Every finding on record at Apple Rehab Colchester

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure the resident was fully assessed by the nurse following a fall with pain and possible injury prior to staff transferring the resident back to bed and failed to ensure a fall risk assessment was completed for the resident per facility policy. The findings include: Resident #1's diagnoses included muscle weakness, cognitive communication deficit, anxiety, depression and schizoaffective disorder (a mental health condition marked primarily by symptoms of schizophrenia such as hallucinations and delusions). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) indicating Resident #1 rarely or never made decisions regarding task of daily living and was dependent on staff for toileting, bed mobility and transfers. The Resident Care Plan dated 10/17/25 identified that Resident #1 was at risk for falls due to multiple risk factors including poor safety awareness and generalized weakness. Interventions directed a low bed, encouraging the resident to ask and wait for staff assistance for transfers and/or toileting, utilizing the call bell for assistance, therapy evaluation and treatment as needed and pharmacy and psychiatric medication reviews. The nurse's note dated 10/18/25 at 4:26 AM identified at 3:40 AM Resident #1 was observed lying in the middle of his/her room, reporting he/she transferred him/herself and ambulated unassisted, leading to the unwitnessed fall. The note identified Resident #1 was complaining of left hip pain and upon assessment, left hip erythema (redness of the skin) was present, no internal or external rotation was observed but limited range of motion was noted to the left lower extremity with complaints of pain ten, ten (10) out of ten (10), with movement. The note indicated Resident #1 was assisted back to bed, the Advanced Practice Registered Nurse (APRN) was notified and orders were obtained for a STAT (immediate) x-ray to the left hip and pelvis, Resident #1 was to remain on bedrest until the x-ray results were received and to apply ice to the left hip for ten (10) minutes every shift for three (3) days. Review of the imaging report dated 10/18/25 identified Resident #1 had sustained an acute (new) left femoral (thigh bone) intertrochanteric fracture (a femur fracture just below the hip joint). The nurse's notes dated 10/18/25 identified Resident #1 was transferred to the hospital via ambulance at 12:45 PM and admitted for the left intertrochanteric fracture. The hospital documentation identified Resident #1 underwent a left femur intramedullary nailing (a surgical procedure where a metal rod is inserted into the center of the femur and is secured with screws at both ends) on 10/19/25. Review of the clinical record failed to identify fall risk assessments had been completed prior to the 10/18/25 fall despite having ten (10) falls from 3/14/25 through 10/15/25 or after the 10/18/25 fall. Interview with 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 11/10/25 at 12:37 PM identified that on 10/18/25 at 3:40 AM she heard a noise from Resident #1's room and when she responded she observed Resident #1 sitting on the floor several feet from the bed and when Resident #1 saw her he/she began yelling dolor (pain in Spanish). LPN #1 explained the nurse aide, Nurse Aide (NA) #1, also responded and she then immediately notified the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1. LPN #1 identified although Resident #1 was anxious and yelling out in pain with any movement, RN #1 directed her and NA #1 to assist in standing Resident #1 prior to Resident #1 being assessed, and Resident #1 repeatedly yelled dolor during the three (3) person stand-pivot transfer back to bed. Interview with RN #1 on 11/10/25 at 1:11 PM identified when he responded to Resident #1's room on 10/18/25 following the fall, Resident #1 was yelling out and was in visible pain and he knew something was wrong. RN #1 explained Resident #1 was very anxious and wanted to get up, but instead of attempting to make Resident #1 comfortable on the floor and assessing him/her with help from other staff to rule out any injuries prior to transferring Resident #1, he directed LPN #1 and NA #1 in assisting him in standing Resident #1 to get Resident #1 back to bed. RN #1 identified Resident #1 was very guarded, tense and yelled out in pain numerous times during the transfer but they continued to transfer Resident #1 from the floor to the wheelchair and then from the wheelchair into bed. RN #1 identified he then assessed Resident #1 in bed, Resident #1 continued to yell out when turned and with range of motion to the left lower extremity. Interview with APRN #1 on 11/10/25 at 1:36 PM identified although Resident #1 is very impulsive, if the resident was yelling out in pain and showing signs and symptoms of pain immediately following the fall, RN #1 should have attempted to assess Resident #1 on the floor to rule out injuries prior to transferring Resident #1 back to bed. Interview with the Director of Nursing (DON) on 11/10/25 at 2:47 PM identified the staff should have attempted to keep Resident #1 on the floor by making him/her comfortable and then RN #1 should have attempted to assess Resident #1 prior to transferring Resident #1, who complained of pain to the left hip prior to being transferred. The DON indicated a fall risk assessment should have been completed by nursing staff at least quarterly, annually and after each fall and she was unsure why they had not been completed per policy. Review of the Falls policy (undated) directed, in part, that a fall risk assessment is to be completed upon admission, quarterly, annually and after a change in condition and the care plan is to be updated promptly with targeted interventions based on the assessment. The RN will assess the resident immediately following a fall. Residents should not be left unattended until they are assessed by the RN and determined safe to remain in the facility. Transfer from the floor will only occur once an RN has completed the assessment and deemed it appropriate.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had sustained a fall, the facility failed implement interventions to ensure the resident was treated for severe pain. The findings include:Resident #1's diagnoses included muscle weakness, cognitive communication deficit, anxiety, depression and schizoaffective disorder (a mental health condition marked primarily by symptoms of schizophrenia such as hallucinations and delusions). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) indicating Resident #1 rarely or never made decisions regarding task of daily living and was dependent on staff for toileting, bed mobility and transfers. The Resident Care Plan dated 10/17/25 identified that Resident #1 was at risk for falls due to multiple risk factors including poor safety awareness and generalized weakness. Interventions directed a low bed, encouraging the resident to ask and wait for staff assistance for transfers and/or toileting, utilizing the call bell for assistance, therapy evaluation and treatment as needed and pharmacy and psychiatric medication reviews. The nurse's note dated 10/18/25 at 4:26 AM identified at 3:40 AM Resident #1 was observed lying in the middle of his/her room, reporting he/she transferred him/herself and ambulated unassisted, leading to the unwitnessed fall. The note identified Resident #1 was complaining of left hip pain and upon assessment, left hip erythema (redness of the skin) was present, no internal or external rotation was observed but limited range of motion was noted to the left lower extremity with complaints of pain ten, ten (10) out of ten (10), with movement. The note indicated Resident #1 was assisted back to bed, the Advanced Practice Registered Nurse (APRN) was notified and orders were obtained for a STAT (immediate) x-ray to the left hip and pelvis, Resident #1 was to remain on bedrest until the x-ray results were received and to apply ice to the left hip for ten (10) minutes every shift for three (3) days. Although the resident complained of severe pain following the fall at 3:40 AM, review of the October 2025 Medication Administration Record identified the application of ice to the left hip was not signed off as administered until the day shift, 7:00 AM to 3:00 PM, and although an order was available the as needed acetaminophen (a pain reliever) was not administered to Resident #1 until 12:20 PM (more than eight (8) hours following the fall) for a pain level of eight (8) out of ten (10). Review of the imaging report dated 10/18/25 identified Resident #1 had sustained an acute (new) left femoral (thigh bone) intertrochanteric fracture (a femur fracture just below the hip joint). The nurse's notes dated 10/18/25 identified Resident #1 was transferred to the hospital via ambulance at 12:45 PM and admitted for the left intertrochanteric fracture. The hospital documentation identified Resident #1 underwent a left femur intramedullary nailing (a surgical procedure where a metal rod is inserted into the center of the femur and is secured with screws at both ends) on 10/19/25. Interview with 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 11/10/25 at 12:37 PM identified that on 10/18/25 at 3:40 AM she heard a noise from Resident #1's room and when she responded she observed Resident #1 sitting on the floor several feet from the bed and when Resident #1 saw her he/she began yelling dolor (pain in Spanish). LPN #1 explained the nurse aide, Nurse Aide (NA) #1, also responded and she then immediately notified the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1. LPN #1 identified although Resident #1 was anxious and yelling out in pain with any movement, RN #1 directed her and NA #1 to assist in standing Resident #1 prior to Resident #1 being assessed, and Resident #1 repeatedly yelled dolor during the three (3) person stand-pivot transfer back to bed. LPN #1 explained although Resident #1 had been yelling out in pain immediately upon the fall, which was abnormal for him/her, she did not medicate Resident #1 for pain prior to the transfer, stating it all happened so quick, and reported that once Resident #1 was back in bed she also did not medicate Resident #1 for pain, apply the ice prior to leaving her shift at 7:00 AM (more than three (3) hours later) or reassess Resident #1's pain. Interview with RN #1 on 11/10/25 at 1:11 PM identified when he responded to Resident #1's room on 10/18/25 following the fall, Resident #1 was yelling out and was in visible pain and he knew something was wrong. RN #1 explained Resident #1 was very anxious and wanted to get up, so prior to addressing the pain or assessing Resident #1, he directed LPN #1 and NA #1 in assisting him in standing Resident #1 to get Resident #1 back to bed. RN #1 identified Resident #1 was fighting against them, was very guarded, tense and yelled out in pain numerous times during the transfer and when he assessed Resident #1 in bed, Resident #1 continued to yell out when turned and with range of motion. RN #1identified he communicated his findings to the APRN ho gave orders and LPN #1 should have applied the ice to the left hip and medicated Resident #1 for pain. Interview with APRN #1 on 11/10/25 at 1:36 PM identified Resident #1 was yelling out in severe pain and with any movement following the fall, she would have expected Resident #1 to be treated for the pain as soon as possible and that the pain was reassessed following the treatment. Interview with the Director of Nursing (DON) on 11/10/25 at 2:47 PM identified although Resident #1 was on scheduled Suboxone in the morning (9:00 AM), in part to treat Resident #1's pain, she would have expected Resident #1 be treated for his/her complaints of left hip pain immediately following the fall and the effectiveness documented prior to the end of the shift. Review of the Pain Assessment policy dated 2018 directed, in part, that the pain assessment form will be completed on admission, readmission, annually, quarterly and upon a significant change in condition. If the resident screens positive for pain, develop interventions to be implemented as quickly as possible to promote maximum comfort and document on the care plan. Evaluate and document effectiveness of current interventions on the pain management monitoring log and/or Medication Administration Record (MAR).

Based on observations, clinical record reviews, facility policy and interviews, the facility failed to ensure a medication cart located in the hallway was locked and the medication was secured to prevent unauthorized access. The findings include:Observations on the A Wing on 11/10/25 at 12:15 PM identified a medication cart in the main hallway off the main entrance, pushed up against the left side of the hall, about half of the way down. The medication cart was noted to be unlocked with an open cup of apple sauce, one (1) pre-poured cup of nutritional supplement, a cell phone on top of the cart and the computer screen was observed to be open and unlocked, displaying resident information. Registered Nurse (RN) #2 was noted to emerge from a resident's room at 12:18 PM. The Director of Nursing (DON) was subsequently notified following the observations. Observations on the A Wing on 11/10/25 at 1:22 PM identified a medication cart in the main hallway off the main entrance, pushed up against the left side of the hall, about two-thirds of the way down. The medication cart was noted to be unlocked with an open cup of apple sauce, one (1) pre-poured cup of nutritional supplement, a cell phone on top of the cart and the computer screen was observed to be open and unlocked, displaying resident information. Multiple residents were observed walking by the open medication cart but did not approach the cart. RN #2 was noted to emerge from a resident's room at 1:27 PM. Interview and observations of the medication cart with RN #2 and the DON on 11/10/25 at 1:27 PM identified RN #2 explained she should not have left any of the above items on the top of the cart with the cart unlocked, unsecured and with the computer screen displaying resident identification. RN #2 indicated although she knows not to do so, there are ambulatory residents in the hallway, she was unable to explain why the medication cart was left the way it was twice in just over one (1) hour. The DON identified RN #2 should not have left items on top of the cart when the cart was unattended and both the medication cart and the computer screen should be locked at all times when the nurse steps away from it. Review of the Medication Administration policy (undated) directed, in part, that medications should be stored in a secure, locked area accessible only to authorized personnel and resident confidentiality is to be maintained by ensuring all medication records are kept private and secure.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #25) reviewed for abuse, the facility failed to ensure the resident was free from inappropriate touching by Resident #41, who had a history of inappropriate touching. The findings include: 1a. Resident #25 was admitted to the facility in April 2024 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety disorder, and major depressive disorder.The care plan dated 4/3/25 identified Resident #25 was involved in a resident-to-resident physical interaction (Resident #25 was inappropriately touched by Resident #41). Interventions included Resident #25 will be encourage not to engage in a kiss and hug with male peer. Offer psychiatric and social services support. The annual MDS dated [DATE] identified Resident #25 had severely impaired cognition and required setup or clean up assistance with bed mobility, transfer, and walk 150 feet. Additionally, Resident #25 had no physical and verbal behaviors directed toward others. The physician's order dated 7/29/25 directed the resident be independent with transfers and gait with rollator walker.The nurse's note dated 8/1/25 at 6:50 PM by the RN Supervisor (RN #4) identified Resident #25 was touched by Resident #41. RN assessment performed and APRN notified. The care plan dated 8/1/25 identified Resident #25 was involved in a resident-to-resident physical interaction. Resident #41 touched Resident #25 inappropriately. Interventions included resident will be seated with female peers not with male peers when participating in recreational activities. Offer psychiatric and social services support.The social services note dated 8/4/25 at 10:59 AM identified a wellness visit was done following an incident Resident #25 had with Resident #41. Resident #25 reports he/she recalled the incident but has no ill effects noted. Social service support and will remain involved as needed.The psychiatric APRN note dated 8/7/25 identified she was asked to see Resident #25 after an alleged incident with Resident #41. Resident #25 does not remember the incident. Resident #25 indicated he/she feels safe at the facility and feels comfortable around all his/her peers. Monitor behavior for depression, loss of interest in activities and isolation. b. Resident #41 was admitted to the facility in May 2024 with diagnoses that included Parkinson's disease with dyskinesia and anxiety disorder.The care plan dated 4/3/25 identified Resident #41 was involved in a resident-to-resident physical interaction. Resident #41 was witnessed kissing female peer (Resident #25). Interventions included offering psychiatric and social services support. RN assessment. Notify the physician and resident representative.The quarterly MDS dated [DATE] identified Resident #41 had intact cognition and had exhibited physical and verbal behavioral symptoms directed towards others. The reportable event form dated 8/1/25 identified Resident #41 was witnessed with arms around the waist of Resident #25. Residents were separated, Resident #25 was assessed by an RN, and Resident #41 was placed on 1:1 monitoring. The Administrator, police, APRN, psychiatric APRN, both power of attorneys were notified. The nurse's note dated 8/1/25 at 4:51 PM by RN #4 identified Resident #41 spoke with the psychiatric APRN via telehealth video conference. Psychiatric APRN felt Resident #41 was safe to come off 1:1 monitoring and to being monitored every 15 minutes. The care plan dated 8/1/25 identified Resident #41 was witnessed touching female peer inappropriately. Interventions included 1:1 monitoring until cleared by psychiatry and then every 15 minutes checks. Encourage resident to sit with male residents at recreation activities. Supervise during recreation activities. Psychiatric and social services follow up. The psychiatric APRN note dated 8/1/25 at 5:17 PM identified she was asked to see Resident #41 today for recent inappropriate sexual comments. Met with Resident #41 via telehealth. Resident #41 is not currently a danger to self or others. Nursing reports Resident #41 without further behavior at this time. This behavior for Resident #41 is not new. Resident #41 reports not making a comment. Discussed overall behaviors and what is not appropriate. Will discontinue 1:1 supervision and used every 15 minutes checks until seen by psychiatrist.The resident locator form dated 8/1/25 at 3:19 PM identified Resident #41 started on every 15 minutes monitor on 8/1/25 at 5:30 PM through 8/6/25 at 6:45 AM.A written statement by RN #4 dated 8/1/25 at 3:19 PM identified NA #4 reported to her that a few residents reported to NA #4 that Resident #41 was touching and cuddling Resident #25. RN #4 immediately went to the location which was A wing dining room and observed Resident #41 leaning into Resident #25's lap with his/her hand on Resident #25's thigh area rubbing and ultimately holding his/her hands. RN #4 indicated she separated the two residents immediately. RN #4 indicated she wheeled Resident #41 out of the dining room into the lobby area where the Administrator was and reported to the Administrator what was reported to her and what she observed. Resident #41 was placed on 1:1 monitoring. The DNS, both power of attorneys, police, and the psychiatrist were notified. A written statement by NA #4 dated 8/1/25 at 3:19 PM identified she came in at 3:00 PM and was informed by a couple of residents that Resident #41 was in the dining room with his/her hands on Resident #25 pants.A written interview by RN #4 on 8/1/25 at 3:19 PM with Resident #56 identified he/she saw Resident #41 holding hands with Resident #25. Resident #56 indicated he/she saw Resident #41 hands on Resident #25 lap and between his/her legs.A written interview by RN #4 on 8/1/25 at 3:19 PM with Resident #39 and Resident #48 indicated both residents stated they saw Resident #41 lean into Resident #25's lap snuggling. Both residents indicated Resident #41 hands were on Resident #25 lap.The APRN note dated 8/4/25 at 11:00 AM identified the DNS notified her there was an incident whereby Resident #41 touched Resident #25 inappropriately and Resident #25 reported at the time it made him/her uncomfortable. Resident #25 was asked about the incident today and fortunately secondary to his/her dementia Resident #25 had no recall of incident. The summary report dated 8/5/25 at 8:45 PM identified during an afternoon activity both residents were seated next to each other. When the activity had ended both residents were observed by other residents holding hands. RN #4 was called and arrived at the dining room and witnessed Resident #41 leaning into Resident #25 lap rubbing his/her thigh and then holding his/her hands. Both residents were separated immediately. Resident #41 indicated he/she didn't do anything wrong, and they were just friendly. Resident #25 was unable to recall the incident. Two residents that attended recreation activity were interviewed and stated, Resident #25 and Resident #41 they were just holding hands and maybe they are lonely and wanted each other's company. Psychiatrist and social services follow up. Care plans updated. Interview with the DNS on 8/12/25 at 8:00 AM identified she was aware of the alleged incident of Resident #41 leaning into Resident #25's lap and rubbing Resident #25 thigh and both residents holding hands. The DNS demonstrated that it was reported to her that Resident #41 hands were above Resident #25 knees on his/her lap/thigh area rubbing the thigh area. The DNS indicated Resident #41 was placed on 1:1 monitoring immediately until seen by the psychiatrist, and both residents care plans were revised. The DNS indicated Resident #41 was placed on every 15 minutes monitoring for a few days and discontinued. Interview with the Administrator on 8/12/25 at 8:45 AM identified she was aware of the alleged incident between Resident #25 and Resident #41. The Administrator indicated RN #4 immediately separated the two residents and placed Resident #41 on 1:1 until evaluated by psychiatry, and an RN assessment was performed on Resident #25. The Administrator indicated an investigation was initiated, and both residents care plans were revised. The Administrator indicated both residents were assessed by the psychiatrist, and Resident #41 was placed on every 15 minutes monitoring after the 1:1 was discontinued by the psychiatrist APRN. Interview with RN #4 on 8/12/25 at 10:47 AM (who worked the 3:00 PM - 11:00 PM shift on 8/1/25 as the RN Supervisor) identified at 3:20 PM NA #4 came and got her. RN #4 indicated she does not remember exactly what NA #4 said. RN #4 indicated she went to the first-floor dining room where recreation had just ended and as she was walking towards the dining room, she observed Resident #41 leaning and rubbing Resident #25 thigh. Resident #25 took Resident #41 hand, and they were holding hands by the time she reached both residents. RN #4 indicated she immediately separated both residents. Interview with Resident #41 on 8/12/25 at 10:26 AM identified Resident #41 indicated he/she does not remember the alleged incident on 8/1/25 at 3:19 PM with Resident #25.Interview with Resident #39 on 8/12/25 at 10:30 AM identified he/she does not remember the alleged incident on 8/1/25 at 3:19 PM involving Resident #25 and Resident #41.Interview with Resident #48 on 8/12/25 at 10:35 AM identified he/she does not remember the alleged incident on 8/1/25 at 3:19 PM involving Resident #25 and Resident #41.Interview with Resident #56 on 8/12/25 at 10:38 AM identified he/she does not remember the alleged incident on 8/1/25 at 3:19 PM involving Resident #25 and Resident #41.Interview with Recreation Director on 8/12/25 at 10:45 AM identified she did not work on 8/1/25 but heard of the alleged incident on 8/2/25. The Recreation Director indicated she had never observed Resident #41 being inappropriate with any of the residents during recreation activities. The Recreation Director indicated she was not aware of Resident #41's history of inappropriately touching Resident #25 because she was not employed by the facility at that time. The Recreation Director indicated she was not directed to keep Resident #25 and Resident #41 separated during recreation activity prior to the alleged incident on 8/1/25. Interview with Recreation Staff #1 on 8/12/25 at 11:03 AM identified on 8/1/25 during the movie activity Resident #25 and Resident #41 were seated next to each other. Recreation Staff #1 indicated she did not observe any inappropriate touching between the two residents. Recreation Staff #1 indicated she left the dining room at 3:06 PM and became aware of the alleged incident the next day. Recreation Staff #1 indicated she had heard and observed Resident #41 touching other residents but was never directed on how to manage Resident #41 behavior or any restrictions until after the most recent incident on 8/1/25. Recreation Staff #1 indicated she was not aware of any incident with Resident #41 prior to 8/1/25. Recreation Staff #1 indicated she had observed Resident #41 rubbing Resident #30's shoulder during a recreation activity sometime in June 2025. She also indicated she had observed Resident #41 touching other residents as well, for example touching their arms, nothing inappropriately. Recreation Staff #1 indicated she would separate the residents and let the nursing staff know. Recreation Staff #1 indicated no residents have ever come to her and complained about Resident #41. A written statement by Recreation Staff #1 on 8/12/25 identified in June 2025 at the start of a recreation program. Resident #41 was heading to a table and stopped next to Resident #30 and said hi, and slightly rubbed his/her shoulder in an unmalicious manner. Recreation Staff #1 indicated she redirected and educated Resident #41 that he/she cannot touch other residents even while saying hi. Recreation Staff #1 indicated Resident #41 went to his/her table and she notified the nursing staff.Interview with the DNS on 8/12/25 at 12:06 PM identified she was not aware of any issues regarding Resident #41 in the month of June. The DNS indicated she would educate and in-service all the staff regarding Resident #41 behavior. The DNS indicated she would discuss with the interdisciplinary team regarding Resident #41's behavior and better intervention.Interview with LPN #1 on 8/12/25 at 12:30 PM identified she does not remember Recreation Staff #1 notifying her of Resident #41 touched Resident #30 sometime in June 2025. Although attempted, an interview with NA #4 was not obtained.Review of the facility abuse policy identified abuse or mistreatment of any kind toward a resident is strictly prohibited. Any allegation of abuse by a staff member, visitor, family member, or resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated, and appropriate action will be taken. Sexual abuse: Any form of sexual harassment, coercion, or assault, including unwanted touching between residents.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #10) reviewed for falls, the facility failed to ensure that 2 staff members were present during care per the care card and physician's orders. The findings include: Resident #10 was admitted to the facility in February 2025 with diagnoses that included chronic obstructive pulmonary disease, urinary retention, and dementia.The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition, was frequently incontinent of bowel, required a urinary catheter for bladder, and required substantial assistance with bathing, dressing, and transfers.The care plan dated 6/10/25 identified Resident #10 had a history of falls. Interventions included close/frequent observation due to poor safety awareness.Review of the clinical record identified Resident #10 was hospitalized from [DATE] - 7/16/25 for UTI and metabolic encephalopathy. A nurse's note dated 7/16/25 at 10:44 PM by RN #4 identified Resident #10 was aggressive and lashing out during bedtime care. RN #4 identified that Resident #10 had not exhibited aggressive behaviors previously and identified interventions would include 2 persons with all care and that the intervention had been added to the care card.Review of the RN supervisor shift report book for 7/16/25 identified multiple report notes written by RN #4 for Resident #10 which included that Resident #10 was to have 2 persons with care at all times. Review of the care card identified Resident #10 was a fall risk and required 2 persons with all care. A physician's order dated 7/17/25 directed to provide assistance of 2 with transfers and a rolling walker.A reportable event form dated 7/17/25, completed by RN #5 (7:00 AM - 3:00 PM RN Supervisor) identified Resident #10 had a witnessed fall at 9:30 AM. The form identified that NA #3 was attempting to transfer Resident #10 from his/her bed to a shower chair with the use of a rolling walker. The form further identified that during the transfer, NA #2 had not utilized a gait belt to assist and Resident #10's knees buckled and the resident was lowered to the floor by NA #3. The form identified Resident #10 had no injuries as a result of the fall and identified NA #3 was the only witness to the fall. RN #5 identified interventions to prevent future falls included use of a gait belt. Interview with RN #4 (3:00 PM - 11:00 PM RN Supervisor) on 8/12/25 at 9:00 AM identified she was called into assess Resident #10 following aggressive behaviors with the nurse aide at bedtime care. RN #4 identified Resident #10 had just been readmitted from the hospital earlier in the shift and had not exhibited aggressive behaviors previously but had a weeklong hospitalization due to a UTI. RN #4 identified that due to the change in behaviors, the hospitalization, and the resident's underlying dementia, she added 2 persons with all care to the resident's care card and also added the order for assist of 2 with rolling walker. RN #4 also identified that she also added the information to the RN supervisor shift report book. RN #4 identified that all nurse aides were responsible to review the care cards for all residents assigned to them as the care cards were a living document and often were changed or had new or additional interventions added for residents. RN #4 also identified that all RN supervisors coming onto shift were responsible to review for the prior 24 hours as well as to update the book with any changes as well. Interview with PT #1 (Director of Rehab) identified that in the last year, the facility had changed its gait belt policy to identify that facility staff were able to use discretion regarding whether or not to use a gait belt with transfers. PT #1 identified that she had not provided any in-service training to staff regarding transferring residents safety without the use of a gait belt and it was her practice, as well as all the therapists and assistants in her department, to always utilize a gait belt with any resident who required an assist of 1 or more. Interview with RN #5 on 8/12/25 at 9:47 AM identified she completed the investigation and reportable event form for Resident #10's witnessed fall on 7/17/25 at 9:30 AM. RN #5 identified that NA #3 was attempting to transfer Resident #10 from the bed to a shower chair when Resident #10 began to fall. RN #5 identified NA #3, who was positioned behind Resident #10, put her arms under Resident #10's armpits and lowered him/her to the floor. RN #5 identified that NA #3 reported she was the only staff member present at the time of the fall and had not utilized a gait belt during the transfer and based on this she added the gait belt as an intervention. RN #5 identified she had been employed at the facility for 3 months and had not received any training or in-services on when to use a gait belt, but she had worked at other facilities, and it was her practice to always use a gait belt for anyone who was a risk for falls. RN #5 also identified that she had been notified by multiple staff at the facility that use of gait belts were optional for all staff. RN #5 identified that the resident care card was typically reviewed by the nurse aides, but she reviewed the RN supervisor book every morning. Upon review of the notes entered by RN #4, RN #5 identified did not recall seeing any notes related to Resident #10 requiring 2 persons with all care and may have missed the notes regarding this.Interview with NA #3 on 8/12/25 at 10:42 AM identified that she was attempting to transfer Resident #10 from the bed to a shower chair on 7/17/25 at 9:30 AM when Resident #10 fell. NA #3 identified she positioned Resident #10's rolling walker next to Resident #10's bed and was standing behind him/her. NA #3 identified Resident #10 had shoes on and a facility provided gown which was open in the back and no other clothing, and Resident #10 was positioned directly in front of NA #3 with Resident #10's back facing NA #3. NA #3 identified that she was unsure if she had her hands on Resident #10's hips while Resident #10 began to transfer and identified she did not routinely utilize a gait belt as it was not required by the facility. NA #3 observed Resident #10 begin to be unable to bear weight and his/her knees buckle, and NA #3 placed her arms under Resident #10's armpits but had to reach up to do so, as Resident #10 was taller than her. NA #3 identified she lowered Resident #10 to the floor but identified it was difficult due to Resident #10's height and inability to bear any weight. NA #3 identified she used her body and arms to lower Resident #10 to the floor and then called for help. NA #3 identified prior to Resident #10's hospital stay, he/she required an assist of 1 with transfers and she had not had any issues transferring Resident #10 prior to 7/17/25. NA #3 identified that for a new resident or a resident she had not provided care for, she would review the care card, but since she typically provided care for Resident #10 since she was assigned to Resident #10's unit and was familiar with him/her, she had not reviewed Resident #10's care card on 7/17/25. NA #3 identified she was not aware that Resident #10 had any issues following his/her return from the hospital on 7/16/25 or that Resident #10 was supposed to have 2 persons with all care. NA #3 also identified that she recently left the facility but had been employed for over a year, and in that time had not received any training on how to assess when to utilize a gait belt.Interview with the DNS on 8/12/25 at 11:17 AM identified she was not aware of any behaviors that occurred with Resident #10 on 7/16/25 or that Resident #10 had been changed to 2 persons with all care. The DNS identified that she felt, even if there had been 2 staff members present or NA #3 had used a gait belt during Resident #10's transfer on 7/17/25 at 9:30 AM, Resident #10 would likely still have fallen but was unable to elaborate why.Although requested, the facility failed to provide policies related to resident transfer assistance. The facility policy on gait belts directed that the policy was to provide guidance on the optional use of gait belts during transfer and ambulation to promote safety and prevent injury for both residents and staff, and that gait belts were available for staff to use as a tool to ensure safe handling and transfers of residents. The policy further directed that staff use their judgment to decide if a gait belt was appropriate, that all staff involved in resident transfers and ambulation should be trained on proper use of gait belts and regular competency checks.The facility policy on falls directed that the facility would identify residents at risk for falls and implement interventions to minimize fall related injuries. The policy further directed that the resident care cards should reflect the resident's fall risk and corresponding precautions.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #6) reviewed for tracheostomy care, the facility failed to ensure that appropriate infection control practices were implemented during tracheostomy care. The findings include: Resident #6 was admitted to the facility in July 2024 with diagnoses that included myocardial infarction, epilepsy, and tracheostomy. A physician's order dated 9/11/24 directed to change disposable inner tracheostomy cannula everyday shift and as needed. The quarterly MDS dated [DATE] identified Resident #6 had severely impaired cognition, was dependent on staff assistance with eating, bathing, and toileting. The MDS also identified Resident #6 required tracheostomy care. The care plan dated 6/30/25 identified Resident #6 had a tracheostomy related to respiratory failure. Interventions included to provide tracheostomy care as ordered and maintain enhanced barrier precautions per facility protocol.An enhanced barrier precautions line list dated 8/6/25 identified Resident #6 was on enhanced barrier precautions (EBP) for a tracheostomy.Observation 8/12/25 at 11:50 AM directly outside of Resident 6's doorway identified a PPE cart with signage posted outside the room door which identified enhanced barrier precautions. The signage directed that everyone entering the room must clean their hands before entering and when leaving the room. The signage also directed that providers and staff must also wear gloves and a gown for high contact resident care activities including device care for tracheostomies.Observation of Resident #6's tracheostomy care beginning at 8/12/25 at 11:50 AM identified RN #5 and LPN #1 were standing inside the room at Resident #6's bedside wearing disposable gloves, and LPN #1 also wearing a disposable surgical mask. Both RN #5 and LPN #1 were without the benefit of gowns. LPN #1 identified she was going to begin to provide tracheostomy care and RN #5 identified she was assisting LPN #1. LPN #1 reached for Resident #6's tracheostomy straps. Prior to LPN #1 initiating care of Resident #6's tracheostomy and following surveyor inquiry related to EBP, LPN #1 and RN #5 identified they were aware that Resident #6 was on enhanced barrier precautions and were then observed dropping their gloves and utilizing hand sanitizer prior to exiting the room. RN #5 and LPN #1 were then observed donning new gloves and a disposable gown in the hallway and reentering Resident #6's room subsequent to surveyor inquiry. Observation at 11:52 AM identified LPN #1 used a bedside table to place the unopened sterile tracheostomy care and cleaning tray without wiping the table down or placing a barrier on the table. LPN #1 was observed touching multiple areas on the table including the underside of the table and then began to touch the suction machine located on Resident #6's night stand. After checking the suction machine, LPN #1 removed a newly opened suction tip from its packaging and touched the tip multiple times with the same gloved hands. At 11:55 AM, LPN #1 removed her gloves but was not observed performing hand hygiene initially. Subsequent to surveyor inquiry, LPN #1 proceeded to Resident #6's bathroom and used the sink to wash her hands with soap and water. At 11:58 AM, LPN #1 was observed opening the sterile tracheostomy care and cleaning kit and began to remove items from the kit including a sterile cup and lid and sterile gloves with her hands. LPN #1 was observed with her hands inside of the kit touching exposed portions of the sterile gloves. During this observation, RN #5 was positioned on the opposite side of Resident #6's bed and was not observed providing any instruction or direction to LPN #1. LPN #1 identified that the items she removed from the kit were to be used sterile and subsequent to surveyor inquiry identified that the items were in fact no longer sterile due to the way they were removed. At 12:05 PM, RN #5 identified she would attempt to locate RN #1 (IP nurse), to assist LPN #1, and exited the room. LPN #1 then identified that while she had performed tracheostomy care and utilized PPE and the sterile cleaning kit previously, she was nervous and frozen due to observation by this surveyor. Observation at 12:08 PM identified RN #1 entered the room and was notified by LPN #1 that she would be unable to complete the tracheostomy care due to being nervous. RN #1 identified she would assist LPN #1 with the tracheostomy care but that a new tracheostomy care and cleaning kit would need to be used due to the previous kit no longer being sterile. RN #1 exited the room and returned at 12:10 PM with a new kit along with being gowned and gloved prior to entering the room. RN #1 and LPN #1 were observed from 12:10 PM - 12:35 PM performing tracheostomy care utilizing a new sterile kit for Resident #6. During the entirety of observation, LPN #1 required substantial direction which included step by step instruction from RN #1 to complete the treatment. Interview with RN #1 at 12:36 PM immediately following the tracheostomy care observations identified that she was unsure what happened and that she was not aware of any issues related to LPN #1 performing tracheostomy care in the past. RN #1 identified that she felt LPN #1 was very nervous due to surveyor observation. RN #1 identified that the facility had provided education to LPN #1 regarding tracheostomy care including use of a sterile cleaning and care kit in 2025 and the education included online modules and in person competencies. RN #1 identified she was also the facility staff development nurse and she would provide additional 1:1 education and hands on training with LPN #1 due to the issues identified during Resident #6's tracheostomy care. Review of LPN #1's education for 2025 materials provided included clinical in-service sign in sheets dated 6/9/25 that identified LPN #1's signature. The in-service education included facility policies related to enhanced barrier precautions, isolation precautions, hand sanitizer use, and hand washing. Further review of the education identified that LPN #1 completed online competencies and nursing skills evaluation related to tracheostomy care on 7/10/25. The documentation provided failed to identify the specific education and skills related to tracheostomy care that were reviewed. The facility policy on enhanced barrier precautions directed that it was the policy of the facility to adhere with CDC and CMS guidelines related to EBP to prevent the transmission of multi drug resistant organisms while promoting resident quality of life. The policy further directed that the facility would implement EBP during high contact resident care activities which included device care for tracheostomies. The policy Further directed that staff would perform hand hygiene and don PPE before providing high contact care to the resident and would doff PPE and perform hand hygiene after providing high contact care to the resident.The facility policy on tracheostomy care directed that the purpose of the policy was to maintain a patent airway and an infection free stoma. Procedure for tracheostomy care directed that a licensed nurse providing the care would wash his/her hands then set up the equipment needed to provide the care which would include a tracheostomy care kit, normal saline, plastic bag, sterile gloves, suction catheter, and suction machine. The procedure also directed that the suction catheter should be applied to the tubing and left in its package, and the tracheostomy care kit should be opened with sterile normal saline poured into containers provided within the kit, the nurse to don the sterile gloves prior to providing suction to the resident.The facility policy on hand washing directed that the purpose of the policy was to ensure that staff washed their hands as a means of preventing the spread of infection, and that all staff would wash their hands including the following conditions: before resident contact, after resident contact, and after handling contaminated items or equipment.The facility policy on use of instant hand sanitizer directed that the purpose of the policy was to prevent the spread of infection and contamination by blood borne pathogens. The policy further directed that when sinks were not readily available, instant hand sanitizer may be used between tasks that normally required hand washing unless hands were visibly soiled and that hand should be washed with soap and water at the first opportunity.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for falls, the facility failed to ensure Resident #1's bed was in the lowest position prior to leaving the room to minimize or prevent an injury. The findings include: Resident #1's diagnoses included cerebellar ataxia (loss of muscle coordination) and a history of falls. The Resident Care Plan dated 3/25/25 identified Resident #1 had a history of falls. Interventions included a low bed with floor mats, body pillows to provide bed boundaries, and remove the bed controller while the resident in bed to prevent the resident from positioning the bed in a high position. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Basic Interview for Mental Status (BIMS) score of 11 out of 15 indicating some memory recall deficits and was dependent on staff for activities of daily living. The nurse aide care card identified revised on 3/30/25 directed for the bed to be placed in the lowest position. The nurse's note dated 4/8/25 at 9:36 AM identified the 7AM-3PM Nursing Supervisor was called to Resident #1's room with a report that Resident #1 had a fall, Resident #1 was noted to be on the floor on the left side of the bed, lying on his/her left side with a bump on the head. The note indicated Resident #1 was assessed, neuro checks, and vital signs were stable, the physician was called, directed to transfer Resident #1 to the Emergency Department, and Resident #1 was transferred at 9:35 AM. The nurse's note dated 4/8/25 at 11:23 PM identified Resident #1 returned to the facility around 7:00 PM with a neck brace. Resident #1 sustained fractures of the C6 and C7 spine and a hematoma to the forehead. The hospital Discharge summary dated [DATE] identified Resident #1 sustained a small neck fracture not requiring surgery and the recommendation was to keep the collar on and follow-up with the neurosurgeon. The summary report dated 4/12/25 identified at approximately 9:10 AM Resident #1 was observed on the floor next to the bed. The investigation identified Resident #1 was upright in bed being fed by staff. The nurse aide noted Resident #1 was not swallowing the food, she went to get the nurse and upon return to the room, Resident #1 was noted to be on the floor. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 5/7/25 at 10:50 AM identified she was called to Resident #1's room after Resident #1 fell out of the bed onto the floor. RN #1 stated she assessed the resident's vital signs and neuro checks to be within normal limits, Resident #1 sustained a bump on the head with slight bleeding, and Resident #1 was transferred to the hospital. RN #1 identified the bed was at waist height, and it should have been in the lowest position when staff are not in the room. Interview with the 7AM-3PM charge nurse, RN #2, on 5/7/25 at 11:15 AM identified she was called into Resident #1's room to assist RN #1 after Resident #1's fall out of bed onto the floor. RN #2 indicated Resident #1 had been declining in health, becoming more restless and agitated, had recent falls, and the bed was always to be in the lowest position. RN #2 identified that when Resident #1 fell, the bed was not in the lowest position. Interview with the 7AM-3PM nurse aide, Nurse Aid (NA) #2, on 5/7/25 at 11:25 AM identified that she had raised Resident #1's bed to waist height to feed Resident #1 breakfast. NA #2 explained she did not return the bed to its lowest position before she left the room, even though she knew the care card directed to always have the bed in the lowest position, because the pillows were all around Resident #1. Review of the Fall: Minimizing Risk of Injury Policy identified that Residents who experience a fall will be evaluated following the occurrence using the interdisciplinary assessment tool to identify the potential causes of the fall, an individualized care plan, and updated interventions as needed to prevent falls and minimize injuries.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two residents (Resident #1 and #5) reviewed for behavioral health, the facility failed to accurately reflect the behaviors that were exhibited and treated. The findings include: 1. A. Resident #1's diagnoses included dementia with behavioral disturbances, panic disorder, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition and was supervision for mobility without an assist device. The Resident Care Plan (RCP) dated 8/8/2024 identified Resident #1 had the potential for altered mood related to diagnosis of dementia, panic disorder, anxiety disorder, and depression. Interventions directed to provide redirection and ensure resident and other's safety if resident appeared upset or angry. Physician orders dated 7/23/2024 directed to monitor for psychotropic behaviors. Monitor for the following: Itching/picking at skin, restlessness (agitation), hitting, increasing complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Physician orders dated 7/24/24 directed to administer Trazodone (antidepressant and sedative) 50 milligrams (mg) as needed (PRN) for anxiety. Review of the MAR (medication administration record) for the month of August 2024 identified Resident #1 received Trazodone 50 mg PRN on 8/4, 8/5, 8/10, 8/12, 8/13, 8/18, 8/21, 8/23, and 8/30/2024 for behaviors. Although review of the Medication Administration Record (MAR) identified there were no behaviors documented on 8/10, 8/12, 8/18 and 8/21/2024, Resident #1 received the PRN Trazodone. Review of the nursing notes failed to identify nursing staff noted the behaviors required per the physician orders (anxiety) for administration of the Trazodone on 8/10, 8/12, 8/18, and 8/21/24. 2. Resident #5's diagnoses included metabolic encephalopathy, dementia with behavioral disturbance, anxiety disorder and depression. Nursing admission assessment dated [DATE] identified Resident #5 had severe cognitive impairment and required assistance for mobility in a wheelchair. Physician orders dated 7/9/2024 directed to monitor for psychotropic behaviors. Monitor for the following: Itching/picking at skin, restlessness (agitation), hitting, increasing complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. The Resident Care Plan (RCP) dated 7/17/24 identified Resident #5 was at risk for potential adverse effects of psychotropic drug use related to diagnosis of anxiety disorder and depression. Interventions directed to monitor mood/behavior, and interactions with other residents for appropriateness. Physician orders dated 7/30/2024 directed to administer Trazodone (antidepressant and sedative) 25 mg as needed for anxiety. Although review of the MAR for August 2024 identified Resident #5 received PRN Trazodone 25 mg on 8/4, 8/5, 8/8, and 8/10/2024 for behaviors, no behaviors were documented on 8/4, 8/5, 8/8, and 8/10/2024. Review of the nursing notes failed to identify nursing staff noted the behaviors required (anxiety) per the physician orders for the administration of Trazodone on 8/4, 8/5, 8/8, and 8/10/2024. Interview with the DON on 09/11/24 at 1:15 PM identified the nursing staff documentation should accurately reflect a resident's behaviors, including documentation to support the need for a PRN medication to be administered to treat behaviors. Interview failed to identify why the behaviors were not monitored. Review of facility Behavior Monitoring/Antipsychotic Medication Policy dated 6/2019 directed in part, residents receiving anti-psychotic medications will have specific target behaviors identified and monitored every shift. Any time a resident is started on an antipsychotic medication, a behavior flow sheet will be initiated, target behavior(s) will be recorded were indicated on the flow sheet, each shift will record, the number of episodes for each behavior, interventions, outcomes and side effects and nursing documentation will be done by exception.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of six residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1. A. Resident #1's diagnoses included dementia with behavioral disturbances, panic disorder, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition and was supervision for mobility without an assist device. The Resident Care Plan (RCP) dated 8/8/2024 identified Resident #1 had the potential for altered mood related to diagnosis of dementia, panic disorder, anxiety disorder, and depression. Interventions directed to provide redirection and ensure resident and other's safety if resident appeared upset or angry. B. Resident #2's diagnoses included traumatic brain injury, dementia with behavioral disturbance, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition and was substantial assistance for mobility with wheelchair. The RCP dated 8/7/2024 identified Resident #2 had a memory deficit with alteration in decision making and thought process. Interventions directed to place resident to an area that is away from noisy areas to promote a higher level of safety. Record review identified Residents #1 and #2 were roommates. A reportable event form dated 8/11/2024 at 10:20 PM identified on 8/12/2024 a staff member reported witnessing Resident #1 hit Resident #2 on the right side of his/her ribs. Resident #1 was separated from Resident #2, provided an alternative room for the night and placed on close observation until seen by psych services. Review of NA #4 written statement dated 8/11/2024 identified Resident #1 came up to NA #4 and pushed the laundry cart into NA #4 and another NA. Resident #1 then went into his/her room and then NA #4 heard Resident #2 yelling. When NA #4 entered the room he/she observed Resident #1 slapping Resident #2 in the stomach/rib area. Review of the incident summary dated 8/17/2024 identified the allegation of abuse was unsubstantiated. Interview with the DON on 9/11/2024 at 1:15 PM identified she did not substantiate abuse because she thought the incident was behavioral and it was not intentional. 2. Resident #3's diagnoses included Alzheimer's disease, dementia, and anxiety disorder. The admission assessment dated [DATE] identified Resident #3 had severely impaired cognition and was independent for mobility without an assistive device. The Resident Care Plan (RCP) dated 8/23/2024 identified Resident #3 had impaired memory, and decision-making skills related to dementia. Interventions directed to allow time for resident to respond when communicating. A reportable event form and investigation dated 8/24/2024 at 1:30 PM identified Resident #3 was hit in the chest by Resident #1. Residents were immediately separated and social services/psychiatry followed up with both residents. A nursing note dated 8/24/2024 at 2:45 PM by LPN #2 identified Resident #1 had been physically aggressive with staff and other residents. Resident #1 started throwing items and pushed over a bed table onto LPN #1, and Resident #1 was seen punching Resident #3. Resident #1 was agitated and difficult to redirect, and the Supervisor was notified. Interview with the DON on 9/11/2024 at 1:15 PM identified she did not substantiate abuse because she thought the incident was behavioral and it was not intentional. 3. A reportable event form and investigation dated 8/26/2024 at 2:36 PM identified Resident #1 pushed Resident #3 as he/she was ambulating on the unit. The DON assessed the residents and observed Resident #1 ambulating toward the door. The DON immediately placed Resident #1 on one-to-one (1:1) observation and the DON accompanied Resident #1 back to his/her room. As the DON was holding Resident #1's hand to accompany him/her back to his/her room they walked past Resident #2 who was sitting in his/her wheelchair. As they passed Resident #2, Resident #1 walked over to Resident #2 and hit him/her in the left eye. The report indicated the DON attempted to stop Resident #1 but was not quick enough. The DON then directly assisted Resident #1 to his/her room. Resident #1 and #3 were assessed by the nurse and identified no injuries. APRN #2 (who was present in the facility) was notified and orders were obtained to transfer Resident #1 to the hospital for evaluation. Facility incident summary dated 9/4/2024 identified there were no prior incidents between Resident #1 and #2. Further, the summary identified Resident #1 was unable to state why he/she was aggressive toward Resident #2. Interview with the DON on 9/18/2024 at 10:25 AM identified on 8/26/24, she was called to the unit to assist with Resident #1's behaviors. The DON stated staff reported Resident #1 had pushed Resident #3, and upon her arrival, DON attempted to re-direct and calm Resident #1 by bringing him/her to his/her room. The DON stated she held Resident #1's hand as she walked Resident #1 to his/her room, and when she stopped at the nursing station, Resident #1 let go, walked over to Resident #2 and hit Resident #2 in his/her left eye. The DON immediately separated the residents and Resident #1 was transferred to the hospital for evaluation. The DON stated Resident #1 was readmitted to the facility on [DATE]. Interview with the DON on 9/11/2024 at 1:15 PM identified she did not substantiate abuse because she thought the incident was behavioral and it was not intentional. 4. Resident #4's diagnoses included dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was alert and oriented and was independent for mobility without an assist device. The Resident Care Plan (RCP) dated 7/31/2024 identified Resident #4 had impaired memory and decision-making skills related to dementia. Interventions directed to allow time for resident to respond when communicating. A reportable event form and investigation dated 9/2/2024 at 4:15 PM identified a NA witnessed Resident #1 wander into Resident #4's room and hit Resident #4's arm and Resident #4 then hit Resident #1 back. The residents were immediately separated. Both residents were assessed for injuries with no injuries identified. Both residents were placed on every 15-minute check until psychiatry evaluations were completed. Review of NA #5 written statement dated 9/2/2024 identified NA #5 was fixing Resident #4's blanket when he/she observed Resident #1 and Resident #4 slap each other. Interview with NA #5 was not obtained during survey. Interview with the DON on 9/11/2024 at 1:15 PM identified she did not substantiate abuse because she thought the incident was behavioral and it was not intentional. The DON indicated the residents were evaluated after each incident above and deemed safe. After the incident on 9/2/2024, Resident #1 was transferred and admitted to the hospital. Review of facility Abuse/Resident Policy dated 7/23/2023 identified abuse and mistreatment of any kind toward a resident is strictly prohibited. Abuse shall be defined as: abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of eight residents (Resident #1, #2, #3, and #4) reviewed for abuse, the facility failed notify the State Agency of an allegation of abuse in a timely manner. The findings include: 1. A. Resident #1's diagnoses included dementia with behavioral disturbances, panic disorder, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition and was supervision for mobility without an assist device. The Resident Care Plan (RCP) dated 8/8/2024 identified Resident #1 had the potential for altered mood related to diagnosis of dementia, panic disorder, anxiety disorder, and depression. Interventions directed to provide redirection and ensure resident and other's safety if resident appeared upset or angry. B. Resident #2's diagnoses included traumatic brain injury, dementia with behavioral disturbance, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition and was substantial assistance for mobility with wheelchair. The RCP dated 8/7/2024 identified Resident #2 had a memory deficit with alteration in decision making and thought process. Interventions directed to place resident to an area that is away from noisy areas to promote a higher level of safety. Record review identified Residents #1 and #2 were roommates. A reportable event form dated 8/11/2024 at 10:20 PM identified on 8/12/2024 a staff member reported witnessing Resident #1 hit Resident #2 on the right side of his/her ribs. Resident #1 was separated from Resident #2, provided an alternative room for the night and placed on close observation until seen by psych services. Review of NA #4 written statement dated 8/11/2024 identified Resident #1 came up to NA #4 and pushed the laundry cart into NA #4 and another NA. Resident #1 then went into his/her room and then NA #4 heard Resident #2 yelling. When NA #4 entered the room he/she observed Resident #1 slapping Resident #2 in the stomach/rib area. Review of the Department of Public Health's FLIS Reportable Event Tracking System identified the incident occurred on 8/11/2024 at 10:20 PM, and the State Agency was notified on 8/12/2024 at 10:02 AM (11 hours and 42 minutes) . 2. Resident #3's diagnoses included Alzheimer's disease, dementia, and anxiety disorder. The admission assessment dated [DATE] identified Resident #3 had severely impaired cognition and was independent for mobility without an assistive device. The Resident Care Plan (RCP) dated 8/23/2024 identified Resident #3 had impaired memory, and decision-making skills related to dementia. Interventions directed to allow time for resident to respond when communicating. A reportable event form and investigation dated 8/24/2024 at 1:30 PM identified Resident #3 was hit in the chest by Resident #1. Residents were immediately separated and social services/psychiatry followed up with both residents. A nursing note dated 8/24/2024 at 2:45 PM by LPN #2 identified Resident #1 had been physically aggressive with staff and other residents. Resident #1 started throwing items and pushed over a bed table onto LPN #1, and Resident #1 was seen punching Resident #3. Resident #1 was agitated and difficult to redirect, and the Supervisor was notified. Review of the Department of Public Health's FLIS Reportable Event Tracking System identified the incident occurred on 8/24/2024 at 1:00 PM and the State Agency was notified on 8/26/2024 at 11:44 AM (76 hours and 44 minutes). 3. Resident #4's diagnoses included dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was alert and oriented and was independent for mobility without an assist device. The Resident Care Plan (RCP) dated 7/31/2024 identified Resident #4 had impaired memory and decision-making skills related to dementia. Interventions directed to allow time for resident to respond when communicating. A reportable event form and investigation dated 9/2/2024 at 4:15 PM identified a NA witnessed Resident #1 wander into Resident #4's room and hit Resident #4's arm and Resident #4 then hit Resident #1 back. The residents were immediately separated. Both residents were assessed for injuries with no injuries identified. Both residents were placed on every 15-minute check until psychiatry evaluations were completed. Review of NA #5 written statement dated 9/2/2024 identified NA #5 was fixing Resident #4's blanket when he/she observed Resident #1 and Resident #4 slap each other. Review of the Department of Public Health's FLIS Reportable Event Tracking System identified the incident occurred on 9/2/2024 at 4:15 PM, and the State Agency was notified on 9/3/2024 at 10:54 AM (18 hours and 39 minutes). Interview with the DON on 9/11/2024 at 1:15 PM identified all allegations of abuse are to be reported to the State Agency within two (2) hours. The DON indicated she was new to the facility. The DON indicated she spoke with staff about the incidents, and she felt the incidents were behavioral and not abuse. Review of facility Abuse/Resident Policy dated 7/23/23 directed in part, the Administrator/DON or designee will immediately conduct an investigation upon submission of a report of FLIS (Facility Licensing and Investigation Section) within two (2) hours of notification of alleged allegation of abuse.

Based on clinical record review, facility documentation review, facility policy review, and interviews for all residents (fifty-seven), reviewed for administration, the facility failed to ensure medications were documented during an electronic charting system outage. The findings include: Review of the MARs for all fifty-seven (57) residents, failed to identify medications were documented during the 11:00 PM to 7:00 AM shift on 9/7in to 9/8/2024. Interview with the DON on 9/11/2024 at 1:15 PM identified on the 11:00 PM to 7:00 AM shift on 9/7 to 9/8/2024, the electronic charting system went down, and the nurses were not able to document the medications. The DON stated the facility was unable to provide any form of verification that the medications were administered. Subsequent to surveyor inquiry, the DON indicated the facility will ensure paper documentation will be initiated upon the next reported outage to ensure documentation is complete. Review of the facility undated PCC (point click care) eMAR Downtime Policy directed in part, for an unplanned downtime, directs staff to immediately switch to paper MARs or backup forms. During downtime, use paper MARs to document all medications (include resident name, medication details, time, and staff initials/signatures). After downtime, enter all paper MAR data into PCC once the system is restored or ensure paper tracking is stored in resident's hard chart. Ensure all information is accurate and complete.

Based on clinical record review, facility documentation review, facility policy review, and interviews for five (5) of twenty-three residents (Resident #1, 4, 11, 5, and 2), reviewed for abuse and/or neglect, the facility failed to ensure allegations of abuse were reported immediately to the State Agency as required (within 2 hours if resulted in serious bodily injury or not later that 24 hours if no bodily injury). The findings include: 1. Resident #1's diagnoses included chronic kidney disease. The annual MDS assessment dated [DATE] identified Resident #1 was alert and oriented, required moderate assistance for transfers and toileting, and Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan dated 3/13/2024 identified that Resident #1 required staff assistance with ADLs and toileting. Interventions directed to assist with toileting needs. Review of the Concern Form (grievance) dated 7/15/2024 identified Resident #1's family member alleged staff were rough when toileting Resident #1 and expressed a concern about the way staff spoke to Resident #1 on 7/14/2024. The summary indicated a NA was not using a professional tone during care, and Hoyer lift (mechanical lift) transfers need to be gentler. Late entry social service note dated 7/15/2024 at 1:09 PM identified the DNS, SW #1 and the Administrator spoke with Resident #1's family member on 7/15/2024 about their concerns and wrote a grievance. Review of the facility Incident Report dated 7/22/2024 (8 days after the incident) identified on 7/14/2024 at 4:00 PM, a family member reported while on a phone call with Resident #1 he/she overheard staff yelling at the resident and stating he/she was exhausting, no one wants to come in his/her room and that he/she was the reason why staff was leaving. Statements from Resident #1 and roommate (Resident #8) were obtained by Social Worker #1 on 7/15/2024. The report further identified the NA #2 was suspended. A written statement from RN #1 dated 7/14/2024 (day of the incident) identified the family notified him on 7/14/2024 at 5 PM that he/she heard staff yelling at Resident #1, telling Resident #1 that he/she was exhausting, and the resident was afraid of retaliation. RN #1 spoke with Resident #1 who stated when he/she drinks a lot, he/she urinates a lot and the NA yells at him/her for ringing the call bell. RN #1 passed a written note onto the next shift for management and the social worker to follow up. Additional information identified Resident #1 described the accused NA, and the NA was subsequently identified as NA #1. Review of the State Agency Reportable Events website verified that the State Agency was notified of the allegation of abuse on 7/22/2024, eight (8) days after the allegation was made. Interview with Administrator #2 (former Administrator) on 8/1/2024 at 11:32 AM identified he was the Administrator when the incident occurred and stated the allegation was abuse. Administrator #2 stated was directed to report all allegations of abuse to corporate for direction, and in this case was directed by corporate to complete a grievance form for this allegation. Administrator #2 stated that the incident should not have occurred, and the facility did not notify the State Agency of the allegation timely. 2. Resident #4's diagnoses included spinal stenosis (narrowing of the space around the spinal cord) and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairment and was dependent on staff for ADLs and maximum assist of two for bed mobility. Review of a nursing note dated 6/18/2024 at 3:38 AM identified at 12:30 AM, Resident #4 alleged he/she had been harmed by a NA during care on the evening of 6/17/2024. Resident #4 alleged that NA #1 stated that he/she was like moving a thousand pounds and that NA #1 was not hurting her back to move Resident #4. Resident #4 further stated that NA #1 is rough with care, used a stern/unfriendly tone when answering the call bell, and had pushed him/her hard several times and hit Resident #4's head into the nightstand. The resident reported slight pain to the left eyebrow and the nurse observed a 2-centimeter by 2-centimeter area of faint swelling and redness to the left brow. Resident #4 indicated that NA #2 witnessed the incident. Facility incident report dated 6/18/2024 identified Resident #4 alleged staff were rough during a Hoyer lift transfer on 6/17/2024 and hit his/her left eyebrow on the nightstand. Review of the Concern Form (grievance) dated 6/20/2024, signed by the Administrator and SW #1, identified Resident #4 reported that staff were rough during a Hoyer lift transfer on 6/18/2024. The grievance summary indicated Resident #4 reported staff were rough during a Hoyer lift transfer and his/her left eyebrow was bumped on the nightstand. During interview with the DNS on 8/8/2024 at 11:45 AM the DNS stated she investigated the allegation, and the facility did not substantiate the allegation, so the allegation was not reported to the State Agency. The DNS stated she was unaware that allegations of abuse were required to be reported within a specified time frame, and believed she could investigate allegations first, and then report only substantiated abuse. The DNS was unable to identify why abuse was not substantiated. 3. Resident #11's diagnoses included cerebral infarction (stroke) affecting the right dominated side and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #11 had moderate cognitive impairment and required assistance with ADLs. Resident #11 reported during the Resident Council meeting held on 7/29/2024 with the Ombudsman that NA #1 has told him/her and his/her roommate to keep their mouths shut and that they talk too much. Resident #11 was reluctant to bring up staff names due to fear of retaliation. The meeting minutes indicated Resident #11's roommate (Resident #21 - MDS dated [DATE] identified moderate cognitive impairment) made the same allegation. The notes further indicated Resident #11 reported that on 7/27/2024, he/she heard NA #1 talking with another staff member about how she was waiting to beat up another staff member. Review of Resident #11's statement dated 8/2/2024 identified that he/she did not want to talk or say anything because he/she was afraid of retaliation from NA #1. Resident #11 alleged a delay in NA #1 providing care, Resident #11 and his/her roommate have had to wait for incontinent care, and NA #1 tells both residents to, shut your mouth, you talk too much. Interview with Resident #11 on 8/6/2024 at 8:52 AM identified NA #1 was disrespectful to both him/her and his/her roommate. Resident #11 indicated NA #1 talks in a threatening manner, and he/she was afraid to report the behavior in fear of retaliation from NA #1. Interview with the Administrator on 8/1/2024 at 2:18 PM identified the Ombudsman notified him of the concerns raised during the Resident Council meeting on 7/29/24, and he did not ask about the specific complaints, and he was preoccupied and did not look at the concerns until 7/30/2024. Further, he reported he did not get a copy of the full meeting minutes until 8/1/2024 and the allegations were reported to the State Agency on 8/2/2024 (four days after the Ombudsman reported the allegations). Interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM identified that she spoke with Resident #11 on 8/1/2024, three (3) days after the resident council meeting, who shared he/she was afraid for his/her roommate. RN #2 stated she did not feel the comments required follow up, so she did not document the information. RN #2 spoke with Resident #11 again the next day (8/2/2024) and the resident stated he/she was afraid of NA #1 and RN #2 notified the State Agency (four days after the allegation was made). Review of the facility incident report dated 7/29/2024 identified the State Agency was notified of the allegations of abuse on 8/2/2024 (four days after the allegation was made). 4. Resident #5's diagnoses included chronic pain syndrome, adjustment disorder with anxiety, and depressed mood. The quarterly MDS assessment dated [DATE] identified Resident #5 was alert and oriented and required maximal assistance for bed mobility and toileting. The RCP dated 5/1/2024 identified Resident #5 required assistance with all ADL's. Interventions directed to assist with ADLs and provide incontinence care. Interview with Resident #5 on 8/1/2024 at 1:53 PM identified that NA #1 is mouthy, at times, verbally bites his/her head off, and speaks in a way that residents should never be spoken to. Surveyor notified RN #2/Corporate Nurse on 8/1/2024 at 2:18 PM of allegations made by Resident #5. RN #2 stated she would look into it. Interview with NA #2 on 8/1/2024 at 12:49 PM identified that Residents #2, 3, 4 and 5 do not want NA #1 to provide care. When she works with NA #1, she provides care for Residents #2, 3, 4 and 5 because they alleged NA #1 turns off the call bell, makes them wait for care and they do not like the way NA #1 talks to them. Interview failed to identify that NA #2 had reported the allegations. Interview with the DNS on 8/8/2024 at 11:45 AM identified that she was not aware that Resident #5 did not want NA #1 caring for him/her. 5. Resident #2's diagnoses included Parkinson's disease and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #2 was alert and oriented, required moderate assistance for bed mobility, maximal assistance for transfers, and was dependent on staff for toileting. The Resident's Care Plan dated 5/31/2024 identified that Resident #2 required staff assistance with ADL's. Review of the Resident Council Concerns written during a Council meeting with the Ombudsman on 7/29/2024 identified Resident #2 reported that it sometimes takes up to an hour before call bells are answered. Resident #2 further alleged that sometimes call bells are turned off and the resident is told to wait because they are short staffed or staff are on break, and alleged residents are made to wait when they are incontinent of urine and feces. The notes indicated that additional residents voiced the same concern. Further, the form identified NA #3 reprimanded Resident #1's roommate and Resident #1 was told that NA #1 and NA #3 were not allowed in his/her room. Review of the facility incident form dated 7/29/2024 and the State Agency reportable event website identified although an incident report was completed regarding Resident #2 concerns reported on 7/29/2024, the State Agency was not notified of the allegation until 8/2/2024, four (4) days after the allegation was made. Interview with Resident #2 on 8/1/2024 at 1:36 PM identified that NA #1 often refused to help him/her when he/she requested to be changed. Resident #2 alleged NA #1 often turns off the call bell and states, I'll send someone else. In addition, Resident #2 stated there was an incident (date unidentified) when he/she needed assistance to get off the toilet. NA #1 refused to help and walked away. Resident #2 indicated she reported the incident to SW #1, and since then, NA #1 is rough when pulling up his/her pants. Surveyor notified RN #2/Corporate Nurse on 8/1/2024 at 2:18 PM of Resident #2's new allegation reported to the surveyor on 8/1/2024. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to identify the facility reported the allegation of abuse/neglect to the State Agency. Review of the facility Grievance Policy dated 11/2013 directed in part, if the concern/complaint is a questionable abuse allegation, the facility's abuse policy and procedure will be followed. Review of facility Abuse Policy (undated) directed in part, to notify the State Agency of allegations of abuse within two (2) hours. The policy further directed the accused staff will be immediately suspended pending the findings of the investigation, and an investigation will be conducted.

Based on record review, and interviews for twelve of twenty-three residents (Residents #13, 14, 15, 12, 11, 1, 7, 10, 4, 9, 2, and 5) reviewed for allegations of abuse, the facility failed to provide evidence that allegations of abuse and/or neglect were thoroughly investigated and failed to ensure an accused staff member was immediately suspended pending investigation to ensure all residents were protected from potential abuse in accordance with facility policy. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #13's diagnoses included convulsions (rapid, involuntary muscle contractions and relaxations resulting in uncontrolled shaking and limb movement), weakness, and anxiety. The admission MDS assessment dated [DATE] identified Resident #13 had moderate cognitive impairment, exhibited no behaviors and required moderate assistance with ADLs and toileting. The Resident Care Plan dated 7/30/2023 identified Resident #13 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs, and incontinent care per policy. Review of the Concern Form dated 7/30/2023 alleged Resident #13 required incontinent care, and a family member rang the call bell several times with no response. The family went into the hallway and observed NA #10 (assigned NA) at the desk talking and then NA #10 then went into a different room; the form indicated the complainant felt as if NA #10 ignored him/her and the ringing call bell. The family member then reported the incident to the nurse who then got the Administrator. The remainder of the form was blank. Interview with DNS #3 on 8/7/2024 at 2:42 PM identified that she was not aware of the allegation and stated if she were notified, she would have requested more information as to how long the resident waited and when care was provided. DNS #3 stated she would possibly report it as an allegation of neglect to the State Agency, and then complete an investigation. DNS #3 stated during July 2023, grievances/concerns would be reviewed during morning meeting and she did not know why she was not made aware of the allegation. Documentation review with DNS #3 on 8/7/2024 failed to identify an investigation was initiated after the allegation on 7/30/2023. 2. Resident #14 had diagnoses that included anxiety and hemiplegia/hemiparesis (muscle weakness or paralysis of one side). The RCP dated 7/13/2024 identified Resident #14 required assistance with ADLs. Interventions directed to assist with ADLs and toileting. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was alert and oriented and required extensive assistance of one staff for toileting and transfers. Review of the Concern Form (grievance) dated 7/30/2023 and signed by RN #7, identified Resident #14's family complained they did not like the way staff members (LPN #5 or NA #7) spoke with and acted toward Resident #14. Resident #14 further complained that NA #7 showered him/her with two other employees present, and while Resident #14 was naked and cold, the employees sprayed each other with water and laughed. The form further identified NA #7 answered the call bell when Resident #14 asked to use the restroom in the middle of the night. NA #7 stated Resident #14 would have to use the bedpan because she was busy. Resident #14 alleged that NA #7 forcefully placed a pad under Resident #14 and roughly placed a bedpan under the resident. When NA #7 removed the bedpan, she raised her voice to direct Resident #14 to roll over. Additional review of the grievance identified the NA was no longer to be assigned to Resident #14. Interview and record review with RN #7 on 8/6/2024 at 3:28 PM identified although she did not recall the specifics of the complaint, she stated she completed the grievance, and she would have given the form to the DNS and the social worker. Interview and record review with the DNS on 8/7/2024 at 12:28 PM identified the grievance form had no investigation attached, and the DNS was unable to provide documentation that an investigation was completed. 3. Resident #15's diagnoses included Parkinson's disease (brain condition that causes slowed movements, rigidity and tremors), depression and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #15 was alert and oriented and required limited assistance hygiene and toileting. The RCP dated 8/15/2023 identified Resident #15 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs, incontinent care per policy, and assist with ADLs. Review of the Concern Form (grievance) dated 8/15/2023 alleged on an unidentified date/time, shower times for Resident #15 varied, the shower was missed on the assigned day, and Resident #15's brief was not changed in a timely manner. Although the allegation was made on 8/15/2024, documentation review with the DNS on 8/7/2024 at 12:28 PM failed to identify an investigation was initiated. 4. Resident #12's diagnoses included displaced fracture of the left femur, Parkinson's disease with dyskinesia (involuntary muscle movement) and depressed mood. The quarterly MDS assessment dated [DATE] identified Resident #12 had moderate cognitive impairment and required maximal assistance with toileting. The RCP dated 8/28/2023 identified Resident #12 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs and incontinent care per policy. Review of the nursing note dated 10/6/2023 at 4:26 PM identified Resident #12 voiced concerns regarding toileting and transfers. Review of an undated and unsigned Concern Form (grievance) identified Resident #12 had a concern that his/her transfers were not going smoothly, and he/she was not getting to the bathroom timely. The form indicated that the Administrator and the DNS were notified on 10/6/2023. Attached staff education dated 10/6/2023 identified to move Resident #12 at his/her speed, however, failed to address the concern regarding toileting. Interview with RN #2/Corporate Nurse on 8/2/24 at 10:11 AM identified there was no documentation of an investigation being completed, and stated an investigation should have been done. 5. Resident #11's diagnoses included cerebral infarction (stroke) affecting the right dominant side, and major depressive disorder. The admission MDS assessment dated [DATE] identified Resident #11 was alert and oriented and was dependent on staff with toileting. The RCP dated 12/8/2023 identified that Resident #11 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs and provide incontinent care. a. The Concern Form dated 12/8/2023 alleged when NA #11 provided care, Resident #11's clothing and bed linens were noted to be heavily saturated. Social service note dated 12/8/2023 at 12:44 PM identified Resident #11 was unable to reach his/her call bell to call for toileting assistance. b. Review of the Resident Council Concerns recorded during a 7/29/2024 meeting with the Ombudsman identified Resident #11 was reluctant to bring up staff names in the meeting due to fear of retaliation. Per the notes, Resident #11 later identified that NA #1 has told him/her and his/her roommate to keep their mouths shut and that they talk too much. The notes indicated Resident #11's roommate (Resident #21) made the same allegation. The notes further indicated Resident #11 reported that on 7/27/2024, he/she heard NA #1 talking with another staff member about how she was waiting to beat up another staff member. Review of Resident #11's statement dated 8/2/2024 identified that he/she did not want to talk or say anything because he/she was afraid of retaliation from NA #1. Resident #11 alleged a delay in NA #1 providing care, Resident #11 and his/her roommate have had to wait for incontinent care, and NA #1 tells both residents to, shut your mouth, you talk too much. Interview with Resident #11 on 8/6/2024 at 8:52 AM identified NA #1 was disrespectful to both him/her and his/her roommate. Resident #11 indicated NA #1 talks in a threatening manner, and he/she was afraid to report the behavior in fear of retaliation from NA #1. Interview with the Administrator on 8/1/2024 at 2:18 PM identified the Ombudsman notified him of the concerns raised during the Resident Council meeting on 7/29/24, and he did not ask about the specific complaints, and he was preoccupied and did not look at the concerns until 7/30/2024. Further, he reported he did not get a copy of the full meeting minutes until 8/1/2024 and the allegations were reported to the State Agency on 8/2/2024 (four days after the Ombudsman reported the allegations). Interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM identified that she spoke with Resident #11 on 8/1/2024 who indicated he/she was worried/afraid for his/her roommate (Resident #21) and RN #2 felt the allegation did not seem concerning, so she did not document the information. RN #2 spoke with Resident #11 again on 8/2/2024 and asked if Resident #11 had a fear of reporting. Resident #11 indicated he/she was afraid of NA #1, and the investigation was initiated at that time (4 days after the allegation was made). 6. Resident #1's diagnoses included chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, required moderate assistance for transfers and toileting, and Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan dated 3/13/2024 identified that Resident #1 required staff assistance with ADLs and toileting. Interventions directed to assist with toileting needs. a. Review of the Concern Form (grievance) dated 3/5/2024, signed by the Administrator and Social Worker (SW) #1, identified there was a concern with Resident #1's bedtime routine and continent care. The summary identified on an unidentified date and time, Resident #1 was not offered the bedpan when requested and was helped to bed around dinner time. The summary identified staff was provided education regarding resident care and dignity. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to provide evidence that an investigation was initiated for the allegation reported on 3/5/2024. b. Review of the Concern Form (grievance) dated 5/16/2024, signed by the Administrator and Social Worker (SW) #1, identified Resident #1 reported on an unidentified date and time, the call light was shut off after staff told him/her that they could not assist him/her, and they would come back later. The form indicated staff were provided education to not to turn off resident call lights unless the resident's request was attended to. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to provide evidence that an investigation was completed for the allegation reported on 5/16/2024. c. Review of the Concern Form (grievance) dated 7/15/2024 and signed by the Social Worker identified Resident #1's family member alleged staff were rough when toileting Resident #1 and expressed a concern about the way staff spoke to Resident #1 on 7/14/2024. The summary indicated a NA was not using a professional tone during care, and Hoyer lift (mechanical lift) transfers need to be gentler. Review of late entry social service note dated 7/15/2024 at 1:09 PM identified the DNS, SW #1 and the Administrator spoke with Resident #1's family member on 7/15/2024 about their concerns and wrote a grievance. Review of facility Incident Report dated 7/22/2024 (8 days after the allegation was reported to the facility by the family member) identified on 7/14/2024 at 4:00 PM a family member reported while he/she was on a phone call with Resident #1 he/she overheard staff yelling at the resident and stating he/she was exhausting, no one wants to come in his/her room and that he/she was the reason why staff was leaving. Statements from Resident #1 and roommate (Resident #8) were obtained by Social Worker #1 on 7/15/2024. The report further identified the NA #2 was suspended. Written statement from RN #1 dated 7/14/2024 (day of the incident) identified the family notified him on 7/14/2024 at 5 PM that he/she heard staff yelling at Resident #1, telling Resident #1 that he/she was exhausting, and the resident was afraid of retaliation. RN #1 spoke with Resident #1 who stated when he/she drinks a lot, he/she urinates a lot and the NA yells at her for ringing the call bell. Resident #1 was educated to ask for a supervisor when an incident of staff yelling occurs, and a written note was passed onto the next shift for management and the social worker to follow up. Additional information identified Resident #1 described the accused NA, and the NA was subsequently identified as NA #1. Interview and record review with RN #1 on 8/1/2024 at 12:52 PM identified he was notified by Person #2 on 7/14/2024 at approximately 3:30 PM that Person #2 heard a staff member talking abusively to Resident #1 and stated the same NA was rough when providing care on 7/14/2024. RN #1 stated it was an allegation of abuse, and he did not investigate who the NA was that provided care and did not remove a staff member from duty. Although RN #1 was notified of the allegations of abuse, he failed to initiate an investigation and failed to remove a staff member from duty to protect residents in accordance with the facility policy. Interview with DNS and DNS #2 (Regional DNS) on 8/1/2024 at 12:20 PM failed to identify an investigation was initiated when the allegation of abuse was made on 7/14/2024. 7. Resident #7's diagnoses included spondylosis (age-related wear of the spinal discs), major depressive disorder and anxiety disorder. Review of the Reportable Event dated 3/19/2024 identified that Resident #7 reported to the Social Worker that on 3/18/2024 he/she asked NA #1 for assistance. Resident #7 alleged NA #1 would not assist him/her, and that NA #1 spoke to them in an unkind manner. Interview with Resident #7 on 8/1/2024 at 2:24 PM stated NA #1 refused to help with toileting, was disrespectful and NA #1 stated it wasn't her job. Resident #7 reported the incident to Administrator #2. Resident #7 spoke with Administrator #2 again the next day and he told him/her that there was no proof that the incident happened. Interview with NA #5 on 8/5/2024 at 3:11 PM identified that Resident #7 had communicated to her that NA #1 would go in Resident #7's room at night, not say anything and would turn off the call bell. She indicated that Resident #7 had stated to her that he/she feared NA #1, and NA #5 reported it to DNS #4. Although attempted, DNS #4 was unavailable for interview. Interview with RN #8 on 8/6/2024 at 8:05 AM identified that she heard NA #1 talk disrespectfully to Resident #7 and tell him/her they needed to wait on 3/18/2024. RN #8 did not report the incident, she stated the resident wanted to report the incident to the Administrator him/herself so she respected his/her wishes. Although attempted, NA #1 was unavailable for interview. Interview with the DNS on 8/5/2024 at 2:05 PM identified when the allegation was made, NA #1 should have been removed from the schedule and an investigation initiated, however, this was not done. 8. Resident #10's diagnoses included spinal stenosis (narrowing of the spinal cord space, causing pain), chronic pain, and weakness. The RCP dated 5/9/2024 identified Resident #10 required staff assistance with ADLs and was incontinent. Interventions directed to assist with toileting and provide incontinent care. Review of the Concern Form (grievance) dated 6/3/2024 identified on unidentified dates/times, Resident #10 was often soiled in the wheelchair. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to identify the facility was able to provide evidence an investigation for the allegation reported on 6/3/2024 was conducted. 9. Resident #4's diagnoses included spinal stenosis (narrowing of the space around the spinal cord) and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairment and was dependent on staff for ADLs and maximum assist of two for bed mobility. Review of nursing note dated 6/18/2024 at 3:38 AM identified at 12:30 AM, Resident #4 alleged that during care on the evening of 6/17/2024, NA #1 stated that he/she was like moving a thousand pounds and that NA #1 was not hurting her back to move Resident #4. Resident #4 further stated that NA #1 is rough with care, used a stern/unfriendly tone when answering the call bell, and had pushed him/her hard several times and hit Resident #4's head into the nightstand. Resident #4 indicated that NA #2 witnessed the incident. Facility incident report dated 6/18/2024 identified Resident #4 alleged staff were rough during a Hoyer lift transfer on 6/18/2024 and hit his/her left eyebrow on the nightstand. Review of the Concern Form (grievance) dated 6/20/2024, signed by the Administrator and SW #1, identified Resident #4 reported that staff were rough during a Hoyer lift transfer on 6/18/2024. The grievance summary indicated Resident #4 reported staff were rough during a Hoyer lift transfer and his/her left eyebrow was bumped on the nightstand. No injury was noted, and staff were provided with education regarding how to transfer a resident with a mechanical lift. Interview with NA #4 on 8/7/2024 at 1:05 PM identified that Resident #4 reported to her that NA #1 hit his/her head on the nightstand while forcefully turning him/her in bed, and she observed a red mark above his/her left eyebrow. NA #4 notified RN #9 immediately. Although documentation review identified an incident report (6/18/2024) and grievance form (6/20/2024) were completed, review failed to identify an investigation was completed. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to identify the facility conducted an investigation for the allegation reported on 6/20/2024. 10. Resident #9's diagnoses included Alzheimer's disease. The 5-day MDS assessment dated [DATE] identified Resident #9 had moderate cognitive impairment, had no rejection of care, and required maximal assistance with toileting and ADLs. The RCP dated 7/3/2024 identified Resident #9 required staff assistance with ADLs. Interventions directed to assist with ADLs and bathing, administer medications as ordered. Review of the Concern Form (grievance) dated 7/16/2024 alleged, on an unidentified date/time, that assistance with showers, washing up and clothing change was not provided. The summary indicated that Resident #9 refused showers and washing up. Review of the RCP failed to identify a care plan for resident refusals of care. Review of progress notes for July 2024 failed to identify any resident refusals of care. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to identify the facility was able to provide evidence of an investigation when concerns were reported on 7/16/2024. 11. Resident #2's diagnoses included Parkinson's disease and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #2 was alert and oriented, required moderate assistance for bed mobility, maximal assistance for transfers, was dependent on staff for toileting. The Resident Care Plan dated 5/31/2024 identified that Resident #2 required staff assistance with ADL's. Interventions directed to assist with ADLs. a. Review of the Resident Council Concerns written during a meeting Council meeting with the Ombudsman on 7/29/2024 identified Resident #2 reported that it sometimes takes up to an hour before call bells are answered. Resident #2 further alleged that sometimes call bells are turned off and the resident is told to wait because they are short staffed or staff are on break, and alleged residents are made to wait when they are incontinent of urine and feces. The notes indicated that additional residents voiced the same concern. Facility documentation identified that the facility initiated an investigation on 8/2/24 although allegations were made on 7/29/2024. b. Interview with Resident #2 on 8/1/2024 at 1:36 PM identified that NA #1 often refused to help him/her when he/she requested to be changed. Resident #2 alleged NA #1 often turns off the call bell and states, I'll send someone else. Resident #2 stated there was an incident (date unidentified) when he/she needed assistance to get off the toilet. NA #1 refused to help and walked away. Resident #2 indicated he/she reported the incident to SW #1, and since then, NA #1 is rough when pulling up his/her pants. The Surveyor notified RN #2 on 8/1/2024 at 2:18 PM of Resident #2's above allegation. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to identify the facility initiated an investigation for the allegation reported on 8/1/2024. 12. Resident #5's diagnoses included chronic pain syndrome, adjustment disorder with anxiety, and depressed mood. The quarterly MDS assessment dated [DATE] identified Resident #5 was alert and oriented and required maximal assistance for bed mobility and toileting. The RCP dated 5/1/2024 identified Resident #5 required assistance with all ADL's. Interventions directed to assist with ADLs and provide incontinence care. Interview with Resident #5 on 8/1/2024 at 1:53 PM identified that NA #1 is mouthy, at times, verbally bites his/her head off and speaks in a way that residents should never be spoken to. Surveyor notified RN #2 on 8/1/2024 at 2:18 PM of allegations made by Resident #5. RN #2 stated she would look into it. Interview with NA #2 on 8/1/2024 at 12:49 PM identified that when she works with NA #1, Residents #2, 3, 4 and 5 do not want NA #1 to provide care because they alleged NA #1 turns off the call bell, makes them wait for care and they do not like the way NA #1 talks to them. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to provide evidence that an investigation was initiated for concerns shared on 8/1/2024. 13. Review of the 6/27/2024 Resident Council Meeting minutes identified that residents expressed concerns with care, having to wait long periods for care, delay in call bell response, and attitudes of certain NAs. The meeting minutes indicated the concerns were addressed, and in one case an investigation led to disciplinary action against the staff in question. Interview with the Recreation Director on 8/6/2024 at 8:56 AM identified he takes the notes during the Resident Council meetings and then presents them to the Administrator to review and sign. The Recreation Director stated he was directed by Administrator #2 to only write basic notes in the meeting minutes and not identify any staff by name. He reported that at the 6/27/2024 Resident Council meeting, he showed residents a video on the Courage to Speak (about abuse and reporting abuse). The Recreation Director stated after the video, some of the residents complained that NA #1 was rude and dismissive to them and withholding of care. The Recreation Director stated he notified the DNS and was told there was no proof of the allegations, and the residents were demented and didn't know when they were last changed. The Recreation Director was unable to provide documentation of meeting attendance due to a computer issue on 7/19/2024. Interview with the DNS on 8/8/2024 at 10:12 AM identified that she could not recall the conversation with the Recreation Director following the 6/27/2024 Resident Council Meeting and was unable to provide documentation that the concerns were investigated. Review of the facility Concern Forms for Residents #1, 2, 4, and 9 during the period of 5/16/2024 through 7/29/2024 and interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM failed to identify the concerns were investigated. RN #2/Corporate Nurse stated she did not know why that was not done. Further, RN #2/Corporate Nurse stated staff spoke with Residents #2, 4, 5, and 6 following their allegations of abuse and/or neglect to the Surveyor, but reported the facility did not feel that the concerns (from Resident's #2, 4, 5, and 6) needed to be investigated as the residents could not provide enough details to substantiate their claims. Interview with the DNS on 8/7/2024 at 12:36 PM identified she was not aware the facility had a grievance book and would expect any nursing or care issues to be brought to her as soon as possible and to be discussed in morning report. Additionally, she identified that the Concern Forms for Resident's #1, 4, and 9 appeared to be allegations of abuse and/or neglect. She identified that she would investigate and then report them to the State Agency if the allegation was substantiated. The DNS indicted she was not aware that she should report allegations to the State Agency regardless of the outcome of the investigation. Review of the facility Grievance Policy dated 11/2013 directed in part, if the concern/complaint is a questionable abuse allegation, the facility's abuse policy and procedure will be followed. Review of facility Abuse Policy (undated) directed in part, that the facility would conduct an investigation into allegations of abuse and the the accused staff will be immediately suspended pending the findings of the investigation.

Based on clinical record review, facility documentation review, facility policy review, and interviews, for 4 of 18 residents (Residents 4, 1, 21 and 23) who alleged rough care was provided by staff and alleged incontinent care was not provided timely, the Facility failed to protect the residents' right to be free from abuse and/or neglect. The failures resulted in a finding of Immediate Jeopardy. Cross reference F610 1. Resident #4's diagnoses included spinal stenosis (narrowing of the space around the spinal cord) and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairment. Review of a nursing note dated 6/18/2024 at 3:38 AM identified that at 12:30 AM, Resident #4 alleged he/she had been harmed by a NA during care on the evening of 6/17/2024. Resident #4 identified that NA #1 stated he/she was like moving a thousand pounds and that NA #1 was not hurting her back to move Resident #4. Resident #4 further stated that NA #1 is rough with care, used a stern/unfriendly tone when answering the call bell, and had pushed him/her hard several times and hit Resident #4's head into the nightstand. The resident reported slight pain to the left eyebrow and the nurse observed a 2-centimeter by 2-centimeter area of faint swelling and redness to the left brow. Resident #4 indicated that NA #2 witnessed the incident. Review of the RN assessment dated [DATE] at 8:03 AM, signed by the DNS, identified that redness was noted to Resident #4's left brow, and he/she complained of a headache. Facility incident report dated 6/18/2024 identified Resident #4 alleged staff were rough during a Hoyer lift transfer that occurred on 6/17/2024 and hit his/her left eyebrow on the nightstand. The report included two (2) statements from NA #2 dated 6/18/2024 that she witnessed the interaction between NA #1 and Resident #4 and identified no abuse was witnessed. Review of the Concern Form (grievance) dated 6/20/2024, signed by Administrator #2 and SW #1 identified Resident #4 reported that staff were rough during a Hoyer lift transfer on 6/18/2024 and his/her left eyebrow was bumped on the nightstand. No injury was noted, and staff were provided with education. Interview with Social Worker #1 on 8/6/2024 at 10:08 AM identified although Resident #4 had a diagnosis of dementia, he/she had consistent recall of the incident and was an accurate reporter. Interview with NA #2 on 8/5/2024 at 2:52 PM identified that on 6/17/2024 on the 3 to 11 PM shift she witnessed NA #1 speak to Resident #4 disrespectfully and forcefully pushed Resident #1, hitting the left side of Resident #4's head on the nightstand. NA #2 stated the area was reddish purple after the incident. NA #2 stated that her written statements dated 6/18/2024 were not accurate of the events she witnessed. NA #2 stated when the DNS interviewed her about the incident, she had NA #1 present. Because she is afraid of NA #1, she did not report the abuse. NA #2 stated she had verbally told the DNS that she witnessed the incident, but because she was interviewed in front of NA #1, she did not write it on her statement. NA #2 further stated NA #1 had been verbally abusive to her in the past and she was afraid of retaliation. Interview with NA #5 on 8/5/2024 at 3:11 PM identified on 6/18/2024 Resident #4 reported to her and another NA (NA #4) that NA #1 shoved him/her forcefully to the left side in the bed (the evening before) and he/she hit his/her head. NA #5 stated she notified RN #9 (11-7 supervisor). Interview with RN #9 on 8/6/2024 at 1:09 PM identified on 6/18/2024, NA #5 reported Resident #4's allegation that NA #1 was rough with care and made verbal comments. RN #9 stated she called and texted the DNS, notified the local police, and completed an incident report. Interview with NA #4 on 8/7/2024 at 1:05 PM identified that Resident #4 alleged NA #1 was rough with care and Resident #4 was afraid of NA #1. Interview with the DNS on 8/8/2024 at 11:45 AM identified although Resident #4's story remained consistent, and NA #2 stated she witnessed NA #1 provide rough care to the resident, the facility did not substantiate the allegation of abuse. The DNS was unable to explain why the allegation of abuse was not substantiated. 2. Resident #1's diagnoses included chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, exhibited no behaviors, required moderate assistance for transfers and toileting, and Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan dated 3/13/2024 identified that Resident #1 required staff assistance with ADLs and toileting. Interventions directed to assist with toileting needs. Review of the Concern Form (grievance) dated 7/15/2024 identified Resident #1's family member alleged staff were rough when toileting Resident #1 and expressed a concern about the way staff spoke to Resident #1 on 7/14/2024. The form was signed by the Social Worker. Late entry Social Service note dated 7/15/2024 at 1:09 PM identified the DNS, SW #1 and the Administrator spoke with Resident #1's family member on 7/15/2024 about their concerns and wrote a grievance. Review of the facility Incident Report dated 7/22/2024 (8 days after the incident) identified on 7/14/2024 at 4:00 PM, a family member reported while on a phone call with Resident #1, he/she overheard staff yelling at the resident stating he/she was exhausting, no one wants to come in his/her room and that he/she was the reason why staff was leaving. Statements from Resident #1 and his/her roommate (Resident #8) were obtained by Social Worker #1 on 7/15/2024. Written statement from RN #1 dated 7/14/2024 (day of the incident) identified the family notified him on 7/14/2024 at 5 PM that he/she heard staff yelling at Resident #1 that he/she is exhausting, and the resident was afraid of retaliation. RN #1 spoke with Resident #1 who stated when he/she drinks a lot, he/she urinates a lot and the NA yells at him/her for ringing the call bell. Resident #1 described the accused NA, and the NA was subsequently identified as NA #1. Review of the facility daily punch details for NA #1 identified that she worked on 7/14, 7/15, 7/17, 7/18, 7/19, 7/22 and 7/23/2024 with a comment that indicated NA #1 was suspended on 7/23/2024. NA #1 returned to work on 7/26/2024. The investigative summary dated 7/25/2024 identified NA #1 was not using a professional tone during care, and that Hoyer lift (mechanical lift) transfers need to be gentler. NA #1 was suspended on 7/23/2024 (9 days after the allegation) and provided with customer service education, sensitivity training and random observations of care (abuse education provided was attached to the summary). Review of Psychiatric APRN note dated 7/16/2024 identified Resident #1 reported he/she was upset with how staff handled him/her when assisting with toileting and the way the NA spoke to him/her while providing care. Interview with Resident #1 on 8/1/2024 at 8:54 AM identified on 7/14/2024, he/she rang the call bell because he/she needed to have a bowel movement and waited for three hours because the NAs kept turning off the call bell. The resident identified when NA #1 entered the room to provide care, NA #1 started yelling at him/her and stated that no one wants to take care of him/her because he/she has to use the toilet too often. Resident #1 indicated when NA #1 transferred him/her to the commode, she pushed him/her hard, hitting Resident #1 into the commode and stated it was painful. Resident #1 also indicated shortly after the incident, his/her family visited and reported they had overheard the staff comments when they were on the phone. Interview with Person #2 on 8/1/2024 at 9:38 AM identified he/she received a call from Resident #1 on 7/14/2024 and she heard a female voice yelling at Resident #1 that he/she was exhausting, and the facility was short staffed because of Resident #1. Person #2 stated that while on the phone with the resident, he/she received a call from Resident #8 (Resident #1's roommate), and he/she put the call with Resident #1 on hold. Resident #8 told him/her that Resident #1 needed help awfully bad, stating he/she was wet and requested that Person #2 come to help Resident #1. Person #2 hung up with Resident #8 and drove to the facility while remaining on the call with Resident #1. When Person #2 arrived in Resident #1's room he/she observed a soiled brief in the waste basket (wet and with feces). Resident #1 asked Person #2 to not report the incident as he/she was concerned that NA #1 would be rough and was afraid of NA #1. Interview with NA #2 on 8/1/2024 at 12:49 PM identified at the beginning of her shift at 3 PM on 7/14/2024, Resident #1's roommate (Resident #8) reported Resident #1 got man handled and he/she was afraid for him/her, and the family arrived at that time and reported the incident to staff. Interview with NA #1 on 8/1/2024 at 1:34 PM identified she denied the allegations that she was rough with or made inappropriate comments to Resident #1. NA #1 further stated Resident #1 had an overactive bladder and that it was not realistic to toilet him/her as often as he/she rings the call bell. Interview with SW #1 on 8/1/24 at 10:19 AM identified that she was aware that a grievance is a minor concern and was aware of the definitions of abuse in accordance with Federal regulations and the requirement for investigations to be completed. SW #1 further stated she follows the direction of the Administrator for grievances and allegations of abuse. She indicated that when she receives a grievance, she notifies the Administrator and the department that the grievance/concern relates to so that an investigation can be initiated. She reported she was concerned regarding the allegation of abuse regarding Resident #1 and notified the Administrator on 7/15/2024. Although SW #1 was concerned about the allegation, she was directed by Administrator #2 to complete a Concern Form. Additionally, she indicated that there have been many issues and complaints from both families and staff regarding NA #1 and stated NA #1 was imposing and intense. SW #1 reported that she was worried for the residents on the weekends when there is no oversight and no social worker present in the facility, however she stated she did not discuss her concerns with the corporate office. Interview with RN #1 (3-11 supervisor) on 8/1/24 at 12:52 PM identified on 7/14/2024 at 3:30 PM, Person #2 (Resident #1's family member) reported to him and LPN #1 that he/she overheard a staff member talking abusively to Resident #1 and reported to RN #1 that the same NA was rough with care. RN #1 identified that it was an allegation of abuse, however, he did not remove the staff member from the schedule. Interview, facility documentation and record review with DNS and DNS #2 (Regional DNS) on 8/1/2024 at 12:20 PM, DNS #2 stated she was aware of the 7/14/2024 allegation of abuse. Interview identified that NA #1 should not have made the comments and should not have been rough when providing care. Interview identified although Resident #1 was alert and oriented, and the incident was heard by Person #2, NA #1 was given disciplinary action for an inappropriate interaction and inappropriate language with a resident, the facility did not substantiate the allegation of abuse. Interview identified although the allegation should have been addressed on 7/14/2024 when it was first reported to RN #1, staff failed to follow facility policy on protecting the residents while an investigation was being conducted. Interview with Administrator #2 (former Administrator) on 8/1/2024 at 11:32 AM identified he was the Administrator when the incident occurred, stated the allegation was abuse, he was directed to report all allegations of abuse to corporate for direction, and in this case was directed to complete a grievance of the allegation. Administrator #2 stated that the incident should not have occurred, and staff failed to implement their policy to remove the accused staff member pending investigation to ensure all residents are protected. Administrator #2 further indicated there had been numerous complaints regarding NA #1 from residents and families, and that there was a folder on NA #1 in the Administrators office. Interview with RN #2 on 8/7/2024 at 3:05 PM identified that NA #1 was irate about being taken off the schedule on 7/23/2024 pending investigation. She indicated that NA #1 was repeatedly calling the facility and staff members personal phones on 8/2/2024, threatening to drive to the facility if she wasn't given information on the investigation. RN #2 indicated that the facility called the police and then NA #1 subsequently called the facility back and stated she was resigning on 8/7/2024. 3. Resident #21 had diagnoses that included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 had moderate cognitive impairment and required assistance with ADLs. Facility incident report dated 7/29/2024 identified Resident #21 reported he/she was in bed too long and was not changed to the point that his/her skin was burning from laying in urine. Resident #21 also complained that he/she had not had a shower in over a month, and NA #5 told him/her and Resident #11 to keep your mouth shut, you both talk too much. Interview on 8/5/2024 at 3:11 PM with NA #5 (worked 11PM - 7:00AM shift) identified on 7/29/2024 at the start of her shift she observed both Resident #11 and #21 (roommates) were incontinent. NA #5 stated she heard NA #1 say to Residents #11 and #21 to mind their own business and she notified RN #3 the residents were incontinent and what she overheard NA #1 say to the residents. Interview with RN #3 on 8/6/2024 at 12:24 PM identified he worked the 3 to 11 PM shift on 7/29/2024, and at the end of his shift NA #5 reported Resident #11 stated the NAs on 3-11 shift were too busy to give care to Resident #11 and #21. RN #5 stated he directed NA #1 and #6 (worked 3-11 PM shift), to provide care that had been omitted for Residents #11 and 21. RN #3 stated did not know what care was given during the shift. Interviews with NA #1 was unable to be obtained during the survey. During interview with NA #6 on 8/8/2024 at 10:45 AM stated they were short staffed and gave care when they could during the shift. NA #6 was unable to identify when Resident #11 and 21 last received care. 4. Resident #23's diagnosis included a history of recent C-difficile infection. The RCP dated 7/11/2024 identified Resident #23 required assistance with ADLS. Interventions directed to assist as needed to meet needs. The 5-day quarterly MDS assessment dated [DATE] identified Resident #23 was alert and oriented and required assistance with mobility and toileting. The Facility grievance dated 8/6/2024 identified two (2) nights ago at 1 AM, Resident #23 rang the bell and requested to be changed (incontinent care). NA #12 responded in a not nice manner that Resident #23 would have to wait, because Resident #23 was just changed. Resident #23 waited until 3:13 AM (two hours and thirteen minutes later) and put the call light on again and the care was provided. Review of the facility incident report dated 8/6/2024 at 4 PM alleged staff was not nice and was nasty when Resident #23 asked to be changed, and Resident #23 rang to request care at 1 AM, and care was not provided until 3:15 AM. NA #12 statement identified she indicate she provided resident care at 1, 4 and 6 AM. Interview with Resident #23 on 8/8/2024 at 1:15 PM confirmed the allegations as described in the grievance and stated he/she had loose stools when he/she requested care. Interview, clinical record review, and facility documentation review with the DNS on 8/8/2024 at 9:35 AM identified Resident #23 was having loose stools related to the C-difficile, and on 8/6/2024 Resident #23 reported that on Saturday night (8/4/2024) he/she requested to be changed about 1 AM. NA #12 answered the call bell and told Resident #23 that she had just provided care and Resident #23 would have to wait. Resident #23 did not ring the bell again until 3 AM because he/she thought the NA was coming back, and care was provided at 3 AM (2 hours after requested). The DNS stated the care should have been provided when Resident #23 requested care at 1 AM. Further, the DNS stated care should have been provided every two (2) hours, not at 1, 4 and 6 AM. The DNS was unable to explain why the allegation was not investigated as an allegation of abuse/neglect, in accordance with facility policy. Although attempted, NA #12 was unavailable for interview during the survey. Review of facility Abuse Policy (undated) directed in part, residents will be free from abuse, and the accused staff will be immediately suspended pending the findings of the investigation.

Based on clinical record review, facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings include: The facility administration failed to: • Ensure continued compliance with the plan of correction from a prior survey to ensure the State Agency was notified timely of reportable events. • Ensure allegations of abuse were investigated timely. • Ensure staff accused of abuse were removed from the schedule timely. • Ensure residents were treated with respect and dignity. • Ensure grievances were responded to timely. • Ensure care plans were reviewed and updated timely. • Ensure annual performance evaluations were completed timely. • Ensure support visits were provided for residents after an allegation of abuse. • Ensure the clinical record was complete and accurate. • Ensure staffing met resident needs and/or the Public Health Code. Please cross reference F550, F565, 600, F609, and F610, F656, F657, F725, F730, F745, F842 and F865. Interview with the Administrator on 8/5/2024 at 2:33 PM identified he had been at the facility for 2 weeks, indicated the facility administration was aware of all the grievances reported as they were signed by the Administrator. The Administrator stated he was unaware if the grievances were reported in a timely manner, and that the grievances regarding abuse should first have been reported to the State Agency and then investigated by the facility (to substantiate or unsubstantiate the allegation). Interview with the Administrator on 8/8/2024 at 10:19 AM failed to identify a process for administrative oversight of the facility processes for allegations of abuse, reporting allegations of abuse, investigating allegations of abuse, and maintaining compliance with a prior plan of correction. The State Agency conducted a survey with an exit date of 2/22/2024 with findings of abuse and findings that the State Agency was not notified timely of a reportable event. The Plan of Correction identified the facility would conduct staff education, audits and QAPI to ensure the State Agency was notified timely, with a correction date of 5/8/2024. Please cross reference F600 and F609 findings. Interview with the Administrator, DNS, RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 3 PM identified although the facility was put back into compliance with the abuse findings and the reporting to the State Agency findings as of 5/8/2024, the facility no longer conducted audits after that time. Interview failed to identify the facility was able to sustain compliance with the previously cited findings. Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the areas of Freedom from Abuse, Reporting of Alleged Violations, and Investigate/prevent/correct Alleged Violation. The facility failed to utilize resources effectively to attain/maintain the resident's well-being. Review of the Administrator Job Description identified the responsibility of the Administrator was to plan, organize, develop, and direct the overall operations of the facility in accordance with current federal, state, and local standards and regulations, and to ensure the highest quality care was given at all times in a safe and secure facility.

Based on facility documentation review, facility policy review and interviews for facility QAPI review, the facility failed to ensure the facility was able to maintain compliance with deficiencies previously identified. The findings include: A complaint survey was completed on 2/22/2024 with findings related to abuse and reporting allegations of abuse to the State Agency timely. The Facility plan of correction (POC) identified audits would be conducted for 30 days or until substantial compliance with QAPI oversight. Facility documentation review identified nine (9) grievances (Residents #1, 4, 9, 10, 11, 12, 13, 14 and 15) regarding allegations of lack of care and/or allegations of abuse/mistreatment that were not reported to the State Agency timely and lacked documentation of comprehensive investigations. Review of the 4/22 and 7/11/2024 QAPI meetings failed to identify the meetings included a review of allegations of abuse/mistreatment and/or grievances. Additional review failed to identify the QAPI directed to discontinue the audits. Review of facility documentation identified the following grievances with allegations of abuse before the POC: • 7/30/2023, Resident #13 • 7/30/2023, Resident #14 • 10/6/2023, Resident #12 • 12/8/2023, Resident #11 Review of facility documentation identified the following grievances with allegations of abuse during the POC: • 3/5/2024, Resident #1 Review of facility documentation identified the following grievances with allegations of abuse after the POC: • 5/16 and 7/15/2024, Resident #1 • 6/3/2024, Resident #10 • 6/20/2024, Resident #4 • 7/16/2024, Resident #9 Interview and facility documentation and grievance review with the Administrator on 8/8/2024 at 10:19 AM identified although the State Agency reviewed facility POC documentation on 5/24/2024 and indicated the facility was back into compliance as of 5/8/2024, the Administrator was unable to explain how the facility maintained compliance after that date. The Administrator stated the QAPI meeting conducted on 4/11/2024 included notations that a complaint survey was conducted with four (4) deficiencies identified, and the plan of correction was not yet approved. The 7/11/2024 QAPI meeting included a notation that the facility was put back into compliance for surveys that occurred in February and March 2024. The Administrator was unable to provide documentation that the QAPI meetings included continued oversight regarding abuse and reporting allegations to the State Agency. Please cross reference F600, F609 and F610.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two (2) of eighteen (18) residents, (Resident #9 and 10), reviewed for abuse, the facility failed to ensure a comprehensive care plan was developed timely to include resident refusals of care. The findings include: 1. Resident #9's diagnoses included Alzheimer's disease, encephalopathy (disturbance of brain function), polyneuropathy (damage of multiple peripheral nerves), unstageable pressure ulcer of back and failure to thrive. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was had moderate cognitive impairment, exhibited no behaviors and required moderate assistance with bed mobility and transfers and maximal assistance with toileting. The Resident Care Plan dated 7/3/2024 identified that Resident #9 required staff assistance with Activities of Daily Living (ADL's) with interventions that directed to assist as needed to meet toileting needs, incontinent care per policy, assist with feeding as needed, and to keep commonly used/needed items within reach. Review of Concern Form dated 7/16/2024 alleged that clothing was not being changed, medications were being handed to Resident #9 in a cup and nursing was not supervising the resident taking the medications, and questions whether showering and/or bathing was being completed. The summary indicated that Resident #9 refuses showers and washing up. Review of July 2024 progress notes failed to identify any resident refusals. Although requested, Nurse Aide documentation for July 2024 was not obtained. The care card for Resident #9 did not indicate any instructions related to care refusals. 2. Resident #10's diagnoses included spinal stenosis (narrowing of the space around the spinal cord putting pressure on the spinal cord and nerves, causing pain), chronic pain, atrial fibrillation, and weakness. The quarterly MDS assessment dated [DATE] identified Resident #10 was moderate cognitive impairment, exhibited no behaviors and required moderate assistance with bed mobility, transfers, personal hygiene and transfers. The Resident Care Plan dated 5/9/2024 identified that Resident #10 required staff assistance with ADL's and had a history of a traumatic left arm amputation with interventions that directed to assist as needed to meet toileting needs, incontinent care per policy, assist the resident to get out of bed prior to breakfast per preference, keep commonly used/needed articles within reach, side rails per physician's orders to assist with bed mobility and transfers per physician's orders. Review of Concern Form dated 6/3/2024 identified that Resident #10 was often soiled in the wheelchair, however, it did not include any further details as to the date, time or shift that the allegation occurred. The summary/findings indicated that Resident #10 doesn't want to wear depends (pull-up briefs) and will not report when he/she is soiled. Review of progress notes for June 2024 failed to identify any refusals. Review of Behavior Monitoring for June 2024 failed to indicate any behaviors for Resident #10. Interview and clinical record review with the DNS on 8/7/2024 at 12:36 PM identified that residents with known refusals should have a care plan to indicate the refusals, what they refuse and interventions to encourage the resident to participate in their plan of care and it should be indicated on their care card. She indicated that the interdisciplinary team will discuss resident updates and changes in morning report and that the MDS nurses attend daily and the MDS nurses are responsible for keeping the comprehensive care plans updated. She identified that neither Resident #9 nor Resident #10 were care planned for refusals but indicated that they should have been. Although requested, a policy on resident refusals was not obtained. Review of the Care Planning policy dated 10/30/2020 directed, in part, that the care plan will include a statement of the problem/focus, reasonable and measurable goals, interventions to achieve goals and the discipline responsible for carrying out the interventions.

Based on clinical record review, facility documentation review, facility policy review, and interviews for eight of nine residents (Resident #13, #14, 15, 12, 11, 1, 10 and 9) reviewed for grievances, the facility failed to ensure grievances were responded to timely and failed to ensure the complainant was notified of the results timely. The findings include: 1. Resident #13's diagnoses included convulsions (rapid, involuntary muscle contractions and relaxations resulting in uncontrolled shaking and limb movement), weakness, and anxiety. The admission MDS assessment dated [DATE] identified Resident #13 had moderate cognitive impairment, exhibited no behaviors and required moderate assistance with ADLs and toileting. The Resident Care Plan dated 7/30/2023 identified Resident #13 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs, and incontinent care per policy. Review of the Concern Form dated 7/30/2023 alleged Resident #13 required incontinent care, and a family member rang the call bell several times with no response. The family went into the hallway and observed NA #10 (assigned NA) at the desk talking and then NA #10 then went into a different room; the form indicated the complainant felt as if NA #10 ignored him/her and the ringing call bell. The family member then reported the incident to the nurse who then got the Administrator. Although Concern Form included a description of the concern, departments contact and signatures by the Administrator and Social Services signatures dated 8/1/2023, the form failed to include a summary, actions taken and a response to the concerned person. Interview with DNS #3 on 8/7/2024 at 2:42 PM identified that she was not aware of the allegation and stated if she were notified, she would have requested more information as to how long the resident waited and when care was provided. DNS #3 stated during July 2023, grievances/concerns were reviewed during morning meeting and she did not know why she was not made aware of the allegation. Interview with NA #10 on 8/8/2024 at 9:39 AM identified he was not aware of the above concern and indicated no one questioned him about it or requested that he write a statement. Documentation review with DNS #3 on 8/7/2024 failed to identify an investigation was initiated after the allegation on 7/30/2023. 2. Resident #14 had diagnoses that included anxiety and hemiplegia/hemiparesis (muscle weakness or paralysis of one side). The RCP dated 7/13/2024 identified Resident #14 required assistance with ADLs. Interventions directed to assist with ADLs and toileting. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was alert and oriented, and required extensive assistance of one staff for toileting and transfers. Review of facility grievance dated 7/30/2023 and signed by RN #7, identified Resident #14's family complained they did not like the way a staff member (LPN #5 or NA #7) spoke with and acted toward Resident #14. Resident #14 further complained that NA #7 showered him/her with two other employees present, and while Resident #14 was naked and cold, the employees sprayed each other with water and laughed. The form further identified NA #7 answered the call bell when Resident #14 asked to use the restroom in the middle of the night. NA #7 stated Resident #14 would have to use the bedpan because she was busy. Resident #14 alleged that NA #7 forcefully placed a pad under Resident #14 and roughly placed a bedpan under the resident. When NA #7 removed the bedpan, she raised her voice to direct Resident #14 to roll over. Additional review of the grievance identified the NA was no longer to be assigned to Resident #14 (the NA was not identified), and the form was not completed to indicate a response was communicated to the person that made the complaint. Record review identified Resident #14 last received a shower prior to the grievance on 7/15/2023 from NA #11. Interview and record review with RN #7 on 8/6/2024 at 3:28 PM identified although she did not recall the specifics of the complaint, she stated she completed the grievance, and she would have given the form to the DNS and the social worker. Interview and record review with SW #1 on 8/7/2024 at 11:30 AM identified although she was aware of the grievance, and she signed the grievance, interview failed to identify the complaint was investigated. Interview and record review with the DNS on 8/7/2024 at 12:28 PM identified the grievance form had no investigation attached, and the DNS was unable to provide documentation that an investigation was completed. Although the grievance identified the staff involved was either LPN #5 or NA #7, the interview identified neither staff worked on 7/29 or 7/30/2023. Further, the DNS was unable to identify what staff was no longer to provide care for Resident #14. The DNS stated the form should be completed to identify the person who made the complaint was notified of the resolution, and she did not know why it was not done. The DNS stated she was new in the position and was unable to explain why there was no investigation completed into the grievance. 3. Resident #15's diagnoses included Parkinson's disease (brain condition that causes slowed movements, rigidity and tremors), depression and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #15 was alert and oriented and required limited assistance hygiene and toileting. The RCP dated 8/15/2023 identified Resident #15 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs, incontinent care per policy, and assist with ADLs. Review of the Concern Form (grievance) dated 8/15/2023 alleged on an unidentified date/time, shower times for Resident #15 varied, the shower was missed on the assigned day, and Resident #15's brief was not changed in a timely manner. Documentation review with the DNS on 8/7/2024 at 12:28 PM identified although the allegation was made on 8/15/2024, and a shower was given on 8/15, 2024, the Form failed to identify an investigation was initiated regarding missed showers and a brief not changed timely. 4. Resident #12's diagnoses included displaced fracture of the left femur, Parkinson's disease with dyskinesia (involuntary muscle movement) and depressed mood. The quarterly MDS assessment dated [DATE] identified Resident #12 had moderate cognitive impairment and required maximal assistance with toileting. The RCP dated 8/28/2023 identified Resident #12 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs and incontinent care per policy. Review of an undated and unsigned Concern Form (grievance) identified Resident #12 had a concern that his/her transfers were not going smoothly, and he/she was not getting to the bathroom timely. The Form indicated that the Administrator and the DNS were notified on 10/6/2023 and staff were educated on 10/6/2023 to move Resident #12 at his/her speed, however, education failed to address the concern regarding toileting. Although the form identified Resident #12 was to be seen by rehab and the APRN for follow-up, the form was not dated or signed by rehab. Further, the form was not completed to indicate a response was communicated to the person that made the complaint, and the lines for the Administrator and Social Services signatures were blank. Interview with RN #2/Corporate Nurse on 8/2/24 at 10:11 AM identified there was no documentation of an investigation being completed. RN #2/Corporate Nurse stated an investigation should have been done and the Concern Form should have been completed. 5. Resident #11's diagnoses included cerebral infarction (stroke) affecting the right dominant side, and major depressive disorder. The admission MDS assessment dated [DATE] identified Resident #11 was alert and oriented and was dependent on staff with toileting. The RCP dated 12/8/2023 identified that Resident #11 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs and provide incontinent care. The Concern Form dated 12/8/2023 alleged when NA #11 provided care, Resident #11's clothing and bed linens were noted to be heavily saturated. The form did not identify any further details or the date and time that the allegation occurred. The summary was blank with no provided information. The actions taken identified that an RN assessment and skin check were completed, call bell placement was verified, NA education and voiding diary education were provided although no education was attached or provided. The form was not completed to indicate a response was communicated to the person that made the complaint. Interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM failed to identify response was communicated to the person that made the complaint. 6. Resident #1's diagnoses included chronic kidney disease. The annual MDS assessment dated [DATE] identified Resident #1 was alert and oriented, required moderate assistance for transfers and toileting, and Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan dated 3/13/2024 identified that Resident #1 required staff assistance with ADLs and toileting. Interventions directed to assist with toileting needs. Review of the Concern Form dated 5/16/2024, signed by the Administrator and Social Worker (SW) #1 identified Resident #1 reported on an unidentified date and time, the call light was shut off after staff told him/her that they could not assist him/her, and they would come back later. No additional information was included on the form regarding the allegation. The summary line was left blank. It reported that the action taken included education to staff not to turn off call lights unless the resident's request was attended to. Further, the form was not completed to indicate a response was communicated to the person that made the complaint. Interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM failed to identify a summary of the investigation was included and a response was communicated to the person that made the complaint. 7. Resident #10's diagnoses included spinal stenosis (narrowing of the spinal cord space, causing pain), chronic pain, and weakness. The RCP dated 5/9/2024 identified Resident #10 required staff assistance with ADLs and was incontinent. Interventions directed to assist with toileting and provide incontinent care. Review of the Concern Form (grievance) dated 6/3/2024 identified on unidentified dates/times, Resident #10 was often soiled in the wheelchair. Interview and facility documentation review with RN #2/Corporate Nurse and RN #10/Corporate Nurse on 8/8/2024 at 12:28 PM failed to identify the facility was able to provide documentation that an investigation for the allegation reported on 6/3/2024 was conducted. Interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM failed to identify a summary of the investigation was included and a response was communicated to the person that made the complaint. 8. Resident #9's diagnoses included Alzheimer's disease. The 5-day MDS assessment dated [DATE] identified Resident #9 had moderate cognitive impairment, had no rejection of care, and required maximal assistance with toileting and ADLs. The RCP dated 7/3/2024 identified Resident #9 required staff assistance with ADLs. Interventions directed to assist with ADLs and bathing, administer medications as ordered. Review of an undated Concern Form identified when Resident #9 was served a meal at an unidentified time, Resident #9 stated he/she did not want the meal and subsequently did not eat. Although the Form indicated the DNS and Dietician were notified on 5/20/2024, the Form failed to identify who completed the form and the staff member who was told Resident #9 did not want the meal. The summary section was blank and was not completed to indicate a response was communicated to the person that made the complaint. Interview with RN #2/Corporate Nurse on 8/2/2024 at 10:11 AM failed to identify a summary of the investigation was included and a response was communicated to the person that made the complaint. Review of facility Grievance Policy dated 11/2013 directed, in part, that an internal investigation will be conducted as soon as possible when a complaint/concern regarding any aspect of resident care is brought to the attention of staff. The complaint/concern will be reviewed with the Administrator and Director of Nursing to determine the severity and investigation process. The complaint/concern will be addressed with the appropriate department who is most directly responsible to ensure prompt and reasonable resolution. The Social Worker will address the complaint/concern with the resident and/or responsible party and document in the resident's record in the Social Work section. The Administrator or designee is responsible for following up on the concern/complaint, ensuring appropriate staff is investigating the concern/complaint and there is documentation regarding a reasonable resolution. The Social Worker or designee will ensure all concern forms are completed. Each form will contain the concern, the resolution and the person who was responsible for resolving the concern. The Social Worker will document the resolution and notification of the resolution to the resident/responsible in the resident's record.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one (1) of eighteen (18) residents, (Resident #22), reviewed for abuse, the facility failed to ensure monitoring was provided in accordance with the plan of care and/or in accordance with physician orders. The findings include: Resident #22's diagnoses included Alzheimer's disease, epilepsy (seizure disorder), dementia with psychotic disturbances and an adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had moderate cognitive impairment, exhibited no behaviors and required supervision assistance with bed mobility, transfers, personal hygiene and toileting. The Resident Care Plan dated 1/26/2024 identified Resident #22 had a history of being impulsive and was not consistently able to control his/her behavior. Interventions directed to offer clear and simple explanations of tasks and occurrences, avoid information overload when he/she is angry or aggressive, with change in behavior assist him/her to another area and spend a few minutes in quiet conversation until anger subsides. Physician's order dated 3/5/2024 directed that Resident #22 was on every 30 minute checks, all shifts. Review of a facility Reportable Event dated 3/14/2024 identified that Resident #22 was placed on one to one observation following a resident-to-resident altercation on 3/14/2024 at 1:00 AM where Resident #4 alleged that Resident #22 hit him/her on both feet. A nursing note dated 3/14/2024 at 12:55 AM identified that Resident #22 had no observed behaviors prior to the incident and Resident #22 reported he/she didn't remember putting his/her hands on Resident #4. The note further identified that Resident #22 was placed on one to one observation following the incident. Review of the facility staffing schedule dated 3/13 and 3/14/2024 failed to identify any staff responsible for the one to one observation for Resident #22 for the 11:00 PM to 7:00 AM and 7:00 AM to 3:00 PM shift until Resident #22 was cleared by psychiatric services. Psychiatric Advanced Practice Registered Nurse (APRN) note dated 3/14/2024 at 4:20 PM identified that Resident #22 was not considered a danger to him/herself or others and to discontinue the one to one observation. A Physician's order dated 3/14/2024 directed to discontinue one to one monitoring on Resident #22 and to continue every 30 minute checks. Review of the facility census identified that Resident #4's room was not changed until 3/15/2024, one day after the allegation against Resident #22. Review of facility documentation failed to identify every 30-minute checks every shift were completed from 3/5/2024 through 6/5/2024 per physician's orders, and that one to one monitoring was completed on 3/14/2024. Interview and clinical record review with the DNS and RN #2 (Regional DNS) on 8/7/2024 at 8:53 AM identified that they were unable to provide documentation for Resident #22 for both the one to one observation on 3/14/2024, and the every 30-minute checks per physician's orders from 3/5/2024 through 6/5/2024. She identified when a resident is placed on a one to one observation it is a nursing measure and does not require a physician's order. She identified that she would expect the staff dedicated to providing one to one observation indicated/identified on the staffing schedule for each shift and there should be one to one observation documentation in the clinical record each shift. She reported she was unable to provide the names of the staff who provided the one to one observation on 3/14/2024 and was unsure if it was provided each shift until Resident #22 was cleared by the psychiatric APRN. Further, she indicated that the every 30 minute checks should have been completed per physician's orders and located in the clinical record and was unsure why it could not be located. Interview with the DNS on 8/8/2024 at 11:45 AM identified that Nurse Aide staff has resident assignments but could not provide documentation of them to identify which NA's had which residents. Additionally, she indicated that the assignments are not transcribed onto the working schedule. Review of the Close Monitoring of a Resident policy (undated) directed, in part, that residents who are exhibiting behaviors that pose a high risk for harm or injury to self or others will be assessed by the RN or designee for close monitoring. If the resident condition is managed by the facility, one to one observation will remain in place until the DNS, ADNS and/or Nursing Supervisor assess the resident's behavior and determines one to one monitoring is no longer necessary. The resident's care plan will reflect the close monitoring. The close monitoring will be documented in the resident's medical record.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two (2) of eighteen (18) residents, (Resident #1 and #7), reviewed for abuse, the facility failed to ensure Resident Care Conferences were held with the resident and/or resident representative quarterly in accordance with facility policy. The findings include: 1. Resident #1's diagnoses included multiple myeloma (cancer of white blood cells in the bone marrow), type II diabetes mellitus, anemia and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors, required moderate assistance for transfers and toileting, and Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) identified that Resident #1 required staff assistance with Activities of Daily Living (ADL's) and toileting with interventions that directed to assist with toileting needs. Prior to the 3/3/2024 MDS, the ADL RCP was last revised on 3/28/2023. Review of the clinical record for Resident #1 failed to identify any documented Resident Care Conferences (RCC) or Care Plan reviews. The facility was only able to provide RCC documentation dated 6/6/2024 at 10:30 AM. 2. Resident #7's diagnoses included spondylosis (age-related wear of the spinal discs), major depressive disorder and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #7 was cognitively intact, exhibited no behaviors and was independent with bed mobility, transfers and toileting. The RCP identified that Resident #7 required assistance with ADL's with interventions that directed to provide incontinent care per policy, and keeping articles within reach. Prior to the 1/17/2024 MDS, the ADL RCP was last revised on 4/14/2022. The facility was able to provide Resident Care Conference documentation that was dated August 1 (no year specified). Interview with Registered Nurse (RN) #10/Corporate Nurse on 8/20/2024 at 2:28 PM identified that although Resident Care Conferences should be conducted quarterly, they were unable to provide either paper or electronic documentation that they had been completed every quarter for Resident # 1 and Resident #7 Review of the Care Planning policy dated 10/30/2020 directed, in part, that a Care Conference to discuss the plan of care will be held at least quarterly. The resident and/or family/responsible party will be invited to attend all care plan conferences. The Care Plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status.

Based on clinical record reviews, observations, review of facility's documentation and interviews for two of four sampled resident (Resident #14 & #46) with facility acquired pressure ulcers, the facility failed to ensure interventions were consistently implemented to prevent the development and subsequent treatment of a pressure ulcer/injury by ensuring the residents' heels were off loaded per the plan of care and physician's orders. The findings include: 1. Resident #14's diagnoses included Alzheimer's disease, heart failure, disorders of plasma- protein metabolism, contracture (shortening and hardening of muscles and tendons or tissue leading to deformity or rigidity of joints) to right hip and knee, contracture to left hip and knee and poly-osteoarthritis. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severe cognitive impairment with no behavioral issues, was totally dependent for all activities of daily living (ADLs), was always incontinent of bowel and bladder and had no issues with swallowing. A review of the Resident Care Plan dated 12/05/2022 identified Resident #14 was at risk for skin breakdown with interventions that included: off load pressure to heels with a pillow and provide a pressure reduction cushion for the chair/wheelchair. The nurse's note dated 1/19/2023 at 11:25 PM identified the nurse was asked to look at Resident #14's left heel. An assessment of heel identified an area of redness. The supervisor was notified and determined the area was DTI (deep tissue injury). A heel protector boot with an opening on the heel was applied to the resident's left leg/foot and the leg was then elevated on a pillow. A wound tracking note written by RN #2 (wound nurse) dated 1/19/2023 identified Resident #14 had a deep tissue injury to the left heel that measured 2.3 centimeters by 1.6 centimeters (length x width), that was purple in color, skin was intact, and no odor noted. The note further identified that the APRN was updated. The nurse's note dated 1/20/2023 at 11:59 AM identified Resident #14's left heel had dark maroon discoloration that measured 2.3cm by 1.6 cm and skin was intact. The note further noted an order for skin prep three times daily along with a wound consultation and bootie to left heel and APRN updated and aware. A physician's order dated 1/20/2023 directed to apply a soft bootie to left heel while out of bed and elevate heels with pillow while in bed and monitor for skin integrity every shift. APRN #2's note dated 1/25/2023 identified Resident #14 had a left heel deep tissue pressure injury that was persistent non-blanchable deep red with maroon or purple discoloration. The pressure ulcer received a status of not healed. Initial wound encounter measurements were 1.5 centimeters (cm) in length by 2 cm in width x 0 cm in depth, with an area of 3 square cm and a volume of 0 cubic cm. There was no drainage noted. The skin surrounding the wound was normal. A nutritional assessment dated [DATE] identified Resident #14 had a regular diet ordered, pureed with thin liquids, milkshake supplements with meals and was not on any fluid restrictions. The note further identified that Resident #14 had no swallowing or chewing issues and required total assistance with feeding. In addition, the assessment identified Resident #14 did not have any significant weight loss in the last 30 days and had a varied oral intake between 50-75 percent. The quarterly MDS dated [DATE] identified Resident #14 had difficulty swallowing, had loss of liquids/solids from mouth when eating or drinking, was at risk for developing pressure ulcers, and had two stage three unhealed pressure ulcers, one of which had presented as a deep tissue injury. A review of the Resident #14's Care Card (utilized by the nurse aids to know what care/assistance the resident requires) identified Resident #14 was totally dependent on assistance and was to have a bootie to the left heel while out of bed and to elevate the left heel on a pillow while in bed. APRN #1's note dated 3/17/2023 identified the left heel was now open and reclassified as a stage three (3) pressure wound that measured at 1 cm in length x 1 cm in width x 0.2 cm in depth, and an area. The note further noted there was a small amount of drainage noted which had no odor, the wound bed was noted to have 76-100% granulation, the skin surrounding the wound was noted to be normal in appearance and, skin moisture was normal. Observations on 5/8/2023, 5/9/2023 and 5/11/2023 between 2:30 PM and 3:30 PM identified Resident #14 lying in bed with his/her feet resting directly on the bed and without the benefit of the left heel being elevated on a pillow. An interview with APRN #1 on 5/11/2023 at 10:13 AM identified Resident #14 had no underlying chronic medical condition like diabetes or peripheral vascular diseases that could have contributed to the development of the pressure ulcer. She further identified that Resident #14 did have lower extremity contractures and without the benefit of the heel elevated on a pillow Resident #14 could have developed a pressure area to the heel and the healing process can be delayed if the heel was not elevated as ordered. An interview with LPN #3 on 5/11/23 identified that as a charge nurse he/she usually tried to follow up and perform checks to ensure the nurse aids are offloading Resident #14's heels, however, due to workload it is not always possible. Interview and observation with RN #2 on 5/11/23 at 2:30 PM identified Resident #14 lying in bed with booties on the feet and the feet were not offloaded but were resting on the mattress. Surveyor observations made on 5/8/23 and 5/9/23 were shared with RN #2. She identified that it was the expectation that staff be consistent with offloading Resident #14's heels. RN #2 identified that failure to offload the resident's heel could have contributed to the development and delayed heeling of the pressure ulcer. Interview with NA #3 on 5/11/2023 at 2:46 PM identified that she usually checks the care card or asks the nurse to determine the resident's level of care. She further identified that she was aware that Resident #14's heels should be offloaded on a pillow but because she was called to an in-service that day and got distracted it was not done. Interview with DNS on 5/16/23 at 11:43 AM identified that Nurse's aides (NAs) and Nurses are responsible to ensure Residents care needs are met. She further identified that NAs are expected to check the care card to determine the Resident's care needs, while the nurses are expected to check the Treatment administration record. Then they are expected to perform activities as directed per MD or plan of care. Review of the facility's wound prevention policy identified that interventions are directed to minimize and eliminate any negative effects of the casual/ contributing factors such as pressure, moisture, friction, shear, and poor nutrition for all residents admitted to the facility. Prevention interventions included weekly body audits, applying, and removing splints and similar devices as ordered and note condition of skin, use pillows to elevate heels while in bed or other pressure reducing devices for feet in the bed or chair. A review of the facility's wound and skin care protocols policy identified that the purpose of the policy was to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions, to provide a systematic approach and monitoring process for promoting healthy skin integrity and providing pressure ulcer care and to promote healing of pressure ulcers in a timely manner. The policy further identified that the care plan including the admission and readmission will address prevention and treatment of pressure ulcer. 2. Resident # 46's diagnoses included left great toe amputation, dementia, Raynaud's syndrome, hypothyroid and hypertension. Review of nursing admission assessment dated [DATE] identified Resident #46 was admitted with a surgical incision to the left great toe, scabbed area to the right finger and bruise to the right forearm. The assessment did not identify any other skin issues. Review of the Braden scale dated 11/22/22 identified Resident #46 scored 19 out of 23 which is indicative of the resident being at low risk for the development of a pressure ulcer. The Resident Care Plan (RCP) dated 11/23/22 identified Resident #46 was at risk for skin breakdown due to decreased mobility, incontinence, pronounced body prominence, poor circulation, altered sensation and mechanical forces. Care plan interventions directed to keep skin clean and dry, Braden scale completed upon admission/re-admission as per facility policy, pressure reducing mattress, turn and re-position per standard of nursing practice and off load heels while in bed. The admission MDS assessment dated [DATE] identified Resident #46 had moderate cognitive impairment, long and short-term memory deficits, required limited assistance with bed mobility, ambulation in the room, dressing and personal hygiene. The assessment further identified Resident #46 required extensive assistance with transfers and toilet use, had a functional limitation in range of motion to a lower extremity, utilized a walker and wheelchair for mobility, had a surgical wound, was at risk for the development of pressure ulcers but did not have any pressure ulcers. Review of the Braden scale dated 12/6/22 identified a score of 21 out of 23 which is indicative of Resident #46 being at low risk for the development of pressure ulcers. The nurse's note dated 12/12/22 at 5:53 PM identified Resident #46 had purple non-blanchable discoloration to the lateral side of the foot that measured 2.0 cm (centimeter) in length by 1.0 cm in width. A physician's order dated 12/12/22 directed skin prep to the left posterior foot every shift to treat the DTI. Review of the Treatment Administration Record (TAR) from 11/22/22 through 12/13/22 failed to reflect documentation that Resident #46's bilateral heels were offloaded while in bed. A physician's order dated 12/14/22 directed to offload heels while in bed every shift for DTI. The Wound Specialist's progress note dated 12/14/22 at 4:50 PM identified Resident #46 had a DTI to the left lateral foot with persistent non-blanchable deep red, maroon/purple discoloration pressure ulcer that measured 1.3 cm in length by 4.5 cm in width by 0 cm in depth with a total area of 5.85 square cm. The Wound Specialist's progress note dated 3/24/23 at 8:58 PM identified Resident #46 had eschar removed from the pressure wound on the left lateral foot. The left lateral foot DTI (pressure wound) was re-classified to a stage 3 pressure ulcer. The note further identified that the pressure wound to left lateral foot measured 1 cm in length by 0.7 cm in width by 0.1 cm in depth with a total area measurement of 0.7 square cm. The physician's order dated 4/15/23 directed to cleanse the left lateral foot with normal saline followed by Medihoney (ointment) to wound bed then Alginate and cover with foam dressing. Observation with LPN #3 on 5/10/23 at 8:40 AM identified Resident #46 lying on the bed with the affected left lateral foot positioned on top of the bed mattress without the benefit of being elevated. Interview with LPN #3 on 5/10/23 at 9:00 AM identified Resident #46's feet should be offloaded with pillows. She indicated that Resident #46 usually kicks the pillow(s) away; however, upon observation, LPN #3 could not locate a pillow on the resident's bed or in the room that would have been utilized to offload the resident's feet. Interview with RN #2 (wound Nurse) on 5/10/23 at 10:50 AM identified that she was responsible for monitoring Resident #46's wound on a weekly basis and conduct wound rounds with the wound specialist. She identified that Resident #46's DTI to the left lateral foot was first identified on 12/12/22 but that the wound had progressed to a stage 3 pressure ulcer. She also identified that the wound was evaluated by the wound specialist on 12/14/22 and the wound specialist confirmed the diagnosis of DTI to the left lateral foot. RN #2 further identified Resident #46 was assessed as a low risk for skin breakdown. She also indicated that Resident #46 had a plan of care to offload heels while in bed prior to the development of the DTI. In addition, RN #2 identified that Resident #46 should not have developed the DTI to the left lateral foot if the nursing staff had consistently offloaded the resident's heels/feet. Interview with the DNS on 5/10/23 at 11:10 AM identified that she identified the DTI to Resident #46's left lateral foot. She further identified that Resident #46 had a plan of care to offload bilateral heels while in bed. The DNS noted that the resident was at low risk for the development of a pressure ulcer and should not have developed a pressure wound. She further noted that the nursing staff was responsible for consistent monitoring of the resident's skin integrity and the implementation of effective interventions when a decline is noticed. Interview with APRN #1 (wound specialist) on 5/11/23 at 11:00 AM identified that the DTI to the left lateral foot was caused by constant pressure but she could not identify what caused the constant pressure to the area. In addition, APRN #1 identified that she expects the nursing staff to monitor the resident's skin integrity and to ensure that offloading is implemented to prevent the development of a pressure ulcer/wound. Review of the Wound Prevention/Interventions for All Residents policy identified interventions are directed toward minimizing and/or eliminating any negative effects of the causal or contributing factor such as pressure, moisture, friction/shear, and poor nutrition for all residents admitted in the facility. The policy further identified that prevention interventions include the nursing assistant observing the skin at least daily for resident's requiring assistance and to utilize pillows to elevate heels while in bed or other pressure reducing devices for the feet while in bed or seated in a chair. 46117

Based on a clinical record review, staff interviews, a review of the facilty documentation and a review of the facility policy for one of three residents reviewed for accidents (Resident#1), the facilty failed to follow the plan of care to prevent an accident that resulted in a significant injury. The findings include: Resident (R) #1 was admitted to the facilty on 1/11/12 with [DIAGNOSES REDACTED]. The individualized resident assignment dated 1/5/18 identified R#1 required the assistance of two persons for care when combative. The behavioral health note dated 4/15/20 identified R#1 with combative and resistive behaviors which occur randomly during the day and with care. Trazadone 25 milligrams (mg) was ordered every 6 hours as needed. Review of the Occupational Therapy discharge summary dated 4/24/20 identified R#1 required total assistance of staff for hygiene, dressing, and toileting. The behavioral health note dated 5/14/20 identified R#1 continued to be resistive and combative with care and directed to continue the administration of trazadone as needed. The note dated 6/11/20 identified trazadone was used intermittently for combative and aggressive behaviors. The quarterly Miminimum Data Set ( (MDS) dated [DATE] identified severe cognitive impairment, extensive assistance of 2 staff members for bed mobility, dependence on 2 staff members for transfers, and did not ambulate. Additionally, R#1 required extensive assistance of one person for dressing and was dependent on one staff for toilet use, personal hygiene and bathing. The care plan dated 6/11/20 identified behaviors that included agitation, restlessness, combativeness such as yelling, spitting and punching staff during care with interventions that included the provision of two care givers when combative and to re-approach R #1 if reassurance during care was ineffective. Physician's orders dated 7/2/20 directed to transfer R #1 via a mechanical lift with the assistance of two staff members. The nursing note written by RN #1 dated 7/18/20 at 5:30 AM identified R#1 was in bed during morning care and R#1's femur appeared dislocated or fractured. R#1 showed nonverbal signs of pain and was administered [MEDICATION NAME]. The physician and family were notified, and R#1 was transferred to the hospital via ambulance at 5:45 PM. Review of the reportable event form dated 7/18/20 identified R#1 was admitted to the hospital with [REDACTED].#1 rolled R#1 in bed. R#1 attempted to kick NA#1 in the chest. R#1 rolled close to the edge of the bed, and to keep R#1 from falling on the floor, NA#1 grabbed R#1 left leg and then heard a pop. The state reportable event form dated 7/18/20 identified R#1 was confused. R #1 could be cooperative and within one minute could become verbally abusive, combative, and spitting requiring 2 to 3 persons to make sure R#1 was positioned properly to prevent an injury to him/herself and staff. The emailed statement written by NA #1 on 7/20/20 identified at approximately 5:00 AM NA #1 asked R#1 if he/she could get R#1 dressed for breakfast and R#1 was hesitant but not resistive. NA #1 proceeded to wash R#1's face and torso and when she went to put on R#1's shirt R#1 became combative. NA #1 then informed R#1 she just had to change the brief and turned R #1 to the left side to remove and replace the brief. Upon turning R#1 to the right-side R#1 attempted to kick NA #1 and R#1 started to fall off the edge of the bed. NA #1 grabbed R#1's left leg near his/her ankle and anchored R#1's bottom with his/her knee to push R#1 back into bed. As NA #1 lifted R#1's left leg back onto the bed she heard a popping sound and R#1's leg went limp. NA #1 immediately notified the nurse. Review of the hospital discharge summary dated 7/24/20 identified R#1 presented to the emergency room from the skilled nursing facilty on 7/18/20 with a left leg deformity after a fall or near fall and imaging revealed a displaced [MEDICATION NAME] femur. Orthopedic surgery was consulted. R#1 underwent a femoral nail insertion on 7/19/20. Review of the physical therapy (PT) evaluation dated 7/27/20 identified prior to the incident R#1 was dependent on staff to complete toileting hygiene, bathing, upper and lower body dressing and activities and may need 2 or more helpers. Additionally, the evaluation identified R#1's prior level of function, required maximum assistance of two persons to move from side to side in bed. Interview with PT#1 on 8/4/20 at 10:00 AM identified R#1 was non ambulatory, required a Hoyer lift for transfers and was dependent on staff to reposition him/herself in bed prior to the incident. PT #1 indicated he/she would expect two staff to provide care to R#1 when R#1 had combative behaviors. Interview with RN #1 (Nursing Supervisor) on 8/4/20 at 11:14 AM identified she was called to assess R#1 after NA #1 had provided morning care. RN#1 indicated R#1's leg was deformed upon assessment and NA#1 informed her R#1 was combative during incontinent care. NA #1 indicated R #1 almost fell off the bed and she attempted to get R#1 back into the bed and heard a pop noise. Additionally, RN#1 indicated NA #1 should not have provided care to R#1 by herself and she would have expected 2 staff to care for R#1 as R#1 could become combative and aggressive at any minute, even if R#1 was calm at the start of care. Furthermore, RN#1 educated the staff that R#1 required assistance of two staff for care to protect both the resident and the staff from injury. Interview with the DNS on 8/4/20 at 11:45 AM identified NA #1 should not have provided care by herself. NA #1 should have also notified the nurse when R#1 became combative during care and re-approached at an alternate time. Additionally, the DNS indicated R#1's behavior was unpredictable and the plan of care was updated to reflect assistance of two staff for all care regardless of the resident's behavior. Interview with NA #1 on 8/5/20 at 5:30 PM identified NA #1 went into R#1's room at approximately 5:00 AM to provide morning care. NA #1 indicated she pulled R#1 up in the bed using both sides of the draw sheet from the top of the bed by herself. NA #1 washed R#1's face and upper body and when she went to put on his/her shirt, R#1 became combative and ripped the mask off NA #1's face. Although, R#1 was combative and agitated, NA#1 proceeded to turn R#1 onto the left side to provide incontinent care and change his/her brief. Once on his/her left side NA #1 used the draw sheet to move R#1 closer to NA#1. NA #1 began to turn R#1 to the right side and R#1 attempted to kick NA #1 and upon lifting his her legs, R#1's legs and buttocks started to fall off the edge of the bed. NA #1 indicated she repositioned R#1 too close to the edge of the bed. NA # 1 identified she grabbed R#1's left leg with her right hand near the ankle and anchored R#1 buttocks on the bed with her knee and pushed R#1's body back into the bed so he/she would not fall on the floor. NA #1 indicated when she moved R#1's left leg onto the bed she heard a pop and immediately notified the nurse. Additionally, NA #1 indicated she did not inform the charge nurse that R#1 became combative during care and should have. NA #1 identified he/she did not know where LPN #1 was as there were other issues on the unit at that time. Additionally, NA #1 felt she had a good rapport with R#1 and although R#1 had unpredictable behavior, she usually did not have problems caring for R#1 by herself. Additionally, NA #1 indicated at night it was hard to rely on extra people for assistance to provide care. NA #1 indicated she should have had someone help her, and she should have re-approached R#1 as he/she was combative and did not. Interview with LPN #1 on 8/5/20 at 9:02 AM identified she was notified by NA #1 that during morning care, R#1 became combative and was about to fall off the bed, and NA #1 grabbed R#1's left leg and heard a pop. LPN #1 notified the nursing supervisor. Additionally, LPN #1 indicated NA #1 did not notified her that R#1 was combative during care and would have expected to be notified so she could assist NA #1. Additionally, LPN #1 indicated R#1 cannot reposition him/herself and required the assistance of two staff members for care when R#1 was combative. Review of the policy entitled Falls: Minimizing the risk of injury directed in part that residents who are at risk for falls would have a care plan that addressed interdisciplinary measures to prevent falls and any environmental or equipment recommendations to prevent injuries. Additionally, an individualized care plan would be developed and updated as needed to identify interventions to prevent falls and minimize injuries.

Based on clinical record reviews and interviews for two of three sampled residents reviewed for hydration (R#30, R# 43), the facility failed to initiate and/or document interventions to prevent dehydration when the resident continuously failed to meet their fluid needs and/or failed to conduct physical assessments for signs and symptoms of dehydration. The findings include: 1. Resident # 43 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of laboratory values taken during the resident's hospitalization on [DATE] identified a BUN level of 30 and a creatinine level of 0.8 (normal 0.6 to 1.3). The dietician's progress note dated 9/16/15 identified that the resident's estimated fluid needs were between 1220 milliliters and 1525 milliliters per day. A 5 day MDS assessment dated [DATE] identified that the resident was cognitively impaired, required extensive assistance with ADL's and limited assistance with eating. Review of the intake and output record from 9/11/15 to 9/30/15 (a total of 19 days) noted that the resident failed to meet the required fluid goals for 17 of those 19 days. For the 17 days that the resident did not meet his/her fluid needs, the fluid intake ranged from 290 milliliters to 1130 milliliters for a twenty four hour period. Review of the meal intake record from 9/12/15-9/30/15 identified that out of 57 possible meals, the resident had zero percent intake for 22 meals, 25 percent intake for 17 meals, 50% intake for 6 meals, 2 meals with 75% eaten and 2 meals with 100% eaten, 3 refusals and 4 meal intake areas were left blank. (Out of the 22 meals with zero percent intakes 12 of those meals were between the dates of 9/26/15 and 9/30/15). Review of a laboratory blood test done on 9/14/15 identified that the BUN was 49 and a creatinine level of 2.1. A dehydration assessment form dated 9/15/15 signed by MD # 1 identified that the resident had not met his/her fluid needs for the previous 3 days, with a notation that encouraging fluids was implemented by the facility with no new orders noted. A review of a dehydration assessment done on 9/25/15 signed by MD # 1 identified that the resident had not met his/her fluid needs the previous 3 days with MD recommendations to encourage fluids. A review of a dehydration assessment dated [DATE] signed by MD # 1 identified that the resident had not met his/her fluid needs for the previous 3 days with physician's orders [REDACTED]. Review of the laboratory tests taken on 9/30/15 identified a BUN of 102 and a creatinine of 4.2. Review of physician's orders [REDACTED]. Review of the clinical record failed to identify that the resident had a comprehensive care plan in place with interventions that addressed the resident's potential for dehydration due to poor oral intake and/or when the BUN was noted as elevated on 9/15/15 and 9/25/15. Interview with LPN # 1 ( the facility MDS coordinator) on 1/21/16 at 11:30 AM identified that although when the resident was admitted he/she had completed an admission interim care plan for potential for dehydration, he/she could not locate a comprehensive care plan to address the resident's decreased oral intake in the medical record. The MDS coordinator stated that he/she was aware of the resident's poor fluid and food intake and should have instituted a comprehensive care plan to address the resident's poor intake and potential for dehydration. The care planning policy identifies that a comprehensive care plan will be developed for each resident, upon admission an interim care plan will be established until a full care plan can be developed. 2. Resident #30's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that the resident was without cognitive deficits, required extensive assistance from 2 staff for mobility and transfers, had a Foley catheter and took a diuretic 7 days a week. The care plan lacked identification of the risk of dehydration. Physician orders [REDACTED]. The dietitian's assessment dated [DATE] identified that the resident's estimated fluid needs were 1709 - 2125 cc per day. The dietitian identified that the resident was on diuretics, had a slightly elevated BUN of 21 at the hospital, had consumed less than needed fluids (since admission) and was at risk for inadequate hydration. Intake and output records from 10/9/15 admission through 10/28/15 discharge, noted that the resident only met his/her fluid needs on 3 out of 18 days monitored for intake and output; 10/12, 14, and 26/15. On 10/26/15, a dehydration assessment noted that resident had not met their fluid goal needs for 3 days. The assessment was faxed to the physician who directed to encourage fluids and get labs with next lab draw. The resident's labs on 10/27/15 noted that the resident's BUN had risen from 21 to 32 (10-24). Interview and clinical record review with the DNS on 01/21/2016 at 12:43 PM failed to provide documentation that a care plan was developed to address the resident's risk for dehydration based on use of diuretics and history, and/or failed to show that interventions were initiated when the resident repeatedly failed to meet his/her fluid goals, and/or that assessments for signs and symptoms of dehydration had been completed other than one on 10/26/15.