Casas Adobes Post Acute Rehab Center

Based on record reveiw, staff interviews and policy review, the facility failed to ensure physician orders were followed as written.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that two residents did not abuse other residents. The deficient practice could result in residents being physically harmed.

Based on clinical record reviews, facility documentation, interviews, and facility policies, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#10). The deficient practice could result medication errors and uncontrolled pain for the residents

Based on review of clinical records, policy review, staff interviews the facility failed to ensure that residents were not abused.

Based on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to ensure 15 residents (#171, #166, #165, #167, #177, #179, #149, #87, #173, #178, #142, #143, #146, #151, #76 and #86) were not subjected to abuse.

Findings include:

Regarding residents #171 and #182

-Resident #171 was admitted on August 14, 2019, with a diagnosis of cerebral infarction.

The Minimum Data Set (MDS) assessment dated August 21, 2019, revealed a Brief Interview for Mental (BIMS) score of 15 that indicated the resident was cognitively intact.

The care plan dated September 19, 2019, revealed that the resident was a wanderer. Interventions included wearing of a Wander Guard and placement on the secure unit for his safety.

A progress note dated September 24, 2019 revealed that a housekeeper reported resident #171 exiting the room and was grabbed by is hand and hit in the back by another resident (#182).

The clinical record revealed the resident was discharged on October 4, 2019.

-Resident #182 was admitted on April 19, 2017 with diagnoses that included dementia and major depressive disorder.

The care plan dated May 2, 2017 included the resident was at risk for impaired thought processes related to dementia and was at risk for a communication problem related to speaking another language.

The MDS assessment dated July 10, 2019 revealed that the resident had moderately impaired cognitive skills.

The progress note dated September 24, 2019 at 9:41 a.m. revealed that the housekeeper reported that resident #182 grabbed the hand and hit the back of resident #171 who exited the room.

The resident was discharged on April 27, 2020.

The facility self-reported the incident to the SA (State Agency) on September 24, 2019 regarding a resident-to-resident altercation. The housekeeping staff (staff #153) reported that resident #182 was observed in the doorway of the room holding the left arm of resident #171and hitting the back of resident #171 with the other arm. Per the documentation, staff #153 removed the hands of resident #182 off of the arm of resident #171; and a certified nurse assistant (CNA/staff #246) found resident #182 in her room and escorted resident #171 back to his room. The report included that resident #182 reported that she hit resident #171 because resident #171 was in her room and had slapped her in the face.

The report also included an interview conducted with a licensed practical nurse (LPN/staff #253) who reported that a CNA told her that resident #182 grabbed the hand of resident #171 because he was in her room and had slapped her in the face. The LPN reported that resident #171 told the LPN that he had to use the bathroom and thought he went into his room.

Regarding residents #168 and #166

-Resident #168 was admitted on August 2, 2019 with diagnoses of dementia with behavioral disturbance, anxiety disorder, and major depressive disorder- severe.

The MDS assessment dated November 9, 2019 revealed a BIMS score of 7 that indicated the resident had severe cognitive impairment.

A care plan dated August 9, 2019, revealed the resident was at risk for impaired thought processes and communication problems related to dementia.

Review of the progress note dated December 31, 2019 included that resident #166 did not remember anything when asked about the incident with resident #168.

The progress note dated January 1, 2020 revealed that an altercation occurred on December 31, 2019 with another resident (#166). The documentation included that resident #168 placed her hands on the shoulder of another resident (#166); and, both residents were shaking each other. The residents were assessed with no injury or bruising noted.

The resident discharged on February 23, 2021.

-Resident #166 was admitted to the facility on August 21, 2019, with diagnoses of psychosis, altered mental status, dementia, and other symptoms and signs involving cognitive functions and awareness.

The care plan dated August 28, 2019 revealed that the resident exhibited behaviors that included paranoid delusions and false accusations, physical and verbal aggression, scratching, pinching, and hitting.

The MDS assessment dated November 26, 2019 included a BIMS score of 12 which indicated the resident had moderate cognitive impairment.

The progress note dated December 31, 2019 included that resident #166 was involved in an incident with another female resident (#168). The documentation included that resident #166 reported that she remembered that she was shoved. Resident #166 was assessed with no injuries noted.

The resident discharged on June 11, 2022.

The facility self-report dated December 31, 2022 revealed a report to the SA regarding a resident-to-resident altercation. The report included an interview with the social services director (SSD/staff #254) who reported that she was in the dining room and heard some noises; and that, residents #166 and #168 were in the hallway clutching each other at the shoulders and a staff separated the residents by escorting resident #168 to the dining room. The documentation also included a CNA reported that resident #168 told resident #166 "no" when resident #166 tried to take the table. It also included that resident #166 pushed resident #168 in the shoulder; and, resident #168 pushed resident #166 back in the shoulders; and that, the CNA entered the room and told both residents to stop and escorted resident #168 to the dining room.

Regarding residents #147 and #165

-Resident #147 was admitted on January 11, 2020, with diagnoses of personal history of other mental and behavioral disorders, and paranoid schizophrenia.
A care plan dated January 11, 2020 revealed the resident was at risk for impaired cognitive function or impaired thought processes related to dementia and needed assistance and supervision with decision making.

The MDS assessment dated January 18, 2020 included a BIMS score of 11 which indicated the resident had moderate cognitive impairment.

A progress note dated April 6, 2020 revealed that resident #147 went after and smacked another resident (#165) in the neck. Per the documentation, resident #147 reported that resident #165 came into his room so when resident #165 walked out, he smacked resident #165. The documentation also included that resident #147 was really agitated and was hard to re-direct.

Another progress note dated April 6, 2020 included that the nurse heard a slapping sound, went in the hallway, and saw resident #147 yelling at another resident (#165). Per the documentation, the nurse separated the two residents; and, resident #165 had a red mark noted on the right side of his jawline. The documentation also included that resident #147 admitted to hitting resident #165 because he wanted to; and that, resident #147 reported that resident #165 did not do anything to him.

The resident was discharged on April 16, 2020.

-Resident #165 was admitted to the facility on March 9, 2020, with diagnoses that included Alzheimer's disease with late onset, dementia with behavioral disturbance, major depressive disorder, cognitive communication deficit, dysphagia- oral phase, schizoaffective disorder, and anxiety disorder.

A review of resident #165's care plan dated March 18, 2020, revealed that the resident had impaired cognitive function or impaired thought processes related to dementia, could be easily agitated, had a communication and hearing problem, and had cultural barriers due to language barrier.

A review of resident #165's MDS dated March 16, 2020, revealed that the resident had severe cognitive impairment.

The progress note dated April 6, 2020 included that the nurse practitioner had been notified and had requested that resident #165 to

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure residents were free from a condition or situation that may cause or suffer injury by failing to ensure that two resident (#148 and #169) did not elope from the facility.

Findings include:

-Resident #148 was admitted on March 29, 2021, with diagnoses of dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, injury of head, psychotic disorder with delusions, delirium, and symptoms and signs involving cognitive functions and awareness.

The elopement/wander evaluation dated March 29, 2021 revealed the resident was high risk for elopement and wandering.

The care plan dated March 29, 2021 revealed the resident was at risk for impaired thought processes related to dementia. However, despite the documentation that the resident was a high risk for elopement and wandering, the care plan did not include interventions to address this risk.

A review the Minimum Data Set (MDS) assessment dated April 5, 2021 revealed a Brief Interview for Mental (BIMS) score of 15 indicating the resident had intact cognition.

The progress note dated April 5, 2021 at 6:00 p.m., revealed the resident was last seen by the nurse who administered a supplement was administered to the resident at 4:55 p.m.; and, the resident asked the nurse what time dinner would be arriving. The documentation included that the certified nursing assistant (CNA) went to deliver the evening meal at 5:15 p.m. and found that the resident was not in his room. Per the documentation, a search of the immediate area was started, a code yellow was initiated and emergency services were initiated at 5:31 p.m. The documentation included that at 5:43 p.m., resident #148 was located by the sheriff's department and was returned to the facility; and that, the resident declined skin evaluation.

The care plan was revised on April 5, 2021 to include that the resident had a potential for injury related to elopement risk and wandering and impaired cognition and safety awareness due to Schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, and history of traumatic brain injury.

The facility self-report dated April 5, 2021 revealed that resident #148 eloped from the facility and was found after 20 minutes in safe condition. The report included an interview with a CNA (staff #256) who stated that resident #148's window was not open when she spoke with him at 4:30 p.m.; and, the CNA did not notice any changes in his behavior, nor did resident #148 make any comments that he wanted to leave the facility.

A review of the facility's investigative report dated April 12, 2021 revealed that the resident was placed on constant supervision with a CNA; and that, the resident was moved to the secured unit.

Based on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to protect the rights of five residents (#1, #4, #2, #5, and #3) to be free from abuse from other residents. The deficient practice could lead to further abuse and residents being placed in an unsafe environment.

Findings include:

Regarding to resident #4 and resident #5

-Resident #5 was admitted on May 4, 2023 with diagnoses of dementia, cognitive communication deficit, and heart disease.

The quarterly MDS (Minimum Data Set) assessment dated August 11, 2023 revealed a BIMs (Brief Interview for Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The assessment also included that the resident had been experiencing verbal behavioral symptoms towards others, rejection of care, and wandering within the 1 - 3 days of the assessment.

The progress note dated August 17, 2023 revealed a staff was with resident #5 who was laying on their left side next to their wheelchair; and that, the wheelchair was also on its side. Per the documentation, another resident (#4) was yelling in the hallway and reported that resident #5 ran over the foot of the other resident (#4) so resident #5 "threw him (referring to resident #4) down." The note also included that resident #5 complained of pain in the left hand and hip.

A review of the x-ray result done on August 18, 2023 revealed there was no fracture or soft tissue trauma of the left hip, left hand, humerus, radius, ulna or the forearm.

-Resident #4 was admitted on May 31, 2023 with diagnoses of dementia, muscle weakness, and cognitive communication deficit.

A review of the care plan revised on August 16, 2023 included a focus area of behavioral disturbances. The goal was that resident #4 understand their verbally abusive behavior. Interventions included providing positive feedback for good behavior, anticipating the needs, and to intervene when resident showed signs of being agitated.

A progress note dated August 17, 2023 revealed that staff heard resident yelling in the hallway. The documentation included that resident #4 accused resident #5 of running over his (referring to resident #4) foot with the wheelchair; and that, resident #4 threw resident #5 onto the floor. The documentation also included that resident #4 was placed on 1:1 staff supervision until the resident was transferred to the ED (emergency department).

The progress note dated August 17, 2023 included resident #4 required a higher level of transfer due to his aggression; and that, resident was transported to the hospital.

The discharge MDS assessment dated August 17, 2023 revealed resident #4 had physical and verbal behaviors including rejection of care and wandering; and that, BIMs score was not completed for resident #4.

An interview with certified nursing assistant (CNA/staff #8) was conducted on April 12, 2024 at 10:03 a.m. The CNA stated she saw the incident between residents #4 and #5. She stated that resident #4 went into the room of resident #5; and, she saw resident #4 lifting the wheelchair with resident #5 in it resulting in resident #5 falling to the floor. The CNA stated that resident #4 was a big and strong guy so he was able to lift the chair. Further, the CNA stated that after witnessing the incident, she separated both residents from each other and the nurse came to help out.

Regarding resident #2 and #3

-Resident #2 was admitted to the facility on April 15, 2022 with diagnoses of dementia, psychosis, and anxiety disorder.

The quarterly MDS assessment dated October 22, 2023 revealed a BIMs score of 8 indicating the resident had moderate cognitive impairment. The assessment included resident #2 had no behavioral symptoms.

A review of a progress note dated September 22, 2023 at 4:04 p.m., revealed staff witnessed resident #2 grab resident #3 from behind and hit resident #3 on his left cheek. Per the documentation, resident #2 and resident #3 were separated and 1:1 staff was placed with resident #2 until he was moved to another unit. It also included that resident #3 had a scratch on the cheek.

The care plan updated on September 22, 2023 revealed interventions to include 1:1 staffing until resident placed in a separate unit. Prior to the altercation, the following interventions were in place: approach resident in a calm manner, discuss resident's behavior with resident if appropriate, provide positive interactions, and administer medications as ordered.

-Resident # 3 was admitted on September 20, 2023 with diagnoses of cognitive communication deficit, metabolic encephalopathy (neurological disorder caused by chemical imbalance), and muscle weakness.

The progress note dated October 10, 2023, revealed resident #3 was entering the dining room and bumped his wheelchair with another resident (#1) who then hit resident #3 on the head. The documentation included that there were no injuries noted and both residents were separated from each other and 15-minute checks were implemented.

A nursing note dated October 14, 2023 at 3:08 p.m., revealed that a staff witnessed resident #3 make contact with the left lower jaw of resident #1. The documentation included immediate interventions were put into place such as a check for injury, 15-minute checks, and both residents were separated. The note also included that facility leadership, family and the sheriff department were notified.

The clinical record revealed that in the days prior to the October 14, 2023 incident, resident #3 had been experiencing an increased inability to sleep, feeling more tired as usual, restlessness, and delusions; and that, resident #3 was administered medication to help them sleep.

A review of the care plan updated on October 16, 2023 included a focus of behavioral disturbances. The goal was that the resident not harming himself or others. Interventions included providing verbal and physical cues to minimize their anxiety and agitation; and redirection and removing the resident them from the current environment when there were signs of agitation.

The discharge MDS, dated October 31, 2023 indicated resident #3 had a BIMs of 15 which indicated the resident was cognitively intact. The same discharge MDS assessment also indicated resident #3 had not exhibited behavioral symptoms.

An interview with resident #2 was conducted on April 11, 2024 at 1:34 p.m. Resident #2 was sitting upright on his bed; and stated that he felt safe in the facility. The resident also said that staff come to see him every morning to give him the pills that he needs.

In an interview with CNA (staff #3) conducted on April 11, 2024 at 2:25 p.m., the CNA said that she was working in the unit when the altercation between resident #2 and #3 took place; and that, she remembered hearing yelling as she was walking down the hall. The CNA stated that she saw resident #2 punch resident #3; and, she separated the two residents and called out for help. Further the CNA said that the behavioral manager had come into the dining room and helped defuse the situation.

Regarding resident #1 and #3

Resident #1 was admitted on May 15, 2023 with diagnoses of chronic obstructive pulmonary disease (COPD), dementia, and a history of strokes.

The quarterly MDS assessment dated August 22, 2023 revealed a BIMS score of 2 indicating the resident had severe cognitive impairment. The assessment also included that resident had exhibited no behavioral symptoms.

A review of the nursing note dated October 14, 2023 at 11:05 a.m., included that another resident (#3) was witnessed making contact with the lower left jaw of resident #1. The documentation also included that immediate interventions were put into place such as a check for injury, 15-minute checks, and both

Based on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to protect the rights of five residents (#1, #4, #2, #5, and #3) to be free from abuse from other residents.

Findings include:

Regarding to resident #4 and resident #5

-Resident #5 was admitted on May 4, 2023 with diagnoses of dementia, cognitive communication deficit, and heart disease.

The quarterly MDS (Minimum Data Set) assessment dated August 11, 2023 revealed a BIMs (Brief Interview for Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The assessment also included that the resident had been experiencing verbal behavioral symptoms towards others, rejection of care, and wandering within the 1 - 3 days of the assessment.

The progress note dated August 17, 2023 revealed a staff was with resident #5 who was laying on their left side next to their wheelchair; and that, the wheelchair was also on its side. Per the documentation, another resident (#4) was yelling in the hallway and reported that resident #5 ran over the foot of the other resident (#4) so resident #5 "threw him (referring to resident #4) down." The note also included that resident #5 complained of pain in the left hand and hip.

A review of the x-ray result done on August 18, 2023 revealed there was no fracture or soft tissue trauma of the left hip, left hand, humerus, radius, ulna or the forearm.

-Resident #4 was admitted on May 31, 2023 with diagnoses of dementia, muscle weakness, and cognitive communication deficit.

A review of the care plan revised on August 16, 2023 included a focus area of behavioral disturbances. The goal was that resident #4 understand their verbally abusive behavior. Interventions included providing positive feedback for good behavior, anticipating the needs, and to intervene when resident showed signs of being agitated.

A progress note dated August 17, 2023 revealed that staff heard resident yelling in the hallway. The documentation included that resident #4 accused resident #5 of running over his (referring to resident #4) foot with the wheelchair; and that, resident #4 threw resident #5 onto the floor. The documentation also included that resident #4 was placed on 1:1 staff supervision until the resident was transferred to the ED (emergency department).

The progress note dated August 17, 2023 included resident #4 required a higher level of transfer due to his aggression; and that, resident was transported to the hospital.

The discharge MDS assessment dated August 17, 2023 revealed resident #4 had physical and verbal behaviors including rejection of care and wandering; and that, BIMs score was not completed for resident #4.

An interview with certified nursing assistant (CNA/staff #8) was conducted on April 12, 2024 at 10:03 a.m. The CNA stated she saw the incident between residents #4 and #5. She stated that resident #4 went into the room of resident #5; and, she saw resident #4 lifting the wheelchair with resident #5 in it resulting in resident #5 falling to the floor. The CNA stated that resident #4 was a big and strong guy so he was able to lift the chair. Further, the CNA stated that after witnessing the incident, she separated both residents from each other and the nurse came to help out.

Regarding resident #2 and #3

-Resident #2 was admitted to the facility on April 15, 2022 with diagnoses of dementia, psychosis, and anxiety disorder.

The quarterly MDS assessment dated October 22, 2023 revealed a BIMs score of 8 indicating the resident had moderate cognitive impairment. The assessment included resident #2 had no behavioral symptoms.

A review of a progress note dated September 22, 2023 at 4:04 p.m., revealed staff witnessed resident #2 grab resident #3 from behind and hit resident #3 on his left cheek. Per the documentation, resident #2 and resident #3 were separated and 1:1 staff was placed with resident #2 until he was moved to another unit. It also included that resident #3 had a scratch on the cheek.

The care plan updated on September 22, 2023 revealed interventions to include 1:1 staffing until resident placed in a separate unit. Prior to the altercation, the following interventions were in place: approach resident in a calm manner, discuss resident's behavior with resident if appropriate, provide positive interactions, and administer medications as ordered.

-Resident # 3 was admitted on September 20, 2023 with diagnoses of cognitive communication deficit, metabolic encephalopathy (neurological disorder caused by chemical imbalance), and muscle weakness.

The progress note dated October 10, 2023, revealed resident #3 was entering the dining room and bumped his wheelchair with another resident (#1) who then hit resident #3 on the head. The documentation included that there were no injuries noted and both residents were separated from each other and 15-minute checks were implemented.

A nursing note dated October 14, 2023 at 3:08 p.m., revealed that a staff witnessed resident #3 make contact with the left lower jaw of resident #1. The documentation included immediate interventions were put into place such as a check for injury, 15-minute checks, and both residents were separated. The note also included that facility leadership, family and the sheriff department were notified.

The clinical record revealed that in the days prior to the October 14, 2023 incident, resident #3 had been experiencing an increased inability to sleep, feeling more tired as usual, restlessness, and delusions; and that, resident #3 was administered medication to help them sleep.

A review of the care plan updated on October 16, 2023 included a focus of behavioral disturbances. The goal was that the resident not harming himself or others. Interventions included providing verbal and physical cues to minimize their anxiety and agitation; and redirection and removing the resident them from the current environment when there were signs of agitation.

The discharge MDS, dated October 31, 2023 indicated resident #3 had a BIMs of 15 which indicated the resident was cognitively intact. The same discharge MDS assessment also indicated resident #3 had not exhibited behavioral symptoms.

An interview with resident #2 was conducted on April 11, 2024 at 1:34 p.m. Resident #2 was sitting upright on his bed; and stated that he felt safe in the facility. The resident also said that staff come to see him every morning to give him the pills that he needs.

In an interview with CNA (staff #3) conducted on April 11, 2024 at 2:25 p.m., the CNA said that she was working in the unit when the altercation between resident #2 and #3 took place; and that, she remembered hearing yelling as she was walking down the hall. The CNA stated that she saw resident #2 punch resident #3; and, she separated the two residents and called out for help. Further the CNA said that the behavioral manager had come into the dining room and helped defuse the situation.

Regarding resident #1 and #3

Resident #1 was admitted on May 15, 2023 with diagnoses of chronic obstructive pulmonary disease (COPD), dementia, and a history of strokes.

The quarterly MDS assessment dated August 22, 2023 revealed a BIMS score of 2 indicating the resident had severe cognitive impairment. The assessment also included that resident had exhibited no behavioral symptoms.

A review of the nursing note dated October 14, 2023 at 11:05 a.m., included that another resident (#3) was witnessed making contact with the lower left jaw of resident #1. The documentation also included that immediate interventions were put into place such as a check for injury, 15-minute checks, and both residents were separated; and that, facility leadership, family, sheriff department were notified.

Based on closed record review, staff interview, and review of the facilitydocumentation, policies and procedures, the facility failed to protect the rights of 3 residents (#92, #71, and #1) to be free from abuse of another (#117 and #460). The deficient practice could result in residents not protected from further abuse.

Findings include:

Regarding resident #92 and #117

-Resident #92 was admitted on February 15, 2022 with diagnoses of major depressive disorder, Stage 3 kidney disease, and a history of strokes.

The annual MDS (Minimum Data Set) assessment dated July 3, 2023 included a BIMS (Brief Interview for Mental Status) score of 13 indicating the resident was cognitively intact.

A review of the electronic health record revealed that on July 19, 2023 resident #117 pulled the hair of resident #92 who then pulled the hair of resident #117. The documentation included that both residents were separated and placed on 15 minute checks; and, resident #117 was moved to a different room.

Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policies, the facility failed to develop and complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident (#47). The deficient practice could result in delayed identification of potential risks and care needs of the resident.

Findings include:

Resident # 47 was admitted on November 9, 2023 with diagnoses of dementia, Parkinson's Disease, and peripheral vascular disease.

The admission MDS (Minimum Data Set) revealed that it was completed on November 16, 2023.

Review of the clinical record revealed no evidence that a quarterly MDS assessments were completed after November 16, 2023.

In an interview with MDS Coordinator (Staff # 91) conducted on March 28, 2024 at 12:50 p.m., The MDS coordinator stated that all residents should have a quarterly MDS Assessment completed to meet facility expectations regardless to what the resident had for an insurance. During the interview, a review of the electronic clinical record was conducted with the MDS coordinator who stated that a quarterly MDS assessment for resident #47 was missing and not done on time. The MDS coordinator stated that when a quarterly MDS Assessment is not completed, it is unknown whether the resident had changes in their status or if facility was able to meet the needs of the resident. The MDS coordinator stated that the resident should have come up on the schedule for an assessment; but it appeared that the schedule for this resident was cleared and did not appear on the scheduler. The MDS coordinator then proceeded to initiate a quarterly MDS dated February 16, 2024 and stated that the quarterly assessment can still be completed but it would not be timely.

An interview was conducted on March 28, 2024 at 1:23 p.m. with the Director of Nursing (DON/Staff # 51) who stated that not having a quarterly MDS Assessment completed would not meet facility expectations. During the interview, a review of the electronic record was conducted with the DON who stated that the quarterly MDS assessment for resident #47 was missing and it should have been completed in the month of February to meet facility expectations.

Review of the facility's Policy titled, "Resident Assessment - Accuracy of Assessment (MDS 3.0)," reviewed May 2023, revealed it is the policy of this facility to ensure that the assessment accurately reflect the resident's status. The physical, mental, and psychosocial conditions of the resident determine the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medial social workers, dieticians, and other professionals in assessing the resident and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs.

Review of the facility's Policy titled, "Resident Assessment - Assessments, Frequency of," (revised May 2021) revealed, it is the policy of this facility that resident assessments shall be developed and reviewed on a timely basis, based on resident condition and RAI guidelines. The interdisciplinary team will document resident assessments and reviews at least quarterly.

Review of the RAI manual dated October 2019 revealed that the primary purpose of the MDS assessment tool is to identify resident care problems that are addressed in an individualized care plan. The Quarterly ARD date is no later than the ARD of the previous OBRA assessment + 92 days and the completion date is no later than the ARD + 14 calendar days.

Based on clinical record review, staff interviews, observation of current facility practice and review of the facility's policies, the facility failed to ensure controlled medications were provided and accounted for in accordance with professional standards for 4 residents (#52, #358, #27) The deficient practice could result in diversion of resident medication.

Findings include:

-Resident #52 was admitted to the facility on December 24, 2018 with diagnoses that included cognitive communication deficit, rheumatoid arthritis, morbid obesity, and bipolar disorder.

The quarterly Minimum Data Set (MDS), dated December 9, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident is cognitively intact. The MDS also revealed resident #52 was on a scheduled pain regimen and also received pain medications as needed.

Review of the current physician order recap revealed Oxycodone-Acetaminophen (narcotic) 5-325 milligrams (mg) every 8 hours for chronic rheumatoid arthritis.

Further review of the clinical record revealed that this order was transcribed onto the MAR (medication administration record); and, the MAR revealed that this medication were documented as administered as ordered.

- Resident #358, they were admitted to the facility on July 25, 2023 with diagnoses that included Cervical Disc Disorder with Myelopathy, muscle weakness, and partial paralysis. The resident was discharged from the facility on February 27, 2024.

The quarterly Minimum Data Set (MDS), dated February 1, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. The MDS also revealed resident #358 was on a scheduled pain regimen and also received pain medications as needed.

The current physician order recap revealed Hydrocodone-Acetaminophen (narcotic) 5-325 milligrams (mg) every 6 hours as needed (PRN) for pain rated 7 though 10.

A review of the February 2024 MAR revealed Hydrocodone-Acetaminophen was not administered as ordered on the evening of February 4, 2024.

The controlled drug record for February 2024 revealed that on February 5, 2024 one tab of Hydrocodone-Acetaminophen was wasted at 5:00 a.m. and 5:00 p.m. The 5:00 a.m. entry had a note written as "wasted" and was signed by a nurse (staff #194). However, the 5:00 p.m. entry was not signed.

-Resident #27, they were admitted to the facility on February 17, 2021 with diagnoses that included paraplegia, Post Traumatic Stress Disorder (PTSD), and a personal history of transient ischemic attack.

The annual Minimum Data Set (MDS), dated February 27, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. The MDS also revealed resident #27 did not have a scheduled pain regimen but did receive pain medications as a PRN.

Resident #27's medication orders revealed they were prescribed Tramadol HCI 50 mg tablet and were to take two tablets by mouth every six hours as needed for pain rated 5 through 10.

February MAR revealed there was no tramadol given to the resident during the evening of February 4, 2024 or in the early morning of February 5, 2024. The same MAR did indicate two tablets of tramadol were administered at 8:10 AM on February 5, 2024 by staff #176.

A review of the controlled drug record reveals three tablets of Tramadol was administered on February 4, 2024 at 2:00 AM by staff #194.

An interview was conducted with a Licensed Practical Nurse (LPN/Staff #88) on March 27, 2024 at 8:24 AM. Staff #88 explained that when a controlled medication was to be wasted, there must be a second nurse observing the wasting of the medication. Staff #88 also indicated there was always a second nurse available at all times in the building; and that, they often get training throughout the year on controlled medication processes.

An interview was conducted with LPN (staff #80) on March 27, 2023 at 8:44 AM. Staff #80 indicated that controlled medication administration should be done according to the resident's orders and if medications were to be wasted, a second nurse was needed to observe the process. Staff #80 also indicated that there was always a second nurse available in the building to waste medications and if a second nurse could not be found, a unit manager can assist.

An interview was conducted with the Director of Nursing (DON/staff #51) on March 28, 2024 at 11:17 AM. When asked what the expectation of documenting the administration of controlled medications, staff #51 indicated the resident's orders must be followed and the documentation is done on the paper form and the electronic health record. When asked what the expectation of wasting controlled medications was. Staff #51 indicated that the nurses have a drug buster at the bottom of the medication carts. Medications must be wasted with another nurse present. Then staff #51 or the pharmacist would process the medications and label them accordingly for the United Parcel Service (UPS) pick-up. Staff #51 indicated the risks associated with controlled medications being wasted with one staff is that medications could be taken and abused by staff.

A review of the facility policy titled "Medication Administration" indicated that controlled medications not administered to a resident "must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record, on the line representing that dose.

Based on observation, staff and resident interviews, and facility policy, the facility failed to ensure that one resident (#124) was free from accident hazards. The deficient practice could result in resident not taking their needed medications as prescribed and other residents gaining access to and taking the medications.

Findings include:

Resident #124 was admitted on 10/17/23 with diagnoses of dementia, bipolar disorder, and cognitive communication deficit.

Review of this resident's care plan included that the resident was admitted to a secured behavior health unit for psychosis, mood disorder and dementia. This care plan also included that this resident has poor safety awareness.

A physician's order dated 2/7/24 included glipizide (hypoglycemic) Oral Tablet 10 mg (milligrams) give 2 tablets by mouth in the morning for Diabetes Mellitus II.

A physician's order dated 3/5/234 included seroquel (antipsychotic) Give 50 mg by mouth two times a day for bipolar disorder as evidenced by auditory hallucinations

A physician's order dated 11/16/23 included depakote sprinkles delayed release 125 mg (antiseizure) give 250 mg by mouth every 8 hours for Bipolar disorder as evidenced by labile mood

A physician's order dated 10/17/23 included metformin (anti-diabetic) 1000 mg give 1 tablet by mouth two times a day for Diabetes Mellitus II.

However, review of the physician's orders did not include an order for self-administration.

An observation was conducted on 3/25/24 at 9:49 A.M. of resident #124's bedside table which included a cup which contained: 2 tablets marked APO glp 10 (glipizide), 1 tablet marked white round 337 (Quetiapine Fumarate), 2 capsules which were blue and white marked 125 (Divalproex), and a white oval tablet marked g12 (Metformin).

An interview was conducted on 3/28/24 at 9:45 A.M. with a Licensed Practical Nurse (LPN/staff #180) who said that when administering medications, you look at computer verify meds, check resident name, the 5 rights, and then you watch them take their meds. This nurse said it is not ok to leave a cup of pills at the bedside.

An interview was conducted on 03/28/24 at 1:31 P.M. with a Certified Nursing Assistant (CNA/staff #172) who said that the nurses usually stay with this resident when she takes her pills but that she has found pills on the resident's bedside table before.

An interview was conducted on 03/28/24 at 1:35 P.M. with an LPN (staff #108) who said that this resident was not ok to take meds on her own but that she's pretty good about it. She said that nurses should make sure she takes her medication.

An interview was conducted on 03/28/24 at 4:15 P.M. with the Director of Nursing (DON/staff #51) who said that her expectation for medication administration was that staff would confirm the right resident, the right medication and the other rights, offer the medication to the patient and then watch the patient and document the administration or refusal. She said that medications left on the bedside table do not meet her expectation and that the facility had identified that issue and had started a QAPI which included assessing patients that wanted to be self administering and to let those patients who could not know that they could not leave the medications at bedside. This DON included that the nurses were educated as well.

A policy titled Medication Administration - Oral, revised 5/22, revealed that it is the policy of this facility to accurately prepare, administer and document oral medications. This policy included that the person administering medication must remain with the resident until all medication has been swallowed.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#84) received safe monitoring of vital signs, to include weights. The deficient practice could result in the potential for complications and the resident not receiving appropriate care and treatment.

Findings include:

Resident #84 was admitted on March 2, 2024 with diagnosis including end stage renal disease, type 2 diabetes, epilepsy, and major depressive disorder.

A review of the MDS (minimum data set) dated March 09, 2024 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact.

A review of the physician orders revealed an order dated March 21, 2024 noting that vitals and weights are to be taken before and after dialysis.

Entries under the vitals section of the electronic health record revealed a weight loss of 41 pounds between the dates of March 13, 2024 and March 19, 2024. A subsequent weight gain of 20.4 pounds was noted for the time ranging from March 19, 2024 through March 27, 2024.

An IDT (interdisciplinary team) notation on March 19, 2024 revealed an entry by staff #195 (dietetic technician, registered). The entry noted that there was significant weight loss in a one-week period and suggested a re-weigh for the resident; however, facility documentation did not reveal evidence of the resident having been re-weighed.

An interview was conducted on March 27, 2024 at 11:02 AM with staff #80 LPN (licensed practical nurse). Staff #80 stated that as part of the assessment process for a resident on dialysis, vitals are taken, which include the resident's weight. She stated that when there is an issue with weights, either a dramatic weight gain or loss then the nurse manager would be notified. She stated that a weight change of 10 pounds or more would be cause for notification.

An interview was conducted on March 27, 2023 at 11:05 AM with staff #153 CNA (certified nursing assistant). Staff #153 stated that CNA's are responsible for conducting the vitals. She stated that if she was monitoring a dialysis resident and observed any changes in weight that she would let the nurse know immediately.

An interview was conducted on March 27, 2024 at 11:29 AM with staff #196 Nurse Manager. Staff #196 stated that weights are discussed on a weekly and emergent basis. She stated that if weight fluctuations were observed she would let the physician and the family know and review possible causes for the change in weight. She stated that Nurse Manager was in charge on tracking resident weights.

An interview was conducted on March 27, 2024 at 11:51 AM with staff #174 LPN. Staff #174 stated that she felt a weight change of 5 pounds could be concerning and would alert the nurse manager of any chnage of 5 or more pounds.

An interview was conducted on March 27, 2024 at 12:00 PM with staff #49 Nurse Manger. Staff #49 stated that fluctuations in weight will always be there with dialysis patients, and stated that staff will weigh residents prior to dialysis and even though they are weighed at the dialysis center, staff would weigh the resident again upon return to the facility. She stated that if there were any abnormalities in weight, the provider would be notified. She stated that she had been the point person for tracking the weights but stated that now the dieticians are tracking weights. She reviewed the residents record and stated that the recent weights may have a documentation error. She stated that the resident should have been re-weighed based on the dramatic change in weight, but had not been. Staff #49 stated that anything over a 5-pound weight change should be actively monitored.

An interview was conducted on March 28, 2024 at 10:21 AM with staff #166 DTR (dietetic technician, registered). She stated that there had recently been a transition from an external entity to internal monitoring of resident weights. She stated that monthly monitoring is conducted, but that weights are reviewed on a daily basis for all residents on dialysis. If there is a concern regarding a resident's weight, she stated that she would ask staff to re-weigh the resident. She stated that at times it is feasible to see up to a 30-pound change in weight for a dialysis resident, she stated, however, these should still be investigated. She reviewed the residents record and stated that a change in weight as noted, should be followed up on regardless, but had not been. She stated that the expectation would be to follow-up and monitor any weight changes of 5 pounds or more. She stated that the risk of not monitoring a resident's change in weight could impact the resident's health.

An interview was conducted on March 28, 2024 at 10:52 AM with staff #51 DON (director of nursing). Staff #51 stated that vitals and weights are taken prior to dialysis and documented on a flow sheet. She stated that weight changes may be contingent on each individual resident and their overall condition. She stated that the expectation would be for any recommendation to reweigh a resident, due to potential weight fluctuations, would communicated, documented and monitored. She stated that facility will be working on a more robust process to include reviewing the IDT (interdisciplinary team) notes with the new medical director. She stated that her expectations are that residents are re-weighed if there is a greater than 5% weight change. She stated that the risk to the resident could include fluid overload, shortness of breath and the need for further evaluation.

A review of the policy entitled weight, with a review date of 2023 revealed that the intent of the policy was to obtain an accurate weight as part of the resident's assessment. A review of the nutrition policy reviewed on July, 2023 revealed that any resident's weight that varies from the previous reporting period by 5% in 30 days would be evaluated by the interdisciplinary team to determine the cause of the weight loss/ gain, what interventions would be required and the need for further recommendations and / or referral. However, the record revealed that the weight loss had been identified by the IDT and the recommendation noted that the resident should be re-weighed, which did not transpire per review of the electronic health record and staff interviews.

Regarding Resident # 1 and # 460:

-Resident # 1 was admitted on May 22, 2021 with diagnoses of Alzheimer's Disease, cognitive communication deficit, major depressive disorder, and unspecified psychosis.

The care-plan initiated July 25, 2022 revealed interventions that included staff will assign seating away from other residents when agitated during meal times.

A review of the quarterly MDS (minimum data set) assessment dated December 15, 2023 revealed a BIMS (brief interview of mental status) score of 2, indicating resident had severe cognitive impairment.

A review of the electronic medical records revealed that on August 11, 2023 at 10:50 a.m., resident # 1 entered the dining room and saw resident #460 sitting in her favorite spot. Per the documentation, resident #1 asked resident #460 to move and as resident #460 was getting up, both residents started having a verbal altercation. The documentation also included that as staff were intervening, resident #1 bumped resident #460 with her walker and resident #460 attempted to push the walker back into Resident #1. Per the documentation, staff were physically in between both residents.

-Resident # 460 was admitted to the facility on May 31, 2023 with diagnoses that included dementia, post-traumatic stress disorder, and Alzheimer's disease.

Review of the MDS assessment dated June 7, 2023 revealed Resident #460 was not assessed for a BIMS score.

A review of the facility investigation dated August 18, 2023 revealed that both resident (#1 and #460) were both on a secured behavioral unit when staff reported that resident #1 walked into the dining room and resident #460 was sitting in a chair that resident #1 wanted. The report also included that resident #1 began to push her walker into Resident #460; staff witnessed the incident and immediately intervened and no injuries were noted to either resident.

An interview was conducted on March 26, 2024 at 11:54 AM with behavioral health unit manager (BHUM/staff # 52) who stated that staff receive abuse in-service trainings. Staff # 52 initially stated she was not sure of how soon it was reported, although later detailed it should be right away because they have a 2-hour window. Staff # 52 stated that the first thing staff do was to ensure both residents were safe during a physical altercation as resident safety comes first.

In an interview with certified nursing assistant (CNA/staff #138) conducted on March 27, 2024 at 11:44 a.m., the CNA stated that facility incorporates in-service training on abuse; and, the abuse protocol was to notify the nurse as soon as possible and make sure residents were safe. The CNA said that she was familiar with resident #1; but, she was not familiar with resident # 460 or any altercation between the two residents.

An interview was conducted on March 27, 2024 at 2:35 p.m. with registered nurse (RN/staff # 49) who stated that if at any time a resident to resident make physical contact, this incident is reported. The RN said that the physical contact does not have to be purposeful to be reportable; and that, comes first. The RN further stated that residents were removed and placed on 15-minute checks whenever physical abuse was suspected.

During an interview with the Director of Nursing (DON/Staff # 51) conducted on March 28, 2024 at 11:40 a.m., the DON stated that during a resident to resident altercation, the residents involved were separated and assessed for any injuries. Further, the DON said that the facility expectations on abuse was that residents were free from abuse.

Review of the facility's Policy titled, "Abuse: Prevention of and Prohibition Against" (revised October 2023) revealed, it is the policy of this facility that each resident has the right to be free from abuse. The facility will provide oversight and monitoring to ensure its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. Policy defines abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Will, as used in this definition of abuse, means the individual must have acted deliberately. Furthermore, policy revealed that physical abuse includes but is not limited to hitting, slapping, pinching, and kicking. The facility will act to protect and prevent abuse and neglect from occurring with the facility by identifying, correcting and intervening in situations in which abuse is more likely to occur.

Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policies, the facility failed to develop and complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident (#47). The deficient practice could result in delayed identification of potential risks and care needs of the resident.

Findings include:

Resident # 47 was admitted on November 9, 2023 with diagnoses of dementia, Parkinson's Disease, and peripheral vascular disease.

The admission MDS (Minimum Data Set) revealed that it was completed on November 16, 2023.

Review of the clinical record revealed no evidence that a quarterly MDS assessments were completed after November 16, 2023.

In an interview with MDS Coordinator (Staff # 91) conducted on March 28, 2024 at 12:50 p.m., The MDS coordinator stated that all residents should have a quarterly MDS Assessment completed to meet facility expectations regardless to what the resident had for an insurance. During the interview, a review of the electronic clinical record was conducted with the MDS coordinator who stated that a quarterly MDS assessment for resident #47 was missing and not done on time. The MDS coordinator stated that when a quarterly MDS Assessment is not completed, it is unknown whether the resident had changes in their status or if facility was able to meet the needs of the resident. The MDS coordinator stated that the resident should have come up on the schedule for an assessment; but it appeared that the schedule for this resident was cleared and did not appear on the scheduler. The MDS coordinator then proceeded to initiate a quarterly MDS dated February 16, 2024 and stated that the quarterly assessment can still be completed but it would not be timely.

An interview was conducted on March 28, 2024 at 1:23 p.m. with the Director of Nursing (DON/Staff # 51) who stated that not having a quarterly MDS Assessment completed would not meet facility expectations. During the interview, a review of the electronic record was conducted with the DON who stated that the quarterly MDS assessment for resident #47 was missing and it should have been completed in the month of February to meet facility expectations.

Review of the facility's Policy titled, "Resident Assessment - Accuracy of Assessment (MDS 3.0)," reviewed May 2023, revealed it is the policy of this facility to ensure that the assessment accurately reflect the resident's status. The physical, mental, and psychosocial conditions of the resident determine the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medial social workers, dieticians, and other professionals in assessing the resident and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs.

Review of the facility's Policy titled, "Resident Assessment - Assessments, Frequency of," (revised May 2021) revealed, it is the policy of this facility that resident assessments shall be developed and reviewed on a timely basis, based on resident condition and RAI guidelines. The interdisciplinary team will document resident assessments and reviews at least quarterly.

Review of the RAI manual dated October 2019 revealed that the primary purpose of the MDS assessment tool is to identify resident care problems that are addressed in an individualized care plan. The Quarterly ARD date is no later than the ARD of the previous OBRA assessment + 92 days and the completion date is no later than the ARD + 14 calendar days.

Based on clinical record review, staff interviews, observation of current facility practice and review of the facility's policies, the facility failed to ensure controlled medications were provided and accounted for in accordance with professional standards for 4 residents (#52, #358, #27) The deficient practice could result in diversion of resident medication.

Findings included:

-Resident #52 was admitted to the facility on December 24, 2018 with diagnoses that included cognitive communication deficit, rheumatoid arthritis, morbid obesity, and bipolar disorder.

The quarterly Minimum Data Set (MDS), dated December 9, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident is cognitively intact. The MDS also revealed resident #52 was on a scheduled pain regimen and also received pain medications as needed.

Review of the current physician order recap revealed Oxycodone-Acetaminophen (narcotic) 5-325 milligrams (mg) every 8 hours for chronic rheumatoid arthritis.

Further review of the clinical record revealed that this order was transcribed onto the MAR (medication administration record); and, the MAR revealed that this medication were documented as administered as ordered.

- Resident #358, they were admitted to the facility on July 25, 2023 with diagnoses that included Cervical Disc Disorder with Myelopathy, muscle weakness, and partial paralysis. The resident was discharged from the facility on February 27, 2024.

The quarterly Minimum Data Set (MDS), dated February 1, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. The MDS also revealed resident #358 was on a scheduled pain regimen and also received pain medications as needed.

The current physician order recap revealed Hydrocodone-Acetaminophen (narcotic) 5-325 milligrams (mg) every 6 hours as needed (PRN) for pain rated 7 though 10.

A review of the February 2024 MAR revealed Hydrocodone-Acetaminophen was not administered as ordered on the evening of February 4, 2024.

The controlled drug record for February 2024 revealed that on February 5, 2024 one tab of Hydrocodone-Acetaminophen was wasted at 5:00 a.m. and 5:00 p.m. The 5:00 a.m. entry had a note written as "wasted" and was signed by a nurse (staff #194). However, the 5:00 p.m. entry was not signed.

-Resident #27, they were admitted to the facility on February 17, 2021 with diagnoses that included paraplegia, Post Traumatic Stress Disorder (PTSD), and a personal history of transient ischemic attack.

The annual Minimum Data Set (MDS), dated February 27, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. The MDS also revealed resident #27 did not have a scheduled pain regimen but did receive pain medications as a PRN.

Resident #27's medication orders revealed they were prescribed Tramadol HCI 50 mg tablet and were to take two tablets by mouth every six hours as needed for pain rated 5 through 10.

February MAR revealed there was no tramadol given to the resident during the evening of February 4, 2024 or in the early morning of February 5, 2024. The same MAR did indicate two tablets of tramadol were administered at 8:10 AM on February 5, 2024 by staff #176.

A review of the controlled drug record reveals three tablets of Tramadol was administered on February 4, 2024 at 2:00 AM by staff #194.

An interview was conducted with a Licensed Practical Nurse (LPN/Staff #88) on March 27, 2024 at 8:24 AM. Staff #88 explained that when a controlled medication was to be wasted, there must be a second nurse observing the wasting of the medication. Staff #88 also indicated there was always a second nurse available at all times in the building; and that, they often get training throughout the year on controlled medication processes.

An interview was conducted with LPN (staff #80) on March 27, 2023 at 8:44 AM. Staff #80 indicated that controlled medication administration should be done according to the resident's orders and if medications were to be wasted, a second nurse was needed to observe the process. Staff #80 also indicated that there was always a second nurse available in the building to waste medications and if a second nurse could not be found, a unit manager can assist.

An interview was conducted with the Director of Nursing (DON/staff #51) on March 28, 2024 at 11:17 AM. When asked what the expectation of documenting the administration of controlled medications, staff #51 indicated the resident's orders must be followed and the documentation is done on the paper form and the electronic health record. When asked what the expectation of wasting controlled medications was. Staff #51 indicated that the nurses have a drug buster at the bottom of the medication carts. Medications must be wasted with another nurse present. Then staff #51 or the pharmacist would process the medications and label them accordingly for the United Parcel Service (UPS) pick-up. Staff #51 indicated the risks associated with controlled medications being wasted with one staff is that medications could be taken and abused by staff.

A review of the facility policy titled "Medication Administration" indicated that controlled medications not administered to a resident "must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record, on the line representing that dose.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#84) received safe monitoring of vital signs, to include weights.

Findings include:

Resident #84 was admitted on March 2, 2024 with diagnosis including end stage renal disease, type 2 diabetes, epilepsy, and major depressive disorder.

A review of the MDS (minimum data set) dated March 09, 2024 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact.

A review of the physician orders revealed an order dated March 21, 2024 noting that vitals and weights are to be taken before and after dialysis.

Entries under the vitals section of the electronic health record revealed a weight loss of 41 pounds between the dates of March 13, 2024 and March 19, 2024. A subsequent weight gain of 20.4 pounds was noted for the time ranging from March 19, 2024 through March 27, 2024.

An IDT (interdisciplinary team) notation on March 19, 2024 revealed an entry by staff #195 (dietetic technician, registered). The entry noted that there was significant weight loss in a one-week period and suggested a re-weigh for the resident; however, facility documentation did not reveal evidence of the resident having been re-weighed.

An interview was conducted on March 27, 2024 at 11:02 AM with staff #80 LPN (licensed practical nurse). Staff #80 stated that as part of the assessment process for a resident on dialysis, vitals are taken, which include the resident's weight. She stated that when there is an issue with weights, either a dramatic weight gain or loss then the nurse manager would be notified. She stated that a weight change of 10 pounds or more would be cause for notification.

An interview was conducted on March 27, 2023 at 11:05 AM with staff #153 CNA (certified nursing assistant). Staff #153 stated that CNA's are responsible for conducting the vitals. She stated that if she was monitoring a dialysis resident and observed any changes in weight that she would let the nurse know immediately.

An interview was conducted on March 27, 2024 at 11:29 AM with staff #196 Nurse Manager. Staff #196 stated that weights are discussed on a weekly and emergent basis. She stated that if weight fluctuations were observed she would let the physician and the family know and review possible causes for the change in weight. She stated that Nurse Manager was in charge on tracking resident weights.

An interview was conducted on March 27, 2024 at 11:51 AM with staff #174 LPN. Staff #174 stated that she felt a weight change of 5 pounds could be concerning and would alert the nurse manager of any chnage of 5 or more pounds.

An interview was conducted on March 27, 2024 at 12:00 PM with staff #49 Nurse Manger. Staff #49 stated that fluctuations in weight will always be there with dialysis patients, and stated that staff will weigh residents prior to dialysis and even though they are weighed at the dialysis center, staff would weigh the resident again upon return to the facility. She stated that if there were any abnormalities in weight, the provider would be notified. She stated that she had been the point person for tracking the weights but stated that now the dieticians are tracking weights. She reviewed the residents record and stated that the recent weights may have a documentation error. She stated that the resident should have been re-weighed based on the dramatic change in weight, but had not been. Staff #49 stated that anything over a 5-pound weight change should be actively monitored.

An interview was conducted on March 28, 2024 at 10:21 AM with staff #166 DTR (dietetic technician, registered). She stated that there had recently been a transition from an external entity to internal monitoring of resident weights. She stated that monthly monitoring is conducted, but that weights are reviewed on a daily basis for all residents on dialysis. If there is a concern regarding a resident's weight, she stated that she would ask staff to re-weigh the resident. She stated that at times it is feasible to see up to a 30-pound change in weight for a dialysis resident, she stated, however, these should still be investigated. She reviewed the residents record and stated that a change in weight as noted, should be followed up on regardless, but had not been. She stated that the expectation would be to follow-up and monitor any weight changes of 5 pounds or more. She stated that the risk of not monitoring a resident's change in weight could impact the resident's health.

An interview was conducted on March 28, 2024 at 10:52 AM with staff #51 DON (director of nursing). Staff #51 stated that vitals and weights are taken prior to dialysis and documented on a flow sheet. She stated that weight changes may be contingent on each individual resident and their overall condition. She stated that the expectation would be for any recommendation to reweigh a resident, due to potential weight fluctuations, would communicated, documented and monitored. She stated that facility will be working on a more robust process to include reviewing the IDT (interdisciplinary team) notes with the new medical director. She stated that her expectations are that residents are re-weighed if there is a greater than 5% weight change. She stated that the risk to the resident could include fluid overload, shortness of breath and the need for further evaluation.

A review of the policy entitled weight, with a review date of 2023 revealed that the intent of the policy was to obtain an accurate weight as part of the resident's assessment. A review of the nutrition policy reviewed on July, 2023 revealed that any resident's weight that varies from the previous reporting period by 5% in 30 days would be evaluated by the interdisciplinary team to determine the cause of the weight loss/ gain, what interventions would be required and the need for further recommendations and / or referral. However, the record revealed that the weight loss had been identified by the IDT and the recommendation noted that the resident should be re-weighed, which did not transpire per review of the electronic health record and staff interviews.

Based on observation, staff and resident interviews, and facility policy, the facility failed to ensure that one resident (#124) was free from a condition or situation that may cause physical injury.

Findings include:

Resident #124 was admitted on 10/17/23 with diagnoses of dementia, bipolar disorder, and cognitive communication deficit.

Review of this resident's care plan included that the resident was admitted to a secured behavior health unit for psychosis, mood disorder and dementia. This care plan also included that this resident has poor safety awareness.

A physician's order dated 2/7/24 included glipizide (hypoglycemic) Oral Tablet 10 mg (milligrams) give 2 tablets by mouth in the morning for Diabetes Mellitus II.

A physician's order dated 3/5/234 included seroquel (antipsychotic) Give 50 mg by mouth two times a day for bipolar disorder as evidenced by auditory hallucinations

A physician's order dated 11/16/23 included depakote sprinkles delayed release 125 mg (antiseizure) give 250 mg by mouth every 8 hours for Bipolar disorder as evidenced by labile mood

A physician's order dated 10/17/23 included metformin (anti-diabetic) 1000 mg give 1 tablet by mouth two times a day for Diabetes Mellitus II.

However, review of the physician's orders did not include an order for self-administration.

An observation was conducted on 3/25/24 at 9:49 A.M. of resident #124's bedside table which included a cup which contained: 2 tablets marked APO glp 10 (glipizide), 1 tablet marked white round 337 (Quetiapine Fumarate), 2 capsules which were blue and white marked 125 (Divalproex), and a white oval tablet marked g12 (Metformin).

An interview was conducted on 3/28/24 at 9:45 A.M. with a Licensed Practical Nurse (LPN/staff #180) who said that when administering medications, you look at computer verify meds, check resident name, the 5 rights, and then you watch them take their meds. This nurse said it is not ok to leave a cup of pills at the bedside.

An interview was conducted on 03/28/24 at 1:31 P.M. with a Certified Nursing Assistant (CNA/staff #172) who said that the nurses usually stay with this resident when she takes her pills but that she has found pills on the resident's bedside table before.

An interview was conducted on 03/28/24 at 1:35 P.M. with an LPN (staff #108) who said that this resident was not ok to take meds on her own but that she's pretty good about it. She said that nurses should make sure she takes her medication.

An interview was conducted on 03/28/24 at 4:15 P.M. with the Director of Nursing (DON/staff #51) who said that her expectation for medication administration was that staff would confirm the right resident, the right medication and the other rights, offer the medication to the patient and then watch the patient and document the administration or refusal. She said that medications left on the bedside table do not meet her expectation and that the facility had identified that issue and had started a QAPI which included assessing patients that wanted to be self administering and to let those patients who could not know that they could not leave the medications at bedside. This DON included that the nurses were educated as well.

A policy titled Medication Administration - Oral, revised 5/22, revealed that it is the policy of this facility to accurately prepare, administer and document oral medications. This policy included that the person administering medication must remain with the resident until all medication has been swallowed.

Based on record review and interview the facility failed to maintain their Emergency Preparedness Plan on the community risk assessments. Failure to develop Emergency Plans based on community risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

Based on record review and interview on April 3, 2024, revealed the facility Emergency Plan had two separate facility based risk assessments in their binder. The number one risk on one assessment was flood and the second was pandemic. Each assessment had top ten which differed on between the two.

During the exit conference on April 3, 2024, the above finding was again acknowledged by the Clinical Manager.

Based on observation the facility failed to maintain special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on April 3, 2024, revealed the following;

1) the 400 Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 35 lbf for the left door and 28 lbf for the right door.

During the exit conference on April 3, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on April 3, 2024, revealed the following;

1) door 619 had excessive gap on the upper handle side
2) door 619 had excessive gap on the upper handle side

Neither door would stop the transfer of heat or smoke.

During the exit conference conducted on April 3, 2024, the above findings were again acknowledged by management team.

Based on interview and record review the facility failed to inspect and maintain the facilities fire /smoke dampers or fusible links. Failing to inspect and maintain the facility smoke dampers may cause harm to the patients and/or staff during an emergency.

NFPA 101 Life Safety Code, 2012 Edition Chapter 21, section 21.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.


NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years.
Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's. NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years. Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Findings include:

Based on interview and record review on April 3, 2024, the facility was unable to provide documentation the fire/smoke dampers had been inspected. The last documented inspection was March 28, 2019.

During the exit conference conducted on April 3, 2024, the above findings were again acknowledged by the management staff.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that five residents (#1, #3, #4, #5, #6) were free from abuse from other residents. The deficient practice could result in other residents being abused.

Findings included:

Regarding Resident #1 and #2:

Resident #1 was admitted to the facility on July 25, 2023 with diagnoses that included schizoaffective disorder, cognitive communication deficit, atherosclerotic heart disease, syncope, hypertension, and mild neurocognitive disorder.

A review of the quarterly MDS (minimum data set) assessment dated November 1, 2023 for resident #1 revealed a BIMS (brief interview of mental status) score of 7, indicating moderate impact on cognition.

Resident #2 was admitted on August 14, 2023 with diagnosis including dementia, major depressive disorder recurrent, dysphagia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease.

A review of the quarterly MDS (minimum data set) dated November 21, 2023 for resident #2 revealed a BIMS (brief interview of mental status) score of 3, indicating severely cognitively impaired.

A review of the progress notes revealed that on November 13, 2023 at 3:52 P.M. resident #1 and resident #2 were self-propelling their wheelchairs out of the dining area, as staff were assisting other residents, words were exchanged between resident #1 and resident #2. Resident #1 accused resident #2 of running over the foot of resident #1. Resident #1 was then observed by staff hit resident #2 in the arm before staff could reach either resident. Staff were noted to have separated the residents and assisted them back to their respective rooms. Resident records revealed that skin checks were conducted and no areas of redness or injuries were observed. The progress notes further revealed that notifications of the director of nursing, family, case manager, provider, and police had transpired. Residents were placed on 15-minute intervals checks.

A review of the facility investigation dated November 16, 2023 revealed that a resident to resident altercation had occurred on November 13, 2023 between resident #1 and resident #2. The investigative report revealed that resident #1 and resident #2 were self-propelling their respective wheelchairs from the dining room area and that the wheelchair of resident #2 made contact with the foot of resident #1 and then that the hand of resident #1 made contact with the arm of resident #2. The investigation cited that the residents were immediately separated and that no injuries had transpired, notifications were made, laboratory assessments ordered and the residents were placed on 15-minute interval checks.

An interview was conducted on February 13, 2024 at 2:35 PM with a certified nursing assistant (CNA, staff #81). Staff #81 stated that staff receive frequent ongoing training regarding abuse and neglect. She further stated that if she were to observe an instance of abuse, whether it involved staff or another resident, she would immediately intervene, ensure the residents safety and report the issue.

An interview was conducted on February 14, 2024 at 10:46 AM with behavioral health unit manager (staff #20). Staff #20 stated that unit 500, 600 and 800 are locked units and that determination to place a resident on either unit is contingent on their behaviors, documentation of behaviors, intensity of behaviors and frequency of behaviors to ensure the residents were a good fit for that unit. She stated that based on the aforementioned criteria, both resident #1 and #2 were deemed a good fit. She stated that staff received ongoing training through the facilities online learning portal as well as recent CPI [Crisis Prevention Institute] training on identifying warning signs for potential behaviors and de-escalation of behaviors. She stated that there is at least one behavioral health training for staff on a monthly basis. Staff #20 stated that the units are staffed contingent on the needs of the resident and based on the facility assessment, and that generally equated to 3 CNAs on each unit. Staff #20 stated that abuse could be verbal or physical and that the expectation was that all residents are free from abuse, whether by another resident, by staff, or other persons.

Regarding Resident #3 and #9:

Resident #3 was admitted to the facility on December 28, 2021 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety disorder, alcohol induced psychotic disorder with hallucinations, Wernicke's encephalopathy, cognitive communication deficit, unsteadiness and dysphagia.

A review of the quarterly MDS for resident #3 assessment dated October 08, 2023, revealed a BIMS score of 14, indicating cognitively intact.

Resident #9 was admitted on August 21, 2017 with diagnoses that included respiratory failure, hemiplegia, hemiparesis, symbolic dysfunction, epilepsy, major depressive disorder-recurrent, traumatic brain injury and schizophrenia.

A review of the annual MDS for resident #9 revealed a BIMS score of 15, indicating cognitively intact.

A review of the progress notes dated November 21, 2023 at 3:56 P.M. revealed that staff #37, a restorative nurse assistant, reported an incident between 2 residents. It was noted that resident #9 was in his wheelchair blocking the doorway and not allowing his roommate to exit the room. Resident #9 was noted to have kicked out with his foot and made contact with the abdomen of resident #3. It was noted that the 2 residents were immediately separated, vitals were obtained, skin assessments completed, no noted injuries reported and that resident #3 denied having any injuries as a result of the incident. It was further noted that 15-minute visual checks were implemented, notifications occurred, and laboratory assessments were ordered.

A review of the facility investigative report revealed that a resident to resident altercation had occurred on November 21, 2023 between resident #3 and resident #9. The report revealed that resident #3 was participating in therapy with staff #37. It was noted that resident #9 was blocking the way for resident #3. Resident #3 and staff 37 asked resident #9 for room to pass and resident #9 stated "no". The foot of resident #9 then made contact with the stomach of resident #3. It was further noted that both residents were immediately separated, skin checks conducted, no injuries were noted, appropriate notifications transpired, residents were placed on 15-minute skin checks, resident #9 was moved to a different room on a different hall, laboratory assessments were ordered and follow-up visits were conducted by the operations manager (staff #133).

An interview was conducted on February 13, 2024 at 9:35 A.M. with resident #3. Resident #3 stated that he was trying to leave the room to meet his therapist and had asked resident #9 to move. He stated that resident #9 did not move and instead kicked him. He said that there were no injuries and that the facility had acted promptly and conducted a head to toe skin assessment and moved resident #9 to another hall. He stated that there have been no further incidents.

An interview was conducted on February 14, 2024 at 3:18 P.M. with staff #37. Staff #37 stated that that resident #3 was at the door of his room wanting to go out, but resident #9 was blocking the door and would not move. She stated that as a CNA was trying to get a walker out of the way, resident #9 kicked resident #3 in the abdomen. She stated that staff separated the residents and moved the residents into separate rooms. She stated that this has been the first time that resident # 9 had ever physically acted out against another resident. She stated in any in

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that five residents (#1, #3, #4, #5, #6) were free from abuse from other residents. The deficient practice could result in other residents being abused.

Findings included:

Regarding Resident #1 and #2:

Resident #1 was admitted to the facility on July 25, 2023 with diagnoses that included schizoaffective disorder, cognitive communication deficit, atherosclerotic heart disease, syncope, hypertension, and mild neurocognitive disorder.

A review of the quarterly MDS (minimum data set) assessment dated November 1, 2023 for resident #1 revealed a BIMS (brief interview of mental status) score of 7, indicating moderate impact on cognition.

Resident #2 was admitted on August 14, 2023 with diagnosis including dementia, major depressive disorder recurrent, dysphagia, cognitive communication deficit, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease.

A review of the quarterly MDS (minimum data set) dated November 21, 2023 for resident #2 revealed a BIMS (brief interview of mental status) score of 3, indicating severely cognitively impaired.

A review of the progress notes revealed that on November 13, 2023 at 3:52 P.M. resident #1 and resident #2 were self-propelling their wheelchairs out of the dining area, as staff were assisting other residents, words were exchanged between resident #1 and resident #2. Resident #1 accused resident #2 of running over the foot of resident #1. Resident #1 was then observed by staff hit resident #2 in the arm before staff could reach either resident. Staff were noted to have separated the residents and assisted them back to their respective rooms. Resident records revealed that skin checks were conducted and no areas of redness or injuries were observed. The progress notes further revealed that notifications of the director of nursing, family, case manager, provider, and police had transpired. Residents were placed on 15-minute intervals checks.

A review of the facility investigation dated November 16, 2023 revealed that a resident to resident altercation had occurred on November 13, 2023 between resident #1 and resident #2. The investigative report revealed that resident #1 and resident #2 were self-propelling their respective wheelchairs from the dining room area and that the wheelchair of resident #2 made contact with the foot of resident #1 and then that the hand of resident #1 made contact with the arm of resident #2. The investigation cited that the residents were immediately separated and that no injuries had transpired, notifications were made, laboratory assessments ordered and the residents were placed on 15-minute interval checks.

An interview was conducted on February 13, 2024 at 2:35 PM with a certified nursing assistant (CNA, staff #81). Staff #81 stated that staff receive frequent ongoing training regarding abuse and neglect. She further stated that if she were to observe an instance of abuse, whether it involved staff or another resident, she would immediately intervene, ensure the residents safety and report the issue.

An interview was conducted on February 14, 2024 at 10:46 AM with behavioral health unit manager (staff #20). Staff #20 stated that unit 500, 600 and 800 are locked units and that determination to place a resident on either unit is contingent on their behaviors, documentation of behaviors, intensity of behaviors and frequency of behaviors to ensure the residents were a good fit for that unit. She stated that based on the aforementioned criteria, both resident #1 and #2 were deemed a good fit. She stated that staff received ongoing training through the facilities online learning portal as well as recent CPI [Crisis Prevention Institute] training on identifying warning signs for potential behaviors and de-escalation of behaviors. She stated that there is at least one behavioral health training for staff on a monthly basis. Staff #20 stated that the units are staffed contingent on the needs of the resident and based on the facility assessment, and that generally equated to 3 CNAs on each unit. Staff #20 stated that abuse could be verbal or physical and that the expectation was that all residents are free from abuse, whether by another resident, by staff, or other persons.

Regarding Resident #3 and #9:

Resident #3 was admitted to the facility on December 28, 2021 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety disorder, alcohol induced psychotic disorder with hallucinations, Wernicke's encephalopathy, cognitive communication deficit, unsteadiness and dysphagia.

A review of the quarterly MDS for resident #3 assessment dated October 08, 2023, revealed a BIMS score of 14, indicating cognitively intact.

Resident #9 was admitted on August 21, 2017 with diagnoses that included respiratory failure, hemiplegia, hemiparesis, symbolic dysfunction, epilepsy, major depressive disorder-recurrent, traumatic brain injury and schizophrenia.

A review of the annual MDS for resident #9 revealed a BIMS score of 15, indicating cognitively intact.

A review of the progress notes dated November 21, 2023 at 3:56 P.M. revealed that staff #37, a restorative nurse assistant, reported an incident between 2 residents. It was noted that resident #9 was in his wheelchair blocking the doorway and not allowing his roommate to exit the room. Resident #9 was noted to have kicked out with his foot and made contact with the abdomen of resident #3. It was noted that the 2 residents were immediately separated, vitals were obtained, skin assessments completed, no noted injuries reported and that resident #3 denied having any injuries as a result of the incident. It was further noted that 15-minute visual checks were implemented, notifications occurred, and laboratory assessments were ordered.

A review of the facility investigative report revealed that a resident to resident altercation had occurred on November 21, 2023 between resident #3 and resident #9. The report revealed that resident #3 was participating in therapy with staff #37. It was noted that resident #9 was blocking the way for resident #3. Resident #3 and staff 37 asked resident #9 for room to pass and resident #9 stated "no". The foot of resident #9 then made contact with the stomach of resident #3. It was further noted that both residents were immediately separated, skin checks conducted, no injuries were noted, appropriate notifications transpired, residents were placed on 15-minute skin checks, resident #9 was moved to a different room on a different hall, laboratory assessments were ordered and follow-up visits were conducted by the operations manager (staff #133).

An interview was conducted on February 13, 2024 at 9:35 A.M. with resident #3. Resident #3 stated that he was trying to leave the room to meet his therapist and had asked resident #9 to move. He stated that resident #9 did not move and instead kicked him. He said that there were no injuries and that the facility had acted promptly and conducted a head to toe skin assessment and moved resident #9 to another hall. He stated that there have been no further incidents.

An interview was conducted on February 14, 2024 at 3:18 P.M. with staff #37. Staff #37 stated that that resident #3 was at the door of his room wanting to go out, but resident #9 was blocking the door and would not move. She stated that as a CNA was trying to get a walker out of the way, resident #9 kicked resident #3 in the abdomen. She stated that staff separated the residents and moved the residents into separate rooms. She stated that this has been the first time that resident # 9 had ever physically acted out against another resident. She stated in any instan

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#99) was free from physical abuse by other residents. The deficient practice could result in further incidents of resident to resident abuse.

Findings include:

Resident #99 was admitted to the facility on July 14, 2022, with diagnoses that included dementia, schizophrenia, weakness, dysphagia, anxiety, depression, and hypertension.

A behavioral care plan with a start date of June 26, 2023 revealed the resident was a wandering risk related to; disoriented to place, impaired safety awareness, and that the resident wanders aimlessly. The goal was that the resident's safety would be maintained. Interventions included assessing for fall risk, and documenting wandering behaviors and interventions.

Review of an Annual Minimum Data Set (MDS) assessment dated July 22, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had significant cognitive impairment.

A review of the clinical record showed a progress note dated January 5, 2023 which revealed the resident was pacing on the unit, going into other people's rooms and was very hard to redirect. The note further revealed that physical assistance was required to keep the resident out of other people's rooms.

A nursing progress note dated January 18, 2023 revealed an incident where the resident had wandered into another person's room, and that resident was noted standing near the doorway. That resident stated he had pushed resident #99 out of his room, causing them to fall into the side wall rail and slide to the floor.

A social services progress note dated January 23, 2023 revealed resident #99 wanders the hallways constantly and is intrusive most shifts, needing constant on hand redirection from staff to keep her safe. It further revealed that she wanders into patient rooms, often taking other resident's food and laying in other resident's beds.

A nursing progress note dated February 2, 2023 revealed the resident was continuing to wander into other resident's rooms all day, taking other resident's food, and was very hard to redirect again requiring physical assistance to keep her from other resident's rooms.

A nursing progress note dated March 9, 2023 revealed another instance where resident #99 had gone into another resident's room, and staff were required to intervene after the resident had slapped resident #99 in his room. It was noted that the right side of the face of resident #99 was reddened after the incident, indicating a negative outcome.

A nursing progress note dated April 7, 2023 revealed that resident #99 continues to wander the unit, going in and out of other resident's rooms and requiring physical assistance to keep her out of other resident's rooms.

However, no care plan interventions were added for any of the documented instances of behavior.

An interview with a licensed practical nurse (LPN/staff #23) was conducted on November 22, 2023 at 9:50 AM. The LPN stated the resident #99 was always in everyone's room, constantly wandering, and that problematic residents are transferred to other units if incidents keep occurring. They also stated that there were more incidences that were not documented because not everyone documents appropriately, however they stated that any time there was an incident she documented it in the progress notes.

An interview with the Director of Nursing (DON/staff #49) was conducted on November 22, 2023 at 10:44 AM. The DON stated that they use multiple units to transfer residents to keep them separate from each other as incidents happen. She further stated that they have to keep track of why they are moving what residents where, and that her expectation when incidents happen is that they follow the facilities policy regarding abuse.

A review of facility policy titled 'Abuse: Prevention of and prohibition against' under the section 'prevention' revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by identifying, assessing, care planning for appropriate interventions that include wandering into other's rooms/space.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#99) was free from physical abuse by other residents. The deficient practice could result in further incidents of resident to resident abuse.

Findings include:

Resident #99 was admitted to the facility on July 14, 2022, with diagnoses that included dementia, schizophrenia, weakness, dysphagia, anxiety, depression, and hypertension.

A behavioral care plan with a start date of June 26, 2023 revealed the resident was a wandering risk related to; disoriented to place, impaired safety awareness, and that the resident wanders aimlessly. The goal was that the resident's safety would be maintained. Interventions included assessing for fall risk, and documenting wandering behaviors and interventions.

Review of an Annual Minimum Data Set (MDS) assessment dated July 22, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had significant cognitive impairment.

A review of the clinical record showed a progress note dated January 5, 2023 which revealed the resident was pacing on the unit, going into other people's rooms and was very hard to redirect. The note further revealed that physical assistance was required to keep the resident out of other people's rooms.

A nursing progress note dated January 18, 2023 revealed an incident where the resident had wandered into another person's room, and that resident was noted standing near the doorway. That resident stated he had pushed resident #99 out of his room, causing them to fall into the side wall rail and slide to the floor.

A social services progress note dated January 23, 2023 revealed resident #99 wanders the hallways constantly and is intrusive most shifts, needing constant on hand redirection from staff to keep her safe. It further revealed that she wanders into patient rooms, often taking other resident's food and laying in other resident's beds.

A nursing progress note dated February 2, 2023 revealed the resident was continuing to wander into other resident's rooms all day, taking other resident's food, and was very hard to redirect again requiring physical assistance to keep her from other resident's rooms.

A nursing progress note dated March 9, 2023 revealed another instance where resident #99 had gone into another resident's room, and staff were required to intervene after the resident had slapped resident #99 in his room. It was noted that the right side of the face of resident #99 was reddened after the incident, indicating a negative outcome.

A nursing progress note dated April 7, 2023 revealed that resident #99 continues to wander the unit, going in and out of other resident's rooms and requiring physical assistance to keep her out of other resident's rooms.

However, no care plan interventions were added for any of the documented instances of behavior.

An interview with a licensed practical nurse (LPN/staff #23) was conducted on November 22, 2023 at 9:50 AM. The LPN stated the resident #99 was always in everyone's room, constantly wandering, and that problematic residents are transferred to other units if incidents keep occurring. They also stated that there were more incidences that were not documented because not everyone documents appropriately, however they stated that any time there was an incident she documented it in the progress notes.

An interview with the Director of Nursing (DON/staff #49) was conducted on November 22, 2023 at 10:44 AM. The DON stated that they use multiple units to transfer residents to keep them separate from each other as incidents happen. She further stated that they have to keep track of why they are moving what residents where, and that her expectation when incidents happen is that they follow the facilities policy regarding abuse.

A review of facility policy titled 'Abuse: Prevention of and prohibition against' under the section 'prevention' revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by identifying, assessing, care planning for appropriate interventions that include wandering into other's rooms/space.