**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents were free from physical restraints imposed for the purposes of convenience, and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #40) reviewed for physical restraints. -The facility failed to ensure that physical restraints were not used on Resident #40 during medication administration via G- tube (a tube inserted through the belly that brings nutrition directly to the stomach), which resulted in Resident #40 suffering from emotional distress and increased behaviors. This failure could place the residents at risk for psychological harm, emotional distress and at risk for injury. Findings included: Record review of Resident #40's face sheet dated 03/15/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (half body paralysis) affecting the right dominant side, dysphagia (difficulty swallowing) type 2 diabetes, hypertension, gastrostomy, muscle weakness, depression, aphasia (inability to speak) and anxiety disorder. Resident #40 was listed as her own responsible party and there was no one listed as having a financial or healthcare durable power of attorney. Resident discharged from the facility on 03/18/23. Record review of Resident #40's admission MDS dated [DATE] revealed, no serious mental illness, intellectual disability or other related conditions, admission from an inpatient rehabilitation facility, resident has unclear speech, usually makes herself self-understood, usually understood by others, moderately impaired cognitive skills for daily decision making, no acute change in mental status, continuous non-fluctuating inattention, continuous non fluctuating disorganized thinking, and no hallucinations or delusions. She was coded as having no behavioral symptoms, no rejection of care, total dependence for most ADLs, use of a wheelchair, active stroke diagnosis, anxiety disorder, depression, no diagnoses of bipolar disorder or psychotic disorder, 2-day use of antipsychotic, 6 day use of antianxiety, 7 day use of antidepressant, receiving speech therapy/occupational therapy and physical therapy. Behavioral symptoms did not trigger a care area and no care planning decision was checked. Physical restraints did not trigger a care area and no care planning decision was checked. Record review of Resident #40's undated care plan revealed, focus- hemiplegia/hemiparesis r/t stoke; intervention- give medications s ordered and pain management as needed. Focus- use of anti-anxiety medications; interventions- administer anti-anxiety medications as ordered, monitor for effects and effectiveness every shift, monitor/document/report PRN any adverse reactions to anti-anxiety therapy. Focus- use of anti-depressant medications; interventions- administer anti-anxiety medications as ordered, monitor for effects and effectiveness every shift, monitor/document/report PRN any adverse reactions to anti-depressant therapy. Focus- requires tube feeding r/t dysphagia; interventions- may crush medications and administer per G-tube, provide Glucerna 1.5 Cal Oral Liquid. Resident #40's care plan did not include her behaviors, refusal of care or the use of restraints. Record review of Resident #40's Hospital Records dated 02/01/23 revealed, agitation, on right upper extremity restraints. Record review of Resident #40's Physician's Orders dated 02/25/23 revealed, enteral- may crush medications and administer per G-tube. Record review of Resident #40's Order Summary Report dated 03/15/23 revealed, no orders for restraints. Record review of Resident #40's EMR on 03/15/23 revealed , no RAP for restraints or documented informed consent for the use of restraints. Record review of the ACNO's notarized witness statement dated 03/15/23 revealed: Resident #40 accepted us but as soon as nurse began to check for placement and residual of gtube, resident swung her arms upwards toward the nurse. Writer (the ACNO) put hands out with palms open, between nurse and patients arm and guided patients arm towards writer explaining she (LVN A) was just checking placement to give medication. Writer and patient held hands once again as patient was emotional. I rubbed her arm holding her close to me reassuring her and comforted her that we were here to help her . As medication went down patient once again became irate and began swinging. Due to patient's agitation nurse stopped medication administration. Record review of the Director of Culture and Engagement's notarized statement dated 03/15/23 revealed: when helping CNA and CMA with transfer from wheelchair to bed, Resident #40 began to fight staff. Resident #40 was yelling and crying the whole time without following any instruction. Resident #40 continues to yell and cry after staffs assisted patient back to bed with 3 people total. Staff attempted to calm patient down by talking to her. Record review of CNA H 's notarized statement dated 03/15/23 revealed, Resident #40 is yelling and fighting she is very agitated today . patient refused Hoyer transfer so we 3 people transferred. Record review of LVN C's notarized statement dated 03/15/23 revealed, writer has never seen patient act like she did today. Resident #40 was yelling , I could hear her all the way to the nurses station. An observation on 03/15/23 at 09:03 AM revealed, LVN A preparing medication for administration via g-tube for Resident #40. She verified the resident information against the MAR, retrieved the medications placing them in individual cups, and crushed the medications. At 09:08 AM, LVN A entered Resident #40's room, the resident initially appeared calm in a hospital gown but as LVN A approached her right side of the bed, raising the blanket and then her gown, Resident #40 began to swat at LVN A's hands. Resident #40's right arm appeared to be paralyzed on the right side, and she moaned as she attempted to move her right arm with her left arm. Resident #40 continued to lift her right arm with her left hand, groaning and grimacing with each attempt. LVN A talked to Resident #40 stating that she would be administering pain medication to help Resident #40 and placed a pillow under Resident #40's right arm to attempt to relieve the resident's discomfort. As LVN A attempted to access Resident #40's G-tube, the resident continued to wale inaudible words and swat at LVN A's hands. The ACNO then entered Resident #40's room and said she normally needs 2 people to help administer medication via G-tube, referring to the resident. The ACNO walked to the left side of Resident #40's bed and held on to Resident #40's left hand. As Resident #40 continued to wail and swat, the ACNO held on to Resident #40 with both arms wrapped around the resident's arm, placing Resident #40's only arm in a fixed position and pulling the resident's arm closer to her body. Resident #40 continued to resist care, swinging her only moveable left arm. The ACNO continued to use force to restrict the resident's movement as she screamed inaudibly, recoiled her body and her left leg. The ACNO continued to restrain Resident #40 as she said, stop fighting, and LVN A started to administer medication via the G-tube, checking for residual and then administering flushes and medications as Resident #40 continued to fight, rile up on her left side and wail. As Resident #40 continued to resist care, riling up as the ACNO restrained her left arm, her G-tube began to backflow. LVN A said she would stop G-tube medication administration due to Resident #40's resistance. An observation on 03/17/23 at 01:35 PM, revealed Resident #40 well dressed, well-groomed in no immediate distress lying in bed with family at bedside. An observation on 03/18/23 at 12: 08 PM revealed, Resident #40 in bed, appeared in no immediate distress with family at bedside and personal items packed. In an interview on 03/15/23 at 09:46 AM, the CNO said Resident #40 was a new admission who had just experienced a new CVA and was under psych consult. He said when Resident #40 admitted to the facility, she would not communicate her needs but was much more controlled now. The CNO said that Resident #40 needed a lot of patience, explanation, and encouragement. The surveyor informed the CNO of the observed used of force to restrict the resident's movement and when asked if facility staff are allowed to restrict a resident with force, the CNO said nursing staff should not forcefully restrict a resident's movement when care was refused but should stop and come back later. He said if a resident continues to refuse care the issue should be escalated to the MD and he was not informed that force was used during G-tube medication administration for Resident #40. In an interview on 03/15/23 at 10:05 AM, LVN A said earlier in the morning Resident #40 refused medication administration via G-tube, so she notified the NP who ordered her to administer Lorazepam as needed. She said usually, the resident's family member was at her bedside but he was not today, leaving the resident irritated and agitated. When asked if holding the resident or using force to restrict the resident's movement was acceptable, she said the ACNO had to use force to prevent Resident #40 from hitting the G-tube. She said it was a special circumstance in which force was used on 03/15/23. LVN A said when the resident initially admitted she was not able to give G-tube medications due to Resident #40's behaviors and the family got mad. In an interview on 03/15/23 at 10:38 AM, the ACNO said that Resident #40 was usually agitated, cries a lot, requires redirection, reassurance and seeing new people agitates her. She said when a resident was agitated nursing staff should redirect/reassure residents and that she was holding Resident #40 to reassure her and not using force to restrict movement. She said physical touch was Resident #40's preference and use of restraints was not allowed. The ACNO said she was hugging Resident #40's arm for Reassurance. In an interview on 03/15/23 at 10:43 AM, the NP said LVN A notified her today (03/15/23)that Resident #40 was resisting/refusing oral meds, so she ordered that the medication be administered via G-tube. She said Resident #40's resistance/refusal of medications has been ongoing since her admission [DATE]). The NP said Resident #40 was normally verbal and required distraction and redirection. She said she received a call from LVN A stating resident was refusing oral meds or she ordered her PRN meds via G-tube. The NP said that force should not be used on resident's who refuse care, but staff should try to redirect and if unsuccessful return at a later time. The NP said she was not called a second time by LVN A, and she was not informed force was used. She said Resident #40 was receiving anti-anxiety meds via IM injection at the previous facility and the use of IM medications when the resident was exhibiting behaviors/refusing care was discussed with her family and was currently pending consent with Resident #40's family. In an interview on 03/15/23 at 01:17 PM, the CNO said the facility was a restraint free facility and that there were no orders for any residents to be restraint and that there was no situation where it would be ok to restrain a resident. He said at no point in time did LVN A and the ACNO inform him that restraints was used. When asked if resident remained agitated despite those attempts and resident fighting, would you expect them to continue with med pass , he said he would expect them to give space because maybe the patient needs more space, more time, and to give resident time to acclimate. In an interview on 03/15/23 at 02:00 PM, the VP of Clinical Operations said he was informed that there were issues passing mediations to Resident #40 via G-tube today (03/15/23) and the resident had a history of agitation and anxiety. He said he was only told staff held her hand. The VP of Clinical Operations said when a resident refuses care nursing staff should back off, give the resident space, notify the MD/family, and come back at a different time. The VP of Clinical Operations said nursing staff were not expected to use force and hugging a resident's arm to stop movement was not acceptable. He said the use of force could place residents at short term risk of psychological trauma and could increase behaviors and in the long term led to more aggressive behaviors. The VP of Clinical Operations said nurses must report all allegations of restraint use must be reported immediately to the CNO who was required to report to the state and necessary entities within 2 hours and an investigation was to be started immediately. He said failure to report restrictions places residents at risk for further restriction. In an interview on 03/15/23 at 02:50 PM, LVN A said looking back at the medication administration from this morning (03/15/23), she would handle it the same way. She said the ACNO held Resident #40's hand to stop her from pulling the G-tube An observation and interview on 03/15/23 at 03:07 PM revealed , Resident #40 in low bed. The resident was hanging half off the bed with legs dangling and feet touching the floor. Staff entered the resident's room and closed the door. Resident #40 was yelling and moaning through the closed door. The Wound Care Nurse said that the resident's observed behaviors was common, Resident #40 was usually restless and would yell, moan and or make noises. She said LVN A and everyone was aware that Resident #40 had those behaviors. In an interview on 3/15/23 at 03:19 PM, Resident #40's family member said he was notified by the facility that force was used while administering medication via G-tube to the resident and he said, what is wrong with it. The family member said that he has had to hold her hand down before in order for staff to administer medication via G-tube to Resident #40. In an interview on 03/15/23 at 03:23 PM, LVN A said restraints was when one was physically trying to stop someone from causing harm to themselves or others. She said the facility was a restraint free facility and he doesn't think this incident involved abuse because abuse would be stopping the patient against their will but Resident #40 was held for reassurance. LVN A said that normally Resident #40's family member helps her every day and when asked if force was ever used in his presence she said, sometimes he needs to do it. She said the family was aware and understands that they had to hold her hands to prevent her from moving or pulling on the G-tube. In an interview on 03/16/23 at 01:21 PM, MD A said Resident #40 admitted to the facility post CVA and had issues in her previous facility with delirium and confusion. He said the resident had metabolic encephalopathy and the only way to treat it would be to treat her symptoms of delirium and electrolyte imbalances. MD A said this was Resident #40's 3rd facility, she had dementia but was never fully diagnosed in an outpatient environment. He said that the use of force in response to behaviors was not appropriate and he was never informed force was used on Resident #40. In an interview on 03/22/23 at 09:53 AM, LVN A said that nursing administration was aware of the difficulties in administering medication via G-tube to Resident #40 because the family member notified the ACNO. She said when Resident #40 admitted she was unable to administer medications via G-tube so, the family was yelling at her because the resident's previous facility was able to do it so she documented it, notified the MD and the resident received a psych consult. LVN A said she knew that a resident could not be forced but the facility was working with the resident. Record review of the facility policy titled 'Restraint Policy' dated 11/2018 revealed, restraints will not be utilized without the consent of the resident and/or responsible party or will not restrain a resident against their will. The facility practices a restraint free environment unless there is an emergency situation that requires a restraint in order to protect the resident or the other residents in the facility in accordance with all state and federal requirements. Physical Restraint- means any manual method or physical or mechanical device material, or equipment attached to the resident's body, which the individual cannot remove easily, and which restricts freedom of movement or normal access to one's body. Physical restraints shall be used by this facility only when it has been determined that they are required to treat a resident's medical symptoms or as therapeutic intervention, as ordered by a physician, and based on overall assessment, a physical restraint assessment, and the care planning process. The facility shall only apply a physical restraint after obtaining the informed consent of the resident, the resident's guardian, or other authorized representative. Informed consent shall include documented information about the potential risks and benefits of all options under consideration including using a restraint, not using a restraint and alternative to restraint use. A physical restraint shall only be applied to a resident by staff who have been in-serviced in the application of the particular type of physical restraint. Record review of the facility policy titled Refusal of Treatment and Medications dated 11/2020 revealed, the facility recognizes that residents have the right to refuse medications and or treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who displays or was diagnosed with a mental illness or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 8 Residents (Resident #40) reviewed for behavioral services. - The facility failed to appropriately treat Resident #40's behaviors by staff restraining the resident during G-tube medication administration. This use of restraints resulted in the resident experiencing acute emotional distress. - The facility failed to appropriately send notifications of Resident #40's behaviors to her attending physician resulting in the MD being unaware of the resident's continuous behaviors/refusal of care. These failures could place residents at risk of mental and psychosocial harm and injury. Findings included: Record review of Resident #40's face sheet dated 03/15/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (half body paralysis) affecting the right dominant side, dysphagia (difficulty swallowing) type 2 diabetes, hypertension, gastrostomy, muscle weakness, depression, aphasia (inability to speak) and anxiety disorder. She did not have a documented diagnoses of dementia, metabolic encephalopathy or any other mental disorders. Resident #40 was listed as her own responsible party and there was no one listed as having a financial or healthcare durable power of attorney. Resident discharged from the facility on 03/18/23. Record review of Resident #40's admission MDS dated [DATE] revealed, no serious mental illness, intellectual disability or other related conditions, admission from an inpatient rehabilitation facility, resident has unclear speech, is usually makes self understood, usually understood by others, moderately impaired cognitive skills for daily decision making, no acute change in mental status, continuous non-fluctuating inattention, continuous non fluctuating disorganized thinking, no hallucinations or delusions. No physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing .), no verbal behavioral symptoms directed towards other, no other behavioral symptoms not directed towards others (hitting, scratching self, disruptive sounds No overall presence of behavioral symptoms, no rejection of care, anxiety disorder, depression, no diagnoses of bipolar disorder or psychotic disorder, 2 day use of antipsychotic, 6 day use of antianxiety, 7 day use of antidepressant, receiving speech therapy/occupational therapy and physical therapy. Behavioral symptoms did not trigger a care area and no care planning decision was checked. Physical restraints did not trigger a care area and no care planning decision was checked. Record review of Resident #40's undated care plan revealed, focus- hemiplegia/hemiparesis r/t stoke; intervention- give medications s ordered and pain management as needed. Focus- use of anti-anxiety medications; interventions- administer anti-anxiety medications as ordered, monitor for effects and effectiveness every shift, monitor/document/report PRN any adverse reactions to anti-anxiety therapy. Focus- use of anti-depressant medications; interventions- administer anti-anxiety medications as ordered, monitor for effects and effectiveness every shift, monitor/document/report PRN any adverse reactions to anti-depressant therapy. Focus- requires tube feeding r/t dysphagia; interventions- may crush medications and administer per G-tube, provide Glucerna 1.5 Cal Oral Liquid. Resident #40's care plan did not include her behaviors, refusal of care or the use of restraints or a diagnosis of dementia. Record review of Resident #40's Hospital Records dated 01/31/23 revealed, Agitation- still has right upper extremity restrained. Record review of Resident #40's Hospital Records dated 02/01/23 revealed, agitation, on right upper extremity restraints. Record review of Resident #40's TX admission Packet dated 02/25/23 revealed, Resident #40 signed her admissions packet. The admission's document was signed on 03/03/2023. Record review of Resident #40's progress note dated 02/25/23 at 8:36 PM revealed, nursing evaluation- pt has expressive aphasia and is unable to make her needs known, completely dependent on staff or family to meet needs. Record review of Resident #40's progress note dated 02/26/23 at 08:13 AM revealed, patient refused her enteral feed and note read patient crying, yelling and combative, very agitated this morning. Patients [family] at bedside would like to skip feeing and attempt to feed her breakfast, hold until next scheduled feeding time. Record review of Resident #40's progress note dated 02/26/23 at 5:45 PM revealed, Pt agitated and anxious, yelling and striking out at staff and family members. MD notification was not documented. Record review of Resident #40's progress note dated 02/26/23 at 08:33 PM revealed, Pt would not lie still for feeding and flush, striking out at staff and yelling. MD notification was not documented. Record review of Resident #40's progress note dated 02/26/23 at 8:50 PM revealed, Additional Comments: Pt is unable to make needs known and is totally dependent on staff and family to meet needs. Pt is very anxious and agitated, yells out and strikes at staff and family members, very difficult to redirect verbally, even with family ,pt does have medication ordered that is effective for the anxiety and agitation. MD notification was not documented. Record review of Resident #40's progress note dated 03/01/23 at 8:16 PM signed by LVN D revealed, pt has frequent outbursts of agitation and is combative at times often striking staff and family members, verbal redirection not effective at all times and pt is medicated for anxiety and agitation. MD notification was not documented. Record review of Resident #40's progress note dated 03/02/23 at 04:58 AM revealed signed by LVN D, there has not been a change in the resident's baseline cognition. Pt continues to be combative and agitated with staff and family members. Pt is totally dependent on staff or family for all needs, she is unable to communicate verbally or non-verbally, frequently agitated and combative with staff and family, staff is not always able to administer meds or bolus feedings and flushes per gtube. MD notification was not documented. Record review of Resident #40's progress note dated 03/02/23 at 10:08 AM signed by LVN A revealed, unable to administer bolus feeding or check her sugar this morning. Patient is fighting, slapping, yelling and screaming. Tried 2 times during this morning. Psych will reevaluate patient today during her rounds. Family member was at her bedside. Record review of Resident #40's progress note dated 03/02/23 at 12:09 PM signed by LVN A revealed, medication was able to administer with bolus feeding with help of another nurse. Record review of Resident #40's undated Care Management note dated 03/02/23 at 12:27 PM revealed, an initial care management meeting was held and the Resident, Resident Representative, Therapy, and the CNO were present. There was no mention of the resident's behaviors or refusal of care and MD notification was not documented. Record review of Resident #40's progress note dated 03/02/23 at 11:49 AM signed by LVN D revealed, resident refused her 120 ml water flush via G-tube. MD notification was not documented. Record review of Resident #40's progress note dated 03/02/23 at 11:51 AM signed by LVN D revealed, resident refused her order for Glucerna 1.5 Cal Oral Liquid- 150 ml via G-tube three times a day only if resident eats less than 50% of her meal. MD notification was not documented. Record review of Resident #40's Progress Note dated 03/03/23 at 09:01 PM signed by LVN I revealed, there has not been a change in the resident's baseline cognition. There was no mood/behavior notes or additional comments. Record review of Resident #40's Progress Note dated 03/04/23 at 10:56 PM signed by LVN I revealed, there has not been a change in the resident's baseline cognition. There was no specific mood/behavior notes or additional comments. Record review of Resident #40's Progress Note dated 03/05/23 at 10:57 PM signed by LVN I revealed, there has not been a change in the resident's baseline cognition. There was no specific mood/behavior notes or additional comments. Record review of Resident #40's progress note dated 03/06/23 at 07:46 AM signed by LVN I revealed, Pt was showing signs of anxiety. Constantly fidgeting, screaming, unable to calm down. PT was given morning meds at 07:20 AM that consist of buspirone to help treat her anxiety. After the pt was given meds through G-tube, the patient aspirated 10 min later at 07:30 AM. Patient was then cleaned up. Pt has calmed down prior to oncoming shift. Notified oncoming shift, will continue to monitor. MD notification was not documented. Record review of Resident #40's Progress notes dated 03/06/23 at 4:25 PM signed by the ACNO revealed, Patient very agitated and anxious, x2 episodes of vomiting. Very agitated constantly needing to be repositioned due to almost falling out of bed. NP in facility assessed patient, new order for Zofran 4mg q6h prn and KUB. Unable to administer any PRN due to constant agitation and combative. Psych notified and ordered a 1xorder of Ativan 1mg IM. Administered and effective. Able to perform KUB, abnormalities noted. Able to administer medications and feedings as ordered. Family aware of behavior, no family at bedside today. MD notification was not documented. Record review of Resident #40's Progress Note dated 03/06/23 at 8:02 PM signed by LVN D revealed, resident refused Glucerna feeding. MD notification was not documented. Record review of Resident #40's progress note dated 03/07/23 at 03:33 AM signed by LVN D revealed, resident refused her 120 ml G-tube water flush. MD notification was not documented. Record review of Resident #40's Progress Note dated 03/07/23 at 08:29 PM signed by LVN D revealed, there has not been a change in the resident's baseline cognition. There was no mood/behavior notes or additional comments. Record review of Resident #40's Progress Note dated 03/08/23 at 09:37 PM signed by LVN I revealed, there has not been a change in the resident's baseline cognition. There was no mood/behavior notes or additional comments. Record review of Resident #40's Progress Note dated 03/09/23 at 09:12 PM signed by LVN I revealed, there has not been a change in the resident's baseline cognition. There was no mood/behavior notes or additional comments. Record review of Resident #40's Progress Note dated 03/10/23 at 08:20 PM signed by LVN D revealed, Pt is able to express herself for some things with gestures and sounds and is refusing formula feeding, she will acceptH2o flush and meds per tube at this time. MD notification was not documented. Record review of Resident #40's Progress Note dated 03/11/23 at 05:05 AM signed by LVN D revealed, resident refused bladder scan. MD notification was not documented. Record review of Resident #40's Progress Note dated 03/11/23 at 07:24 PM signed by LVN D revealed, Pt is able to express herself for some things with gestures and sounds and is refusing formula feeding, she will acceptH2o flush and meds per tube at this time. MD notification was not documented. Record review of Resident #40's Progress Note dated 03/12/23 at signed by LVN D 03:11 AM revealed, resident refused bladder scan. MD notification was not documented. Record review of Resident #40's progress note dated 03/12/23 at 6:00 PM signed by LVN A revealed, Medication and treatments well tolerated during dayshift. PO administration attempted with PRN Pain medication and was unsuccessful, patient refused. Family at bedside. Patient was calmed today, able to get up in WC and rolling around the facility. Record review of Resident #40's progress note dated 03/12/23 at 07:28 PM signed by LVN D revealed, Pt is able to express herself for some things with gestures and sounds and is refusing formula feeding, she will accept H2o flush and meds per tube at this time. MD notification was not documented. Record review of Resident #40's progress note dated 03/13/23 at 01:32 AM signed by LVN D revealed, Pt refused feeding, shaking head no and hand gestures, does not want the tube feeding. Pt has been eating small amounts frequently throughout the day per family members. MD notification was not documented. Record review of Resident #40's progress note dated 03/13/23 signed by LVN J revealed, behaviors were observed at 07:39 AM, 09:03 AM, 09:04 AM, and 09:05 AM. The exact behavior observed was not documented. Record review of Resident #40's Progress Note dated 03/15/23 at 10:09 AM signed by LVN A revealed, NP was doing rounds at this time, reported about patient's behavior. No new orders at this time. Record review of Resident #40's Behavioral and Psychotropic Medication Evaluation progress note dated 03/15/23 at 4:36 PM revealed, Patient noted very agitated this morning, Patient's family were not at bedside today as usually every morning. Reported to NP and received the orders to administer medication via G-Tube. Usually, patient is calm and let nurses administer peg tube medicine when partner is at bedside. When we administer medicine in the morning, usually family hold patient's hand while nurse administer medication. Consult for Psych in place. Record review of Resident #40's progress note dated 03/15/23 at 05:47 PM revealed, MD A was doing rounds at this time, gave to this nurse verbal orders for Clonazepam 0.5 Bid schedule. Family were notified. Family signed the consents for medication. He also signed for Lorazepam 2mg/ml Q8H PRN for agitation. Record review of Resident #40's progress note dated 03/15/23 at 9:16 PM revealed, Resident #40s Clonazepam was Unable to dispense, the exact reason was not documented. Record review of Resident #40's IDT meeting summary dated 03/16/23 revealed, emergency meeting held to identify actions in patient's plan of care in regard to behaviors, diagnosis and overall-wellbeing . NP noted patient's dementia diagnosis on progress note, diagnosis was not previously listed on patient's overall diagnosis or facility care plan. It is also noted that patient had refusal of care and behaviors at previous care setting . IDT team agrees that holding hands/soothing serves as a good intervention. Hand holding has been added to the patient's care plan, acknowledging that movement is not restricted. Record review of Resident #40's progress note dated 03/16/23 at 07:21 AM revealed, entered room to check on Resident #40. Family member at bedside in recliner. Resident was quiet upon my entry. She started crying and moaning while I was speaking with [family member]. He stated that resident had a quiet night. Will continue to monitor guests well-being. He had no questions or concerns regarding her care. Record review of Resident #40's progress note dated 03/16/23 at 08:53 AM signed by the VP of Clinical Operations revealed, attempt made for peg tube medication administration. Resident kicking, screaming, and grabbing nurse's arm. Documented refusal and attempted crushed medications. Facility staff attempted to communicate with guest the importance of taking the prescribed medications. Resident again refused crushed medications. Physician notified of refusal awaiting further orders. Family aware at bedside. Record review of Resident #40's Progress notes dated 03/16/23 at 10:16 AM- 11:03 AM signed by LVN C revealed, patient refused meds, slapped writers hand. MD notification was not documented. Record review of Resident #40's Progress notes dated 03/16/23 at 12:39 PM signed by LVN C revealed, received order from MD A to send patient out for altered mental status. Record review of Resident #40's Progress notes dated 03/16/23 at 7:30 PM signed by LVN K revealed, Patient readmitted from the hospital, CR scan of head/brain and chest x-ray showed no changes or findings. The hospital did a UA which indicated the beginning of UTI and an antibiotic was prescribed. The hospital nurse said Resident #40 was anxious during the ER visit and family and other staff had to assist to comfort and reassure the resident to get through the exams. Record review of Resident #40's progress note dated 03/16/23 at 8:02 PM signed by LVN K revealed, pt agitated when nurse entered the room and would not allow nurse to come close/ did not allow assessment to be done. CNA and nurse entered room together. family at bedside. plan of care continues. Record review of Resident #40's progress note dated 03/16/23 at 8:41 PM signed by LVN K revealed, a morning dose of Lorazepam for anxiety was administered and the day shift nurse reported it was not effective. Record review of Resident #40's progress note dated 03/17/23 at 02:07 AM signed by LVN K revealed, nurse attempted to administer PRN Tramadol50 mg and PRN lorazepam 0.5mg crushed in apple sauce per spouse request however pt refused at this time. MD notification was not documented. Record review of Resident #40's progress note dated 03/17/23 at 02:18 AM signed by LVN K revealed, nurse repositioned Resident #40 for comfort. Family educated on plan of care. Pt refused medication to be administered PO as ordered. Record review of Review of Resident #40's progress not dated 03/17/23 at 04:43 AM signed by LVN K revealed, family member upset due to nurse not being able to give medication via gtube. explained plan of care and doctors' orders but pt.'s family continued to yell at staff and made threats to nurse. MD/NP to follow up during morning rounds. DON notified and aware pt agitated and did not allow writer to come close to her. CNA in room with nurse. Record review of Resident #40's progress note dated 03/17/23 at 05:02 AM signed by LVN K revealed, Resident #40 refused her enteral fee, did not allow the nurse to get close to her and refused care from the nurse. Family at bedside, safety checks throughout shift however pt continued to scream and kick at nurse. Record review of Resident #40's progress note dated 03/17/23 at 09:01 AM revealed, Resident #40 was under the care of MD A with dx of vascular dementia, aphasia, CVA, right hemiparesis following CVA, dysphagia, Hypertension, depression, and anxiety. Resident has behavior of shouting, grabbing, crying, refusal of care/ treatment Record review shows that patient was on restraints at some point during her stay at the hospital. Record review of Resident #40's progress note dated 03/17/23 at 02:07 AM revealed, nurse attempted to administer PRN Tramadol50 mg and PRN lorazepam 0.5mg crushed in apple sauce per spouse request however pt refused at this time. Record review of Resident #40's progress note dated 03/18/23 at 12:30 AM revealed, all medications and blood sugar checks refused by Resident #40 this am and at this time, several attempts made. Resident #40 continued to clamp her mouth shut, crying and pushing medications away. will continue to monitor for changes and report as needed. family member at bedside. Record review of Resident #40's progress note dated 03/18/23 at 2:06 PM revealed, nursing staff tried to administer medications again. Resident #40 is still refusing with pushing, and crying, family members at bedside. An observation on 03/15/23 at 09:03 AM revealed, LVN A preparing medication for administration via g-tube for Resident #40. She verified the resident information against the MAR, retrieved the medications placing them in individual cups, and crushed the medications. At 09:08 AM, LVN A entered Resident #40's room, the resident initially appeared calm in a hospital gown but as LVN A approached her right side of the bed, raising the blanket and then her gown, Resident #40 began to swat at LVN A's hands. Resident #40's right arm appeared to be paralyzed on the right side, and she moaned as she attempted to move her right arm with her left arm. Resident #40 continued to lift her right arm with her left hand, groaning and grimacing with each attempt. LVN A talked to Resident #40 stating that she would be administering pain medication to help Resident #40 and placed a pillow under Resident #40's right arm to attempt to relieve the resident's discomfort. As LVN A attempted to access Resident #40's G-tube, the resident continued to wale inaudible words and swat at LVN A's hands. The ACNO then entered Resident #40's room and said she normally needs 2 people to help administer medication via G-tube, referring to the resident. The ACNO walked to the left side of Resident #40's bed and held on to Resident #40's left hand. As Resident #40 continued to wail and swat, the ACNO held on to Resident #40 with both arms wrapped around the resident's arm, placing Resident #40's only arm in a fixed position and pulling the resident's arm closer to her body. Resident #40 continued to resist care, swinging her only moveable left arm. The ACNO continued to use force to restrict the resident's movement as she screamed inaudibly, recoiled her body and her left leg. The ACNO continued to restrain Resident #40 as she said, stop fighting, and LVN A started to administer medication via the G-tube, checking for residual and then administering flushes and medications as Resident #40 continued to fight, rile up on her left side and wail. As Resident #40 continued to resist care, riling up as the ACNO restrained her left arm, her g-tube began to backflow. LVN A said she would stop G-tube medication administration due to Resident #40's resistance. An observation on 03/17/23 at 08:47 AM revealed, Resident #40's family member approach LVN H as she stood at her nursing cart. He asked LVN H to administer medication via G-tube to Resident #40 but LVN H said she could not because there was not an order. The family member asked for Resident #40's MDs phone number because the facility was too scared to do anything and then walked back to the resident's room, closing the door behind him. An observation on 03/17/23 at 08:52 AM revealed, Resident #40's door shut but resident could be heard screaming in room. In an interview on 03/15/23 at 09:46 AM, the CNO said Resident #40 was a new admission who had just experienced a new CVA and was under psych consult. He said when Resident #40 admitted to the facility she would not communicate her needs but was much more controlled now. In an interview on 03/15/23 at 10:38 AM, the ACNO said that Resident #40 was usually agitated, cries a lot, required redirection, reassurance and seeing new people agitates her. In an interview on 03/15/23 at 10:43 AM, the NP said LVN A notified her that Resident #40 was resisting/refusing oral meds, so she ordered that the medication be administered via G-tube. She said Resident #40's resistance/refusal of medications has been ongoing since her admission [DATE]). The NP said Resident #40 was normally verbal and required distraction and redirection. She said Resident #40 was receiving anti-anxiety meds via IM injection at the previous facility and the use of IM medications when the resident was exhibiting behaviors/refusing care was discussed with her family and was currently pending consent with Resident #40's family. In an interview on 03/15/23 at 01:17 PM, the CNO said Resident #40 had a history of refusing care, shouting, behaviors, received antipsychotics and was on psych services. He said to his knowledge the resident didn't have a diagnosis of dementia or Alzheimer's disease. He said residents with behaviors should be care planed for behaviors because care plan should be patient centered and Resident #40's care plan should have addressed her behaviors and resisting care. He said documentation of behaviors should be accurate and reflect the state of the resident in real time. When asked if resident remained agitated despite those attempts and resident fighting, would you expect them to continue with med pass, the CNO said he would expect staff to give space because maybe the patient needed more space, more time and to give resident time to acclimate. In an interview on 03/15/23 at 02:00 PM, the VP of Clinical Operations said Resident #40 had a history of agitation and anxiety. He said that residents with behaviors and continual refusal of care should be care planed for behaviors and these behaviors should be documented in a behavioral note, on the MAR and TAR in order for staff to know about the resident's behaviors and how to approach the resident. An observation and interview on 03/15/23 at 03:07 PM revealed , Resident #40 in low bed. The resident was hanging half off the bed with legs dangling and feet touching the floor. Staff entered the resident's room and closed the door. Resident #40 was yelling and moaning through the closed door. The Wound Care Nurse said that the resident's observed behaviors was common, Resident #40 was usually restless and would yell, moan and or make noises. She said LVN A and everyone was aware that Resident #40 had those behaviors. In an interview on 3/15/23 at 03:19 PM, when Resident #40's family member was asked if he was notified by the facility that force was used while administering medication via G-tube to the resident he said what is wrong with it. The family member said he has had to hold her hand down before in order for staff to administer medication via G-tube to Resident #40. In an interview on 03/16/23 at 10:13 AM, the VP of Clinical Operations said that Resident #40 has remained combative and continues to refuse care. He said that nursing staff have been unable to provide Resident #40 medications or G-tube feeds due to her behaviors, so MD A ordered for her to be sent out for altered mental status. In an interview on 03/16/23 at 10:16 AM, the VP of Clinical Operations said that Resident #40's behaviors had increased, and earlier in the morning (03/16/23) she grabbed Family Member #1 by the throat when he was being assertive trying to get the resident to take medications via G-tube. In an interview on 03/16/23 at 11:05 AM, the Director of Admissions said she was involved in the admission of Resident #40 and she completed a bedside visit at the resident's previous fac. She said the staff who function as clinical liaisons usually meet with the resident prior to admission to complete an assessment on the resident but could not determine if a bedside visit was completed for Resident #40. The Director of Admissions said the Clinical Liaison Staff had to have clinical training or clinical credentials to assess the residents and a red, yellow, green sheet was used to determine if a resident is admitted (green), needs further clinical evaluation (yellow), or cannot be admitted (red). She said resident's that fall in the yellow grid require further evaluation by nursing prior to admission but facility was unaware of Resident #40's behaviors prior to admission and as a result no one with nursing credentials reviewed the resident's chart prior to admission. The Director of Admissions said that Resident #40's admission was determined only by the clinical liaison. She said she did not have any documentation to show Resident #40's assessment prior to admissions. In an interview on 03/16/23 at 01:21 PM, MD A said Resident #40 admitted to the facility post CVA and had issues in her previous facility with delirium and confusion . He said the resident had metabolic encephalopathy and the only way to treat it would be to treat her symptoms of delirium and electrolyte imbalances. MD A said this was Resident #40's 3rd facility, she had dementia but was never fully diagnosed in an outpatient environment. MD A said he would expect to be notified of a resident's continuous refusal of care/medications/nutritional support. He said when medications or non-medical interventions are unable to control a resident's behaviors then the resident should be accessed for any acute problems or change in condition MD A said he was not informed of Resident #40's continuous refusal and the family never shared any concerns about her behaviors. He said if he was informed, he would have performed an acute assessment to identify any change of conditions and called a family meeting in regards to her behaviors. He said once the facility was unable to medically manage Resident #40 then she should have been sent out for further evaluation. In an interview on 03/16/23 at 01:48 PM, the Director or Rehabilitation said therapy completed Resident #40's initial assessment on 02/26/23 and she her chart was documented for staff to take precautions due to her aphasia and behaviors. She said on 03/15/23 Resident #30 was emotional and attempted to hit therapist. In an interview on 03/16/23 at 02:08 PM, PT A said that Resident #40 had been combative since admission and on and off. She said the resident would hit or scratch the PT staff but the resident understood the staff. PT A said that Resident #40 would grab at her family member jacket, as well as hit and swat at him during her PT sessions . She said she performed therapy with the resident on 03/15/23 and Resident #40 was the most tearful, emotional, and agitated as she had ever seen her. PT A said Resident #40 was not safe to be alone and that the resident swatted at her, so she backed away. She said she heard Resident #40 was non-compliant with medication administration the last week and would spit out her meds. In an interview on 03/16/23 at 02:35 PM, the VP of Clinical Operations said Resident #40's G-tube medication administration was discontinued by the MD and upon further review of the resident's admission records from the in hospital rehab facility, it was identified that the resident had to be physically restrained while she was in there due to her behaviors. He said no one saw it in her records, and no one saw her history of behaviors or restraints. The VP of Clinical Operations said an admission grid should be used in determining if a resident was green, yellow or red. He said since the behaviors and use of restraints was missed the resident did not go under further evaluation or nursing review prior to admission. The VP of Clinical Operations said if the facility was aware of the Resident #40's behaviors or use of restraints prior to admission they would have waited until the resident had a decrease in behaviors and was restraint free before she was admitted . In an interview on 03/17/23 at 08:42 AM, LVN H said that Resident #40 has been fighting care this morning. She said the resident would not allow her BP to be checked and refused her medication. She said Resident #40's family kept insisting that the resident receive medication through her G-tube, but the doctor had not approved administration of medication via g-tube. She said that when she last worked on Tuesday (03/14/23) Resident #40 received medication via G-tube because when she tried to give it to her by mouth the resident would take the pill and try and pocket it. LVN H said Resident #40 seemed more agitated today. In an interview on 03/17/23 at 10:10 AM, the Psychiatric Practitioner said she had only seen Resident #40 twice. She said on admission Resident #40 was screaming, restless, sporadic, impulsive and could not be redirected. The resident could not follow direction, gestures and was incoherent . The Psychiatric Practitioner said Resident #40 wasn't properly diagnosed coming into the facility and she had no prior history of mental disorders. She said that the Resident had vascular dementia and the facility was treating the symptoms with psychotropic medications. The Psychiatric Practitioner said she was not informed of R[TRUNCATED]