head and getting nicked with razors on 07/09/19, staff were monitoring the resident's room for razors. However, she stated the resident's Comprehensive Care Plan was not revised related to the incidents on 07/09/19 or 07/16/19 related to the resident nicking himself/herself with razors, nor was it updated with intervention to prevent recurrence such as monitoring the resident's room for razors. Further interview with LPN #8, revealed the Comprehensive Care Plan was also not revised related to interventions staff was implementing related to monitoring the resident every fifteen (15) minutes and monitoring the resident's room for cigarettes related to the resident's aggressive behaviors on 07/17/19. Further interview revealed Resident #57's Comprehensive Care Plan and Nurse Aide Care Plan should have been revised with current interventions related to behaviors in order for staff involved in the resident's care to be knowledgeable of how to provide care for the resident. Interview with the Social Services Director, on 07/19/19 at 12:16 PM, revealed she was responsible to ensure the Comprehensive Care Plan was revised and implemented related to behaviors. Per interview, she read all nursing notes from the last twenty-four (24) hours for every resident each morning to ensure if behaviors symptoms were present the resident's care planned interventions were in place and there was no further interventions necessary. She stated it was important to revise the Comprehensive Care Plan to identify and address behaviors in order to ensure a resident's psychosocial wellbeing was maintained and quality care was provided for the residents. Further interview revealed Resident #57's Comprehensive Care Plan should have been revised related to the resident's behaviors with interventions to prevent recurrence related to the resident nicking self with razors on 07/09/19, and 07/16/19 and related to his/her aggressive behaviors on 07/17/19. Interview with the Assistant Director of Nursing (ADON), on 07/19/19 at 4:33 PM, revealed staff was expected to utilize the Care Plans and be familiar with the interventions to be implemented for each individual resident including monitoring as outlined in the Care Plans. Per interview, it was important the Comprehensive Plans and Nurse Aide Care Plans be revised related to behaviors exhibited with interventions to prevent recurrence in order for staff to safely care for the residents. Interview with the Director of Nursing (DON), on 07/19/19 at 5:46 PM, revealed she expected the facility policies related to Care Plans to be implemented by staff. Per interview, Resident #57's Comprehensive Care Plan and Nurse Aide Care Plan should have been revised related to the resident's behaviors with interventions to prevent recurrence related to the resident nicking self with razors on 07/09/19, and 07/16/19 and related to his/her aggressive behaviors on 07/17/19. Per interview, the Care Plans were a reference for staff to utilize in providing necessary care for the well being of the residents. Interview with the Administrator, on 07/19/19 at 6:49 PM, revealed Resident #57's Comprehensive Care Plan should have been revised with new interventions to prevent recurrence after the resident nicked himself/herself with razors on 07/09/19, and 07/16/19 and after the resident exhibited behaviors on 07/17/19. Per interview, this was important to ensure the resident was supervised to maintain his/her safety and for the safety of the other residents and staff.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to provide an environment that was free from accident hazards and failed to provide supervision to each resident to prevent avoidable accidents including implementing interventions to reduce hazard(s) and risk(s), monitoring for effectiveness and modifying interventions when necessary for one (1) of twenty-one (21) sampled residents, (Resident #57). Observation on 07/16/19 at 11:33 PM, revealed the State Agency Representative entered the hallway and noticed Resident #57 walking down the hall to the dining room with blood running down the back of his/her scalp and on to his/her shirt. The facility investigation determined the resident had two (2) disposable razors in his/her room and had received the cuts to his/her scalp from shaving his/her head unsupervised. The findings include: Review of the facility's Policy titled, Accidents and Incidents- Investigation and Reporting, dated revised 07/2017, revealed all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. Further review of the Policy, revealed the facility Safety Committee should review the incident/accident reports related to accident or safety hazards in the facility and analyze any individual resident vulnerabilities. Review of Resident #57's medical record revealed the facility admitted the resident on 05/17/17 with diagnoses including, but not limited to Alcohol Dependence With Alcohol-Induced Persisting Dementia and Aphasia following unspecified Cerebrovascular Disease. Review of Resident #57's Quarterly Minimum Data Set (MDS) Assessment, dated 06/21/19 revealed the resident had no hearing or vision deficit; however, the resident had expressive aphasia and was only sometimes understood. Additionally, the resident had a Brief Interview of Mental status (BIMS) score of three (03) out of fifteen (15) indicating severe cognitive impairment. Per the MDS Assessment, the resident had no delirium, no hallucinations and no delusions. Review of Resident #57's Comprehensive Care Plan, revised 06/24/19, revealed a focus of Behavioral Symptoms stating there were times the resident could be explosive with staff, and the resident was known to refuse showers. The goal stated behavioral symptoms would be managed. Interventions included psychiatric consult per orders, acute charting to monitor irritability as needed (PRN), and allow ample time to process and respond to information. Further review of Resident #57's Comprehensive Care Plan, revised 06/24/19, revealed a focus of Activities of Daily Living (ADL) Function stating the resident was alert and verbal and could make needs known. The goal stated the resident would continue current status of ADL's. Interventions included: elopement risk, able to feed self, ambulates independently, dressing with limited assistance of one (1) staff, oral care every shift and as needed per self with supervision and set up, personal hygiene per limited assistance of one (1) staff, and shower two (2) times per week with limited assistance of one (1) staff in the AM. Review of the Incident/Condition Report, dated 07/09/19, revealed Resident #57 was noted to shave his/her head with a razor. The Report revealed Social Services searched the resident's room to remove razors. Per the Report, the resident was educated to the dangers, and also there were several nicks noted on the resident's scalp. Further review of the Report, under Possible Causative Factor, revealed Resident Caused. The Power of Attorney (POA) and Physician were notified. The Report documented no new interventions or orders, but stated would continue to monitor. Observation on 07/16/19 at 11:33 PM, revealed the State Survey Representative entered the hallway and noticed Resident #57 walking down the hall to the dining room with blood running down the back of the resident's scalp and on to his/her shirt. The State Survey Representative made staff aware. Review of the Incident/Condition Report, dated 07/16/19, revealed, Resident #57 was found in dining room, with small nicks noted on left posterior scalp, area cleansed with wound cleanser 4 x 4 (guaze) applied, blotted dry, and applied polymer and med fix to area of denuded skin. Under the section titled, Possible Causative Factor, the report noted the resident had two (2) disposable razors and small scissors in the drawer by the sink in the resident's room. The POA and Physician were notified. Under the section titled, New Interventions/Orders, it stated, areas were cleansed on the scalp with wound cleanser, blot dry, and to apply polyamine every three (3) days and PRN (as needed ) for seven (7) days and re-evaluate. However, there was no interventions noted to prevent recurrence. Interview with Licensed Practical Nurse (LPN) #8, on 07/18/19 at 3:23 PM, revealed she had worked there for twenty (20) years and she was assigned to Resident #57 on 07/16/19. She stated they were checking the resident's room daily for razors. She further stated she did not know if the resident was coming up to the nurse's station and asking for razors or not, but in the past Resident #57 was independent with shaving his/her face. Per interview, this same resident had another shaving incident on 07/09/19 and the decision was made to take razors out of his/her room. Further interview revealed she was not sure where Resident #57 was getting the razors because they kept razors secured and locked up in the clean utility closet. She further stated she notified the Physician of the incident with the razor on 07/16/19, and the Physician stated to follow the facility protocol. Per interview, staff was monitoring the resident's room for razors and staff would report any razors found and these would be removed. Interview on 07/18/19 at 3:37 PM, with Unit Manager #2, revealed Resident #57 was independent except for showers and some ADL assistance was needed. She stated he/she, was sometimes loud, and had issues communicating because of dementia. She further stated she did not know how the resident got the razors, and further stated Resident #57 never verbalized about wanting to shave his/her head. Per interview, the resident usually went to the beauty shop for a hair cut. Interview on 07/18/19 at 3:48 PM, with LPN #8/Weekend Supervisor, revealed Resident #57 was pretty independent. She stated staff helped with bathing and setting up his/her tooth brush, and the resident required assistance with shaving. She further stated she was not sure how the resident was getting the razors. Further interview revealed she was aware of the first incident with the razors on 07/09/19; however, she was not aware of the incident on 07/16/19. She stated the razors were locked up in the clean utility room, so staff would have to get them out for the residents. Continued interview revealed typically they would include on the Comprehensive Care Plan for the resident to not have razors; however, she was not sure if the resident was care planned for no razors. She reviewed Resident #57's Nurse Aide Care Plan and stated there was no intervention stating the resident could not have razors. She further stated the risk factors related to the resident having the availability of razors included infection, wounds, and possibly cutting his/her neck which could be real bad. Per interview, the resident's Nurse Aide Care Plan should have been updated to state the resident could not have razors. Interview with State Registered Nurse Aide (SRNA) #6, 07/19/19 at 10:00 AM, who often cared for Resident #57, revealed the resident was independent with care except for showers and shaving. She stated the resident must be supervised while shaving. Further interview revealed the razors were kept in the clean utility room and only staff had access to the room where the razors were stored. Further, sometimes razors were left in the shower room, and the resident may have been able to pick up a razor from the shower room if staff inadvertently left one in there. Interview with Registered Nurse (RN) #4/Quality Assurance (QA) Nurse, on 07/19/19 at 10:45 AM, revealed she had worked at the facility for three (3) years, and had only been in the role of QA Nurse for a month. She stated prior to this role she was a floor nurse. She further stated it was staff's responsibility to make sure the residents were safe at all times. Per interview, the razors were not kept in resident rooms, but were kept in the supply closet which was not accessible to residents. She stated the razors were disposable, so they should be used once and then disposed of in the sharps containers. She further stated the only way the resident could have obtained the razor, was if someone had taken razors to the shower room and hadn't yet removed the razors and supplies after assisting a resident with a shower. Per interview, it was also possible the resident my know the code to get into the shower room. Additional interview revealed when an incident happened, staff filled out an Incident/Accident Report and added the residents to the acute charting list. Per interview, the Nurse Aide Care Plan and Comprehensive Care Plan would be revised with new interventions related to the incident to prevent recurrence. The QA Nurse stated there was no intervention on Resident #57's Nurse Aide Care Plan stating the resident could not have a razor, but this intervention should have been added to the care plan after the first incident on 07/09/19 in order for the State Registered Nurse Aides (SRNA) to be aware of this. She stated there was a break down in the system and the fact that the resident could not have razors may not have been communicated to staff caring for the resident. Per interview, the risk factors related to the resident obtaining a razor included harm to himself/herself or others. The QA Nurse stated there was the potential for great harm if residents had sharps of any kind. Continued interview revealed there needed to be behavioral monitoring in place to ensure Resident #57 did not have access to razors. Interview with State Registered Nurse Aide (SRNA) #2, on 07/19/19 at 11:15 AM, revealed razors were kept in the clean utility room and once they were used they were to be placed in the red biohazard box. She stated residents sometimes asked for a razor to shave themselves, and she would ask if she could assist, so they would not shave self alone. She further stated she was not aware of the incident regarding Resident #57 shaving his/her head. SRNA #2 reviewed the Nurse Aide Care Plan and confirmed there was not anything on the document related to the resident not being allowed to have razors. She further stated it would be important for that information to be on the Nurse Aide Care Plan and to be communicated to staff in an attempt to prevent the resident from further injuring himself/herself. Interview with the MDS Coordinator, on 07/19/19 at 1:35 PM, revealed she had been working at the facility for twenty (20) years in the MDS role. She stated Resident #57 had dementia and it was related to alcohol dependence. She further stated the resident had a hard time communicating at times. Further interview revealed the incidents related to the resident nicking himself/herself with razors had been communicated in shift report. Per interview, she was unsure how the resident obtained the razors, as staff did not let residents have sharp objects in their rooms. She stated if residents had access to razors they could harm themselves or someone else. She further stated Resident #57 should have had adequate supervision to prevent the resident from obtaining more razors after the first incident of the resident nicking himself with the razors. Further, the Nurse Aide Care Plan as well as the Comprehensive Care Plan should have been revised with an intervention not to allow the resident to have razors as well as to monitor room related to razors. Interview with the Assistant Director of Nursing (ADON), on 07/19/19 at 3:30 PM, revealed she had worked at the facility for six (6) years. She stated the facility kept Care Plans in Binders at both nurses station for A side and B side, and Care Plans were also in the computer under Point Click Care. She further stated Care Plans/Nurse Aide Care Plans were also hanging in the residents' closets for easy reference while providing care. Further interview revealed she had received an incident report stating Resident #57 had nicked his/her head with a razor, and the razor was removed from his/her room by the Social Service Director on 07/09/19. She stated she did not know how the resident got the razors as they were kept in a clean utility room with a keypad door. She stated the resident was then monitored with acute charting documented with frequent checks to ensure razors were not in the resident's room. She further stated no residents were allowed to have razors in their rooms and no sharps were to be left out. Further interview revealed Resident #57 should have been care planned to ensure the resident did not have access to razors and everyone should have been on high alert to ensure the resident did not have a razor in order to prevent the resident from harming self or others. Interview with the Social Services Director, on 07/19/19 at 3:45 PM, revealed she had worked at the facility for thirteen (13) years. She stated she was not sure how Resident #57 obtained the razors the first time; however, her assistant was the one that removed them from the resident's room and stated they didn't look like facility razors. Further, she had no clue how the resident obtained the razors and scissors the second time, but they had been removed from the resident's room. She stated she felt like there was a lack of monitoring related to this issue. Continued interview revealed everyone would need to be aware the resident was not allowed to have razors, as the facility had a responsibility to keep the resident safe. Interview with the Director of Nursing (DON), on 07/19/19 at 4:10 PM, revealed she had worked at the facility for twelve (12) years. She stated it was her expectation the nurses would have notified all staff caring for Resident #57 when the first razor incident happened in order for staff to keep an eye out for razors in the resident's room and to supervise and monitor the resident closely to prevent recurrence. Per interview, there was a lack of supervision for this resident and the resident had the potential to seriously cut himself/herself with the razors. She stated, My expectation is for all changes of conditions, orders and incidents to be updated on the care plans immediately. She stated Resident #57's Comprehensive Care Plan and Nurse Aide Care Plan should have been revised after the first razor incident in order to monitor for any razors in the resident's room and to monitor for access to razors. She further stated she was not sure where the resident obtained razors or scissors on 07/16/19; however, it was her expectation for staff to supervise residents when shaving and it was also her expectation for staff to maintain the resident's safety and the safety of the other residents. Interview with the Administrator, on 07/19/19 at 6:45 PM, revealed it was discussed in employee orientation that used razors were to be disposed of in the sharps container and staff was re-educated on this annually. Per interview it was her expectation staff ensured residents did not have access to razors and sharps and any razors noted in residents rooms be removed. Further, for any accident/incident, the Incident Report should be immediately completed with new interventions to prevent recurrence. Additional interview revealed Resident #57's Comprehensive Care Plan and Nurse Aide Care Plan should have been revised with new interventions to prevent recurrence after the resident nicked himself/herself with the razors. Per interview, this was to ensure the resident was supervised to maintain his/her safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #53's clinical record revealed the facility admitted the resident on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Dementia with Behavioral Disturbance, Major Depressive Disorder, and Restlessness and Agitation. Review of Resident #53's CCP, revealed a focus of psychotropic drug use with an initiation date of [DATE]. The goal stated the resident would be/remain free of psychotropic drug related complications. The interventions included: administer psychotropic medications as ordered by physician; monitor for side effects and effectiveness; monitor/document/report as needed any adverse reactions of psychotropic medications; Psych to see as needed; consult with pharmacy and Physician to consider dosage reduction when clinically appropriate at least quarterly; and monitor/record occurrence of target behavior symptoms and document per facility protocol. Review of Resident #53's CCP, revealed a focus related to Anxiety Disorder with an initiation date of [DATE]. The goal stated the resident would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. The interventions included: administer anti-anxiety medications as ordered by physician and monitor for side effects and effectiveness; monitor resident for safety; monitor/document/report as needed any adverse reactions related to Anti-anxiety therapy and monitor/record occurrence of target behavior symptoms and document per facility protocol. However, the CCP was not developed with interventions to be implemented prior to adminsitration of a PRN antianxiety medication. Review of Resident #53's CCP, revealed a focus of behavioral symptoms with an initiation date of [DATE]. The goal stated the resident would have behavioral symptoms managed with new or current interventions through target date. The interventions included: redirect resident when exhibiting inappropriate behaviors; approach resident with a positive attitude and smile; continue medications for anxiety as needed; Ativan (anti-anxiety medication) four (4) times a day routinely; Seroquel related to agitation/anxiety; continue medication related to depression; encourage resident to call for assistance with having shortness of air and observe every fifteen (15) minutes as needed; and offer sweets and coffee to redirect. However, the CCP was not developed to identify the resident's target behaviors. Further review of the CCP, revealed a focus of antipsychotics with an initiation date of [DATE]. The goal stated the resident would be free from discomfort or adverse reactions to antipsychotic medications by next review. The interventions included: administer medications per order; monitor for side effects of medications including lethargy, weakness, falls, decline in activities of daily living, agitation, dizziness, and extrapyramidal signs or symptoms; and labs per orders. Continued review of Resident #53's CCP, revealed a focus of antidepressant use with an initiation date of [DATE]. The goal stated the resident would be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions included: administer antidepressant medications as ordered; monitor as needed for adverse reactions to antidepressants, change in mood, behaviors, cognition, hallucinations, delusions, social isolation, suicidal thoughts, decline in Activities of Daily Living (ADLs), constipation, gait changes, balance problems, weight loss, fatigue, dizziness, tremors and dry mouth. Review of Resident #53's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (03) out of fifteen (15) indicating severe cognitive impairment. Further review revealed Section N-Medications, revealed Resident #53 received antipsychotic medication five (5) days; antianxiety medications five (5) days; and antidepressant medication five (5) days out of seven (7) days during the seven (7) day look back period. Review of Resident #69's Monthly [DATE] Physician's Orders, revealed psychotropic medication orders for ABH Gel gel 0.5 milliliter (ml) to wrist every six (6) hours for behaviors with a start date of [DATE] (compounded drug containing Ativan, Benadryl and Haldol); Sertraline 25 mg at HS for depression with a start date of [DATE] (antidepressant medication); Lorazepam 1.0 mg at bedtime (HS) for anxiety with a start date of [DATE] (antianxiety medication); and Ziprasidone 20 mg twice a day for psychosis with a start date of [DATE] (antipsychotic medication). Review of the Medication Administration Record (MAR) revealed a PRN (as needed) Lorazepam one (1) mg was administered on [DATE] at 9:30 PM, [DATE] at 10:00 PM, and [DATE] at 10:50 AM. However, review of the medical record revealed there was no documented evidence of behavioral health interventions implemented prior to pharmacological intervention nor was there documented justification for the PRN medication on [DATE], [DATE], and [DATE] . In addition, there was no documentation related to the effectiveness/ineffectiveness of the medication on these dates. Review of the [DATE] Progress Notes, and [DATE] Progress Notes, revealed no documentation related to the resident's behaviors or lack of behaviors for the month. Review of the Behavioral/Intervention Monthly Flow Record, dated [DATE], revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The two (2) target behaviors listed for the medications was agitation and anxiety. There were one hundred eighty (180) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, one hundred thirty-three (133) opportunities had incomplete documentation. Review of the Behavioral/Intervention Monthly Flow Record, dated [DATE], revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The one (1) target behavior listed for the medication was physical aggression. There were fifty (50) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty-six (36) opportunities had incomplete documentation. There was no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring for Resident #53 related to any of the resident's Psychotropic medications per review of the Behavioral/Intervention Monthly Flow Records for June and [DATE], as outlined in the CCP. Based on interview, record review, and review of facility policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's mental and psychosocial needs for five (5) of twenty-one (21) sampled residents (Residents #3, #7, #18, #53, and #69). There was no documented evidence Comprehensive Care Plans (CCPs) were consistently developed to identify target behaviors with individualized interventions to manage behavior symptoms for residents receiving Psychotropic Medications. In addition, there was no documented evidence the CCPs were consistently implemented related to monitoring behaviors and monitoring for adverse affects of psychotropic drugs. These failures affected Resident #3, #7, #18, #53, and #69. (Refer to F-758, and F-745) The findings include: Review of the facility's Care Planning-Interdisciplinary Team Policy, revised [DATE], revealed the facility would develop and implement a person centered care plan for each resident. Additionally, the Comprehensive Care Plan (CCP) was based on the resident assessment, (Minimum Data Set Assessment). Review of the facility's Using the Care Plan Policy, revised [DATE], revealed the CCP was used in developing the resident's daily routine and documentation must be consistent with the resident's CCP. Review of the facility's Behavior/Intervention Monthly Flow Record, revealed target behaviors, interventions, outcome and medication side effects would be monitored. Per the Flow Record, the number of behavior episodes was recorded in the box; a Potential Side Effect numerical Code or a blank box would indicate psychotropic drug use side effects; Outcome Interventions Codes were plus sign (+) for improved, zero (0) for unchanged and minus sign (-), for worsened. 1. Review of Resident #3's clinical record revealed the facility admitted the Resident on [DATE], with diagnoses including, but not limited to Alzheimer's Dementia, Major Depressive Disorder, Bipolar Disorder, and Anxiety Disorder. Review of Resident #3's Comprehensive Care Plan (CCP), revised [DATE], revealed the resident received Buspar related to Anxiety Disorder. The goal stated the resident would be free from discomfort or adverse reactions related to antianxiety therapy. Interventions included: administer antianxiety medication as ordered by the physician and monitor for side effects and effectiveness; monitor the resident frequently for safety related to increase risk associated with taking antianxiety medication; and monitor/document/report as necessary adverse reactions of antianxiety medication such as lack of energy, confusion, aggressive impulsive behaviors, and hallucinations. Continued review of Resident #3's CCP, revised [DATE] revealed the resident had Behavioral Symptoms including delusions, hallucinations, anger and aggressive behaviors related to diagnosis of Alzheimer's, Depression with Psychosis, Anxiety, Bipolar and Insomnia. The goal stated the resident would have fewer behavioral symptoms. Interventions included:monitor psychotropic medication changes as they occur. However, there was no documented evidence the CCP was developed to include individualized interventions for managing ongoing behavior symptoms. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (07) out of fifteen (15) indicating severe cognitive impairment. Per the MDS Assessment, the resident had no delirium, no hallucinations, and no delusions. Continued review revealed the facility assessed the resident as having no physical, verbal or other behavioral symptoms directed towards others; no rejection of care present and no wandering present. Further review revealed the resident received seven (7) days of antipsychotic, antianxiety, and antidepressant medication during the seven (7) day look back period. Review of Resident #3's Monthly [DATE] Physician's Orders, revealed orders for psychotropic medication to include Bupropion 150 milligrams (mg) every twelve (12) hours twice a day for bipolar/depression, with a start date of [DATE] (antidepressant medication); Buspar 7.5 mg four (4) times a day for anxiety, with a start date of [DATE] (antianxiety medication); Risperidone 0.50 mg at HS (hour of sleep) for psychosis, with a start date of [DATE] (antipsychotic medication); Risperidone 0.25 mg once daily for psychosis, with a start date of [DATE]; Lamotrigine 200 mg every morning for Bipolar Disorder, with a start date of [DATE] (mood stablizer); and L-methylfolate 15 mg at HS for depression/mood, with a start date of [DATE] (form of folate used to treat depression). Review of the Nurse's Note, dated [DATE] at 4:00 PM, revealed the resident was yelling out and talking about off the wall things; looking for his/her significant other who was deceased . Review of a subsequent Nurse's Note, dated [DATE] at 1:39 PM, revealed staff reported Resident #3 had not been in a very good mood over the past weekend, and the nurse spoke with the Psych Counselor concerning the resident's mood. Review of the Nurses Note, dated [DATE] at 11:15 AM, revealed new orders were received to send the resident to the hospital for further evaluation related to change in mental status and increased behaviors. According to the Note, the resident was upset, and continued to refuse to go. Although Resident #3's Progress Notes, dated [DATE] at 4:00 PM; [DATE] at 1:39 PM; and [DATE] at 11:15 AM, revealed the resident was exhibiting mood/behaviors symptoms, there was no documented evidence of behavioral interventions or outcomes of the above behaviors or ongoing monitoring of behavioral symptoms as outlined in the CCP. Review of the Behavior/Intervention Monthly Flow Record, dated 05/2019, revealed there was a Flow Record for only one (1) of five (5) prescribed psychotropic medications, Risperidone. There was one (1) target behavior listed for the medication, hallucinations. There were ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-eight (28) opportunities had incomplete documentation related to Risperidone medication. Review of the Behavior/Intervention Monthly Flow Record, dated 06/2019, revealed there was a Flow Record for only one (1) of five (5) prescribed psychotropic medications, Risperidone. There was one (1) target behavior listed for the medication, hallucinations. There were ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty-three (33) opportunities had incomplete documentation related to Risperidone medication. Review of the Behavior/Intervention Monthly Flow Record, from [DATE] through [DATE], revealed there was a Flow Record for only one (1) of five (5) prescribed psychotropic medications, Risperidone. There was two (2) target behaviors listed which included verbal aggression and refusing care. There were ninety-six (96) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-five (25) had incomplete documentation related to Risperidone medication. Review of the Behavior/Intervention Monthly Flow Records for May, June, and [DATE], revealed failed opportunities to monitor behavior symptoms and psychotropic drug side effects. Further review revealed inaccurate documentation on the Flow Sheets as there was no documented evidence the behaviors documented in the Progress Notes on [DATE] at 4:00 PM; [DATE] at 1:39 PM; and [DATE] at 11:15 AM were captured on the Flow Sheets. Continued review revealed no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring per the Flow Sheets as outlined in the CCP. 2. Review of Resident #18's clinical record revealed the facility admitted the resident on [DATE], with diagnoses including, but not limited to Alzheimer's Disease, Paranoid Personality Disorder, Anxiety Disorder, Insomnia, and Recurrent Depressive Disorder. Review of Resident #18's CCP, revised [DATE], revealed the resident received Seroquel Antipsychotic Medication related to Paranoid Personality Disorder. The goal stated the resident would be free from discomfort or adverse reactions to antipsychotic medications. Interventions included: administer medications per orders; monitor for side effects of medications such as lethargy, weakness, falls, decline in Activities of Daily Living, agitation; and monitor for target behaviors. Continued review of Resident #18's CCP, revised [DATE], revealed the resident received Psychotropic Medications and was at risk for side effects. The goal stated the resident would not experience undesired effects from medication use. Interventions included: give medications as ordered; monitor for target behaviors; observe for side effects of medications; observe/document/notify for changes with medications adjustments. However, the CCP was not developed to identify the target behaviors. Additional review of Resident #18's CCP, revised [DATE], revealed the resident received Antianxiety Medication related to anxiety. The goal stated the resident would be free from discomfort or adverse reactions. Interventions included: give medication per orders; monitor for safety; and monitor for side effects such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation and depression. Continued review of Resident #18's CCP, revised [DATE], revealed the resident received Antidepressant Medications, Lexapro, Trazadone, and Remeron related to Depression, appetite, and insomnia. The goal stated the resident would be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included: administer medication as ordered; monitor PRN (as needed)for adverse reactions to antidepressant medications such as change in mood, behaviors, cognition, hallucinations, delusions, social isolation, decline in Activities of Daily Living (ADLs, balance problems, weight loss, fatigue and dry mouth. Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (03) out of fifteen (15) indicating severe cognitive impairment. Per the MDS Assessment, the resident had no delirium, no hallucinations, and no delusions. However the facility assessed the resident as having disorganized thinking present and fluctuating. Continued review revealed the Resident had no physical, verbal or other behavioral symptoms directed towards others; no rejection of care present and no wandering present during the seven (7) day look back period. Further, the Resident received seven (7) days of antipsychotic, antianxiety, and antidepressant medication during the seven (7) day look back period. Review pf Resident #18's CCP, revised [DATE], revealed the resident had behavior symptoms related to diagnosis of Alzheimer's/Dementia, anxiety, Paranoid Personality Disorder, Depressive Disorder, and insomnia; history of combativeness, agitation, delusions, cursing, and yelling. The goal stated the resident would have behavior symptoms managed with new and current interventions. Interventions included: report any behaviors to social services; continue medications for paranoia, insomnia, depression and anxiety; psych evaluation and treat for diagnosis; Haldol (antipsychotic) one (1) time dose [DATE]; and discontinue noon dose of Seroquel ([DATE]). However, the CCP was not developed with individualized interventions for managing ongoing behavior symptoms nor was the CCP developed with interventions for non-pharmalogical approaches prior to administration of PRN (as needed) psychotropic medications. Review of the Monthly [DATE] Physician's Orders, revealed psychotropic medication orders for Citalopram 10 mg every morning for Depressive Disorder with a start date of [DATE] (antidepressant medication); Remeron 15 mg daily for Depressive Disorder with a start date of [DATE] (antidepressant medication); Trazadone 100 mg at bedtime for insomnia with a start date of [DATE] (antidepressant medication); Quetiapine Fumarate 25 mg three (3) times a day for Paranoid Personality Disorder with a start date of [DATE] (antipsychotic medication); Haldol 2 mg, one (1) time dose for increased anger, combativeness and aggression with a start date of [DATE] (antipsychotic medication); and Alprazolam 0.5 mg twice a day for anxiety with a start date of [DATE] (antianxiety medication). Review of the Social Services' Note, dated [DATE] at 10:20 AM, revealed the resident switches from subject to subject, as conversation was illogical and the resident had a decline in health related to disease process. Review of the Nurse's Note, dated [DATE] at 2:54 AM, revealed Resident #18 was talking to himself/herself as an aide went into the room; and the resident threatened, swung and cussed at the aide. Review of the Nurse's Note, dated [DATE] at 3:20 AM, revealed Resident #18's representative was notified of behaviors and inquired as to why as needed (PRN) Haldol had been discontinued. Continued review revealed the Nurse's Note, dated [DATE] at 4:57 AM, revealed Haldol 2 mg intramuscular one (1) dose now was administered related to increased anger, combativeness and aggression. However, the medical record revealed there was no documented evidence individualized ongoing behavioral health approaches were implemented prior to the pharmacological intervention. Review of Resident #18's Nurse's Note, dated [DATE] at 12:24 AM, revealed the resident refused his/her medication after multiple attempts per the nurse. Review of Resident #18's Nurse's Note, dated [DATE] at 1:26 PM, revealed the resident had a poor appetite all day and refused eating assistance from staff. Review of Resident #18's Nurse's Note, dated [DATE] at 9:00 PM, revealed the resident was combative with an aide. Although Resident #18's Progress Notes, [DATE] through [DATE] revealed seven (7) notes related to behavioral health symptoms dated [DATE] at 10:20 AM; [DATE] at 02:54 AM; [DATE] at 03:20 AM; [DATE] at 04:57 AM; [DATE] at 12:24 AM; [DATE] at 1:26 PM and on [DATE] at 9:00 PM. However, there was no documented evidence of behavioral interventions or outcomes related to the behaviors or ongoing monitoring of behavioral symptoms as outlined in the CCP. Review of #18's Behavior/Intervention Monthly Flow Record, dated 05/2019, revealed there was a Flow Record for only one (1) of the five (5) prescribed psychotropic medications, Seroquel, with one (1) target behavior listed, Paranoia. There was ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-eight (28) opportunities had incomplete documentation per the Flow Record. Review of Resident #18's Behavior/Intervention Monthly Flow Record, dated 06/2019, revealed there was a Flow Record for only one (1) of the six (6) prescribed psychotropic medications, Seroquel, with two (2) target behaviors listed including Paranoia, and combative behavior. There were one hundred eighty (180) opportunities for staff to complete documentation including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, fifty -seven (57) opportunities had incomplete documentation per the Flow Record. Review of #18's Behavior/Intervention Monthly Flow Record, from [DATE] through [DATE], revealed there was a Flow Record for only one (1) one of the five (5) prescribed psychotropic medications, Seroquel, with two (2) target behaviors listed including combative and refuses care. There were ninety-six (96) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty (30) opportunities had incomplete documentation as per the Flow Record. Further review revealed the Behavior/Intervention Monthly Flow Records dated 05/2019, 06/2019, and 07/2019, revealed failed opportunities to monitor behavioral symptoms and psychotropic drug side effects. In addition, there was inaccurate documentation as there was no documented evidence the behaviors noted in the Progress Notes dated [DATE] at 10:20 AM; [DATE] at 02:54 AM; [DATE] at 03:20 AM; [DATE] at 04:57 AM; [DATE] at 12:24 AM; [DATE] at 1:26 PM and on [DATE] at 9:00 PM were captured on the Flow Sheets. Continued review revealed no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring per the Flow Sheets as outlined in the CCP. 3. Review of Resident #69's clinical record revealed the facility admitted the resident on [DATE], with diagnoses including, but not limited to Alzheimer's Disease, Dementia with Lewy Bodies, Visual Hallucinations, Anorexia, Recurrent Depressive Disorder, and Anxiety Disorder. Review of Resident #69's CCP, revised [DATE], revealed the resident received Ativan related to Anxiety Disorder, Psychosis, Lewy Body, and [NAME] Bonnet Syndrome and had target behaviors including visual and audio hallucinations, accusations, aggression towards staff, verbally abusive, and refuses care. The goal stated the resident would be free from discomfort or adverse reactions related to antianxiety therapy. Interventions included administer antianxiety medications as ordered and monitor for side effects and effectiveness; monitor/document/report as needed adverse reactions to antianxiety therapy and monitor/record occurrences of target behavior symptoms and document per facility protocol. Continued review of Resident #69's CCP, revised [DATE] revealed the resident received Antidepressant medication, Zoloft related to Depression. The goal stated the resident would be free from discomfort or adverse reaction related to antidepressant therapy. Interventions included administer antidepressant medications as ordered; and monitor for adverse reactions to antidepressants, such as change in mood, behaviors, hallucinations, delusions, weight loss, and fatigue. Additional review of Resident #69's CCP, revised [DATE], revealed the resident received antipsychotic medications including ABH gel and Geodon related to Dementia and Psychosis. The goal stated the resident would be free from discomfort of adverse reactions to antipsychotic medications. Interventions included monitor for side effects of medications such as lethargy, weakness, falls, decline in Activities of Daily Living (ADLs), agitation, and dizziness. Continued review of Resident #69's CCP, revised [DATE], revealed the resident received Psychotropic Drugs and had multiple behaviors daily. The goal stated the resident would be/remain free of psychotropic drug related complications or behavioral impairment. Interventions included administer psychotropic medication as ordered and monitor for side effects and effectiveness; monitor for target behaviors; and monitor/record occurrences of target behaviors and document per the facility protocol. Further review of Resident #69's CCP, revised [DATE], revealed the resident had behavioral symptoms such as hallucinations, delusions, paranoia, and combativeness. The goal stated the resident would remain safe despite behavioral symptoms. Interventions included monitor for hallucinations and delusions for improvement or worsening and continue medications related to psychiatric diagnoses. Review of the Progress Notes, dated [DATE] at 10:30 PM, revealed the resident was having tearful episodes related to being lonely and having nobody to talk to and feeling like family was not caring about him/her anymore. Per the Notes, tender loving care given to the resident and he/she appeared calmer. Further review revealed a Nurse's Note, dated [DATE] at 9:00 PM, revealing the resident was noted sitting naked on the floor with television on his/her right foot. However, review of the Progress Notes, dated [DATE] at 10:30 PM and [DATE] at 9:00 PM, revealed there was no documented evidence of behavioral interventions or outcomes of the above behaviors or ongoing monitoring of behavioral symptoms as outlined in the CCP. Review of Resident #69's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score Mental of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Per the MDS Assessment, the resident had no delirium, no hallucinations, no delusions, and no behaviors during the look back period. Further, the facility assessed the resident as receiving seven (7) days of antipsychotic, antianxiety, and antidepressant medications out of the past seven (7) days. However, the documented behavioral events in the medical record during the look back period were not captured in the MDS Assessment (Refer to F-641). Review of the Monthly [DATE], Physician's Orders, dated [DATE] revealed psychotropic medication orders for ABH Gel gel 0.5 milliliter (ml) to wrist every six (6) hours for behaviors with a start date of [DATE] (compounded drug containing Ativan, Benadryl and Haldol); Sertraline 25 mg at HS for depression with a start date of [DATE] (antidepressant medication); Lorazepam 1.0 mg at bedtime (HS) for anxiety with a start date of [DATE] (antianxiety medication); and Ziprasidone 20 mg twice a day for psychosis with a start date of [DATE] (antipsychotic medication). Review of the Behavior/Intervention Monthly Flow Record, dated 05/2019 revealed only one (1) of four (4) prescribed psychotropic medications, Geodon (ziprasidone), had a Flow Record with two (2) target behaviors listed including hallucinations and delusions. There were ninety-three (93) opportunities for staff to complete documentation including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-three (23) opportunities had incomplete documentation. There was no documented evidence of a Behavior/Intervention Monthly Flow Record for [DATE]. Review of the Behavior/Intervention Monthly Flow Record, dated 07/2019 revealed only one (1) of the four (4) prescribed psychotropic medications, Geodon, had a Flow Record with two (2) target behaviors listed including hallucinations and delusions. There were fifty-one (51) opportunities for staff to complete documentation including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, seventeen (17) opportunities had incomplete documentation. Further review revealed the Behavior/Intervention Monthly Flow Records dated 05/2019, and 07/2019, revealed inaccurate documentation as behaviors were not captured as compared to behaviors noted otherwise in the medical record. In addition, there was no documented evidence of individualized behavioral interventions and no documented evidence of consistent Psychotropic Drug use side effects and behavior symptom monitoring as outlined in the CCP. 5. Review of Resident #7's clinical record revealed the facility admitted the resident on [DATE], with diagnoses including, but not limited to Dementia with Behavioral Disturbances, Anxiety Disorder, and Depressive Disorder. Review of Resident #7's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (03) out of fifteen (15) indicating severe cognitive impairment. Per the MDS Assessment, the resident was assessed as having no delirium, no hallucinations, and no delusions. Continued review of the MDS Assessment revealed the facility assessed the resident as having no physical, verbal or other behavioral symptoms directed towards others; as exhibiting no rejection of care or wandering during the look back period. Further, the resident was assessed as receiving antipsychotic, antianxiety, and antidepressant medication seven (7) days out of the past seven (7) days. Review of Resident #7's Comprehensive Care Plan, revised [DATE], revealed the resident received Seroquel (antipsychotic medication), Buspar (antianxiety medication) and Pristiq medication to treat depression) related to Major Neurocognitive Disorder, Anxiety Disorder and Major Depression. The goal stated the resident would not experience any undesired effects from medication use through next review. Interventions included: attempt gradual dose reductions per federal regulation unless clinically contraindicated indications are known, monitor target behaviors, and Psych to see as ordered. However, the CCP was not developed to identify the target behaviors. Additional review of Resident #7's Comprehensive Care Plan, revised [DATE] revealed the resident receiv[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #53's clinical record revealed the facility admitted the resident on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, and Restlessness and Agitation. Review of Resident #53's Monthly [DATE] Physician's Orders, revealed active orders for Ativan (Lorazepam) 1.0 mg by mouth every eight (8) hours as needed for Anxiety (antianxiety medication) initiated [DATE]; Lexapro 10 mg tablet by mouth once daily for Anxiety (antidepressant and antianxiety medication) initiated [DATE]. Ativan 0.5 mg tablet give one tablet by mouth four (4) times a day for Anxiety initiated [DATE] and Seroquel 25 mg tablet by mouth twice a day for Agitation (antipsychotic medication) initiated [DATE]. Review of the Medication Administration Record (MAR) revealed a PRN (as needed)Lorazepam one (1) mg was administered on [DATE] at 9:30 PM, [DATE] at 10:00 PM, and [DATE] at 10:50 AM. However, review of the medical record revealed there was no documented evidence of behavioral health interventions implemented prior to pharmacological intervention nor was there documented justification for the PRN medication on [DATE], [DATE], and [DATE]. Review of Resident #53's Behavioral/Intervention Monthly Flow Record, dated [DATE], revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The two (2) target behaviors listed for the medications was agitation and anxiety. There were one hundred eighty (180) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, one hundred thirty-three (133) opportunities had incomplete documentation. Review of Resident #53's Behavioral/Intervention Monthly Flow Record, dated [DATE], revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The one (1) target behavior listed for the medication was physical aggression. There were fifty (50) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty-six (36) opportunities had incomplete documentation. There was no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring for Resident #53 related to any of the resident's Psychotropic medications per review of the Behavioral/Intervention Monthly Flow Records for June and [DATE]. The facility failed to ensure each resident's psychotropic drug regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well being. There was no documented evidence of adequate monitoring for efficacy and adverse consequences for psychotropic medications. In addition, there was no documented evidence non-pharmacological interventions were used prior to administering a PRN (as needed) psychotropic medication. These failures affected six (6) of (21) twenty-one sampled residents (Resident #3, #7, #18, #53, #57, and #69). Review of the facility's Behavior/Intervention Monthly Flow Sheets revealed target behaviors, interventions, outcome and medication side effects of each psychotropic medication were to be monitored. However, review of Resident #3, #7, #18, #53, #57, and #69's Flow Sheets, revealed not all psychotropic medications were listed on the Flow Sheets to be monitored and not all target behaviors were identified. In addition, staff failed to consistently document on the Flow Sheets each shift. Also, review of the Nurse's Notes revealed no documented evidence non-pharmacological interventions were attempted prior to the administration of a PRN (as needed) psychotropic medication for Residents #18 and #53. The findings include: Review of the facility's Behavior Management Policy, dated [DATE], revealed the policy was to provide guidance for behavior management and appropriate medication interventions. Further review revealed the licensed nurse will document in the resident's care plan to reflect non-drug interventions taken prior to drug treatment, use of psychoactive medication(s) and any reduction plan. The IDT (Interdisciplinary Team) and/or licensed nurse's progress note will reflect the effectiveness of the psychoactive medication, a reduction plan and any side effects experienced by the resident and interventions taken. The monitoring of behavioral occurrence for psychotropic medications in use will be entered into the Medication Administration Record every shift. On a monthly basis, the occurrence of behaviors will be tallied, in addition to any occurrence of adverse reactions. Review of the facility's Medication Monitoring and Management Policy, dated [DATE], revealed all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for efficacy, risks, benefits and harm or adverse consequences. Review of the facility's Behavior/Intervention Monthly Flow Record, revealed target behaviors, interventions, outcome and medication side effects would be monitored. Per the Flow Record, the number of behavior episodes was recorded in the box; a Potential Side Effect numerical Code or a blank box would indicate psychotropic drug use side effects; Outcome Interventions Codes were plus sign (+) for improved, zero (0) for unchanged and minus sign (-), for worsened. 1. Review of Resident #3's medical record revealed the facility admitted the Resident on [DATE], with diagnoses including, but not limited to Alzheimer's Dementia, Major Depressive Disorder, Bipolar Disorder, and Anxiety Disorder. Review of Resident #3's Monthly [DATE] Physician's Orders, revealed psychotropic medication orders including Bupropion 150 milligrams (mg) every twelve (12) hours twice a day for bipolar/depression, with a start date of [DATE] (antidepressant medication); Buspar 7.5 mg four (4) times a day for anxiety, with a start date of [DATE] (antianxiety medication); Risperidone 0.50 mg at HS (hour of sleep) for psychosis, with a start date of [DATE] (antipsychotic medication); Risperidone 0.25 mg once daily for psychosis, with a start date of [DATE]; Lamotrigine 200 mg every morning for Bipolar Disorder, with a start date of [DATE] (mood stablizer); and L-methylfolate 15 mg at HS for depression/mood, with a start date of [DATE] (form of folate used to treat depression). Review of Resident #3's Nurse's Note, dated [DATE] at 4:00 PM, revealed the resident was yelling out and talking about off the wall things; looking for his/her significant other who was deceased . Review of a subsequent Nurse's Note, dated [DATE] at 1:39 PM, revealed staff reported the resident had not been in a very good mood over the past weekend, and the nurse spoke with the Psych Counselor concerning the resident's mood. Further review revealed a Nurses Note, dated [DATE] at 11:15 AM, revealing new orders were received to send the resident to the hospital for further evaluation related to change in mental status and increased behaviors. Per the Note, the resident was upset, and continued to refuse to go. However, review of Resident #3's Behavior/Intervention Monthly Flow Record, dated 05/2019, revealed there was a Flow Record for only one (1) of the five (5) prescribed psychotropic medications, Risperidone. The one (1) target behavior listed for the medication was hallucinations. There were ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-eight (28) opportunities had incomplete documentation. Review of Resident #3's Behavior/Intervention Monthly Flow Record, dated 06/2019, revealed there was a Flow Record for only one (1) of the five (5) prescribed psychotropic medications, Risperidone. The one (1) target behavior listed for the medication was hallucinations. There were ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty-three (33) opportunities had incomplete documentation. Review of Resident #3's Behavior/Intervention Monthly Flow Record, from [DATE] through [DATE], revealed there was a Flow Record for only one (1) of the five (5) prescribed psychotropic medications, Risperidone. There was two (2) target behaviors listed including verbal aggression and refusing care. There were ninety-six (96) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-five (25) had incomplete documentation. Further review revealed the Behavior/Intervention Monthly Flow Records dated 05/2019, 06/ 2019, and 07/2019, revealed inaccurate documentation as behaviors were not captured as compared to the behaviors noted in the Nurse's Notes. In addition, there was no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring related to any of the resident's Psychotropic medications. 2. Review of Resident #18's medical record revealed the facility admitted the resident on [DATE], with diagnoses including, but not limited to Alzheimer's Disease, Paranoid Personality Disorder, Anxiety Disorder, Insomnia, and Recurrent Depressive Disorder. Review of Resident #18's Monthly [DATE] Physician's Orders, revealed psychotropic medication orders for Citalopram 10 mg every morning for Depressive Disorder with a start date of [DATE] (antidepressant medication); Remeron 15 mg daily for Depressive Disorder with a start date of [DATE] (antidepressant medication); Trazadone 100 mg at bedtime for insomnia with a start date of [DATE] (antidepressant medication); Quetiapine Fumarate 25 mg three (3) times a day for Paranoid Personality Disorder with a start date of [DATE] (antipsychotic medication); Haldol 2 mg, one (1) time dose for increased anger, combativeness and aggression with a start date of [DATE] (antipsychotic medication); and Alprazolam 0.5 mg twice a day for anxiety with a start date of [DATE] (antianxiety medication). Review of Resident #18's Social Services' Note, dated [DATE] at 10:20 AM, revealed the resident switches from subject to subject, as conversation was illogical. Resident with decline in health related to disease process. Review of the Nurse's Note, dated [DATE] at 2:54 AM, revealed the resident was talking to himself/herself as an aide went into the room; and the resident threatened, swung and cussed at the aide. Per the Note, the resident refused medication. Review of the Nurse's Note, dated [DATE] at 3:20 AM, revealed the resident's representative was notified of behaviors and inquired as to why as needed (PRN) Haldol had been discontinued. Further review revealed a Nurse's Note, dated [DATE] at 4:57 AM, revealed Haldol 2 mg intramuscular one (1) dose now was administered related to increased anger, combativeness and aggression. However, the medical record revealed there was no documented evidence individualized ongoing behavioral health approaches were implemented prior to the pharmacological intervention. Review of the Nurse's Note, dated [DATE] at 12:24 AM, revealed the resident refused his/her medication after multiple attempts per the nurse. Review of the Nurse's Note, dated [DATE] at 1:26 PM, revealed the resident had a poor appetite all day and refused eating assistance from staff. Review of the Nurse's Note, dated [DATE] at 9:00 PM, revealed the resident was combative with an aide. Review of #18's Behavior/Intervention Monthly Flow Record, dated 05/2019, revealed there was a Flow Record for only one (1) of the five (5) prescribed psychotropic medications, Seroquel, with one (1) target behavior listed, Paranoia. There was ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-eight (28) opportunities had incomplete documentation per the Flow Record. Review of Resident #18's Behavior/Intervention Monthly Flow Record, dated 06/2019, revealed there was a Flow Record for only one (1) of the six (6) prescribed psychotropic medications, Seroquel, with two (2) target behaviors listed including Paranoia, and combative behavior. There were one hundred eighty (180) opportunities for staff to complete documentation including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, fifty -seven (57) opportunities had incomplete documentation per the Flow Record. Review of #18's Behavior/Intervention Monthly Flow Record, from [DATE] through [DATE], revealed there was a Flow Record for only one (1) one of the five (5) prescribed psychotropic medications, Seroquel, with two (2) target behaviors listed including combative and refuses care. There were ninety-six (96) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty (30) opportunities had incomplete documentation as per the Flow Record. Further review revealed the Behavior/Intervention Monthly Flow Records dated 05/2019, 06/2019, and 07/2019, revealed inaccurate documentation as behaviors were not captured as compared with the behaviors noted in the Nurses Notes. In addition, there was no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring related to any of the resident's Psychotropic medications. 3. Review of Resident #69's medical record revealed the facility admitted the Resident on [DATE], with diagnoses including, but not limited to Alzheimer's Disease, Dementia with Lewy Bodies, Visual Hallucinations, Anorexia, Recurrent Depressive Disorder, and Anxiety Disorder. Review of Resident #69's Monthly [DATE] Physician's Orders, revealed psychotropic medication orders for ABH Gel gel 0.5 milliliter (ml) to wrist every six (6) hours for behaviors with a start date of [DATE] (compounded drug containing Ativan, Benadryl and Haldol); Sertraline 25 mg at HS for depression with a start date of [DATE] (antidepressant medication); Lorazepam 1.0 mg at bedtime (HS) for anxiety with a start date of [DATE] (antianxiety medication); and Ziprasidone 20 mg twice a day for psychosis with a start date of [DATE] (antipsychotic medication). Review of Resident #69's Progress Notes, dated [DATE] at 10:30 PM, revealed the resident was having tearful episodes related to being lonely and having nobody to talk to and feeling like family was not caring about him/her anymore. Per the Notes, tender loving care given to the resident and he/she was calmer. Additional review revealed a Nurse's Note, dated [DATE] at 9:00 PM, revealing the resident was noted sitting naked on the floor with television on his/her right foot. Review of Resident #69's Behavior/Intervention Monthly Flow Record, dated 05/2019 revealed only one (1) of four (4) prescribed psychotropic medications, Geodon (ziprasidone), had a Flow Record with two (2) target behaviors listed including hallucinations and delusions. There were ninety-three (93) opportunities for staff to complete documentation including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-three (23) opportunities had incomplete documentation. There was no documented evidence of a Behavior/Intervention Monthly Flow Record for [DATE]. Review of Resident #69's Behavior/Intervention Monthly Flow Record, dated 07/2019 revealed only one (1) of the four (4) prescribed psychotropic medications, Geodon, had a Flow Record with two (2) target behaviors listed including hallucinations and delusions. There were fifty-one (51) opportunities for staff to complete documentation including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, seventeen (17) opportunities had incomplete documentation. Further review revealed the Behavior/Intervention Monthly Flow Records dated 05/2019, and 07/2019, revealed inaccurate documentation as behaviors were not captured as compared to behaviors noted otherwise in the medical record. In addition, there was no documented evidence of consistent Psychotropic Drug use side effects and behavior symptom monitoring related to any of the resident's Psychotropic medications. 5. Review of Resident #7's medical record revealed the facility admitted the resident on [DATE], with diagnoses including, but not limited to Dementia with Behavioral Disturbances, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #7's Monthly [DATE] Physician's Orders, revealed psychotropic medication orders including: Bupropion 10 mg four (4) times a day for anxiety, with a start date of [DATE] (antidepressant medication); Seroquel 25 mg, one (1) tablet daily for major depressive disorder, with a start date of [DATE] (antipsychotic medication); and Pristiq 50 mg once daily for generalized anxiety disorder with a start date of [DATE] (medication used to treat depression). Review of Resident #7's Behavior/Intervention Monthly Flow Record, dated 05/2019, revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The one (1) target behavior listed for the medication was exit seeking. There were ninety-three (93) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, twenty-eight (28) opportunities had incomplete documentation. Review of Resident #7's Behavior/Intervention Monthly Flow Record, dated 06/2019, revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The one (1) target behavior listed for the medication was exit seeking. There were ninety (90) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, thirty-three (33) opportunities had incomplete documentation. Review of Resident #7's Behavior/Intervention Monthly Flow Record, dated 07/2019. Continued review revealed there was a Flow Record for only one (1) of the three (3) prescribed psychotropic medications, Seroquel. The one (1) target behavior listed for the medication was exit seeking. There were fifty (50) opportunities for staff to document information including number of episodes, intervention, outcome and side effects for the day, evening and night shifts on the Flow Record; however, eighteen (18) opportunities had incomplete documentation. There was no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring related to any of the resident's psychotropic medications for Resident #7. 6. Review of Resident #57's medical record revealed the facility admitted the resident on [DATE] with diagnoses including, but not limited to Alcohol Dependence with Alcohol-Induced Persisting Dementia, and Aphasia following unspecified Cerebrovascular Disease. Review of Resident #57's Monthly [DATE] Physician's Orders, revealed orders for Luvox 100 mg, give one (1) tablet by mouth two (2) times a day for major depressive disorder, order initiated on [DATE]. There was no documented evidence of a Behavior/Intervention Monthly Flow Record, for the Luvox medication for the month of May, June and [DATE] and no documented evidence of ongoing Psychotropic Drug use side effects and behavior symptom monitoring. Interview with the MDS Coordinator, on [DATE] at 12:00 PM, revealed residents who received psychotropic medications should have behavior monitoring and drug side effects monitoring ongoing. Per interview, the Behavior/Intervention Monthly Flow Records should entail all psychotropic medications, with target behaviors, and these Flow Records should be completed each shift with accurate documentation. Further, it was important to ensure there was individualized behavioral interventions implemented and consistent and ongoing monitoring of behaviors as it was important to provide quality care to residents, and to ensure their medications were effective. Interview with the Social Services Director, on [DATE] at 12:16 PM, revealed she ensured monitoring of behaviors and psychotropic medications by attending the morning clinical meeting with the department heads, to discuss behaviors that occurred in the last twenty-four (24) hours; reviewing the medical record for the previous twenty-four (24) hours for every resident; and talking with staff and residents each morning. However, she stated she did not review Behavior/Intervention Flow Records until the end of the month for accuracy or completion and expected direct care staff to inform her when there was changes in a resident's behavioral health. She stated she should have ensured each psychotropic medication for each resident had a Behavior/Intervention Monthly Flow Record and with all target behaviors listed; however, until this survey she thought only antipsychotic medications needed to be monitored per these Flow Records. Further interview revealed it was important to ensure behaviors and psychotropic drug side effects were monitored consistently day-to-day, shift-to-shift, to ensure medication was therapeutic and necessary. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 4:33 PM revealed staff should ensure ongoing monitoring of the residents' behaviors and any adverse consequences related to psychotropic drug use to ensure psychotropic medications were only administered as necessary. Interview with the Director of Nursing, (DON), on [DATE] at 5:46 PM, revealed the Behavior/Intervention Monthly Flow Records should have been completed for each psychotropic medication the residents were receiving with all target behaviors listed, and this was the SSD's responsibility these Flow Records were completed correctly. Per interview, there should have been consistent and accurate documentation in order to ensure there was consistent monitoring of behaviors and psychotropic drug use on the Behavior/Intervention Monthly Flow Records, and there should have been closer auditing of these Records. Further interview revealed it was important to provide consistent monitoring for resident behaviors and use of psychotropic drugs to ensure residents were free from unnecessary medications and to ensure there were no adverse side effects or reactions from the medications. Additional interview revealed it was her expectation non-pharmacological interventions be implemented prior to use of a PRN psychotropic medication. Interview with the Administrator, on [DATE] at 6:49 PM, revealed there should be monitoring of behaviors and psychotropic drug side effects on a daily basis to ensure residents were free from drug side effects or negative outcomes and to ensure the residents' behaviors were stable with the use of the medications. Per interview, this was to ensure residents were free from unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure licensed staff followed professional standards of practice in regard to assessment and documentation of a resident's fall for one (1) of twenty-two (22) sampled residents, Resident #50. The resident sustained a fall on 03/19/18, which resulted in fractures to the resident's right Sacral Ala (back), base of the right Superior Pubic Ramus (pelvic), and the mid right Inferior Pubic. The nurse failed to perform a physical assessment of the resident to ensure no injuries occurred during the fall. In addition, the nurse failed to report the fall to the next shift, failed to initiate a fall investigation, and failed to communicate the fall on the twenty-four (24) hour report that would notify other nurses to monitor the resident for complications from the fall. This failure resulted in delayed treatment for the resident causing pain. The findings include: Review of the Nursing Practice Standard for Licensed Practical/Vocational Nurse, from the National Association of Licensed Practical Nurses (LPN), updated December 2015, revealed the LPN shall function with other members of the health care team to promote and maintain health, prevent disease and disability, and care for and rehabilitate individuals who experience an altered health status. The LPN shall know and utilize the nursing process in planning, implementing, and evaluating health services and nursing care for the individual. Planning health services included assessment/data collection of the health status of the individual, reporting the information, and identification of health goals. Implementing health services included observing, recording, and reporting significant changes, which required interventions or different goals. Review of the Kentucky Board of Nursing Advisory Opinion Statement #27, Components of Licensed Practical Nursing Practice, revised May 2018, revealed LPNs may function under direction as direct care providers in a variety of structured practice settings, such as nursing units, specialty units, and respiratory, physical, and occupational therapy areas. Components of LPN practice included, but were not limited to, assessment by making observations of appearance and behavior, measurements of physical structure and physiologic function, and observations of a client's subjective and objective signs and symptoms. Interpreting data should include determining a client's need for nursing intervention based upon data gathered regarding the client's health status. Review of the facility's Fall Policy, revised 06/19/09, revealed when a fall occurred, immediate action would be taken in accordance with the post-fall protocol that included the Post Falls Assessment and Root Cause Investigation Report, which were completed by the nurse and nurse aide assigned to the resident. After a fall, the Charge Nurse would complete a Post Falls Investigation, assessment for causative factors, implement appropriate interventions, and make any needed changes to the care plan. The fall would be placed on the 24-hour report and the family/ responsible party would be notified of the fall. If there were an injury, the Director of Nursing (DON) and Administrator would be notified. The Charge Nurse would document the condition of the resident and other information as outlined in the Post Fall Protocol. Review of Resident #50's clinical record revealed the facility admitted the resident on 02/06/18 with diagnoses that included Dementia, Repeated Falls, Osteoarthritis, and Weakness. Review of Resident #50's Progress Notes, dated 03/20/18, revealed the resident complained of right hip/groin pain, an x-ray was obtained, and Tylenol was administered. The x-ray findings were negative for fractures but revealed mild Osteoarthritis of the right hip. On 03/21/18, a new order for Occupation Therapy (OT) to evaluate and treat the resident was obtained. On 03/22/18, the resident complained of leg pain and Tylenol was administered. On 03/23/18, an order for Bio-freeze and Gabapentin was obtained for pain in the right peri-area. At 7:43 PM, the nurse documented the resident complained of right hip/leg pain and had a hard time bearing weight on the right leg. Tylenol was administered. On 03/26/18, documentation revealed the resident had increased pain to the right hip/pelvic area and had a hard time bearing weight. The resident grabbed at the right leg when transferred and stated, it hurts really bad. The physician was notified and ordered a Magnetic Resonance Imaging (MRI) and start Tramadol 50 milligram (mg) every six (6) hours as needed for pain. At 4:43 PM, the OT recommended a MRI of right hip due to the resident's continued complaints of pain and decreased mobility. The MRI was scheduled for 04/02/18. On 03/28/18 at 9:27 AM, documentation revealed Resident #50 was holding the right leg, grimacing, and when the nurse asked the resident if he/she was hurting, the resident grabbed the right leg and stated yes while holding the upper part of the right leg. Review of the MRI, dated 04/02/18, revealed acute fractures of the Sacral Ala, base of the right Superior Pubic Ramus, and the mid right Inferior Pubic. Review of the Fall Scene Investigation Report revealed on 03/19/18 at 4:30 AM, staff found Resident #50 on the floor in a pool of urine. The report stated it appeared the resident had urinated on the floor and scooted self in the urine. The report stated vital signs and neuro checks were started; however, no vital signs were recorded on the report and review of the clinical record revealed the nurse did not document an assessment of the resident in the record. In addition, interviews with the ADON, DON, and Administrator revealed the nurse did not complete a post fall assessment of the resident to determine if the resident had any injuries and did not notify the next shift about the fall so they could monitor. Telephone interviews, on 05/10/18, with CNA #8 at 5:30 PM, CNA #10 at 5:50 PM, and CNA #11 at 6:21 PM, revealed Resident #50 fell on [DATE] and LPN #7 was notified. The nurse did not assess the resident but instructed the CNAs to get the resident off the floor and into bed. Per the CNA interviews, they were not aware the nurse had not reported the resident's fall. Telephone interview with LPN #5, on 05/10/18 at 4:05 PM, revealed the resident had increased pain and had a hard time bearing weight on the right leg. She stated the resident kept grabbing his/her inner leg and said, it hurts bad. She stated the pain medication helped some, but the pain returned. LPN #5 stated she did not receive information in shift report about the resident's fall. She revealed when a resident fell, the nurse conducted a Huddle meeting to determine the cause of the fall and noted the fall information on the 24-hour report. She stated the nurse should assess the resident for injury by assessing the range of motion, completing neuro checks, and a pain assessment. The nurse should also obtain vital signs. Interview with the DON and ADON, on 05/10/18 at 3:05 PM, revealed they were not aware of Resident #50's fall on 03/19/18, until 04/02/18 when the results of MRI were received. The DON stated when nursing staff heard about Resident #50's fractures, they informed her the resident fell on [DATE]. The DON stated she interviewed staff who worked that night and four (4) CNAs confirmed the resident's fall and told her they reported the fall to the nurse (LPN #7). The DON stated the CNAs told her they found the resident on the floor and immediately called for LPN #7 and she came in and asked the resident if he/she was okay and then told the CNAs to put the resident back into bed. Per the DON, the CNAs reported to her LPN #7 did not assess the resident, including range of motion, after the fall. In addition, the nurse did not report the resident's fall, did not document the fall on the 24-hour report, did not complete the acute charting, did not notify the physician and family of the fall, and did not initiate the post fall investigation. The ADON stated LPN #7 did not communicate with the first shift nurse regarding the resident's fall before she left that morning. The night shift CNAs told the DON they were unaware the nurse did not report the fall and did not document in the record. The DON and ADON did not learn of the resident's fall until after the MRI results on 04/02/18, fourteen (14) days later. The ADON stated she completed the Fall Scene Investigation Report on 04/06/18 during the IDT meeting. According to the DON, when she interviewed LPN #7, the LPN denied the resident fell. Interview with the Administrator, on 05/10/18 at 4:30 PM, revealed the nurse (LPN #7) did not follow the facility's process when she did not conduct a Huddle meeting immediately after the resident's fall, did not assess the resident after the fall, did not complete a Fall Investigation Report, or communicate the resident's fall on the 24-hour report. In addition, the nurse did not initiate acute charting that would have communicated to other nurses, and when interviewed, the nurse denied the resident fell. In addition, the Administrator stated the CNAs did not report the fall either. She felt the resident's pain was addressed through communication on the 24-hour report, medications, x-rays, and continued investigation of the resident's pain. Attempts to interview LPN #7 were unsuccessful. The nurse's cell phone had restrictions and would not allow calls to go through. LPN #7 was no longer employed at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide the necessary care and services related personal hygiene for two (2) of twenty-two (22) sampled residents, Resident #48 and #84. The findings include: 1. Review of the facility's Bathing Policy and Procedure, not dated, revealed the facility would assess each individual resident's bathing preference upon admission or as requested. A bath assignment would be made based on room number and time of day as requested by the resident, and type of bathing would be acknowledged based on a questionnaire completed on admission by the resident and/or family. Review of the clinical record for Resident #48 revealed a Quarterly Minimum Data Set (MDS), dated [DATE]. Per the MDS, the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. In addition, the facility determined the resident required physical help of one (1) staff with bathing. Interview, on 05/09/18 2:16 PM, with Resident #48 revealed he/she was supposed to receive two (2) showers per week, and the showers were scheduled for Tuesdays and Fridays in the evenings. The resident stated he/she did not receive his/her shower on 05/04/18, which meant he/she went an entire week without receiving a shower. Resident #48 stated staff told him/her they ran out of time to provide his/her shower. Resident #48 stated he/she perspired at the skin folds, had a history of a skin rash, and not receiving the scheduled shower was concerning. He/she stated it did not make him/her feel good about his/her own personal hygiene. The resident stated a Certified Nursing Assistant (CNA) had offered to help him/her dress in clean clothes on the morning of 05/08/18. However, Resident #48 stated he/she refused to do so until the shower was provided. The resident stated at that point, the CNA assisted him/her with taking a shower. Interview, on 05/10/18 at 8:55 AM, with CNA #1 revealed a list of scheduled showers for residents was located at the time clock for staff to view at the beginning of each shift and CNAs should review the list to be aware of each resident who was due for a shower that shift. CNA #1 stated after staff gave a resident his/her shower, a shower document was completed and turned in to the unit nurse for review. She also stated if a resident refused a shower, the CNA filled out the form documenting the resident's refusal and turned it in to the nurse on duty. She stated the DON also reviewed the shower documents. Review of Shower Sheets, dated 04/24/18 to 05/08/18, revealed no shower sheet for Resident #48 for 05/04/18. Interview, on 05/10/18 at 2:20 PM, with CNA #5 revealed he was on duty on 05/04/18, and worked Resident #48's Hall. He stated he worked with a CNA who was still in orientation. CNA #5 stated he thought the CNA in orientation might have been assigned to provide care for Resident #48. CNA #5 stated he was not aware Resident #48 did not receive a shower until today, when he was made aware by the supervisor. Interview, on 05/10/18 at 1:40 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #48 received an antifungal powder to his/her skin folds, as ordered, for redness to the folds in the skin. LPN #2 stated she had not heard in shift report or otherwise that Resident #48 missed a scheduled shower. The nurse further stated the CNAs completed shower sheets after providing the shower, which were reviewed by the nurse to monitor for skin changes. LPN #2 stated a refusal form was completed if the resident refused the bath or shower on his/her scheduled shower day. LPN#2 stated the purpose of maintaining a shower schedule and providing showers was to ensure each resident received the necessary care for good personal hygiene. Interview, on 05/10/18 at 1:50 PM, with the DON revealed CNAs should complete shower sheets at the end of each resident shower and then reviewed by the nurse. She stated she and the Assistant Director of Nursing also reviewed the shower sheets to ensure they were reviewed and signed by the nurse, and to ensure there were no newly acquired skin conditions that might need additional attention. The DON stated the purpose of maintaining the resident shower/bath schedule was to provide each resident with services that supported good personal hygiene. She also stated bathing and grooming helped the residents be more comfortable and maintain dignity. The DON revealed bath/shower time provided staff with additional opportunities to observe the resident's skin and to report any skin changes to the nurse. 2. Review of the facility's policy, Bowel and Bladder Continence Program, revised 11/01/17, revealed the facility strived to support resident dignity and self-esteem by helping to maintain or improve the level of elimination function to the maximum degree possible. The policy revealed residents' elimination status was assessed and an appropriate plan and intervention was established and implemented after admission, annually, and with significant changes. If it was determined that a bowel and/or bladder program would be beneficial, the resident would be placed in the scheduled toileting program. Review of the clinical record for Resident #84 revealed a Quarterly MDS, dated [DATE]. The MDS stated the facility assessed Resident #84 with a BIMS score of thirteen (13) out of fifteen (15) and determined he/she was interviewable. Further review of the MDS revealed the resident was totally dependent upon staff for toileting, was frequently incontinent of urine, and was on a toileting program. Review of the CNA Care Plan, dated April 2018, revealed Resident #84 was incontinent of bladder and should be toileted upon rising, within ½ hour before and after meals, and at bedtime. Further review of the care plan revealed the resident required the assistance of one (1) person. Observation, on 05/08/18 at 10:38 AM, revealed Resident #84 in a wheelchair at the bedside with his/her eyes closed. At 2:47 PM, the resident was in a wheelchair at the bedside with his/her eyes closed and a lunch tray on the over the bed table. At 3:50 PM, the resident was in a wheelchair next to the bed with his/her eyes closed. Further observation at 4:33 PM, revealed Resident #84 in a wheelchair at the bedside with a urine odor noted in the room. Interview with the resident during the observation revealed he/she had not been toileted. Continued observation of Resident #84, on 05/08/18 at 4:37 PM, revealed there was a wet ring on the seat of his/her pants soaked through to the wheelchair cushion. Interview with CNA #6 during the observation revealed it appeared incontinent care had not been provided for the resident within the last two (2) hours. Interview with Resident #84, on 05/09/18 at 10:17 AM, revealed the resident sometimes urinated in his/her pants because staff did not get to the room fast enough. According to the resident, staff did not always toilet him/her after meals. Interview with CNA #2, on 05/10/18 at 9:08 AM, revealed the CNAs were responsible for toileting and providing incontinent care for Resident #84 every two (2) hours and as needed. She stated it was important to toilet the resident to ensure he/she remained dry and to prevent skin breakdown. CNA #2 stated Resident #84 did not always notify staff when he/she needed to go to the bathroom. Interview with CNA #4, on 05/10/18 at 9:51 AM, revealed she attempted to toilet Resident #84 on 05/08/18 around 1:00 PM, but the resident was asleep. She stated she asked the resident if he/she wanted to go to the bathroom, but the resident went back to sleep. The CNA revealed she did not check the resident to ensure his/her brief was dry. She further revealed she did not attempt to toilet or provide incontinent care for the resident for the remainder of her shift, which ended at 3:00 PM. CNA #4 stated it was important to toilet and provide incontinent care for residents to prevent skin breakdown Interview with LPN #1, on 05/10/18 at 9:25 AM, revealed nurses were responsible for monitoring the CNAs to ensure appropriate resident care was provided. The LPN stated Resident #84 was incontinent of urine, not able to reposition in the wheelchair independently, and was at increased risk for skin breakdown. The LPN revealed she was not aware of any concerns regarding Resident #84's incontinent care. Interview with LPN #5, on 05/10/18 at 11:50 AM, revealed she monitored resident care during medication pass, treatments, and by conducting random checks. LPN #5 stated the CNAs should notify the nurse if they were unable to provide incontinent care. The LPN stated Resident #84 was sometimes incontinent and it was important to ensure he/she was dry to prevent potential skin breakdown, urinary tract infection, or odors in the resident's room. Interview with the DON, on 05/10/18 at 11:35 AM, revealed the CNAs were responsible for following a resident's toileting plan and checking for episodes of incontinence regardless if the resident was awake or asleep. The DON stated it was important to toilet residents in order to maintain dignity and prevent potential skin issues. The DON revealed she was not aware of any concerns regarding staff not providing scheduled toileting or incontinent care. Interview with the Administrator, on 05/10/18 at 3:30 PM, revealed she had not identified any concerns regarding incontinent care for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility's fall policy and fall investigation, it was determined the facility failed to ensure all falls were investigated promptly to determine the root cause of the fall and implement interventions to prevent further falls for one (1) of twenty-two (22) sampled residents, Resident #50. Resident #50 sustained a fall on 03/19/18 at 4:30 AM, when the resident attempted an unassisted transfer from the bed and fell to the floor. There was no documented evidence the nurse assessed the resident for injury. The next day (03/20/18), the resident complained of pain in the right hip/pelvic area. A portable x-ray was obtained and revealed no fractures. However, the resident continued to complain of pain and the physician (who was not informed of the resident's fall) ordered Bio-freeze medication for Arthritis. The resident's complaints of pain continued and staff interviews revealed the resident could no longer ambulate without pain. A Magnetic Resonance Imaging (MRI) was completed on 04/02/18 with findings of fractures to the right Sacral Ala (back), base of the right Superior Pubic Ramus (pelvic) and the mid right Inferior Pubic. Through interview it was discovered the nurse had not assessed the resident for injury after the fall, failed to report the fall, failed to initiate the fall investigation, failed to initiate acute charting, and failed to communicate the fall on the twenty-four (24) hour report that would notify the other nurses to monitor the resident for complications from the fall. This failure resulted in delayed treatment for the resident causing unnecessary pain. The findings include: Review of the facility's Fall Policy, revised 06/19/09, revealed when a fall occurred, immediate action would be taken in accordance with the post-fall protocol that included the Post Falls Assessment and Root Cause Investigation Report, which were completed by the nurse and nurse aide assigned to the resident. After a fall, the Charge Nurse would complete a Post Falls Investigation, assessment for causative factors, implement appropriate interventions, and make any needed changes to the care plan. The fall would be placed on the 24-hour report and the family/ responsible party would be notified of the fall. If there were an injury, the Director of Nursing (DON) and Administrator would be notified. The Charge Nurse would document the condition of the resident and other information as outlined in the Post Fall Protocol. On the first business day following a fall, the DON/Assistant DON and the Interdisciplinary Team (IDT) would meet and discuss causative factors, interventions, and other relevant information and review the findings of the incident. Review of Resident #50's clinical record revealed the facility admitted the resident on 02/06/18, with diagnoses that included Dementia, Repeated Falls, Osteoarthritis, and Weakness. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) and determined the resident interviewable. Further review revealed the resident required limited assistance of one (1) staff for ambulation and transfers. The resident was assessed to be unsteady when moving from seated to standing position; however, was able to stabilize self without physical assistance from staff. Review of a Falls Risk Assessment, dated 03/13/18, revealed the facility identified Resident #50 to be at risk for falling due to problems with functional status (balance and gait problems and weakness). Other risk factors included history of falls and medications. Review of Resident #50's Fall Care Plan, initiated 02/16/18 and revised 04/09/18, revealed the resident had a history of falls. The resident transferred independently in the room and ambulated per self with a rolling walker. Review of the Certified Nursing Assistant (CNA) Care Plan for March 2018 revealed on 03/12/18, the resident became independent with ambulation and transfers in the room. Review of a Fall Scene Investigation Report revealed on 03/19/18 at 4:30 AM, staff found Resident #50 on the floor in a pool of urine. The report stated it appeared the resident had urinated on the floor and had scooted self in the urine. The report stated vital signs and neuro checks were started. However, no vital signs were recorded on the report and review of the clinical record revealed the nurse did not document any assessment of the resident in the record. In addition, interviews with the ADON, DON, and Administrator revealed the nurse did not complete a post fall assessment of the resident to determine if the resident had any injuries and did not report the fall to the next shift for monitoring. Review of Resident #50's Progress Notes revealed on 03/20/18, the resident complained of left knee pain. An x-ray was obtained and Tylenol was administered at that time. X-ray findings were negative for fractures but revealed mild Osteoarthritis of the right hip. Interview with CNA #7, on 05/10/18 at 2:45 PM, revealed she cared for Resident #50 often and was familiar with the resident's care. She stated she was unaware the resident had fallen and had not received any information about a fall from the other CNAs. She stated the resident screamed and complained of pain during a transfer from the wheelchair to the bed and held his/her leg. She observed a small bruise to the resident's right hip area and reported that to Registered Nurse (RN) #1. She noticed whenever she rolled the resident over or moved the resident, the resident screamed in pain. She stated it took two (2) to three (3) CNAs to turn the resident when he/she was mostly independent before. Interview with RN #1, on 05/10/18 at 2:50 PM, revealed she was familiar with Resident #50's care. She stated CNA #7 reported the bruise and resident's pain the evening of 03/20/18, and she called the physician and obtained the order for the portable x-ray. She stated the resident complained of pain when he/she was assisted to the toilet. She stated she passed along in report about the resident's pain but did not know about the resident's fall and had not received any information during shift report that the resident had fallen. Continued review of Progress Notes revealed on 03/21/18, a new order for Occupation Therapy (OT) to evaluate and treat the resident was obtained. On 03/22/18, the resident complained of leg pain and Tylenol was administered. On 03/23/18, a new order for Bio-freeze and Gabapentin was ordered for pain in the right peri-area. At 7:43 PM, the nurse documented the resident complained of right hip/leg pain and was having a hard time bearing weight on the right leg. Tylenol was administered. On 03/26/18, the resident was noted with increased pain to the right hip/pelvic area and was having a hard time bearing weight. The nurse documented the resident was grabbing at the right leg when being transferred and stated, It hurts really bad. The physician was notified and ordered an MRI and start Tramadol as needed for pain. At 4:43 PM, the OT recommended a MRI of right hip due to the resident's continued complaints of pain and decreased mobility. The MRI was schedule to be completed on 04/02/18. The progress notes revealed on 03/28/18, the resident was holding his/her right leg and grimacing and when the nurse asked the resident if he/she was hurting, the resident grabbed the right leg and stated yes while holding the upper part of the right leg. Continued review of the record revealed a MRI was completed at the hospital on [DATE], with findings of acute fractures to the Sacral Ala, base of the right Superior Pubic Ramus, and the mid right Inferior Pubic. Review of the Fall Prevention IDT Note, dated 04/06/18, revealed the root cause of the fall was Resident #50 had slipped in urine. Review of the care plan for incontinence, initiated 02/06/18, revealed the resident was on a toileting program. Observation of Resident #50, on 05/08/18 at 10:05 AM, revealed the resident sitting in a wheelchair in his/her room with the door closed. Interview with the resident revealed he/she could not recall if he/she had fallen. Interview with the resident on 05/10/18 at 2:03 PM, revealed the resident continued to stated he/she had not fallen. Interview with the ADON, on 05/10/18 at 8:35 AM, revealed Resident #50 had a total of three (3) falls since admission. The first fall occurred on 02/13/18 in the resident's room and was witnessed by staff. The resident sat on the side of the bed, started to walk to the bathroom, and lost his/her balance; hitting his/her head on the bathroom door as the resident fell to the floor. Neuro checks were completed and were the only intervention implemented. The IDT reviewed the fall the next day and updated the care plan with interventions of a low bed, bed against the wall, and nonskid strips from the bed to the bathroom. The next week, IDT added anti-tippers to the resident's wheelchair, anti-roll backs, and a dump seat as a fall precaution, even though the resident had not fallen from the wheelchair. On 03/12/18, the IDT discontinued the low bed as the resident was independent with bed mobility and was able to ambulate with a walker. The ADON stated the resident had another fall on 03/19/18 and provided the Fall Scene Investigation Report for review. However, the ADON did not provide information that the fall resulted in fractures to the pelvis and back. She did not include the nurse had not assessed the resident after the fall or report the fall to the next shift nurse. Therefore, when the resident continued to complain of pain, nobody but a few staff knew the resident had fallen. She stated the resident had a third fall on 04/20/18 at midnight. The resident was found on the floor in the doorway and told the nurse he/she had slipped out of the wheelchair. No visible injuries were noted. Interview with LPN #5 via telephone, on 05/10/18 at 4:05 PM, revealed Resident #50 had increased pain and had a hard time bearing weight on the right leg. She stated the resident kept grabbing his/her inner leg and said, it hurts bad. When pain medication was given, the pain subsided some but returned. She could not recall the date, but after the MRI results were reported, CNA #8 (third shift) reported the resident fell on [DATE], and she then informed the ADON. She stated the CNAs had not reported to her the resident had a fall and she had not received any information in shift report about the resident's fall. She revealed when a resident had a fall, a Huddle meeting (the nurse on duty would conduct) was conducted to determine the cause of the fall. She stated the nurse would communicate the fall information on the 24-hour report. She stated the nurse would assess the resident for injury, which included range of motion, neuro checks, and pain assessment, and checked the vital signs. Interview with CNA #10 via telephone, on 05/10/18 at 5:50 PM, revealed she and another CNA found Resident #50 on the floor on 03/19/18. She stated she heard a yell for help coming from the resident's room and found the resident sitting on the floor in the upright position, wet with urine. One of the CNAs got the nurse and the nurse came into the room and asked the resident if he/she was hurt. The nurse then told the CNAs to get the resident up and put him/her back into bed. The CNA stated she did not report the resident's fall to anyone other than the nurse; however, if she knew the nurse had not reported the resident's fall, she would have told another nurse. After the fall, she noticed the resident was sore and instead of walking to the bathroom as before, the resident wanted to use the wheelchair. Interview with CNA #8, via telephone, on 05/10/18 at 5:30 PM, revealed she worked the night Resident #50 fell and stated she heard the other CNAs talking and went into the resident's room and saw the resident sitting on the floor. She stated CNA #11 notified the nurse and when the nurse came into the resident's room, she looked at the resident but did not assess the resident and instructed the CNAs to get him/her off the floor. The following Friday (did not know the date) she was informed of the resident's pain and not being able to walk. After hearing of the resident's fractures, she informed LPN #5 of the resident's fall. She stated she was unaware the nurse had not reported the fall and she had not forwarded that information either. Interview with CNA #11 via telephone, on 05/10/18 at 6:21 PM, revealed she worked the night of 03/19/18 when Resident #50 fell. She stated she heard a scream, went to the resident's room, and found the resident on the floor wet with urine. She went to get the nurse (LPN #7) who looked at the resident's bottom but she could not recall if the resident's bottom was red. The nurse asked the resident if he/she was in pain and the resident said no. CNA #11 stated she did not work again for over a week but the next time she cared for Resident #50, the resident complained of pain in the right leg when attempting to transfer or ambulate. She revealed when the resident was placed on the toilet, the resident would hold the area where it hurt and say ouch. She stated she reported that to a nurse but could not recall the name of the nurse. She stated the resident complained his/her leg was hurting but nobody listened. Interview with the Nurse Practitioner (NP) via telephone, on 05/10/18 at 2:27 PM, revealed Resident #50 continued to complain of pain after the negative portable x-ray was obtained. She stated she and staff thought the pain was from the Osteoarthritis, ordered Bio-freeze, and increased the Tylenol frequency from every six (6) hours to every four (4) hours. She stated the resident had ongoing pain of the right leg and she became concern when the resident had difficulty walking. The NP stated she ordered the MRI for further testing of the resident's pain and immobility. She stated she became very concerned when the resident continued to complain of pain for almost two (2) weeks and was unable to walk. She was familiar with the resident's care and the resident was able to ambulate independently before the complaints of pain. She stated staff did not notify the physician or herself regarding the resident's fall on 03/19/18, and learned of the fall after the MRI revealed the resident had fractures. Per interview, she did not recall if the facility requested to send the resident to the emergency room for an evaluation after the fall, but stated that was common practice especially if the resident complained of continued pain. Interview with the DON and ADON, on 05/10/18 at 3:05 PM, revealed neither were aware of the 03/19/18 fall until after the MRI was completed, fourteen (14) days after the fall, and then they started an investigation to determine how Resident #50 sustained the fractures. The DON stated when the nursing staff heard about the resident's fractures, they came forward and informed her of the resident's fall on 03/19/18. She interviewed staff that worked that night and four (4) CNAs confirmed the resident's fall and told her they reported the fall to the nurse working that night (LPN #7). The DON stated the CNAs told her they found the resident on the floor and immediately called for the nurse. The nurse came into the resident's room and asked the resident if he/she was okay and then told the CNAs to put the resident back into bed. The DON revealed the CNAs told her they did not know the nurse did not report the fall or document the fall in the record. The DON and the ADON stated the nurse did not complete an assessment of the resident after the fall. In addition, the nurse did not report the resident's fall, did not document the fall on the 24-hour report or complete the acute charting, she did not notify the physician and family of the fall, and did not initiate the post fall investigation. The ADON stated she completed the Fall Scene Investigation Report on 04/06/18 during the IDT meeting. She stated LPN #7 did not communicate with the first shift nurse regarding the resident's fall before the nurse left the facility at 7:15 AM. The ADON stated when the resident complained of pain the next day, a portable x-ray was obtained and since the fall was not communicated to other staff or the physician, the facility was looking for the resident's pain in the wrong place. According to the DON, she interviewed LPN #7 and the nurse denied the resident had fallen. However, the four (4) CNAs in the room after the resident's fall stated the nurse was in the resident's room and did not perform a full nursing assessment. They told the DON the nurse did not check the range of motion at that time. Interview with the Administrator, on 05/10/18 at 4:30 PM, revealed she became aware on 04/02/18 of Resident #50's injurious fall, after the MRI revealed fractures. She stated the nurse (LPN #7) did not follow the facility's process when she did not conduct a Huddle meeting immediately after the resident's fall, assess the resident after the fall, complete a Fall Investigation Report, or communicate the resident's fall on the 24-hour report. In addition, the nurse did not initiate charting that would have communicated to other nurses. She stated the DON and the ADON conducted most of the investigation and the nurse was interviewed and denied the resident fell. She stated the CNAs did not report the fall either. She felt the resident's pain had been addressed through continued communication on the 24-hour report, medications, x-rays, and continued investigation of the resident's pain. LPN #7 was no longer employed at the facility. Two (2) attempts to contact LPN #7 were made on 05/10/18 via telephone; however, the call would not go through. The nurse did not answer her cell phone and it would not allow a message to be left.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure expired medications were removed from one (1) of six (6) medication carts. Observation of the 200 Hall medication cart revealed it contained an expired inhaler. The findings include: Review of the facility's policy, Disposal of Medications and Medication-Related Supplies, dated 07/09/12, revealed medications awaiting disposal or return were stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Medications were to be removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration). Observation of the 200 Hall Medication Cart, on 05/08/18 at 8:44 AM, revealed a Ventolin HFA inhaler with a dispensed date of 05/05/16 and an expiration date of June 2017. Interview with Licensed Practical Nurse (LPN) #2, on 05/10/18 at 8:51 AM, revealed the Ventolin HFA inhaler was expired and might not be effective, which if used, it might not relieve a resident's respiratory distress. LPN #2 stated every nurse was responsible to check for expired medications and she had been in charge of the medication cart. Interview with the Quality Assurance Nurse, on 05/10/18 at 2:55 PM, revealed the 11:00 PM to 7:00 AM nurse checked for expiration dates of medications; however, she stated every nurse working the medication cart also checked. She further stated if the inhaler was expired, it could have ill effects for the resident, such as difficulty breathing, and could possibly not work for the resident. Interview with the Director of Nursing (DON), on 05/10/18 at 10:30 AM, revealed all nurses were responsible to ensure medications were not expired. She stated medications were checked prior to being administered and in addition to that, the night shift nurses checked the medication carts for expired medications. The DON stated when a medication was expired, it was disposed with the pharmacy or trashed and should not be left in the medication cart. She further stated an expired inhaler could have a negative effect on the resident such as difficulty breathing. The DON stated she expected staff to monitor the medication carts and discard expired medications. Interview with the Administrator, on 05/10/18 at 2:20 PM, revealed if a nurse noticed an expired medication, the nurse should remove it from the medication cart and send it back to the pharmacy. She stated pharmacy had audited the carts and the facility had a Quality Assurance Nurse who conducted audits. The Administrator stated it was not acceptable practice to have expired medications in the medication carts.