**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident (R291) did not abuse 2 out of 18 sampled Residents (R290 and R33.) R291 has a history of exhibiting socially inappropriate/disruptive behavior towards staff and other residents. The facility was aware of R291's behavior and this behavior was noted in R291's care plan. R291's care plan indicates R291 is one on one supervision while resident awake, door alarm, and 15-minute checks while resident is sleeping. Despite knowing these behaviors, the facility did not ensure R291 had adequate supervision which led to R291 entering R290's room, physically grabbing R290's head while R290 was in bed, and screaming and swearing at R290 to Get the fuck out of my bed. On the annual survey, R291 entered R33's room and Surveyor observed R291 hit R33 on the head. Surveyor observed R291 agitated, difficult to redirect, and going in to R33's room twice, the second time R291 hit R33 on the head. Surveyor observed R291 attempting several times to enter R290's room. Surveyor observed a staff attempting to support R291 but was not successful. No other staff or management came to support R291 during this time. The facility previously had an immediate jeopardy that began on 9/8/22 and was removed on 10/21/22 due to abuse and not supervising R291. The facility's Plan of Correction (POC) states, in part, 1:1 supervision of resident when outside of the resident's room Ongoing 15-minute checks completed by floor nurse or assigned CNA (Certified Nursing Assistant) door alarm present . The facility's failure to ensure adequate supervision to prevent abuse created a finding of immediate jeopardy that began on 1/6/23. Surveyor notified the Director of Operations and Director of Nursing of the immediate jeopardy on 1/11/23 at 12:30 PM. The immediate jeopardy was removed on 1/10/23; however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. Evidenced by: The facility policy titled Abuse Prevention Program with a revision date of December 2016, states in part; Policy Statement our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. In Sexual Abuse of Older Nursing Home Residents: A Literature Review, the authors note the statement by the World Health Organization, Regardless of the type of abuse psychological, physical, sexual, financial, and neglect, it will certainly result in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302365/ R291 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, Restlessness and agitation, Depression, and Alcohol abuse. R291's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/13/22, indicates R291 has a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney (APOAHC). R291's Comprehensive Care Plan, indicates, in part: Problem start date: 10/27/22, Behavioral Symptoms - Resident has expressed sexual behaviors towards others and based on assessment is unable to consensually participate in this type of behavior. Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by sexually inappropriate behaviors and foul language towards staff and other residents. Long Term Goal Target Date 3/16/23: Resident will accept redirection when exhibiting socially inappropriate/disruptive behavior toward staff or other residents. Approach: Start Date 10/27/22, administer medications per physician orders, assess resident as needed using the sexuality and intimacy worksheet, remind resident he is married and provide education related to appropriate interactions with others, avoid over-stimulation, identify and report possible triggers for suggestive or sexual language, maintain a calm, slow, understandable approach and environment for and with resident. Observe and report socially inappropriate/disruptive behaviors when around others. Provide snack (ice cream), provide meaningful engagement or activities to resident, remove resident from group activities when behavior is unacceptable, remove resident from other resident's rooms and unsafe situations. Staff should watch their body language staff wear appropriate attire. Staff should be aware of their own body language and conversations they are having with coworkers, visitors and residents. Staff should explain their role upon entering room. Address the resident formally and maintain their professionalism. When available, have male caregivers and nurses provide care for resident. One on one supervision while resident awake. Door alarm and 15-minute checks while resident sleeping. Problem start date: 10/19/22, Behavioral Symptoms - Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Long Term Goal Target Date 3/16/23 Resident will wander safely within specified boundaries. Approach 10/20/22 Door sensor alarm to resident's doorway to be turned on when in his room. Resident to have one on one supervision when awake. Maintain a calm environment and approach to the resident. Redirect resident if wandering into another room; offer resident to stay by nurses' station to be in line of sight of staff. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Problem start date: 10/4/22, Behavioral Symptoms - Resident uses inappropriate language towards others. Longer Term Goal Target Date 3/16/23 Resident will accept redirection from staff when using inappropriate language towards others. Approach 10/4/22 gently but firmly inform resident that inappropriate language are not welcome. Do not engage in discussion. Maintain a calm, slow, understandable approach . Problem start date: 9/13/22, Potential for elopement r/t cognitive status, unaware of safety concerns. Long Term Goal Target Date 3/16/23 Pt. will make no attempts of elopement E/B no sounding of code alert. Approach 9/13/22 check function weekly. Check placement every shift per nursing. Code alert bracelet to left ankle. #10. Gently redirect from stairwells and/or elevators. Picture of resident in all identified locations. Problem start date: 8/24/22 Behavioral Symptoms- Resident has been known to make sexually inappropriate comments towards staff and grabbing at staff. Long Term Goal Target Date 3/16/23 Resident will accept assistance from staff, if resident is not redirectable, staff will ensure resident is safe, leave resident's room and reapproach. Approach 10/20/22 door sensor alarm in resident's doorway to be turned on when resident is in his room. Resident to have one on one supervision. Approach start date 10/4/22 gently but firmly inform resident that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Approach start date 9/8/22 resident to have supervision when around female residents. Staff to ensure no inappropriate interactions . Problem start date: 5/6/22 Behavioral Symptoms - APOAHC stated resident has a history of grabbing other residents aggressively and becoming physically aggressive with staff. APOAHC indicated resident has not made any sense when he talks; resident is able to form words, but the words together do not make sense. Resident has used swear words often. Approach start date 5/6/22 Staff can attempt to redirect resident. Staff should have a calm approach when interacting with resident. Ask simple yes, no questions. Staff can meet with resident 1:1 if needed/able. If resident becomes agitated staff can reapproach after giving resident time to calm down. During periods of increased agitation, remove resident away from other residents and take to safe area to calm down. Approach start date 8/2/22 Approaches to redirect resident to his own room. Sign placed outside of resident's room to direct him to his own room. Surveyor asked for R291's Certified Nursing Assistant (CNA) Care Card. Facility provided a document titled, Profile Care Plan Approaches which states, in part: Nutritional Status 6/9/22, .1:1 supervision at meals .If you have to leave resident, move all food and inedible items out of his reach. Behavioral Symptoms 10/4/22, Gently but firmly inform R291 that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Behavioral Symptoms 10/27/22, Resident should be placed in a calm and quiet environment at least an arms length away from other residents to ensure resident's safety. Surveyor reviewed Physician Order Report 1/1/23-1/31/23 which states, in part: Start date, 8/29/22 May be seen by behavioral health, start date 8/29/22 Target Behavior: (sexual inappropriateness, increased resident distress, dangerous to self or others) At the end of each shift mark frequency - how often behavior occurred and intensity - how resident responded to redirection, intensity code: 0=did not occur, 1=easily altered, 2=difficult to redirect. Special instructions staff note: add frequency and intensity med notes to order for tracking. Every shift; day, pm, noc. Start date, 9/13/22 Check placement of wander guard every shift. Start date, 9/20/22 check wander guard function weekly. Start date, 11/24/22 Update POA with any instances of combative behavior (call daughter). Start date, 11/28/22 Check function of door alarm sensor Qshift. Every shift; day, pm, noc. Surveyor reviewed behavior tracking from 12/1/22-1/10/23 .target behavior sexual inappropriateness, increase resident distress, dangerous to self or others .out of the 41 days reviewed there is see note documented for 20 of the days. The behavior documentation is not consistently tracking intensity or frequency. Progress notes reviewed, 12/11/22 13:47 (1:47 PM) .talking and swearing very loudly at the lunch table. He did not become aggressive physically but continued to be very vocal and curse .12/16/22 14:23 (2:23 PM), He swung at CNA and connected with her left shoulder-did not cause injury. 12/17/22 21:24 (9:24 PM), CNA needed assistance with toileting resident, while nurse and CNA were toileting resident, he hit CNA in her face causing her to bite the inside of her lip. Nurse and CNA redirected and educated resident. After toileting resident, staff was able to place resident in bed 12/18/22 22:13 (10:13 PM), Resident looking for the bathroom; was redirected back to his room Writer entered room to find CNAs in bedroom with resident in bathroom pacing. Writer offered assist to resident. Resident stated, I gotta take a piss and they told me I had to come in here.Resident proceeded to pull out his penis and pee in the corner .CNAs attempted to intervene which agitated resident more. Writer instructed CNAs to step back as to not overwhelm resident resident did make comments with washing of his penis and tried to grab writer's hand to move back to location, was easily redirected 12/24/22 23:48 (11:48 PM), Staff reported that during shift change resident slapped the evening shift care giver. Care giver was trying to assist resident and resident slapped her. 1/1/23 0:00 (12:00 AM), Resident trying to visit with a female resident this PM, resident was hard to redirect .1/9/23 9:41 AM, .he punched first CNA in the face. 1/9/23 18:24 (6:24 PM), .resident combative with staff, hitting at staff member. 1/10/23 16:09 (4:09 PM), .resident struck another resident .1/11/23 23:36 (11:36 PM), .CNA stated that resident had been sleeping in recliner and became restless and got up. CNA was assisting with incontinence cares when resident punched her in the eye. RT (right) eye with green/purple bruising and swelling to upper eyelid . Surveyor reviewed notes from Behavioral Care Solutions (BCS) from time of admission with BCS, 9/16/22, states, in part: Patient referred for BCS services for vulgar language and aggressive behavior towards staff .9/29/22, Can get anxious and agitated at times. It is reported he did have a physical altercation with peer. Confused with poor memory 10/21/22, Note: writer received phone call from SW and nursing staff, report patient with recent increased aggression toward peers and staff, now has been wandering. Now has 1:1 sitting when out of his room and a door alarm to alert staff when he is leaving his room .Per staff, he has increased behaviors of aggression and agitation in the PM hours .11/1/22, Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction 12/21/22, Today behavioral documentation was reviewed and reported the following symptoms: Resident yelling get the fuck out of here! Go back to your room! and continued yelling despite redirection (11/17). Cursing at others (10/23), some false beliefs expressed at times. Staff able to easily redirect, left alone to settle and re-approach. Spoke to nursing staff, it is reported that patient hit CNA during toileting assistance on 12/17/22. It is reported that at times he will wander to find the bathroom. He becomes agitated during this time and irritated staff believe it is due to his worsening Dementia and memory. Some increased confusion reported in the evening hours Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction R290 was admitted to the facility on [DATE] with diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Nausea, Anxiety Disorder, and Pain. R290's most recent MDS with ARD of 10/23/22, indicates R290 has a BIMS score of 10, indicating R290 is moderately impaired. R290 is own person. Care plan Problem start date 10/26/22 mobility: WC for mobility. Able to propel per self. Staff to assist as needed .GROOMING/DRESSING/TOILETING: Own teeth. Set up for oral cares, UB (upper body) hygiene/grooming. Assist as needed to complete UB cares. 1 assist for LB (lower body) dressing, peri-care and showers. Scheduled toileting/check and change every 2-3 hours and PRN to decrease incontinence, promote skin integrity and dignity BEHAVIOR AND COGNITION: A&O x4. Pleasant and cooperative .STOP sign on room door to deter unwanted visitors. Surveyor reviewed Grievance/Concern Form; Date the concern occurred: 1/6/23. Summary of concern: R290 stated to me that on Friday night resident (R291) entered her room, and started moving her blinds back and forth. He also approached her and said get the hell out of my bed Resident states she had her call light on. Also states this has happened before. She was very upset. Emotional support given. RN J (Registered Nurse) completed grievance form. R33 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety Disorder, Sensorineural hearing loss, Difficulty in walking, and Cognitive communication deficit. R33's most recent MDS with ARD of 1/3/23, indicates R33 has a BIMS score of 6 out of 15 indicating R33 is severely impaired. R33 has an Activated Health Care Power of Attorney. R33's Care Plan states, in part, Problem start date 10/21/22 Resident expresses sadness/anger when she recalls having to take her daughter and leave her abusive husband previously in her life. There are no known triggers for resident. Long Term Goal Target Date: 4/10/23 Resident will demonstrate a healthy acceptance of her outcome with that situation. Approach start date 10/21/22 allow resident to express feelings. Assess for mood/behavior problems. Identify positive relationships that resident could draw on for support. Resident does not like to discuss her past physical abuse as this is how she copes with this. Staff will redirect and reassure resident if resident becomes triggered by the past event. On 1/9/23 at 4:00 PM, Surveyor introduced self to R291. R291 was in room, sitting in recliner with feet up, hands behind head, and watching TV. R291 was appropriately dressed and looked up at Surveyor and smiled. R291 started talking about trucking and was repeatedly swearing using the F word. At first R291 was smiling but he started pointing and talking about an issue with trucking. He had tears in his eyes, began frowning, started swearing louder with more aggression. R291's door alarm was activated when Surveyor walked through room door. CNA Z (Certified Nursing Assistant) approached Surveyor after alarm was sounded. CNA Z indicated R291 has a door alarm for safety reasons. R291 wanders into other resident's bedrooms. CNA Z indicated R291 is on 15-minute checks and has the door alarm when he is in his room. CNA Z indicated R291 is supposed to be one on one supervision when he is out in the common areas of the facility. CNA Z indicated there are times staff will forget to turn the alarm on and R291 will wander to the completely opposite side of the nursing home. CNA Z indicated other residents are frustrated and scared when R291 goes into their rooms. Surveyor asked if there were rooms that R291 was more likely to go in. CNA Z pointed at the two rooms (R290 and R33) next to R291. CNA Z indicated R33 doesn't seem bothered by R291 going into R33's room, but R33 forgets things right after they happen. CNA Z indicated R290 does not like when R291 goes into her room and that she is scared of R291. On 1/9/23 at 4:30 PM, Surveyor observed R291 sitting near the nurses' station. Surveyor observed the staff at the nurses' station leave the area and R291 was left with no staff near or with R291. No one on one support provided. On 1/10/23 at 8:00AM-8:20AM, Surveyor observed R291 sitting at the edge of his bed. No staff were present inside or outside of room. Door alarm was turned on. On 1/10/23 at 8:27AM-9:15AM, Surveyor observed R291 sitting in the dining room eating breakfast. R291 was sitting at a table by himself with his back turned to others and looking out the window. Staff were present assisting other residents with their meal trays and coming in and out of the dining room area. No one on one support provided. On 1/10/23 at 9:30 AM, Surveyor observed R291 sitting in wheelchair near the nurses' station. Two staff were near the computers and were talking. No one on one support provided. On 1/10/23 at 10:24 AM-12:20 PM, Surveyor observed R291 in bedroom sitting in recliner with feet up, awake and watching TV. On 1/10/23 at 9:22 AM, Surveyor introduced self to R290. Surveyor observed R290's room door shut with a small sign on door. The sign was in a shape of a hexagon, with a hand on it, light red in color, and said STOP. R290 indicated she was doing okay and that she had been at the facility since October 2022. R290 indicated she has concerns with her neighbor, R291. R290 indicated R291 is not a safe person to be around and that the stop sign on her door does not work at all. R290 indicated R291 walks into her room and will use her bathroom and that this has happened at least three different times. R290 indicated she has voiced concerns about this and the only thing that was put in place was the stop sign on the door. R290 indicated she does not understand why R291 can't be moved, that she is terrified of him, and that all the staff in the facility know this. R290 indicated that on 1/6/23 at 9:09 PM, R291 came into her room. R290 indicated this time was different than the other three times R291 entered her room. R290 indicated on 1/6/23 she was in bed, door shut, and her lights off. Surveyor observed R290's bed and noted that the head of the bed is in a direction where if someone enters the room, you would not be able to see who entered. R290 indicated she heard her bedroom door open, and her lights came on. R290 stated, The guy next door came right next to my bed and screamed, Get the fuck out of my bed. He uses the F word all the time. R290 indicated R291 was naked except for an adult brief on. R290 indicated R291 grabbed her head and continued yelling and swearing. R290 indicated she put her call light on and was repeatedly pressing the call light. R290 indicated R291 went to her blinds and was messing around with them and then took a chair and threw it. R290 indicated R291 is very strong, he's not big, but rough and very strong. R290 indicated she kept pressing the call light and that she didn't know what to do. R290 indicated she thought R291 was going to crawl into bed with her. R290 indicated, I was frightened to death. As R290 replayed the incident Surveyor observed tears in her eyes, she was holding her hands tightly and shaking. R290 indicated she did not hear R291's door alarm go off that night. R290 indicated there are times she hears the alarm, so she knows he is out and there are times that she doesn't hear the alarm and he is in her room. R290 indicated she listens for the alarm, but that it is not always reliable. R290 indicated R291 then left her room and a few minutes later a staff answered her call light. R290 indicated she told the staff what had just happened, and the staff kept saying, I'm so sorry, I'm so sorry. R290 indicated she did not know the name of the staff that answered the call light but knew that it was one of the CNAs that were working that evening. R290 indicated someone must have reported the incident because AC W (Admissions Coordinator) came and talked to her twice about it on Monday. R290 indicated there were three staff in her bathroom talking to her about the incident on Monday evening. R290 indicated one staff said, Oh, he (R291) has hit her many times. R290 indicated R291 has never physically harmed her before, but everyone knows she is scared to death of him and disgusted by him. R290 indicated she can't even stand to look at him. R290 stated, People know, everyone knows I have problems with him, nothing got done, and then the incident on that Friday happened. I can't handle this. Surveyor observed R290's voice raising and becoming louder with more panic. R290 stated, DM K (Dietary Manager) told me last week that I don't have to worry, he won't be sitting next to me [during meals]. She knows! Everyone knows. I don't want that guy next door. On 1/10/23 at 11:55 AM, CNA U indicated there is a list of people with their pictures of who wanders. CNA U indicated she knows who is at risk for wandering because she is a regular staff. CNA U indicated R291 wanders into other people's rooms. Surveyor asked what supervision is provided to R291. CNA U indicated that he is basically a one on one support when he's not in his room. CNA U indicated they had a document they were signing off for 15-minute checks for R291 as well. CNA U indicated she can not find the sheet and does not know if the 15-minute checks still need to be completed. CNA U indicated R291 needs to have eyes on him, and that staff will have him sit at the nurses' station so everyone can keep an eye on him. CNA U indicated the door alarm that is used doesn't always go off when it should. CNA U indicated she heard that R291 touched another resident, R290, and now they don't sit near each other during meals. CNA U indicated that when R291 is difficult to redirect having a different staff step in and assist works well. Sometimes that different face is all that is needed for a reset. Surveyor observed CNA U ask coworker if 15-minute checks are still in place. Coworker stated, I can't find the documentation, so I don't know. On 1/10/23 at 2:45 PM, AA KK (Activity Aide) indicated R290 is terrified of R291. AA KK indicated that R291 went into R290's room the other night and was throwing things around and cursing at R290. AA KK indicated she witnessed R290 tell another staff about the incident last night (1/9/23). AA KK indicated R290 was afraid to go to bed last night. AA KK indicated that AC W had a conversation with R290 about the incident as well. AA KK indicated staff struggle with R291 and that he is known to grab others so he has to sit at his own table. AA KK indicated R291 went into another resident's room recently and she struggled to get him out of the room and that he was swearing at staff. AA KK indicated that she has had to take R291 from room to room while she is assisting other residents. AA KK indicated she will have him sit outside the room with the bedroom door closed. AA KK indicated she wouldn't know if R291 has an activity care plan. AA KK indicated that the nurse tells her if she needs to know something regarding a resident. On 1/10/23 at 2:45PM, CNA I indicated she has worked with R291 when he was on the 2nd floor as well as him being on the 3rd floor. CNA I indicated R291 has some behaviors, and some are more sexual. CNA I indicated R291 is a retired truck driver and that he likes motorcycles. CNA I indicated that he will wander into other resident rooms. CNA I indicated for interventions they will walk with R291 and give him something else to do. CNA I indicated R291 will sit by the nurses' station and sometimes they have to take him room to room to ensure everyone's safety. CNA I indicated the approach is very important with R291, you have to ask him if he wants to do something. CNA I indicated he goes into R290's room quite often. Just recently R291 was saying inappropriate things to R290 and now R290 does not want to sit near R291 at mealtimes. There was something they had to sign so everyone knows they don't sit next to each other. R290 is afraid of R291. R291 will go into R33's room, but she doesn't even know he is in there. CNA I indicated the door alarm takes a while to come on and it's not that loud. CNA I indicated R291 is both one on one supervision and line of sight. CNA I indicated they usually do 15-minute checks or like a half an hour check. CNA I indicated R291 can get combative when trying to redirect, and approach is so important. CNA I indicated that sometimes the staff attitude is more of the issue. On 1/10/23 at 3:00 PM, Surveyor observed R291 sitting in the recliner in his room with his back to the door. On 1/10/23 at 3:06 PM, Surveyor observed R291's sensor alarm on the door frame sounding. Surveyor observed R291 ambulating independently in the hall while wearing socks, 1 shoe on the wrong foot, jeans, and no shirt. Surveyor observed R33 sitting in the hall outside her room as R291 walked by R33 to get to the TV area across from the dining room before sitting down. On 1/10/23 at 3:07 PM, Surveyor observed RA D (Resident Assistant) assist R291 with putting his shirt on and escorted him back to his room. On 1/10/23 at 3:10 PM, CNA V indicated when R291 is in his bedroom he can be alone. CNA V indicated that the door alarm needs to be on. CNA V indicated there are times that staff forget to turn on the alarm, if R291 walks past the elevator then the wander guard alarm goes off. CNA V indicated there are times the door alarm goes off and R291 is sitting in his recliner and there are times it doesn't go off and he's out of his room. CNA V indicated they were doing 15-minute checks, but that they haven't been lately and that she (CNA V) doesn't know where the sign off sheet went. CNA V indicated the timeframe of the checks had changed quite a bit and that management lets them know. CNA V indicated that when R291 is out of his room he needs to always have staff around him and that he will sit near the nurses' station. CNA V indicated that R291 cycles and that there are times that he is up all night long. CNA V indicated that R291 doesn't like to wear or keep clothes on, and that staff try their best to encourage him to have something on. CNA V indicated R291 gets agitated and wants to be up and walking around more on the PM shifts. CNA V indicated that during the day R291 is always in his room, it's like he's trapped in there. CNA V is not aware if the activities department does any activities with R291. CNA V indicated the approach is incredibly important with R291. Regular staff that know R291 will say, Come sit in your truck seat! when trying to assist him in sitting in wheelchair. CNA V indicated R291 also loves motorcycles. CNA V indicated the facility does provide dementia care training, but that this CNA has never worked with someone so aggressive before and they have not had training that's more specific. CNA V indicated it takes a different approach when working with someone that is this aggressive. CNA V indicated she knows that R290 is scared of R291. R290's room door is always shut. CNA V indicated that if R291's alarm goes off and staff are in someone else's room they can't get to him right away. CNA V indicated that R291 has been able to get to R290's bedroom because staff can't get there in time. CNA V indicated she knows that R290 doesn't want to sit next to R291 during meals because they all had to recently sign a sheet that explained that. CNA V indicated R291 will wander into other people's bedrooms, and this upsets them as well. On 1/10/23 at 3:17 PM, Surveyor observed R291's sensor alarm sounding as he walked from his room directly across the hall into R33's bathroom carrying a chux (incontinence pad.) Surveyor observed there were no staff present as R291 entered R33's bathroom. Surveyor alerted RA D (Resident Assistant) that R291 was in R33's room. RA D entered R33's room and escorted R291 out of R33's room. On 1/10/23 at 3:19 PM, Surveyor asked RA D if R291 should be in other residents' rooms? RA D replied, No. Surveyor asked RA D, has R291 entered R33's room prior to today? RA D stated, Yes. RA D added, If I'm being honest, he should be in a dementia unit. RA D added, R291 has a thing about going in two (2) resident (R33 and R290) rooms. Surveyor asked RA D, does it bother either R33 or R290 when R291 enters their rooms? RA D stated, R33 doesn't mind, she will talk with R291. It is important to note, R33 has a history of being abused by a family member in the home prior to being admitted to the facility. R33 is moderately cognitively impaired and is unable to recall the abuse. Surveyor asked, how d[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure safety and prevent accidents for 1 of 2 residents (R291) reviewed for wandering and resident to resident altercations, and residents' environment is free of accident hazards for 3 of 3 sampled residents (R34, R8, and R28) reviewed for falls, 2 of 2 units with unsecured chemicals, and 2 of 2 residents (R5 and R7) with medication left at bedside. Example 1 R291 is at high risk for wandering and has a known history of aggressive behaviors toward other residents and staff. The facility failed to implement appropriate interventions, failed to follow resident care plans, and failed to put adequate supervision in place. R291 was not being supervised and had a physical altercation with R290 and R33. The facility's failure to provide adequate supervision for a resident known to wander and with a known history of aggressive behaviors toward others created a finding of immediate jeopardy (IJ) that began on 1/1/23. Surveyor notified the Director of Operations and Director of Nursing of the immediate jeopardy on 1/11/23 at 12:30 PM. The immediate jeopardy was removed on 1/10/23, however the deficient practice continues at a scope/severity of G as the facility continues to implement its action plan. Evidenced by: The facility policy titled Wandering and Elopement with a revision date of March 2019, states in part; Policy Statement The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. R291 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, Restlessness and agitation, Depression, and Alcohol abuse. R291's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/13/22, indicates R291 has a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney. R291's Comprehensive Care Plan, indicates, in part: Problem start date: 10/27/22, Behavioral Symptoms- Resident has expressed sexual behaviors towards others and based on assessment is unable to consensually participate in this type of behavior. Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by sexually inappropriate behaviors and foul language towards staff and other residents. Long Term Goal Target Date 3/16/23: Resident will accept redirection when exhibiting socially inappropriate/disruptive behavior toward staff or other residents. Approach: Start Date 10/27/22, administer medications per physician orders, assess resident as needed using the sexuality and intimacy worksheet, remind resident he is married and provide education related to appropriate interactions with others, avoid over-stimulation, identify and report possible triggers for suggestive or sexual language, maintain a calm, slow, understandable approach and environment for and with resident. Observe and report socially inappropriate/disruptive behaviors when around others. Provide snack (ice cream), provide meaningful engagement or activities to resident, remove resident from group activities when behavior is unacceptable, remove resident from other resident's rooms and unsafe situations. Staff should watch their body language staff wear appropriate attire. Staff should be aware of their own body language and conversations they are having with coworkers, visitors and residents. Staff should explain their role upon entering room. Address the resident formally and maintain their professionalism. When available, have male caregivers and nurses provide care for resident. One on one supervision while resident awake. Door alarm and 15-minute checks while resident sleeping. Problem start date: 10/19/22, Behavioral Symptoms- Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Long Term Goal Target Date 3/16/23 Resident will wander safely within specified boundaries. Approach 10/20/22 Door sensor alarm to resident's doorway to be turned on when in his room. Resident to have one on one supervision when awake. Maintain a calm environment and approach to the resident. Redirect resident if wandering into another room; offer resident to stay by nurses' station to be in line of sight of staff. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Problem start date: 10/4/22, Behavioral Symptoms- Resident uses inappropriate language towards others. Longer Term Goal Target Date 3/16/23 Resident will accept redirection from staff when using inappropriate language towards others. Approach 10/4/22 gently but firmly informed resident that inappropriate language are not welcome. Do not engage in discussion. Maintain a calm, slow, understandable approach . Problem start date: 9/13/22, Potential for elopement r/t cognitive status, unaware of safety concerns. Long Term Goal Target Date 3/16/23 Pt. will make no attempts of elopement E/B no sounding of code alert. Approach 9/13/22 check function weekly. Check placement every shift per nursing. Code alert bracelet to left ankle. #10. Gently redirect from stairwells and/or elevators. Picture of resident in all identified locations. Problem start date: 8/24/22 Behavioral Symptoms- Resident has been known to make sexually inappropriate comments towards staff and grabbing at staff. Long Term Goal Target Date 3/16/23 Resident will accept assistance from staff, if resident is not redirectable, staff will ensure resident is safe, leave resident's room and reapproach. Approach 10/20/22 door sensor alarm in resident's doorway to be turned on when resident is in his room. Resident to have one on one supervision. Approach start date 10/4/22 gently but firmly inform resident that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Approach start date 9/8/22 resident to have supervision when around female residents. Staff to ensure no inappropriate interactions . Problem start date: 5/6/22 Behavioral Symptoms- APOAHC (Activated Power of Attorney for Health Care) stated resident has a history of grabbing other residents aggressively and becoming physically aggressive with staff. APOAHC indicated resident has not made any sense when he talks; resident is able to form words, but the words together do not make sense. Resident has used swear words often. Approach start date 5/6/22 Staff can attempt to redirect resident. Staff should have a calm approach when interacting with resident. Ask simple yes, no questions. Staff can meet with resident 1:1 if needed/able. If resident becomes agitated staff can reapproach after giving resident time to calm down. During periods of increased agitation, remove resident away from other residents and take to safe area to calm down. Approach start date 8/2/22 Approaches to redirect resident to his own room. Sign placed outside of resident's room to direct him to his own room. Surveyor asked for R291's Certified Nursing Assistant (CNA) Care Card. Facility provided a document titled, Profile Care Plan Approaches, which states in part: Nutritional Status 6/9/22, .1:1 supervision at meals .If you have to leave resident, move all food and inedible items out of his reach. Behavioral Symptoms 10/4/22, Gently but firmly inform R291 that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Behavioral Symptoms 10/27/22, Resident should be placed in a calm and quiet environment at least an arms length away from other residents to ensure resident's safety. Surveyor reviewed Physician Order Report 1/1/23-1/31/23 which states in part: Start date, 8/29/22 May be seen by behavioral health, start date 8/29/22 Target Behavior: (sexual inappropriateness, increase resident distress, dangerous to self or others) At the end of each shift mark frequency- how often behavior occurred and intensity- how resident responded to redirection, intensity code: 0=did not occur, 1=easily altered, 2=difficult to redirect. Special instructions staff note: add frequency and intensity med notes to order for tracking. Every shift; day, pm, noc. Start date, 9/13/22 Check placement of wander guard every shift. Start date, 9/20/22 check wander guard function weekly. Start date, 11/24/22 Update POA with any instances of combative behavior (call daughter). Start date, 11/28/22 Check function of door alarm sensor Qshift. Every shift; day, pm, noc. Surveyor reviewed behavior tracking from 12/1/22-1/10/23 .target behavior sexual inappropriateness, increase resident distress, dangerous to self or others .out of the 41 days reviewed there is see note documented for 20 of the days. The behavior documentation is not consistently tracking intensity or frequency. Progress notes reviewed, 12/11/22 13:47 .talking and swearing very loudly at the lunch table. He did not become aggressive physically but continued to be very vocal and curse .12/16/22 14:23, He swung at CNA and connected with her left shoulder-did not cause injury. 12/17/22 21:24, CNA needed assistance with toileting resident, while nurse and CNA were toileting resident, he hit CNA in her face causing her to bite the inside of her lip. Nurse and CNA redirected and educated resident. after toileting resident, staff was able to place resident in bed 12/18/22 22:13 (10:13 PM), Resident looking for the bathroom; was redirected back to his room Writer entered room to find CNA's in bedroom with resident in bathroom pacing. Writer offered assist to resident. Resident stated, I gotta take a piss and they told me I had to come in here.Resident proceeded to pull out his penis and pee in the corner .CNAs attempted to intervene which agitated resident more. Writer instructed CNAs to step back as to not overwhelm resident resident did make comments with washing of his penis and tried to grab writer's hand to move back to location, was easily redirected 12/24/22 23:48 (11:48 PM), Staff reported that during shift change resident slapped the evening shift care giver. Care giver was trying to assist resident and resident slapped her. 1/1/23 0:00 (12:00 AM), Resident trying to visit with a female resident this PM, resident was hard to redirect .1/9/23 9:41 AM, .he punched first CNA in the face. 1/9/23 18:24 (6:24 PM), .resident combative with staff, hitting at staff member. 1/10/23 16:09 (4:09 PM), .resident struck another resident .1/11/23 23:36 (11:36 PM), .CNA stated that resident had been sleeping in recliner and became restless and got up. CNA was assisting with incontinence cares when resident punched her in the eye. RT (right)eye with green/purpe bruising and swelling to upper eyelid . Surveyor reviewed notes from Behavioral Care Solutions (BCS) from time of admission with BCS. On 9/16/22, states, in part: Patient referred for BCS services for vulgar language and aggressive behavior towards staff .9/29/22, Can get anxious and agitated at times. It is reported he did have a physical altercation with peer. Confused with poor memory 10/21/22, Note: writer received phone call from SW (Social Worker) and nursing staff, report patient with recent increased aggression toward peers and staff, now has been wandering. Now has 1:1 sitting when out of his room and a door alarm to alert staff when he is leaving his room .Per staff, he has increased behaviors of aggression and agitation in the PM hours .11/1/22, Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction 12/21/22,Today behavioral documentation was reviewed and reported the following symptoms: Resident yelling get the fuck out of here! Go back to your room! and continued yelling despite redirection (11/17). Cursing at others (10/23), some false beliefs expressed at times. Staff able to easily redirect, left alone to settle and re-approach. Spoke to nursing staff, it is reported that patient hit CNA during toileting assistance on 12/17/22. It is reported that at times he will wander to find the bathroom. He becomes agitated during this time and irritated staff believe it is due to his worsening Dementia and memory. Some increased confusion reported in the evening hours Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction On 1/9/23 at 4:00 PM, R291 was in his bedroom, sitting in recliner with feet up, hands behind head, and watching TV. R291's door alarm was activated when Surveyor walked through bedroom door. CNA Z (Certified Nursing Assistant) approached Surveyor after alarm sounded. CNA Z indicated R291 has a door alarm for safety reasons. R291 wanders into other residents' bedrooms. CNA Z indicated R291 is on 15-minute checks and has the door alarm when he is in his room. CNA Z indicated R291 is supposed to be one on one supervision when he is out in the common areas of the facility. CNA Z indicated there are times staff will forget to turn the alarm on and R291 will wander to the completely opposite side of the nursing home. CNA Z indicated other residents are frustrated and scared when R291 goes into their bedrooms. On 1/9/23 at 4:30 PM, Surveyor observed R291 sitting near the nurses' station. Surveyor observed the staff at the nurses' station leave the area and R291 was left with no staff near or with R291. No one on one support provided. On 1/10/23 at 8:00 AM-8:20 AM, Surveyor observed R291 sitting at the edge of his bed. No staff were present inside or outside of room. Door alarm was turned on. On 1/10/23 at 8:27 AM-9:15 AM, Surveyor observed R291 sitting in the dining room eating breakfast. R291 was sitting at a table by himself with his back turned to others and looking out the window. Staff were present assisting other residents with their meal trays and coming in and out of the dining room area. No one on one support provided. On 1/10/23 at 9:30 AM, Surveyor observed R291 sitting in a wheelchair near the nurses' station. Two staff were near the computers and were talking. No one on one support provided. On 1/10/23 at 10:24 AM-12:20PM, Surveyor observed R291 in bedroom sitting in recliner with feet up, awake and watching TV. On 1/10/23 at 11:55 AM, CNA U indicated there is a list of people with their pictures of who wanders. CNA U indicated she knows who is at risk for wandering because she is a regular staff. CNA U indicated R291 wanders into other people's rooms. Surveyor asked what supervision is provided to R291? CNA U indicated that he is basically a one on one support when he's not in room. CNA U indicated they had a document they were signing off for 15-minute checks for R291 as well. CNA U indicated she can not find the sheet and does not know if the 15-minute checks still need to be completed. CNA U indicated R291 needs to have eyes on him, and that staff will have him sit at the nurses' station so everyone can keep an eye on him. Surveyor observed CNA U asked coworker if 15-minute checks are still in place? Coworker stated, I can't find the documentation, so I don't know. On 1/10/23 at 2:45 PM, AA KK (Activity Aide) indicated R290 is terrified of R291. AA KK indicated that R291 went into R290's bedroom the other night and was throwing things around and cursing at R290. AA KK indicated R291 went into another resident's room recently and she struggled to get him out of the room and that he was swearing at staff. On 1/10/23 at 2:45 PM, CNA I indicated R291 will sit by the nurses' station and sometimes they have to take him room to room to ensure everyone's safety. CNA I indicated the door alarm takes a while to come on and it's not that loud. CNA I indicated R921 is both one on one supervision and line of sight. CNA I indicated they usually do 15-minute checks or like a half an hour check. On 1/10/23 at 3:00 PM, LPN G (Licensed Practical Nurse) indicated R291's door alarm should be on when he is in his bedroom. LPN G indicated she is not sure if he's still on 15-minute checks right now. LPN G indicated she is not sure if R291 is on one to one supports right now, but that she doesn't think he is. LPN G indicated they try to keep an eye on him. On 1/10/23 at 3:06 PM, Surveyor observed R291's sensor alarm on the door frame alarming. Surveyor observed R291 ambulating independently in the hall while wearing socks, 1 shoe on the wrong foot, jeans, and no shirt. Surveyor observed R33 sitting in the hall outside her room as R291 walked by R33 to get to the TV area across from the dining room before sitting down. On 1/10/23 at 3:07 PM, Surveyor observed RA D (Resident Assistant) assist R291 with putting his shirt on and escorted him back to his room. On 1/10/23 at 3:10PM, CNA V indicated when R291 is in his room he can be alone. CNA V indicated that the door alarm needs to be on. CNA V indicated there are times that staff forget to turn on the alarm, if R291 walks past the elevator then the wander guard alarm goes off. CNA V indicated there are times the door alarm goes off and R291 is sitting in his recliner and there are times it doesn't go off and he's out of his room. CNA V indicated they were doing 15-minute checks, but that they haven't been lately and that she (CNA V) doesn't know where the sign off sheet went. CNA V indicated the timeframe of the checks had changed quite a bit and that management lets them know. CNA V indicated that when R291 is out of his room he needs to always have staff around him and that he will sit near the nurses' station. CNA V indicated that if R291's alarm goes off and staff are in someone else's room they can't get to him right away. CNA V indicated R291 will wander into other people's rooms, and this upsets them. On 1/10/23 at 3:17 PM, Surveyor observed R291's sensor alarm sounding as he walked from his room directly across the hall into R33's bathroom carrying a chux (incontinence pad). Surveyor observed there were no staff present as R291 entered R33's bathroom. Surveyor alerted RA D (Resident Assistant) that R291 was in R33's room. RA D entered R33's room and escorted R291 out of R33's room. On 1/10/23 at 3:19 PM, Surveyor asked RA D if R291 should be in other residents' rooms? RA D replied, No. Surveyor asked RA D, has R291 entered R33's room prior to today? RA D stated, Yes. RA D added, If I'm being honest, he should be in a dementia unit. RA D added, R291 has a thing about going in two (2) resident (R33 and R290) rooms. Surveyor asked RA D, does it bother either R33 or R290 when R291 enters their rooms? RA D stated, R33 doesn't mind, she will talk with R291. It is important to note, R33 has a history of being abused by a family member in the home prior to being admitted to the facility. R33 is moderately cognitively impaired and is unable to recall the abuse. Surveyor asked, how does R290 feel when R291 enters her room? RA D added, She's scared shitless of him - terrified! On 1/10/23 at 3:20 PM, Surveyor observed R291's sensor alarm sounding again. RA D approached R291 attempting to assist him. On 1/10/23 at 3:23 PM, Surveyor observed R291's sensor alarm going off again. RA D stated to R291, have a seat, as R291 is still standing. R291 stated, all I have to do is sit in the chair? R291 stated, waki [NAME]. Surveyor observed R33 wearing a Santa hat while sitting inside the entry way of her room drinking a soda. Surveyor observed RA D standing in between R33 and R291. R291 looked at R33 and stated, Hey pee wee I'm Santa Claus as he reached out and hit R33 on the top of her head. R33 exclaimed, Ouch! Surveyor observed RA D telling R291 to sit right here (in his wheelchair). R291 refused to sit down and continued to ambulate. Surveyor observed R291 attempted to repeatedly enter R290's room. RA D held the doorknob to prevent R291 from opening R290's door. RA D stated, Hey R291, we can't go that way, as R291 is walking toward the elevators setting off the WanderGuard alarm. R291 turned around and was looking in R33's room. On 1/10/23 at 3:25 PM, Surveyor spoke with RA D. RA D stated nobody likes to help her with R291 and he is a 2 assist. RA D stated, R291 is not allowed to be within arm's reach of another resident. RA D stated, R291 sundowns (A symptom that often occurs in people with dementia. Sundowning or sundown syndrome, is common in dementia patients and refers to the onset of of hard-to-manage behaviors toward the end of the day.) RA D stated, R291 gets aggressive and has been known to swing and pull other residents' hair. Surveyor asked RA D, whose hair did R291 pull? RA D stated, R291 has pulled R290's hair. Surveyor asked RA D did you observe R291 make contact with R33's head. RA D stated, Yes. RA D stated, R290 told me about R291 pulling her hair last night. RA D clarified she was not working when the hair pulling incident occurred last week. RA D stated, R291 is not to be within arm's reach of other residents. Surveyor asked RA D, when was arm's reach put in place? RA D stated, I have no idea. RA D stated, if R291 is in his room I can walk away (leave him) as his motion sensor is on at all times. Surveyor asked RA D, is R291 on 1:1? RA D stated, I don't know. Surveyor asked RA D, what interventions are effective with R291? RA D stated, if R291 is more agitated we redirect him with Cheetos or ice cream. RA D stated, this works most of the time, however, some days it's like this and never ending. Surveyor asked RA D is it acceptable for a resident to hit another resident? RA D stated, no. Surveyor asked RA D, what will you do with this information? RA D stated, she will report this to the nurse immediately. Note, while Surveyor was speaking with RA D, we stayed in proximity of R291's room at all times. On 1/10/23 at 3:39 PM, Surveyor spoke with R33. Surveyor asked R33, do you feel safe? R33 replied, Oh yes. Surveyor asked R33 do any residents bother you? R33 stated, No. Surveyor asked R33 do any residents come into your room uninvited? R33 stated, No. Surveyor asked R33, has another resident ever hit you? R33 stated, No. Surveyor asked R33, has anybody hit you today? R33 stated, No. Note, the facility failed to keep their most vulnerable residents safe. Using the concept of a reasonable person, women don't want to be touched by strangers and would feel threatened, unsafe, and vulnerable if unable to defend themselves from unwanted physical violence. On 1/10/23 at 4:04 PM, ADON C (Assistant Director of Nursing) indicated she was aware of the incident that occurred on 1/6/23 between R290 and R291. Surveyor asked ADON C what one on one means? ADON C indicated that it means one staff with resident. On 1/11/23 at 8:28 AM, DON B (Director of Nursing) provided Surveyor documentation for R291's 15-minute checks. DON B provided no documentation for 15-minute checks after 1/1/23. On the 15-minute check documentation for 1/1/23 it states, 1-1, No checks done - no staff to do checks 2-10pm. DON B indicated ADON C was looking into why that was written because there were staff working that evening. DON B indicated she cannot speak about the past, but moving forward, education is now being provided on what one on one supports mean. Surveyor asked DON B what does one on one supports mean? DON B indicated it means one staff assigned to resident. DON B indicated she would provide more documentation on the 15-minute checks if she finds the documentation. Note, no further documentation was provided to Surveyor. On 1/12/23 at 2:48 PM, RN J (Registered Nurse) indicated R291 will go into other people's bathrooms, and he has peed on other people's bathroom floors before. RN J indicated R291 is supposed to be a one on one when he is out of his bedroom, but that he still sneaks out of his room. RN J indicated she is glad R291 is a one on one now on the second floor. RN J indicated R291's door alarm doesn't always work correctly, sometimes it goes off and he's sitting in his recliner and sometimes staff forget to put on the alarm before they leave the room. RN J indicated he (R291) really has to be one on one supports because of his falls as well. The moment you leave him he could fall, his gait is off. He really should be in a Dementia Care unit. It's like he doesn't have any control . The facility's failure to provide adequate supervision to prevent resident to resident altercations created a finding of immediate jeopardy. The facility removed the jeopardy on 1/10/23 when the following was implemented: R291's care plan was updated on 1/10/23 with new interventions developed and initiated to support safety and location awareness to protect him and other residents from harm. Interventions include one on one supervision at all times, his room has been moved to the 2nd floor to decrease stimulation. On 1/12 new approach techniques put in place in the form of hand in hand techniques when walking with resident. A schedule created on 1/10 indicates by timeframe what staff member is responsible for providing one on one supervision 24 hours per day. 2 staff members will be present on unit at all times with one providing one on one supervision to R291 at all times. Staff have walkie talkie and access to phone to contact other staff or to dial 911 in the event of an emergency. R290 and R33's care plans were evaluated on 1/12 for need for increased supervision or other safety interventions. IDT did not feel R290 or R33 required increased supervision as R291 has been moved off unit and neither of the female residents were agressors. R290 and R33 will be observed daily for any psychosocial impacts such as increased behaviors, change in routine, or self isolation that may relate to incidents that involved R291. Staff education provided by Director of Operations and Director of Nursing started on 1/10/23 and includes new care plan interventions for R291 including definition of one on one, sensor alarm use, hand in hand approach techniques, what to do in the event of an emergency, how to protect residents from abuse or negative incidents and putting interventions in place to support resident centered care and safety. Education will also be provided on R291 and R33's observation needs. Group in-services will be held 1/13. Any staff who has not already been educated will be educated by the start of their next shift. Consultation with MD, DPOA, and IDT on 1/9, 1/10, 1/11, and 1/12 to evaluate and develop care interventions to support R291. Referral started 1/12 to [NAME] Gero Psych unit. R291 was seen by Behavioral Health Services on 1/12. Ongoing collaboration and evaluation will occur with MD, IDT, and DPOA to support R291 and to support effectiveness and response of current interventions and treatments, development or modification of interventions as needed to support individualized comprehensive care and safety for R291 and other residents. All other residents care plans were reviewed by 1/12 to ensure appropriate interventions are in place to ensure individualized care interventions in place to support the highest level of safety and quality of life. Resident Safety Policy will be reviewed at the Quality Assurance Meeting 1/13. A Quality Assurance Meeting will take place on 1/13/2023. Director of Nursing and or designee will do daily spot checks on various shifts at least 5 times per week for 2 weeks and then 3 times per week for 2 weeks and then 3 times per week ongoing - to ensure one on one supervision is in place for R291, sensor alarm in place and functioning. 3 random residents care plans will be audited per week by Director of Nursing or designee to validate care interventions and ensure safety and other interventions are implemented and followed. All findings will be brought to the Quality Improvement Committee for review. Example 2 R291 has had multiple falls since his admission to the facility. The facility failed to implement appropriate fall interventions and identify and explore possible root causes for R291's falls. R291 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, Restlessness and agitation, Depression, Pain in left hip, Pain in right knee, Muscle wasting and atrophy, Alcohol abuse, Unspecified hearing loss, and Repeated Falls. R291's most recent MDS with ARD of 12/13/22, indicates R291 has a BIMS score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney. R291's Comprehensive Care Plan, indicates, in part: Approach Start Date 5/11/22 DEVICES: Hoyer lift PRN, WC, Bilateral transfer bars, 2WW. TRANSFERS: When resident is alert, awake and willing to participate he transfers with 2 WW and 2 assist and ambulates with 2 assist and 2 WW. Needs extra time to process information. Encourage with ice cream. Keep your voice upbeat and cheerful. May use Hoyer and 2 assist if not awake and alert. MOBILITY: See transfer info for info regarding ambulation ability. WC for mobility. Staff to assist. GROOMING/DRESSING/TOILETING: Own teeth. Staff to assist with oral cares. Dependent on staff for 2 assist with ADLs. Check and change/offer toileting every 2-3 hours and PRN during day, every 4 hours at noc with use of family provided extra absorbent briefs. Trial tuck brief at night to keep open to air. Problem Start Date 5/6/22 Category Falls DX: left hip fracture with IM nailing. DX: Alzheimer disease with decreased safety awareness. Long Term Goal Target Date 3/16/23 Will have decreased risk of injuries r/t fall events. Approach Start Date: 12/6/22 Gripper strips on floor at bedside. Approach Start Date: 9/21/22 Toilet after meals. Approach Start Date: 9/10/22 Pharmacist med review. Approach Start Date: 7/12/22 Resident is capable of sitting/kneeling on floor in front of WC and then raising self back into WC. Not a true fall if witnessed as movement is purposeful. Approach Start Date: 6/21/22 Low bed. Approach Start Date: 5/12/22 Frequent rounds. Unable to comprehend use of call light. Approach Start Date: 5/12/22 Keep frequently used items within reach. Resident enjoys being in recliner near nursing station for comfort and socialization with staff. Approach Start Date: 5/12/22 OT/PT as ordered. Approach Start Date: 5/12/22 Pain management. Approach Start Date: 5/6/22 Bed against wall. Surveyor reviewed R291's Fall Event Reports. Fall Event Reports indicate in part: Event Date: 6/18/22 14:28 (2:28PM) . Location of fall: Day Room, Describe: Resident observed lying on floor on left side. Resident was previously seen in wheelchair by nurse station. [NAME] (Moves all Extremities). Neuro checks WNL (Within Normal Limitis). VSS (Vital Signs Stable). No injury noted. Resident assisted back into wheelchair with 2 staff assist. Denies pain. DON notified. Message left with POA to return call for update. Was fall witnessed: No. No injury, no pain. Interventions: None of the Above . Event Date: 6/19/22 21:44 (9:44PM) . Location of fall: Resident Room, Describe: Heard someone say goddammit and hear a noise. This writer and CNA went and looked to see where it came from and CNA found resident on floor in front of table with lamp on it. Resident can't say what he was doing. No injury noted. VSS/Neuro's WNL. Was fall witnessed: No. No injury, no pain. Interventions: Other-scoop mattress if available Event Date: 7/11/22 21:00 (9:00PM) . Description: Resident on bilateral knees earlier this pm. At 21:00 found [NAME][TRUNCATED]