**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00140159. Based on observation, interview and record review, the facility failed to maintain continuity of care according to professional standards following a change of condition related to a toe injury for 1 of 3 residents (R102) reviewed for quality of care, resulting in lack of communication, delay in assessment, treatment, and inaccurate documentation, that resulted in osteomyelitis and amputation of toes. Findings include: According to the National Library of Medicine, October 2016, Continuity of care is concerned with the quality of care over time. ideal is the delivery of a 'seamless service' through integration, coordination, and the sharing of information between different providers . https://pubmed.ncbi.nlm.nih.gov/17018200/ Review of R102's Face Sheet reported the resident had diagnoses that included hemiplegia and hemiparesis following a stroke affecting his left non-dominant side, weakness, need for assistance with personal care, and type 2 diabetes mellitus. During an interview on 11/1/2023 at 8:43 AM, Family Member (FM) G stated, I am not (R102's) DPOA. On a Friday evening 9/15/23, we got a call from the facility (R102) was going to the ER, for stitches. It was the right foot between the 4th and 5th toes. He got 4-5 stitches. He did not know how he did it. He was cognitively aware of things; he did not have a guardian. He complained of pain. We would go every couple of days to see him. He complained on 9/17/2023 of foot hurting and throbbing. His foot was wrapped with a little discharge through the bandages. This was on Sunday. We went over on Wednesday, 9/20/2023, the residents were going to the fair, he did not go because of foot pain. He said the pain was 10/10 and they were giving him pain medications. He was sent to the ER on [DATE] for the throbbing pain in his foot. I went to the hospital then and he was being admitted for an infection in his foot. The hospital told me his white blood count was high. On 9/27/2023, I think, they removed his right pinky toe with an infection down to the arch of his foot. On 9/29/2023 the hospital had to do another surgery to wash out the infection and ended up removing the 4th toe because of the infection. Review of R102's Event Report reported Event Date 9/15/2023 at 12:36 PM with a Completed Date 9/19/2023 at 12:40 PM. -Description of the event: R (right) foot wedge of 4th and 5th toe. -Exact Date/Time Discovered: 9/15/2023 at 1:00 PM -Type of Injury: Other-fissure/crack in skin -Location and Size of Skin alteration: Interdigital 4th & 5th toe 0.1 cm (centimeter) x 1.3 cm x 0.1 cm -Space between 4th and 5th toe - small amount of blood loss -irregular wound edges -1/10 mild pain -Activity unknown during skin alteration occurrence -cleansed area covered with non-adherent dressing -seen by podiatry and received new order to start betadine daily for 14-days or until healed -Notification Guidelines: 9/15/2023 at 1:00 PM Medical Director and Emergency Contact -Evaluation: Wound referral made with wound specialist. Resident to follow-up with specialist on 9/19(2023). During an interview on 11/1/2023 at 3:20 PM, Registered Nurse (RN) P stated, He cut his toe on a day I was working on another unit. His nurse called me, and I came to help her. He almost severed his left pinky toe off. He told me he had felt something squishy in his shoe earlier in the day. When I took his shoe off there was nothing in it to cut him. But there was blood everywhere. He said he had transferred himself to his wheelchair earlier and wondered if he did not catch on something and cut it that way before putting his shoe on. I cleaned his foot and toe and wrapped it. I told him he had to go to the hospital because I could not do anything for the toe here. He did not want to go to the ER. A doctor was in the area and stopped by to look at (R102's) foot. There was nothing he could do here to fix the toe so the resident was sent out to the hospital. He came back with stitches holding the toe together and was to leave them in for 10 days. I cared for him about 6-7 days later and had to change the bandage because the dressing was saturated with blood and drainage. I saw the stitches were gone. (R102) told me a nurse took them out because they were not doing anything for him. I told him the stitches were keeping his toe together. The wound looked infected. I told the 1st shift nurse to assess the wound. I do not know why she did not. I told the Director of Nursing (DON B) about what I saw and he told me to keep it to myself because a nurse (Licensed Practical Nurse (LPN) N) was the one that had done it (removed the stitches) and they needed him to staff the floor. During an interview on 11/7/2023 at 7:59 AM, Registered Nurse (RN) P stated, (R102's) dressing change for his toe was daily and PRN (as needed). The order just showed up in the treatment part of his medical record. I did not have to write a progress note that I did it. I was told that I put things in my progress notes that would trigger State to investigate and would have to change my progress notes. I typed a long thing and ended up changing it. I noticed (R102's) pinky toe and told the DON and wound nurse. I looked at his toe because his dressing fell off. His sutures were missing. (R102) said the nurse before me, (LPN N), took them out the night before. (R102) told me the nurse he took them out because they weren't doing anything, I told them they were keeping his toe on. I reported to the wound nurse and the DON. The DON told me to keep it to myself because there no way of telling if that nurse did it. I told the DON that (R102) was cognitively with it and would not lie. The last time I saw the toe it looked bruised, and the sutures were gone. It did not look necrotic. I did tell the wound nurse that she needed to look at it because the sutures were missing. I felt the wound nurse should have known what was going on with his toe. During an interview and record review on 11/7/23 at 9:44 AM, Director of Nursing (DON) B stated, At some point (R102) injured his toe putting his shoe on. He should have had a care plan for toes. I do not see one. Care Plans set the guidelines for the care of that resident. I do not know who removed the sutures. It should have been documented in the MAR and the Progress Note who and when the sutures were removed. During an interview and record review on 11/7/2023 at 9:44 AM, former ADON (Assistant Director of Nursing) K stated, (R102) had an issue with his toe. The wound nurse should document in progress notes and care plan as well. While reviewing R102's medical chart, former ADON K stated, (R102) was sent out on 9/15/23 with a laceration on his right toe. He went out to the ER on [DATE] and had 3 sutures and was sent back to the facility on 9/16/23 at 1:00 AM. Further review of R102's physician orders with former ADON K who stated, It was reported on 9/16/2023 the primary doctor at the facility was to take out the sutures or if unavailable to send to the ER to take out. It does not state when to take them out. Per our nurse in a Progress Note, the hospital note stated that the sutures should be taken out in 10 days. That was directly off the ER discharge instructions. During an interview on 11/8/2023 9:59 AM, LPN N stated, I would do dressing changes on (R102) but I did not chart that I did them. It looked infected. I guess I should have. I worked nights and it was not on my assignment. I would write on the 24-hour nurse to nurse report and put it in the doctor's communication book that he needed to see the toe as soon as possible. I could tell the doctor what was going on, but they will tell me something different or do what I did. A lot of times nurses leave messages and the doctor never calls back, that's why I did not call the doctor. I cannot remember if I documented, or I did not document. During an interview and record review on 11/7/2023 at 11:00 AM, LPN/Wound Nurse O stated, (R102) was seen by podiatry in the morning of 9/15/2023. I charted that. It was a fissure crack in the skin, between the right 4th and 5th toe. I made a wound referral that day. He was seen by the wound specialist on 9/19/2023 for the fissure. Also, on 9/15/23 at 8:00 PM a nurse, (LPN P), charted she found a laceration on the right foot between the 4th and 5th toe. She asked the resident how it happened, and he did not know. He found the blood when he took the shoe off. The resident found the blood everywhere when he took off his shoe. (LPN P) sent him to the ER. I charted on 9/19/23 when he was seen by the wound doctor, R102 said he was trying to put the shoe on the wrong foot and that is how he got the laceration. The wound doctor said it was a laceration, she looked at the sutures, there was 6 sutures in place. The order states from the ER not to remove the sutures for 10 days. The night before he left on 9/25/2023 for the ER again, I asked the resident who took the sutures out, and R102 told me the night nurse, (LPN N), took them out. I told (DON B) that (R102) the night nurse had taken them out. LPN O reviewed R102's medical chart, stating, It says (R102) on 9/26/23 took off his dressing. (LPN P) charted on 9/26/23 that (R102) told her the dressing was too tight. She replaced the dressing. I went with the wound specialist's PA on the 9/26/23, Tuesday, doing normal wound rounds, and we noticed his right 5th toe was necrotic. It was very mobile and partially detached. I didn't chart that his dressing was not on. I asked him what had happened, and he was unsure of what happened. I'm not finding that (LPN P) charted on what condition the toe was in on 9/26/23. When I saw the toe was necrotic, the PA and I went to the Medical Director, who was in the building and told him. (R102) was sent to the ER and never came back. It looked like it was reinjured. I do not think he picked at it. The last skin assessment was 9/16/23 and it said there were 3 sutures between 4th and 5th pinky toe. I know there were 6 sutures. During a telephone interview on 11/7/2023 at 11:31 AM, Licensed Practical Nurse (LPN) L stated, I do not know who removed (R102's) sutures. If they were removed, they should be documented on the TAR (Treatment Administration Record) and the Progress Notes. During an interview and record review on 11/7/2023 at 3:12 PM, LPN/Wound Nurse O stated, The reason there is no notes in the nurse's notes is because the facility charts by exception. Nurses only chart when they see a change in condition. So, in reading (R102's) notes, there was a note on 9/26/2023 at 5:42 AM and then the last note on 9/26/2023 at 9:00 AM. So I am thinking that sometime between 5:42 AM and 9:00 AM he injured that foot again which cause it to become detached and necrotic. Review of [NAME], [NAME], & [NAME] (www.journals.lww.com, July,2004) making an exception in charting revealed Charting by exception (CBE) was designed to eliminate lengthy and repetitive notes It departs from traditional systems by requiring documentation of significant or abnormal findings only. You may need to supplement your CBE documentation if you not an assessment finding that is not part of a normal assessment; document your assessment findings in a narrative progress note. During an interview and record review on 11/7/2023 at 4:38 PM, LPN L stated, Typically nurses would be documenting in Progress Notes the condition of the wound they did a dressing change on. However, (LPN O) the wound nurse, documents measurements once a week on wound rounds. Yes, I should document the decline of a wound. LPN reviewed R102's Progress Notes she had written, stating, I'm sure I worked those days. I did not document the condition of the wound and probably made a note to wound nurse (LPN O) and just gave it to her, telling her the toe was looking bad. Review of R102's Order Summary, dated 9/15/2023, Ok to transfer to hospital Once - one time 8:30 PM. Review of R102's General Emergency Department discharge instructions, dated [DATE], reported the resident was treated for a laceration (cut) that required sutures (stitches). Follow-up with your doctor or come back here or go to the nearest Emergency Department to have your sutures take out in 10 days .You should seek medical attention immediately .at the nearest emergency department if any of the following occurs .the wound smells bad or has a lot of drainage . Review of R102's Order Summary dated 9/16/2023, Primary doctor to take sutures out. If unavailable send to (name of hospital) hospital to take out. Once - One time 12:00 PM. Review of R102's Care Plans did not reveal a person-centered treatment plan had been initiated for the right 4th and 5th toe injury. Review of R102's Order Summary dated 9/19/2023, revealed, cleanse laceration to R (right) toe with wound cleanser, pat dry, apply calcium alginate with silver then apply 4x4 gauze and wrap with Kerlix daily Once a day 06:00 AM to 2:00 PM. Review of R102's Medication Administration Record/Treatment Administration Record (MAR/TAR) 9/1/2023-9/30/2023, revealed on 9/16/2023 at 12:00 PM, a Licensed Practical Nurse (LPN) documented they had completed the order to remove the sutures, Primary doctor to take sutures out. If unavailable send to (name of hospital) hospital to take out. It was noted there was no documentation in the resident's nursing notes/progress notes or the physician notes that the sutures had been removed. Review of R102's MAR/TAR 9/1/2023-9/30/2023, reported nurses had documented they had completed the order, Cleanse laceration to R (right) 5th toe with wound cleanser, pat dry, apply calcium alginate w/(with) silver then apply 4x4 gauze & wrap with Kerlix daily. It was noted there was no documentation in the resident's progress notes of the wound's condition with dressing changes. Review of R102's Podiatry Exam Note, 9/13/2023, revealed, .small fissure in the 4th interdigital space right foot with serosanguinous drainage . Review of R102's Skin Body Assessment, observation date 9/16/2023 1:30 AM, reported skin impairment of the right pinky toe had 3 new sutures placed between the right pinky toe and the 4th toe. Review of R102's Progress Notes reported, -9/15/2023 8:01 PM, R102 was in bed with a lot of blood on the floor. Resident stated he was not sure what happened, he noticed the blood after he took off his shoes. The nurse cleaned the right foot and found bleeding between the 4th and 5th toe with a deep wound. It was suggested he be sent out (referring to a hospital emergency room). -9/15/2023 9:49 PM, R102 was transferred to the hospital due to the laceration between the 4th and 5th toes on right foot. -9/16/2023 1:24 AM, the facility received report from the hospital stating R102 got 3 sutures between his right 4th and 5th toe. An x-ray was done with normal results. R102 returned to the facility. It was noted in the Hospital Summary dated 9/15/2023 stating the resident received 6 sutures. -9/16/2023 1:33 PM, per the hospital, R102 was to follow up with his doctor or go back to the hospital, or nearest emergency department for suture removal in 10 days. It was noted on R102's MAR/TAR 9/16/2023, documentation indicated the sutures were removed on 9/16/2023. -9/19/2023 9:40 AM ER follow-up for R102 recent ER visit where he had a foot laceration and sent to ER on [DATE] where he received 3 stitches. Laceration was seen with no signs or symptoms of infection and open to air. -9/19/2023 12:44 PM, weekly wound assessment of wound between 4th and 5th on right foot with wound specialist, reconfirmed wound had 6 sutures in place with order not to remove for 10 days. There was no sign or symptoms of infection noted at that time. New orders to follow-up with wound specialist in 7 days. Will continue to monitor for any changes or concerns. -9/26/2023 5:42 AM, R102 took his right foot dressing off during the night stating It was too tight. The resident's foot was cleaned with a new bandage applied. R102 denied pain during this shift. It was noted there was no documentation of the wound's condition. -9/26/2023 9:00 AM, upon weekly wound rounds with wound specialist, R102 right 5th toe was observed to be 100% necrotic (dead tissue), very mobile, and partially detached. Wound specialist recommendation was to send resident to hospital. -9/26/2023 11:34 AM, R102 was seen by the wound medical doctor with orders to be sent to the hospital for debridement of 5th toe on right foot. The emergency medical service was called and transferred resident to hospital. -9/26/2023 2:25 PM, Nurse Practitioner note, R102 reported increased pain to left foot toe laceration and toe noted with swelling and surrounding erythema. Resident rated pain 5/10. R102 was scheduled to be seen by in-house wound provider the next day. It was noted, the wound was to the right foot and not the left foot. - 9/27/2023 09:22 AM, IDT (Interdisciplinary Team) note: Resident sent out yesterday to ER for evaluation of right little toe that was hanging half off foot. Remains at hospital for possible amputation. Review of R102's Wound Management 9/19/2023 12:42 PM, reported the wound to the right pinky toe has serosanguineous exudate (drainage), small wound tissues very moist, drainage less than 25 percent dressing, and wound healing status was stable. Review of R102's Wound Physician's Visit Report 9/19/2023 reported the information was obtained from the resident's chart and was seen for follow-up and management of the wound. History of the R102 web space between his right 4th and 5th toes identified on 9/15/2023 by a trauma. The resident complained of increased drainage. Nursing staff reported Podiatrist (foot doctor) identified a fissure between the right 4th and 5th toes on 9/15/2023. Later that evening, nursing staff noted a large area of blood on R102's bedroom floor. The resident reported to the wound physician that he accidentally tried putting his left shoe on his right foot and his right 5th toe got caught on shoe causing a large laceration between the 4th and 5th webspace. R102 was sent to the hospital ER and had sutures placed. The x-ray of the right foot while in the ER was normal. Wound specialist was re-consulted to evaluate and treat. The resident appeared to have goo judgement and insight. The Wound Assessment reported the right web space between the 4th and 5th toes was a full thickness trauma wound with initial wound encounter measurements of 2.6 cm (centimeters) length x 0.8 cm width x 0.1 cm depth, with an area of 2.08 sq (square) cm and a volume of 0.208 cubic cm. There was a moderate amount of sero-sanguineous drainage (blood tinged) noted which had no odor with 50% slough (yellow/white material in wound bed). R102's wound pain level was 2/10 (2 out of 10). There were 6 sutures in place and appeared a portion of the wound was left to close by secondary intention as sutures did not span the entire length of the wound. The wound provider performed a procedure, skin/subcutaneous tissue level surgical debridement (Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) with a total area debrided of 1.04 sq cm. Adipose (yellow layer of fat beneath the skin) and subcutaneous (full thickness tissue) were removed along with devitalized tissue (necrotic tissue (dead), exudate (fluid that leaks out of blood vessels into nearby tissues), and slough. Post debridement measurements: 2.6 cm length x 0.8 cm width x 0.7 cm depth, with an area of 2.08 sq cm and a volume of 1.456 cubic cm. The tactile feedback from the sterile scalpel used to perform the debridement suggested the wound probes to the bone. Wound Orders: cleanse wound with normal saline (NS) or wound cleanser, apply calcium alginate with silver to promote autolytic debridement, cover with gauze, secure dressing Kerlix and change dressing daily, as needed (PRN) for soiling, saturation, or accidental removal. Follow-up with wound physician within 7 days. Avoid wearing shoe on right foot. Coordination of Care: Data and history pertinent to the resident's care was obtained from the resident's chart, nursing staff, and resident. Review of R102's Wound Physician's Visit Report 9/26/2023 reported the information was obtained from the resident's chart and was seen for follow-up and management of the wound. History of the R102 web space between his right 4th and 5th toes identified on 9/15/2023 by a trauma. R102 stated his toe doesn't look like a human toe. He stated he started noticing a color change yesterday, (/25/2023. Resident denied any additional trauma to the toe since last visit, (9/19/2023). Nursing staff reports concerns for wound infection. The Wound Assessment reported the webspace between the 4th and 5th toes was a full thickness trauma wound and received a status of Not Healed. Subsequent wound encounter measurements were 2.8 cm length x 3.1 cm width x 1.2 cm depth, with an area of 9/69 sq cm and a volume of 10.416 cubic cm. There was a moderate amount of yellow drainage noted which had no odor. The wound was deteriorating. Significant deterioration with new necrosis to plantar (sole of foot), medial aspect (inner edge) of the 5th toe. Sutures were in place. Wound probes to bone. Debridement not performed due to wound not appropriate for bedside debridement, risks outweigh benefits. Deterioration due to necrosis 100 percent. Resident was transferred to the hospital ER for further evaluation. Discussed possible outcomes including amputation with resident. Informed DON (Director of Nursing B) of clinical findings. It was noted on R102's MAR/TAR dated 9/16/2023, 1 day after the resident received the sutures, they were removed. Review of R102's Hospital Notes dated 9/26/2023, revealed, .admit date : [DATE] .apparently nursing home had removed the sutures and there is pus draining from the wound .It does not appear that patient (R102) has been on outpatient antibiotics for wound .resident brought into operating room .distal aspect of the right foot where the wound was assessed. There is noted to be extensive infection would per the material extruding from the wound between the fourth and fifth toes. The fifth toe was dislocated dorsally and had exposed bone at the base of proximal phalanx .the decision was made to perform a fifth reamputation, leaving it open given the extensive nature of this infection .There was an extensive amount of purulent material as well as a wound on the plantar aspect of the foot with purulent material coming out of the bottom of the foot at roughly the fifth metatarsal neck area .This is most likely the origination of the wound itself .There is an extensive amount of purulent material extending up the flexor tendon sheath which was opened appropriately. Intraoperative aerobic, anaerobic, and fungal cultures were obtained and sent for Gram stain and culture and sensitivity. At this time, the fifth metatarsal head was assessed and noted have osteomyelitic changes. The dorsal aspect of the fifth metatarsal was extremely soft and necrotic in nature. Diagnosis: Foot wound/Osteomyelitis .toe amputation . Further review of R102's Hospital Notes dated 9/26/2023, revealed, .admit date : [DATE] .9/29/2023 .resident brought into operating room .attention was directed to the lateral foot (right) .there was noted to be purulence draining from the area immediately .coming from the medial proximal aspect of the plantar foot near the FHL tendon .purulence continued to be expressed from the proximal medial foot area .open a small area on the medial midfoot area .purulence was expressed from the site as well. Nonviable tissues were resected .additional portion of bone was removed. Nonviable bone die to the osteomyelitis . continued necrotic tissue to the plantar soft tissues as well as continued purulence expressed .It was felt that the infection was too extensive and this area would ultimately be nonviable, especially with the extensive soft tissue involvement and necrosis. Incision was made to remove the fourth toe .based on the persistent and extensive nature of the infection, decision was made to return to the OR (operating room) in a couple of days for repeat I&D .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is linked to intake # MI00138591 This citation contains 2 Deficiency Practice Statements, DPS #1 and #2. DPS #1 Based on observations/interviews/record review, the facility failed to protect the resident's right to be free from staff to resident verbal and physical abuse for 1 (Resident #21) of 19 residents reviewed for abuse, resulting in Resident #21 sustaining a reddened and bruised area extended across the front of his neck and a bandaged wound was present on his upper torso. Findings include: Review of a facility Abuse Prevention Program Policy and Procedure document revised on 9/22, revealed the intent states: Each resident has the right to be free from abuse .of any type by staff or anyone. The facility will provide a safe resident environmnet and portect residents from abuse. Review of an admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section F of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. Review of a Care Plan for Resident #21, with a start date of 2/10/22 revealed a problem/goal/approach as follows: problem: (Resident #21) removes his shirt at times . Goal (Resident #21) will be dressed prior to leaving his room approaches included: Gently remind (Resident #21) that he should be dressed, offer 2 options, Assist (Resident #21) with putting clothing back on .keep a very positive tone .avoid statements like 'You have to put your shirt on' .approach from the front .avoid power struggles . Further review of the Care Plan for Resident #21 revealed a problem/goal/approach initiated on 12/22/21 as follows: problem: (Resident #21's) ADL (activities of daily living) abilities .vary and fluctuate r/t (related to) cognitive impairment. Goal: (Resident #21) will be clean .and participate in cares . Approaches: Do not rush (Resident #21) .if resistive, stop and reapproach .do not force task .provide care in pairs. During on observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the front of his neck and a bandaged wound was present on his upper torso. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm revealed Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, Get the f*** out of here (Resident #21's name) after providing cares to the resident while alone in the resident's room. Physically injuries were discovered on Resident #21's neck and upper torso. Review of Statement Form dated 8/1/23 at 3:10pm revealed Resident #21 verbalized two words, choked and pushed when asked what happened when CENA LL cared for him a few minutes prior to the interview. In an interview on 8/7/23 at 3:31pm, CENA T reported he saw Resident #21 at approximately 3:11pm on 8/1/23 as a nurse was assessing injuries to his neck and upper torso. CENA T reported Resident #21's neck was very red and new skin tear was present on his upper torso. CENA T described Resident #21 as upset and shaking. CENA T reported he had seen Resident #21 a few minutes before this encounter at which time Resident #21 had no injuries. CENA T reported the injuries were evident after agency CENA LL provided cares to Resident #21. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she saw Resident #21 walk out of his room on 8/1/23 at approximately 3:10pm, clutching his throat and motioning for the nurse to help him. LPN NN described Resident #21 as very distraught and reported the resident appeared fearful. LPN NN reported the front of Resident #21's neck was bright red with new bruising and new skin tear was present near his mid clavicle when she saw him in the hallway. LPN NN saw Resident #21 a few minutes before the incident and there was no redness on his neck/wound at that time. Resident #21 gestured toward his room where CENA LL was at that time. LPN NN asked agency CENA LL what happened, agency CENA LL indicated he pushed Resident #21 down because the resident became aggressive during cares. LPN NN reported several staff did not know how to care for Resident #21 because of his dementia with behaviors and that the facility could have done more (training) to avoid this. LPN NN also stated I could see something like this was going to happen, because they (the staff) don't know how to care for (Resident #21's name). In an interview on 8/8/23 at 8:10am, Nursing Home Administrator A reported he investigated the incident that occurred on 8/1/23 involving agency CENA LL and Resident #21. NHA A confirmed that staff reported hearing agency CENA LL yell an obscenity at Resident #21 and then found injuries on Resident #21's neck and upper torso. NHA A reported agency CENA LL admitted to pushing Resident #21, causing him to fall on the ground but based on Resident #21's injuries, the event appeared a little more aggressive than that. NHA A indicated at the time of this interview that the facility was unsure what if any dementia training agency CENA LL had. NHA A reported the facility had not provided agency staff with dementia training and was awaiting training information from the agency in which CENA LL was employed. In a telephone interview on 8/8/23 at 8:27am, agency Certified Nursing Assistant (CENA) LL reported he provided personal hygiene and dressing assistance to Resident #21 at approximately 3:00pm on 8/1/23. CENA L described caring for Resident #21 as always a struggle, a wrestling match. CENA LL reported during cares on 8/1/23, Resident #21 was standing with his back facing his bed as he attempted to assist Resident #21 with donning a shirt. Agency CENA LL threaded Resident #21's right arm through a sleeve several times, but Resident #21 removed his arm from the sleeve each time. CENA LL reported he continued trying to put the shirt on Resident #21 and did so as quickly as possible. CENA LL reported he kept saying You've got to get your shirt on and continued to attempt to dress Resident #21, during which time the resident became more resistant. Agency CENA LL then went behind Resident #21 and snatched (quickly pulled) the shirt over the resident's head. Resident #21 stood with a shirt over his head, his eyes covered, as CENA LL came around in front of him. Resident #21 grabbed ahold of the CENA's shirt. Agency CENA LL stated he felt Resident #21 was trying to restrain him. Agency CENA LL reported he placed both hands on Resident #21's upper body, near his clavicles and neck and pushed the resident backward. The resident fell back onto his bed and then bounced off the bed and landed on the floor. Agency CENA reported the shirt was twisted tightly around Resident #21's neck at that time and the CENA had to remove it in order redress Resident #21. Agency CENA LL then went behind Resident #21 who sat on the floor, placed his arms under Resident #21's armpits, and lifted the Resident back on his feet. Agency CENA LL then asked the resident Why are you trying to hurt me? Resident #21 walked out of the room. Agency CENA LL reported he probably did swear at (Resident #21) as the resident left his room. CENA LL reported he was unsure how the bruising and redness on Resident #21's neck and the skin tear on his clavicle occurred but acknowledged it must have happened while Agency CENA was providing care. Agency CENA LL reported the facility provided brief verbal instructions on caring for Resident #21 at the beginning of each shift. The instructions given on 8/1/23 were to use 2 staff members to assist the resident, no additional information was provided. Agency CENA LL reported he was familiar with Resident #21 and had cared for him several times previously. Agency CENA LL stated I always just try to get it done really fast because he always fights, referring to providing care for Resident #21. Agency CENA LL reported he did not know what approaches were listed in Resident #21's care plan, other than the resident requiring assist of 2 staff. CENA LL reported the staffing level on 8/1/23 was sufficient to meet resident needs but when he could not find another staff member right away, he opted to provide care alone to save time. Agency CENA LL reported the facility, nor the agency had not given him any dementia training. In an interview on 8/10/23 at 1:05pm, Assistant Director of Nursing (ADON) C reported she was asked to evaluate Resident #21 on 8/1/23 at approximately 3:30pm. ADON C reported she immediately noticed Resident #21's neck was red from one side to the other across the front of his neck. ADON C reported she asked the resident what happened, and he responded by making the universal gesture for choking by placing both hands up near his neck. ADON C also noted a new wound was present on Resident #21's mid clavicle. In an interview on 8/8/23 at 11:37am, Nursing Home Administrator (NHA) A reported he learned the facility wrongfully assumed the staffing agency (who employed all the contractual nursing staff in the facility), had provided the nursing staff with any necessary training. NHA learned the agency provided no training of any kind, including dementia care training and abuse training. Review of a Resident Progress Note dated 8/1/23 at 4:46pm revealed Resident #21 was noted to have redness around his neck and a new skin tear to his upper right chest that was treated, and a dressing applied. Review of a Resident Progress Note dated 8/2/23 at 8:37am revealed Resident #21 had the following injuries: A 6.5cm x 3.0cm dark purple bruise noted to mid clavicle/near neck with a 1.5cm x2.0cm V-shaped skin tear to center of bruise. There is a 2.0cm x 3.5cm dark purple bruise to L clavicle near neck. Review of an Observation Detail List Report dated 8/2/23 at 8:56am revealed Resident #21 had the following injuries: L clavicle purple bruise 2.0cm x 3.5cm. Mid clavicle purple bruise 6.5cm x 3.0cm. Mid clavicle skin tear 1.5cm x 2.0cm x 0.1cm. Using the reasonable person concept, though Resident #21 had decreased ability to verbally express his own thoughts due to his mental diagnoses, he was clearly angry and fearful following the verbal and physical abuse that occurred on 8/1/23. This fear has the potential to continue well past the date of the incident based on the reasonable person concept. As the resident had a court appointed guardian, no family was available to interview as to the presumed feeling of Resident #21. Review of a facility policy titled Abuse Prevention Program Policy and Procedure, section titled Staff to Resident Abuse revealed the following: (Facility Name) will not consider striking a combative resident an appropriate response in any situation. It is also not acceptable for any staff members to claim his/her action was reflexive . This portion of the citation pertains to intakes #MI00138589 and #MI00138592 DPS #2 Based on observations, interviews and record review, the facility failed to prevent resident to resident physical abuse for 2 (Resident #32 and Resident #13) of 19 residents by Resident #21 reviewed for abuse, resulting in feelings of fear of Resident #21. Findings include: Resident #32 Review of an admission Record dated 5/2/22 for Resident #32 revealed the resident was admitted to the facility with the following pertinent diagnoses: Major Depressive Disorder, Unspecified Dementia (progressive loss of cognitive abilities), Weakness. Review of a Care Plan dated 5/4/22 for Resident #2 revealed problem/goal/approaches as stated: Problem (Resident #32's name) can no longer safely care for self at home . Goal (Resident #32's name) will reside at (facility name) while maintaining her dignity and highest level of functioning as possible Approaches Staff to provide 24-hour supervision. Review of a Minimum Data Set (MDS) assessment for Resident #32 dated 5/2/23 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #32 was cognitively impaired. Review of Section E of the MDS revealed Resident #32 had no episodes of delusions (irrational beliefs). Section F revealed Resident #32 used a wheelchair for mobility and could not walk. Review of a Facility Reported Incident revealed on 7/24/23 at 4:15pm, Resident #32 was sitting in the dining room when staff heard her yell He pulled my hair!. Staff responded, found Resident #21 standing next to Resident #32. Resident #32 reported that Resident #21 grabbed her soda and when she told Resident #21 No, he grabbed her ponytail and pulled. In an interview on 8/10/23 at 9:52 am, Resident #32 was lying in bed but reported she wanted to talk. Resident #32 reported she felt afraid of (Resident #21's name) when he pulled her hair. Resident #32 stated He's too much for me. I'm definitely afraid of him and don't want him close to me. Resident #32 reported she continued to go to the dining room but was worried she might have another stressful interaction with Resident #21. Resident #13 Review of an admission Record dated 3/29/22 for Resident #13 revealed the resident was admitted with the following pertinent diagnoses: Mood Disorder, Dementia (progressive loss of cognitive abilities), Aphasia (impaired ability to verbalize thoughts) and Weakness. Review of a Care Plan dated 7/21/22 revealed problem/goal/approaches as follows: problem (Resident #13's name) can no longer safely care for self at home . Goal (Resident #13's name) will reside at (facility name) .while maintaining her dignity and highest level of functioning possible Approaches Staff to provide 24-hour supervision. Review of a Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident scored 4/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated Resident #13 was severely cognitively impaired. Section D of the MDS revealed Resident #13 expressed feeling down, depressed, or hopeless. Section E of the MDS revealed Resident #13 had no hallucinations (perception of something that is not present) or delusions (false beliefs about reality). Review of a Facility Reported Incident dated 7/27/23 at 7:49pm revealed Resident #13 was sitting near the nurse's station when a staff member observed Resident #21 grab Resident #13 by the forehead and hair. In an interview, Certified Nursing Assistant (CENA) U reported she witness Resident #21 grabbing Resident #13 by the forehead on 7/27/23. Resident #21 had his right hand on Resident #13's forehead and pulled head back. Resident #21 immediately stopped when CENA U intervened. CENA U described Resident #13 as scared, crying, and hysterical for a few minutes. Using the reasonable person concept, though Resident #13 had decreased ability to verbally express her thoughts, she was clearly frightened and emotional upset by the Resident #21's actions of grabbing her forehead and forcefully pulling her head back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the care plan for a resident who had known dementia behaviors and required 2-person physical assistance, in 1 (Resident #21) of 19 residents reviewing for care planning, resulting in Resident #21 receiving physical injury and psychosocial harm during cares. Findings include: Review of an admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section F of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. Review of a Care Plan for Resident #21, with a start date of 2/10/22 revealed a problem/goal/approach as follows: problem (Resident #21) removes his shirt at times . Goal (Resident #21) will be dressed prior to leaving his room approaches included: Gently remind (Resident #21) that he should be dressed, offer 2 options, Assist (Resident #21) with putting clothing back on .keep a very positive tone .avoid statements like 'You have to put your shirt on' .approach from the front .avoid power struggles . Further review of the Care Plan for Resident #21 revealed a problem/goal/approach initiated on 12/22/21 as follows: problem: (Resident #21's) ADL (activities of daily living) abilities .vary and fluctuate r/t (related to) cognitive impairment. Goal: (Resident #21) will be clean .and participate in cares . Approaches: Do not rush (Resident #21) .if resistive, stop and reapproach .do not force task .provide care in pairs. A problem/goal/approach dated 1/23/23 revealed the following: problem (Resident #21's name) may become aggressive when attempts are made to change his clothes . Goal (Resident #21's name) will accept assistance without hitting, shoving, scratching .Approaches: avoid power struggles with (Resident #21's name). Do not force him to change his clothes .maintain calm environment .when (Resident #21's name) becomes physically abusive, STOP and try task later. During on observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the base of his neck and a bandaged wound was present on his upper torso. In a telephone interview on 8/8/23 at 8:27am, agency Certified Nursing Assistant (CENA) LL reported he provided personal hygiene and dressing assistance to Resident #21 at approximately 3:00pm on 8/1/23. CENA L described caring for Resident #21 as always a struggle, a wrestling match and that he generally performed care for Resident #21 quickly because it was always a fight. CENA LL reported during cares on 8/1/23, he (CENA LL) repeatedly told Resident#21 You've got to get a shirt on and quickly pulled a shirt over Resident #21's head. When Resident #21 responded by grabbing the CENA's shirt, CENA LL felt Resident #21 was trying to restrain him. CENA LL admitted he pushed Resident #21 backward from a standing position, using both hands on Resident #21's upper body. The resident fell back onto his bed and then bounced off the bed and landed on the floor. Agency CENA reported the shirt was twisted tightly around Resident #21's neck at that time and the CENA had to remove it in order redress Resident #21. CENA LL reported he was unsure how the bruising, redness on Resident #21's neck, and the skin tear on his clavicle occurred but acknowledged it must have happened because of his actions. Agency CENA LL reported he was familiar with Resident #21 and had cared for him several times previously but did not know what care plan interventions staff were supposed to use when caring for Resident #21. Agency CENA LL indicated the only intervention he was aware of was Resident #21 required assist of 2 staff for care. CENA LL reported the staffing level on 8/1/23 was sufficient to meet resident needs on 8/1/23, but when he could not find another staff member right away, he opted to provide care alone to save time. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm revealed Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, after providing cares to the resident while alone in the resident's room. Physically injuries were discovered on Resident #21's neck and upper torso. In an interview on 8/7/23 at 3:31pm, Certified Nursing Assistant (CENA) T reported he saw Resident #21 at approximately 3:11pm on 8/1/23 as a nurse was assessing injuries to his neck and upper torso. CENA T reported Resident #21's neck was very red and new skin tear was present on his upper torso. CENA T described Resident #21 as upset and shaking. CENA T reported he had seen Resident #21 a few minutes before this encounter at which time Resident #21 had no injuries. CENA T reported the injuries were evident after agency CENA LL provided cares to Resident #21. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she saw Resident #21 walk out of his room on 8/1/23 at approximately 3:10pm, clutching his throat and motioning for the nurse to help him. LPN NN described Resident #21 as very distraught and reported the resident appeared fearful. LPN NN reported the front of Resident #21's neck was bright red with new bruising and new skin tear was present near his mid clavicle when she saw him in the hallway. LPN NN saw Resident #21 a few minutes before the incident and there was no redness on his neck/wound at that time. Resident #21 gestured toward his room where Certified Nursing Assistant LL was at that time. LPN NN asked agency CENA LL what happened, agency CENA LL indicated he pushed Resident #21 down because the resident became aggressive during cares. LPN NN reported several staff did not know how to care for Resident #21 because of his dementia with behaviors and that the facility could have done more (training) to avoid this. LPN NN also stated I could see something like this was going to happen, because they (the staff) don't know how to care for (Resident #21's name). Using the reasonable person concept, though Resident #21 could not verbally express his emotional distress, he was clearly fearful and anxious following the altercation that took place during his care. According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences.A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care .

This citation pertains to intake # MI00138591 Based on observations, interview, and record review the facility failed to provide in depth Dementia Care training to all current, newly hired and agency employed staff resulting in an incident of staff to resident abuse for Resident #21, with a potential for a decline in physical, mental, and psychosocial well- being and unmet care needs for all residents with dementia. Findings include: Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed . there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. Common causes and risk factors leading to this abuse include poor training . Review of a facility policy titled Abuse Prevention Program Policy and Procedure, last revised 9/22, a section titled Training revealed the following: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following . Aggressive and/or catastrophic reactions of residents .Resistance to care .Dementia Training for staff to educate on choosing the appropriate response for the Behavior using person-centered care strategies. Review of an admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section G of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. During an observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the base of his neck and a bandaged wound was present on his upper torso. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm, revealed Agency Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, Get the f*** out of here (Resident #21's name) after providing cares to the resident while alone in the resident's room. Per the facility investigation, physical injuries were discovered on Resident #21's neck and upper torso. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she witnessed Resident #21 as he came out of his room on 8/1/23 clutching his neck, appearing very distraught with redness, and bruising around his neck and a wound on his upper chest. LPN NN reported Resident #21 had been alone in his room with Agency Certified Nursing Assistant (CENA) LL. When asked, CENA LL reported to LPN NN that he had pushed Resident #21 down because the resident became physically aggressive during cares. LPN NN stated . I could see that something like this was going to happen .the facility should have done more . because the staff don't know how to care for Resident #21. In a telephone interview on 8/8/23 at 8:27am, CENA LL reported he frequently struggled to provide care for Resident #21 because the encounters were always . a wrestling match. CENA LL reported he felt threatened when Resident #21 grabbed his shirt during care on 8/1/23 and as a result, CENA LL pushed Resident #21, causing him to fall on the floor. CENA LL acknowledged the resident had bruising, redness, and a skin tear because of the incident. CENA LL reported the facility had not provided any training related to caring for Residents who had dementia/dementia behaviors. In an interview on 8/8/23 at 11:37am, NHA A reported he learned the facility wrongfully assumed the Staffing Agency (who employed all the contractual nursing staff in the facility), had provided the nursing staff with any necessary training. NHA learned the Staffing Agency provided no training of any kind, including dementia care training. Review of a Plan of Correction from a survey that exited on 6/27/23 revealed the facility agreed to provide all staff education on Dementia Care and Resident Aggression. The facility contacted a psychiatric service company to set up an in-person training for staff. The alleged compliance date for this training was 7/25/23. At the time of survey entry on 8/7/23, the training still had not been completed. Review of staff training materials initiated by the facility on 8/2/23 revealed a Dementia/Care of Cognitively Impaired Training posttest, which only measured the trainee's most basic knowledge of dementia. The materials did not encompass how to effectively care for a Resident with dementia. The posttest questions related to basic knowledge of dementia i.e., A set routine is important for a person with Alzheimer's Dementia. True/False, The person with Alzheimer's Dementia can control their behavior. True/False. The test did not determine if staff understood that a resident's behaviors might also serve as a means for the resident to communicate an unmet need, rather than as an act of intentional aggression. Yelling at a distressed resident is the best way to get him or her to listen. True/False. The test did not determine if the staff understood or even knew effective ways of communicating with a person with dementia, other than knowing that yelling was not the best way to do so. Review of a Resident Aggression Pre/Post Test provided by the facility on 8/7/23 revealed a 5-question test that covered only basic information related to aggression, i.e., a question stated, If an episode of resident-to-resident aggression is abusive, it must be reported . True/False. The test did not determine if the staff understood how to avoid episodes of resident-to-resident aggression, only that if an episode occurred, it should be reported. Another question stated, At times, staff members may contribute to aggression by ignoring a resident who agitated. The test served to determine only if a staff member understood that ignoring an agitated resident would not solve the issue and did not evaluate if the staff member had any knowledge how to effectively reduce and manage aggressive behaviors. Review of Facility Assessment dated 4/2/23, revealed, . For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired . No mention of behavioral health services education to be provided to all staff and agency staff. Review of the spreadsheet of course completions received 8/14/23, revealed, 14 employees out of 75 employees and 51 agency staff had not completed the education for Behavioral Health Services for the previous 12 months. Review of Annual Education Calendar revealed, Behavioral Health Services education was provided November 2022. In an interview on 08/09/23 02:54 PM, Regional Director of Nursing GG reported the education and training was monitored by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) prior to the implementation of the vendor education program which started in May 2023. In an interview on 08/10/23 at 2:22 PM, Administrator A reported we have some work to do on monitoring education completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes: MI00132446, MI00136322, MI00136324, MI00136326, MI00136328, MI00136330, MI00137222, MI00137224, MI00137540, MI00137886 Based on observation, interview, and record review the facility failed to protect the resident ' s right to be free from resident to resident physical abuse by Resident #100 in 8 of 9 residents (Resident #113, Resident #109, Resident #106, Resident #111, Resident #108, Resident #105, Resident #107, Resident #110) reviewed for abuse, resulting Resident #113 feeling unsafe in her home, Resident #109 sustaining a head laceration, Resident #106 being slapped in the face leaving redness, Resident #111 sustaining minor injuries with continued anger, Resident #108 feeling as if Resident #100 was out to get her, Resident #107 having her arm twisted, and Resident #'s 105 and 110 being abused by Resident #100. Findings include: In an interview on 6/20/23 at 1:23 PM, the Ombudsman reported in regard to Resident #100 that there were concerns at that time that he was wandering and doing his own thing at the facility without interventions from staff. Ombusman stated, I know they have sent him out for psych evals and he just gets sent back. I have had multiple conversations with the NHA that staff need to know where (Resident #100) is at all times if they are not going to do one on ones with him and staff seems to go about their day and not have any clue where he is half the time. Residents are afraid of him. If you get in (Resident #100's) way, he gets very aggressive and violent and I am afraid a resident is going to get hurt. In an interview on 6/21/23 at 9:37am, Resident #113 reported there was a resident at the facility named Wandering (Resident Name omitted) (Referring to Resident #100) who stood at their (Resident #113 and her roommate) doorway and they (Resident #113 and her roommate) had to yell at him to get away. Resident #113 reported did not feel safe with (Resident #100) at the facility. Resident #100 Review of an admission Record revealed Resident #100 was a male, originally admitted to the facility on [DATE] with the following pertinent diagnoses: Vascular Dementia (general term describing problems with reasoning, planning, judgement, and memory caused by impaired blood flow to the brain) with behavioral disturbance, Alcohol-induced persisting Dementia, Disorientation (state of mental confusion), Restlessness and Agitation, Anxiety Disorder, Weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100 dated 6/12/23, revealed Resident #100 entered the facility from a psychiatric hospital on [DATE]. Resident #100 was sometimes able to make self-understood and sometimes understood others. A Brief Inventory of Mental Status (BIMS) assessment was not attempted due to Resident #100's severe cognitive impairment. Section D (Mood) of the MDS revealed Resident #100 displayed trouble falling asleep or sleeping too much, trouble concentrating on things such as reading or watching television and several days of being short tempered, easily annoyed. Section E (Behavior) of the MDS revealed Resident #100 rejected care 1 to 3 days during the assessment period and wandered daily. Section G (Functional Status) revealed Resident #100 walked independently but was unsteady and required extensive assistance of 2 staff to transfer from one surface to another, i.e., from sitting to standing. Review of a current Care Plan for Resident #100 revealed a problem initiated on 5/25/23 He becomes extremely restless and agitated which may escalate into physical aggression toward others. Approaches for this problem included: Assess if (Resident #100's) behavioral/mood symptoms present a danger to himself and/or others. Intervene as needed Engage (Resident #100) in brief conversation, redirect to an activity, offer food/drink . Separate (Resident #100) from other residents immediately with any display of anger or irritability . Review of Facility Reported Incidents from 10/14/22-5/23-23 revealed Resident #100 was involved in 12 Resident to Resident altercations, all 12 took place in the afternoon or early evening, 7 occurred in the dining room, 5 involved Resident #100 reaching for or taking another Residents' cup. All incidents occurred in the common areas of the facility. 10 of the 12 incidents involved other Residents who also had a diagnosis of dementia with behaviors. 8 of the incidents were unwitnessed by staff. 4 incidents involved Resident #100 either touching or pulling another Resident's hair. I incident involved Resident #100 grabbing another Resident's personal belongings. During the altercations, Resident's #109, #111 and #100 had minor injuries. Review of an Observation Detail List Report dated 5/22/23 at 6:32pm revealed Resident #100 had scratches on his right arm following an altercation with Resident #111. Report stated Nurse walked in to see chocolate milk thrown at resident (Resident #100) by another resident (Resident #111) and both resident were throwing fists and grabbing and scratching each other. In an interview on 6/21/23 at 2:57pm, Certified Nursing Assistant (CENA) H reported it was not possible to provide enough supervision for Resident #100. CENA H found Resident #100 and another Resident in an altercations by the nurse's station on 6/20/23, both were trying to gain possession of a filled coffee cup with no other staff present. CENA H reported there was no opportunity to intervene before both Residents were upset, physically grabbing for the cup and at risk for having a hot beverage spill on them. CENA H also reported that Resident #100 was often up all-night walking, and no staff were available to supervise him. CENA H confirmed she witnessed the altercations between Resident #100 and Resident #109 and Resident #100 and Resident #110( 2 seperate altercations). CENA H reported she did not observe the events leading up to the altercations, the Residents were unsupervised at that point, but heard yelling and arrived to find the Residents in physical altercations involving a coffee cup. In an interview on 6/21/23 at 4:14pm Licensed Practical Nurse (LPN) O reported Resident #100 had periods in which he did not sleep for up to 3 days at a time and when that occurred, Resident #100 became manic (exhibiting extreme behaviors). LPN O reported that Resident #100 wandered the halls for hours at times, became extremely fatigued, looked exhausted and could not be constantly supervised. Review of the electronic medical record revealed on 6/22/23 Resident #100 was transferred to a chair in the sunshine room at 5:39am. During an observation on 6/22/23 at 8:14am, Resident #100 remained in the Sunshine Room near a dining table, seated on a metal folding chair. Resident #100 was alone in the room. A breakfast tray sat on the table near Resident #100 who sat facing the middle of the room. The food on the tray was neatly placed in sections of the tray, no indentations were present to indicate Resident #100 had tried to eat it. A spilled bowl of oatmeal was on the floor, with approximately 75% of the content on Resident #100's pants, socks and right foot dressing. Resident #100's feet had edema (swelling which can be associated with legs being in a dependent position for long periods of time), the right foot was bandaged, reddened swollen exposed skin was evident just above the dressing. A spoon rested on the floor between Resident #100's feet. Resident #100 was awake, sat flexed at the waist at 80 degrees, attempted to pick up the spoon between his feet. Mucus, approximately 4 in length, hung from Resident #100's nose. Resident #100 licked oatmeal residue off his fingers as his torso remained in the forward flexed 80 degree angle for the next 19 minutes. At that time Registered Nurse (RN) T was heard outside the door of the Sunshine Room saying Did anyone know this man was down here? Certified Nursing Assistant (CENA) J responded and stated No, I did not. CENA J entered the room and began cleaning the oatmeal of Resident's pants. During an observation on 6/21/23 between 2:35pm-2:51pm, Resident #100 wandered from a crowded area across from the nurse's station to the end of the hall, entered the Sunshine Room for 30 seconds, then returned down the hall to the nurse's station. Resident carried 3 empty coffee cups as he completed this route twice, unobserved by staff. In an interview on 6/27/23 at 9:22am Housekeeper FF reported a schedule was initiated for housekeeping staff to check the floor of the Sunshine Room after each meal because Resident #100 frequently urinated there when unsupervised. Housekeeper FF reported she found urine on the floor in the Sunshine Room several times a week and that Resident #100 was the only Resident who had this behavior. In an interview on 6/27/23 at 10:02 am with Laundry Supervisor/Certified Nursing Assistant (CENA) K, it was revealed that Resident #100 regularly urinated on the floor of the Sunshine Room when he was unsupervised. When asked about the frequency of this happening, CENA K reported it had happened as often as daily. CENA K reported it was likely urine had seeped under the tiles due to the frequency in which Resident #100 urinated on the floor and the smell was difficult to resolve as a result. During an observation on 6/21/23 at 10:21am, a strong smell of urine was present in the Sunshine Room. The room was empty at the time. During an observation on 6/26/23 at 4:15pm, a strong smell of urine was present in the Sunshine Room. The room was empty, floor appeared clean. During an observation on 6/27/23 at 8:43am, a strong smell of urine was present in the Sunshine Room. The room was empty at the time. Resident #109 Review of an Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 scored 4 of 15 on a Brief Inventory of Mental Status (BIMS) assessment which indicated the Resident was severely cognitively impaired. Resident #109 had episodes of disorganized thoughts but did not display aggressive behaviors toward others. Resident #109 was independent with using a wheelchair for mobility and did not ambulate. Review of a Facility Reported Incident report dated 4/11/23 revealed Resident #109 was struck in the head twice with a coffee cup by Resident #100 at 4:00pm in the dining room of the facility. Resident #109 was heard screaming and reported the incident to Licensed Practical Nurse (LPN) W who responded. Resident #109 had a 1.5 cm laceration on her head. In an interview on 6/21/23 at 2:57pm, Certified Nursing Assistant (CENA) H reported she observed the altercation involving Resident #109 and Resident #100 and said she did not know what triggered Resident #100, but it often seemed to involve cups. CENA H felt it was impossible to monitor Resident #100 all the time and impossible to predict the altercations that could arise. In an interview on 6/26/23 at 10:02am Licensed Practical Nurse (LPN) W reported she heard Resident #109 screaming on 4/11/23 and found her in the dining room with a laceration on her head. Resident #100 was standing near Resident #109 and was removed from the room. LPN W reported Resident #100 had frequent altercations with others. In an interview with Resident #109 on 6/22/23 at 10:52am, the resident could not recall the incident. Based on a reasonable person concept, Resident #109 would not have wanted to be hit twice in the head causing head trauma and would likely have had lingering pain due to the resident to resident abuse that occurred. Resident #106 Review on an admission Record dated 10/21/16 revealed Resident #106 was admitted to the facility with the following pertinent diagnoses: Dementia with Agitation, Diffuse Traumatic Brain Injury, Major Depressive Disorder, Anxiety Disorder and Muscle Weakness. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 scored 6 of 15 on a Brief Interview for Mental Status (BIMS) assessment which indicated she was severely cognitively impaired. Resident #106 expressed feelings of depression during 7-11 days during the 14-day assessment period. Review of a current Care Plan for Resident #106 revealed problem/goal/approaches stated, Diagnosis of depression .sadness may also display as anger when confusion is increased . Interventions for this problem included avoid over-stimulation .other physically aggressive Residents, assess whether behaviors endanger (Resident's Name), intervene if necessary . Review of a Facility Reported Incident dated 12/19/22 at 6:42pm, revealed Resident #106 was involved in an unwitnessed Resident to Resident altercation. A former Resident who had a Brief Interview for Mental Status score of 15 (cognitively intact) reported that Resident #106 was hit in the face by Resident #100. Resident #106 was found screaming and crying hysterically and reported she had been hit in the face. Staff observed that Resident #106 had a reddened area on her face that extended from her cheek to her forehead. Resident #100 was agitated, used profanity, and verbalized threats toward staff as they removed him from the area. In an interview on 6/21/23 at 11:14am, Resident #106 was unable to recall the altercation that took place with Resident #100. Based on the reasonable person concept, Resident #106 would not have wanted to be slapped in the face so hard it left a reddened area on her face leaving her screaming and crying hysterically. Resident #111 Review of an Admissions Record dated 11/16/14 revealed Resident #111 was admitted to the facility with pertinent diagnoses that included: Vascular Dementia with behavioral disturbances(a disease causing a progressive decline in cognitive skills), Major Depressive Disorder, Anxiety Disorder, Post Concussive Syndrome (symptoms that occur after a brain injury which may include physical, cognitive, behavioral or emotional in nature), and Receptive-Expressive Language Disorder(decreased ability to understand others and express own thoughts). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 scored 4 of 15 on a Brief Interview for Mental Status (BIMS) assessment which indicated he had a severe cognitive impairment. Review of a current Care Plan for Resident #111 revealed a Problem, Goal and Approaches as follows: Problem: behavioral disturbance .flipping people off, yells, says curse words Goal: Maintain behavioral functioning and management of symptoms Approaches: Avoid other physically aggressive Residents, Assess whether behavior endangers (Resident name) or others, Intervene. Resident #111's current Care Plan also revealed a Problem, Goal, Approaches which stated: Problem Does not like others around his personal space in the dining room, Goal Will exhibit decreased agitation, Approaches Attempt to keep in calm environment and away from large groups of people if he appears agitated, Remind (Resident Name) not to use profanity, use finger gestures or call others names, Remove from common areas as needed. Review of a Facility Reported Incident report dated 5/22/23 revealed Resident #111 and Resident #100 were unsupervised in the dining room when an altercation occurred between them. The altercation took place after Resident #100 attempted to take a cup from Resident #111. When a nurse arrived, Resident #111 threw the cup at Resident #100 and both Residents were punching and grabbing each other. Both Residents had abrasions on their arms. On 5/24/23 Resident #111 remained angry about the incident and yelled when he discussed it with the Social Services Director. During on observation on 6/22/23 at 9:11am, Resident #100 was standing in the hallway near the nurse's station. Resident #111 sat nearby in a wheelchair and pointed his hand in a gun shape at Resident #100 and made 2 shooting sounds while bending his thumb in a trigger motion. Resident #111 then gestured with his thumb, in a motion used by baseball officials to indicate out and pointed at Resident #100. Using the reasonable person concept, though Resident #111 had decreased ability to verbally express his own thoughts, he was clearly still angry with Resident #100 as identified by the threatening behavior of pretending to shoot Resident #100 and indicated he was going to be taken out. Resident #108 Review of an admission Record dated 9/15/21 revealed Resident #108 was admitted to the facility with the following pertinent diagnoses: Hemiplegia (paralysis on one side), Hemiparesis (loss of strength on one side), Major Depressive Disorder, and Generalized Anxiety Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated the Resident was cognitively intact. Resident #108 had no symptoms of delusions (misconceptions contrary to reality), no behaviors or episodes of aggression toward others. Resident #108 was independent with wheelchair mobility. Review of a current Care Plan revealed a problem/goal/approaches initiated on 8/19/21which stated: Problem (Resident Name) .requires 24-hour care/supervision .Goal (Resident Name) will reside at (facility name) for 24-hour care/supervision while maintaining her dignity and highest level of functioning .Approaches Staff to provide 24-hour supervision. Review of a Facility Reported Incident report dated 2/18/23, 4:34pm, revealed Resident #108 was heard saying ouch and reported she had been kicked in the leg by Resident #100 while in the hallway. Review of a Facility Reported Incident report dated 3/13/23 revealed Resident #108 was attending an activity in the Sunshine Room when Resident #100 approached her with a raised arm while holding a coffee cup and appeared as though he was going to hit Resident #108. Resident #100 was removed from the room. Resident #108 was fearful after this incident and called the police due to being fearful. In an interview on 6/21/23 at 2:42pm Resident #108 reported Resident #100 kicked her in the leg on 2/18/23. Resident #108 reported she believed Resident #100 was stressed after being told to leave the Sunshine Room (activity room near Resident #108's room) and acted out when he encountered Resident #108 in the hallway. Resident #108 reported she was not injured when Resident #100 kicked her, but it did hurt, and thought the Resident was out to get her. Resident #105 Review of an admission Record dated 5/23/22 revealed Resident #105 was admitted to the facility with the following pertinent diagnoses: Unspecified Dementia (progressive disease resulting in loss of cognitive skills) with behavioral disturbance, Major Depressive Disorder, Anxiety Disorder. Review of a Minimum Data Set (MDS) for Resident #105 dated 5/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #105 was severely cognitively impaired. Resident #105 experienced disorganized thinking (rambling or irrelevant conversation), had episodes of feeling badly about herself, feeling depressed, and wandered. Section E of the MDS revealed Resident #105 wandered during 1-3 days of the assessment period. Review of Facility Reported Incidents revealed Resident #105's hair was pulled by Resident #100 on 10/28/22 and 5/23/23. Both incidents occurred in common areas of the facility, one was witnessed by a staff member, the other was reported by a resident. The unwitnessed incident occurred across from the nurse's station where staff were working nearby. The staff looked up after being alerted of the situation by another Resident and observed Resident #100 walking away. In an interview on 6/22/23 at 9:42am, Certified Nursing Assistant (CENA) I reported she witnessed Resident #100 tug on Resident #105's hair as he walked by on 5/23/23. Both residents were near the nurse's station in the hallway. Resident #105 was calling out that day. CENA I reported Resident #100's behaviors, such as pulling Resident #105's hair, were triggered by other residents who call out and although the staff try to keep a distance between Resident #100 and others, they could not always supervise the common areas. During an observation on 6/21/23 at 1:56pm, Resident #105 was in the common area near the nurse's station calling out and reaching for those who passed by. During an observation on 6/21/23 at 4:07pm, Resident #105 was in her wheelchair near the doorway in her room, appeared frustrated and called her roommate a pain in the a** in a loud tone. No staff were present to intervene. During an observation on 6/22/23 at 1:56pm, Resident #105 propelled her wheelchair in the hallway, approached a room where another resident was calling out, Resident #105 yelled loudly Shut up, shut up Dam .t. No staff were present to intervene. Resident #107 Review of an admission Record dated 8/20/18 revealed Resident #107 was admitted to the facility with the following pertinent diagnoses: Bipolar Disorder (mental condition marked by alternating periods of elation and depression), Dementia (a progressive disease causing decline in cognitive skills), Generalized Anxiety Disorder, Schizophrenia, and Moderate Intellectual Disabilities. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 scored 9 of 15 on a Brief Interview for Mental Status (BIMS) assessment which indicated he had a moderate cognitive impairment. Resident #107 showed no evidence of delusions (misconceptions contrary to reality) and had episodes of aggressive behavior during the assessment period. Review of a current Care Plan for Resident #107 revealed problem/goal/approach as follows: (Resident #107) requires 24-hour supervision .Goal (Resident #107) will reside at (facility name) for 24-hour supervision while maintaining his dignity .Approaches . Provide 24 hour supervision. Review of a Facility Reported Incident report dated 1/12/23 at 4:35 pm revealed Resident #107 was involved in a Resident to Resident altercation in his arm was grabbed and twisted by Resident #100. Resident #100 tried to take Resident #107's coffee cup. Per the report, the incident was not initially witnessed by staff but upon entering the dining room, staff observed Resident #100 twisting Resident #107's arm. Resident #110 Review of an admission Record dated 11/28/22 revealed Resident #110 was admitted to the facility with pertinent diagnoses that included: Mood Disorder with Depressive Features, Dementia with Moderate Mood Disturbance, and Anxiety Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 scored 4 of 15 on a Brief Interview for Mental Status (BMS) assessment which indicated she had a severe cognitive impairment. Resident #110 had episodes of verbal and physical aggression 4 to 6 days during the 14-day assessment period. Resident #110 was not able to walk and was dependent on staff for moving her wheelchair. Review of a current Care Plan for Resident #110 revealed a Problem/Goal/Approach of Problem: Displays extreme restlessness and agitation, verbal and physical Goal Will not harm self or others Approaches Avoid over-stimulation .other physically aggressive Residents, Keep away from other Residents when extremely agitated. Review of a Facility Reported Incident report dated 5/10/23 revealed on 5/9/23 at 7:55pm Resident #110 was sitting in a common area displaying verbal behaviors, yelling out and disturbing others. Staff attempted to redirect without success and did not remove Resident #110 from the area. Resident #100 who was known to be triggered by noise, walked by, and pulled Resident #110's hair. Review of a Facility Reported Incident dated 5/22/23 revealed on 5/21/23 at 6:35pm, Resident #110 was sitting near the nurse's station with a cup of coffee. Per the report, Resident #110 yelled at Resident #100 as he walked by, and Resident #100 grabbed Resident #110's arm. In an interview on 6/21/23 at 2:57pm, Certified Nursing Assistant (CENA) H reported she observed an altercation involving Resident #110 and Resident #100 and said she did not know what triggered Resident #100, but it often seemed to involve cups. CENA H reported during the most recent incident, both Resident #110 and Resident #100 were in the area across from the nurse's station. No other staff were present. CENA H arrived to find Resident #100 trying to take a cup out of Resident #110's hands. Both Residents were struggling for possession of the cup. CENA H felt it was impossible to monitor Resident #100 all the time and impossible to predict the altercations that could arise. During an observation on 6/21/23 at 4:00pm, Resident #110 was sitting in her wheelchair near the nurse's station calling out to others as they passed by. The common area was congested with several residents in wheelchairs, 2 were calling out as Resident #100 ambulated between their wheelchairs. In an interview on 6/27/23 at 11:48am, Director of Nursing (DON) B reported the area around the nurse's station should be kept clear to avoid additional incidents of Resident #100 becoming overwhelmed and acting out toward other residents. In an interview on 6/27/23 at 9:28am, Certified Nursing Assistant (CENA) G revealed a nurse was supposed to supervise residents in the dining room during each meal. CENA G reported this supervision was usually provided during the day shift but was inconsistent during the afternoon shift. CENA G expressed concern about the lack of supervision in the dining room because anything could happen. Review of Resident Council minutes dated 5/18/23 revealed Residents expressed a concern which stated A nurse needs to help feed (assist Residents who cannot eat independently) and be in the dining room for safety.