Every finding on record at Century Villa, Inc

Based on observation, interview and record review, the facility failed to ensure licensed nursing staff informed four out of four sampled residents (Residents 11, 22, 23, and 51) of the medications prior to medication administration.These deficient practices violated Residents 11, 22, 23, and 51's right to participate during medication administration.FindingsDuring a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and dementia (a progressive state of decline in mental abilities).During a review of Resident 11's History & Physical (H&P), dated 2/22/2025, the H&P indicated Resident 11 had fluctuating capacity to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 3/5/2026, the MDS indicated Resident 11 was usually able to understand and be understood by others. The MDS indicated Resident 11 required partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene, toileting hygiene, showering/bathing, lower body dressing, and personal hygiene. During an observation on 4/9/2026 at 10:09 a.m. in Resident 11's room, Licensed Vocational Nurse (LVN) 1 was observed giving Resident 11 medication cups without explaining what medications were being administered. Resident 11 then swallowed the pills.During a review of Resident 22's admission Record, the admission record indicated Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 22's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 was usually able to understand and be understood by others. The MDS indicated Resident 22 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 22's H&P dated 12/22/2025, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During an observation on 4/9/2026 at 9:48 a.m. in Resident 22's room, LVN 1 was observed giving Resident 22 medication cups without explaining what medications were being administered. Resident 22 then swallowed the pills.During a review of Resident 23's admission Record, the admission record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, and anxiety (a feeling of fear, dread, and uneasiness).During a review of Resident 23's H&P dated 12/15/2025, the H&P indicated Resident 23 had the capacity to understand and make decisions.During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 was able to understand and be understood by others. The MDS indicated Resident 23 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 4/9/2026 at 8:58 a.m. in Resident 23's room, LVN 3 was observed giving Resident 23 medication cups without explaining what medications were being administered. Resident 23 then swallowed the pills.During a review of Resident 51's admission Record, the admission record indicated Resident 51 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 51's diagnoses included COPD, paranoid schizophrenia, and anxiety.During a review of Resident 51's H&P dated 11/17/2025, the H&P indicated Resident 51 had fluctuating capacity to understand and make decisions.During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 was usually able to understand and be understood by others. The MDS indicated Resident 51 required partial/moderate assistance from staff for toileting hygiene, shower/bathe self, lower body, and putting on/taking off footwear. During an observation on 4/9/2026 at 9:58 a.m. in Resident 51's room, LVN 1 was observed giving Resident 51 medication cups without explaining what medications were being administered. Resident 51 then swallowed the pills.During an interview on 4/9/2026 at 11:30 a.m. with LVN 1, LVN 1 stated if the residents ask what medication you are giving them you should tell them. LVN 1 stated residents need to know what medication they are receiving in case they want to refuse.During a review of P&P titled Resident Rights dated January 2026, the P&P indicated the facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.During a review of P&P titled Medication Administration dated January 2026, the P&P indicated the administering nurse should explain the purpose of the visit.

Based on interview and record review, the facility failed to ensure the arbitration agreement accurately reflected the residents' right to rescind the agreement within 30 days for three out of three sampled residents (Residents 15, 26, and 41).This deficient practice had the potential to misinform residents of their rights and limit their ability to voluntarily withdraw from the arbitration agreement.Findingsa. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included schizoaffective disorder bipolar type (a mental illness that is characterized by disturbance in thought), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 15's History and Physical (H&P) dated 12/8/2025, the H&P indicated Resident 15 had fluctuating capacity to understand and make decisions.During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 15's cognition (process of thinking) was intact and unimpaired. The MDS indicated Resident 15 was independent in functional abilities including eating toileting dressing and personal hygiene. The MDS indicated Resident 15 independently without the use of a wheelchair, walker or cane. b. During a review of Resident 26's admission Record, the admission Record indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia and suicidal ideations (thinking about wanting to die or considering suicide)During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26's cognition was intact and unimpaired. The MDS indicated Resident 26 was independent with activities of daily living eating (bathing, toileting, and eating), required set-up assistance from one staff member for toileting and required supervision from staff for bathing and lower body dressing. Resident 26 was able to walk about the facility independently without the use of a walker or wheelchair.During a review of Resident 26's H&P, dated 3/3/2026, the H&P indicated Resident 26 had the capacity to understand and make decisions.c. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety disorder (being worried nervous or scared most of the time) and depression (feeling sad and low for long periods of time). During a review of Resident 41's H&P dated 7/31/2025 the H&P indicated Resident 41 had fluctuating capacity to understand and make decisions.During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41's cognition was intact and unimpaired. The MDS indicated Resident 41 was independent in functional abilities including eating toileting dressing and personal hygiene. The MDS indicated Resident 41 walked about independently without the use of a wheelchair, walker or cane. During a review of the facility's Arbitration Agreement title, Resident -Facility Arbitration Agreement undated, the Arbitration Agreement indicated, This agreement may not be rescinded by written notice within thirty (30) days of signature.During a concurrent interview and record review on 4/9/2026 at 3:43 p.m., with the Social Services Director (SSD), the SSD indicated the Facility Arbitration Agreement had a typographical error indicating residents may not rescind the agreement, the SSD indicated that was the agreement residents were signing the last 3 years. The SSD indicated the agreements containing the typographical were signed by Resident 15 on 6/6/2025, Resident 26 on 1/19/2026, and Resident 41 on 7/31/2024. During an interview on 4/10/2026 at 10:10 a.m., with the Administrator (ADM), the ADM indicated having the typographical error in the Resident -Facility Arbitration Agreement had the potential to violate resident rights by not providing the residents with the 30-day time period to rescind the agreement.During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, dated 1/2026, the P&P indicated, It is the policy of this facility not to enter into a pre- dispute agreement for binding arbitration with any resident or resident representative nor require that a resident sign an arbitration agreement as a conditions of admission to the facility.

Based on interview and record review, the facility failed to complete discharge documents for one of one sampled resident (Resident 84) prior to discharge on [DATE]. This failure has the potential for Resident 84 to not know the appeal process and for the receiving facility to have inaccurate information of Resident 84.FindingsDuring a review of Resident 84's admission record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses including unspecified complicated cataract (a medical condition that causes blurred vision), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD, a progressive, long-term lung disease that makes it hard to breathe).During a review of Resident 84's History & Physical (H&P), dated 7/10/2025, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions.During a review of Resident 84's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 84 was discharged to the home/community and would not return to the facility. The MDS indicated an active discharge plan was in process for a return to the community.During a review of Resident 84's physician order, dated 3/19/2026, the physician order indicated Resident 84 may discharge to an assisted living facility for lower-level care.During a review of Resident 84's progress notes, dated 3/19/2026, the progress notes indicated Resident 84 was alert, oriented, and stable for transfer to a lower level of care. The progress notes indicated Resident 84 was discharged on 3/19/2026 at 10:20 a.m. in stable condition with all current medications, personal belongings, and necessary documents.During a concurrent interview and record review on 4/9/2026 at 1:00 p.m. with the Social Services Director (SSD), Resident 84's medical records were reviewed. There was no Notice of Proposed Transfer nor discharge summary in the medical records. The SSD stated the nurses fill out the Notice of Proposed Transfer and oversee faxing the notice to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). The SSD stated it was important to let the resident know the discharge information because the Notice also included information regarding an appeal process. The SSD stated it was important to let the ombudsman know that the resident would be transferred to another facility. During a concurrent interview and record review on 4/9/2026 at 1:30 p.m. with the Director of Nursing (DON), Resident 84's medical records were reviewed. The DON stated there was no discharge summary. DON stated it was very important to document the discharge summary. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge (Including AMA), dated 01/2026, the P&P indicated for non-emergency discharges (initiated by the facility, return not anticipated), the Social Services Director would notify the resident and resident's representative in writing at least 30 days before the resident is transferred or discharged . The P&P indicated the contents of the notice must include the reason for transfer or discharge, effective date of transfer or discharge, the location to which the resident is transferred or discharged , and a statement of the resident's appeal rights. The P&P indicated for a community discharge, a discharge summary and plan of care should be prepared for the resident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9) had care plans (a personalized document outlining a resident's health needs, goals, and specific interventions) for diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).This deficient practice had the potential to result in delayed care and services for Resident 9's mental health.FindingsDuring a review of Resident 9's admission Record, the admission record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included unspecified dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 9's History and Physical (H&P) dated 10/9/2025, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 1/13/2026, the MDS indicated Resident 9 was usually understood and could usually understand others. The MDS indicated Resident 9's cognition (ability to think and understand) was moderately impaired. The MDS indicated Resident 86 was independent with eating and oral hygiene. During a concurrent interview and record review on 4/9/2026 at 11:35 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 9's Care Plans were reviewed. The care plans indicated there were no care plans for schizophrenia or depression. LVN 1 stated there should be a care plan for diagnoses schizophrenia, and depression so staff would know the interventions (actions to take to improve a situation) in case Resident 9 showed behavioral issues.During an interview on 4/10/2026 at 9:20 a.m. with the MDS Nurse, MDS Nurse stated the initiation of care plans was a team effort and should be checked during quarterly updates of the MDS by the MDS Nurse. The MDS Nurse stated the purpose of the care plan was to ensure Resident 9's goals and interventions are being met. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Care Plans dated 1/2026, the P&P indicated the comprehensive care plan would describe services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated the comprehensive care plan would include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on interview and record review the facility failed to ensure physician orders for lab work, medical procedures, chest x-ray and dental referral were carried out for one of four sampled residents (Resident 26).This deficient practice had the potential to result in delayed diagnosis, delayed treatment, and/or worsening of Resident 26's condition.FindingsDuring a review of Resident 26's admission Record, the admission Record indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbance in thought) and suicidal ideations (thinking about wanting to die or considering suicide)During a review of Resident 26's Minimum Data Set (MDS- a resident assessment tool), dated 1/29/2026, the MDS indicated Resident 26's cognition (process of thinking) was intact and unimpaired. The MDS indicated Resident 26 was independent with activities of daily living eating (bathing, toileting, and eating), required set-up assistance from one staff member for toileting and required supervision from staff for bathing and lower body dressing. Resident 26 was able to walk about the facility independently without the use of a walker or wheelchair.During a review of Resident 26's History and Physical (H&P), dated 3/3/2026, the H&P indicated Resident 26 had the capacity to understand and make decisions.During a review of Resident 26's Ear Nose and Throat Consultation note (ENT note), dated 3/26/2026, the ENT note indicated Resident 26 was diagnosed with a right jaw lymph node and to refer to dentist (referral to dentist for further evaluation).During an interview on 4/8/2026 at 11:48 a.m. with the Social Service Director (SSD), the SSD stated they missed the order to refer Resident 26 to the dentist. The SSD stated she was not aware of the referral request and placed the ENT note in the logbook without alerting the dentist about the order for the dental referral.During a review of Resident 26's physician progress notes dated 4/3/2026, the physician progress notes indicated Resident 26 wanted to be tested for pancreatic, colon cancer and other types of cancer because he claimed his sister was dying of cancer. The PPN indicated a request for Resident 26 to have a stool for occult blood (a test to detect blood in the stool), a chest x-ray (a photo imaging exam of the lungs, heart, airways and ribs used to detect abnormalities), an abdominal ultrasound (a scan that shows organs in the belly, the liver, gallbladder, kidneys, pancreas and blood vessels used to detect abnormalities), and a colonoscopy (a procedure where a camera scope is used to look inside the colon and rectum to detect abnormalities).During a concurrent interview and record review on 4/8/2026 at 11:48 a.m., with the Director of Staff Development (DSD), the DSD stated orders for the stool for occult blood, chest x-ray, abdominal ultrasound, and colonoscopy were not carried over into Resident 26's physician orders and therefore missed and not transcribed. The DSD stated Resident 26 did not receive the lab work or testing that the physician ordered on 4/3/2026. The DSD stated the delay could potentially delay care and services for Resident 26. During review of the facility's Policy and Procedure (P&P) titled Medication Orders, dated 1/2026, the P&P indicated for handwritten orders signed by the physician, the charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic order format.

Based on interview and record review, the facility failed to protect residents right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was physically attacked by Resident 2, who had a known history of agitation and aggressive behaviors toward others. The facility failed to:1. Implement its policy and procedure (P&P) titled, Abuse, Neglect and Exploitation which indicated each resident had the right to be free from abuse and neglect.2. Implement its P&P titled Behavior Management Plan, which indicated, residents with behavioral concerns will have a behavioral management plan to ensure they received appropriate services and interventions to meet their needs. These deficient practices resulted in Resident 2 punching Resident 1 on the right side of the face causing Resident 1 to sustain a hematoma (broken blood vessels) on the head and left ear bleeding, that required hospitalization in a general acute care hospital (GACH), where he was diagnosed with a right frontal (to the front and adjacent to the forehead) scalp (the skin covering the head) hematoma. Resident 1 underwent a repair of a one-centimeter ([cm] - unit of measurement) laceration (skin cut) to the left ear that required sutures (a basic wound closure technique where individual stitches are placed and tied separately along the length of the wound). Resident 1 was still admitted to the GACH as of 8/20/2025.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 4/22/2025, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 6/26/2025, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from staff with activities of daily living (ADL's - routine tasks/activities) such as oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 1's Change in Condition Evaluation ([COC] - a communication tool used to communicate a resident's change of condition), dated 7/28/2025, the COC indicated Resident 1 was found on the floor with Resident 2 on top of him. The COC indicated Resident 1 stated Resident 2 hit him and pushed him to the floor. The COC indicated Resident 1 was bleeding from the left ear and had a hematoma on the right side of his face. The COC indicated Resident 1 was transferred to the GACH for evaluation and treatment. During a review of Resident 1's GACH Emergency Report (ER), dated 7/28/2025, the report indicated Resident 1 presented to the ER with injuries to his head, hand, neck, and a left ear laceration. The ER Report indicated Resident 1's Computed Tomography scan ([CT] process of taking pictures of body parts to diagnose and treat disease and injury) of the head indicated Resident 1 had a right frontal hematoma. The ER Report indicated Resident 1 had a 1-centimeter ([cm] - unit of measurement) laceration to his left ear that required sutures (a basic wound closure technique where individual stitches are placed and tied separately along the length of the wound). During a review of Resident 2's Face Sheet, the Face Sheet indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 2's H&P, dated 6/28/2025, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's MDS assessment, dated 7/10/2025, the MDS indicated Resident 2's cognitive skills for daily decision making were intact. The MDS indicated Resident 2 was independent (Resident completes the activity by themself with no assistance from a helper) on ADLs such as eating, toileting hygiene, and upper body dressing. During a review of Resident 2's GACH Psychiatric Evaluation Notes prior to admission to the facility, dated 6/14/2025, the notes indicated Resident 2 was admitted to the GACH on a 5150 (an involuntary 72-hour psychiatric hold, allowing law enforcement or designated mental health professionals to detain individuals who, due to a mental health disorder, are deemed a danger to themselves or others) for danger to others. The Psychiatric Evaluation Notes indicated, Resident 2 was involved in a physical altercation with another resident and had been increasingly agitated and aggressive toward others without any provocation (an action or statement that is intended to make someone angry). During a review of Resident 2's Initial Psychiatric Evaluation in the facility, dated 7/14/2025, The initial Psychiatric Evaluation indicated, Resident 2 was agitated, paranoid (unjustified suspicion and mistrust of other people or their actions) and anxious. The Initial Psychiatric Evaluation indicated a treatment plan to observe Resident 2 for deterioration in function, increase socialization to prevent isolation and compliance of medication. During a review of Resident 2's Progress Notes, dated 7/28/2025, the Progress Notes indicated Resident 2 had experienced an auditory hallucination (perceptions of sound when no actual sound is present) commanding him to fight. The progress Notes indicated Resident 2 went to Resident 1's room and physically attacked Resident 1 and put him on the floor. During a review of the facility's Five Day Follow Up Investigative Report, dated 8/1/2025, the report indicated on 7/28/2025 CNA 1 witnessed Resident 2 hitting Resident 1 across the face and both residents lost their balance and fell to the ground. The report indicated Residents 1 and 2 were separated immediately and assessed by staff. The report indicated Resident 1 was transferred to the GACH for further evaluation. During a telephone interview on 8/6/2025 at 12:19 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 7/28/2025 at approximately 5 a.m., she heard a staff calling for help from Resident 1's room, she ran to the resident room and observed Resident 2 coming out of Resident 1's room. LVN 1 stated she found Resident 1 lying on his back on the floor with a hematoma on the right side of his forehead. LVN 1 stated she observed a moderate amount of blood coming from Resident 1's left ear. During an interview on 8/6/2025 at 3:02 p.m., with CNA 1, CNA 1 stated on 7/28/2025 at around 5:00 a.m., she was assisting another resident and heard a loud noise coming from Resident 1's room. CNA 1 stated she ran to Resident 1's room, observed Resident 1 on the floor and Resident 2 on top of him. CNA 1 stated she observed Resident 2 punching Resident 1's head and right side of the resident's face with both fists. CNA 1 stated she observed bruises on Resident 1's face and left ear was bleeding. CNA 1 stated she tried to stop Resident 2 from punching Resident 1 but Resident 2 tried to hit her (CNA 1). CNA 1 stated she left Resident 1 and Resident 2 in the room while Resident 2 continued hitting Resident 1, went outside and screamed for help. CNA 1 stated there was a lot of blood on the floor. During an interview on 8/6/2025 at 3:54 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 2 had a history of aggressive behavior and physical altercation with another resident prior to admission to the facility. The MDSN stated there was no comprehensive care plan developed addressing Resident 2's potential to be physically aggressive to others because Resident 1's aggressive behavior was only a history. The MDSN stated he did not develop a care plan for Resident 2's history of physically aggressive behavior until Resident 2 displayed the actual behavior by attacking Resident 1 on 7/28/2025. During an interview on 8/6/2025 at 4:10 p.m., with the Director of Staff Development (DSD), the DSD stated residents with a history of physical aggressive behavior should have a comprehensive care plan so staff could identify any triggers and better manage the resident's behaviors, provide supervision, and implement other interventions to ensure the safety and well-being of the residents in the facility. The DSD stated she had no answer why the MDSN did not develop a care plan with measurable interventions related to Resident 2's history of physical altercation prior to admission to the facility. The DSD stated without a care planning there was a chance to escalate Resident 2's aggressive behavior. During an interview on 8/8/2025 at 2:26 p.m., with the Social Service Director (SSD), the SSD stated failure to develop a comprehensive care plan for a resident with a known history of physical aggression could lead to a resident-to-resident altercation and physical abuse. The SSD stated the physical abuse Resident 1 suffered from Resident 2 could have been prevented if the facility had provided close monitoring and supervision to Resident 2, given the resident's history of physical altercation with other residents prior to admission to the facility. During an interview on 8/8/2025 at 3:36 p.m., with the Administrator (ADM), the ADM stated all residents had the right to be free from any forms of abuse. The ADM stated Resident 2 should have been closely monitored given his history of agitation and aggressive behavior. The ADM stated that since Resident 1 sustained an injury, the facility did not prevent Resident 1 from physical abuse by Resident 2. During a review of the facility's undated P&P, titled Abuse, Neglect and Exploitation, the P&P indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated Physical abuse includes, but not limited to hitting, slapping, punching and kicking. The P&P indicated, Prevention of Abuse, Neglect, and Exploitation - the facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of resident: l. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. During a review of the facility's undated P&P, titled Behavior Management Plan, the P&P indicated, Residents who exhibit behavioral concerns may require a behavioral management plan to ensure they are receiving appropriate services and interventions to meet their needs.

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of three sampled residents (Resident 2) by failing to:1. Ensure Resident 2's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices. Findings:During a review of Resident 2's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 2's History and Physical (H&P), dated 6/28/2025, the H&P indicated, Resident 2 could make needs known but cannot make medical decisions. During a review of Resident 2's MDS assessment, dated 7/10/2025, the MDS indicated, Resident 2 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 2 was independent (Resident completes the activity by themself with no assistance from a helper) with eating, toileting hygiene, and upper body dressing. During a review of Resident 2's Order Summary Report (a document containing active orders), dated 8/6/2026, the Order Summary Report indicated, the physician placed a telephone order on 6/27/2025 for Resident 2 to start on Depakote 500 milligrams ([mg] - metric unit of measurement, used for medication dosage/and or amount) by mouth to give 1 tablet by mouth every 12 hours (9 a.m. and 9 p.m.) for bipolar disorder manifested by fluctuation in mood as evidenced by sudden angry outburst due to responding to internal stimuli for no form of provocation. During a concurrent interview and record review on 8/6/2025 at 1:21 p.m., with the Minimum Data Set Nurse (MDSN), Resident 2's MDS assessment, dated 7/10/2025, was reviewed. The MDSN stated Resident 2 was taking Depakote which is considered as anti-convulsant medication. The MDSN stated there should a check marked on MDS Section N0415 under anticonvulsant medication. The MDSN stated the MDS assessment was completed inaccurately. The MDSN stated per Resident Assessment Instrument ([RAI] - a guide that helps nursing home staff use to assess residents and develop care plans) manual coding of medications should be based on the pharmacological (relating to the use of drugs to treat a condition) classification of the medication not based on the reason it was prescribed. The MDSN stated he had not been coding Depakote medication as anticonvulsant in the past and it was not a red flagged. The MDSN stated accuracy of assessment in the MDS was important because it entails the condition and needs of the resident and for continuity of care. During a review of the facility's undated policy and procedure (P&P), titled Conducting an Accurate Resident Assessment, the P&P indicated, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.

Based on record review and interview, the facility failed to respond to a request for the account balance of personal funds for one of three residents' (Resident 1).This deficient practice resulted in the facility retaining Resident 1's funds after being discharged from the facility.Findings:During a review of Resident 1's admission Record (face sheet), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anemia (a condition in which the body does not have enough red blood cells to carry oxygen throughout the body), chronic kidney disease (progressive damage and loss of function in the kidneys), and gastrostomy status (presence of a gastrostomy tube which is a surgical opening in the stomach for nutrition support).During a review of Resident 1's History and Physical (H&P) dated 1/12/2025, the H&P indicated Resident 1 was alert and oriented to person (a person is aware of and can identify the people around them).During a review of Resident 1's Minimum Data Set (MDS - a comprehensive quarterly resident assessment) dated 6/7/2025, the MDS indicated Resident 1 rarely had the ability to make self understood and rarely had the ability to understand others. The MDS indicated Resident 1was dependent on a helper to do all of the effort for oral hygiene, toileting hygiene, bathing, and dressing upper and lower body.During a review of Resident 1's Durable Unlimited Power of Attorney (POA) dated 5/20/2009, the POA indicated Resident 1 granted her son full and unlimited power of attorney (appointing someone to act on behalf of another person for financial, legal, or healthcare decisions.)During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic osteomyelitis (inflammation of the bone or bone marrow, usually due to infection.)During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to make self understood and the ability to understand others. The MDS indicated Resident 2 was dependent on a helper to do all of the effort for toileting hygiene, bathing, and dressing upper and lower body.During a review of Resident 2's H&P dated 7/2/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including diabetes, and atrial fibrillation.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 rarely had the ability to make self understood and rarely had the ability to understand others. The MDS indicated Resident 3 was dependent on a helper to do all of the effort for oral hygiene, toileting hygiene, bathing, and dressing upper and lower body.During a review of Resident 3's H&P dated 5/31/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 7/21/2025 at 1:57 pm with the Business Office Manager (BOM), Resident 1's Trust Transaction History (TTH-a history of withdrawals and deposits of funds to a resident's account) dated 2/1/2025 - 6/30/2025, was reviewed. The TTH indicated Resident 1 had a closing balance of $1,504.04. The BOM stated she received information that Resident 1's POA requested the balance while the BOM was away from the facility between March and June of 2025. As of the survey date 7/21/2025, the BOM stated she had not responded to the POA regarding Resident 1's personal funds account balance.A review of the facility Policy & Procedures (P&P) undated, the P&P indicated Quarterly statements will be provided in writing to the resident, or the resident's representative within 30 days after the end of the quarter and upon request.

Based on observation, interview, and record review the facility failed to: 1. Ensure two out of four sampled residents (Resident 57): nasal cannula and humidifiers (a medical device that provides supplemental oxygen to a patient through their nose) were dated, labeled and (Resident 36) GT feeding was changed per physcian orders. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents. Findings: a. During a review of Resident 57's Admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 57's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and chronic heart failure (a condition where the heart can't pump blood efficiently). During a review of Resident 57's History and Physical (H&P), dated 12/20/2024, the H&P indicated, Resident 57 did not have the capacity to understand and make decisions. During a review of Resident 57's Minimum Data Set ([MDS] a resident assessment tool), dated 1/15/2025, the MDS indicated Resident 57's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 57 was substantial assistance on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 57 health condition included shortness of breath (trouble breathing) with exertion (walking, bathing, transferring, and when lying flat. During an observation on 2/4/2025 at 9:57 a.m. in Resident 57's room, there a humidifier attached to a concentrator (it takes air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) and a nasal cannula connected to the humidifier. The humidifier was dated 12/20/2024 and the nasal cannula was not dated and labeled. During a review of Resident 57's physician orders titled, Order Summary Report, dated 12/10/2024, the physician orders indicated oxygen at two liters ([L] -a metric unit of measurement used to calculate volumes) per minute continuously every shift for shortness of breath and wheezing (a high-pitched whistling sound that indicates a person may be having trouble breathing). During a concurrent observation and interview on 2/5/2025 at 12:08 p.m. with Licensed Vocational Nurse (LVN) 3 in Resident 57's room, Resident 57 had a humidifier attached to a concentrator dated 12/20/2024 and the nasal cannula was not dated and labeled. LVN 3 stated the humidifier should have been changed every two weeks. LVN 3 stated the humidifier provides moisture to the resident and if it was not changed every two weeks it could cause a respiratory infection. LVN 3 stated the nasal cannula needed to be changed every two weeks to prevent respiratory infection. During an interview on 2/5/2025 at 12:32 p.m. with Minimum Data Set (MDS) Nurse, the MDS Nurse stated the humidifier and nasal cannula tubing should be changed weekly. The MDS Nurse stated the nasal cannula could get clogged with mucus dryness, condensation (water collects) buildup in the tubing. The MDS Nurse stated not changing the humidifier and the nasal cannula tubing weekly could cause Resident 57's COPD to exacerbate (to make a disease or its symptoms worse). During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, date unknown, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated the following equipment and supplies a nasal cannula and humidifier bottle will be necessary when performing this procedure. The P&P did not indicate issues regarding infection control. During a review of facility's policy and procedure (P&P) titled, Oxygen Concentrator, date unknown, the P&P indicated to administer oxygen for the treatment of certain disease or conditions. The P&P indicated the care of the concentrator were to change tubing weekly, change humidifier every seven days or as needed, and change nebulizer tubing every seven days. 49906 b. During an observation on 2/4/2025 at 10:28 am at Resident 36's bedside, a 50.7-ounce container of Jevity 1.2 cal enteral nutrition was hanging from an IV pole dated 2/2/2025 5am. The container had 200 mL's of formula remaining. During a review of Resident 36's Admission Record, the admission record indicated the facility readmitted on [DATE] with diagnoses that included dysphagia (swallowing difficulty), ileus (a condition where the normal movement of food and waste through the gut is impaired), and cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and spinal cord). During a review of the Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 36 usually had the ability to express ideas and wants and sometimes had the ability to understand others. The MDS also indicated Resident 36 was dependent (helper does all the effort) in all functional abilities. During a review of Resident 36's Order Summary Report, dated 2/3/2025, the report indicated Enteral Feed Order every shift Jevity 1.2 @ 40cc x 20 hours to yield 800cc/1200 kcal in 24 hours via continuous feeding pump. Turn feeding off at 10am or till dose is completed. During a review of the manufacturers product information titled Jevity 1.2 Cal, the document indicated to hang for no more than 24 hours and that all medical foods, regardless of type of administration system, require careful handling because they can support microbial (bacteria) growth. During a concurrent interview and record review on 2/7/2025 at 9:18 am with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 36's enteral nutrition should be changed everyday because it is no longer fresh. It is like food being left out and could cause diarrhea, constipation, or vomiting. A review of a picture taken on 2/4/2025 at 10:29 am at Resident 36's bedside, of the Jevity container dated 2/2/2025 5am without a nurse's signature or initials, LVN 2 stated the container hanging there should be dated 2/3/2025 if it was changed every twenty-four hours as ordered. During a review of the facility's policy and procedure (P&P) titled Enteral Nutrition, undated, the P&P indicated, Adequate nutritional support through enteral feeding will be provided to residents as ordered.

Based on interview and record review, the facility failed to ensure care plan interventions for two of four sampled residents (Residents 44 and 90) were implemented. The facility failed to implement: 1. Resident 44's care plan interventions regarding skin care for an ankle monitor. 2. Resident 90's care plan interventions regarding the resident leaving the facility temporarily with family. These failures placed Resident 44 and 90 at risk of not having their needs being met. Findings: a. During a review of Resident 44's Admission Record, the Admission Record indicated the facility admitted Resident 44 on 2/22/2019 and readmitted on [DATE] with diagnoses including COPD, epilepsy, and schizophrenia (a mental disorder characterized by disturbances in thought). During a review of the Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 44 rarely/never had the ability to express ideas and wants and rarely/never had the ability to understand others. The MDS also indicated Resident 44 was dependent (helper does all the effort) in all functional abilities. During a concurrent observation and interview on 2/6/2025 at 10:29 am with Certified Nursing Assistant (CNA) 3, at Resident 44's bedside, Resident 44 was observed asleep. There was a brown electrical cord and black electrical power pack hanging from the foot of the bed. CNA 3 stated the plug was for Resident 44's ankle monitor and was unplugged during hygiene care and the charge nurses are responsible for keeping it charged. CNA 3 also stated the device has been connected to Resident 44's left ankle since he was admitted and if it runs out of power, the police show up to make sure Resident 44 is still in the facility. During a concurrent observation, interview, and record review on 2/6/2025 at 1:00 pm with Licensed Vocational Nurse (LVN) 4, at Resident 44's bedside, LVN 4 confirmed the presence of the ankle monitor on the left and stated there should be some material between it and the skin to protect from skin breakdown. At the nursing station, LVN 4 confirmed there was no care plan in Resident 44's health record regarding the ankle monitor. During an interview on 2/6/2025 at 2:20 pm with the Social Services Director (SSD), the SSD stated no paperwork was given to the facility by law enforcement regarding Resident 44's ankle monitor and that it was present on admission. The SSD stated there should be some paperwork in his chart regarding the device in case of emergency. During an interview on 2/7/2025 at 2:34 pm with the Director of Nursing (DON), the DON stated she does not know why Resident 44 has an ankle monitor. Everyone knows the device is there and no one has reported any skin issues. DON also stated there should be a care plan to ensure there is no skin break down. During a review of the facility's P&P titled Comprehensive Care Plans, undated the P&P indicated that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that addresses a resident's medical, nursing, and mental and psychosocial needs. b. During a review of Resident 90's Admission Record, the Admission Record indicated the facility admitted Resident 90 on 12/11/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing) , epilepsy (a chronic disorder characterized by recurrent, unprovoked seizures), major depressive disorder (a condition that involves persistent feelings of sadness and hopelessness), and paranoid schizophrenia (feelings of distrust and suspicion of others for no reason in addition to hearing or seeing things that are not there). During a review of the MDS, dated [DATE], the MDS indicated Resident 90 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 90 was independent with self-care and mobility (walking). During a review of Resident 90's Order Summary Report dated 2/1/2025, the report indicated an order on 12/11/2024 the resident may go for temporary leave of absence with companion and on indicated on 12/25/2024 the resident may go out for temporary leave of absence with family as needed. During a concurrent interview and record review on 2/7/2025 at 9:42 am with LVN 1, LVN 1 stated there should be an order and care plan for residents leaving the facility. The MDS Nurse is responsible for the care plan initiation. During a review of Resident 90's care plan, initiated 12/13/2024, LVN 1 did not see a focus area with goals and interventions for leaving the facility temporarily. LVN 1 stated he did not know how the residents' safety would be ensured while out of facility, but a care plan indicating goals and interventions would help. During an interview on 2/6/2025 at 1:50 pm with the MDS Nurse (MDSN), the MDSN stated he is responsible for care plan initiation and licensed nurses and other administrators can make revisions. MDSN stated he never thought of doing a care plan for residents leaving the facility temporarily but thinks there should at least be an assessment done when they leave and when they come back. During a review of the facility's policy and procedure (P&P) titled Out on Pass Policy, undated, the P&P indicated individuals who leave the facility on a temporary pass shall do so in a manner that ensures their safety, maintains proper documentation, and upholds facility guidelines.

Based on observation and interview the facility failed to: 1. Ensure call light device was placed within reach for one of 18 sampled residents (Resident 56). This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services. Findings: During a review of Resident 56's Admission Record, the Admission Record indicated, Resident 56 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 56's diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 56's History and Physical (H&P), dated 4/30/24, the H&P indicated Resident 56 had fluctuating capacity to understand and make decisions. A review of Resident 56's Minimum Data Set (MDS - a federally mandated resident assessment tool)), dated 1/24/25, indicated Resident 56 was assessed to have comprehend (the action or capability of understanding something) most conversation. The MDS indicated Resident 56 required supervision or touching assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, showering, sit to stand, chair/bed-to-chair transfer, and toilet transfer. During a concurrent observation and interview on 2/4/25 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 56's room, the resident call lights was hanging on the overhead light above Resident 56's bed, not within reach for the resident. CNA 1 stated the call light was not within reach for the Resident 56. CNA 1 stated the call light should be next to him for an emergency. CNA 1 stated if the call light was not within reach the resident could potentially fall, have breathing issues and not get the help they needed. During an interview on 2/7/25 at 9:06 a.m. with the Director of Staff Development (DSD), DSD stated if the call light were not within reach the resident could not get the help they needed in case of an emergency. During an interview on 2/7/25 at 10:28 a.m. with the Director of Nursing (DON), the DON stated the call light should always be within reach for the resident. The [NAME] stated it would potentially be dangerous for the resident not able to call for help when it was needed. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, (undated), the P&P indicated, when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review the facility failed to: 1.Ensure one out four sampled residents (Resident 57) had a revised care plan for oxygen therapy (the medical practice of providing a patient with supplemental oxygen). This deficient practice of not having a revised care plan to indicate when to administer oxygen therapy placed Resident 57 at risk of not meeting the care plan goal as indicated. Findings: During a review of Resident 57's Admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 57's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and chronic heart failure (a condition where the heart can't pump blood efficiently). During a review of Resident 57's History and Physical (H&P), dated 12/20/2024, the H&P indicated, Resident 57 did not have capacity to understand and make decisions. During a review of Resident 57's Minimum Data Set ([MDS] a resident assessment tool), dated 1/15/2025, the MDS indicated Resident 57's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 57 was substantial assistance on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 57 health condition included shortness of breath (trouble breathing) with exertion (walking, bathing, transferring, and when lying flat. During a review of Resident 57's physician orders titled, Order Summary Report, dated 12/10/2024, the physician orders indicated oxygen at two liters ([L] -a metric unit of measurement used to calculate volumes) per minute continuously every shift for shortness of breath and wheezing (a high-pitched whistling sound that indicates a person may be having trouble breathing). During a review of Resident 57's care plan titled, Risk for Shortness of Breath due to Chronic Respiratory Failure, dated 10/10/2024 the care plan indicated Resident 57 goals were not to have shortness of breath. The care plan interventions indicated to have oxygen available if ordered or as needed. During a concurrent interview and record review on 2/5/2025 at 12:32 p.m. with Minimum Data Set (MDS) Nurse, Resident 57's care plan titled, Risk for Shortness of Breath, dated 10/10/2024 was reviewed. The care plan goal indicated Resident 57 will have no shortness of breath daily. The care plan interventions indicated to have oxygen available if ordered or as needed. The MDS Nurse stated the care plan interventions should have been revised to state the frequency, route, when to change the nasal canula (a thin, flexible tube that delivers oxygen to a patient through their nose), and humidifier (a device that adds moisture to oxygen to prevent irritation of the nose and throat). The MDS Nurse stated it was important to revise the care plan so the staff will know when to give the oxygen such as when the saturation (measures the amount of oxygen in a patient's blood) is too low. The MDS Nurse stated it was also important to know when to change the nasal canula and humidifier. The MDS Nurse stated with incomplete interventions could affect Resident 57's care plan goals therefore the goal will not be met. During a review of facility's policy and procedure (P&P) titled, Reviewing and Revising the Care Plan, date unknown, the P&P indicated the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The P&P indicated the care will be updated with the new or modified interventions. The P&P indicated the care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observation and interview, the facility failed to: 1. Conceal a sign containing personal information for one of two residents, (Resident 44), by posting it on the wall above the resident's bed. This deficient practice violated the resident's right to have personal information shielded from public view. Findings: During an initial tour on 2/4/2025 at 10:13, a handwritten sign disclosed Law enforcement device to be plugged in was posted above the Resident's 44 bed. During a review of Resident 44's Admission Record, the admission record indicated the facility admitted Resident 44 on 2/22/2019 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing), epilepsy (a chronic disorder characterized by recurrent, unprovoked seizures), and schizophrenia (a mental disorder characterized by disturbances in thought). During a review of the MDS, the MDS indicated Resident 44 rarely/never had the ability to express ideas and wants and rarely/never had the ability to understand others. The MDS also indicated Resident 44 was dependent (helper does all the effort) in all functional abilities. During a concurrent observation and interview on 2/6/2025 at 10:29 am at Resident 44's bedside with CNA 3, CNA 3 stated she was on staff when Resident 44 was originally admitted with the device, and the sign above his bed has been on the wall the whole time. CNA 3 stated the sign probably should not be there with Resident 44's personal information on it. The nurses leave it plugged in because the police come looking for Resident 44 when the battery dies. During a concurrent observation and interview on 2/6/2025 at 1:00 pm with Licensed Vocational Nurse (LVN) 4, at Resident 44's bedside, LVN 4 stated the sign placed above the bed states the resident has a device from a law enforcement agency. LVN 4 stated the sign is indicating Resident 44 has some issues with the law. LVN 4 also stated the sign above the bed does not protect Resident 44's privacy and it should have been placed in his chart. During an interview on 2/7/2025 at 2:34 pm with the Director of Nursing (DON), the DON stated the sign above Resident 44's bed is a violation of his privacy. The DON also stated the sign was there when she started working at the facility one year ago and she never questioned it. The last time an agent came out to check the devices' power, she asked about it and the agent stated it was court ordered and the sign needs to be posted so facility staff know it needs to be kept charged. During a review of the facility's policy and procedure (P&P) titled Posting Signs Policy, undated, the P&P indicated all signs posted within the facility shall comply with regulatory requirements. The P&P also stated signs with confidential resident information shall be displayed discreetly or in restricted areas only.

Based on interview, and record review, the facility failed to: 1. Properly obtain orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for two of four sampled residents (Resident 3, Resident 52). This deficient practice had the potential for Resident 3 and Resident 52 to experience a delay in interventions if they were positive for orthostatic hypotension (low blood pressure). Findings: a. During a review of Resident 3's Face Sheet, it indicated Resident 3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 3's Care Plan, dated 11/7/2024 it indicated Resident 3 had hypertension (high blood pressure) and an intervention included to monitor for side effects of blood pressure medications by checking orthostatic hypotension. During a review of Resident 3's Order Summary, an order was placed on 10/5/2024 to monitor orthostatic blood pressure sitting and lying weekly on Saturday in the evening. During a review of Resident 3's Blood Pressure Summary, dated 1/2025- 2/2025, Resident 3 had the following blood pressure recorded: 2/1/2025 6:40 p.m. 128 / 70 millimeters per mercury (mmHg- unit of measurement) Lying 2/1/2025 6:40 p.m. 136 / 84 mmHg Sitting 2/1/2025 8:14 a.m. 140 / 80 mmHg Sitting 1/25/2025 7:28 p.m. 128 / 70 mmHg Lying 1/25/2025 7:27 p.m. 136 / 80 mmHg Sitting 1/25/2025 9:01 a.m. 124 / 71 mmHg Sitting 1/25/2025 9:00 a.m. 124 / 71 mmHg Sitting 1/18/2025 8:24 p.m. 128 / 74 mmHg Lying 1/18/2025 7:24 p.m. 136 / 80 mmHg Sitting 1/18/2025 9:03 a.m. 140 / 61 mmHg Sitting b. During a review of Resident 52's Face Sheet, it indicated Resident 52 was originally admitted on [DATE] and readmitted on [DATE] with a diagnosis that included schizophrenia. During a review of Resident 52's Care Plan, dated 12/3/2024 it indicated Resident 52 had hypertension and an intervention included to monitor for side effects of blood pressure medications by checking orthostatic hypotension. During a review of Resident 52's Order Summary, an order was placed on 1/3/2025 to monitor orthostatic blood pressure sitting and lying weekly on Saturday in the evening. During a review of Resident 52's Blood Pressure Summary, dated 1/2025- 2/2025, Resident 52 had the following blood pressure recorded: 2/1/2025 10:40 p.m. 122 / 80 mmHg Lying 2/1/2025 10:40 p.m. 120 / 60 mmHg Sitting 1/25/2025 11:22 p.m. 116 / 84 mmHg Lying 1/25/2025 11:21 p.m. 122 / 60 mmHg Sitting 1/18/2025 6:14 p.m. 120 / 76 mmHg Lying 1/18/2025 6:12 p.m. 134 / 76 mmHg Lying 1/11/2025 10:19 p.m. 108 / 60 mmHg Sitting 1/11/2025 10:15 p.m. 122 / 66 mmHg Lying 1/4/2025 9:16 p.m. 120 / 66 mmHg Lying 1/4/2025 9:15 p.m. 122 / 74 mmHg Sitting During an interview on 2/6/2025 at 1:35 p.m. with Registered Nurse (RN) 1, RN 1 stated the method to take orthostatic blood pressure is by taking a blood pressure reading with the resident lying down first. Then, they would sit up and have them sit for about 5 minutes and take another blood pressure reading. RN 1 stated you must wait about 5 minutes between the position change to allow for their body to adjust to the change in position. RN 1 stated the nurse will report to the physician if there is a change of over 20mm/Hg for During a concurrent interview and record review on 2/6/2025 at 1:48 p.m. with RN 1, Resident 3 and Resident 52's Blood Pressure Summary dated 1/2025- 2/2025 was reviewed. RN 1 stated in some of the blood pressure documentation, the time they were taken was only 1 minute apart and that is not correct because the nurse needs to wait about 5 minutes from the lying to sitting position to allow the body to adjust to the change, not doing so means it is an inaccurate reading. RN 1 further stated according to the documentation of the blood pressure, the staff who took the readings took it in the sitting position first and then lying. RN 1 stated this method is incorrect and stated the first blood pressure reading should be lying first and then sitting and doing it in the reverse order is not how orthostatic blood pressure readings are to be taken. If it is done incorrectly, the nurse wouldn't know if the resident had orthostatic hypotension. During a review of the facility's policy and procedures (P&P), titled Orthostatic Hypotension Policy, undated, it indicated individuals are advised to change positions gradually, moving from lying to sitting before standing to prevent sudden drops in blood pressure, and blood pressure shall be measured in three positions- lying, sitting, and standing.

Based on observation, interview and record review the facility failed to: 1. Ensure one of four sampled residents (Resident 32) was supervised and wore a smoking apron during smoking break. This deficient practice had the potential to put residents at risk for injury due to lack of supervision and maintain proper safety precautions while smoking. Findings: During a review of Resident 32's Admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated, Resident 32 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 32's diagnoses included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 32's History and Physical (H&P), dated 2/4/25, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Care Plan for smoking, initiated on 2/4/25, the care plan indicated, the resident would not smoke without supervision. The care plan also indicated, the resident required a smoking apron while smoking., During a review of Resident 32's Smoking Assessment Form, dated 2/4/25, the Smoking Assessment Form indicated, resident must be supervised at all times and wear protective non-flammable smoking apron when smoking. During a concurrent observation and interview on 2/4/25 at 3:15 p.m. with the Assistant Activities Director (AAD), in the dining room next to the opening to the sliding glass door where the residents were smoking. Resident 32 was sitting in the wheelchair in the smoking patio with her back to the sliding glass door, and not wearing a smoking apron. The AAD stated Resident 32 needed supervision and a smoking apron. AAD stated when Resident 32's cigarette was lit the smoking apron should have been put on, and resident should have been facing the sliding glass door. AAD stated it is important to place the smoking apron and supervise while smoking for the resident's safety. AAD stated this was to help prevent resident from harm, such as getting burned or starting a fire. During an interview on 2/4/25 at 4:00 p.m. with the Activities Director (AD), AD stated the activity staff does not smoke so we supervise by the opening of the sliding glass door. Residents who need supervision should be facing forward so we can supervise them. AD stated that Resident 32 back was facing he door and did not have on a smoking apron. AD stated that Resident 32 did need supervision and a smoking bib. AD stated this was not a way to supervise her, she should have had a smoking apron on and facing the door. AD stated that resident did have a napkin on lap while smoking this is a huge safety hazard. AD stated there was potential for resident to drop cigarette, burn herself or start a fire. During an interview on 2/7/25 at 10:28 a.m. with the Director of Nursing (DON), the DON stated smoking assessments let us know if the resident was a safe smoker or needed interventions such as supervision and smoking aprons. The DON stated the actives staff oversaw giving and lighting cigarettes, placing smoking aprons, and supervising resident while smoking. The DON stated that if there was not proper supervision, or if the resident was not wearing a smoking apron when needed, it was a safety issue. The DON stated there was a potential for harm to the resident, the resident could burn their clothes, skin, or even start a fire. During a review of the facility's policy and procedure (P&P) titled, Resident Smoking, (undated), the P&P indicated, facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. Supervision will be provided as indicated on each resident's care plan.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 39) had an assessment and order for the use of siderails. This deficient practice had the potential to result in inappropriate use of siderails for Resident 39 and could lead to injuries. Findings: During an observation on 2/4/2025 at 9:20 a.m., Resident 39 was resting in bed with 1 siderail up on each side of him. During a review of Resident 39's Admission Record, it indicated Resident 39 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and encephalopathy (a medical condition that affects the brain's function). During a review of Resident 39's Order Summary Report, there were no orders seen for the use of siderails. During an interview on 2/6/2025 at 1:25 p.m. with Registered Nurse (RN) 1, RN 1 stated residents who should have or want to have siderails need to have an Interdisciplinary Team (IDT) Meeting to determine if it is appropriate for them to use. RN 1 stated residents who are not fully alert and able to follow safety directions should not have siderails. If it is determined that siderails are appropriate for the resident, they would call the physician to put in an order. During an interview on 2/6/2025 at 2:15 p.m. with the Minimum Data Set Nurse (MDSN), MDSN stated an IDT meeting would be held to determine if it is safe for the resident to have siderails. MDSN stated Resident 39 did not have an assessment done or an order for the use of siderails. MDSN stated sometimes siderails are not appropriate like if they are not alert enough to follow directions or if they have unsteady gait or if they were not able to use it at all. An order for siderails is also needed so the physicians and the care team are all on the same page. During a review of the facility's policy and procedure (P&P), undated, it indicated an assessment of the resident's symptoms and the reason for using siderails would be conducted prior to use and would be documented in the residents' record.

Based on observation, interview, and record review, the facility failed to: 1. Discard a bottle of expired cranberry extract in the medication cart. 2. Label a bottle of opened docusate liquid with the open date. This deficient practice had the potential for the residents to receive ineffective medication dosages. Findings: During an observation on [DATE] at 11:30 a.m., of medication cart #3 at nurses station #3, a bottle of cranberry juice extract had an expiration date of ,d+[DATE] and a bottle of opened docusate sodium liquid did not have an open date was found. During an interview on [DATE] at 11:54 a.m. with the Treatment Nurse (TN), the RN stated the cranberry juice extract was expired and should have been disposed of. If left in the cart, there is potential for the resident to receive the expired medication, and that medication could have not been as effective. TN also stated the bottle of opened docusate liquid should have an open date on it, if not, the nurses would not have known when it was opened. During a review of the facility's policy and procedure (P&P), titled Storage of Medications, undated, it indicated the facility should not use discontinued, outdated or deteriorated drugs, and all such drugs should be returned to the pharmacy or destroyed. It also indicated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review the facility failed to: 1. Ensure one out of four sampled residents (Resident 84) food items stored in Resident 84's room were not dated and labeled. This deficient practice of not having food items dated and labeled had the potential to for Resident 84 to cause a stomach infection (an inflammation of the stomach and intestines caused by bacteria). Findings: During a review of Resident 84's Admission Record (Face Sheet), the Face Sheet indicated Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included cervicalgia (neck pain or discomfort in the upper spine), idiopathic neuropathy (a condition where nerve damage occurs with no identifiable cause), and anxiety (a feeling of apprehension or dread that can be caused by a real or perceived threat). During a review of Resident 84's History and Physical (H&P), dated 11/24/2024, the H&P indicated Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's Minimum Data Set ([MDS] a mandated assessment tool), dated 12/28/2024 the MDS indicated, Resident 84's cognition (ability to learn, reason, remember, understand, and make decisions) he was able to understand. The MDS indicated Resident 84 was independent with personal hygiene, dressing, and eating. The MDS indicated Resident 84 was on a therapeutic diet (a meal plan that helps patients manage health conditions). During an observation on 2/4/2025 in Resident 84's room there were 1 liter ([l]-a metric unit of measurement used to calculate volume) of coke-cola bottle, a large bag of opened ruffles potato chips, and an open jar of Cheez Whiz were not dated or labeled. During an interview on 2/4/2025 at 12:53 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated when Resident 84 brought in outside food (food brought into a healthcare facility by a patient or visitor) the food items were to be dated and labeled by the staff. LVN 3 stated the food items should not bed stored in the resident room for no more than three days. LVN 3 stated keeping the food items in Resident 84's room for more than three days had the potential for the resident to have stomach problems such as diarrhea (having loose or watery stools more than three times a day). During a concurrent observation and interview on 2/5/2025 at 3:24 p.m. with Certified Nursing Assistant (CNA) 2, in Resident 84's room, Resident 84 had 1 liter ([l]-a metric unit of measurement used to calculate volume) of coke-cola bottle, a large bag of opened ruffles potato chips, and an open jar of Cheez Whiz were not dated or labeled. CNA 2 stated food items in the resident's rooms were to be dated. CNA 2 stated once the food item is opened the staff is to keep track of the date and throw the food item once its pass three days. CNA 2 stated if the food items in Resident 84's room she could get a stomach illness. During a review of facility's policy and procedure (P&P) titled, Use and Storage of Food Brought in by Family or Visitors, date unknown, the P&P indicated it is the right of the residents of this facility to have food [NAME] in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. The P&P indicated all food items must be labeled with content and dated and must be consumed within three days. The P&P indicated if food items were not consumed within three days, food will be thrown away by facility staff. The P&P indicated all food items brought in to the facility must be kept in the resident room inside a lock tight container.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 22), by failing to: 1. Document the correct information on the when the resident transferred to a different facility. This deficient practice had the potential to result in confusion and incomplete assessment of the resident's needs and could lead to a lack of or delay in delivery of necessary care or services to Resident 22. Findings: During a review of Resident 22's Admission Record (front page of the chart that contains a summary of basic information about the resident), the admission record indicated, Resident 22 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 22's diagnoses included chronic kidney disease ([CKD], condition which the kidneys are damaged and cannot filter blood as well as they should), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 22's History and Physical (H&P), dated 11/24/24, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool)), dated 11/26/24, indicated Resident 22 was assessed to comprehend (the action or capability of understanding something) most conversation. The MDS indicated Resident 22 required supervision or touching assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, showering, sit to stand, chair/bed-to-chair transfer, and toilet transfer. During a concurrent interview and record review on 2/4/25 at 9:06 a.m. with Director of Staff Development (DSD), Resident 22's SNF/NF to Hospital Transfer Form (Transfer form) dated 2/3/25, the transfer form Resident 22 was sent to Los Angeles Downtown Medical Center on 11/20/24 [NAME] to behavior symptoms. The transfer form indicated most current vital signs were dated blood pressure 124/72 on 1/25/25, heart rate 78 on 1/19/25, respiratory rate 16 on 1/19/25, temperature 97.2 degrees Fahrenheit on 1/19/25 and oxygen saturation level 97 percent on 1/19/25. The transfer form indicated report called in to receiving facility on 2/3/25 at 4:50 p.m. DSD stated the Resident 22 wanted to go to the facility she was before, so we arranged her transfer, Resident 22 was transferred on 2/3/25. DSD stated the transfer form was not filled out correctly, the vitals should have been from the day she left the facility. DSD stated it is very important to document correct, it was a guide to know what is happing with the resident. DSD stated if the documentation was not correct, it could affect the type of care the resident receives. DSD stated this can potentially harm the resident. During an interview on 2/7/25 at 10:13 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 22 was transferred to another facility that she wanted to go to. RN 2 stated I forgot to updated the transfer form with the correct information. RN2 stated documentation not done correctly may affect the resident in the correct care given to resident. During an interview on 2/7/25 at 10:28 a.m. with the Director of Nursing (DON), the DON stated documenting correctly was important, it was how we know the condition of the resident. DON stated when a resident is being transferred out of our facility it was important to document correctly the vitals, mode of transportation, where resident was going. DON stated if documentation was not done correctly there would be no way to know if the resident was stable, where the resident went to, who picked them up. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, (undated), the P&P indicated, all services provided to the resident, or any changes in the resident's medial or mental condition, shall be documented in the resident's medical record.

Based on interview and record review the facility failed to: 1. Ensure one out of four sampled residents (Resident 84) was administered pain medication as needed. This deficient practice of not administering pain medication for Resident 84 had the potential to increase pain and discomfort. Findings: During a review of Resident 84's Admission Record (Face Sheet), the Face Sheet indicated Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included cervicalgia (neck pain or discomfort in the upper spine), idiopathic neuropathy (a condition where nerve damage occurs with no identifiable cause), and anxiety (a feeling of apprehension or dread that can be caused by a real or perceived threat). During a review of Resident 84's History and Physical (H&P), dated 11/24/2024, the H&P indicated Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's Minimum Data Set ([MDS] a mandated assessment tool), dated 12/28/2024 the MDS indicated, Resident 84's cognition (ability to learn, reason, remember, understand, and make decisions) he was able to understand. The MDS indicated Resident 84 was independent with personal hygiene, dressing, and eating. The MDS indicated Resident 84's numeric rating scale (a system where patients rate their pain intensity using numbers on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable) of pain intensity was seven out of ten and had the potential to interfere with day-to-day activities. During a review of Resident 84's controlled drug record, titled Antibiotic or Controlled Drug Record, dated 11/30/2025 the Antibiotic or Controlled Drug Record indicated to give one tablet of tramadol 50mg every six hours as needed for severe pain. The Antibiotic or Controlled Drug Record indicated tramadol 50mg was removed on 11/30/2025 at 5:00 p.m. During a review of Resident 84's Electronic Medication Administration Record ([eMAR]- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/30/2024, the eMAR indicated on 11/30/2024 Resident 84 did not receive her tramadol 50mg at 5:00 p.m. During a review of Resident 84's controlled drug record, titled Antibiotic or Controlled Drug Record, dated 12/1/2024, the Antibiotic or Controlled Drug Record indicated to give one tablet of tramadol 50mg every six hours as needed for severe pain. The Antibiotic or Controlled Drug Record indicated tramadol 50mg was removed on 12/1/2024 at 12:00 p.m. During a review of Resident 84's Electronic Medication Administration Record ([eMAR]- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/1/2024, the eMAR indicated on 12/1/2024 Resident 84 did not receive her tramadol 50mg at 12:00 p.m. During an interview on 2/6/2025 at 12:45 p.m. with Resident 84, Resident 84 stated she had chronic pain (pain that persists for a prolonged period lasting beyond the normal healing time after an injury or illness) in her neck and when she requested for pain medication there was a delay and did not receive her pain medication. Resident 84 stated the delay in not receiving the pain medication mad her neck pain worse. Resident 84 stated the delay of not receiving her pain medication made her feel frustrated and upset. During a concurrent interview and record review on 2/7/2025 at 1:01 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 84's Antibiotic or Control Drug Record and eMAR, dated 11/30/2024 and 12/1/2024 was reviewed. The Antibiotic or Control Drug Record indicated on 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. tramadol 50mg was removed from medication cart. The eMAR indicated Resident 84 did not receive tramadol 50mg 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. LVN 2 stated the protocol is to remove the pain medication from the narcotic medication cart, sign on the Antibiotic or Control Drug Record log that the medication was removed. LVN 2 stated once the medication is removed from the narcotic cart the time and date should correspond with the eMAR. LVN 2 stated the eMAR does not show the pain medication given nor was documented that it was given to Resident 84. LVN 2 stated not given the pain medication to Resident 84 could cause her to feel not happy and feel worse. During an interview on 2/7/2025 at 1:22 p.m. with Minimum Data Set (MDS) Nurse, Resident 84's Antibiotic or Control Drug Record and eMAR, dated 11/30/2024 and 12/1/2024 was reviewed. The Antibiotic or Control Drug Record indicated on 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. tramadol 50mg was removed from medication cart. The eMAR indicated Resident 84 did not receive tramadol 50mg 11/30/2024 at 5:00 p.m. and 12/1/2024 at 12:00 p.m. The MDS Nurse stated it does not look like the tramadol pain medication was given to Resident 84. The MDS Nurse stated it could make Resident 84 agitated and increase her discomfort. During a review of facility's policy and procedure (P&P) titled, Charge Nurse, date unknown, the P&P indicated ensures that policies and procedures are complied with by nursing personnel assigned. The P&P indicated the charge nurse prepares and administers medications as per physicians' orders. During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 11/2017, the P&P indicated review MAR to identify medication to be administered. The P&P indicated to administer with 60 minutes prior to or after scheduled times unless otherwise ordered by physician. The P&P indicated sign MAR after medication administration.

Based on observation, interview, and record review the facility failed to ensure one of three sample residents (Resident 1), was not physically abused. Licensed Vocational Nurse (LVN) 1 punched Resident 1 in the face. This deficient practice resulted in Resident 1 developing a swollen and bruised left eye. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (serious mental disorder in which people interpret reality abnormally), anxiety disorder (feeling of worry or fear), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living). During a review of Resident 1 ' s History and Physical (H&P), dated 2/19/2023, the H&P indicated, Resident 1 had the capacity to understand and make decisions intermittently related to acute psychosis (a clinical syndrome that involves hallucinations [perception of something not present], delusions [unable to tell what is real from what is imagined], disorganized thoughts or behaviors, or some combination within an acute timeframe often less than 1 month). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care screening and assessment tool), dated 2/26/2023, the MDS indicated Resident 1 had the capacity to understand and be understood intermittently. The MDS indicated Resident 1 had trouble concentrating, no physical behavioral symptoms directed toward others, and verbal behavioral symptoms directed toward others. The MDS indicated Resident 1 required supervision with activities of daily living ([ADL] activities related to personal care) when walking in corridor and toileting. During a review of Resident 1 ' s Nurses Notes, dated 4/21/2023, indicated on 4/21/2023 at 3:00 a.m., Resident 1 was making loud noises in the hallway with Resident 4. LVN 1 intervened and separated the two residents (Resident 1 and Resident 4). Nurses Notes indicated on 4/21/2023 at 3:45 a.m., Resident 1 followed LVN 1 to the nurse station and started talking about shooting people and LVN 1 tried to calm down Resident 1 by asking him to go to his room then Resident 1 hit LVN 1 in the mouth. On 4/21/2023 Resident 1 was escorted to his room without any incidents. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation ([SBAR] communication form) form, dated 4/21/2023, indicated Resident 1 had a change of condition ([COC] a clinical deviation from a resident's baseline) with symptom, or sign observed and evaluated with a black eye (an area of bruised skin around the eye resulting from a blow). During a review of Resident 1 ' s Interdisciplinary Care Plan, titled Alteration in Skin Integrity, dated 4/21/2023, indicated, Resident 1 had left lower eyelid slight discoloration measuring 0.3 x ([by] proximity of measurement) 0.5 centimeters ([cm] unit of measurement). During a review of Resident 1 ' s Interdisciplinary Care Plan titled, Aggressive Behavior (behavior that is intended to harm another individual who does not wish to be harmed) dated 4/21/2023, the care plan indicated Resident 1 had an incident with staff, Resident 1 was anxious, restless and had delusional behavior (having false or unrealistic beliefs or opinions). Care plan indicated Resident 1 stated he had a fight with someone where he was screaming, yelling, and should be shooting unnamed resident. The care plan indicated Resident 1 stated he was fighting like animal, hit unnamed person and someone wearing a green and black jacket hit him (Resident 1). During a review of Certified Nurse Assistant (CNA 2) interview record (written statement) regarding the incident that happened on 4/21/2023, CNA 2 indicated he heard loud yelling coming from Nursing Station 1 and saw Resident 1 and LVN 1 were engaged in verbal confrontation. CNA 2 indicated Resident 1 called LVN 1 a racial remark Ni ER and hit LVN 1 in the mouth. CNA 2 put himself in between Resident 1 and LVN 1 to de-escalate the situation with his hands up and palms open to let Resident 1 know he was not trying to be the aggressor. Resident 1 took some steps back and was focused on CNA 2, then LVN 1 ran from behind CNA 2 and tackled Resident 1 to the floor. CNA 2 stated while Resident 1 was on his back on the floor, LVN 1 put his knees on each one of Resident 1 arms to keep Resident 1 still on the floor and started to strike Resident 1 across his face. CNA 2 indicated the tackle was not needed because he (CNA 2) was already in between Resident 1 and LVN 1 to deescalate the situation. During an observation on 5/4/2023 at 11:00 a.m., Resident 1 was in hallway near his (Resident 1) room, Resident 1 was observed with swelling and bruising around his left eye. During a telephone interview on 5/4/2023 at 2:00 p.m., with CNA 2, CNA 2 stated he witnessed Resident 1 and Licensed Vocational Nurse (LVN) 1 arguing and heard Resident 1 call LVN 1 a racial remark Ni er. CNA 2 stated Resident 1 was observed in a fighting posture and LVN 1 told Resident 1 you are not going to do anything. CNA 2 stated he saw Resident 1 hit LVN 1 in the mouth, then CNA 2 (with his hands up in a non-aggressive gesture) stood in between Resident 1 and LVN 1 to stop Resident 1 from hitting LVN 1. Resident 1 stopped hitting LVN 1. Resident 1 stepped away from LVN 1 then LVN 1 tackled Resident 1 to the ground and slapped Resident 1 in the face. CNA 2 stated Resident 1 fought back and tried to kick LVN 1 off him. CNA 2 stated LVN 1 should know that Resident 1 was a psychiatric (having mental illness) patient and should not hit Resident 1. During a telephone interview on 5/4/2023 at 3:00 p.m., with LVN 1, LVN 1 stated, he was the charge nurse the night of 4/21/23 at 3:00 a.m. and was assigned to Resident 1. LVN 1 stated, Resident 1 was fixated with Room A and he (LVN 1) asked Resident 1 to move away from the room. LVN 1 tried to make Resident 1 go to his room but instead of going back to his room, Resident 1 followed him (LVN 1) to the nursing station and yelled an inappropriate racial comment Ni er. and hit him (LVN 1) in the mouth and neck. LVN 1 stated he tried to block the hits and moved away from Resident 1. LVN 1 stated Resident 1 stopped hitting him and walked back to his room. LVN stated he should have run for his life, de-escalated (reduce the potential for violent situation), and redirected Resident 1. LVN 1 stated he never hit him (Resident 1). During an interview on 5/4/2023 at 3:40p.m., with the Director of Staff Development (DSD), the DSD stated she interviewed the staff and Resident 1. The DSD stated CNA 2 reported LVN 1 hit Resident 1 in the face. Resident 1 admitted hitting LVN 1 and said, The staff (LVN 1) punched him back. CNA 2 and Resident 1 statements were aligned about Resident 1 being hit by LVN 1. The DSD stated LVN 1 denied hitting Resident 1 and said he was hit by Resident 1. The DSD stated Resident 1 presented with discoloration of the left eye lid that morning. Resident 1 should not have been hit by staff or anyone. The DSD stated LVN 1 resigned on 4/24/23. During an interview on 5/4/2023 at 3:55 p.m., with the Director of Nursing (DON) regarding the incident that happened on 4/21/2023, the DON stated LVN 1 reported Resident 1 had aggressive behavior and hit LVN 1 during the night shift. The DON stated during rounds on 4/21/12 at 6:00 a.m., she noticed Resident 1 left eye was discolored. The DON stated she asked Resident 1 what happened, and Resident 1 said, he hit someone, and someone hit him back. The DON stated, LVN 1 stated he does not know what happen to Resident 1 ' s eye. The DON stated CNA 2 was called by the DSD and was told Resident 1 hit LVN 1, and LVN 1 charged Resident 1 to the floor and punched Resident 1 in the face. The DON stated it was not okay for staff to hit residents. It was important to give good customer service and abusive behavior (a wide range of actions, words, and behaviors that are intended to control, manipulate, or harm another person) was not tolerated at the facility. During an interview on 5/4/2023 at 4:15 p.m., with the Administrator (ADM), the ADM stated, CNA 2 reported Resident 1 punched LVN 1 and LVN 1 hit Resident 1 in the face. The ADM stated the DON was doing rounds in the morning and noticed the discoloration to Resident 1 ' s left eye. The ADM stated CNA 2 reported LVN 1 hit Resident 1 in the face. Resident 1 was sent to the hospital on 4/21/2023. The ADM stated it was not okay to hit residents and abusive behavior was not tolerated. During a concurrent interview and record review on 5/30/2023 at 3:15 p.m., with the DON, Resident 1 ' s Nurses Notes, dated 4/21/2023 was reviewed. Nurses Notes indicated Resident 1 stated he had a fight where he fought like an animal, he was screaming, yelling and should shout and shoot him (did not name who). Nurses ' notes indicated Resident 1 stated he hit them (did not indicate who) but he (did not specify name) hit him. The DON stated he asked Resident 1 who hit him, and Resident 1 stated he does not know, he was wearing a green uniform and black jacket. Nurses ' notes indicated at around 7 a.m., slight discoloration was noted on Resident 1 ' s lower left eye lid. The DON stated, she was doing rounds that morning and noticed discoloration to Resident 1 ' s left eye. During a review of the facility ' s policy and procedure (P&P) titled, Charge Nurse-RN/LVN Job Description, undated, the P&P indicated, The primary purpose of your job position was to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the certified nursing assistants. All care and supervision must be in accordance with current federal, state, and local standards, guidelines, regulations, and laws that govern our facility .Complies with abuse prevention & reporting policies and procedures. During a review of the facility ' s policy and procedure (P&P), titled Promoting/Maintaining Resident Dignity, dated (2022), indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. During a review of the facility ' s P&P, titled Abuse, Neglect and Exploitation (the action or fact of treating someone unfairly in order to benefit from their work), dated 2023, indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals . Physical abuse includes, but is not limited to hitting, slapping, pinching, and kicking.

Based on observation, interview and record review, the facility failed to follow a resident's plan of care and a policy regarding using mechanical lifts (any type of lift used for transferring residents) with a two-person physical assist and ensure the accurate size sling was used in transferring residents for one of three sampled residents (Resident 4). Resident 4, who was assessed as a high risk for falls and required a two-person physical assist with transfer, was transferred using a one-person and fell out of the standing lift's sling (a type of mechanical lift used for transferring) to the floor sustaining a fracture (broken bone). This deficient practice resulted in Resident 4 falling from a standing lift due to the standing lift sling being too large and a one-person physical assist with transferring and sustained a comminuted fracture (a break of the bone that occur after a high-impact trauma; the bone broken into several pieces) of the distal tibia (leg bone) above the left ankle and requiring pain medication (extra strength (ES) Tylenol (mild pain medication) a transfer to a general acute care hospital (GACH) for care and treatment. Findings: A review of Resident 4's Admission Record indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's history and physical (H/P), dated 12/20/18, indicated Resident 4 had the capacity to understand and make decisions. A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/10/19, indicated Resident 4's Brief Interview for Mental Status ((BIMS) a mental assessment test) score was 13 (13-15= cognition (thought process) intact. According to the MDS, Resident 4 was non-ambulatory and required extensive assistance of a two-person physical assist for transferring and all her activities of daily living ((ADLs) daily care, such as grooming and bathing etc.) due to her ability to only stabilize with staff assistance. The MDS indicated Resident 4 had impairment on both sides of the upper extremities and utilized a wheelchair for mobility. A review of Resident 4's Fall Risk Assessment, dated 2/1/19 indicated the resident was assessed as having a score of 13. According to the Fall Risk Assessment, a total score of 10 or more represented a high risk. A review of Resident 4's care plan, dated 2/1/19 and titled, Fall Risk indicated the staff's interventions included for the staff to check the adaptive aids (are used to help with performing daily living activities and to improve a person's quality of life) to ensure they are working properly and in good repair. A review of Resident 4's Care plan, dated 2/1/19 and titled, Needs Assistance with ADLs: Extensive assist with transfers, the staff's approach included to assist the resident with transfers and request extra help as needed. A review of a quarterly Interdisciplinary Team ((IDT) a meeting to develop care that meets the patient needs and goals) care conference record, dated 2/1/19, indicated the areas reviewed during the conference included Resident 4's fall risk, which indicated the resident's needs were met and the care and goals were achieved. A review of a nurses' note, dated 4/27/19 and timed at 6 a.m., indicated while the Certified Nursing Assistant (CNA) was transferring Resident 4 from the bed to the wheelchair, the resident mistakenly removed one of her hands from the sling. The nurses' note indicated Resident 4 was assisted by two CNAs to the floor to avoid falling and injury. The note indicated Resident 4 did not sustain a fall, however slid onto the floor per the facility's policy. The note further indicated Resident 4 stated that she became weak while being transferred. A review of a nurses' note, dated 4/27/19 and timed at 7:30 a.m., indicated Resident 4 called her family member (FM1) and lied that she fell , but actually she slid down. A review of the physician's orders [REDACTED]. A review of another physician's orders [REDACTED]. A review of the GACH's history and physical (H/P) for Resident 4 indicated the resident was evaluated in the Emergency Department (ED) on 4/27/19 at 9:48 a.m., for a complaint of leg pain from a fall. According to the GACH physician's assessment note, Resident 4 stated she was being transferred by a lift when she was dropped. The assessment indicated that Resident 4 complained in ED of bilateral non-radiating ankle pain of 8 out 10 (on a scale of 10 being the worse) and was given [MEDICATION NAME] sulfate (a strong narcotic pain medication) 4 milligram (mg) intramuscular ((IM) injection into the muscle) and 600 mg [MEDICATION NAME] ((NSAID) non-steroidal anti-[MEDICAL CONDITION] drug). A review of Resident 4's left ankle x-ray report, dated, 4/27/19, indicated a comminuted [MEDICAL CONDITION] tibia above the ankle. On 5/3/19 at 12:33 p.m., during an interview, FM 1 stated a week prior, the facility's staff dropped the resident (Resident 4), while transferring the resident from the bed to the wheelchair in a lift, which caused Resident 4 to break her leg. FM 1 stated according to Resident 4, she was assisted by one CNA while being transferred. FM 1 stated the lift sling was too big and she had informed the staff on multiple occasions of the lift sling being too big, but the staff told her the sling/lift [NAME]et that fit Resident 4 was in the washer. FM 1 further stated the staff was aware of the sling being too big for Resident 4, but nothing changed. On 5/3/19 at 2:08 p.m., during an interview and record, the Director of Nursing (DON) reviewed the nurses' note, dated 4/27/19 and timed at 6:30 a.m. The DON stated the support of the standing lift's sling is not dependent on a resident holding the standing lift's sling and is the cause of Resident 4 falling from the sling when she removed her hands from the lift's sling. On 5/3/19 at 2:11 p.m., during an interview, Resident 4 stated she fell on to the floor when only one CNA transferred her from the bed to a wheelchair using standing lift sling. Resident she fell on to the floor by the room's door. On 5/9/19 at 4:55 p.m., during a telephone interview, CNA 5 stated in the early morning hours she transferred Resident 4 alone and without any staff assistance, from the bed to a chair using a standing lift device. CNA 5 stated she usually transferred Resident 4 alone because the staff was always too busy. CNA 5 stated the standing lift's sling was too large for Resident 4. CNA5 stated the staff had searched for three to four days for a sling that fit Resident 4 but they were unable to locate one that fit. On 5/13/19 at 9 a.m., during a concurrent observation of the facility's standing lift and an interview, Restorative Nursing Assistant ((RNA 1) a certified nursing assistant (CNA) who has additional, specialized training in restorative nursing care) stated a standing lift was utilized for residents that required transfer from the bed to a chair. RNA 1 stated a two-person physical assist was required for residents using the standing lift. RNA 1 stated the standing lift's slings are in different colors that indicated the difference in sizes; the blue colored sling was the standard size, the beige colored sling was larger and the loops for the handles are bigger and longer. On 5/13/19 at 9:25 a.m., during an observation in the facility's laundry room, there were several clean standing lift's slings of medium (blue in color) sized in a plastic storage container. On 5/13/19 at 10:48 a.m., during a concurrent observation and interview, the facility's large gray standing lift's sling was observed and the Director of Staff Development (DSD) stated the facility only had one gray extra-large sling for the standing lift and two or three blue standard size slings. The DSD stated the weight capacity and size observed on the gray sling indicated extra-large with a weight limitation of 450 pounds (lbs.). The DSD stated the minimum weight for the extra- large sling was 200 Lbs. and Resident 4 weighed approximately 130-160 lbs. The DSD stated that the blue sling should have been used for Resident 4 during the transfer on 4/27/19. On 5/13/19 at 12:37 p.m., during a telephone interview, the DON stated according to the CNAs, the blue standing lift sling was for medium sized residents with a weight capacity of 100 to 150 lbs. and the gray slings were for residents who weighed 200 lbs. During a record review of Resident 4's MDS, dated [DATE], indicated the resident weighed 133 lbs., thus a medium standing lift sling should have been used. A review of an In-service Educational Record, dated 10/26/18 and titled, Use of Mechanical Lifts and Slings, conducted by the DSD, indicated the blue slings were used for residents who weighed 130-250 lbs. and the gray slings were used for residents who weighed 260-350 lbs. The in-service indicated there should be two or more staff assist when using any mechanical lifts with residents. The In-service Educational Record had 32 staff members who signed in attendance, which included CNA5's signature. A review of the facility's revised policy, dated 4/2007 and titled, Lifting Machine, Using a Portable, indicated to review the resident's care plan to assess for any special needs of the resident before using. The policy also indicated the portable lift can be used by one (1) nursing assistant if the resident can participate in the lifting procedures, if not, two (2) nursing assistants will be required to perform the transfer. A review of the facility's revised policy dated 12/2007 and titled, Falls and Fall Risk Managing, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review the facility failed to ensure three of 20 sampled residents (8, 17, 20) did not feel verbally abused by a dietary staff member. This failure resulted in residents feeling scared, upset, sad, and disrespected. Findings: a. On September 27, 2016 at 11 a.m., a group meeting was held that included eight of the facility's alert and oriented residents. When asked about the dietary staff members, three of eight residents stated some of the kitchen staff members were rude and they had yelled at them. One resident complained of a dietary staff member even yelling at her in a language other than English. A review of the medical records indicated Resident 20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A resident data collection sheet, dated May 22, 2016 indicated Resident 20 was readmitted to the facility. The resident was described as alert & oriented, readily answered questions, quick to comprehend and was involved in her plan of care. It was indicated Resident 20 had good motivation towards rehabilitation. A resident care plan dated May 22, 2016, addressed Resident 20's use of [MEDICAL CONDITION] medications which included antianxiety and antidepressants. The nursing plan indicated the resident should be approached in a calm manner and her concerns reassured and alleviated. The social service quarterly update notes, dated August 22, 2016 indicated Resident 20 needed daily support from the staff in areas including social interaction with others. It was also indicated the staff would encourage the resident to express her concerns, feelings and frustration. The Minimum Data Set (MDS, a resident care assessment and screening tool), dated August 26, 2016 indicated Resident 20 had the ability to understand others and make herself understood. The MDS assessment indicated there was no impairment of Resident 20's hearing and her vision was adequate. A psychological consultation notes, dated September 15, 2016 indicated Resident 20 had [DIAGNOSES REDACTED]. activities). The notes further indicated the resident had acute (current) stressors as well as past experiences contributing to her depression and anxiety. A review of the September 2016 recapitulated of the physicians orders indicated Resident 20 was receiving [MEDICATION NAME] 60 milligram (mg) and [MEDICATION NAME] 20 mg daily for depression. In addition, on September 26, 2016 the order indicated an increase of the resident's [MEDICATION NAME] (antianxiety) from 7.5 mg to 15 mg daily. On September 29, 2016 at 2:35 p.m., in an interview with the Dietary Supervisor (DS) stated the only complaints she was familiar with was about Employee 25 who had been too loud. She stated the complaint came from two or three residents stating they had thought the same employee was angry with them any time they asked for something. The DS stated she conducted a one on one training to Employee 25 and he was aware of the complaints from the residents. The DS stated she did not report the incident to the Administrator, but could understand how the residents may have felt Employee 25 was verbally abusive. On September 29, 2016 at 3:05 p.m., in an interview with Employee 26 stated the complaints against Employee 25 had been ongoing. She stated when the residents go to the kitchen asking for coffee, cookies or anything else, Employee 25 yells at them and slams the door in their faces. She stated he is mean, bitter and angry. She stated he's not just loud, he is mean. Employee 26 stated approximately ten different residents had verbalized their complaints to her regarding Employee 25's behavior. She stated Employee 25 had yelled at her on several occasions. She stated the Licensed staff had been around when Employee 25 would yell at the residents but they usually don't do anything about it. On September 29, 2016 at 4:15 p.m., Resident 20 stated she had problems with Employee 25. The resident stated she would sometimes go to the kitchen and ask for fruit, a sandwich or graham crackers but Employee 25 yells at her in a very loud voice and makes her wait. Resident 20 stated when Employee 25 yells at her it makes her feel bad. Resident 20 stated she was afraid if she complained about his behavior the facility would take it out on her. Resident 20 stated Employee 25's behavior had been going on for a while. She stated it got to a point where she didn't want to be bothered with him and would attempt to make request from other dietary staff members but Employee 25 would still interfere and yell at her while she was talking with someone else. She stated he was just mean and seemed angry all the time. She stated it felt as if Employee 25 was badgering her for no reason. Resident 20 stated there was one time when he yelled at her and then slammed the door in her face. Resident 20 stated she had reported the behavior to other staff members but after reporting the behavior she was told Employee 25's supervisor had been informed as well. Resident 20 stated she did not report the behavior to management (Director of Nursing, Administrator) because she was afraid she would be put out of the facility. Resident 20 stated Employee 25 made her feel bad and more depressed. On September 30, 2016 at 9:25 am, in an interview with Employee 25 stated he attends to the the residents' needs when they knock on the kitchen door. He stated there are times when he is busy, but he always get the residents what they ask for. He stated he was aware of his tone of voice being loud and remembered his supervisor speaking to him two months ago about customer service. However, he did not remember specifically what she talked to him about. Employee 25 stated he did not remember the supervisor talking to him about being loud and he was not aware residents felt he was loud, mean or angry. Stated he has not had any resident or any staff tell him face to face that he is loud, rude, mean or angry. However, he stated he could understand how a resident may have felt his loud tone could be verbally abusive. A review of an undated facility policy and procedure titled Abuse indicated verbal abuse is the use of oral or gestured language that willfully includes disparaging terms within the hearing distance of a resident. Facility supervisors will monitor the behavior of staff members that are indicative of high stress levels that may lead to abuse or escalate a continuum of aggression. Facility supervisors are to immediately correct and intervene in reported or identified situations in which abuse is at risk of occurring. b. A review of the medical records indicated Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A neuropsychological consultation notes, dated February 18, 2016 indicated Resident 8 had a history of [REDACTED]. The resident data collection sheet, dated July 16, 2016 indicated Resident 8 was alert and oriented, answered questions readily and was quick to comprehend. It was indicate the resident was involved in her plan of care. A resident care plan, dated July 16, 2016 addressed Resident 8's use of [MEDICAL CONDITION] medications which included antidepressants. The interventions indicated to approach the resident in a calm manner and her concerns reassured and alleviated. A psycho - social assessment form, dated July 16, 2016 indicated Resident 8 needed daily support from the staff in areas including social interaction with others. It was also indicated staff would encourage the resident to express her concerns, feelings and frustration. The physician's orders [REDACTED]. The resident was also receiving [MEDICATION NAME] 50 mg daily, [MEDICATION NAME] 40 mg and Trazadone 100 mg every night to treat and manage the depression. The Minimum Data Set (MDS, a resident assessment and care screening tool), dated July 23, 2016 indicated Resident 8 had the cognitive ability to understand others and make herself understood. The MDS assessment indicated the resident had adequate hearing and vision. Resident 8 did not display any [MEDICAL CONDITION] (confusion) or behaviors during the assessment period. On September 28, 2016 at 1:30 p.m., in an interview with Resident 8 stated when she went to the kitchen to ask for something Employee 25 went crazy. The resident stated Employee 25 started yelling at her in a non English language and kept saying Get out of here. Resident 8 stated It makes me so mad when someone screams at me. The resident stated she did not go to the kitchen anymore to ask for anything. Resident 8 stated she just cloud not deal with it and the yelling makes her feel angry and ignorant. A review of an undated facility policy and procedure titled Abuse Investigations indicated abuse included intimidation and mental anguish. It was indicated any allegation of abuse or any form of behavior that could be construed as a form of abuse shall be investigated. The results of all investigations shall be reported to the Administrator or a designated representative. c. A review of the medical record indicated Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The history and physical, dated May 13, 2016 indicated Resident 17 had the capacity to understand and make decisions. A resident data collection sheet, dated May 12, 2016 indicated Resident 17 was alert and oriented, readily answered questions, was fairly motivated toward rehabilitation and involved in her plan of care. A psycho - social assessment form, dated May 12, 2016 indicated Resident 17 felt overwhelmed upon admission. It was indicated the resident was in need of daily support from facility staff and should be encouraged to express her feelings, concerns and frustrations. A resident care plan, dated May 31, 2016 addressed Resident 17 being administered [MEDICAL CONDITION] medication including antidepressants. The intervention indicated the resident should be approached in a calm manner and her concerns reassured and alleviated. A review of the physicians orders, dated June 13, 2016 indicated Resident 17 was receiving [MEDICATION NAME] 25 mg every morning for depression. The Minimum Data Set (MDS, an assessment and care screening tool), dated August 23, 2016 indicated Resident 17 was able to understand others and make herself understood. The resident had adequate hearing and vision. The MDS assessment indicated Resident 17 had no behaviors or episodes of [MEDICAL CONDITION] (confusion) during the assessment period. On September 29, 2016, Resident 17 stated some of the kitchen staff yell at her when she ask for something like coffee from the kitchen. The resident further stated Employee 25 was mean. A review of an undated facility policy and procedure titled Abuse indicated adequate supervision would be provided to ensure inappropriate behavior by staff would be identified. The policy indicated each resident has the right to be free from mistreatment.