**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, video footage, and interviews, the facility failed to ensure Resident (R)45 was free from physical abuse from Certified Nursing Assistant (CNA)1. Findings include: Review of the facility policy titled, Protection from Harm Policy last revised, November 2024 revealed A significant aspect of residents' rights is the right to be free from abuse/neglect. The facilities of C. M. [NAME], Jr. Nursing Care Center have a 'zero tolerance' for any type of abuse. A. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. G. Mistreatment means inappropriate treatment or exploitation of a resident. I. Physical Abuse means hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. Review of R45's Face Sheet revealed R45 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, depression, difficulty in walking, history of falling, other lack of coordination, and unsteadiness on feet. Review of R45's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/25, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. Review of surveillance video footage provided by the facility, recorded on 05/13/25 at 3:23 PM, revealed R45 in the unit day area attempting multiple times to headbutt, punch, and kick CNA1. CNA1 then attempted to move in front of R45, who tripped her with his foot/leg. CNA1 then turned to face R45, grabbed and lifted his leg to her hip level, held it there for a few moments, then dropped it back down while saying something to R45 before walking away and the video ends. Review of CNA1's Notice of Termination dated 04/24/25, revealed, After reviewing statements and video footage for Friday, April 18, 2025, you were observed in the main hallway on your unit turning a patient around in his wheelchair. This action resulted in the resident becoming combative, and he began swinging his fist and kicking his feet at you. You grabbed the patient's legs, saying to him, I'm not the one! You then dropped the patients' legs back to the floor. During an interview with R45 on 05/13/25 at 3:29 PM, revealed he could not recall anything from the incident with CNA1. R45 stated he tried to avoid negative encounters if he can. The resident denies being fearful for his life. During an interview with the Physical Therapist (PT) on 05/14/25 at 10:08 AM, revealed the incident occurred in the day area on Unit 122 (secure/all male unit). R45 was considered a new admission at that time. The PT stated she was coming down the main center hall. Once she reached the entrance to the day area, she saw R45 head-butt CNA1. The PT explained she was distracted by another resident on her left side. She turned around and walked back towards R45 because he was her patient that day for therapy. She saw R45 punching CNA1 but was unable to recall if he connected with the punches. The PT expressed uncertainty about whether he tried to kick the CNA or attempted to trip her. She observed CNA1 standing in front of the resident, locking his wheelchair and grabbing his legs at her waist level. CNA1 said something to the resident about a problem, but she couldn't recall exactly what was said at that time. The tone of her (CNA1) voice was stern. The PT reported that she walked up to intervene, expressing that she was taken aback and instructed everyone to step away to cool off. R45's nurse was nearby at the cart. The PT stated she notified the DON (Director of Nursing) about the incident. The PT mentioned that R45 has a history of behaviors; however, he had not displayed them with her. During a phone interview with Licensed Practical Nurse (LPN)1 on 05/14/25 at 10:27 AM, revealed she witnessed the event and was R45's nurse on the day of the incident. R45 was a new admission at the time and had a history of dementia with behaviors. LPN1 stated that while she was standing at the med cart, she saw CNA1 forcibly move R45's wheelchair. R45 responded by trying to headbutt CNA1 by throwing his head backward. CNA1 then walked beside R45, and he attempted to punch her. CNA1 then walked in front of R45's wheelchair, where he tried to trip her and then kicked at her. CNA1 then grabbed both of R45's legs and pulled them up into the air while telling the resident, I'm not the one, in a loud, aggravated tone, and then dropped his legs down, slightly rocking R45's wheelchair before walking off. LPN1 stated that initially, she was in shock; she assessed the resident, and he appeared to be fine at baseline with no injuries following the encounter. During a phone interview with CNA1, on 05/14/25 at 11:20 AM, revealed she had been employed at the facility for approximately a year. CNA1 confirmed that she was R45's aide and recalled the encounter with R45. CNA1 stated that she began to move R45's wheelchair from the middle of the hallway. R45 started to attempt to headbutt her in the stomach/abdomen area. CNA1 stated she turned R45 away from other residents, and he began to punch and kick her. CNA1 admitted to grabbing R45's legs and lifting them to her hip level before releasing them. She indicated that she was not going to bend over and place R45's legs on the ground. CNA1 reported that she told R45, I'm not the one that bothered you, I'm not the one and noted that other staff and residents were present during this encounter. CNA1 mentioned that she was suspended pending investigation, and a few days later terminated due to the allegation of physical abuse. During an interview with the Facility Administrator (FA) in the presence of the Director of Nursing (DON) on 05/15/25 at 1:51 PM, revealed he is responsible for the investigating and submissions of reportable's, with the assistance of the DON. The FA revealed he was notified of R45's incident related to physical abuse on 04/18/25 by the DON. The FA states he was told that R45 became aggressive with CNA1, and CNA1 lifted R45's legs and held his legs up for a few seconds, then dropped them back down. The protocol was followed, and CNA1 was suspended following the allegation and escorted from the facility. The FA stated that, per clinical staff, R45 was assessed and had no apparent injuries. R45's Representative (RP), and Medical Director (MD) were notified of the alleged event. The FA revealed he ran the video footage back and saw CNA1 lift R45's legs immediately after R45 attempted to trip her. She held his legs up at her waist height for a moment. She then dropped R45's legs to the floor and returned to assisting other residents. The FA agrees that the lifting of the resident's legs to her waist height and dropping them was not acceptable and deems these actions to have been unnecessary. CNA1 should have walked away and allowed R45 to cool down, but she did not follow the process. Three unsuccessful attempts were made to contact R45's RP via phone on 05/13/25 at 3:40 PM, 05/14/25 at 10:05 AM, and 1:07 PM.

Based on review of facility policy, record review, and interviews, the facility failed to ensure an assistive device was implemented to prevent injury for one (Resident (R)12) of three residents reviewed for falls out of a sample of eighteen residents. R12, who had a history of previous falls and orders for hip protectors, sustained a fall that resulted in a right hip fracture after the facility failed to provide this assistive device designed to prevent injury. Findings include: Review of the facility's policy, titled Fall Prevention & Management Program, reviewed 06/20, revealed the purpose was to provide guidelines for falls and repeat fall preventive intervention. Review of the policy revealed that for all residents, Individualize equipment specific to resident's needs. Review of R12's hard-copy medical record included a Face Sheet, which indicated R12 had diagnoses including Alzheimer's disease, dementia, spondylosis, osteoporosis and lack of coordination. R12's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/21 revealed the resident was severely cognitively (SC) impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15. Per this MDS, R12 was independent in ambulation. Review of Physician Orders dated 06/01/21- 06/30/21, in R12's medical record under the Physician Orders tab, revealed that since at least 05/26/21 when all orders were reviewed, the resident had an order for protective/adaptive device: wear hipsters while out of bed [OOB]. Review of the Care Plan Report provided by the facility, with a goal date of 10/13/21 revealed the resident had a history of falls including, but not limited to 03/23/19, and 03/23/21. The Care Plan revealed Falls were listed as a problem, noting the resident was at risk for falls r/t [related to] dementia with psychosis, taking melatonin for sleep, BIMS of 03 (SC), sun downing and wandering behavior. Review of the interventions listed on the care plan revealed that they included, Please have resident wear hipsters while OOB per MD [physician] order. Per this care plan, R12 used a rollator for mobility. Review of Nursing Progress Notes dated 06/14/21 at 3:13 PM, in the medical record under the Progress Notes tab, revealed R12 was found on the floor outside his room. The resident had gone outside his room without his walker. He complained of leg pain and pointed to his right upper thigh. He had external rotation of the right foot and was only moving his toes; he did not want to move his leg. The physician and family were notified, and the resident was sent to the emergency room. Review of an investigation folder provided by the facility, titled STONE PAVILION INCIDENT REPORT, dated 06/14/21, revealed R12's accident was an unwitnessed fall. Review of an Orthopedic Surgery Consult Note dated 06/14/21 revealed the fall resulted in a right intertrochanteric (hip) fracture which required surgical repair. Review of a statement in the investigation report by a former facility employee revealed, I heard resident yelling he was hurting and for someone to help him. I assisted resident to his feet with another co-worker, then we lower him back to the floor. We call for assistance. Review of the fall investigation revealed that the investigation form included a section listing various interventions/devices, and measures that could be in place at the time of the fall. The instructions on the form stated staff should check the form if the listed device was in place. The instructions further noted that staff were to check a different column if the device was ordered but was not in use at the time of the fall. Review of both columns revealed that hipsters were included on the list as one of the devices whose presence was to be assessed. However, there were no check marks in either column or evidence anywhere throughout the investigation that the hipsters were in place per the physician's order. An interview with the Director of Nursing (DON) on 10/13/21 at 5:07 PM revealed that none of the staff involved in R12's fracture on 06/14/21 were available for interview. The DON revealed that if the form was not checked to show that an intervention (i.e. hipsters) was in place, it meant that the device/intervention was not in use at the time of the fall. In addition, further interview with the DON revealed that staff should not have picked the resident up off the floor prior to an assessment of the resident, explaining that this against what we do. The DON stated that the resident's injury could be worsened by getting the resident up prior to assessment. An interview was conducted on 10/13/21 at 6:04 PM with the physician who immediately responded to R12's fall/injury. The physician confirmed that R12 was not wearing the protective device (hipsters) at the time of the fall. Further interview with the physician revealed that she initially was unaware that staff had assisted the resident up from the floor prior to assessment, as the resident was still on the floor when the doctor got there. The physician added she later learned that the resident was gotten up prior to assessment, and confirmed that this should not have occurred, as it could have caused more pain or displacement.

Based on record review, interview, and review of facility policy, the facility failed to effectively monitor weights and follow prescribed physician orders for nutritional supplement administration for one resident (Resident (R) 26) who sustained an apparent significant weight loss, out of six residents reviewed for nutritional status. Findings include: Review of R26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/21, revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating the resident had significant cognitive impairment. The assessment identified the resident had diagnoses including dementia and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The MDS documented R26 required set up assistance from staff for meals, weighed 147 pounds (lbs) at the time of the assessment, and had sustained a weight loss of five percent (%) or greater in the last 30 days or 10% or greater in the last six months. Review of hard copy flow sheets titled, Monthly Weights Sheet, revealed the following: The 04/21 Monthly Weights Sheet documented R26 weighed 155.6 lbs on 04/03/21. The 05/21 Monthly Weights Sheet, documented R26 weighed 148.5 lbs on 05/04/21. The 06/21 Monthly Weights Sheet, did not document a weight for R26. The Resident Weight Report, with a date range of 07/01/21 to 10/12/21, which the facility provided from the electronic medical record (EMR), documented the following weights for R26: 07/07/21 - 157.4 lbs; 08/02/21 = 147.2 lbs; 08/17/21 = 139.0 lbs; 09/02/21 = 179.4 lbs; 10/02/21 = 110.0 lbs; and 10/08/21 = 137.6 lbs. Review of the Monthly Weight Sheet documents and the Resident Weight Report form indicated that, if the weights were accurate as documented, R26 sustained a significant weight loss of 11.57% weight loss between 04/03/21 to 10/08/21. Review of the hard copy 06/22/21 Patient Report, under the Laboratory tab, showed that during this period of time, R26 had a Total Protein blood level (total amount of two classes of proteins found in the fluid portion of a person's blood) of 5.2 grams per decilitre (g/dL) indicating the resident's protein level was below the normal range of 6.0 to 8.5 g/dL. The report also documented an Albumin level (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) of 3.5 g/dL with a reference interval of 3.5 to 4.6 g/dL, indicating R26's level was at the lowest end of the normal range. a. Failure to follow physician orders: Review of the Care Plan Report, regarding Nutritional Status, with a goal date of 11/17/21, documented R26 required a mechanically altered diet related to a history of oropharyngeal dysphagia (swallowing difficulties occurring in the mouth or throat) and chewing difficulties related to missing and worn teeth. The care plan included, but was not limited to, the following interventions: Ensure Plus [type of nutritional supplement] per MD [Medical Doctor] orders- see MD orders. Assess nutrition status quarterly and prn [as needed]. Monitor and record weight monthly and prn. Monitor and record meal intake at each meal. The October 2021 Physician Order Sheet, included an order with start date of 07/16/21 directing staff to provide, Ensure Plus 1 [one] container for meal intake < [less than] 50%. The facility provided an ADL [Activities of Daily Living] Verification Worksheet from the EMR which included all observations between 06/01/21 12:00 AM (EDT) and 10/13/21 8:45 AM (EDT) [sic], and documented meal percentage intakes for R26. Review of the worksheet revealed R26 consumed 50% or less of a meal 175 times out of a total of 245 meals between 07/16/21 through 10/12/21. Review of the Medication Administration Records (MAR) titled, August 2021 Medications, September 2021 Medications, and October 2021 Medications, included the 07/16/21 physician's order for staff to provide, Ensure Plus 1 container for meal intake < 50%. The forms failed to include any evidence that staff administered Ensure as ordered for each meal in which the resident's food consumption was less than 50% during August, September, and October 2021. b. Failure to accurately monitor resident's weight as needed/recommended: Review of the quarterly dietary progress note dated 08/13/21 at 2:06 PM, written by the Registered Dietician (RD) and provided by the facility, revealed R26 averaged a 45% meal percentage intake in the previous seven days, had an order for staff to provide an Ensure Plus if 50% or less of a meal was consumed, and R26 sustained a 6.3% weight loss in the last 30 days. In this note, the RD recommended weekly weight monitoring, to get more accurate weight trend [sic]. A Special Review dietary progress note dated 9/29/21 at 9:09 AM written by the RD revealed the weights were, showing inconsistencies .is most likely inaccurate .will recommend to continue weekly weights to get a more accurate weight trend. Review of all weight records provided by the facility revealed that the facility failed to obtain weekly weights as first recommended by the RD on 08/13/21. Weekly weights were not documented between 08/17/21 - 09/02/21, and 09/02/21 - 10/02/21. During an interview on 10/13/21 at 9:25 AM, the RD reported she monitored the nutritional status for all residents to assess if their nutritional needs were being met and made recommendations to the doctors based on her findings. She reported the Certified Nurse Aides (CNAs) were responsible for weighing the residents and she reviewed those weights on a monthly basis. The RD said the facility had been having issues with the weights. She went on to explain the facility previously had a designated staff member who collected all the weights to ensure consistency, however that person left approximately one year ago. Since that time there had not been a designated staff member to obtain the resident weights. The RD stated that if she identified a significant difference from the previous weight, she sent an email to alert the staff to ensure a re-weight was completed but she may not see the reweigh result for a week or two. The RD stated she was not notified by staff of weight discrepancies and did not know the exact facility policy regarding weights. The RD stated in the past she received a monthly email with all the resident weights with reweighs documented in that report, but now she runs her own report. The RD explained the facility recently identified the accuracy of weights had become inconsistent, so in-services were completed with the CNAs, and unit managers began to complete reweighs. She said she received the October 2021 weights from the unit managers over the past two weeks, which appeared to be more consistent. The RD confirmed R26 routinely ate 50% or less of meals in the last three months and staff were to provide an Ensure if that occurred. During an interview on 10/13/21 at 12:25 PM, CNA1 reported R26 frequently ate 50% or less of meals. CNA1 stated that she would give the resident Ensure at times but had no evidence when/if this occurred. During an interview on 10/13/21 at 12:28 PM, Licensed Practical Nurse (LPN) 2 and Registered Nurse (RN) 3 reported CNAs took resident weights and documented them into the electronic medical record. RN3 reported the CNAs were good at notifying the nurses if they saw a change in weight. LPN2 and RN3 were unsure if R26 had lost weight and confirmed his documented weights were inconsistent. RN3 reported the facility previously had a designated staff member who was responsible for weights, but that staff member no longer worked at the facility and no one else had been designated to perform this task. LPN2 and RN3 confirmed staff were to follow physician orders to administer Ensure if the resident ate 50% or less of the meal. During an interview on 10/13/21 at 12:47 PM, RN4 reported she was the manager of the unit on which R26 resided. RN4 stated the facility had identified there was a problem with weight accuracy and was in the process of attempting to correct the issue. She confirmed there had not been a designated staff person to take resident weights for approximately one year. She reported she had a list of residents who were ordered to have weekly weights and confirmed R26 was not on the list. RN4 stated that the RD completed reviews for residents' nutritional status, then made recommendations which went to the physician for review and were implemented if ordered by the physician. She was not aware the RD had made a recommendation to complete weekly weights for R26 or that there was a physician order to provide an Ensure Plus for a meal intake of 50% or less. During an interview on 10/13/2021 at 1:26 PM, R26's physician reported she sometimes received emails from the RD following her review and sometimes did not. The physician stated she may have overlooked the RD's recommendation to conduct weekly weights for R26. The physician said weight monitoring and documentation issues had worsened after the facility's new electronic medical record had been implemented in July 2021. She explained the new system caused difficulty for nurses to view PRN (as needed) orders, such as providing an Ensure if the resident consumed 50% or less of a meal. R26's physician confirmed it was the facility staff's responsibility to complete physician orders. Review of the facility policy titled, Weight Policy, with an effective/revised date of 11/20, revealed, Weights are taken by one designated staff member .When weighing the resident, a resident who has a 5 pound or more weight change is re-weighed to ensure accuracy. Re-weight is completed within 24 hours .Any significant weight change (gain or loss) will be reported to the MD/NP [Medical Doctor/Nurse Practitioner], nutritionalist, and family by the appropriate designee on the unit or charge nurse. Review of the facility policy titled, Nutritional Care Policy, with a review date of 05/21 revealed it did not address the need to follow physician-prescribed orders for nutritional supplements.