Every finding on record at Beadles New Beginnings

Based on record review and interview, the facility failed to develop comprehensive care plan interventions for trauma informed care for 1 (#20) of 2 sampled residents reviewed for PTSD.The DON identified 29 residents resided in the facility and two residents had PTSD. Findings: A quarterly assessment for Resident #20, dated 02/11/26, showed the resident was originally admitted on [DATE] and had a BIMS score of 15, indicating intact cognition. The assessment showed Resident #20 had diagnoses which included schizoaffective disorder, major depressive disorder, anxiety, and PTSD. A care plan for Resident #20, updated on 02/23/26, did not show interventions for PTSD. A monthly medication review for Resident #20, dated 04/13/26, showed the resident received the following medications: a. hydroxyzine (an antihistamine) 50mg three times daily for anxiety, b. paliperidone (an antipsychotic) 9mg daily in evenings for schizophrenia,c. duloxetine (a selective serotonin and norepinephrine reuptake inhibitors) 60mg daily for depression, d. fluphenazine (an antipsychotic) 2.5mg twice daily for schizoaffective disorder, ande. trazodone (a serotonin receptor antagonists and reuptake inhibitor) 100mg at bedtime for depression. On 04/30/26 at 10:55 a.m., CNA #1, CNA #3, and CNA #4 stated they did not know Resident #20 had a diagnosis of PTSD. On 04/30/26 at 11:16 a.m., the DON stated they were not aware of any specific care interventions for Resident #20's PTSD. On 04/30/26 at 11:30 a.m., the MDS coordinator verified PTSD should have been included in the resident's comprehensive care plan.

Based on observation, record review, and interview, the facility failed to ensure a resident who utilized a Velcro belt in their wheelchair was assessed for use for 1 (#31) of 1 sampled resident reviewed for accidents. The DON identified one resident used a Velcro safety belt in a wheelchair. Findings: On 04/27/26 at 12:22 p.m., Resident #31 was observed sitting in a wheelchair in the dining room with a loosely fitting Velcro belt in place around their waist. On 04/29/26 at 11:29 a.m., CMA #1 was observed to instruct Resident #31 to remove the Velcro belt. Resident #31 was observed to release the belt only after CMA #1 reassured them they would help secure the belt back in place. A facility policy titled Restraints, updated 05/12/23, read in part, All residents must have an assessment performed to determine the safety and protective needs of the resident prior to application of restraints or medical protective devices.the medical record must include: a. the reason for the restraints, b. symptom condition, and alternative attempts prior to restraint implementation, c. criteria for continued, or discontinued of restraint device, d. assessment at least monthly for continuation of the need for the restraint, and e. an order of a physician permitted by the state and by the facility. A care plan for Resident #31, initiated 01/14/25, showed the resident was at risk for falls related to mobility behaviors. An intervention in the care plan for Resident #31, dated 04/08/25, showed Velcro belt in place on wheelchair. A quarterly MDS assessment for Resident #31, dated 04/21/26, showed the resident was admitted to facility on 04/26/17 with a BIMS score of 0, indicating severe cognitive impairment. A diagnoses list for Resident #31, updated 04/23/26, showed the resident had diagnoses of pervasive developmental disorders, sever intellectual disabilities, and hypersomnia. On 04/28/26 at 8:08 a.m., Resident #31's family member stated the Velcro belt prevented the resident from falling out when they leaned forward to pick up something from the floor. On 04/28/26 at 12:20 p.m., the DON and the MDS coordinator verified a restraint assessment or ongoing documentation had not been completed. The DON stated no physician order or pre-restraining assessment was written. The DON stated they had not documented criteria for the need to discontinue or continue the Velcro belt. The MDS coordinator stated the restraint section was not checked on the MDS because movement was not prevented and was used to enable movement and promote mobility.

Based on observation, record review and interview, the facility failed to ensure hand hygiene was performed during the provision of wound care to help prevent the development and transmission of communicable diseases and infections for1 (#18) of 1 observation for pressure ulcers. The administrator identified 29 residents resided in the facility. The DON identified two residents with wound care treatments.Findings: On 04/28/26 at 3:09 p.m., during a wound care observation for Resident #18, LPN #1 was observed to clean, dry, measure, and apply treatment and dressing to the wound as ordered. LPN #1 was not observed to change their gloves after cleansing the wound and before applying the clean treatment. On 04/28/2026 at 3:18 p.m., LPN #1 was observed to remove their gloves and placed them in a red bag. A quarterly assessment for Resident #18, dated 04/06/26, showed the resident had a pressure ulcer and was dependent with mobility. A physician's order for Resident #18, dated 04/26/26, showed wound care orders to coccyx every day. An undated policy titled Clean Dressing Change Infection Control Policy, read in part, It is the policy of the facility to ensure dressing changes are performed in accordance with State and Federal regulations and national guidelines.Remove dressing and place in the resident's trash can, doff gloves, perform hand hygiene, don clean gloves, cleanse wound with gauze and prescribed cleaning solution using single outward strokes.Doff gloves, perform hand hygiene, don clean gloves, apply treatment if ordered, doff gloves, perform hand hygiene, don clean gloves, apply clean dressing as ordered. On 04/28/26 at 3:22 p.m., LPN #1 stated the policy and procedure for hand hygiene during wound care was to sanitize in between dirty and clean. They stated when the dirty dressing was removed, gloves should be changed, and again anytime they touched something dirty with those gloves. LPN #1 stated they thought they had changed their gloves before applying the treatment and stated they should have. On 04/29/26 at 1:05 p.m., IP #1 read the entire policy when asked what the policy for hand hygiene was with wound care. On 04/29/26 at 1:13 p.m., IP #1 stated they would expect to perform hand hygiene after cleaning a wound and prior to the application of the treatment.

Based on record review and interview, the facility failed to submit direct care staffing information based on payroll data. The Resident Census and Conditions of Resident, dated 07/25/23 documented the census was 29. Findings: The Quality of Care Reports, dated January thru June 2023, documented the staffing ratios were at or above the required ratio. On 07/27/23 at 12:25 p.m., the Administrator was asked who was responsible to enter the staffing data into the Payroll Based Journal. The Administrator stated the Payroll Based Journal had not been entered or submitted since October 2022.

Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for five (#5, 11, 15, 23, and #24) of 13 sampled residents whose care plans were reviewed. The facility failed to develop care plans to address: a. contractures and restorative services for Res #5. b. a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. pressure ulcer care for Res #23. d. ostomy care for Res #11. e. diuretic use for Res #24. The ''Census and Conditions of Residents report documented 33 residents resided in the facility. Findings: 1. Res #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 08/11/21, documented restorative services for passive ROM. The quarterly assessment, dated 05/05/22, documented the resident was moderately impaired with decision making skills, required assistance with ADLs, had impairment in both lower extremities, and received hospice services. The EHR documented the resident received restorative services ten times in the last four months. On 06/21/22 at 2:57 p.m., the restorative aide stated the resident would participate in restorative services about every other day. She stated there were some days she refused to participate. She stated the resident had a contracture in her left knee for several years. On 06/22/22 at 10:44 a.m., the DON stated there should have been a care plan for contractures/ROM and restorative services. On 06/22/22 at 11:21 a.m., the resident was observed with CNA #1 and the DON. The resident was observed to have a slight contracture to her left knee and both feet. The DON stated the resident's contractures may be due to her [CONDITION(S)]. 2. Res #15 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 08/05/21, documented to administer [MEDICATION(S)] R insulin per sliding scale. A physician order, dated 10/01/21, documented to inject [MEDICATION(S)] insulin 40 units in the morning and 40 units at bedtime. A physician order, dated 02/13/22, documented in inject a Freestyle system kit for blood glucose monitoring every 14 days. A quarterly assessment, dated 04/28/22, documented the resident was severely impaired with cognition and required limited assistance with most ADLs. The assessment documented the resident received insulin medication seven days in the look back period. A care plan, dated 05/11/22, documented the resident was on a NCS diet. The care plan documented she feeds herself and makes her own choices. The care plan documented the resident was on two diuretic medications. The care plan did not document the resident had diabetes or received insulin medication. On 06/23/22 at 12:09 p.m., the DON stated there should have been a diabetic care plan for resident #15. 3. Res #23 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/24/22, documented the resident was severely impaired with cognition and required limited assistance with ADLs. The assessment documented the resident had two unhealed pressure ulcers. A care plan, review date of 05/31/22, did not document the resident was at risk or had pressure ulcers. On 06/21/22 at 8:47 a.m., Res #23 was observed sitting in her recliner. She stated she thought the pressure ulcer was gone but was not sure. On 06/22/22 at 10:33 a.m., the DON stated she had been the one doing the care plans from December until recently. The DON stated Res #23 should have had a skin care plan. 4. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 04/20/22, documented the resident had an ostomy, moderate cognitive impairment, and required extensive assistance with most ADL's. A physician order, dated 05/03/22, documented to change the [CONDITION(S)] appliance weekly on Tuesdays. On 06/21/22 at 2:32 p.m., ostomy care was observed being performed by LPN #1. Res #11 stated his appliance was different and had been showing the staff how to do it. As of the record review on 6/23/22 at 10:50 a.m., there was no ostomy care plan for resident #11. On 6/23/22 at 10:52 a.m., the DON stated that she had not care planned the ostomy. She stated there should be one and would fix it. 5. Res #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 01/12/20, documented [MEDICATION(S)] (a diuretic medication) 20 mg, give two tablets every 24 hours as needed for swelling related to nonrheumatic aortic valve disorder. A physician order, dated 03/24/22, documented [MEDICATION(S)] (a diuretic) 25 mg in the morning related to hypertension. A significant change assessment, dated 05/26/22, documented the resident was severely cognitively impaired and received a diuretic five of seven days during the look-back period. A care plan, with a review date of 06/04/22, had no care plan related to diuretic use. On 06/22/22 at 5:27 p.m., the DON stated there was no diuretic care plan.

Based on observation and interview, the facility failed to provide permanently affixed compartment for storage of refrigerated controlled drugs. The Census and Conditions of Residents report documented 33 residents resided in the facility. Findings: On 6/23/22 at 2:48 p.m., ACMA #1 was observed during a narcotic count and stated that liquid [MEDICATION(S)] was kept in the refrigerator. She was observed opening the refrigerator which contained a black plastic lock box with a three digit combination lock. She was observed picking up the box to examine it. The box was not affixed to the refrigerator and was able to be removed in its entirety. On 6/23/22 at 3:25 p.m. the DON stated the facility had just got refrigerators and they had not yet secured the controlled drug storage box.

Based on record review and interview, the facility failed to obtain laboratory services as ordered by the physician for two (#5 and #24) of five residents sampled for medication review. The Resident Census and Conditions of Residents'' report documented 33 residents resided in the facility. Findiings: 1. Res #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 04/15/21, documented to obtain a [MEDICATION(S)] level every six months starting on 05/01/21. A physician order, dated 04/15/21, documented to administer [MEDICATION(S)] 125 mcg in the morning for heart failure. A quarterly assessment, dated 05/05/22, documented the resident was moderately cognitively impaired. On 06/22/22 at 2:00 p.m., the DON was asked to provide the [MEDICATION(S)] lab results. On 06/22/22 at 3:20 p.m., the DON stated she could not find the [MEDICATION(S)] level lab results. 2. Resident #24's physician order, dated 05/14/21, documented to inject B-12 1000 mcg/ml on the 14th of every month for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 01/03/22, documented to collect a B-12 level annually. A MRR, dated 04/04/22, documented the B-12 lab due January 2022 was not found in the lab results. On 06/23/22 at 11:47 a.m., the DON stated the B-12 lab requested in January was not found. She stated she had called the lab and they did not have it. She stated she did not believe it was drawn or rescheduled to be drawn at a later date.

Based on record review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The facility failed to: a. keep the scoops handles from being in contact with the flour in the bins. b. label and date opened drinks and applesauce in the refrigerators. c. perform hand hygiene after touching unclean surfaces during meal service and meal pass. The Census and Conditions of Residents form documented 33 residents lived in the facility. Findings: 1. On 06/21/22 at 8:05 a.m., during initial tour of the kitchen, observations of two cups of applesauce in the refrigerator with loose plastic wrap over both cups with no date was observed. A small scoop was observed in a small flour bin in the storage room with the handle touching the flour. The scoop for the large flour bin was observed with the handle up and flour all over the handle. On 06/21/22 at 8:15 a.m., in the walk in refrigerator, a green pitcher with milk in it was not labeled or dated and a bottle of opened Gatorade was not labeled or dated. On 06/21/22 at 8:16 a.m., the DM stated they marked the date on the tray the product was sitting on. The tray observed had a date for the cake but not the applesauce. She stated the items should be dated individually if served and put back in the refrigerator. The DM stated the scoop should not be laying in the small flour bin but the scoops could be in the bins if the handles were sticking up. She stated the milk and opened Gatorade should have been labeled and dated. On 06/23/22 at 8:17 a.m., cook #1 was showing the surveyor the temperature book for the steam table. Cook #1 then went and put on gloves and made a resident an omelet for breakfast. The cook did not wash their hands before putting on the gloves. The cook was observed to touch the omelet with ungloved bare left hand then with gloved right hand. On 06/23/22 at 8:25 a.m., cook #1 was observed to touch dirty dishes with gloved hands and then make a resident a piece of toast. At 8:28 a.m., the cook cut the toast with a knife that had been placed with other used dirty utensils and then took the utensils to the dish room to be washed. On 06/23/22 at 9:38 a.m., the DM stated the kitchen staff should wash their hands before making a meal and when touching anything dirty. 2. On 06/22/22 at 8:17 a.m., hand hygiene was observed before meal trays were passed. ACMA #1 was observed to deliver a meal to a resident and get the resident a cup of coffee and help with meal set up. ACMA #1 then pushed the cart up the hall and touched her face and another resident's knee. ACMA #1 then went back to the food cart got a meal for another resident, assisted the resident to the dining room to sit at the table, and set up the resident meal, cutting up her food and touched the water glass by the rim. Hand hygiene was not observed before assisting the resident. ACMA #1 was observed to take a meal tray to room 101. During meal set up for the resident the ACMA wiped her hands on her scrubs and then continued with placing sweetener in the resident's hot cereal. On 06/22/22 at 8:32 a.m., ACMA #1 was observed at the meal cart. She touched her scrub pants, retrieved a tray, took it to a resident in the dining room, assisted with meal set up, touched the resident on the back, then performed hand hygiene. On 06/23/22 at 9:56 a.m., the DON stated she would expect to see the staff performing hand hygiene between residents when passing meals.

Based on record review, observation, and interview, the facility failed to ensure proper hand hygiene was performed while providing wound care for two (#15 and #23) and ostomy care for one (#11) of three residents observed during care. The Census and Conditions of Residents form documented 33 residents lived in the facility. Findings: 1. Res #15 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/28/22, documented the resident was severely impaired with cognition and required limited assistance with most ADLs. The assessment documented the resident had no pressure ulcers. A care plan, dated 05/11/22, documented the resident had impaired skin integrity and to administer treatment as ordered and monitor for effectiveness. On 6/22/22 at 2:18 p.m., wound care was observed for Res #15. During wound care of the resident's finger on her right hand, RN #1 did not perform hand hygiene after cleaning the wound on the resident's finger. RN#1 then retrieved a roll of toilet paper, opened it, got some toilet paper off the roll, and handed it to the DON to wipe the resident's nose while still wearing the same gloves. The RN then proceeded to apply treatment to the resident's finger and dressed the wound in the same gloves. On 06/23/22 at 10:58 a.m., the DON stated there were infection control issues during the resident's wound care and the nurse should have changed her gloves and performed hand hygiene between dirty and clean. 2. Res #23 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/24/22, documented the resident was severely impaired with cognition and required limited assistance with ADLs. The assessment documented the resident had two unhealed pressure ulcers. A care plan, review date of 05/31/22, did not document the resident was at risk or had pressure ulcers. On 06/22/22 at 2:06 p.m., RN #1 performed wound care for Res #23. RN #1 did not remove her gloves or perform hand hygiene after cleaning the residents wound before administering treatment and dressing. On 06/22/22 at 2:15 p.m., the DON stated the nurse should have changed her gloves and performed hand hygiene between dirty and clean. 3. Res #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 04/20/22, documented the resident had an ostomy, moderate cognitive impairment, and required extensive assistance with most ADL's. A physician order, dated 05/03/22, documented to change the [CONDITION(S)] appliance weekly on Tuesdays. On 06/21/22 at 2:32 p.m., LPN #1 was observed performing ostomy care for Res #11. During the procedure the nurse failed to change her gloves after touching the soiled ostomy bag and before touching and placing the new ostomy wafer. The nurse then removed her gloves and was observed affixing the new ostomy bag without gloves. She did not perform hand hygiene after removing gloves.

Based on record review and interview the facility failed to ensure a code status was designated for one (#8) of three residents sampled for advance directives. The Resident Census and Conditions of Residents documented 33 residents resided in the facility. Findings: Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 4/13/22, documented resident #8 was severely cognitively impaired and required limited assistance with ADL's. On 6/21/22 a record review was conducted and there was no code status documented in resident #8's chart. On 6/21/22 at 5:00 p.m., LPN #1 stated she believed the resident's code status was DNR, but could not find any documentation in the chart. On 6/21/22 at 5:04 p.m., the executive assistant stated she had checked all the places she could think of for a code status in resident #8's chart, but could not find any information. On 6/22/22 at 10:50 a.m., the DON stated she would have to call resident #8's family regarding the code status. She stated that a number of people review this information at admission including the social services and front office staff.

Based on record review and interview the facility failed to notify the State Health Care Authority of a resident with a new serious mental illness for one (#5) of one resident reviewed for PASRR evaluations. The ''Census and Conditions of Residents'' report documented four residents received antipsychotic medications. Findings: Res #5 was admitted to the facility on [DATE] and at that time did not have any serious mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's current EHR diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/22/22 at 9:50 a.m., the DON stated she could not find where the facility had notified the state. She stated she was not aware they had to notify the state when there were new serious psychiatric diagnoses.

Based on record review and interview the facility failed to update the care plan for one (#11) of one sampled resident reviewed for falls. The Resident Census and Conditions of Residents documented 33 residents resided in the facility. Findings: Res #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 07/20/21, documented the resident was placed in a wheechair after a fall due to an unsteady gait. An incident report, dated 11/18/21, documented a new intervention to declutter by bathroom door, and encourage and educate the resident to use the walker while walking. A fall risk evaluation, dated 03/02/22, documented Res #32 was at risk for falls with a score of 13. A quarterly assessment, dated 06/01/22, documented the resident was severely cognitively impaired, independent with transfers, independent with walking, had range of motion limitation to one upper extremity, used a rolling walker, and had one fall with major injury since previous assessment. A care plan, review date of 06/05/22, documented the resident was at low risk for falls. The care plan did not include an unsteady gait as a risk for falls. The care plan did not address the interventions documented related to the falls that occurred on 07/20/21 or 11/18/21. On 06/21/22 at 8:28 a.m., resident #32 was observed using the rolling walker to walk down the hall without staff assistance. The resident had a slow shuffling gait and walked hunched over the walker. On 06/22/22 at 8:39 a.m., CNA #1 stated the staff were to supervise the resident, make sure the walker was with the resident, ensure the room was clear of clutter, and walk with the resident for long distances. 06/22/22 at 10:35 a.m. the DON stated she was the care plan person from December of 2021 until May of this year and she did not believe she updated the care plan after the falls for Res #32.

Based on record review, observation, and interview the facility failed to develop and implement fall interventions for one (#11) of one resident reviewed for falls. The Resident Census and Conditions of Residents documented 33 residents resided in the facility. Findings: Res #32 had diagnoses which included dementia, anxiety, and [CONDITION(S)]. A fall risk evaluation, dated 03/02/22, documented the resident at risk for falls with a score of 13. An incident report, dated 03/12/22, documented the resident had a fall resulting in a fracture. The contributing factor listed the resident's shoes were loose. A quarterly assessment, dated 06/01/22, documented the resident was severely cognitively impaired, independent with transfers, independent with walking, had range of motion limitation to one upper extremity, used a rolling walker, and had one fall with major injury since previous assessment. A care plan, review date of 06/05/22, documented the resident was at low risk for falls. The care plan did not include an unsteady gait as a risk for falls. The care plan did not address the cause for the fall or an intervention to prevent recurrence. On 06/21/22 at 8:28 a.m., Res #32 was observed using the rolling walker to walk down the hall without staff assistance. The resident had a slow shuffling gait and walked hunched over the walker. On 06/22/22 at 8:39 a.m., CNA #1 stated the staff were to supervise the resident, make sure the walker was with the resident, ensure the room was clear of clutter, and walk with the resident for long distances. On 06/22/22 at 9:37 a.m., RN #1 stated she was involved with coming up with interventions after falls. Regarding the fall with injury, she stated she did not remember what the intervention was, but she was sure they did something. She stated the interventions were communicated via verbal report and the care plan. On 06/22/22 at 10:35 a.m. the DON stated she was the care plan person from December of 2021 until May of this year, and she did not believe she updated the care plan after the fall for Res #32.

Based on record review and interview, the facility failed to ensure the pharmacist provided monthly medication regimen reviews (MRRs) and failed to ensure the physician responded to the MRRs for one (#24) of five sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents report documented 21 residents on psychoactive medications. Findings: Res #24 had diagnoses which included hypertension and anxiety. The facility was unable to produce an MRR for June of 2021. The facility was unable to produce an MRR for August of 2021. A MRR, dated 10/05/21, documented a request for a trial reduction of the resident's [MEDICATION(S)] 5 mg every 24 hours as needed. There was no response from the physician documented. A MRR, dated 04/04/22, documented a blood pressure and pulse for the resident's [MEDICATION(S)] was needed. There was no response from the physician documented. A significant change assessment, dated 5/26/22, documented the resident was severely cognitively impaired and required limited to extensive assistance with ADL's. On 6/22/22 at 3:21 p.m., the DON stated there was no physician response form found for the dates requested.

Based on record review, and interviews, the facility failed to: ~ ensure resident #1 and #2 were free from inappropriate touching by resident #3, and ~ ensure resident #4 and other unidentified residents were free from hitting, kicking, pinching, and scratching by resident #7 of seven residents reviewed for abuse. This resulted in resident #2 being fearful after an incident of resident #3 touching her inappropriately. The Administrator identified 38 residents resided in the facility. Findings: An Abuse Policy, revised on 09/12/20, read in part, .It is the policy of the facility .to maintain an environment where residents are free from abuse .Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking .Sexual abuse is non-consensual sexual contact of any type with a resident. Generally, sexual contact is nonconsensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent . No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection .Training about challenging behaviors and how to intervene .Communication of reports of resident .abuse .The facility provides identification, ongoing assessment .for appropriate interventions and monitoring of resident with needs and behaviors that might lead to conflict or neglect, such as .residents with a history of cognitive deficits .aggressive behaviors, resident who have behaviors such as entering other residents' rooms, wandering behaviors .socially inappropriate behaviors . 1. Resident #3 (alleged perpetrator) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly assessment, dated 5/11/21, documented the resident had severe cognitive impairment. It documented he was independent with ambulation, and locomotion on and off the unit. A Behavior Note, dated 06/07/21 at 1:25 p.m., documented, .Nurse then observed [resident #3] put his hand in female residents shirt and grope her. Nurse started approaching resident and he quickly began ambulating towards his room. Nurse explained to resident that this is unacceptable behavior. Resident #2 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior Note, dated 08/21/21 at 3:59 p.m., documented, [Res #3] witnessed by 3 staff members with his hand down [Res #1]s shirt. When one staff member calls out [Res #3]'s name, [Res #3] lifted his hand out of shirt and walked back down to room. This LN approaches [Res #3] and states hey buddy, were you just touching that young lady? [Res #3] replies, kick me out of here or whatever .you want to do this LN leaves [Res #3] .[Res #3] continues to walk to same female res's room and look at her . Res #3 was sent to local ER for evaluation. A Behavior Note, dated 08/21/21 at 10:26 p.m., documented, ER nurse .called .saying resident is ready to return to facility .Staff encouraged by this LN to carefully monitor [Res #3] and his behavior. A Behavior Note, dated 10/02/21 at 8:00 p.m., documented, [Res #3] was accused of touching [Res #2] inappropriately. Spoke with [Res #3] and told him that groping female residents is inappropriate. He got upset and stated just send me to Fort Supply. I told him that it was closed down and he wasn't going anywhere, but he needs to stay in his room. [Res #3] got back in his bed and no further behaviors were reported or observed. A Health Status Note, dated 10/02/21 at 8:00 p.m., documented, [Res #2] reported to staff that a male resident came into her room and touched her breast under her clothing. This male resident was seen earlier talking to resident in her room and was asked to get out of her room which he did at that time. [Res #2] became scared and came out to sit at nurses' station for awhile after reporting what he had done. Resident was given popcorn and reassurance that she would be safe. She returned to her room appx an hour later. A Behavior Note, dated 10/14/21 at 7:15 p.m., documented, [Res #3] found in [Res #2]'s room standing over her to her left side as she was sitting in her recliner. [Res #2] made a soft sound/gasp. [Res #3] began backing away as I came to her doorway and she was clutching her loose button up shirt tighter. [Res #3] was told to get out of there and go to his own room and leave this female resident alone. Resident became angry and said just send me to Western State or Fort Supply. [Res #3] was assisted across the hall back to his own room and strongly encouraged to stay there. Res #3 was placed on one on one observation until he was discharged to a behavioral facility. A state reported incident report attachment, faxed 10/20/21, documented, After the 08/21/21 .Review of behavior notes for [Res #3] revealed additional incidents of inappropriate physical touching and verbal abuse perpetrated by [Res #3] against female staff and residents, which were not reported to administration until APS investigation of an incident occurring on 10/14/21 .Prior to the incident .this admin shared information with the nursing staff on our [electronical] messaging app regarding .dealing with reporting abuse .in a nursing facility along with our policy. This was obviously not followed by all staff, but on 8/21/2021 and 10/14/2021, it was . [DON and Administrator] are educating all staff again on reporting incidents of abuse, increased clarification of what constitutes abuse, i.e. verbal, sexual, etc. and expressing that while these are also behaviors that need to be documented, documenting the behavior alone is not fully adhering to policy .Future incidents of abuse will be reported as incidents in the EHR, thereby triggering notification of DON and Administrator .We will implement a checks and balances system to ensure proper future reporting . A state reported follow up note, dated 10/26/21, documented, [Res #3] was transferred to [a behavioral facility] on 10/22/21. At this time, there is no intention of readmission, due to potential criminal charges pending against him . On 11/01/21 at 3:05 p.m., the administrator and DON were asked about the incident from 06/07/21. They stated it was not reported, not investigated, and abuse policy was no followed. They were asked what carefully monitor Res #3's behaviors indicated as instructed by the LN on 08/21/21. The DON stated they monitored behaviors every shift. They were asked about the incident from 10/02/21. They stated it wasn't reported, and they weren't aware at the time of the incident. The DON stated there were no new interventions implemented. They were asked if the incident from 10/14/21 was thoroughly investigated because only the involved residents and staff were interviewed. Should other resident or staff had been interviewed to determine the extent of the abuse. The Administrator stated he feels it was thoroughly investigated because he assumed the other residents would have said something. 2. Res #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, read in part, . 07/24/2021 at 16:11 [4:11 p.m.] Health Status Note .Resident sitting out by nurses station in her w/c when resident [#7] went by in her w/c stopping and slapping residents right hand several times very hard. No bruising noted at this time. Will pass along to next shift to monitor residents hand . There was no other documentation of this incident. On 11/01/21 at 3:45 p.m., Res #4's progress note, dated 07/24/21, was reviewed with the DON. She was asked what was done after Res #4 was hit by another resident. She replied, she was unaware of the incident. She was asked if there was a state report done. She replied, no. The administrator was asked if there was a state report for this incident. He replied that he didn't know about the incident. 3. Res #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #7's Care Plan, read in part, .Behavior care plan: the resident has a behavior problem hitting, kicking, spitting, throwing things, scratching at the staff r/t anxiety, pain and dementia .Date Initiated: 03/19/2021 . A Progress note, read in part, .07/06/2021 at 17:48 [5:48 p.m.] Behavior note .Resident up and down hallways and pulling on staff and other resident's clothes, hitting staff and residents, hollering out at others and down hall . A Progress note, read in part, .07/18/2021 at 17:46 [5:46 p.m.] Behavior note .Resident exit seeking, yelling help me, help me die, pinches various other residents while self propelling up and down hallway in wheelchair. She is throwing dishes, furniture, going in and out of other resident rooms .After approximately 10 minutes resident propels self into solarium and throws coffee on a residents [visitor] . A Progress note, read in part, .07/22/2021 at 16:06 [4:06 p.m.] Behavior note .Res continues towards staff and other residents. Res hitting other residents and yelling. Hitting staff and resisting care. No interventions successful . A Progress note, read in part, .07/22/2021 at 16:38 [4:38 p.m.] Behavior note .Res cont to be combative towards other residents. Pinching res's. Staff cont to redirect . A Progress note, read in part, .07/22/2021 at 17:36 [5:36 p.m.] Behavior note .Res cont to hit, scratch, pinch and kick other res and staff. [Physician] contacted . A Progress note, read in part, .07/24/2021 at 16:11 [4:11 p.m.] Behavior Note .Res yelling in hall, resistant to care. Hitting and scratching staff. Res approaches another resident and hit right hand multiple times then attempts to dig nails into other residents hand. Staff redirects res . Progress notes were reviewed from 06/01/2021 to 11/01/2021 for any other behaviors. Through out survey, Res #7 was observed in her wheelchair in the hallway with staff nearby to monitor her behaviors and intervened when needed. On 11/01/21 at 3:45 p.m., Res #7's progress note, dated 07/06/2021, was reviewed with the DON. She was asked if this incident would be considered resident to resident abuse. She replied, yes. She was asked if this incident should have been reported. She replied, yes. Res #7's progress note, dated 07/18/2021, was reviewed with the DON. She was asked if this would be considered resident to resident abuse. She replied, yes. She was asked if this incident was reported. She stated, I did not report that to state. Res #7's progress notes, dated 07/22/2021 which documented three different episodes of abusive behaviors from 4:06 p.m. to 5:36 p.m. was reviewed with the DON. She was asked if Res #7 was separated from other residents from 4:06 p.m. to 4:38 p.m. She did not respond. The DON was asked why the resident was able to continue to be abusive toward other residents as documented from 4:06 p.m. until 5:36 p.m. She stated, I don't have a good answer for that. The DON was unable to specify other residents involved in these incidents. The DON and Administrator were not aware of any of the incidents reviewed for Res #4 and Res #7. No abuse investigations were completed for these incidents. On 11/02/21, the facility provided documentation of in-services conducted related to Abuse presented by National LTC Ombudsman, and the facility's Abuse policy. In-service logs documented the following training was completed by all staff by 10/30/21. Interviews with staff demonstrated understanding of how to identify, report, and protect residents from abuse.

Based on record review, and interviews, the facility failed to ensure the abuse policy was implemented for five (#1, 2, 3, 4, and #7) of seven sampled residents reviewed for abuse. This resulted in: ~ resident #2 being fearful after an incident of resident #3 touching her inappropriately, ~ resident #1 being touched inappropriately by resident #3, and ~ resident #4 and other unidentified residents were free from hitting, kicking, pinching, and scratching by resident #7. The Administrator identified 38 residents resided in the facility. Findings: An Abuse Policy, revised on 09/12/20, read in part, .It is the policy of the facility .to maintain an environment where residents are free from abuse .The Nursing Home Administrator or designee DON will report abuse to the state agency per State and Federal requirements .Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking .Sexual abuse is non-consensual sexual contact of any type with a resident. Generally, sexual contact is nonconsensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent . No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection .Training about challenging behaviors and how to intervene .Communication of reports of resident .abuse .The facility provides identification, ongoing assessment .for appropriate interventions and monitoring of resident with needs and behaviors that might lead to conflict or neglect, such as .residents with a history of cognitive deficits .aggressive behaviors, resident who have behaviors such as entering other residents' rooms, wandering behaviors .socially inappropriate behaviors . Staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents .It is the policy .all staff monitor residents and will know how to identify potential signs and symptoms of abuse .reports of abuse .are promptly and thoroughly investigated .The investigation will include .who was involved .residents' statements .For .cognitively impaired residents .attempt to interview resident first .observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings . Procedures are in place to provide the resident with a safe, protected environment during the investigation .If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator .Examine, assess and interview the resident and other residents potentially affected as soon as possible to determine any injury and identify any immediate clinical interventions necessary . Employees must always report any abuse or suspicion of abuse immediately to the Administrator .If the incident or allegation is considered reportable, the Administrator or designee will make an initial .report .A follow up investigation will be submitted .within five working days . 1. Resident #3 (alleged perpetrator) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly assessment, dated 5/11/21, documented the resident had severe cognitive impairment. It documented he was independent with ambulation, and locomotion on and off unit. A Behavior Note, dated 06/07/21 at 1:25 p.m., documented, .Nurse then observed [resident #3] put his hand in female residents shirt and grope her. Nurse started approaching resident and he quickly began ambulating towards his room. Nurse explained to resident that this is unacceptable behavior. This incident was not reported, investigated, or corrective actions implemented. Resident #2 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior Note, dated 08/21/21 at 3:59 p.m., documented, [Res #3] witnessed by 3 staff members with his hand down [Res #1]s shirt. When one staff member calls out [Res #3]'s name, [Res #3] lifted his hand out of shirt and walked back down to room. This LN approaches [Res #3] and states hey buddy, were you just touching that young lady? [Res #3] replies, kick me out of here or whatever .you want to do this LN leaves [Res #3] .[Res #3] continues to walk to same female res's room and look at her . Res #3 was sent to local ER for evaluation. A Behavior Note, dated 08/21/21 at 10:26 p.m., documented, ER nurse .called .saying resident is ready to return to facility .Staff encouraged by this LN to carefully monitor [Res #3] and his behavior. This incident was not reported to OSDH at the time of the incident, and was not investigated. A Behavior Note, dated 10/02/21 at 8:00 p.m., documented, [Res #3] was accused of touching [Res #2] inappropriately. Spoke with [Res #3] and told him that groping female residents is inappropriate. He got upset and stated just send me to Fort Supply. I told him that it was closed down and he wasn't going anywhere, but he needs to stay in his room. [Res #3] got back in his bed and no further behaviors were reported or observed. A Health Status Note, dated 10/02/21 at 8:00 p.m., documented, [Res #2] reported to staff that a male resident came into her room and touched her breast under her clothing. This male resident was seen earlier talking to resident in her room and was asked to get out of her room which he did at that time. [Res #2] became scared and came out to sit at nurses' station for awhile after reporting what he had done. Resident was given popcorn and reassurance that she would be safe. She returned to her room appx an hour later. This incident was not reported, investigation was not completed, and no new intervention was implemented to prevent further abuse. A Behavior Note, dated 10/14/21 at 7:15 p.m., documented, [Res #3] found in [Res #2]'s room standing over her to her left side as she was sitting in her recliner. [Res #2] made a soft sound/gasp. [Res #3] began backing away as I came to her doorway and she was clutching her loose button up shirt tighter. [Res #3] was told to get out of there and go to his own room and leave this female resident alone. Resident became angry and said just send me to Western State or Fort Supply. [Res #3] was assisted across the hall back to his own room and strongly encouraged to stay there. Res #3 was placed on one on one observation until he was discharged to a behavioral facility. A state reported incident report attachment, faxed 10/20/21, documented, After the 08/21/21 .Review of behavior notes for [Res #3] revealed additional incidents of inappropriate physical touching and verbal abuse perpetrated by [Res #3] against female staff and residents, which were not reported to administration until APS investigation of an incident occurring on 10/14/21 .Prior to the incident .this admin shared information with the nursing staff on our [electronical] messaging app regarding .dealing with reporting abuse .in a nursing facility along with our policy. This was obviously not followed by all staff, but on 8/21/2021 and 10/14/2021, it was . [DON and Administrator] are educating all staff again on reporting incidents of abuse, increased clarification of what constitutes abuse, i.e. verbal, sexual, etc. and expressing that while these are also behaviors that need to be documented, documenting the behavior alone is not fully adhering to policy .Future incidents of abuse will be reported as incidents in the EHR, thereby triggering notification of DON and Administrator .We will implement a checks and balances system to ensure proper future reporting . A state reported follow up note, dated 10/26/21, documented, [Res #3] was transferred to [a behavioral facility] on 10/22/21. At this time, there is no intention of readmission, due to potential criminal charges pending against him . On 11/01/21 at 3:05 p.m., the administrator and DON was asked if the abuse policy was followed for the incident from 06/07/21. They stated the abuse policy was followed. They were asked if the incident from 08/21/21 was investigated and reported per policy. They stated they called law enforcement and thought they would investigate. They stated they did not complete state incident report at the time of the event. They were asked if the abuse policy was followed for incident from 10/02/21. They stated they weren't aware at the time of the incident, and the abuse policy wasn't followed. They were asked if the incident from 10/14/21 was thoroughly investigated because only the involved residents and staff were interviewed. Should other residents and staff had been interviewed to determine the extent of the abuse. The Administrator stated he feels it was thoroughly investigated because he assumed the other residents would have said something. 2. Res #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, read in part, . 07/24/2021 at 16:11 [4:11 p.m.] Health Status Note .Resident sitting out by nurses station in her w/c when resident [#7] went by in her w/c stopping and slapping residents right hand several times very hard. No bruising noted at this time. Will pass along to next shift to monitor residents hand . There was no other documentation of this incident. On 11/01/21 at 3:45 p.m., Res #4's progress note, dated 07/24/21, was reviewed with the DON. She was asked what was done after Res #4 was hit by another resident. She replied, she was unaware of the incident. She was asked if there was a state report done. She replied, no. The administrator was asked if there was a state report for this incident. He replied, he didn't know about the incident. 3. Res #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #7's Care Plan, read in part, .Behavior care plan: the resident has a behavior problem hitting, kicking, spitting, throwing things, scratching at the staff r/t anxiety, pain and dementia .Date Initiated: 03/19/2021 . A Progress note, read in part, .07/06/2021 at 17:48 [5:48 p.m.] Behavior note .Resident up and down hallways and pulling on staff and other resident's clothes, hitting staff and residents, hollering out at others and down hall . A Progress note, read in part, .07/18/2021 at 17:46 [5:46 p.m.] Behavior note .Resident exit seeking, yelling help me, help me die, pinches various other residents while self propelling up and down hallway in wheelchair. She is throwing dishes, furniture, going in and out of other resident rooms .After approximately 10 minutes resident propels self into solarium and throws coffee on a residents [visitor] . A Progress note, read in part, .07/22/2021 at 16:06 [4:06 p.m.] Behavior note .Res continues towards staff and other residents. Res hitting other residents and yelling. Hitting staff and resisting care. No interventions successful . A Progress note, read in part, .07/22/2021 at 16:38 [4:38 p.m.] Behavior note .Res cont to be combative towards other residents. Pinching res's. Staff cont to redirect . A Progress note, read in part, .07/22/2021 at 17:36 [5:36 p.m.] Behavior note .Res cont to hit, scratch, pinch and kick other res and staff. [Physician] contacted . A Progress note, read in part, .07/24/2021 at 16:11 [4:11 p.m.] Behavior Note .Res yelling in hall, resistant to care. Hitting and scratching staff. Res approaches another resident and hit right hand multiple times then attempts to dig nails into other residents hand. Staff redirects res . Progress notes were reviewed from 06/01/2021 to 11/01/2021 for any other behaviors. Throughout survey, Res #7 was observed in her wheelchair in the hallway with staff nearby to monitor her behaviors and intervened when needed. On 11/01/21 at 3:45 p.m., Res #7's progress note, dated 07/06/2021, was reviewed with the DON. She was asked if this incident would be considered resident to resident abuse. She replied, yes. She was asked if this incident should have been reported. She replied, yes. Res #7's progress note, dated 07/18/2021, was reviewed with the DON. She was asked if this would be considered resident to resident abuse. She replied, yes. She was asked if this incident was reported. She stated, I did not report that to state. Res #7's progress notes, dated 07/22/2021 which documented three different episodes of abusive behaviors from 4:06 p.m. to 5:36 p.m. was reviewed with the DON. She was asked if Res #7 was separated from other residents from 4:06 p.m. to 4:38 p.m. She did not respond. The DON was asked why the resident was able to continue to be abusive toward other residents as documented from 4:06 p.m. until 5:36 p.m. She stated, I don't have a good answer for that. The DON was unable to specify other residents involved in these incidents. The DON and Administrator were not aware of any of the incidents reviewed for Res #4 and Res #7. No abuse investigations were completed for these incidents. On 11/02/21, the facility provided documentation of in-services conducted related to Abuse presented by National LTC Ombudsman, and the facility's Abuse policy. In-service logs documented the following training was completed by all staff by 10/30/21. Interviews with staff demonstrated understanding of how to identify, report, and protect residents from abuse.

Based on record review, and interviews, the facility failed to ensure allegations of abuse (inappropriate touching, hitting, kicking, scratching, and pinching) were reported for five (#1, 2, 3, 4, and #7) of seven sampled residents reviewed for abuse. This resulted in resident #2 being fearful after an incident of resident #3 touching her inappropriately The Administrator identified 38 residents resided in the facility. Findings: An Abuse Policy, revised on 09/12/20, read in part, .The Nursing Home Administrator or designee DON will report abuse to the state agency per State and Federal requirements . Employees must always report any abuse or suspicion of abuse immediately to the Administrator .If the incident or allegation is considered reportable, the Administrator or designee will make an initial .report .A follow up investigation will be submitted .within five working days . 1. Resident #3 (alleged perpetrator) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly assessment, dated 5/11/21, documented the resident had severe cognitive impairment. It documented he was independent with ambulation, and locomotion on and off unit. A Behavior Note, dated 06/07/21 at 1:25 p.m., documented, .Nurse then observed [resident #3] put his hand in female residents shirt and grope her. Nurse started approaching resident and he quickly began ambulating towards his room. Nurse explained to resident that this is unacceptable behavior. This incident was not reported. Resident #2 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior Note, dated 08/21/21 at 3:59 p.m., documented, [Res #3] witnessed by 3 staff members with his hand down [Res #1]s shirt. When one staff member calls out [Res #3]'s name, [Res #3] lifted his hand out of shirt and walked back down to room. This LN approaches [Res #3] and states hey buddy, were you just touching that young lady? [Res #3] replies, kick me out of here or whatever .you want to do this LN leaves [Res #3] .[Res #3] continues to walk to same female res's room and look at her . This incident was not reported to OSDH at the time of the incident. A Behavior Note, dated 10/02/21 at 8:00 p.m., documented, [Res #3] was accused of touching [Res #2] inappropriately. Spoke with [Res #3] and told him that groping female residents is inappropriate. He got upset and stated just send me to Fort Supply. I told him that it was closed down and he wasn't going anywhere, but he needs to stay in his room. [Res #3] got back in his bed and no further behaviors were reported or observed. A Health Status Note, dated 10/02/21 at 8:00 p.m., documented, [Res #2] reported to staff that a male resident came into her room and touched her breast under her clothing. This male resident was seen earlier talking to resident in her room and was asked to get out of her room which he did at that time. [Res #2] became scared and came out to sit at nurses' station for awhile after reporting what he had done. Resident was given popcorn and reassurance that she would be safe. She returned to her room appx an hour later. This incident was not reported. A Behavior Note, dated 10/14/21 at 7:15 p.m., documented, [Res #3] found in [Res #2]'s room standing over her to her left side as she was sitting in her recliner. [Res #2] made a soft sound/gasp. [Res #3] began backing away as I came to her doorway and she was clutching her loose button up shirt tighter. [Res #3] was told to get out of there and go to his own room and leave this female resident alone. Resident became angry and said just send me to Western State or Fort Supply. [Res #3] was assisted across the hall back to his own room and strongly encouraged to stay there. Res #3 was placed on one on one observation until he was discharged to a behavioral facility. A state reported incident report attachment, faxed 10/20/21, documented, After the 08/21/21 .Review of behavior notes for [Res #3] revealed additional incidents of inappropriate physical touching and verbal abuse perpetrated by [Res #3] against female staff and residents, which were not reported to administration until APS investigation of an incident occurring on 10/14/21 .Prior to the incident .this admin shared information with the nursing staff on our [electronical] messaging app regarding .dealing with reporting abuse .in a nursing facility along with our policy. This was obviously not followed by all staff, but on 8/21/2021 and 10/14/2021, it was . [DON and Administrator] are educating all staff again on reporting incidents of abuse, increased clarification of what constitutes abuse, i.e. verbal, sexual, etc. and expressing that while these are also behaviors that need to be documented, documenting the behavior alone is not fully adhering to policy .Future incidents of abuse will be reported as incidents in the EHR, thereby triggering notification of DON and Administrator .We will implement a checks and balances system to ensure proper future reporting . A state reported follow up note, dated 10/26/21, documented, [Res #3] was transferred to [a behavioral facility] on 10/22/21. At this time, there is no intention of readmission, due to potential criminal charges pending against him . On 11/01/21 at 3:05 p.m., the administrator and DON was asked if the incident from 06/07/21 was reported. They stated it was not reported. They were asked if the incident from 08/21/21 was reported per policy. They stated they did not complete a state incident report at the time of the event. They were asked if the incident from 10/02/21 was reported. They stated it wasn't reported, and they weren't aware at the time of the incident. 2. Res #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, read in part, . 07/24/2021 at 16:11 [4:11 p.m.] Health Status Note .Resident sitting out by nurses station in her w/c when resident [#7] went by in her w/c stopping and slapping residents right hand several times very hard. No bruising noted at this time. Will pass along to next shift to monitor residents hand . There was no other documentation of this incident. On 11/01/21 at 3:45 p.m., Res #4's progress note, dated 07/24/21, was reviewed with the DON. She was asked what was done after Res #4 was hit by another resident. She replied, she was unaware of the incident. She was asked if there was a state report done. She replied, no. The administrator was asked if there was a state report for this incident. He replied, he didn't know about the incident. 3. Res #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #7's Care Plan, read in part, .Behavior care plan: the resident has a behavior problem hitting, kicking, spitting, throwing things, scratching at the staff r/t anxiety, pain and dementia .Date Initiated: 03/19/2021 . A Progress note, read in part, .07/06/2021 at 17:48 [5:48 p.m.] Behavior note .Resident up and down hallways and pulling on staff and other resident's clothes, hitting staff and residents, hollering out at others and down hall . A Progress note, read in part, .07/18/2021 at 17:46 [5:46 p.m.] Behavior note .Resident exit seeking, yelling help me, help me die, pinches various other residents while self propelling up and down hallway in wheelchair. She is throwing dishes, furniture, going in and out of other resident rooms .After approximately 10 minutes resident propels self into solarium and throws coffee on a residents [visitor] . A Progress note, read in part, .07/22/2021 at 16:06 [4:06 p.m.] Behavior note .Res continues towards staff and other residents. Res hitting other residents and yelling. Hitting staff and resisting care. No interventions successful . A Progress note, read in part, .07/22/2021 at 16:38 [4:38 p.m.] Behavior note .Res cont to be combative towards other residents. Pinching res's. Staff cont to redirect . A Progress note, read in part, .07/22/2021 at 17:36 [5:36 p.m.] Behavior note .Res cont to hit, scratch, pinch and kick other res and staff. [Physician] contacted . A Progress note, read in part, .07/24/2021 at 16:11 [4:11 p.m.] Behavior Note .Res yelling in hall, resistant to care. Hitting and scratching staff. Res approaches another resident and hit right hand multiple times then attempts to dig nails into other residents hand. Staff redirects res . Progress notes were reviewed from 06/01/2021 to 11/01/2021 for any other behaviors. Throughout survey, Res #7 was observed in her wheelchair in the hallway with staff nearby to monitor her behaviors and intervened when needed. On 11/01/21 at 3:45 p.m., Res #7's progress note, dated 07/06/2021, was reviewed with the DON. She was asked if this incident would be considered resident to resident abuse. She replied, yes. She was asked if this incident should have been reported. She replied, yes. Res #7's progress note, dated 07/18/2021, was reviewed with the DON. She was asked if this would be considered resident to resident abuse. She replied, yes. She was asked if this incident was reported. She stated, I did not report that to state. Res #7's progress notes, dated 07/22/2021 which documented three different episodes of abusive behaviors from 4:06 p.m. to 5:36 p.m. was reviewed with the DON. She was asked if Res #7 was separated from other residents from 4:06 p.m. to 4:38 p.m. She did not respond. The DON was asked why the resident was able to continue to be abusive toward other residents as documented from 4:06 p.m. until 5:36 p.m. She stated, I don't have a good answer for that. The DON was unable to specify other residents involved in these incidents. The DON and Administrator were not aware of any of the incidents reviewed for Res #4 and Res #7. No abuse investigations were completed for these incidents. On 11/02/21, the facility provided documentation of in-services conducted related to Abuse presented by National LTC Ombudsman, and the facility's Abuse policy. In-service logs documented the following training was completed by all staff by 10/30/21. Interviews with staff demonstrated understanding of how to identify, report, and protect residents from abuse.

Based on record review, and interviews, the facility failed to ensure allegations of abuse (inappropriate touching, hitting, kiching, scratching, and pinching) was reported, investigated, and interventions were implemented to protect residents from abuse for five (#1, 2, 3, 4, and #7) of seven sampled residents reviewed for abuse. This resulted in resident #2 being fearful after an incident of resident #3 touching her inappropriately. The Administrator identified 38 residents resided in the facility. Findings: An Abuse Policy, revised on 09/12/20, read in part, .No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection .Training about challenging behaviors and how to intervene .Communication of reports of resident .abuse .The facility provides identification, ongoing assessment .for appropriate interventions and monitoring of resident with needs and behaviors that might lead to conflict or neglect, such as .residents with a history of cognitive deficits .aggressive behaviors, resident who have behaviors such as entering other residents' rooms, wandering behaviors .socially inappropriate behaviors . Staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents .It is the policy .all staff monitor residents and will know how to identify potential signs and symptoms of abuse .reports of abuse .are promptly and thoroughly investigated .The investigation will include .who was involved .residents' statements .For .cognitively impaired residents .attempt to interview resident first .observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings . Procedures are in place to provide the resident with a safe, protected environment during the investigation .If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator .Examine, assess and interview the resident and other residents potentially affected as soon as possible to determine any injury and identify any immediate clinical interventions necessary .Employees must always report any abuse or suspicion of abuse immediately to the Administrator . 1. Resident #3 (alleged perpetrator) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly assessment, dated 5/11/21, documented the resident had severe cognitive impairment. It documented he was independent with ambulation, and locomotion on and off the unit. A Behavior Note, dated 06/07/21 at 1:25 p.m., documented, .Nurse then observed [resident #3] put his hand in female residents shirt and grope her. Nurse started approaching resident and he quickly began ambulating towards his room. Nurse explained to resident that this is unacceptable behavior. This incident was not reported, investigated, or corrective actions implemented. An Alert Note, dated 06/11/21 at 1:10 p.m., documented, This LN notified [physician] of res sexual behaviors towards females. [Physician] states to make sure we tell res this behavior is not okay and to notify if it continues. Resident #2 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 (victim) admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior Note, dated 08/21/21 at 3:59 p.m., documented, [Res #3] witnessed by 3 staff members with his hand down [Res #1]s shirt. When one staff member calls out [Res #3]'s name, [Res #3] lifted his hand out of shirt and walked back down to room. This LN approaches [Res #3] and states hey buddy, were you just touching that young lady? [Res #3] replies, kick me out of here or whatever .you want to do this LN leaves [Res #3] .[Res #3] continues to walk to same female res's room and look at her . A Summary for Providers note, dated 08/21/21 at 5:02 p.m., documented, .Physician respond .Send to ER for psych eval, possible EOD . A Behavior Note, dated 08/21/21 at 10:26 p.m., documented, ER nurse .called .saying resident is ready to return to facility .Staff encouraged by this LN to carefully monitor [Res #3] and his behavior. This incident was not reported to OSDH, and was not investigated. A Behavior Note, dated 10/02/21 at 8:00 p.m., documented, [Res #3] was accused of touching [Res #2] inappropriately. Spoke with [Res #3] and told him that groping female residents is inappropriate. He got upset and stated just send me to Fort Supply. I told him that it was closed down and he wasn't going anywhere, but he needs to stay in his room. [Res #3] got back in his bed and no further behaviors were reported or observed. A Health Status Note, dated 10/02/21 at 8:00 p.m., documented, [Res #2] reported to staff that a male resident came into her room and touched her breast under her clothing. This male resident was seen earlier talking to resident in her room and was asked to get out of her room which he did at that time. [Res #2] became scared and came out to sit at nurses' station for awhile after reporting what he had done. Resident was given popcorn and reassurance that she would be safe. She returned to her room appx an hour later. This incident was not reported, investigation was not completed, and no new intervention was implement to prevent further abuse. A Behavior Note, dated 10/14/21 at 7:15 p.m., documented, [Res #3] found in [Res #2]'s room standing over her to her left side as she was sitting in her recliner. [Res #2] made a soft sound/gasp. [Res #3] began backing away as I came to her doorway and she was clutching her loose button up shirt tighter. [Res #3] was told to get out of there and go to his own room and leave this female resident alone. Resident became angry and said just send me to Western State or Fort Supply. [Res #3] was assisted across the hall back to his own room and strongly encouraged to stay there. Res #3 was placed on one on one observation until he was discharged to a behavioral facility. This incident was not thoroughly investigated by not interviewing other residents to find out any other incidents that had not been reported. A state reported incident report attachment, faxed 10/20/21, documented, After the 08/21/21 .Review of behavior notes for [Res #3] revealed additional incidents of inappropriate physical touching and verbal abuse perpetrated by [Res #3] against female staff and residents, which were not reported to administration until APS investigation of an incident occurring on 10/14/21 .Prior to the incident .this admin shared information with the nursing staff on our [electronical] messaging app regarding .dealing with reporting abuse .in a nursing facility along with our policy. This was obviously not followed by all staff, but on 8/21/2021 and 10/14/2021, it was . [DON and Administrator] are educating all staff again on reporting incidents of abuse, increased clarification of what constitutes abuse, i.e. verbal, sexual, etc. and expressing that while these are also behaviors that need to be documented, documenting the behavior alone is not fully adhering to policy .Future incidents of abuse will be reported as incidents in the EHR, thereby triggering notification of DON and Administrator .We will implement a checks and balances system to ensure proper future reporting . A state reported follow up note, dated 10/26/21, documented, [Res #3] was transferred to [a behavioral facility] on 10/22/21. At this time, there is no intention of readmission, due to potential criminal charges pending against him . On 11/01/21 at 3:05 p.m., the administrator and DON was asked if the incident from 06/07/21 was reported, investigated, and what interventions were put in place to protect other residents. They stated it was not reported, and not investigated. They stated the intervention was routine staff observations. They were asked if the incident from 08/21/21 was investigated and reported per guidelines. They stated they called law enforcement and thought they would investigate. They stated they did not complete state incident report at the time of the event. They were asked what carefully monitor Res #3's behavior indicated as instructed by LN on 08/21/21. The DON stated they monitored behaviors every shift. They were asked if the incident from 10/02/21 was reported, investigated, and what interventions were put in place to protect other residents. They stated it wasn't reported, and they weren't aware at the time of the incident. The DON stated there were no new interventions implemented. They were asked if the incident from 10/14/21 was thoroughly investigated, because only the involved residents and staff were interviewed. Should other residents and staff had been interviewed to identify the extent of the abuse. The Administrator stated he feels it was thoroughly investigated because he assumed the other residents would have said something. 2. Res #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, read in part, . 07/24/2021 at 16:11 [4:11 p.m.] Health Status Note .Resident sitting out by nurses station in her w/c when resident [#7] went by in her w/c stopping and slapping residents right hand several times very hard. No bruising noted at this time. Will pass along to next shift to monitor residents hand . There was no other documentation of this incident. On 11/01/21 at 3:45 p.m., Res #4's progress note, dated 07/24/21, was reviewed with the DON. She was asked what was done after Res #4 was hit by another resident. She replied, she was unaware of the incident. She was asked if there was a state report done. She replied, no. The administrator was asked if there was a state report for this incident. He replied, he didn't know about the incident. 3. Res #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #7's Care Plan, read in part, .Behavior care plan: the resident has a behavior problem hitting, kicking, spitting, throwing things, scratching at the staff r/t anxiety, pain and dementia .Date Initiated: 03/19/2021 . A Progress note, read in part, .07/06/2021 at 17:48 [5:48 p.m.] Behavior note .Resident up and down hallways and pulling on staff and other resident's clothes, hitting staff and residents, hollering out at others and down hall . A Progress note, read in part, .07/18/2021 at 17:46 [5:46 p.m.] Behavior note .Resident exit seeking, yelling help me, help me die, pinches various other residents while self propelling up and down hallway in wheelchair. She is throwing dishes, furniture, going in and out of other resident rooms .After approximately 10 minutes resident propels self into solarium and throws coffee on a residents [visitor] . A Progress note, read in part, .07/22/2021 at 16:06 [4:06 p.m.] Behavior note .Res continues towards staff and other residents. Res hitting other residents and yelling. Hitting staff and resisting care. No interventions successful . A Progress note, read in part, .07/22/2021 at 16:38 [4:38 p.m.] Behavior note .Res cont to be combative towards other residents. Pinching res's. Staff cont to redirect . A Progress note, read in part, .07/22/2021 at 17:36 [5:36 p.m.] Behavior note .Res cont to hit, scratch, pinch and kick other res and staff. [Physician] contacted . A Progress note, read in part, .07/24/2021 at 16:11 [4:11 p.m.] Behavior Note .Res yelling in hall, resistant to care. Hitting and scratching staff. Res approaches another resident and hit right hand multiple times then attempts to dig nails into other residents hand. Staff redirects res . Progress notes were reviewed from 06/01/2021 to 11/01/2021 for any other resident behaviors. Through out the survey, Res #7 was observed in her wheelchair in the hallway with staff nearby to monitor her behaviors and intervened when needed. On 11/01/21 at 3:45 p.m., Res #7's progress note, dated 07/06/2021, was reviewed with the DON. She was asked if this incident would be considered resident to resident abuse. She replied, yes. She was asked if this incident should have been reported. She replied, yes. Res #7's progress note, dated 07/18/2021, was reviewed with the DON. She was asked if this would be considered resident to resident abuse. She replied, yes. She was asked if this incident was reported. She stated, I did not report that to state. Res #7's progress notes, dated 07/22/2021 which documented three different episodes of abusive behaviors from 4:06 p.m. to 5:36 p.m. was reviewed with the DON. She was asked if Res #7 was separated from other residents from 4:06 p.m. to 4:38 p.m. She did not respond. The DON was asked why the resident was able to continue to be abusive toward other residents as documented from 4:06 p.m. until 5:36 p.m. She stated, I don't have a good answer for that. The DON was unable to specify other residents involved in these incidents. The DON and Administrator were not aware of any of the incidents reviewed for Res #4 and Res #7. No abuse investigations were completed for these incidents. On 11/02/21, the facility provided documentation of in-services conducted related to Abuse presented by National LTC Ombudsman, and the facility's Abuse policy. In-service logs documented the following training was completed by all staff by 10/30/21. Interviews with staff demonstrated understanding of how to identify, report, and protect residents from abuse.

Based on record review and staff interviews, it was determined the facility failed to ensure: ~ a physician's order was obtained to conduct COVID-19 testing for three (#1, 2 and #3) of three sampled residents and ~ staff were screened in accordance to CMS and CDC guidance in order to prevent the spread of infection for three (#1 transport driver, 2 certified nurse aide and #3 licensed practical nurse) of three sampled staff reviewed for infection control related to COVID-19. The facility identified 42 residents who resided in the facility. Findings: The CDC guidance titled, Symptoms of Coronavirus, dated 05/13/20, documented: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness .People with these symptoms may have COVID-19: .Fever or chills .Cough .Shortness of breath or difficulty breathing .Fatigue .Muscle or body aches .Headache .New loss of taste or smell .Sore throat .Congestion or runny nose .Nausea or vomiting .Diarrhea . Influenza (Flu) and COVID-19 are both contagious respiratory illnesses, but they are caused by [MEDICAL CONDITION] .Because some of the symptoms of flu and COVID-19 are similar, it may be hard to tell the difference between them based on symptoms alone, and testing may be needed to help confirm a diagnosis . The CMS QSO 20-39-NH document, dated 09/17/20, documented, .Core Principles of COVID-19 Infection Prevention .Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms . A facility COVID-19 infection control policy, revised 05/18/20, documented, .Monitoring employees for fever or respiratory symptoms, such as, new or changed cough, shortness of breath, and sore throat at the beginning of their shift, the middle of their shift, and at the end of their shift .Actively taking their temperature and document absence of shortness of breath, new or changed cough, and sore throat . 1. Resident #1 had [DIAGNOSES REDACTED]. The resident had been tested for COVID-19 on 11/13/20, 11/17/20, 11/24/20, 11/27/20 and on 12/01/20. The resident did not have physician's orders for as needed COVID-19 testing. Resident #2 had [DIAGNOSES REDACTED]. The resident did not have physician's orders for as needed COVID-19 testing. Resident #3 had [DIAGNOSES REDACTED]. The resident did not have physician's orders for as needed COVID-19 testing. On 12/09/20 at 12:15 p.m., the director of nursing (DON) was asked to provide physicians' orders for the above residents' COVID-19 tests. At 12:30 p.m., the DON provided lab requisitions, dated 08/25/20, for a COVID-19 test. She was asked if this was considered an as needed order for testing. She stated it was the lab requisition needed in order to get the test done. The DON was asked if the facility did not have as needed physicians' orders for COVID-19 testing. She stated that was correct. 2. Licensed practical nurse #3's time record documented she worked on 07/08, 07/09, 07/11, 07/17, 07/20, 07/21, 07/22, 08/16, 08/19, 08/20, 08/24 and 08/30. Her staff screening sheets documented screenings had been only been conducted five of the 12 shifts worked. Certified nurse aide #2's time record documented she worked on 10/01, 10/02, 10/05/10/06, 10/07 and 11/28/20. Her staff screening sheets documented screenings had only been conducted on one of the six shifts worked. Transport driver #1's time record documented she worked on 10/01, 10/03, 10/06, 10/08, 10/10, 10/13, 10/15, 10/17, 10/20, 10/22, 10/24, 10/29, 10/31, and 11/05/20. Her staff screening sheets documented screenings had only been conducted one of the 14 shifts she worked. At 1:00 p.m., the infection preventionist was asked who monitored staff screenings. She stated she did. She was asked if she had any issues with staff conducting the screens. She stated, Yes. At 1:20 p.m., the administrator and DON were shown the above staff schedules and screens and were asked if there was any other documentation of staff screenings. At 1:29 p.m., the DON stated, I do not have anything else.

Based on observation and interview, it was determined the facility failed to ensure survey results were posted and readily accessible to residents, family members and legal representatives of the residents. The facility census was 55. Findings: On 08/20/19 at 3:00 p.m., during the resident council interview, the residents were asked if they had access to the most recent survey results. One resident stated the results are posted on the bulletin board by the administrator's office. She stated the results are posted in a high level. At 4:28 p.m., survey results dated 08/28/17 were observed to be posted approximately 4 feet high, in a plastic sleeve, on the bulletin board next to the administrator's office. At 5:05 p.m., the administrator was asked where the most current survey results were posted. She stated, The most current results are in my office. The administrator was asked where were the designated areas for the survey results to be posted. She stated, Usually on the bulletin board. She gestured to the plastic sleeve that contained the results from 08/28/17. The administrator was asked if the designated areas was readily accessible to residents or their family/representative who would wish to review them. She stated, Not if they are in a wheelchair, it is too high to reach.