Every finding on record at Carrington, LLC D/B/A the Carrington

Based on observation of video footage, staff and resident interviews, record review, and facility policy review, the facility failed to honor a resident's right to be treated with dignity and respect for one (1) of seven (7) residents sampled. Resident #1Findings include:Record review of facility policy titled, Resident Rights dated 10/24/22, revealed, .The resident has a right to be treated with respect and dignity . Review of video footage of the incident dated 3/10/26 at 10:07 AM revealed Resident #1 was propelling his wheelchair near the front door in the main hallway, and he turned to go back down the hall. He was on the same side of hall as Certified Nursing Assistant (CNA) #1, who was standing in the beauty shop doorway which was located approximately halfway down that hall past multiple offices. The resident approached the beauty shop door where CNA #1 was standing. He slowed his speed and looked into the doorway. Both hands of Resident #1 were on the wheelchair wheels. As he slowed, CNA #1 hit the brim on his cap with a light to moderate force which caused the resident's head to be pushed down towards his chest slightly. Both of his hands were still on his wheelchair wheels and at that point, the resident removed his right hand from the wheel and used his arm to elbow CNA #1 in her thigh/hip area. The video revealed the resident did not touch CNA #1 until she popped his cap brim.During a phone interview on 4/8/26 at 2:13 PM, CNA #1 revealed that Resident #1 hit or brushed against her butt and grabbed her shirt and bra strap and she tapped his cap brim to get him to let go. She acknowledged she had been in-serviced on abuse, neglect, resident rights, and dementia care and she should have used her dementia training and backed up from the resident rather than agitating him. She stated she watched the video footage, but still thought Resident #1 was in the wrong by hitting her butt, even though video footage revealed his hands did not leave the wheels of his wheelchair until after his cap was hit by CNA #1.An interview with Resident #1 on 4/8/26 at 2:10 PM, revealed he had an altercation with CNA #1 when she hit the brim of the cap he was wearing and she blamed him for initiating the altercation. When speaking of the event with CNA #1, Resident #1 revealed that She always does things like that and I don't like it and she knows I don't play like that, but she keeps doing it. He stated I should be treated right, and it wasn't right for her to do that to me. He stated that CNA #1 blamed the altercation on him even though she was the one that started it and he was glad there was camera footage that proved what occurred. He acknowledged he did not feel abused, but he felt that she failed to treat him with respect. During an interview on 4/9/26 at 11:40 AM, the Director of Nursing (DON) acknowledged that each resident had the right to be treated with dignity and respect and when CNA #1 initiated an altercation with Resident #1, the facility failed to honor this right. An interview with the Administrator on 4/9/26 at 11:50 AM, revealed each resident has the right to be treated with dignity and respect. He acknowledged that a staff member initiated an altercation with a resident which did not honor the resident's rights. He confirmed the facility failed to honor the rights of Resident #1 to be treated with dignity and respect. Record review of in-service titled Resident Rights revealed CNA #1 completed this training on 1/30/26.Record review of Resident #1's admission Record revealed the facility admitted resident on 10/22/19, with diagnoses that included surgical amputation of leg and Type 2 Diabetes Mellitus.Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was intact cognitively.

Based on observation, interview, and facility policy review the facility failed to properly store and label opened food items in the refrigerator for one (1) of three (3) kitchen tours. Findings Include:Review of the facility policy Storage of Refrigerated Food with revised date of 10/08 revealed .5. All non-hazardous, opened foods are labeled with name of food, date stored and use-by date. 6. All hazardous foods are labeled with name of food and date to be discarded or the date stored .An observation during the initial tour of the kitchen on 12/01/25 at 10:25 AM, revealed three (3) six- ounce packages containing lunch meat that were opened and not labeled or dated. During an interview on 12/01/25 at 10:30 AM with Dietary Cook, she confirmed that the three packages of lunch meat were not dated or labeled. She identified the meat as one package of roast beef, one package of turkey bologna, and one package of turkey ham. She revealed that the meat packages were opened a couple days ago but she could not recall the exact date. Dietary [NAME] revealed that the kitchen staff were supposed to label and date food items when they opened them and supposed to dispose of opened meat within four days of opening. She revealed that failing to label and date food items when opened could cause residents to receive spoiled food which could cause food poisoning and other food borne illnesses. An interview on 12/01/25 at 10:40 AM with Dietary Manager revealed that they were supposed to date and label any food items when they were opened. She confirmed that there were three packages of undated, unlabeled lunch meat in the refrigerator and stated, This could cause residents to get sick. Dietary Manager revealed that they had in-serviced kitchen staff on dating and labelling open food items and they had signage up reminding them to do so, but sometimes it still got missed. She revealed that the purpose of dating and labeling opened stored foods was to keep track and know when to dispose of food items that might be spoiled, containimg bacteria growth to prevent food [NAME] illnesses throughout the facility. She revealed that she would do better about checking behind the kitchen staff to ensure foods are properly dated, stored and labeled.

Based on observation, family and staff interview, record review, and facility policy review, the facility failed to provide personal grooming, including removal of facial hair and routine hair care for two (2) of four (4) residents reviewed for activities of daily living (ADLs). Resident #1 and #25 Findings Include: Review of the facility policy Activities of Daily Living (ADLs) with revised date of 01/19/15 revealed, Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene Resident #1 An observation of Resident #1 on 12/02/2025 at 8:50 AM revealed she was sitting in her wheelchair in the dining room. The resident had prominent gray facial hair growth along the upper lip and scattered coarse gray hairs on the chin measuring approximately (one-half) 1/2 inch in length. Further observation revealed the resident's hair was long and visibly oily. An observation and interview with Certified Nurse Aide (CNA) #1 on 12/02/25 at 11:10 AM revealed Resident #1 was scheduled to receive a shower during the evening shift. CNA #1 stated it was the responsibility of the aides to wash the resident's hair and address any facial hair during bathing. She described Resident #1's hair as greasy and oily and stated the resident's facial hair was long and had been present for some time. An observation and interview with the Director of Nursing (DON) on 12/02/25 at 11:17 AM revealed her expectations were for the aides to shampoo residents' hair and remove or trim female facial hair during bathing. She confirmed Resident #1 had facial hair and her hair appeared greasy at the time of observation. Record review of the Restorative Nursing Screener/GG Evaluation dated 10/15/25 revealed Resident #1 was dependent on staff for bathing and required substantial/maximal assistance with personal hygiene. Record review of the admission Record revealed the facility admitted Resident #1 on 9/05/24 with medical diagnoses that included Unspecified Atrial Fibrillation and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/25 revealed under section C a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #1 was cognitively intact.Resident #25 An observation and interview with Resident #25's spouse on 12/02/2025 at 8:25 AM revealed Resident #25 sitting up in her wheelchair eating breakfast with her spouse at her side. She had multiple white hairs to her chin and upper neck and had scattered black hairs above her upper lip. Resident #25's spouse revealed that she was particular with her facial hair and liked to keep it shaved off. He stated, She would feel a whole lot better if they would keep her shaved. During an observation and interview on 12/02/25 at 11:33 AM with Licensed Practical Nurse (LPN) #1 in Resident #25's room, she confirmed that Resident #25 had multiple white facial hairs on her chin and upper neck and that she had black hairs scattered above her top lip. LPN #1 revealed that Resident #25's facial hair should be removed during her shower time and confirmed that the resident had not been shaved in a while. LPN #1 also revealed that no one had ever reported to her that Resident #25 refused for her facial hair to be removed. An interview on 12/02/25 at 11:36 AM with the CNA Supervisor, revealed that Resident #25's facial hair should be removed during her shower time and stated, I wouldn't want to be seen like that with facial hair, and it should be removed. An interview on 12/02/25 at 11:41 AM with Registered Nurse (RN) Supervisor, revealed that personal hygiene included removal of facial hair and that it should be completed during the residents' shower. Record review of Resident #25's admission Record revealed an admission date of 01/08/19 and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Aphasia Following Cerebral Infarction. Record review of Resident #25's MDS with ARD of 09/15/25 under Section C, revealed a BIMS Score of 10 which indicated that she had moderate cognitive deficits.

Based on observation, staff interview, and record review, the facility failed to ensure the environment was free of accident hazards when a resident room was mopped and the floor was left wet, without use of a caution sign for one (1) of 31 occupied rooms and failed to provide adequate supervision for a resident on a blood thinner who was shaving with a disposable razor for one (1) of 19 sampled residents. Resident #29 Findings Include: The facility provided a statement on letterhead that read, (Proper name of the facility) does not have a specific policy that addresses hazards within the facility. room [ROOM NUMBER] An observation during initial tour on 12/01/25 at 10:42 AM revealed Housekeeping #1 mopping the floor inside room [ROOM NUMBER]. After mopping the entire room floor, she moved onto another room and did not place a caution sign to notify the residents, staff, and visitors that the floor was wet. The floor was visibly wet from the doorway entrance and posed a fall hazard. An interview with Housekeeping #1 on 12/01/25 at 10:58 AM revealed when she mopped the resident rooms, she never left a caution sign in place and stated she was not trained to do that. During an interview with the Housekeeping Supervisor on 12/02/25 at 2:53 PM, she revealed Housekeeping #1 was a new employee, but she had been trained to always use caution signs anytime they were mopping, and the floor was wet. She confirmed this should be done so that nobody falls. RESIDENT #29 An observation on 12/01/25 at 10:50 AM, revealed Resident #29 sitting in his wheelchair in his bathroom in front of the mirror and he was shaving himself with a regular disposable razor. An observation on 12/02/25 at 8:30 AM revealed two disposable razors in Resident #29's bathroom setting on the right corner of the countertop next to the sink. During an observation and interview on 12/02/25 at 10:26 AM with Licensed Practical Nurse (LPN) #1, she confirmed that there were two disposable razors in Resident #29's bathroom. She confirmed that he should not have regular razors in the room with him due to the risk of cutting himself and that he was on blood thinners and had a risk of bleeding. An interview on 12/02/25 at 10:40 AM with Registered Nurse (RN) Supervisor, revealed that the residents did not shave themselves at all with a regular disposable razor. She revealed that the residents were assisted with shaving during shower times and that he should not have regular disposable razors in his bathroom and confirmed that he cannot shave himself unsupervised because he is on a blood thinner. She also revealed that she wasn't sure why he was shaving himself or how he got those razors. RN Supervisor confirmed that having regular razors in his room was hazardous and an accident waiting to happen and they needed to get him an electric razor that he could use safely. During an interview on 12/02/25 at 3:35 PM with the Administrator, he confirmed that it was a hazard for Resident #29 to have access to regular razors to shave himself. He also confirmed that Resident #29 required supervision while shaving due to his risk of bleeding from being on anticoagulants. Record review of Resident #29's admission Record revealed an admission date of 04/30/25 and that he had diagnoses that included Stage 5 (five) Kidney Disease, Type II Diabetes Mellitus, and Unspecified Atrial Fibrillation. Record review of Resident #29's Order Summary Report revealed an order dated 05/05/25 for Eliquis Oral Tablet 2.5 MG (milligrams) (Apixaban) Give 1 (one) tablet by mouth two times a day related to Unspecified Atrial Fibrillation. Record review of Resident #29's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/03/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) Score of 99 which indicated that he was unable to complete the interview.

Based on observation, family and staff interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan for routine hair hygiene and facial hair removal for three (3) of 19 care plans reviewed. Resident #1, Resident #25 and Resident #29 Findings Include: Review of the facility policy titled Care Plans revised 2/20/2020 revealed under, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. Resident #1 Record review of the Care Plan Report for Resident #1 revealed under, Focus: I require extensive assist with all of my Activities of Daily Living (ADL) care related to physical and cognitive limitations secondary to absence left leg below the knee, and dementia. There were no listed interventions/tasks to address personal hygiene care. During an observation of Resident #1 on 12/02/2025 at 8:50 AM, she was sitting in her wheelchair in the dining room. The resident had prominent gray facial hair growth along the upper lip and scattered coarse gray hairs on the chin measuring approximately (one-half) 1/2 inch in length. Further observation revealed the resident's hair was long and visibly oily. During an observation and interview with Certified Nurse Aide (CNA) #1 on 12/02/25 at 11:10 AM, she confirmed Resident #1's hair was greasy and oily and stated the resident's facial hair was also long and had been present on her face for some time. An interview with the Minimum Data Set (MDS) Nurse #1 on 12/03/25 at 10:45 AM revealed the purpose of Resident #1's care plan was to inform the staff of what specific care to provide. She confirmed the care plan was not developed for personal hygiene related to hair care and facial hair and stated it should have been. Record review of the admission Record revealed the facility admitted Resident #1 on 9/05/24 with medical diagnoses that included Unspecified Atrial Fibrillation and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/25 revealed under section C a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #1 was cognitively intact. Resident #25 Record review of Resident #25's Care Plan Report revealed that she had an ADL self-care deficit and/or mobility deficit related to Hemiplegia of the Right Dominant Side with interventions that included partial to moderate assistance with oral hygiene and facial care as desired by resident. On 12/02/2025 at 8:25 AM an observation and interview with Resident #25's spouse revealed the resident sitting up in her wheelchair eating breakfast with her spouse at her side. She had multiple white hairs to her chin and upper neck and scattered black hairs above her upper lip. Resident #25's spouse revealed that she was particular with her facial hair and liked to keep it shaved off. He stated, She would feel a whole lot better if they would keep her shaved. On 12/02/25 at 11:33 AM during an observation and interview with LPN #1, in Resident #25's room, she confirmed that the resident had multiple white facial hairs on her chin, upper neck and had black hairs scattered above her top lip. LPN #1 revealed that her facial hair should be removed during her shower time and confirmed that Resident #25 had not been shaved in a while. LPN #1 asked Resident #25 if she wanted her facial hair removed and she stated, Yes. An interview on 12/02/25 at 11:56 AM with MDS Nurse #2, revealed that she was responsible for updating care plans. She revealed that the purpose of the care plan was to identify resident-specific needs and wishes and to formulate the plan of care so that all staff members knew how to take care of each resident. MDS Nurse #2 observed Resident #25's care plan and confirmed that her care plan included the removal of facial hair, and that the care plan was not followed. Record review of Resident #25's admission Record revealed an admission date of 01/08/19 and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Aphasia Following Cerebral Infarction. Record review of Resident #25's MDS with ARD of 09/15/25 under Section C, revealed a BIMS Score of 10 which indicated that she had moderate cognitive deficits. Resident #29 Record review of Resident #29's Care Plan Report revealed that he required supervision assist with his ADL care related to Muscle Weakness. On 12/01/25 at 10:50 AM, an observation revealed Resident #29 sitting in his wheelchair alone in his bathroom in front of the mirror and he was shaving himself with a regular disposable razor. On 12/02/25 at 10:26 AM during an observation and interview with Licensed Practical Nurse (LPN) #1, she confirmed that there were two disposable razors in Resident #29's bathroom. She revealed that he should not have regular razors in the room with him due to a risk of cutting himself or the risk of other residents coming in and taking them. She also revealed that Resident #29 required supervision with shaving, he was on blood thinners and had a risk for bleeding. On 12/02/25 at 10:40 AM an interview with Registered Nurse (RN) Supervisor, revealed that the residents did not shave themselves at all with a regular razor and that the CNAs should do that during ADL care when they showered. An interview with MDS Nurse #2 on 12/02/25 at 11:56 AM reviewed Resident #29's Care Plan and confirmed that he required supervision assistance with his ADLs and she confirmed that since he shaved himself without supervision, his care plan was not followed. Record review of Resident #29's admission Record revealed an admission date of 04/30/25 and that he had diagnoses that included Stage 5 (five) Kidney Disease, Type II Diabetes Mellitus, and Unspecified Atrial Fibrillation. Record review of Resident #29's Order Summary Report revealed an order dated 05/05/25 for Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 (one) tablet by mouth two times a day related to Unspecified Atrial Fibrillation. Record review of Resident #29's MDS with ARD of 11/03/25 under Section C, revealed a BIMS Score of 99 which indicated that he was unable to complete the interview.

Based on observation, staff interview, and record review, the facility failed to provide a safe homelike environment in resident rooms as evidenced by furniture being in poor condition observed on one (1) of three (3) halls during the survey. Findings include: Record review of a statement on facility letterhead, undated and signed by the facility Administrator revealed (Proper Name of Facility) does not have a written policy at this time on environmental cleanliness or maintenance of the environment fixtures within the facility that would support providing a homelike environment. An observation, on 2/6/24 at 1:15 PM, revealed the bedside tables, dresser, and closet doors were scuffed and in poor condition in room [ROOM NUMBER]. The furniture was medium brown in color. The edges of the top of the A bedside tables were worn to a a light beige color and had rough areas. The B bedside table corner was rough with tiny splinters and the drawer pull for the top drawer was missing. The closet doors had numerous areas where varnish was scuffed off and the lower edge of the closet doors had an area that measured two (2) feet from the bottom that had rough gouges. The dresser in the room had numerous 1 to 3 inch scuffs and scrapes over it. An observation and interview, on 2/7/24 at 12:20 PM, with Certified Nursing Assistant (CNA) #1 confirmed the rough edges on the bedside table. She stated that the rough edges could cause an abrasion or someone could get a splinter from it. An observation and interview on 2/7/24 at 3:15 PM, with the Administrator (ADM) confirmed the condition of the furniture and stated that all of the furniture in the building needed to be replaced to provide the residents with a nice and safe homelike environment. An interview, on 2/8/24 at 10:30 AM, with the ADM revealed the facility did not a have a policy at this time on environmental cleanliness or maintenance of environmental fixtures within the facility that would support providing a homelike environment and provided a statement reflecting there was not a policy for environmental cleanliness.

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possible spread of infection as evidenced by placing a pulse oximeter in a nurse's uniform pocket during a medication pass for one (1) of three (3) nebulizer treatments observed. Resident #31 Findings include: Record review of the facility policy titled, Cleaning and Disinfection of Resident Care Equipment, undated, revealed Policy: Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection . An observation, during medication pass, on 2/7/24 at 8:40 AM, revealed Licensed Practical Nurse (LPN) #1 administered a nebulizer treatment to Resident #31. LPN #1 entered Resident #31's room with medications on a tray. She placed the tray on the over bed table and then removed a pulse oximeter from her uniform pocket and checked the resident's oxygen saturation level and pulse. She then removed the oximeter and placed it back in her uniform pocket. She removed the meter from her pocket and rechecked the oxygen saturation when the nebulizer treatment was complete. She put the pulse oximeter back in her pocket and continued with her medication pass. LPN #1 did not clean the pulse oximeter before or after use on the resident. Upon return to the medication cart, LPN #1 cleaned the medication tray and placed it back in the cart but left the pulse oximeter in her pocket. A telephone interview on 02/08/24 at 8:50 AM, with LPN #1 confirmed the pulse oximeter was in her pocket. She stated that she keeps it in her pocket until she gets in the room. When asked by the surveyor if that could cause any problems, she stated it could if her pockets were dirty. She stated she remembered gloves should not be in your pockets, but she didn't think about the pulse oximeter. She stated that could pass germs to the resident. An interview, with LPN #2 on 02/08/24 at 08:56 AM, revealed that she cleans the pulse oximeter at the beginning of her shift and then cleans it between each resident. She stated that she never puts it in her pocket because they are dirty and would contaminate it. An interview, on 02/08/24 at 09:07 AM with the Director of Nursing (DON) stated the pulse oximeter should be cleaned and ready for use at the beginning of the shift and cleaned again when staff exit the resident's room after use and stored on the cart. It should not be in the staff's pocket at anytime. Record review of the Physician Orders List for Resident #31 revealed an order date of 2/1/14 under Special Requirements with Brief Instructions: . Document O2 (oxygen) Sat (saturation) before and after respiratory treatment . Review of the In-service Form dated 11/06/23, titled Weekly Infection Control-Nurses and CNA's revealed .Maintain clean and operable equipment and to prevent growth and spread of bacteria in our facility . Review of the list of attendees revealed LPN #1 attended the in-service. Review of the in-service form dated 11/06/23, titled Weekly Infection Control-Nurses and CNA's revealed it's purpose was to maintain clean and operable equipment and to prevent growth and spread of bacteria in the facility. Review of the list of attendees revealed LPN #1 attended the in-service. Review of the facility Face Sheet for Resident #31 revealed an admitted [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #31 was cognitively intact.

F610 S/S=D Based on observation, record review, facility policy and procedure review, and interviews, the facility failed to thoroughly investigate the events of an alleged event of abuse to Resident #1 by a staff member. Resident #1 was one (1) of five (5) residents reviewed for abuse. Review of the facility policy and procedure titled Abuse Program dated Revised May 23, 2017, revealed: Investigation: The facility will thoroughly investigate, under the direction of the Administrator or Director of Operations/Director of Clinical Operations the time of any findings of potential abuse or neglect to determine the cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The Administrator of designee shall report any suspected abuse and neglect outlined in this policy within 2 hours to the Department of Health or Office of Long-term Care as required. Interview on 4/7/2022 at 10:50 A.M. with the Director of Nursing (DON) revealed that an employee Physical Therapy Supervisor (PTS) was told by resident #1 that there was a picture of a male penis on her cell phone. The DON obtained the timeline of the administrator's investigation and the documentation that was completed by the administrator. The materials of the facility investigation were reviewed. The DON stated that to her knowledge the investigation was completed, and all supporting documentation was contained in the investigation. ecord review of the facility investigation revealed that there were no statements from the PTS or the DPT who had initially reported the incident on 03/29/22 to the Social Worker in the morning stand up meeting. There were 69 pages of investigation materials reviewed. The record review contained the name and phone number of the Attorney General's (AG) investigator. There were no lists of resident names that had the use of a cell phone/computer in the facility. There were no lists of residents in the facility that had Facebook accounts. There was no documentation contained in the facility investigation that education had been provided to all the residents concerning the reporting of inappropriate materials sent on the cell phones/computers. There was no documentation in the facility investigation that the residents were educated on the appropriate use of a cell phone/computer in the facility. The facility investigation was not thorough enough to completely establish the attempts that were made by the facility to provide protection and safety for all residents in the facility and to prevent the abuse of residents. Interview on 4/7/2022 at 11:18 P.M. with the ADM, via DON's cell phone, revealed that he first received word on 3/29/2022 at approximately 11:45 A.M., that an obscene photo of a male penis was on the cell phone of resident (Res#1). The resident had told the PT Supervisor, (PTS) that a staff member, Housekeeping Supervisor (HS) had sent the picture of the male penis to her. Surveyor asked the ADM if he had a statement of any type from the (PTS) in his investigation. The ADM stated that he did not obtain a written statement or a verbal statement from the PT Supervisor. The ADM stated that he did not have any staff interviews or statements (verbal or written) in his investigation because they were not necessary. ADM stated that when he interviewed the resident #1 with the SW that she gave them her cell phone and the Facebook profile of the staff member (HS) was posted with the picture of a male penis. ADM stated that he talked to the staff member (HS) on the day of the discovery, 3/29/2022, and he confirmed that he did send a picture to resident #1 but that it was not a dirty picture it was a picture of a melted candy bar. The ADM stated that he had confirmed through the Facebook profile of (HS) that the picture was sent to the resident (Res #1) on 12/30/2021. The ADM stated that he terminated the (HS) on 3/29/2021 for sending inappropriate information to a facility resident. ADM stated that he felt that the information he obtained was enough to terminate the staff member, (HS) and to establish that the resident (Res #1) had received an inappropriate picture of a male penis on her cell phone from the HS. Interview on 4/7/22 at 12:00 noon with the Attorney General's (AG) Investigator, revealed that he came to the facility on [DATE] and talked to the family of the resident and talked to the resident (Res #1). AG obtained the cell phone of Res #1 and had possession of the evidence of the penis picture that was on Res #1's phone. AG confirmed that the staff member (HS) had sent the picture of the penis to Res #1. AG also stated that the staff member (HS) and the resident did not know each other prior to Res #1's admission to the facility. AG stated that he had a warrant for the staff member (HS) and would be going to his home to visit with the staff member and to obtain his cell phone. AG stated that the pictures that were sent to Res #1 was a cyber-crime, and he was turning over the cell phone of the resident and of the staff member to the AG's cyber-crime unit for review. Interview on 4/7/2022 at 12:45 P.M. with the Physical Therapy Supervisor (PTS) revealed that she had been working with the resident #1 four (4) times each week in the therapy department for several months. PTS had been employed at the facility for approximately [AGE] years. The PTS stated that Res #1 usually was in the PT department each morning early waiting on her to start therapy at approximately 8:00 A.M. and that on 3/29/2022 she was not there waiting. PTS stated that on 3/29/2022 at 8:00 A.M. Res #1 was not at the department for therapy and that was unusual. The PTS went to the room of Res #1 along with another physical therapist, Doctor of Physical Therapy (DPT). When they got to Res #1's room she was still in bed and was clearly upset and angry. Res #1 told them that she hated the staff at the facility and was upset that two (2) of the CNA's had gotten her cell phone and were trying to block her dick pictures that she had on her phone. Res #1 told them that CNA#2 and CNA #3 had tried to block her phone and were trying to erase her dick pictures from her phone that had been sent to her by a staff member (HS)Housekeeping Supervisor. Res #1 told both PT's that the Housekeeping Supervisor had sent her a picture of his penis. The PTs stated that Res #1 was clearly and visibly upset, and she was cussing and saying, I hate those mother [OBSCENITY] s and [OBSCENITY] es. Res #1 was refusing to go to therapy and that was very unusual. PTS stated that she went to stand up and reported the incident to the Social Worker (SW) on 3/29/2022 at approximately 10:45 A.M. The PTS stated that the facility administrator did not interview her or ask her any questions concerning the alleged incident/matter of the pictures on Res #1's cell phone. The administrator had not obtained a written statement from the PTS to date. The PTS stated that she felt that the information given to her by Res #1 was clearly inappropriate and was abuse of a resident. PTS stated that she had never been given any information like this before from Res #1. She stated that this was the first time that she had seen Res #1 cussing and acting angry like she was on the morning of 3/29/2022. PTS stated that she believed that Res #1 was telling the truth on 3/29/2022. PTS stated that she was positive that Res #1 had not known the staff member (HS) prior to her admission to the facility. Interview on 4/7/2022 at 1:00 P.M. with the Doctor of Physical Therapy, DPT stated that on 3/29/2022 at approximately 8:30 A.M. she and the PTS went to the room of Res #1 to see why she was not at therapy on 3/29/2022. Upon entering the room and asking why she was still in the bed and not at therapy, Res #1 replied: I hate all those mother [OBSCENITY] s and [OBSCENITY] es. They want to block my phone and get my dick pictures from my phone. Res #1 was cussing and was visibly upset and in a foul mood. She refused to go to physical therapy on 3/29/2022. Res #1 said that staff member (HS) had sent her a dick pic to send to another staff member, a girl (CNA #1). Res #1 stated that she did not want the staff member to get fired and that he had sent the dick pic to her phone so she could send it on to another staff member. Res #1 stated that CNA #2 had tried to block her phone and that she wanted her dick pics. The DPT stated that the PTS had reported the incident to the Social Worker (SW) at the Stand-Up meeting on 3/29/2022 10:45 A.M. The DPT stated that to date no one from the facility had asked her for a statement of the events that occurred on 3/29/2022, and she had not given a written report of the events of 3/29/2022 with Res #1. DPT stated that she had never seen or heard Res #1 angry like she was on 3/29/2022. DPT stated that she had no knowledge of Res #1 being involved in any inappropriate behaviors prior to 3/29/2022. No resident had ever reported anything inappropriate prior to 3/29/2022. Interview on 4/7/2022 at 1:40 P.M. with the Social Worker (SW) revealed that she was told by the PTS that Res #1 had told her that she had a picture of a male penis on her phone that was sent to her by the Housekeeping Supervisor (HS). SW immediately went to talk to the resident by herself to see what had transpired. Res #1 was upset and was cussing that there were two (2) Certified Nursing Assistants (CNA's) CNA #2, and CNA #3, that were trying to block her phone and she had dick pics on her phone from (HS). SW was given the cell phone of Res #1 and she scrolled through her social media account with the permission of Res #1 and found a post from (HS) dated 12/30/2021 that contained a photo of a male penis. Res #1 did not want to get HS in trouble, and she was upset that he may get fired. SW confirmed that the photo was posted on 12/30/2021 from the Facebook private message account of the HS to the resident (Res #1). (SW) provided the surveyor with a viewing of a copy of the posting from HS dated 12/30/2021 that had HS name and profile attached to a photo of a male penis. SW reported the findings from her interview with Res #1 to the facility administrator (ADM) and they both together returned to interview Res #1. SW stated that Res #1 told them both that she had received the photo on 12/30/2021 of the male penis from the HS to send to another employee (CNA #1). SW confirmed that the CNA #1 had worked at the facility but that she had left the facility's employment on 12/3/2020. SW stated that back in 2018 Res #1 had posted a picture of a female vagina and that it was immediately taken down. SW stated that she has not had any reports of inappropriate social media postings from or to Res #1 since 2018. Record review of the personnel files of (CNA #1) revealed that she terminated her employment with the facility on 12/03/2020. No other negative findings were found in the personnel records of (CNA#1). Reviewed the personnel file of HS and there were no negative findings in his personnel record. The record review of the facility's investigation revealed that there were no statements from the two (2) CNA's that Res #1 had named that were blocking her phone. There were no statements in the facility's investigation from (CNA #2) or (CNA #3). The record review revealed that the facility had not obtained statements from any staff members or from Res #1 to answer the questions of how the photos came about or how the HS and Res #1 had become so familiar with each other. The facility investigation did not establish if Res #1 and HS had known each other prior to the admission of Res #1 to the facility on [DATE]. The facility investigation did not establish which residents in the facility used cell phones and computers. The facility investigation did not include any statements from cognitive residents and other staff members concerning inappropriate events of conduct at the facility. There were no in-services or education of residents after the events of alleged abuse on 3/29/2022 took place. The facility did not report the alleged abuse to the MSDH office within two (2) hours of occurrence as outlined in the regulations and the facility policy and procedure. The timeline submitted by the ADM documented that he received the report of the alleged abuse at 11:45 A.M. on 3/29/2022 and that he placed the staff member (HS) on investigative leave at 12:15 P.M. on 3/29/2022. The timeline submitted by the ADM documented that the local police department was notified at 1:30 P.M. on 3/29/2022 and that the MSDH office was notified by phone on 3/29/2022 at 3:45 P.M. Interview on 4/7/2022 at 2:00 P.M. with (CNA #2) revealed that he had worked at the facility for approximately one and a half years. CNA #2 stated that he worked in the housekeeping/laundry department with (HS) as his supervisor. He stated that the HS had hired him at the facility and that recently in 12/2021 he had become a CNA at the facility. CNA #2 stated that he had not attempted to block Res #1 and he had not had a discussion with Res #1 about her cell phone. CNA #2 stated that he had not worked the night of 3/28/2022 as Res #1 had told the SW. He stated that he was off from work on 3/28/2022. CNA #2 stated that he had no knowledge that Res #1 had inappropriate photos on her phone. Res #1 had asked CNA #2 to be Facebook friends, but he had never accepted her friend requests. CNA #2 stated that he had not been interviewed by the facility about the alleged abuse of 3/29/2022 between Res #1 and the HS. CNA #2 stated that he found it hard to believe that HS had sent an inappropriate photo to Res #1. He felt that the HS was a very supportive and fare supervisor and that he had never witnessed any inappropriate behaviors between HS and any staff or residents. CNA #2 stated that they had regular in-services and training on abuse and neglect. CNA #2 stated that any inappropriate exchanges between staff members and residents of any type would be an example of abuse. Interview and observation on 4/7/2022 at 2:10 P.M. with (Res #1) revealed that she was a young female in bed with the covers up around her body to her waist and dressed in street clothes. The television was on and she was alone in her room eating orange sherbet with a spoon. Res #1 had a frown on her face, and he affect was hostile and angry. She told the surveyor that she was not doing well and that she was awaiting a transfer to another facility. Res #1 stated that her sister lived in Starkville and was her RP but that she wanted to get away from her sister and from the staff at the facility because they got up in my business and she wanted to be left alone. Res #1 asked the surveyor to leave her room and angrily verbalized that she did not want to talk. No interview with the resident was obtained on 4/7/2022 per the request of Res #1. Record review of the face sheet of Res #1 revealed that she had been admitted to the facility on [DATE]. Res #1's date of birth was 4/17/1974. Res #1 had admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] Section C. documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated that Res #1 was cognitive. Interview with ADM on 4/7/2022 at 3:30 P.M. revealed that he did meet with the RP, and he was aware of the request to have Res #1 moved to another facility. He stated that the SW had sent the request for transfer papers to the facility that the family and the Res #1 had requested. ADM stated that he was very shocked that the HS had sent the picture to Res #1. ADM stated that the HS was a very good employee and was well liked by the other staff and residents. ADM stated that he felt that Res #1 had asked the HS to send her the photo. ADM stated that he had been told by the HS that he had known Res #1 for years and that they were friends prior to her admission and that the picture was a joke between the HS and Res #1. The HS denied that the picture was of a penis. He stated to the ADM that it was of a melted candy bar.

F600 S/S=D Based on interviews, observations, facility policy and procedure reviews and record reviews, the facility failed to prevent abuse and neglect when a staff member sent inappropriate pictures to Resident #1's cell phone, for one (1) of five (5) residents reviewed for abuse. Findings Include: Review of the facility policy and procedure titled Abuse Program dated revised May 23, 2017, revealed It is the policy of this facility to take all steps necessary to maintain an environment free of abuse, Neglect, exploitation, misappropriation of resident property, and involuntary seclusion. The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, sponsors, visitors, and other care givers who provide care and services on behalf of the facility. Abuse means the will infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes abuse facilitated or enabled using technology. Review of the facility policy and procedure titled: Cellular Telephone Policy dated Revised August 26, 2016, read: In addition to telephone services, many cell phones or cellular providers offer a host of additional functions and/or services, including test messaging and digital photography. It is not possible to list all the services available. Whether enumerated or not, employees and volunteers are prohibited from using any of these services while at work. Interview on 4/7/2022 at 11:18 P.M. with the ADM, via DON's cell phone, revealed that he first received word on 3/29/2022 at approximately 11:45 A.M., that an obscene photo of a male penis was on the cell phone of resident (Res#1). The resident had told the PT Supervisor, (PTS) that a staff member, Housekeeping Supervisor (HS) had sent the picture of the male penis to her. The ADM stated that when he interviewed Resident #1 with the SW and that she gave them her cell phone and the Facebook profile of the staff member (HS) was posted with the picture of a male penis. ADM stated that he talked to the staff member (HS) on the day of the discovery, 3/29/2022, and he confirmed that he did send a picture to Resident #1 but that it was not a dirty picture it was a picture of a melted candy bar. The ADM stated that he had confirmed through the Facebook profile of the (HS) that the picture was sent to the resident (Res #1) on 12/30/2021. The ADM stated that he terminated the (HS) on 3/29/2021 for sending inappropriate information to a facility resident. The ADM stated that he felt that the information he obtained was enough to terminate the staff member, (HS) and to establish that the resident (Res #1) had received an inappropriate picture of a male penis on her cell phone from the HS. Interview on 4/7/2022 at 10:50 A.M. with the Director of Nursing (DON) revealed that on 03/29/22 employee Physical Therapy Supervisor (PTS) was told by Resident #1 early that morning that there was a picture of a male penis on her cell phone. The materials of the facility investigation were reviewed. The DON stated that to her knowledge the investigation was completed, and all supporting documentation was contained in the investigation. Interview on 4/7/22 at 12:00 noon with the Attorney General's (AG) Investigator, revealed that he came to the facility on [DATE] and talked to the family of the resident and talked to the resident (Res #1). AG obtained the cell phone of Res #1 and had possession of the evidence of the penis picture that was on Res #1's phone. AG confirmed that the staff member (HS) had sent the picture of the penis to Res #1. AG also stated that the staff member (HS) and the resident did not know each other prior to Res #1's admission to the facility. AG stated that he had a warrant for the staff member (HS) and would be going to his home to visit with the staff member and to obtain his cell phone. AG stated that the pictures that were sent to Res #1 was a cyber-crime, and he was turning over the cell phone of the resident and of the staff member to the AG's cyber-crime unit for review. Interview on 4/7/2022 at 12:45 P.M. with the Physical Therapy Supervisor (PTS) revealed that she had been working with the resident #1 four (4) times each week in the therapy department for several months. PTS had been employed at the facility for approximately [AGE] years. The PTS stated that Res #1 usually was in the PT department each morning early waiting on her to start therapy at approximately 8:00 A.M. and that on 3/29/2022 she was not there waiting. PTS stated that on 3/29/2022 at 8:00 A.M. Res #1 was not at the department for therapy and that was unusual. The PTS went to the room of Res #1 along with another physical therapist, Doctor of Physical Therapy (DPT). When they got to Res #1's room she was still in bed and was clearly upset and angry. Res #1 told them that she hated the staff at the facility and was upset that two (2) of the CNA's had gotten her cell phone and were trying to block her dick pictures that she had on her phone. Res #1 told them that CNA#2 and CNA #3 had tried to block her phone and were trying to erase her dick pictures from her phone that had been sent to her by a staff member (HS) Housekeeping Supervisor. Res #1 told both PT's that the Housekeeping Supervisor had sent her a picture of his penis. The PTs stated that Res #1 was clearly and visibly upset, and she was cussing and saying, I hate those mother [OBSCENITY] s and [OBSCENITY] es. Res #1 was refusing to go to therapy and that was very unusual. PTS stated that she went to stand up and reported the incident to the Social Worker (SW) on 3/29/2022 at approximately 10:45 A.M. The PTS stated that she felt that the information given to her by Res #1 was clearly inappropriate and was abuse of a resident. PTS stated that she had never been given any information like this before from Res #1. She stated that this was the first time that she had seen Res #1 cussing and acting angry like she was on the morning of 3/29/2022. PTS stated that she believed that Res #1 was telling the truth on 3/29/2022. Interview on 4/7/2022 at 1:00 P.M. with the Doctor of Physical Therapy, DPT stated that on 3/29/2022 at approximately 8:30 A.M. she and the PTS went to the room of Res #1 to see why she was not at therapy on 3/29/2022. Upon entering the room and asking why she was still in the bed and not at therapy, Res #1 replied: I hate all those mother [OBSCENITY] s and [OBSCENITY] es. They want to block my phone and get my dick pictures from my phone. Res #1 was cussing and was visibly upset and in a foul mood. She refused to go to physical therapy on 3/29/2022. Res #1 said that staff member (HS) had sent her a dick pic to send to another staff member, a girl (CNA #1). Res #1 stated that she did not want the staff member to get fired and that he had sent the dick pic to her phone so she could send it on to another staff member. Res #1 stated that CNA #2 had tried to block her phone and that she wanted her dick pics. The DPT stated that the PTS had reported the incident to the Social Worker (SW) at the Stand-Up meeting on 3/29/2022 10:45 A.M. The DPT stated that she had never seen or heard Res #1 angry like she was on 3/29/2022. DPT stated that she had no knowledge of Res #1 being involved in any inappropriate behaviors prior to 3/29/2022. No resident had ever reported anything inappropriate prior to 3/29/2022. Interview on 4/7/2022 at 1:40 P.M. with the Social Worker (SW) revealed that she was told by the PTS that Res #1 had told her that she had a picture of a male penis on her phone that was sent to her by the Housekeeping Supervisor (HS). SW immediately went to talk to the resident by herself to see what had transpired. Res #1 was upset and was cussing that there were two (2) Certified Nursing Assistants (CNA's) CNA #2, and CNA #3, that were trying to block her phone and she had dick pics on her phone from (HS). SW was given the cell phone of Res #1 and she scrolled through her social media account with the permission of Res #1 and found a post from (HS) dated 12/30/2021 that contained a photo of a male penis. Res #1 did not want to get HS in trouble, and she was upset that he may get fired. SW confirmed that the photo was posted on 12/30/2021 from the Facebook private message account of the HS to the resident (Res #1). (SW) provided the surveyor with a viewing of a copy of the posting from HS dated 12/30/2021 that had HS name and profile attached to a photo of a male penis. SW reported the findings from her interview with Res #1 to the facility administrator (ADM) and they both together returned to interview Res #1. SW stated that Res #1 told them both that she had received the photo on 12/30/2021 of the male penis from the HS to send to another employee (CNA #1). SW confirmed that the CNA #1 had worked at the facility but that she had left the facility's employment on 12/3/2020. SW stated that back in 2018 Res #1 had posted a picture of a female vagina and that it was immediately taken down. SW stated that she has not had any reports of inappropriate social media postings from or to Res #1 since 2018. Interview and observation on 4/7/2022 at 2:10 P.M. with (Res #1) revealed that she was a young female in bed with the covers up around her body to her waist and dressed in street clothes. The television was on and she was alone in her room eating orange sherbet with a spoon. Res #1 had a frown on her face, and he affect was hostile and angry. She told the surveyor that she was not doing well and that she was awaiting a transfer to another facility. Res #1 stated that her sister lived nearby and was her RP but that she wanted to get away from her sister and from the staff at the facility because they got up in my business and she wanted to be left alone. Res #1 asked the surveyor to leave her room and angrily verbalized that she did not want to talk. No interview with the resident was obtained on 4/7/2022 per the request of Res #1. Record review of the face sheet of Res #1 revealed that she had been admitted to the facility on [DATE]. Res #1's date of birth was 4/17/1974. Res #1 had admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] Section C. documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated that Res #1 was cognitive. Interview on 4/7/2022 at 2:45 P.M. with the Responsible Party (RP) sister of Res #1, revealed that she had been sent a picture of a penis from her sister, Res #1 back around the first of the new year in January of 2022. She stated that she asked her sister Res #1 where in the world did such a dirty picture come from and why was she sending it to her on her Facebook. Res #1 told RP that a staff member named (HS) had sent it to her to send to another employee. RP told her sister Res #1 to take down that awful picture of a male penis and to report it to the DON and ADM. RP stated that her sister told her that she had reported the photo to the facility staff. RP stated that since the facility had been told about the photo that she assumed that the matter had been handled and the (HS) had been fired. The RP stated that her sister did not know the HS prior to her admission to the facility. RP stated that she is highly upset about the events of the photo having been sent to her sister's Facebook by an employee of the facility. RP stated that she wants Res #1 moved to another facility because she feels that the safety of her sister is at risk because so many people know about the photo being sent to Res #1. RP stated that she gave the AG permission to take the phone of her sister and trace the source of the photo. RP stated that she hoped that the AG arrests the person or persons that sent the photo to her sister Res #1. RP stated that she and her siblings met with the facility staff last week to discuss the alleged events of 3/29/2022. RP expressed that she was very troubled by the fact that a staff member had sent her sister Res #1 such an inappropriate photo. Interview with ADM on 4/7/2022 at 3:30 P.M. revealed that he did meet with the RP, and he was aware of the request to have Res #1 moved to another facility. He stated that the SW had sent the request for transfer papers to the facility that the family and the Res #1 had requested. ADM stated that he was very shocked that the HS had sent the picture to Res #1. ADM stated that the HS was a very good employee and was well liked by the other staff and residents. ADM stated that he had been told by the HS that he had known Res #1 for years and that they were friends prior to her admission and that the picture was a joke between the HS and Res #1. The HS denied that the picture was of a penis. He stated to the ADM that it was of a melted candy bar.

Based on resident interview, staff interview, record review and facility policy review, the facility failed to prevent the verbal abuse of one (1) of twenty-three (23) residents reviewed for abuse, Resident #1. Findings Include: Review of the facility's policy titled, Abuse Program, dated 05-23-2017, revealed, It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free of verbal, sexual, physical and mental abuse, neglect, exploitation, misappropriate of resident property, and involuntary seclusion . Definitions: . Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident . Review of Resident #1's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#1's most recent Minimum Data Set (MDS) dated [DATE], revealed his Brief Interview of Mental Status (BIMS) score to be 15, which makes him cognitively intact and able to answer questions appropriately. He requires extensive assistance of one staff member for his Activities of Daily Living (ADL's). Review of the facility's Reportable Incident Form dated 05-05-2021, revealed on 05-02-2021 at approximately 8:00 AM, Certified Nurse Aide (CNA)#2 and CNA#3 were in Resident #1's room assisting he and his roommate with their breakfast trays, when CNA#1 stepped into the room and stated the room smelled like sh**. CNA#1 went to hand Resident #1 a cup of coffee, and he hit it out of her hand causing it to spill on the floor, and stated, I don't want[OBSCENITY]from you. A verbal exchange of words occurred between Resident #1 and CNA#1, and she stepped out into the hallway and yelled for the supervisor and said, Y'all better come and get this M****** F*****before I beat his M***** F******* a**. [NAME] be on his a** like white on rice. Registered Nurse (RN) #1 arrived in the room, escorted CNA#1 out and down the hallway, and came back to interview Resident #1. CNA#1 was suspended and walked out to the time clock and out the door. CNA#1 was terminated following the complete investigation and not allowed back on the property. On 05-11-2021 at 11:15 AM, during an interview with the Administrator, concerning this incident, she stated CNA #2, and CNA#3 were passing out breakfast trays. CNA#1 came into the room with a cup of coffee and on her way in the door, told Resident #1 his room smelled like sh**. He got upset and offended at what she said, and hit the cup of coffee out of her hands and onto the floor. He told her he didn't want sh** from her. There was a verbal exchange between the two of them, and CNA#1 stepped outside the doorway into the hallway and starting yelling for the RN Supervisor stating, Y'all better come and get this M*****F***** before I beat his M***** F****** a**. [NAME] be on his a** like white on rice. RN#1 arrived in the room, and removed CNA#1, and took her down the hallway. She came back and asked Resident #1 what had happened. Once she heard the whole story, she escorted CNA#1 to get her things, and then took her to the time clock and escorted her out of the building. The Administrator stated CNA#1 had worked for her before and she never acted out like that. She never had any complaints about her care or attitude. On 05-12-2021 at 10:30 AM, during an interview with CNA#2, she stated, she and CNA#3 were passing out breakfast trays in Resident #1's room.They were helping pass out the trays, however, that room was not on their assignment sheets, it was CNA#1's room. While they were setting up the trays, CNA#1 walked into the room with a cup of coffee and said the room smelled like sh**. Resident #1 and CNA #1 were going back and forth at each other, and CNA#3 told them to stop. CNA#1 had coffee and Resident #1 hit it out of her hand. CNA#1 went to the doorway and hollered down the hall to the supervisor, Y'all better come and get this M***** F***** before I whoop his a**. RN#1 came and got CNA#1 and took her out of the room. CNA#2 stayed with the resident until she came back to talk to him and see what happened. On 05-12-2021 at 1:00 PM, during an interview with CNA#3, she stated, they were passing out breakfast trays in Resident #1's room for CNA#1, because they were not their residents to take care of that day. They were helping CNA #1 out. I was fixing a tray and heard bickering back and forth and heard something hit the wall. It was the cup of coffee. I told CNA#1 to leave the room and calm down. She went out into the hall and called the supervisor and said, Y'all better come and get this fat M***** F*****, looking like Uncle [NAME], before I whoop his M***** F****** a**. The supervisor came to the room and took CNA#1 out and down the hallway, and we didn't see her again after that. On 05-12-2021 at 2:30 PM, during an interview with Resident #1, he stated another CNA was helping him set up his breakfast tray when CNA #1 walked into the room and told him his room smelled like pee and sh**. He states he told her, it didn't smell that way till you came in and if you don't like it, you can leave. Resident #1 stated, she tried to hand him a cup of coffee after that and he hit it to the floor and told her he didn't want sh** from her now, and to get her ugly a** out of here. He stated the supervisor had come in because of all the yelling and cussing, and got CNA#1 out of his room. He didn't see her again after that. When asked by the SA if he heard what CNA#1 was yelling about while she was in the hallway, he stated, yeah, she said somebody better come get me cause she was gonna whip my M****** F******* a**. He stated he was not afraid of her, and didn't feel threatened during the exchange of words. He was just not going to allow her to do him like that and it made him mad that she came in running her mouth. The SA attempted several times and left voicemail for CNA#1 to return a call for interview. She had not responded and the SA did not recieve a call back from her. The SA attempted to reach RN #1 for interview, as she was not scheduled to work until the weekend. She had a written statement for the investigation that revealed, I was at the nurses station at approximately 8:00 am and heard someone yell from B hall, Somebody better come get this man. I went down the hall and CNA #1, was standing in resident's room yelling, he slapped that coffee out of my hand! I told her to step out of the room and explained to her that's not how to handle the situation appropriately and if there's a problem she needs to come to me. I then asked the resident, (Formal name) Resident #1 what happened. He stated, she came in here and said it smelled like sh**. It didn't smell like that until she got in here. Yeah, I slapped that coffee out of her hand. I'm not mad about it. I'm not scared of that girl. While in the resident's room, I turned my back and messaged the DON to inform her of (formal name) CNA#1's attitude. I was told to fire her. (Formal name) CNA #1 began to yell while standing outside the resident's room, I'll beat that M***** F*****'s a**. If he does it again [NAME] be on his like white on rice! While standing between the resident and (formal name) CNA #1, I told her she cannot speak to a resident that way and to stay out of that room. She was pushing meal trays at this time back to the dining room. I spoke with the resident and roommate to ensure they weren't upset about the situation. They both stated they weren't bothered about it. I closed the room door. (Formal Name ) Licensed Practical Nurse (LPN) #1 and I met CNA #1 coming out of the dining room and told her to come with us to the front office. I explained to her that her attitude and threatening a resident cannot be tolerated and she is fired. (formal name) LPN #1 and I accompanied her down to the nurse's station to gather her belonging. We then walked her to the time clock to clock out and to the front door to exit the facility. She did not make any inappropriate comments at this time. At 8:35 AM the administrator was notified of the situation. A review of CNA#1's employee file revealed a Personnel Termination Notice dated 05-02-2021 which stated, dc' d (discharged ) due to staff to res. (resident) verbal abuse, cursing a resident - verbiage s--t, M-F, and threatened to whip his black a-s. This form was signed by the administrator on 05-05-2021.

Based on staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for Resident #2 and #36 for Foley Catheter and Resident #26 for Urinary Tract Infection [MEDICAL CONDITION]; three (3) of 19 care plans reviewed. Findings Include: Review of the facility's policy, Care Plans, last updated 3/28/18, revealed: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. Resident #26 Review of Resident #26's medical record revealed the Resident was admitted to the hospital on [DATE], with a Urinary Tract Infection [MEDICAL CONDITION] and returned to the facility on [DATE]. There was no evidence to indicate a care plan was developed upon her return from the hospital for the new [DIAGNOSES REDACTED]. On 11/14/19 at 11:07 AM an interview with the Director of Nursing (DON) revealed she was not here during that time and the MDS Nurse was new and was in orientation. On 11/14/19 at 11:08 AM, an interview with the Administrator revealed the DON at the time was responsible for developing new care plans. The Administrator stated the facility has always brought new orders to the stand up meeting daily, but will now start updating and developing care plans during the stand up meeting. The Administrator stated development of care plans and updating care plans has been a problem, and will be monitored during stand up meetings. Resident #36 A review of Resident #36's medical record revealed she was admitted to the facility on [DATE], with a Foley catheter. Review of Resident #36's current care plan revealed the facility failed to develop a care plan related to the Foley catheter. On 11/13/19 at 2:40 PM, an interview with the DON revealed the resident was admitted on [DATE], with the Foley catheter due to [MEDICAL CONDITION] and staff failed to care plan the Foley catheter. During an interview on 11/13/19 at 2:47 PM, the Minimum Data Set (MDS) Coordinator stated upon admission, she assesses the resident and care plans any problem areas. The MDS Coordinator stated she failed to recognize the Resident had a Foley catheter and did not care plan the catheter. K. Raines Resident #2 On 11/13/19 at 2:00 PM, observation revealed Resident #2 had a Foley catheter. Record reveal revealed Resident #2 had a Foley Catheter inserted on 02/13/19, and the resident had a physician's orders [REDACTED]. Review of Resident #2's current care plan revealed the resident did not have a care plan to monitor the care of the Foley catheter. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD), dated 08/05/19, revealed the resident had a catheter, but the facility failed to develop a care plan. An interview with the Director of Nursing (DON) on 11/13/19 at 2:20 PM, confirmed the resident did not have a care plan for the Foley catheter and stated, I guess it just got over looked and no one developed a care plan. During an interview with the MDS Nurse on 11/13/19 at 2:40 PM, she stated she had began the MDS position in September. She reviewed the record and stated she did not find a care plan for the Foley catheter for Resident #2 and stated, We will have to add a care plan for the catheter right away. The DON and the MDS Nurse both confirmed, during their respective interviews, that they have weekly high risk meetings and discuss residents with catheters, but they did not check to verify the resident had a care plan for the Foley catheter during those meetings. They confirmed that the only time they evaluated for a care plan is during the quarterly or annual MDS assessments.

Based on record review, policy/procedure review and interviews on 2/12/19, Certified Nurses Aide (CNA) #1 disconnected the Intravenous (IV) Peripherally Inserted Central Catheter (PICC) line from the PICC site and removed the IV pump, with tubing, from one (1) of four (4) residents reviewed, Resident #2. This act was outside of her scope of practice as a CNA. The IV PICC line care plan for Resident #2 revealed all IV care and procedures were to be performed by a nurse. Findings include: Review of the Care Plan Policy/Procedure, undated, revealed: PR[NAME]EDURE: #6 Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention. Review of the policy, Intravenous Fluids (IV)Policy/Procedure, revised (MONTH) 16, (YEAR), revealed Basic Responsibility: Registered Nurse, Licensed Nurse with I.V. Certification. Review of Resident #2's care plans revealed a Problem Onset date of 01/30/19, I recieve IV antibiotics as related to an infection in my right knee. The Role for the IV Approaches is documented N, which indicates Nursing staff are responsible for the care. Record review revealed the facility admitted Resident #2 on 11/13/18, with a [DIAGNOSES REDACTED]. Resident #2 was discharged from the facility on 3/2/19. Review of physician's orders [REDACTED]. The antibiotic ordered was [MEDICATION NAME] 600 milligram (mg)/300 milliliters (ml)-D5W-Give 600 mg per PICC line at 300 ml/hr every 12 hours for four (4) weeks. The stop date was 2/28/19. Review of a facility investigation, dated 2/15/19, revealed that on 2/12/19, on the night shift, CNA #1 went into the room of Resident #2 and disconnected the IV line from her PICC site and removed the IV pump from the residents room due to the pump alarming. RN #1 was in the facility parking lot during this time. RN #1 and CNA #1 were suspended during the investigation then terminated after the investigation was complete. Review of the Handwritten and signed statement by CNA #1, dated 2/12/19, revealed the IV pump was alarming and upsetting Resident #2. RN #1 was outside of the facility at the time. From my experience as a phlebotomist and Certified medical technician (CMT) and Hospital CNA for 6 years I went off of instinct and experience. I disconnected the IV infusion line and the cleaned the port in her arm with alcohol and then removed the IV pole from her room and took it to the nurse station. I realized after I had done this that I shouldn't have and that I am no longer in the hospital environment. Interview with the Director of Nurses (DON) on 4/11/19 at 10:35 AM, revealed there was no harm to Resident #2 as a result of CNA #1 disconnecting the IV line. Interview with the DON on 4/12/19 at 10:20 AM, revealed It is our policy that IV's and IV therapy is done by RN's only. We don't even allow Licensed Practical Nurses (LPNs) to do IV therapy. NO, CNA's are not allowed to unhook an IV, push buttons on an IV pump, can't administer IV medication, or have anything to do with an IV. The same goes for enteral feedings and feeding pumps.

Based on Resident Trust Fund (RTF) record review, outside record review (Medicaid and Outside Accounting Firm) and staff interviews, the facility failed to ensure the accuracy of accounting by the Business Office Manager (BOM) from (MONTH) (YEAR) to (MONTH) (YEAR). The BOM failed to do monthly reconciliation's, provide quarterly statements to residents, and provide documentation of money coming in/out of the facility resident trust petty cash fund. This affected 15 of 30 residents who authorized the facility to manage funds in the resident trust account, Residents #1 to #15. Findings Include: Review of the facility's Job Description for the Business Office Manager, no date, revealed: Maintain accounts receivable, bank deposits, daily census records and reports, and monthly, quarterly, and annual reports as documentation for balance sheets, profit and loss statements, various tax returns, and cast (cash) reimbursement reports. Functions: 1. Keep financial records current 3. Make bank deposits. 6. Prepare accounting reports. Review of the facility's booklet titled, Resident Rights, with most recent copy right date of 2013, outlined the following related to Money and Property- Your right to have your money and property protected means that if we are involved in handling funds and property belonging to you, we will do so responsibly. Our policies and procedures regarding money and property management Include: 1. If requested by a resident in writing, we will hold, safeguard, manage and account for a resident's personal funds placed on deposit with us. 3. We will account for all resident funds according to generally acceptable accounting principles. Resident funds will not be commingled with facility funds or the funds of any other person. RTF (resident trust funds) process policy is used to keep up with the resident accounts and trust. It is a computer entry system that should ensure acceptable accounting methods if utilized as per the procedures. Record review revealed a Medicaid Audit was conducted on 09/17/18, and the RTF account was found to have discrepancies in five resident accounts. The Medicaid Auditor found a ten cent discrepancy in the trust fund statement and bank statements from (MONTH) (YEAR) to (MONTH) (YEAR). An interview, on 11/27/18 at 8:30 AM, with the Administrator, revealed concerns identified on the Medicaid Audit with the resident trust fund accounts brought about hiring an independent accounting firm to verify all 30 resident accounts on 10/18/18. Record review revealed the accounting firm reviewed the accounts from (MONTH) (YEAR) to (MONTH) (YEAR). An interview, on 11/27/18 at 10:00 AM, with the accounting firm representative revealed through her investigation of the accounts that there were numerous problems with the bookkeeping methods that included: 1.The procedure to maintain the trust account had hot been followed, 2. There was no oversight to ensure acceptable accounting methods were implemented, 3. There was not a single entry for petty cash being signed in or out for months, and 4. Quarterly statements were not provided to the residents or family members. The accounting firm representative stated she was unable to determine any discrepancies in the bank statement, and the trust fund balance. Review of the accounting firm representative's examples of findings from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the following: September (YEAR): The trust statement documented $10.01 disbursed but no check had been written for disbursement. A check was also written to replenish petty cash. October (YEAR): Resident #3 had a $40.00 deposit that was zeroed out of the account instead of being put in petty cash for the payment to the beautician. November (YEAR): The Beautician received a check for $170.00. The account only had a $150.00 deposit which created a $20.00 discrepancy. December (YEAR): Resident #10 showed two Veteran Administration (VA) deposits for $90.00. As a result $180.00 had to be added to Resident #10's account. January (YEAR): Resident #14 had a check written for $29.45. The check was voided, but the entry was not removed from the RTF (Resident Trust Fund) February (YEAR): Resident #9 had $1269.00 deposited. The bank statement did not reflect a payment to the facility in that amount. March (YEAR): Resident #7 had a check written for $20.29, this check was not recorded in the RTF register. Resident #10 had a reissue to reimburse $76.43. The original check was not voided prior to reissue. April (YEAR): Resident #9 had two checks that were not deposited, and resulted in a reversal of funds. No issues in May, (MONTH) or (MONTH) (YEAR). August (YEAR): All residents were affected. There was $40 that had not been deposited into a resident account for the beauty shop. Interest had not been posted to resident accounts. September (YEAR): Residents #1, #2, #4, #5, #6, #10, and #12 had cash amount totaling $313.00 (disbursed at different amounts) that had not been deposited to their accounts. Resident #15 had a withdrawal for $2230.86, but there was no check or invoice indicating the withdrawal The Administrator was interviewed, on 11/27/18 at 8:30 AM. She revealed the facility first became aware of the problem with the resident trust account after the Medicaid audit in (MONTH) (YEAR), and the company decided to have an independent firm review the accounts. The Administrator stated there were numerous issues with the Resident Trust Account. The Administrator stated the Business Office Manager (BOM) was responsible for the RTF, and she had been employed with the facility for nine years, and in the BOM position for six years. The Administrator stated she was next in line, and she had believed it was being done. The Administrator stated she had no concerns or suspicions of RTF diversions or theft. The Administrator stated she was covering the RTF until a new BOM was hired. The Administrator stated she is following the book to ensure the RTF if safe and accounted for.

Based on review of the Resident Trial Balance Sheets, staff interviews, and policy review, the facility failed to notify the resident or their representatives of balances over the amount of $3300.00, therefore causing the resident to become private pay status. This affected Resident #10, for one (1) of 30 residents whose funds were managed by the facility. Findings Include: Review of the facility's Resident Rights booklet, with a most recent copy right date of 2013, revealed: Money and Property: Your right to have money and property protected means that if we are involved in handling funds and property belonging to you, we will do so responsibly. Our policies and procedures regarding the money and property management include: 1. If requested by a resident in writing, we will hold, safeguard, manage, and account for a resident's personal funds placed on deposit with us. 2. We will maintain personal funds of smaller amounts in an account of petty cash fund that does not pay interest. 3. We will account for all resident funds according to generally accepted accounting principles. Resident funds will not be commingled with the facility funds or the funds of any other person, other than another resident. 7. We will notify each Medicaid resident when his or her balance of personal funds comes within $200 of the Medicaid limit, and the effect of this on eligibility. An interview, with the Administrator, on 11/27/18 at 8:30 AM, revealed the Administrator stated the Business Office Manager (BOM) was responsible for the RTF, and she had been employed with the facility for nine years, and in the BOM position for six years. The Administrator stated she was next in line, and she had believed it was being done. The Administrator stated the facility first became aware of the problem with the resident trust account after the Medicaid audit in (MONTH) (YEAR), and the company decided to have an independent firm review the accounts. The Administrator stated there were numerous issues with the Resident Trust Account. The Administrator stated she was next in line, and she had believed it was being done. The Administrator stated she had no concerns or suspicions of RTF diversions or theft. The Administrator stated she was covering the RTF until a new BOM was hired. The Administrator stated she is following the book to ensure the RTF if safe and accounted for. Review of the Face Sheet revealed Resident #10 was admitted by the facility on 05/17/13. On 09/20/18, Resident #10's family gave authorization for the facility to manage her funds. Record review revealed a Medicaid audit as conducted by the state, on 09/17/18 and revealed Resident #10 was over the $3300.00 limit, and she was allowed to keep the money in her trust fund account. Review of the Resident Trust Statement, from 02/02/18 to 10/31/18, revealed balances in the account were as follows: 02/02/18- $3671.61 03/02/18 -$5962.50 04/27/18- $7518.67 05/13/18- $9074.99 06/01/18- $ .45 07/03/18- $ .26 08/03/18 -$ .67 09/10/18 - $8476.08 On 09/14/18, a check was written to cover the resident's lodging (private pay) for $6600 bringing the account balance to $1876.08 During an interview conducted with the administrator, on 11/27/18 at 12:30 PM, it was revealed the family or resident are suppose to be given notices that money needs to be spent down to $3200.00. The Administrator stated the money needs to be utilized.

Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan to include the use of a physical restraint for one (1) of three (3) residents reviewed for restraint devices; Resident #29. Findings include: A review of the facility's policy titled, Care Plans, undated, revealed each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. A review of the facility's policy titled, Restraint Policy, undated, revealed care plan updates are to occur approximately every quarter, and/or as a goal or approach direction changes. Record review revealed there was no Restraint Care Plan regarding the use of the half tray attached to Resident #29's wheel chair. Further review revealed there was not a Physician Order, Restraint Assessment, Restraint Consent, or Restraint Clinical Documentation for the half tray. On 10/15/18 at 2:39 PM, an observation revealed Resident #29 was in her room sitting in her wheelchair with her eyes closed. Resident #29 had a half tray secured to her wheelchair. On 10/16/18 at 10:55 AM, an observation revealed Resident #29 was sitting in her wheelchair with a half tray attached to her wheelchair. Resident #29 did not know how to let the half tray up and down upon request by the surveyor. During an interview, on 10/15/18 at 2:40 PM, Registered Nurse (RN) #1 revealed Resident #29 used the half tray to place her books on it, and she was able to remove the tray as needed. On 10/16 18 at 11:00 AM, during an interview with RN #2, she revealed the half tray was to help keep Resident #29 in the wheel chair, and to keep Resident #29 from falling. On 10/16/18 at 11:05 AM, an interview and observation of Resident #29 revealed, when the surveyor asked Resident #29 to remove the half tray in front of her, Resident # 29 stated, no, I can't take it off, no, I don't know how to take it off. The resident then turned to RN #2, and told her, This is our little secret, and then she removed the tray from in front of her by letting the tray down. During an interview, on 10/17/18 at 12:00 Noon, the Director of Nurses (DON) revealed she stated going forward, the facility staff will complete a restraint assessment, get a therapy screen to determine the most appropriate device, get a physician's orders [REDACTED]. Review of Resident #29's Minimum Data Sets (MDSs) with Assessment Reference Dates (ARDs) of 09/03/18 (Quarterly), 06/10/18 (Significant Change), and 05/14/18 (Quarterly), revealed Section P for Restraints indicated restraints were not in use. Resident #29's Basic Interview for Mental Status (BIMS) score on each of the aforementioned MDSs was 3, which indicated severe cognitive impairment. A review of the facility's Face Sheet, revealed Resident #29 was admitted by the facility, on 11/12/12, with a [DIAGNOSES REDACTED]. Review of Resident #29's Quarterly MDS, with an ARD of 09/03/18, revealed Resident #29 required extensive assistance with one person physical assistance with bed mobility, transfers, dressing, and toilet use. Further review of the MDS revealed Resident #29 required supervision with one person physical assistance with locomotion on and off the unit and personal hygiene. Resident #29 did not have any Range of Motion (ROM) limitations to either side of her extremities, and used a wheel chair for her mobility device. Resident #29 exhibited clear speech, had moderate hearing difficulty, and was usually able to make herself understood, and understood others.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide services to maintain the resident's ability to remain continent of bowel for one (1) of two (2) residents reviewed for Activities of Daily Living (ADLs); Resident #13. Findings include: Review of the facility's policy titled, Activities of Daily Living (ADL), revised 01/19/15, provided the following information: The facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to 3. Toilet. Policy Explanation and Compliance Guidelines: 1. Conditions which may demonstrate unavoidable decline in ADLs include: a. Natural progression of the resident's disease state. b. Deterioration of the resident's physical condition associated with the onset of a physical or mental disability while receiving care to restore or maintain functional abilities. c. Refusal of care and treatment by the resident or his/her surrogate to maintain functional abilities. 2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. A resident who is unable to carry out activities of daily tiving (living) will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 4. The facility witt (will) identify resident triggers tkough (through) the Care Area Assessment (CAA) process to assess causal tactors (factors) for decline, potential decline or lack of improvement. 5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. Observation of Resident #13, on 10/15/18 at 10:45 AM, revealed the resident sat in the recliner in her room. The resident was very verbal talking with staff. The resident's speech could be understood as she voiced her needs to staff and followed directions given to her by the staff. Observation of Resident #13, on 10/15/18 at 2:16 PM, revealed she remained up in her chair with her eyes closed. Review of Resident #13's Significant Change in Status Minimum Data Set (MDS), an assessment completed by the facility to guide the completion of the care plan, with an Assessment Reference Date (ARD), end point of the assessment period, of 02/24/18, indicated under Section B: Hearing, Speech, and Vision, the resident had clear speech, could be understood by others, and usually understood others. Review of Section C: Cognitive Patterns, documented her Brief Interview for Mental Status (BIMs) score was four out of 15, which indicated her cognitive skills for daily decision making were severely impaired. Section I: Active Diagnoses, indicated her [DIAGNOSES REDACTED]. Section G: Functional Status, indicated Resident #13 required extensive assistance of one person for bed mobility, transfers, dressing, and toilet use. Review of Section H: Bladder and Bowel, indicated the resident was, Always continent of bowel. Review of the resident's Quarterly MDS, with an ARD of 05/14/18, indicated under Section H that Resident #13 was, Always continent of bowel. Review of the Quarterly MDS, with an ARD of 08/06/18, indicated under Section H that Resident #13 was, Frequently incontinent of bowel. Review of Section H: 0500 indicated no toileting program was in use . to manage the resident's bowel continence. Further review of the Quarterly MDS (08/06/18) revealed there were no other changes documented to indicate the cause of the resident's decline in bowel continence. A review of the resident's Progress Notes, and interviews conducted with the staff revealed there were no factors documented to indicate that Resident #13's decline in bowel continence from Always continent to Frequently incontinent was considered an unavoidable decline in ADLs as defined by the facility's Activities of Daily Living (ADL) policy. During an interview, on 10/16/18 at 4:55 PM, Licensed Practical Nurse (LPN) #1 stated she was the staff member responsible for completion of the residents' MDS assessments, and for directing the Interdisciplinary Team in care planning to ensure the necessary care is provided to prevent a resident's decline in ADL function. LPN #1 verified Resident #13's decline in bowel continence, and a request was made for evidence of the interventions implemented to address the decline in Resident #13's bowel continence. LPN #1 stated, There was no bowel training program or bowel assessment completed. LPN #1 was unable to provide evidence to verify that a care plan meeting was held during the quarter of the year when Resident #13's bowel status changed on the Quarterly MDS dated [DATE]. LPN #1 searched the electronic record and her calendar, and then stated, I can't find where we had a meeting, or any notes from a meeting for the resident (Resident #13) to discuss the changes. During an interview with the Director of Nursing (DON), on 10/17/18 at 8:04 AM, the DON verified no assessment of Resident #13's bowel function/continence status had been completed, nor had a bowel training program been implemented for the resident. The DON stated there should have been an assessment of Resident #13's bowel continence status and interventions implemented to attempt to restore her bowel continence. During an interview, on 10/17/18 at 9:30 AM, Certified Nurse Aide (CNA) #1 stated, (Resident #13) is pretty much incontinent all the time . she is sleepy and just doesn't tell us.

Based on observation, staff interview, record review, and facility policy review, the facility failed to revise the comprehensive care plan related to bowel incontinence for one (1) of two (2) residents reviewed for activities of daily living; Resident #13, and related to the use of a physical restraint for one (1) of three (3) residents reviewed for physical restraints; Resident #29. Findings include: A review of the facility's policy titled, Care Plans, undated, revealed each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The care plan will be reviewed and/or revised at quarterly intervals in conjunction with the completion of the Minimum Data Set (MDS) assessments, (quarterly, significant changes, and annual), and with changes in resident's conditions as needed. Responsibility: All members of the interdisciplinary team. Monitored by the Administrator. Definitions: Interdisciplinary - all disciplines work together to develop approaches to help residents meet needs or resolve problems. Care Plan - contains resident problems/needs/strengths, resident goals, and interdisciplinary approaches. 7. The IDT note(s) are to reflect a review of the Care Plan goals and approaches. A review of the facility's policy titled, Restraint Policy, undated, revealed care plan updates are to occur approximately every quarter and/or as a goal or approach direction changes. Observation of Resident #13, on 10/15/18 at 10:45 AM, revealed the resident sat in the recliner in her room. The resident was very verbal talking with staff. The resident's speech could be understood as she voiced her needs to staff and followed directions given to her by the staff. Review of Resident #13's Significant Change in Status Minimum Data Set (MDS), an assessment completed by the facility to guide the completion of the care plan, with an Assessment Reference Date (ARD), end point of the assessment period, of 02/24/18, indicated under Section I: Active Diagnoses, the resident had [DIAGNOSES REDACTED]. Review of Section C: Cognitive Patterns, documented a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident had severely impaired cognitive skills for daily decision making. Section G: Functional Status, indicated the resident required extensive assistance of one person for bed mobility, transfers, dressing, and toileting. Review of Section H: Bladder and Bowel, documented the resident was, Always continent of bowel. Review of the Quarterly MDS, with an ARD of 05/14/18, documented under Section H that Resident #13 was, Always continent of bowel. Review of the Quarterly MDS with an ARD date of 08/06/18, documented under Section H that Resident #13 was, Frequently incontinent of bowel. Review of Section H: 0500 indicated no toileting program was in use . to manage the resident's bowel continence. Further review of the Quarterly MDS (08/06/18) revealed there were no other changes documented to indicate the cause of the resident's decline in bowel continence. During an interview, on 10/16/18 at 4:55 PM, Licensed Practical Nurse (LPN) #1 stated she was the staff member responsible for completion of the residents' MDS assessments and care plans. LPN #1 reviewed Resident #13's three MDS assessments (02/24/18, 05/14/18, and 08/06/18) and the change in the resident's bowel continence to Frequently incontinent on the 08/06/18 Quarterly MDS assessment. A request was made for a copy of the plan of care that addressed the resident's change in bowel continence and directed the staff in the approaches and goals for Resident #13's increased toileting needs. LPN #1 stated, I did not do a care plan. Review of the resident's currently active care plan with LPN #1 at this time, revealed the care plan included Falls, Constipation, Pain, Anxiety, Bladder Incontinence, Use of [MEDICAL CONDITION] Medicine, [MEDICAL CONDITION], Pain Left Hip, and Aggressive Behavior. LPN #1 verified that Resident #13's care plan did not include a plan for frequent bowel incontinence. When asked what information or documentation was used to code the change in Resident #13's bowel status on her 08/06/18 Quarterly MDS assessment from Always continent to Frequently incontinent, LPN #1 stated she reviewed the resident's Bowel Monthly Flow Record. Review of the resident's Bowel Monthly Flow Record for the seven-day look-back period of the 08/06/18 MDS, indicated the resident was incontinent of bowel two times during the seven-day assessment period. This changed the resident's bowel status from Always continent to Frequently incontinent of bowel, and indicated a need for revision of Resident #13's comprehensive care plan. LPN #1, who also holds the care plan meetings with the Interdisciplinary Team, was unable to provide evidence to verify that a care plan meeting was held during the quarter of the year when Resident #13's bowel status changed on her 08/06/18 Quarterly MDS. LPN #1 searched the electronic record and her calendar and stated, I can't find where we had a meeting, or any notes from a meeting for the resident (Resident #13) to discuss the changes. During an interview with the Director of Nursing (DON) on 10/17/18 at 8:04 AM, the DON reviewed Resident #13's care plan and verified that did not include a care plan for bowel incontinence. The DON stated there should have been a revision to the comprehensive care plan when the resident had a change in bowel continence as documented in the 08/06/18 Quarterly MDS. Resident #29 Record review revealed, there was no Restraint Care Plan for the use of the half tray secured to Resident #29's wheel chair. Further review revealed there was not a Physician Order, Restraint Assessment, Restraint Consent, or Restraint Clinical Documentation for the half tray. An observation, on 10/15/18 at 2:39 PM, revealed Resident #29 was sitting in her wheel chair in her room with her eyes closed. Resident #29 had a half tray secured to her wheelchair. On 10/16/18 at 10:55 AM, Resident #29 was observed sitting in her wheelchair with the half tray attached to her wheelchair. Resident #29 demonstrated she did not know how to let the half tray up and down upon request by the surveyor. On 10/15/18 at 2:40 PM, an interview revealed Registered Nurse (RN) #1 stated Resident #29 used the half tray to place her books on it, and that Resident #29 was able to remove the tray as needed. On 10/16 18 at 11:00 AM, an interview with RN #2, revealed the half tray was to help keep Resident #29 in the wheel chair, and to keep Resident #29 from falling. An interview and observation, on 10/16/18 at 11:05 AM, revealed when the surveyor asked Resident #29 to remove the half tray in front of her, Resident #29 stated, no, I can't take it off, no, I don't know how to take it off. The resident then turned to RN #2, and told her, This is our little secret and removed the tray from in front of her, by letting the tray down. The Director of Nurses (DON) revealed during an interview, on 10/17/18 at 12:00 Noon, that going forward, the facility staff will complete a restraint assessment, get a therapy screen to determine the most appropriate device, get a physician's orders [REDACTED]. Review of Resident #29's Minimum Data Sets (MDSs) with Assessment Reference Dates (ARDs) of 09/03/18 (Quarterly), 06/10/18 (Significant Change), and 05/14/18 (Quarterly), revealed Section P for Restraints indicated restraints were not in use. Resident #29's Basic Interview for Mental Status (BIMS) score on each of the aforementioned MDSs was 3, which indicated severe cognitive impairment. A review of the facility's Face Sheet revealed, Resident #29 was admitted by the facility, on 11/12/12, with a [DIAGNOSES REDACTED]. Review of Resident #29's Quarterly MDS, with an ARD of 09/03/18, revealed Resident #29 required extensive assistance with one person physical assistance with bed mobility, transfers, dressing, and toilet use. Further review of the MDS revealed Resident #29 required supervision with one person physical assistance with locomotion on and off the unit and personal hygiene. Resident #29 did not have any Range of Motion (ROM) limitations to either side of her extremities, and used a wheel chair for her mobility device. Resident #29 exhibited clear speech, had moderate hearing difficulty, and was usually able to make herself understood, and understood others.

Based on observation, staff interview, and facility policy review, the facility failed to properly label opened multi-dose vials of medications and dispose of expired medications in one (1) of one (1) medication rooms observed. Findings include: Review of the facility's undated policy titled, Medication Storage revealed the following information: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy . 12. The following medications must be removed from stock and disposed of properly on a continuing basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers. Observation of the contents of the medication refrigerator located in the medication storage room, on 10/16/18 at 11:00 AM, revealed the following: 1. One multi-dose vial of [MEDICATION NAME] (an antianxiety medication) 2 milligrams (mg)/milliliter (mL) with an expiration date of 08/20/18. 2. One multi-dose vial of Influenza Vaccine that had been opened, but was not dated with the date the staff opened the vial. 3. One multi-dose vial of [MEDICATION NAME] Purified Protein Derivative (for [MEDICATION NAME] testing) 5 TU/0.1 mL that had been opened, but was not dated with the date the staff opened the vial. On 10/16/18 at 11:04 AM, RN #1 verified that the multi-dose vials of Influenza Vaccine and [MEDICATION NAME] testing solution had been opened and accessed by the staff, but were not dated when opened/accessed. RN #1 stated the staff is to date multi-dose vials when opened/accessed and are to dispose of any opened/accessed vials after 28 days. During an interview, on 10/16/18 at 11:06 AM, the RN Staff Development Coordinator verified the multi-dose vial of [MEDICATION NAME] 2 mg/mL had expired. Review of the Centers for Disease Control and Prevention (CDC) article, Frequently Asked Questions (FAQs) Regarding Safe Practices for Medical Injections, updated 08/16/16, accessed online at: https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html, provided the following information regarding multi-dose medication vials: . Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 (16) recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose (vial) has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review of the manufacturer's Product Information data sheet, revised 04/2016, indicated, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded.

Based on observation, staff interview, record review, and facility policy review, the facility failed to assess Resident #29 for a restraint device, for one (1) of three (3) residents with restraint devices observed. Findings include: A review of the facility's policy titled, Physician's Order for A Physical Restraint Device, undated, revealed: All residents requiring a physical restraint must have a physician's order. The physician order must state the type of restraint. A signed consent must be obtained from the responsible party to include the potential complications related to the use of a restraint. A review of the facility's policy titled, Restraint Policy, undated, revealed all residents using a restraint are to be evaluated and re-evaluated approximately every quarter. A specific physician's order is to be entered in the resident's medical record which states reason, length of time to be used, type of restraint, when to be used, and the corresponding diagnosis. On 10/15/18 at 2:39 PM, Resident # 29 was observed in her room sitting in her wheelchair with her eyes closed. Resident #29 was observed to have a half tray attached to her wheelchair. On 10/16/18 at 10:55 AM, Resident #29 was observed sitting in her wheelchair with a half tray attached to her wheelchair. Resident #29 did not know how to let the half tray up and down upon the request by the surveyor. On 10/15/18 at 2:40 PM, an interview with Registered Nurse (RN) #1, revealed Resident #29 used the half tray to place her books on it, and she was able to remove the tray as needed. On 10/16 18 at 11:00 AM, an interview with RN #2, revealed the half tray was to help keep Resident #29 in the wheel chair, and to help keep Resident #29 from falling. On 10/16/18 at 11:05 AM, an interview with Resident #29, revealed when the surveyor asked Resident #29 to remove the half tray in front of her, Resident #29 stated, no, I can't take it off, no, I don't know how to take it off. The resident then turned to RN #2 and told her, This is our little secret, and removed the tray from in front of her, by letting the tray down. On 10/17/18 at 12:00 Noon, an interview with the Director of Nurses (DON), revealed the DON stated going forward, the facility staff will complete a restraint assessment, get a therapy screen to determine the most appropriate device, get a physician's order, obtain a consent signed by the Resident Representative (RR), complete the restraint necessity assessment, have documentation regarding the restraint device, complete a restraint reduction, use a restraint only as a last resort, and use the most least restrictive device. Record review revealed there was no Physician order for [REDACTED]. A review of the facility's Face Sheet, revealed Resident #29 was admitted by the facility, on 11/12/12, with a [DIAGNOSES REDACTED]. Review of Resident #29's Minimum Data Sets (MDSs) with Assessment Reference Dates (ARDs) of 09/03/18 (Quarterly), 06/10/18 (Significant Change), and 05/14/18 (Quarterly), revealed Section P for Restraints indicated restraints were not in use. Resident #29's Basic Interview for Mental Status (BIMS) score on each of the aforementioned MDSs was 3, which indicated severe cognitive impairment. Review of Resident #29's Quarterly MDS, with an ARD of 09/03/18, revealed Resident #29 required extensive assistance with one person physical assistance with bed mobility, transfers, dressing, and toilet use. Further review of the MDS revealed Resident #29 required supervision with one person physical assistance with locomotion on and off the unit and personal hygiene. Resident #29 did not have any Range of Motion (ROM) limitations to either side of her extremities, and used a wheel chair for her mobility device. Resident #29 exhibited clear speech, had moderate hearing difficulty, and was usually able to make herself understood, and understood others.

Based on record review, staff interview, and facility policy review, the facility failed to report an allegation of abuse in the designated reporting time frames for two (2) of five (5) facility reportable incidents reviewed; Resident #42 and Resident #19. Findings include: Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, with a revised date of 04/30/18, revealed: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately to the Administrator of the facility and to the appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. The Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation stated: 2. The Director of Nursing Services, Administrator, or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but not later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 (two) hours after discovery or forming the suspicion. Resident #42 A review of the Reportable Incident Form submitted to the Mississippi State Department of Health (MSDH), on 09/23/18, revealed an allegation of physical abuse that occurred on 9/23/18 at 5:20 AM. Resident #42 accused a Certified Nursing Assistant (CNA) of hitting her during incontinent care. The second CNA present during the incontinent care witnessed the incident, and stated the accused CNA did not hit Resident #42. The second CNA stated Resident #42 hit the other CNA in her stomach and side, and the CNA redirected Resident #42, and told her not to hit her. Resident #42 accused the CNA of hitting her. The second CNA confirmed the other CNA's hands were on the resident's brief, and she did not hit the resident. The CNAs reported the incident to the Licensed Practical Nurse (LPN), and the LPN assessed Resident #42 for any signs of pain/discomfort, emotional, physical, or mental distress. Resident #42 was observed resting quietly the remainder of the shift. At 7:11 AM, the LPN asked Resident #42 about the CNA hitting her, and Resident #42 denied the incident, and/or any claim of harm. On 10/16/18 at 3:37 PM, an interview with the facility Administrator revealed she did not call in the report alleging abuse until 9:18 AM, on 09/23/18, because serious bodily injury did not occur to the resident. The Administrator stated she did not think it had to be called in if bodily injury did not occur. A call to the Triage Department at the MSDH, on 10/16/18 at 3:30 PM, revealed the allegation of abuse related to Resident #42 was reported on 9/23/18 at 9:19 AM. This was approximately four (4) hours after the incident occurred. On 10/16/18 at 3:45 PM, an interview with the Administrator revealed she stated she went back and read the reporting regulation, and realizes now it should have been called in within two (2) hours. Resident #19 2. Review of the medical record for Resident #19 revealed the Face Sheet indicated the resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment completed by the facility to aide in the preparation of the care plan, with an Assessment Reference Date (ARD), the end of the assessment period, of 08/13/18, indicated Resident #19 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating moderately impaired cognition. Review of a Reportable Incident Form, dated 08/13/18, revealed the facility's Administrator completed an internal report of an allegation made by Resident #19 that an unknown staff member hit her on 08/10/18 at 10:00 AM. Further review of the internal report indicated the facility's Social Service Director interviewed Resident #19 on 08/13/18 (no time) and documented the resident reported, I couldn't turn over so when (sic) they turned me over with their big hands and my left side is sore. The report indicated, During the interview with the Social Service Director, the resident stated that someone asked her to turn over and when she said she couldn't that's when they hit her in her left side. Review of a Departmental Notes document, dated 08/10/18 at 10:24 AM, completed by the Registered Nurse Supervisor revealed the following information, It was reported to this nurse by resident (#19), that her back was hurting because someone turned me over so hard and my back is sore when I breath (sic) it is sore. Myself and the treatment nurse spoke with (the) resident she states my butt was bothering me so bad that they were trying to put cream on and I could not turn over. They turned me over with their big hands and my left side is sore. Treatment nurse assessed (the resident) no redness or bruising noted. Pain meds given . Review of a Departmental Notes document, dated 08/10/18 at 9:49 PM, (late entry for 4:30 PM), FNP (Family Nurse Practitioner) called unit (and) said she looked at (the) x-ray (and it) did not show (a) fracture, that the pain was from a deep contusion and she would be sore for a couple days, and for staff to offer [MEDICATION NAME] (a narcotic pain medication) as ordered to relieve discomfort. Review of the facility's investigation failed to provide evidence to indicate the facility reported the allegation of staff to resident abuse made by Resident #19 on 08/10/18 at 10:00 AM to the Mississippi Department of Health per regulation. During an interview with the Administrator on 10/15/18 at 4:00 PM, a request was made for documentation that verified a report was filed with the Mississippi Department of Health related to Resident #19's allegation of staff to resident abuse. The Administrator stated, I don't have any documented evidence of when I reported the incident. I called it in on my cell phone on 08/10/18, but I have no proof. The Triage Unit of the Mississippi Department of Health was contacted by the survey team on 10/16/18 at 3:10 PM. The report of the incident of staff to resident abuse related to Resident #19 was not made until 08/11/18 at 10:39 AM. During an interview on 10/16/18 at 3:20 PM, the Administrator was informed that the official date and time the Triage Unit of the Mississippi Department of Health received the report was 08/11/18 at 10:39 AM. The Administrator stated, Thanks for saving me the trouble of trying to find any proof. The Administrator acknowledged the allegation should have been reported to the Triage Unit of the Mississippi Department of Health within two hours from the time she received the report of Resident #19's allegation of staff to resident abuse.