Every finding on record at Bayberry Skilled Nursing & Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure six of 15 sampled residents (Resident 2, Resident 3, Resident 4, Resident 6, Resident 7 and Resident 8) were free from physical abuse when: 1. Resident 1 pushed and punched Resident 2;2. Resident 3 spat on Resident 4, after Resident 4 called Resident 3 a racial slur;3. Resident 5 punched Resident 6 four times;4. Resident 7 and Resident 8 hit each other. This failure had the potential to result in physical, mental and emotional harm for Resident 2, Resident 3, Resident 4, Resident 6, Resident 7 and Resident 8. 1. During a review of Resident 1's admission Record, printed 7/14/26, the Record indicated Resident 1 was admitted to the facility in 2026 with a diagnosis of schizophrenia (a mental condition which made it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real), unspecified (a diagnosis given when a person shows clear signs of a mental health condition with psychosis, but the doctor did not have enough specific information or details to fit it into a more precise category). During a review of Resident 2's admission Record, printed 7/14/26, the Record indicated Resident 2 was admitted in 2026 with diagnosis of schizophrenia, unspecified.During an interview on 7/18/26, at 12:18 p.m., with Mental Health Worker (MHW) 1, MHW 1 stated they witnessed a physical altercation between Resident 1 and Resident 2 on 5/15/26. MHW 1 stated while in the dining room, Resident 1 asked Resident 2 why they were staring at them. MHW 1 stated they offered both residents to change seats and both residents declined. MHW 1 stated both residents were staring at each other and [NAME] after, they both got up. Resident 1 pushed and punched Resident 2 in the chest with a closed fist which drove Resident 2 backwards against a television. MHW 1 stated residents have the right to be free from abuse.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 5/15/26, the SBAR indicated .client stood up, pushed peer toward the wall, struck client in the chest with a closed fist.During a review of Resident 2's Care Plan Report, initiated 5/15/26, the Report indicated Experienced alleged/suspected abuse as evidence by physical altercation with peer. At risk for emotional disturbance and/or trauma. 2. During a review of Resident 3's admission Record, printed 7/14/26, the Record indicated Resident 3 was admitted in 2026 with diagnosis of schizoaffective disorder, bipolar type (a mental health condition that combined symptoms of schizophrenia with extreme mood swings). During a review of Resident 4's admission Record, printed 7/14/26, the Record indicated Resident 4 was admitted in 2024 with diagnosis of schizophrenia, unspecified.During an interview on 7/14/26, at 1:48 p.m., with MHW 2, MHW 2 stated they witnessed a verbal and physical altercation between Resident 3 and Resident 4 on 5/28/26. MHW 1 stated Resident 4 called Resident 3 the N word and Resident 3 yelled and spat on Resident 4.During a review of Resident 3's SBAR dated 5/28/26, the SBAR indicated client expressed inappropriate verbal exchanges and spitting towards a fellow peer while waiting for a smoke break.During a review of Resident 4's Care Plan Report, initiated 5/28/26, the Report indicated Experienced alleged/suspected abuse as evidence by being spat on by peer. At risk for emotional disturbance and/or trauma. 3. During a review of Resident 5's admission Record, printed 7/14/26, the Record indicated Resident 5 was admitted in 2026 with diagnosis of schizophrenia, unspecified. During a review of Record 6's admission Record, printed 7/14/26, the Record indicated Resident 6 was admitted in 2025 with diagnosis of schizophrenia, unspecified.During an interview on 7/16/26, at 10:17 a.m., with MHW 3, MHW 3 stated they witnessed Resident 5 hit Resident 6 multiple times on 6/23/26. MHW 3 stated Resident 6 was sitting down watching a movie in the dining room when Resident 5 approached Resident 6, stood over Resident 6 and and hit Resident 6 four times in the head with a closed fist. MHW 3 stated Resident 6 used their hands and arms to cover their head.During a review of Resident 5's SBAR, dated 6/23/26, the SBAR indicated Client exited [their] room toward the main dining room and approached peer while peer was seated during a group. Client struck peer multiple times with a closed fist without provocation.During a review of Resident 6's Care Plan Report, initiated 6/23/26, the Report indicated Experienced alleged/suspected abuse as evidence by being struck by peer with closed fist. At risk for emotional disturbance and/or trauma. 4. During a review of Resident 7's admission Record, printed 7/14/26, the Record indicated Resident 7 was admitted in 2025 with diagnosis of schizophrenia, unspecified. During a review of Resident 8's admission Record, printed 7/14/26, the Record indicated Resident 8 was admitted in 2026 with diagnosis of generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday issues like health, money, or work). During a review of Resident 8's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 6/3/26, the record indicated Resident 8's BIMS score was 15 (cognitively intact).During an interview on 7/14/26, at 1:57 p.m. with MHW 2, MHW 2 stated they witnessed a physical altercation between Resident 7 and Resident 8 on 7/2/26. MHW 2 stated the alteration had already started when they came upon Resident 7 and Resident 8 in the hallway. Resident 7 threw a punch toward Resident 8 and missed. MHW 2 stated Resident 8 ducked under the punch and grabbed Resident 7, then both residents fell to the floor. MHW 2 stated Resident 8 punched Resident 7 when they were on the floor.During an interview on 7/14/26, at 2:27 p.m., with Resident 8, Resident 8 stated they were attacked about a week and a half ago. Resident 8 stated it made them feel pissed.During an interview on 7/15/26, at 3:04 p.m., with Assistant Director of Nursing (ADON), ADON stated abuse could have put residents at risk for physical and emotional harm. ADON stated it was important to protect residents from abuse, so they were safe and feel safe. ADON stated residents had the right to be free from abuse.During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse, dated 7/2/26, the Report indicated [Resident 8] was attending a group activity in the dining room when [Resident 7] approached [Resident 8] and struck [Resident 8] multiple times in the face with a closed fist. The altercation continued into the hallway, where both clients fell to the floor during the incident.During a review of Resident 8's Care Plan Report, initiated 7/2/26, the Report indicated Experienced alleged/suspected abuse as evidence by being struck by peer. At risk for emotional disturbance and/or trauma.During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, Residents have the right to be free from abuse. This includes but is not limited to. verbal, mental. or physical abuse. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives. Protect resident from abuse. by anyone including. other residents .

Based on observation, interview and record review, for one of two sampled residents (Resident 6) who were reviewed for accidents, the facility failed to ensure two staff were present and bed rails were provided during incontinent care (providing support for individuals who cannot control their bladder or bowels) when Certified Nursing Assistant (CNA) 2 let go of Resident 6, with no bed rail to hold onto. Resident 6 fell out of bed and sustained fracture of the surgical neck of the left humerus with fracture line extension to the greater tuberosity (left shoulder fracture).During a review of Resident 6's admission Record (AR) dated 1/5/26, the AR indicated Resident 6 was admitted to the facility in November 2025 with multiple diagnoses that included hemiplegia (paralysis that affects only one side of the body) affecting right dominant side, and morbid obesity (severe obesity, excessive fat stores and a body mass index of 40 or higher (BMI, a measure of body fat based on height and weight, normal BMI 18.5-24.9).During review of Resident 6's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive [mental processes involved in gaining knowledge and comprehension] status regarding attention, orientation, and ability to register and recall information) score of 15. A BIMS score of 13-15 is an indication of intact cognitive response.During a concurrent observation and interview on 1/5/26 at 10:38 a.m. with Resident 6, in the hallway close to Resident 6's room, Resident 6 wore a sling on the left arm. Resident 6 stated she had to wear it after falling two weeks after admission to the facility. Resident 6 stated falling out of bed when CNA 2 placed her in a right-side lying position but did not instruct her to hold onto anything. Resident 6 was unsure if there was a bed rail. Resident 6 stated she rolled out of bed, landing on her left side, and experienced immediate significant pain in the left shoulder after the fall. Resident 6 stated she was then sent to the hospital for treatment.During a review of Resident 6's Progress Notes dated 12/2/25, the Progress Notes indicated, on 12/2/25, at 5:20 a.m., CNA 2 Noticed that the resident had fallen. The Progress Notes further indicated, Resident 6 was turned on her side near the edge of the bed and slid off, resulting in the fall. Resident 6 was transferred to the hospital for further evaluation due to concern of possible injury or fracture.During a review of Resident 6's Emergency Department (ED) Provider Notes dated 12/2/25, the ED Notes indicated Resident 6 sustained an impacted (bone pieces are jammed together) fracture of the surgical neck with extension to the greater tuberosity (fracture of the left shoulder) and had been placed in a sling.During a telephone interview on 1/6/26 at 11:21 a.m. with CNA 2, CNA 2 stated, on 12/2/25, around 5-5:30 a.m., CNA 2 went to Resident 6's bedside to provide incontinent care. CNA 2 stated he informed Resident 6 of his intention to change her, to which Resident 6 responded with a faint mumble. CNA 2 stated he proceeded to change Resident 6 and her bed linen, which were soaked with urine. CNA 2 described himself as a tall person. CNA 2 stated he raised the bed height to his waist level and positioned himself on Resident 6's left side. CNA 2 then requested Resident 6 to turn to her right side (CNA 2 faced Resident 6's back) while he applied the fitted sheet to the foot of the bed. During this process, CNA 2 stated he observed Resident 6's legs began to slide towards the edge of the bed before she turned completely to her right and rolled out of bed. CNA 2 stated he reached over the bed to prevent Resident 6 from falling but found it difficult due to Resident 6's weight and her deep sleep state, Like she was in a deep coma. CNA 2 stated he was not familiar with Resident 6's care as it was his first assignment with her and that he did not receive any report or instructions from the charge nurse at the start of the shift. CNA 2 also stated he tried to ask assistance from other staff, but none were available as they were all occupied. CNA 2 stated there were no rails attached to Resident 6's bed.During a review of Resident 6's bed mobility care plan, undated, the care plan indicated interventions that included providing quarter rails on both sides of the bed to enable positioning and increase mobility. During a telephone interview on 1/7/26 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated CNA 2 did not ask for help and only informed her after Resident 6 had fallen out of bed.During a review of Resident 6's IDT (Interdisciplinary Team, a group of individuals representing different departments of the facility): Post Accident/Fall (IDTPA), undated, the IDTPA indicated, improper positioning during care, specifically placing the resident too close to the mattress edge while turning, likely contributed to the fall. To prevent re-occurrence, the follow-up measures included reinforcing proper bedside positioning techniques and re-educating CNAs on continuous physical support during turns.During a review of the facility's policy and procedure (P&P), titled Repositioning, undated, the P&P indicated, to reposition a resident in bed, check the care plan for resident's specific positioning needs and the resident's level of participation, lower the side rails (if applicable) on the side where you are standing, use two people and a draw sheet to avoid shearing (when layers of skin tissue slide in opposite directions, damaging blood vessels and deep tissue, like sliding down in a chair or bed) while turning resident in bed, encourage the resident to participate if able, and encourage the resident to hold the side rail with the top arm in the direction of the turn.During an interview on 1/8/26 at 11:10 a.m. with Director of Staff Development (DSD), DSD stated, CNA 2 should have called for help, communicated with the charge nurse of his inability to get help from another staff, and ensured Resident 6 was fully awake before providing care. DSD stated, following the fall incident, CNA 2 was removed from the schedule and not allowed to return to work

Based on observation, interview, and record review, the facility failed to ensure accurate coding of the Minimum Data Set (MDS, a resident assessment tool to drive resident care plan) for four of seven sampled residents (Resident 42, 49, 52, and 64) when residents' tobacco use was incorrectly coded as No on the MDS despite evidence of tobacco use. This failure resulted in an inaccurate reflection of the residents' smoking status and had the potential to affect the development and implantation of resident-centered care plans.During a review of the admission Records (ARs) for Resident 42, 49, 52, and 64, printed on 1/7/25, the records indicated that these residents were admitted to the facility on [DATE], 12/3/25, 5/16/24, and 11/7/24, respectively.During observations on 1/6/26 and 1/7/26 at 11:35 a.m., Residents 42, 49, 52 and 64 were observed smoking on the recreation patio in Special Treatment Program (STP) unit.During an interview on 1/6/25 at 11:45 a.m., unit supervisor, Licensed Vocational Nurse (LVN) 2 stated Residents 42, 49, 52, and 64 were assigned to Group A, which had scheduled smoking time at 8:00 a.m., 11:30 a.m., 1:45 p.m., 4:30 p.m., and 8:00 p.m. daily.During a record review of the Smoking Risk assessments for Residents 42, 49, 52, and 64 dated 11/7/25, 12/3/25, 11/11/25, and 11/10/25, respectively, the assessments indicated Residents 42, 49, 52, and 64 were identified as smokers.During a record review of the MDS for Resident 42, 49, 52 and 64, dated 5/12/25, 12/10/25, 5/15/25, and 11/10/25, respectively, the Current Tobacco Use item was coded as NO.During an interview on 1/7/25 at 12:24 p.m., MDS Coordinator (MDSC) stated the tobacco use item on the MDS for Resident 42, 49, 52, and 64 should have been coded as Yes. MDSC stated that smoking was part of the treatment for residents in the facility's STP unit, where these residents resided. MDSC stated that MDS coding triggers the development of residents' care plans, and inaccurate MDS coding could potentially affect the development of resident-centered care plans.During a review of facility's Policy and Procedure (P&P) titled Resident Assessments, revision date 10/2023, No.12, indicated that information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Based on observation, interview, and facility document review, the facility failed to provide an accurate and complete diet manual reference for all diets provided in the facility.This failure had the potential to result in residents receiving diets that do not match physicians' orders. Findings:During a concurrent observation and interview on 1/06/2026 at 11:28 a.m. with Restorative Nursing Assistant/ Certified Nursing Assistant 1 (RNA/CNA 1) at the nursing station, RNA/CNA 1 could not locate the diet manual. Once RNA/CNA 1 received assistance, she was able to locate the manual. RNA/CNA 1 stated that she could not locate the information for the soft and bite size (SB6) diet in the diet manual. RNA/CNA 1 stated that she would not know where to find the information if she had questions about the diet.During a review of the facility's Generations Diet Manual for Bayberry Community, dated 10/20/25, the diet manual did not include information on the puree, soft and bite size (SB6) and minced and moist diets.During a review of the facility's Diet Spreadsheet (a sheet containing the kind and amount of food each diet would receive) dated Tuesday Week 2 Day 11, the diet spreadsheet indicated puree, SB6 and minced and moist diets.During an interview on 1/06/2026 at 11:35 a.m. with Registered Dietitian (RD 1), RD 1 stated, that he approved the diet manual 10/20/25 and acknowledged that the diet manual does not include information regarding the puree, SB6 and minced and moist diets. RD 1 stated, the mechanically altered diet information should be included so that the nurses have a reference. RD 1 was not aware of who provided the diet manual or the diet spreadsheets.

Based on observation, interview, and facility document review, the facility failed to provide mechanically altered foods according to the menu for SB6 diets (a therapeutic, texture-modified eating plan for individuals with swallowing difficulties, weak chewing muscles, or high choking risks).This failure had the potential to result in decreased satisfaction with food and/or decreased nutrient intake for one out of six (Resident 26) residents receiving SB6 diets.Findings:During a review of Diet Spreadsheet, dated Tuesday Week 2 Day 11, the diet spreadsheet indicated the SB6 diet served for lunch was beef stroganoff (minced), egg noodles (chopped), spinach (chopped), white bread (slurry), cookie (chopped).During a concurrent observation and interview on 1/06/2026 at 12 p.m. with DC in the kitchen during trayline, Resident 26's tray contained chopped pieces 1/2 inch in length of beef stroganoff, chopped macaroni noodles, chopped spinach, slurry bread and a regular cookie. DC stated that the items on the tray do not match the diet spreadsheet for SB6 diet.During a review of the facility's policy and procedure (P&P) titled, Menus, dated March 2023, the P&P indicated, menus are planned to meet the nutritional needs of the residents in accordance with the physician's diet order, the approved diet manual, federal/ state regulations.On 1/07/2026 11:00 am, the Registered Dietitian 2 (RD 2) was informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to prepare foods in a form designed to meet individual needs, as hard candy was found on resident's meal tray with a physician's order for SB6 diet (a therapeutic, texture-modified eating plan for individuals with swallowing difficulties, weak chewing muscles, or high choking risks). These failures had the potential to result in difficulty swallowing, chewing, and a decrease in food and nutrient intake in one out of six (Resident 26) residents receiving SB6 diets.Findings:During a concurrent observation and interview on 1/5/2026 at 12:24 p.m. with Resident 26 in her room, the lunch meal tray was on the bedside table in front of the resident. The meal tray contained all appropriate items in addition to two pieces of wrapped hard candy. Resident 26 stated The people who brought me the tray brought me the candy.During an observation on 1/5/2026 at 12:26 p.m. in Resident 26's room, Licensed Vocational Nurse 8 (LVN 8) walked in the room, delivered a container of Ensure (oral nutritional drink to help people meet their daily nutritional needs with regular food intake is insufficient) on the resident's meal tray and walked out of the room without acknowledging the hard candy on the meal tray.During an interview on 1/5/2026 at 12:28 p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 who delivered the tray stated, the candy shouldn't be on the tray and she didn't know how it got there.During an interview on 1/5/2026 at 12:30 p.m. with LVN 8, LVN 8 confirmed that Resident 26 had a diet order of SB6 and that residents on a SB6 diet shouldn't receive candy.During a review of Resident 26's Order Summary Report, dated 1/7/26, the Order Summary Report indicated, Resident 26 had an order for Regular Diet Soft and Bite-Sized texture, Thin Liquids consistency, Aspiration (the act of breathing in or drawing fluid into the lungs) precautions; Extra sauce or gravy on the side, straw ok, chopped meat for diet.During a review of the facility's diet spreadsheet titled Generations Health Care Menu Week 2 Day 10 Monday Lunch, dated 1/5/2026, the diet spreadsheet indicated residents on a SB6 diet would include the following foods on the meal tray:-V8 juice-Chicken thigh chopped-Mashed potatoes-Green peas-Apricot halves chopped-Poultry gravy-2% MilkDuring a review of the facility's P&P titled, Menus, dated March 2023, the P&P indicated, menus are planned to meet the nutritional needs of the residents in accordance with the physician's diet order, the approved diet manual, federal/ state regulations.During a review of the IDDSI guideline website titled IDDSI, dated 1/2019, the IDSSI guideline indicated, Level 6 Soft and Bite Sized should avoid foods with chewy characteristics such as lollies/ candies/ sweets.

Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary environment when:1. Gloves were not used appropriately;2. Food preparation equipment and utensils were not clean or in good working condition;3. Ice machine bin was dirty and not cleaned per manufacturer instructions;These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food and/or leading to food borne illness for 78 residents who received food from the kitchen with a total census of 78.1.During an observation on 1/06/2026 at 12 p.m. in the kitchen during meal tray line, Dietary Aide (DA) used his gloved hands to touch a container of oil, handles on refrigerator, dial on stove and then touched ready to eat hamburger buns and cheese.During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated, plastic gloves should be worn to avoid direct contact with food.Hands must be washed prior to putting on gloves and any glove changes.During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, use tongs and utensils for handling and preparing food instead of hands.According to the 2022 Federal Food Code, if used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.2. During a concurrent observation and interview on 1/05/2026 at 10:00 a.m. with DC in the kitchen, the following was observed and confirmed by DC:- Refrigerator 1 with rusty shelves sheet pans with grime and black residue.- Two sheet pans with grime and black residue.- Two large frying pans with thick black residue.- Three cutting boards were heavily marred.During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, the facility follow procedures to ensure sanitized utensils and equipment are being used.During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated, the sinks, cutting boards, utensils and equipment will be cleaned and sanitized after each use and cutting boards may be nonporous acrylic and in good condition without deep cuts.3. During a concurrent observation and interview on 1/5/2026 at 2:07 p.m., with Maintenance Supervisor (MS) in the kitchen near the ice machine. MS stated that he cleans the ice machine weekly and monthly. MS explained the process used to clean the ice machine. MS opened up the machine's front panel, and the contents were visibly clean. MS stated that the vendor cleans the ice machine, including the bin, every six months. MS stated that ice removal and bin cleaning occur only during the vendor's 6-month service. MS stated he does not remove the ice or clean the bin when he does the weekly and monthly cleaning of the ice machine. MS put on gloves and wiped the ice bin with a clean white towel. The white towel had black particles from the bin of the ice machine. The MS acknowledged the white towel had dirt from wiping the bin.During a review of the Scotsman Ice Systems User's Manual, dated October 2014, the manual indicated it is the user's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained.Sanitize the ice storage bin as frequently as local health codes require, and every time the ice machine is cleaned and sanitized.During a review of the Smart Care Planned Maintenance of Ice Machine report, dated 11/4/2025, the report indicated the ice bin was found to be dirty with biofilm present.A review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated .(A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch .

Based on observation, interview, and facility document review, the facility failed to ensure:Residents had a location to safely store perishable foods.Residents' food was separated from facility food.This failure had the potential to cause foodborne illnesses from unsafe food storage, decreased food intake and did not provide a homelike environment for 78 residents who consumed food out of a total census of 78.Findings:During a concurrent observation and interview on 1/05/2026 at 10:00 a.m. with DC in the kitchen, it was observed that a resident's popsicles were stored in the reach in freezer in the kitchen with facility food. DC stated that Nancy's popsicles are stored in the freezer for her to eat any time.During an interview on 1/05/2026 at 1:45 p.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated, the facility does not have a refrigerator, so perishable food must be consumed immediately. During an interview on 1/05/2026 at 1:55 p.m. with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated, there isn't a way to store perishable food. RNS 2 stated residents must consume their food from the outside right away.Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit.Review of the facility's P&P titled, Foods Brought by Family/Visitors, dated March 2022, the P&P indicated, perishable foods cannot be stored in the facility and should be consumed within two hours to ensure patient safety.On 01/07/2026 11:00 am, RD 2 was informed and acknowledged the above findings.

Based on observation, interview , and record review the facility failed to ensure safe infection prevention practices with census of 82 when: 1. Shared glucometer (device measuring blood sugar) was not cleaned and sanitized in-between resident care. 2. Licensed Nurse did not put on gloves before assessing Resident 14's swelling and redness to the Right eye. These unsafe practices could result in spread of infection among vulnerable elderly residents in the facility. Findings: 1. During a medication administration observation with Licensed Nurse (LVN 6), on 1/5/26, at 4:06 PM, at the Station 1 hallway, LVN 6 was observed placing a glucometer and supplies in a small tray and was taken into Resident 6's room to measure blood sugar (or BG). LVN 6 placed the tray on top of bedside table, then with gloved hand poked Resident 6's right index finger with lancet (a pricking device) to get drops of blood and then soaked the test strip (a small strip transmits blood content to glucometer machine) attached to the glucometer with blood to get the BG measurement. LVN 6 when exited the room, removed her gloves without using hand sanitizer and then placed the glucometer back into the cart without cleaning or sanitizing. LVN 6 did not clean the small tray taken inside Resident 6's room. LVN 6 then moved on to next resident in another room to administer the evening shift medications. During an interview with LVN 6 on January 5, 2026, at 4:20 PM, LVN 6 stated that the glucometer did not need to be cleaned and sanitized after each use. LVN 6 explained that the glucometer was cleaned and sanitized three times during the work shift: at the beginning, in the middle, and toward the end. Additionally, LVN 6 acknowledged that she did not clean or sanitize the glucometer and the small tray taken inside the room. During an interview with facility's Infection Prevention Nurse (IP), on 1/8/26, at 11:20 AM, the IP stated the nursing staff had been trained to clean hands with sanitizer before and after using gloves during resident care. IP stated blood pressure cuff and pulse-ox devices were considered non-critical equipment (health care equipment that touch intact skin acting as a low-risk barrier for infection) and cleaned when visibly soiled. IP stated cleaning in-between resident care was not required. IP stated the facility was using CDC guidelines with [NAME] classification (Instruments are categorized as critical, semi-critical, or non-critical) and the facility followed manufacturer instructions for use (MIFU) on cleaning. IP did not provide any document on MIFU for BP and pulse-ox devices. IP stated the nursing staff should have cleaned and sanitized glucometer with Sani-cloth (sanitizing wipe) wipes in-between resident use and it needed to remain wet for 2 minutes. During an interview with Director of Nursing (DON), in his office, on 1/8/26, at 12:20 PM, the DON stated the facility was following the CDC guidelines and manufacturer specification for care and cleaning. DON stated he relied on IP nurses to educate the staff to follow infection prevention workflow to prevent spread of infections. During a review of the facility's policy, titled Cleaning and Disinfecting of Resident-Care items and Equipment, last revised on 9/2022, the policy indicated Resident -care equipment, including reusable items . will be cleaned and disinfected according to current CDC recommendations for disinfection . The policy further indicated The [NAME] Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care. The policy indicated that glucometer was a critical item that carried high risk of infection. The policy considered blood pressure cuff a non-critical (items that came in contact with intact skin). The policy further indicated non-critical items required cleaning followed by either low or intermittent level disinfection following manufacture's instruction. The policy indicated Reusable items are cleaned and disinfected or sterilized when visibly soiled, after use on a contact precautions or enteric contact precaution and periodically (e.g., stethoscopes, durable medical equipment). They policy referenced CDC guidelines for disinfection and sterilization in healthcare facilities 2008 During a review of Association for Professionals in Infection Control (APIC) document titled Strategies to mitigate cross contamination of non-critical medical devices, dated 2021, the document indicated Non-invasive portable clinical items shared among patients are part of the patient's immediate surroundings and may pose a threat of pathogen transmission. These items are not typically assigned to a specific patient and may be overlooked when establishing routine disinfection practices. Micro-organisms can live on these items' surfaces for long periods, with the micro-organisms' life spans depending in part on the material of the surface, the ambient air temperature and humidity, and the presence of organic material. The occurrence of infection from contaminated environmental surfaces and non-critical medical devices has been documented in the literature . inappropriate disinfection practices increase the risk of HAIs transmitted from such items . non-critical patient care items still frequently serve as reservoirs for multi-drug-resistant organisms (MDROs, bugs that antibiotic can't kill) . as well as other pathogens . healthcare providers seem to have a false sense of security that materials are microbiologically clean when they are visually clean. They urge healthcare providers to presume that surfaces are unclean rather than clean. During a review of CDC' s document, titled Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 2008 and 2023, the document indicated 3C. Remove visible organic residue (e.g., residue of blood and tissue) and inorganic salts with cleaning. Use cleaning agents that are capable of removing visible organic and inorganic residues. 4c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). 5g. uncertainty exists about the presence of multidrug resistant organisms on such surfaces. See recommendation 5n for recommendations requiring cleaning and disinfecting blood-contaminated surfaces. During a review of instruction sheet by manufacturer of Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer used by the facility), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System , dated 9/2024, the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions) indicated Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not clean and disinfected after use? . It is important that long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. During a review of the Center for Disease Control (A federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, last accessed on 1/15/26 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared. 2. During a review of Resident 14's admission Record, printed on 1/6/26, indicated resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (muscle weakness on one side of the body, complete paralysis) and hemiparesis (partial weakness), and a need for assistance in personal care. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 11/6/25, indicated resident only spoke his native language, had clear speech, was able to make himself understood, and was able to understand others. During a concurrent observation and interview on 1/5/26, at 11:38 a.m., with Rehabilitation Assistant 1 (RA 1), in Resident 14's room, resident's right upper eyelid appeared red, swollen, and with slight watery discharge. Resident stated his right eye/eyelid hurt a little but does not know what was going on with it. Resident denied receiving any nursing care related to his right upper eyelid condition. During a concurrent observation, interview, and record review on 1/6/26, at 10:35 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 14's medical records and Weekly Evaluations did not show documentation that resident had any recently reported change of condition to his right upper eyelid. Upon interview and assessment of Resident 14, in his room, resident's right upper eyelid was noted with redness, swelling, and with slight clear, watery discharge. Resident denied itchiness to the right eye/eyelid yet stated the right eye area was crusty in the morning when he woke up. Resident 14 stated this condition of his right upper eyelid has been going on for a week with a pain level of 2 (based on a pain scale, Numeric Rating Scale, 0=no pain, 10=worst. RNS 1, after performing hand hygiene and without donning gloves, assessed and touched the resident's right upper eyelid. RNS 1 stated since Resident 14's skin area to the right eye was intact, it was okay not to wear gloves during skin assessment. During an interview on 1/7/26, at 11:07 a.m., with the Infection Preventionist (IP), IP stated when assessing a resident's eye area with visible signs and symptoms of inflammation, license nurse should perform hand hygiene then wear gloves before touching the resident to reduce the risk of transmission of bacteria or cross-contamination. A review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment – Gloves, dated 2001, indicated, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and or non-intact skin. A review of the facility's P&P titled, Policies and Procedures – Infection Prevention and Control, dated 2001, indicated, The facility adopted infection prevention and control policies and procedures are intended to help maintain safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.All personnel are trained on infection prevention and control policies and procedures upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control.

Based on observation, interview and record review, the facility failed to ensure safe pharmaceutical services with census of 82 residents when:Non-narcotic prescription drugs destruction was not witnessed by two licensed staff from April 2025 to August 2025.Hazardous drugs (or HD, medication that can cause harm posing risks to healthcare workers and patients through exposure during handling) were not stored and handled safely in the medication carts and during medication administration.These failed practices had the potential to result in drug diversion (unauthorized drug use) and unsafe drug handling for both staff and residents.Findings1. During an interview and record review, with Licensed Nurse (LVN 9), on 1/5/26 at 10:29 a.m., in Med Room on Station 2, LVN 9 stated non-narcotic prescription medications were disposed every 2 weeks and logged in the non-narcotic drug logbook. LVN 9 stated the disposal of non-narcotic drug form required only a one-person signature. LVN 9 confirmed there was only one signature on the non-narcotic drug disposal for April 2025 through August 2025.During a review of the facility's logbook, titled Non-Narcotic Destruction, with date range of April 2025 through August 2025, the Non-Narcotic logbook indicated the medication destruction were not witnessed by two-person signatures for the stated dates.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), the DON confirmed non-narcotic drug destruction occurred monthly, every other Sunday, and the form required two - person signatures as witness. The DON confirmed the Non-Narcotic Destruction Logbook dated April 2025 through August 2025, had only one signature.2. During concurrent medication cart inspection and interview, on 1/5/26 at 10:00 a.m., on station 2, with Licensed Psychiatric Technician (LPT), the medication cart stored multiple liquid bottles of a hazardous medication called valproic acid (drug used to treat mood disorder and seizure). The valproic acid bottles were labeled with NIOSH-2 warning (National Institute for Occupational Safety and Health, a federal agency that ensures safety of handling hazardous material for health care workers) and one bottle had red color medication dripping on the outer surface of the product and the label. Further observation indicated that none of the bottles were stored in a Ziplock bag to prevent contamination. LPT stated she did not know what the label NIOSH-2 was for and was not aware of safe handling.During a concurrent medication administration observation and interview with Licensed Nurse (LVN 1), on 1/6/25 at 9:17 a.m., LVN 1 was observed administering a hazardous medication called spironolactone (blood pressure drug) that was labeled as NIOSH to Resident 33 without use of protective gloves. LVN 1 stated she did not know what NIOSH label meant and did not recall having an in-service on how to handle hazardous medications.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), the DON stated that the needed to look into how to address handling hazardous drugs commonly used in the facility. The [NAME] stated it was safe to use gloves when handling any hazardous drugs. During a review of the facility's policy and procedure, titled Hazardous Drugs, dated April 2019, the policy indicated Any staff member who comes in contact with hazardous drugs are trained and exhibit competency in handling these drugs according to current safety and practice standards (according to manufacture guidance and drug package inserts). Hazardous drug handling areas are clearly marked with signs designating the hazard. Hazardous drugs are labeled, stored and transported in accordance with current USP (the United States Pharmacopeia) standards. Staff are trained on and required to wear personal protective equipment (PPE, includes gloves, mask, or gown) specific to the risk of exposure and activities preformed.During a review of the facility's policy and procedure, titled Pharmacy Services Overview, dated April 2019 the policy and procedure indicated Pharmaceutical services consist of the provision of medication related information to health care professionals. Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal law and consistent with standard of practice. The consultant pharmacist in collaboration with the dispensing pharmacy and facility oversees the development of procedures related to pharmacy services, including labeling and storage of medications and training and competency of personnel.Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, the document indicated Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. Further review of the document indicated to use single glove for handling intact tablet form and double glove for handling oral liquid form of the hazardous medications as directed.

Based on interviews and record reviews, the facility failed to ensure medication use parameters ordered by the doctor were followed in 3 out of 30 sampled residents (Resident 4, Resident 6, and Resident 9) when:Resident 4's blood sugar parameters for insulin (drug in shot form to treat blood sugar disease) were not followed as ordered by medical doctor.Resident 6's opioid medication use did not follow the pain level ordered by the medical doctor.Resident 9's blood pressure drug parameter was not followed.These failed practices could contribute to unsafe medication use and residents not benefiting from prescribed medication and/or experience side effects.1. During a record review of the Resident 4's Order Summary Report, dated 1/8/26, the record indicated the following orders: NovoLOG Flex Pen Subcutaneous (or SC, inject under the skin) solution Pen-Injector (or Flex Pen, a pen shaped insulin container) . (insulin Aspart, a short acting insulin): Inject 3 units subcutaneously with meals . hold if patient doesn't eat meal; Start date: 10/21/25 (Novolog is a type on insulin, unit is a measure of insulin dose). Hypoglycemia protocol (low blood sugar guide)- Able to take PO (orally): follow 15/15 rule: Give 15 gm ( gm is gram, a unit of measure) fast acting carbohydrate as needed for hypoglycemia; blood sugar less than 70 mg/dL (normal blood sugar is 80-120, mg/dL is milligram per deciliter, a measure of blood sugar level); may repeat in 15 minutes.The orders did not specify any parameter for hyperglycemia or when the nursing staff should call the doctor for further guidance.During a record review of the Resident 4's Medication Administration Record (or MAR), dated 12/2025, the MAR record indicated insulin was held and noted as No Med Required-Outside Parameters as follow:12/4/25 at 5 PM for BG (Blood Sugar) of 97 (Thursday)12/5/25 at 5 PM for BG of 111(Friday)12/6/25 at 7 AM for BG 89 (Saturday)12/16/26 at 5 PM for BG of 108 (Tuesday)12/19/25 at 5PM for BG of 92 (Friday)12/21/25 at 12 noon for BG 99 (Sunday)12/24/25 at 12 noon for BG 87 (Wednesday)12/25/25 at 5 PM for BG 107 (Thursday)12/28/25 at 5 PM for BG 99 (Sunday)The nursing notes did not reflect on why the doses were held or if the medical doctor was contacted. 2. During a record review of the Resident 6's Medication Administration Record (or MAR), dated 1/2026, the MAR record indicated patient was receiving a pain medication called Norco (an opioid pain killer) as follow: Hydrocodone-Acetaminophen oral tablet 5-325 MG (same as Norco, a combination of opioid and plain Tylenol in one pill; MG is milligram, a unit of measure); Give 1 tablet by mouth every 6 hours as needed for Moderate pain 4-7, severe pain 8-10 ( pain level intensity is from 1 to 10, and 10 being the most painful) .; start date 12/3/25Further review of the MAR record indicated the pain medication was administered to Resident 6 when pain level was documented as zero (no pain) on the following days:1/3/26 at 8:25 PM, 1/4/26 at 7:59 PM, 1/5/26 at 8:48 PM, and 1/6/25 at 8:34 PM. 3. During a record review of the Resident 9's Medication Administration Record (or MAR), dated 1/2026, the MAR record indicated patient was receiving a medication with safety parameters called midodrine (help raise the blood pressure due to the disease process causing low blood pressure that could contribute to fall or other risks) as follow: Midodrine (drug help raise blood pressure) oral tablet 5 MG; Give 1 tablet by mouth every 8 hours for hypotension (low blood pressure); hold if SBP > (more than) 130 mmHg ( mmHg a measure blood pressure); start date:9/9/25Further review of MAR record indicated the midodrine hold parameters were not followed on 1//1/26 at 11 PM for BP of 139/84 mmHg, and on 1/2/26 a 3 PM for BP of 146/89 mmHg. In an interview with Licensed Nurse 4 (LVN 4), on 1/8/26, at Nurse Station number 1 , LVN 4 stated she followed the hold parameters for insulin when written in MAR and it was easier to address the parameters at the point of administration rather than going back and forth to other areas of the patient's record. LVN 4 stated she measured the blood pressure prior to giving any medication affecting blood pressure with parameters. LVN 4 stated pain level was documented in the MAR every time a pain medication was given, and they needed to do a follow up to see if resident was pain free or comfortable. In a concurrent record review and interview with Director of Nursing (DON), in his office, on 1/8/26, at 1:20 PM, the DON reviewed the nursing hold parameters documentation for Resident 4, Resident 6, and Resident 9. The DON stated the nursing staff should have clarified the orders with medical provider and followed the order if parameters were in place.A review of facility policy, titled Administering Medications, dated 2001, the policy indicated Medications are administered in a safe and timely manner, and as prescribed. The policy on section 4 indicated Medications are administered in accordance with prescriber order, including any required time frame.

Based on observation, interview and record review, the facility failed to ensure safe storage of medications and supplies with expired, unlabeled and comingled drugs in the medication's rooms and medication carts with resident census of 82.These unsafe practices had the potential for residents to receive medications with reduced potency and may contribute to medication errors.During an observation and concurrent interview, on 1/5/26 at 10:35 a.m., with License Vocational Nurse (LVN 9), in medication room on Station 2 , the following were observed:i. Comingled medications with different routes of administration were stored on the same shelf with no dividers. Medication included liquid prescription drugs, non-prescription pills were stored side by side with topical product such as topical head lice drug along with enema and rectal suppositories.ii. Expired medications and supplements were stored in the cabinets included: packages of Beneprotein (instant protein powder) with expiration date of 5/2025, Ingress (drug for movement disorder) with expiration date of 12/06/25, Nicotine gum (used to quit smoking) box with expiration date of 12/31/25, and opened single use sterile bottles of normal saline irrigation bottles when the label indicated to discard after opening.LVN 9 acknowledged the findings and removed the outdated products.During an observation and interview, on 1/5/26 at 11:27 a.m., with LVN 10, in medication room on Station 1, there were 3 bottles of hand sanitizer with an expiration date of 2022. LVN 10 confirmed the findings and stated that the expired items should have been thrown out.During an observation and concurrent interview, on 1/5/26 at 10:35 a.m., with License Vocational Nurse (LVN 9), in medication room on Station 2, the following were observed:i. Comingled medications with different routes of administration were stored on the same shelf with no dividers. Medication included liquid prescription drugs, non-prescription pills were stored side by side with topical product such as topical head lice drug along with enema and rectal suppositories.ii. Expired medications and supplements were stored in the cabinets included: packages of Beneprotein (instant protein powder) with expiration date of 5/2025, Ingress (drug for movement disorder) with expiration date of 12/06/25, Nicotine gum (used to quit smoking) box with expiration date of 12/31/25, and opened single use sterile bottles of normal saline irrigation bottles when the label indicated to discard after opening.LVN 9 acknowledged the findings and removed the outdated products.During an observation and interview, on 1/5/26 at 11:27 a.m., with LVN 10, in medication room on Station 1, there were 3 bottles of hand sanitizer with an expiration date of 2022. LVN 10 confirmed the findings and stated that the expired items should have been thrown out.During an inspection of Medication cart 1C, and interview with LVN 10, on 1/5/26 at 11:4 a.m., the medication cart stored the following:i. Opened and undated bottle of test strip used to measure blood sugar when the product label indicated to discard the bottle 90 days after first opening it.ii. Duoneb (inhalation medication brand name) packaging was open, and outer wrap was exposed and had an open date of 12/22/25. The drug label instructions on the box indicated to discard 2 weeks after opening.LVN 10 confirmed the findings and stated the medication should have been thrown out and reordered.During an inspection of treatment cart (cart stored medication and supplies for wound care) and interview with Registered Nurse (RN 2), on 1/5/25 at 12:15 p.m., at station 1 hallway, the treatment cart stored an opened packet of 'Aquacel advantage sterile dressing package (supply used to treat wound), and an expired box of Adaptic non adhesive dressing ( wound care product) expired on 10/ 31/2024. RN 2 confirmed the findings and stated that the open sterile dressing and the expired items should have been thrown out.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), in his office, the DON stated the expectation was for the nurses to follow the medication storage room and medication cart cleaning schedule and procedure. The medication room and cart cleaning/audit schedule indicated what aspects of the medication room and cart should have been addressed. The night shift was responsible for ensuring medication were not comingled, expired medications were removed, the medication area were cleaned and organized, and the medication carts were audited for expired and unlabeled drugs or products. DON stated the expectation was for the wound treatment nurses to clean their carts and dispose of open and expired items.During review of the facility policy and procedure, titled Administering Medications, dated 2001, the policy indicated when opening a multi-dose container, the date opened is recorded on the container. Vials labeled as single dose, or single use' are not used on multiple residents. Such vials are used only for one resident in a single procedure.During review facility policy titled Medication, Labeling and Storage dated 2007, the policy indicated multi dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from other medications.During an inspection of Medication cart 1C, and interview with LVN 10, on 1/5/26 at 11:4 a.m., the medication cart stored the following:i. Opened and undated bottle of test strip used to measure blood sugar when the product label indicated to discard the bottle 90 days after first opening it.ii. Duoneb (inhalation medication brand name) packaging was open, and outer wrap was exposed and had an open date of 12/22/25. The drug label instructions on the box indicated to discard 2 weeks after opening.LVN 10 confirmed the findings and stated the medication should have been thrown out and reordered.During an inspection of treatment cart (cart stored medication and supplies for wound care) and interview with Registered Nurse (RN 2), on 1/5/25 at 12:15 p.m., at station 1 hallway, the treatment cart stored an opened packet of 'Aquacel advantage sterile dressing package (supply used to treat wound), and an expired box of Adaptic non adhesive dressing ( wound care product) expired on 10/ 31/2024. RN 2 confirmed the findings and stated that the open sterile dressing and the expired items should have been thrown out.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), in his office, the DON stated the expectation was for the nurses to follow the medication storage room and medication cart cleaning schedule and procedure. The medication room and cart cleaning/audit schedule indicated what aspects of the medication room and cart should have been addressed. The night shift was responsible for ensuring medication were not comingled, expired medications were removed, the medication area were cleaned and organized, and the medication carts were audited for expired and unlabeled drugs or products. DON stated the expectation was for the wound treatment nurses to clean their carts and dispose of open and expired items.During review of the facility policy and procedure, titled Administering Medications, dated 2001, the policy indicated when opening a multi-dose container , the date opened is recorded on the container. Vials labeled as single dose, or single use' are not used on multiple residents. Such vials are used only for one resident in a single procedure.During review facility policy titled Medication, Labeling and Storage dated 2007, the policy indicated multi dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such , and are stored separately from other medications.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) reviewed for allegations of abuse was free from physical abuse when Certified Nursing Assistant (CNA) 1 forcefully turned Resident 1 while on the shower chair, forcefully removed Resident 1's clothing, hitting Resident 1's hand, and pulling Resident 1's hair. This failure resulted in Resident 1 to experience physical abuse and pain. Findings: During a review of Resident 1's undated admission Record , the admission Record printed on 5/5/25 indicated, Resident 1 was admitted in the facility on 5/15/23 with a diagnosis of Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills, ultimately impacting the ability to carry out even simple tasks). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) , dated 1/20/25, the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 3 out of 15, indicating sever cognitive impairment. During a phone interview on 6/5/25 at 1:24 p.m. with Certified Nursing Assistant Student (CNAS) 1, CNAS 1 stated seeing CNA 1 forcefully turned Resident 1 who was sitting on a shower chair in the room causing Resident 1's left arm to hit the wall by the door. CNAS 1 stated hearing Resident 1 saying No, no, no when CNAS 1 was trying to remove Resident 1's top in the shower room. CNAS 1 stated informing CNA 1 that Resident 1 kept saying no. CNAS 1 stated seeing CNA 1 enter the shower room and forcefully removed Resident 1's top. CNAS 1 also stated seeing CNA 1 smack Resident 1's right hand and pull Resident 1's hair on the left side when Resident 1 pinched CNA 1's hand. During a phone interview on 6/5/25 at 2:08 p.m. with CNA 1, CNA 1 stated she tried to communicate to Resident 1 through hand gestures but was unsuccessful when Resident 1 was combative prior to shower. CNA 1 stated placing Resident 1's left and right arm on her abdomen with one hand to stop Resident 1 from hurting her. During a phone interview on 6/5/25 at 3:31 p.m. with CNAS 2, CNAS 2 stated seeing CNA 1 forcing to take Resident 1's clothes. CNAS 2 stated seeing Resident 1 pinch and push CNA 1's hand away. CNAS 2 stated seeing CNA 1 pinning Resident 1's hand down, using force to take Resident 1's clothes off. CNAS 2 stated seeing CNA 1 slap Resident 1's hand. During a review of Resident 1's Progress Notes , dated 3/27/25, the Progress Notes indicated, facility staff made contact with Resident 1's hand in a slapping motion and tugged a part of Resident 1's hair. The progress notes indicated, Resident 1 had a new pain on left later/left front shoulder on assessment. The progress notes also indicated Resident 1 showed signs of pain. During a review of facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program , dated 4/21, the P&P indicated, Resident have the right to be free from abuse . This includes but is not limited to freedom from . physical abuse .

Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary environment when: 1. Kitchen Floors were not clean and maintained in good condition; 2. Chicken was not thawed safely; 3. The ice machine was not clean and was not cleaned according to manufacturer's instructions; 4. A can opener was not clean; and 5. Cutting boards were not clean and were in poor condition These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food, leading to food borne illness and/or food related illness for 80 residents who received food from the kitchen out of a census of 80. 1. An observation in the kitchen on 6/24/24 at 10:09 a.m., showed the floor between the reach in refrigerator and the warewashing sink with broken and missing tiles. The floor had an uneven surface. During an interview with the Maintenance Supervisor (MS) and a concurrent observation in the kitchen on 6/25/24 at 12:39 p.m., MS stated he was aware of the broken tiles throughout the kitchen floor. MS stated the floor was so old he could not get the same tiles to replace the cracked and missing tiles, so tried to replace with white tiles. Some of the smooth white tiles, MS used to replace the older tiles, were also cracked. Some tiles were loose. A loose tile on the floor between the warewashing sink and a reach-in refrigerator was moved and there were at least 7 insects under the tile. The insects were not identified but were long and thin, about an inch long. An observation in the kitchen and concurrent interview with DS on 6/25/24 at 12:52 p.m., showed black and brown residue build-up on the floor under the warewashing sink, closer to the wall. The tile floor under the sink did not come into contact with the wall so there was a gap of over an inch between floor tiles and the wall in some areas. DS stated the dark residue looked like food residue. DS stated the floor under the warewashing sink did not get cleaned. During an observation in the kitchen on 6/26/24 at 10:17 a.m., the floor under the warewashing sink was wiped with a white napkin and a significant amount of black/brown, sticky residue wiped off onto the napkin. During an interview on 6/26/24 at 10:25 a.m., the Administrator (Admin) stated she was aware of the condition of the floor in the kitchen and the floors were and ongoing project and the floors were part of QAPI (Quality Assurance and Performance Improvement). Admin was unable to state how long the floors were monitored in QAPI. Then Admin stated the kitchen floors were not picked up as an active PIP (Performance Improvement Project). Admin stated, the things being worked on in QAPI were things we know definitely need improvement which were typically related to clinical. Admin stated the facility did receive bids to fix the floor but there was no evidence provided by Admin to show the facility was moving forward with either of the two bids provided (flooring bids dated 2/15/24 and 2/20/24). On 6/26/24 at 11:17 a.m., MS stated he worked in the facility for seven years and the floor in the kitchen was already in poor condition when he started. MS stated the floors have gotten worse over time. Review of the facility's P&P titled Floor Safety dated 2023, showed floors will be maintained to maximize safety. Floors should be kept clean. According to the 2022 Federal Food Code, floors are to be designed, constructed, and installed so they are smooth and easily cleanable. In food establishments in which cleaning methods other than water flushing are used floor cleaning floors, the floor and wall junctures are to be coved and closed to no larger than one millimeter. Floors in which water flush cleaning methods are used, the floor and wall junctures shall be coved and sealed. In addition, premises are to be maintained free of insects. 2. An observation during the initial tour of the kitchen on 6/24/24 at 9:48 a.m., showed a large pan of raw chicken stored in a reach-in refrigerator. The label on the pan showed the preparation date was Sunday 6/23/24 and the use by date was 6/26/24. The label also showed SL: 3 days. The chicken was very soft to the touch and felt thawed. During an observation and interview with the Dietary Supervisor (DS) and [NAME] (C) 1 on 6/24/24 at 10:10 a.m., DS looked at the thawed chicken with the preparation date 6/23/24 and stored in the walk-in refrigerator. DS stated C1 placed the chicken in the refrigerator to thaw on Saturday 6/22/24 but changed the label on Sunday to show a preparation date of 6/23/24. Then DS stated if the chicken was placed in the refrigerator on Saturday, the label should show Saturday 6/22/24. C1 explained the chicken was leftover chicken from what was not used from a prior meal. DS and C1 explained the staff used a label making machine and the machine could only print a label showing the current date, not a past date. So, if staff used the label maker to make a new label for a food already being stored on a past date, such as the chicken, the label showed the current date, not the actual date the chicken was placed in the refrigerator. DS stated, in cases like this, staff had to make a handwritten label to show the correct date. During an interview on 6/24/24 at 10:17 a.m., C1 stated he remembered he had two batches of chicken thawing and the chicken he thawed on Saturday was already used and he placed a second batch of chicken to thaw in the refrigerator on Sunday. C1 stated he thawed the chicken with the preparation date label 6/23/24 under running water then he placed it back in the refrigerator to use on Tuesday 6/26/24. During an interview with C1 and DS on 6/25/24 at 8:55 a.m., C1 stated he was marinating the chicken observed in the refrigerator yesterday with the preparation date 6/23/24. Then he stated he thawed the chicken under running water this morning. C1 stated he did not measure the temperature of the running water when he thawed the chicken under the water. C1 stated it could take up to an hour to thaw raw chicken under running water. When C1 was asked if there was time/temperature documentation for the chicken for when he stated he thawed it under runner water the prior day and placed back in the refrigerator, C1 stated no. Then C1 stated he did not thaw the chicken under running water and only thawed the chicken in the refrigerator. Then DS confirmed she did hear C1 say he (C1) thawed the chicken under running water on Sunday (6/23/24) and placed it back in the refrigerator. DS confirmed there were no critical control points measured (time/temperature) to ensure the chicken was thawed and stored safely after being thawed under running water then placed back in the refrigerator to use on a future date. DS told C1 to discard the chicken from 6/23/24 which was being marinated for lunch and to thaw another batch of chicken. An observation and interview with C1 and DS on 6/25/24 at 9:46 a.m., showed C1 placed frozen chicken pieces in a metal pan and placed the pan in the food preparation sink and turned the water on so water flowed into the pan with the chicken. The chicken pieces did not fully fit inside the pan. So, when the water ran into the pan, the chicken was not submerged. The chicken pieces stuck out of the water over four inches. When C1 was asked if he measured the water temperature, he confirmed he did, and it was about 75 degrees Fahrenheit (F). When C1 and DS were asked if the chicken was being thawed appropriately, DS stated yes, because the chicken was under running water. When the surveyor pointed out the chicken was not fully submerged in the water. Then DS confirmed the chicken needed to be fully submerged in the water. DS measured the temperature of the water with a thermometer and stated the water was 76 degrees F. DS measured the running water temperature again with a different thermometer and stated the temperature was 75.4 degrees F. DS confirmed only the cold water was on and this was the coldest the water would get. Review of the facility's policy & procedure (P&P) titled General HACCP Guidelines for Food Safety, dated 2017, the P&P showed the time-temperature connection was limiting the time food is in the temperature danger zone (TDZ). Food must be held above 135 degrees F or below 41 degrees F. Limit the time that food is in the TDZ to no more than four hours combined total for all preparation (thawing, preparation, and re-handling). In addition, the P&P showed two safe thawing practices - a. thaw meat, fish and/or poultry in a refrigerator; b. completely submerge the item in clean running water (below 70 degrees F) that is running fast enough to agitate and float off loose ice particles. 3. During an observation in the kitchen with the Maintenance Supervisor (MS) on 12/25/24 at 12:26 p.m., MS described how he cleaned the ice machine. MS stated the ice machine was scheduled for cleaning once a month, but he actually cleaned it once a week. MS stated he sanitized everything on the ice machine. MS stated he opened the ice machine and wiped the evaporator plate (a metal grid inside the ice machine where water runs over then freezes to make ice cubes). Then MS stated a deep cleaning was done every six months. MS showed the chemical used for what he stated was sanitizing. The container of the chemical showed it was a Scale Remover for Ice Machines. MS showed the chemical container he stated he used for monthly cleanings. This chemical was Ice Machine Sanitizer. MS stated he did the last weekly cleaning last Friday. MS stated he did not have the ice machine manufacturer's manual to show directions for cleaning the machine. As the observation and interview of the ice machine continued on 12/25/24 beginning at 12:26 p.m., MS opened the top of the ice machine and removed the evaporator plate cover. A white wire was attached to a plastic, rectangle piece attached to the plastic to the side of the evaporator plate. MS stated the plastic rectangle piece was a sensor. There was dark brown residue along the entire crevice of the wire and the and there was dark brown/black residue around the area of the sensor. MS stated he did not touch the sensor or wire when he cleaned the ice machine because it was very sensitive. It was noted the wire and the sensor were inside the ice machine over opening to the ice bin, where the ice was stored, and moisture droplets were formed on the parts of the upper inside area and could drip down into the ice. Review of the undated manufacturer's manual provided by MS for the ice machine titled [Ice machine brand] Installation and User's Manual for Modular Cuber [model numbers], showed to pour the ice machine scale remover into the reservoir and the unit will circulate the scale remover, then drain and flush. The directions also showed to locate two sensors, an ice thickness sensor as well as the water level sensor. The directions showed how to clean both sensors. The directions showed to thoroughly wash all surfaces of the ice thickness sensor and water level sensor with a sanitizer solution. In addition, all interior surfaces of the freezing compartment (excluding evaporator cover and right side panel liner) with sanitize solution. It was noted the directions did not indicate to wipe the evaporator with scale remover. According to the 2022 Federal Food Code, food-contact surfaces of equipment are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of an accumulation of dust, dirt, and other debris. 4. An observation and interview at 9:50 a.m., showed an industrial can opener held in a base attached to a food preparation table. The green insert inside the base had black, brown, and white residue and particles on the subsurface. In addition, the can opener blade had black and brown, sticky residue imbedded line crevice where the blade attached to the base of the can opener. DS stated the can opener was just cleaned this morning by running it through the dish machine. DS stated she did not consider the blade clean, and the dishwasher could rerun it through the machine if it did not come out clean. DS confirmed the base was not clean. DS also stated the can opener holder was cleaned every three months but if it was soiled prior to three months it needed to be cleaned as needed. Review of the facility's P&P titled Cleaning Instructions: Can Opener dated 2023, showed the can opener will be cleaned after each use. To clean a handheld can opener, clean in sink filled with soapy water. Pay special attention to the blade and moving parts. Use a brush to get into the crevices. Rinse, sanitize, and air dry. In addition, remove the rubber insert. Clean in a sink filled with soapy water. Rinse, sanitize, and air dry. According to the 2022 Federal Food Code, food-contact surfaces of equipment are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of an accumulation of food residue and other debris. 5. An observation in the kitchen and concurrent interview with DS on 6/24/24 at 11:40 a.m., showed seven acrylic cutting boards stored in a rack. Three of seven cutting boards were significantly scratched with plastic coating peeling off the surfaces. One of the three scratched cutting boards had black residue imbedded in the surface of both sides of the board. Another of the three scratched cutting boards, which was green, had white residue build-up on the surface which scraped off. This board was so scratched almost the entire board appeared white. DS stated cutting boards were replaced as needed. DS stated the scratched cutting boards were overused and two of the scratched cutting boards were dirty. Review of the P&P titled Cleaning Instructions: Cutting Boards dated 2023, showed cutting boards will be cleaned and sanitized after each use. Cutting boards should be replaced when the surface is deeply scored. According to the 2022 Federal Food Code, multiuse food-contact surfaces are to be clean be smooth and free from inclusions, pits, and similar imperfections. Food-contact surfaces of equipment are to be clean to sight and touch. Surfaces such as cutting boards that are subject to scratching and scoring are to be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.

Based on observation, interview, and record review, the facility failed to ensure: 1. Family members could bring in food for residents. 2. Residents had a location to safely store perishable food. 3. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 80 residents who took food by mouth out of a census of 80. Findings: During an interview on 6/24/24 at 11:21 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the facility did not have any refrigerators to store resident food in, and perishable foods were thrown away. During an interview on 6/24/24 at 11:25 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed that there was no refrigerator on the unit to store food in, and that perishable resident food was thrown away if the resident did not want to consume the food at the time it was provided. During an interview on 6/24/24 at 11:27 a.m., the Assistant Director of Nursing (ADON) stated typically perishable food brought in by family members was not stored for residents. ADON stated the family members were asked not to bring food in for residents. During an interview on 6/24/24 at 11:29 a.m. with the Director of Nursing (DON), the DON stated food is brought in for residents by family members was not stored and the facility let family members know there was not a refrigerator to store food. DON stated family was asked not to bring food in food to the facility. DON stated once food enters the Resident room it was contaminated. When DON was asked if food that did not enter the resident room could it be stored, DON stated the facility did not have a refrigerator. During a review of the facility's policy and procedure titled Food Brought by Family/Visitors, undated, the policy indicated family members should inform nursing staff of their desire to bring food into the facility. The Clinical Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. Perishable foods must be discarded after an appropriate time (specific to food and temperature). It was noted this policy did not describe how to safely store food brought in by family and visitors.

Based on observation, interview, and facility document review, the facility failed to provide pureed vegetables according to the menu for residents receiving pureed diets. This failure had the potential to result in decreased satisfaction with food and/or decreased nutrient intake for four out of five (Residents 29, 54, 3, 30) residents who received pureed diets. Findings: An observation in the kitchen and interview with the Dietary Supervisor (DS) and [NAME] (C) 1 on 6/24/24 at 10:25 a.m., showed metal pans in the oven. C1 stated the food in the metal pans included pureed carrots. C1 stated he placed the pureed food in the oven about 9:50. DS stated tray line normally started about 11:45 a.m. Review of the Diet Spreadsheet dated Monday Week 2 Cycle 17, showed the vegetables served for lunch on 6/24/24 were sliced carrots, and the pureed textured diets received pureed sliced carrots. During an observation and interview with DS on 6/24/24 at 12:45 p.m., test trays were conducted, and the regular textured and pureed textured food served to residents for lunch were sampled. The pureed carrots were flavorless and had an unpleasant gummy/sticky texture. The regular carrots tasted well-seasoned. DS confirmed the texture of the pureed carrots were gummy. DS also agreed the pureed carrots lacked flavor. During an interview on 6/25/24 at 9:35 a.m., C1 confirmed he prepared the carrots for served for lunch yesterday (6/24/24). C1 stated the regular textured carrots were cooked in the steamer then he put seasoning on the carrots including salt, pepper, paprika, and some garlic powder. C1 stated the for the pureed carrots, the carrots were boiled and pureed, and seasoning was not added. C1 stated he did not usually add seasoning to pureed vegetables. During an interview and concurrent document review of recipes on 6/25/24 at 9:40 a.m., DS stated the regular textured carrots should be pureed rather than preparing a separate batch of carrots for the pureed texture. DS confirmed according to the recipes the regular carrots were prepared, then pureed. Review of the recipe for sliced carrots dated 2/2/23 showed to ingredients included frozen sliced carrots, and seasoning - Signature Blend, Salt Free. Review of the recipe for Sliced Carrots (Puree) dated 1/7/2017, showed to prepare Sliced Carrots according to the recipe, then puree in a food processor. Review of the policy and procedure titled, Standardized Recipes, dated 2023, indicated standardized recipes will be used when preparing menu items.

Based on observation, interview, and record review, the facility failed to ensure proper labeling of biologicals (made from a variety of natural sources human, animal, or microorganisms and are used to treat, prevent, or diagnose diseases and medical conditions) when one opened multi-dose vial of Tuberculin Purified Protein Derivative (PPD- indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease.) was unlabeled and undated with an open date. This failure had the potential for residents to receive a false test result due to Tuberculin PPD with reduced potency from being used past their discard date. Findings: During a concurrent observation and interview on 06/26/24 at 9:12 a.m. with RN (Registered Nurse) 1 in the medication room, one 1 milliliter (mL) multi-dose vial of PPD was in the refrigerator without a vial cap and a label of the open date. RN 1 stated, the vial could have been opened months ago and should have an open date label. During a concurrent interview and record review on 06/26/24 at 1:15 p.m. with IP (Infection Preventionist), the undated pharmacy expiration reference list was reviewed. The pharmacy expiration reference list indicated opened tuberculin test vials should be discarded after 30 days. During a review of the Tuberculin PPD product information from www.fda.gov/media/74862/download?attachment dated November 2013, indicated Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on observation, interview and facility document review, the facility failed to provide the texture of food prescribed for one resident (Resident 62). This failure had the potential to cause one Resident 62 to choke on the food provided out of 80 residents who received food from the kitchen. Findings: During a record review, Resident 62's Admission Record showed Resident 62 was diagnosed with oropharyngeal phase dysphagia (swallowing problems occurring in the mouth and/or throat. During a record review for Resident 62, the Speech Therapy Treatment Encounter Note(s) dated 6/19/24 and 6/24/24 showed Resident 62 was assessed by SLP and current foods in both reports were Soft + Bite-Sized Foods SB6. A concurrent observation and document review during tray-line food service on 6/24/24 at 12:25 p.m., showed staff placed food on resident trays according to the physician prescribed diet printed on a tray ticket and the Diet Spreadsheet dated Monday Week 2 Cycle 17. The tray ticket for Resident 62 showed he was prescribed a Soft & Bite-Sized SB6, Mildly Thick Liquids, Renal diet. The spreadsheet showed the dessert for Soft & Bite Sized diets was Red Gelatin (cubes) and the dessert for Renal diets was 5 each Vanilla Wafers. Kitchen staff placed a cup filled with red gelatin and a cup filled with vanilla wafers broken up into bite-sized pieces, on Resident 62's tray then began placing food on the next resident tray. During a consecutive interview on 6/24/24 at 12:27 p.m., the Dietary Supervisor (DS) was asked if vanilla wafers were an appropriate texture for soft & bite sized diets. DS stated she needed to ask the Registered Dietitian. During an interview on 6/24/24 at 12:35 p.m., DS stated she spoke with the Speech Language Pathologist (SLP) who said Resident 62 should receive applesauce instead of cookies because the cookies might me too hard. During a virtual interview on 6/26/24 at 9:54 a.m., SLP stated vanilla wafers were not appropriate for as Soft & Bite Sized diet. SLP stated normally the wafers were soaked in milk to make them softer for the Soft & Bite Sized diet but milk was not appropriate for the Renal diet. SLP stated Resident 62 was edentulous (having to teeth) and if the resident attempted to eat the wafers he could have trouble chewing and might spit the wafers out or in the worst case scenario, could choke. SLP stated she noticed the menu spreadsheet used in the kitchen did not have IDDSI (International Dysphagia [difficulty swallowing] Diet Standardization Initiative; a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures) for the Renal diet. Review of the facility's Dietary Manual dated 2020 and approved by the Administrator, Dietitian, Medical Director, and Director of Nursing in 2024, showed the IDDSI Soft and Bite Size (level 6, Blue) diet is indicated for the resident who has difficulty chewing or swallowing the food items included in the Regular diet . and is intended for residents who would benefit from foods that can be easily and safely chewed and swallowed. Food offered on this diet are soft, tender and moist with no separate thin liquids. Refer to a speech-language pathologist as needed. A RDN [Registered Dietitian Nutritionist] can individualize this diet to provide resident preferences in a modified form. The description of the diet showed foods should be soft enough to cut with a spoon, foods are to be moistened with small amounts of added liquid such as milk, to avoid hard or crunchy foods which may be difficult to chew. In addition, dry cookies were listed under the foods to avoid.

Based on observation, interview, and record review, the facility failed to ensure all equipment was maintained in good working order when one of three freezers did not maintain food frozen solid. This failure to improperly store food had the potential to result in decreased quality of food as well as foodborne illness to residents receiving food from the kitchen. Findings: During an observation on 6/24/24 at 9:29 a.m., the temperature of freezer 1 was 19 degrees Fahrenheit (F). Items inside the freezer, including individual cartons of supplement shakes and pie crusts were soft to the touch and not frozen solid. During a concurrent observation and interview on 6/24/24 at 10:05 a.m. with the Dietary Supervisor (DS), freezer 1 and its contents were observed again. Seven uncooked pie dough crusts labeled with a received date of 4/22/24 were all noted as being soft to the touch, along with 2 angel food cakes labeled with a received date of 5/24/24. The DS then opened two health shakes stored in the freezer, which were not frozen solid and had a gooey, pudding-like consistency and ice build-up on the surface. The DS stated the shakes should not be this consistency and should be frozen solid. During a concurrent observation and interview on 6/26/24 at 9:20 a.m. with the DS, freezer 1 was 20 degrees F. During a review of the facility's policy and procedure (P&P) titled Food Storage, dated 2017, the policy indicated All freezer units will . be kept in good working condition at all times . and Frozen foods must be maintained a temperature to keep the food frozen solid.

Based on interviews and record review, the facility failed to follow the Grievance/Complaint policy and procedure to inform the resident, or responsible person of the investigation results and actions taken for one (Resident 1) of three sampled residents when the Administrator (Admin) did not inform Resident 1 of the investigation findings. The complaint was about Registered Nurse (RN 1) not treating Resident 1 with dignity and respect. This deficient practice had the potential to cause Resident 1 emotional distress. Findings: During an interview on 11/21/22 at 11:05 a.m., Resident 1 stated he asked Admin for a meeting appointment. Resident 1 stated Admin met with him and informed Admin that he was not getting along with RN 1 because RN 1 screamed and shouted at him, treated him like a child and did not treat him with dignity and respect. Resident 1 stated Admin said she would follow up with Resident 1 and Admin never did. Review of the Admission-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 6/25/22, indicated Resident 1's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 1 ' s diagnoses included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one ' s daily activities). During an interview on 11/22/22 at 10:00 a.m., Admin stated Resident 1 informed her about the friction he was having with RN 1. Admin stated she did not remember if she followed up with Resident 1. During an interview on 11/2/22 at 10:40 a.m., RN 1 stated he admitted that sometimes he was stern with Resident 1 because Resident 1 always asked for one thing or another. RN 1 stated Resident 1 sometimes made sexual innuendoes. During a review of the facility ' s Grievance tracking log on 11/22/22 at 10:40 a.m., in the presence of the Director of Social Services (DSS), there were no concerns reported from January 2022 to October 2022. The facility's policy and procedure titled, Resident Grievance/Complaint revised December 2004, indicated; A resident, his or her representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members etc. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. Within seven working days of the date you filed the grievance; you will receive a written summary of the results of the investigation.

Based on interview and record review, the staff failed to report an incident of sexual abuse in a timely manner, and failed to protect one (Resident A) of seven sampled residents when CNA 1 observed a contracted housekeeper (HSK) in an oral sex act with the resident. CNA 1 did not report the incident to the licensed nurse or Executive Director (ED, abuse coordinator) for several hours, nor make any attempt to comfort or protect the resident. This failure resulted in a delay in protection and assessment of Resident A, who had dementia (progressive difficulty with memory, thinking, and comprehension), and could not reasonably consent to such an act. Findings: An investigation was begun based on a report by the facility on 8/24/15. On 8/25/15 at 12:37 p.m., the ED stated in an interview that Certified Nursing Assistant (CNA 1) working from 3:00 p.m. to 11:00 p.m. shift witnessed a sexual event on 8/23/15 at 4:30 p.m., between their contracted employee HSK and Resident A. ED stated CNA 1 relayed the abuse to her coworkers, CNA 2 and CNA 3. However, CNA 1 did not report it, and CNA 2 and CNA 3 informed Licensed Vocational Nurse (LVN 1) of the abuse after the shift was over, about five hours after the incident occurred. The ED stated LVN 1 left phone messages to contact him regarding resident abuse, and ED contacted the Director of Nursing (DON) at 2 a.m. to discuss the incident. ED stated he expected nursing staff to report the abuse immediately. Record review on 8/25/15, reflected Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/25/15 review of the Abuse Prevention policy and procedure, dated 5/15/03, indicated residents most at risk of abuse, may include, but are not limited to, residents who have dementia or psychosocial dysfunction. Review of the policy and procedure, dated 5/22/13, titled, Responding to and Investigating an Abuse Allegation, directed staff to report sexual abuse, immediately to the Administrator and to other officials. Key steps are: 1. Appoint someone to stay with the resident for protection and comfort and 2. Preserve all physical evidence of assault pending investigation. a. Do not allow patient to shower/bath, [MEDICATION NAME] or brush teeth. b. Save all clothing worn and linen at the time of the assault. c. Place each item of clothing and linen in a separate paper bag. d. Do not disturb anything in the area where the assault occurred. On 8/25/15 at 2:26 p.m., LVN 1 verified the sequence of events, and stated he phoned CNA 1 around 11:15 p.m. to confirm the abuse. When LVN 1 could not reach the ED, he called the DON, and the DON directed him to interview Resident A. LVN 1 stated he woke up Resident A at 11:30 p.m. Resident A was groggy, and told him she had not talked with the HSK. On 8/25/15 at 3:08 p.m., during an interview with CNA 1, she stated on 8/23/15 at 4:30 p.m., she noticed Resident A's privacy curtain completely drawn, which is so unusual for that time (of day). CNA 1 entered the room to check on the resident, looked around the curtain, and observed HSK's penis inside Resident A's mouth. When HSK saw CNA 1, he withdrew himself and zipped up his pants. CNA 1 stated she left the room, and HSK followed her asking if she needed the garbage taken out and she told him, No, No, just leave! CNA 1 stated she did not ask the resident if she was okay or ask what happened at any time during the shift. CNA 1 failed to report the abuse (to the nurse or ED) because she was scared, had no evidence, and did not want to be involved in an investigation. CNA 1 stated she should have reported the abuse right away. On 8/25/15 at 5 p.m., in an interview with CNA 2, she stated she learned about the sexual abuse between 5 p.m. and 6 p.m., and encouraged CNA 1 to report the abuse because she witnessed it, but CNA 1 was too scared. On 8/26/15 at 4:15 p.m., CNA 3 stated in an interview that he was with another resident at 4:30 p.m., and CNA 1 approached him and told him she saw HSK sexually abusing Resident A. CNA 3 tried to convince CNA 1 to report the abuse because she saw it. CNA 3 stated he was the first person CNA 1 told, and relayed the abuse incident to CNA 2. On 8/25/15 at 4:45 p.m., in an interview with Resident A, the resident stated she did not recall any physical contact with HSK, other than shaking his hand. Further record review reflected the resident received medications which could have affected her memory. The physician order's dated 3/23/15, indicated Resident A was to [MEDICATION NAME](sleeping pill) 5 milligrams (mg), and [MEDICATION NAME] (antianxiety medication) 1 mg at bed time (9:00 p.m.) The Medication Administration Record [REDACTED]. On 9/23/15 at 10:35 a.m., Resident A's physician (MD 1) stated [MEDICATION NAME] causes a person to not think straight, and the combination of these medications (Ambien) will worsen short term memory problems. MD 1 stated she ordered a psychologist consultation to evaluate the resident's thinking and decision-making ability. The psychologist's report and mini-mental status exam (MMSE, a method for grading the cognitive state), dated 8/25/15 through 8/26/15, reflected the resident did not think anything happened to her, and had mildly impaired judgement and increasing time confusion, and the patient's capacity to make medical decisions should be called into question. According to the National Committee for the Prevention of Elder Abuse (NCPEA), sexual abuse includes any sexual conduct with a person who lacks the mental capacity to exercise consent. Reference: (www.preventelderabuse.org) On 8/28/15 at 7:51 a.m., the psychologist stated, that given Resident A's short term memory loss, No, she is not able to give consent for sexual activity. Review of the care plan dated 10/21/14, Impaired Cognitive Function, related to short term memory loss, indicated Resident A needs supervision with all decision-making. Potential risks of oral sex, in addition [MEDICAL CONDITION](human immunodeficiency virus) that can destroy so many of the cells that fight off infections and disease), other [MEDICAL CONDITION] (STD's) including [MEDICAL CONDITIONS], syphilis (bacteria causing long term health problems), gonorrhea (highly contagious bacterial infection), genital warts (common [MEDICAL CONDITION]), intestinal parasites, and [MEDICAL CONDITION] (highly contagious liver infection). (Reference: www.cdc.gov <http://www.cdc.gov>) During an interview, on 8/28/15 at 9:35 a.m., HSK stated, It 's a mistake .I 'm sorry, it won't happen again, and confirmed CNA 1 's witnessed account of the event. Note: HSK was immediately suspended after the incident to protect other residents. The police investigative report dated 8/26/15, reflected HSK admitted to having Resident A perform oral sex on him, and he knew it was wrong to have sex with the resident under any circumstances. On 11/10/15 at 10:12 a.m., Resident A's daughter stated she was shocked to hear of her mother's sexual abuse, and it was not consistent with what her mother would normally do. On 10/15/15 at 10:08 a.m., the contracted company 's attorney (ATTY) stated he was appalled to learn of the abuse, and that HSK was terminated from his employment.

Based on observation, interview and record review for Resident 1, the facility failed to ensure that CNA1 and CNA 2 (certified nurses aides) treated one of one sampled rsidents (Resident 1) with dignity and respect during care. Resident 1 refused care for a change of briefs at 5:00 a.m. on 7/8/15 and CNAs 1 and 2 held his arm and proceeded to provide care resulting in Resident 1 becoming agitated during the care and withdrawn after the care. Findings: Review of the clinical record showed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS-assessment tool used to direct resident care), dated 1/18/14, indicated Resident 1 was cognitively intact. Resident 1 was capable of making himself understood and his speech was clear. In an interview on 7/16/15 at 12:20 p.m., the Executive Director (ED) stated the following : On 7/8/15, CNA 1 and CNA 2 provided care to Resident 1even though he was resistant to care. CNA 2 held down Resident 1's right hand (left hand was not mobile) while CNA 1 provided care. CNA 1 and CNA 2 did not report to Registered Nurse (RN) 1 that Resident 1 refused care. According to the ED, CNA 1 and CNA 2 should have taken a step back from Resident 1 when he refused care, saying, No, as he had a right to refuse care. Resident 1 was upset about the incident. In an observation and concurrent interview on 7/16/15 at 1:00 p.m., Resident 1 stated he was awakened around 5:00 a.m. on 7/8/15 by CNA 1 to change his clothes. Resident 1 stated he told CNA 1 and CNA 2, No, and to get out of his room. Resident 1 demonstrated how CNA 2 held his right wrist against the side rail of the bed by placing his right hand against the side rail. Resident 1 stated he told CNA 1 and CNA 2 to stop what they were doing, but CNA 1 and CNA 2 continued to provide care. Resident 1 stated CNA 1 twisted his left wrist and he was very upset. Resident 1 stated he could not put into words how he felt about the incident, and that what they did was not right. In an interview and concurrent record review on 7/16/15 at 2:20 p.m., the Director of Staff Development (DSD) stated CNA 1 and CNA 2 should have reported to their charge nurse if Resident 1 refused care. In a telephone interview on 7/20/15 at 1:25 p.m., CNA 1 stated he would continue to provide care if a resident continued to be angry or agitated. In a telephone interview on 7/20/15 at 1:45 p.m., CNA 2 confirmed Resident 1 got agitated during the care provided on 7/8/15. In a telephone interview on 8/11/15 at 9:30 a.m., Registered Nurse (RN) 1 stated Resident 1 reported CNA 1 yanked off Resident 1's blanket before providing care and that Resident 1 felt humiliated by that action. RN 1 stated Resident 1 reported CNA 2 held Resident 1's right hand. RN 1 stated Resident 1 was highly upset and got agitated from the care he received. Record review of Resident 1's Progress note, dated 7/11/15, showed, Appears to be withdrawn and displays occasional agitation. Review of the facility's policy and procedure titled, Resident Rights, revised on 4/28/09, showed, Residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care. Review of the facility's undated policy, Interventions for Distressing Behavior, indicated if resident refused care staff are to, Choose schedules consistent with the resident's interests and preferences. Re-approach at a later time.

Based on observation, interview and record review, for one (Resident 3) of 19 sampled selected residents the facility failed to ensure that Resident 3 was protected from abuse. by Resident 3 sustained physical and psychological injuries after she refused care from Certified Nurse Assistants (CNAs) 2 and 4 and they forced her to get her briefs changed in a physical and verbal confrontation. Findings: During an observation and concurrent interview on 2/12/15 at 9:40 a.m., Resident 3 stated she had reported an incident that occurred on 2/4/15. Resident 3 stated Certified Nursing Assistant (CNA 2) entered her room without introducing herself around 4:00 a.m. on 2/4/15 and wanted to change her adult briefs. Resident 3 told CNA 2 that she did not need to be changed and refused care. Resident 3 stated both CNA 2 and CNA 4 then entered her room a second time, turned her light on and proceeded to change her adult brief. Resident 3 stated that CNA 2 said to her that she was going to be changed whether she liked it or not. Resident 3 stated that CNA 4 held both of her hands down while CNA 2 changed her adult brief. Resident 3 stated that this made her mad and that she had to fight them off as they changed her. Resident 3 stated that the CNA 2 and CNA 4 did not listen to her as she refused care. Resident 3 stated she did not need to be changed if she did not want to be changed. Resident 3 stated she was angry that the facility could have someone like CNA 2 and CNA 4 working at the facility and what they did was not right. Resident 3 showed where she had been injured on her left lower arm. There was red and black discoloration spread throughout the back of Resident 3's left hand and also red and black discoloration on the back of her left forearm. Both had gauze dressings on top of the injuries. Resident 3 stated that her skin came off as a result of when CNA 4 held both of her hands down. Resident 3 stated that the skin tears hurt a lot and that they bled at both sites. Record review of Resident 3's Minimum Data Assessment (MDS, an assessment tool used to direct resident care), dated 1/21/15, showed a Brief Interview for Mental Status (screening tool that aids in detecting cognitive impairment) score of 15, indicating Resident 3's thinking and reasoning ability was intact. Resident 3's MDS showed that Resident 3 had clear speech and could make herself understood. Resident 3's MDS also showed that Resident 3 required only one person's physical assistance for moving in bed and for toilet use. In an interview on 2/12/15 at 1:15 p.m., the Social Service Designee (SSD) stated that Resident 3 did not like to be woken up before 6 a.m. by anyone. The SSD stated that Resident 3 was angry and upset after the incident and preferred that CNA 2 and CNA 4 not care for her any longer. The SSD confirmed that Resident 3 was alert and orientated, and was able to make her needs known. In a telephone interview on 2/12/15 at 1:40 p.m., Registered Nurse (RN 1) stated that she had found Resident 3 to be upset and did not want to be wakened early in the morning to receive care. RN 1 stated that Resident 3 said, "Get out, get out," to CNA 2 and CNA 4. RN 1 stated that Resident 3 had fragile skin upon admission to the facility. When asked if Resident 3 used her call light to and asked to be cared for, RN 1 stated that she did not think Resident 3 used her call light for any needs at the time of that incident. In a telephone interview on 2/12/15 at 1:55 p.m., CNA 2 stated that she went into Resident 3's room to check on her. CNA 2 stated that Resident 3 did not want her to touch or change her when she awakened her. CNA 2 stated that she asked CNA 4 to assist her with Resident 3 for care. CNA 2 stated that Resident 3 was really upset and tried to fight off CNA 4 when they changed her. CNA 2 stated that she tried to do her job with what she had and that, "When you have 95 patients with four to five CNAs, it is very difficult and a lot of things going on." CNA 2 stated that she had spoken to RN 1 prior to Resident 3's being injured and that RN 1 did not say much of anything. CNA 2 stated that she did not know if RN 1 heard her or not. In an interview on 2/13/15 at 9:25 a.m., Resident 3 stated that her sleep had not been good since the incident and that she was afraid if the two CNAs were to come back to give her care. Resident 3 looked at her left hand and wrist injuries and stated that it, "Kind of makes me mad thinking of it (referring to the incident)." In a telephone interview on 2/13/15 at 9:55 a.m., CNA 4 stated that Resident 3 complained on 2/4/15 when he helped CNA 2 pull the resident up in bed. In an interview on 2/13/15 at 1:15 p.m., the Executive Director (ED) confirmed that Resident 3 refused care when CNA 2 wanted to change her on 2/4/15. When asked what he expected CNA 2 to do when Resident 3 refused care, the ED stated that CNA 2 needed to go to her nurse, so that the nurse could talk to the resident. Review of the facility's policy and procedures titled, "Abuse," last revised on 8/31/12, showed, "Patients have the right to be free of verbal, sexual physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, neglect and misappropriation of patient property." Review of the facility's policy and procedures titled, "Resident Rights," last revised on 4/28/09, showed, "Resident Rights include the resident's right to: have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care." Review of the Progress Notes on 2/13/15, documentation by the ED, dated 2/6/15, showed, "Identified cause: CNA provided care despite resident's refusal. Documentation by RN 1 dated on 2/5/15, showed, "Late entry for 2/4/15 at 5 a.m.: called to resident 3's room by CNAs. Resident (Resident 3) yelling "Get out" repeatedly, and flinging her arms. Observed smear of blood on siderail and noted skin tear on dorsum (back) of left hand. When nurse asked what happened, resident said she should not have been awoken at noc (night). Area on left hand already being monitored for purplish bruise, now with superficial skin tear with scant bleeding, 2x4cm (2 by 4 centimeters), cleaned with normal saline and steristrips (adhesive to hold edges of a wound together) applied."